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NATIONAL LIBRARY OF MEDICINE
             Washington
Founded 1836
U. S. Department of Health, Education, and Welfare
             Public Health Service 
 
 
Jp
THE
SCIENCE  AND  ART
SURGERY.
A TREATISE ON SURGICAL INJURIES, DISEASES,
           AND OPERATIONS,
BY  •
      JOHN  EEICHSEN,
PROFESSOR OF SUEOERT AND OF CLINICAL SURGERY IN UNIVERSITY COLLEGE,
     AND SURGEON TO UNIVERSITY COLLEGE HOSPITAL.
       AN IMPROVED AMERICAN EDITION,
                FROM
THE SECOND ENLAEGEDAND CAEEFUIIY EEVISED LONDON EDITION.


             ILLUSTRATED BY

    FOUR HUNDRED AND SEVENTEEN ENGRAVINGS ON WOOD.
     PHILADELPHIA:
BLANCHARD  AND  LEA.
          1859. 
1653
              Entered, according to Act of Congress, in the year 1858, by
                         BLANCHARD AND  LEA,
in  the Clerk's Office of the District Court of the United States for the Eastern District of
                                Pennsylvania.

                            COLLI N ST_ P & I X T £ K . 
AMERICAN PUBLISHERS'  ADVERTISEMENT.
  The high reputation which this work has so rapidly obtained in
this country, has stimulated the publishers to render the present
edition in every respect worthy the confidence of the American
profession.  During its passage through the press the sheets have
been submitted to a competent surgeon, with the object of embody-
ing in it whatever might  be requisite to its improvement.   There
has been found, however, but little to add; the careful revision and
extensive additions of the author having rendered unnecessary most
of the notes which were introduced in the former American edition,
and having brought the work thoroughly up to the present condition
of European surgery.  A  few notes  and a small number of wood-
cuts only have therefore been introduced, elucidating some  points
of American practice. These additions are enclosed in brackets [ ].

  Philadelphia, December, 1858.
(v) 
 
PREFACE.
  In preparing a Second Edition of this work for the press every
page has been carefully revised.  Some chapters have been almost
completely re-written, the text has been considerably enlarged, and
upwards of one hundred and sixty new illustrations have been intro-
duced.  The additions are almost exclusively of a practical charac-
ter ; my wish being to make the work a guide to the practitioner as
well as a text-book to the student.   Having this double object in
view, I have entered with much minuteness into many practical
details, which I think will be found to be as useful to the student as
they are important to the practitioner.  My increasing experience
as a teacher leading me to fear that  there is no little risk of the cul-
tivation of the Art not keeping pace with the progress of the Science
of Surgery.
  The general arrangement of the work has been preserved.   It is
divided into three parts:—The First Division, under the head of
"First Principles," contains some general observations on Operative
Surgery, and more specially on Amputations, together with a con-
densed view of the Nature and Treatment of Inflammation.   The
Second Division  comprises the consideration of Surgical Injuries,
and the Third that of Surgical Diseases.
  In considering both Injuries and Diseases it has appeared to me
to be more consistent with a natural arrangement to  treat 1st, of
those common to all parts of the body, as Wounds, Abscesses, Ul-
cers, &c.   2d. The Diseases and  Injuries of Special Tissues, as of
the Osseous Tissue,—Fractures and Necrosis; of the Vascular Tis-
sue,—"Wounds of Blood Vessels and Aneurisms.  And 3d. The
Diseases and Injuries of Regions.
  The more Special Operations I have considered as part of the
Treatment of the different Injuries and Diseases for which they are
required; a plan  that, I thought, would  be  more practically useful
than to describe them apart as a separate subject.  I have limited
                                                    (vii) 
PREFACE.
the Consideration of Affections of the Eyes to  Injuries of those
organs, their Diseases being a special subject, that would require
for its proper description more space than could be allotted it in this
Work.
  In discussing the numerous topics that are  embraced in a system-
atic Treatise on Surgery such as this, I have endeavored, so far as
lies within its scope, and without entering into anything like an his-
torical account, to ascribe to whomsoever it may be due the merit
of improvements in Practice, or of discoveries in  Pathology.  In
some cases, I may perhaps have accidentally omitted doing so, and
in other  instances, where the observation had become as it  were
the established and common property of the  profession, I may pur-
posely have avoided encumbering the text with  names  and refer-
ences.  In order to remedy this deficiency to some  extent, I would
beg to refer the reader to the more special Treatises on the subject-
matter of the different  chapters.   Thus I would particularly direct
his attention to the admirable Lectures on Pathology by Mr. Paget,
to which I have been much indebted  in preparing  the chapters on
Inflammation and on Tumors.  To the works  by Sir B. Brodie on
Diseases of the Joints and Urinary Organs, to  the Treatise of Stanley
on the Bones, of Lawrence  on Plernia, of Fergusson  on Practical
Surgery, of Cooper on Fractures  and Dislocations, of Travers on
Injuries of the Intestines, of Guthrie on Wounds  of Arteries, of
Sir R. Carswell on the Elementary Forms of Disease, and to those
of Acton and Langston Parker on Syphilis.  To the most excellent
works of my former teachers, Samuel Cooper and  Robert Liston,
whose names I cannot mention without a ready and  deep-felt expres-
sion of gratitude for much valuable instruction and personal kind-
ness received from them in former years, I would  especially refer
the reader.
   For any clerical errors in the work,  I must beg  the  reader's
indulgence.   It has been prepared and written in the  midst of the
harassing and  onerous duties that devolve  upon a Hospital Sur-
geon, a Teacher of Surgery, and a Private Practitioner  in the Me-
tropolis, and which are but little favorable to literary pursuits.
   In conclusion, I must express my acknowledgments to Mr. Hulme
for much valuable assistance in carrying this volume through the
Press.
                                        JOHN  ERICHSEN.
   Loxdon, September, 1857. 
CONTENTS.
DIVISION  FIRST.
FIRST  PRINCIPLES.

    CHAPTER  I.
PAGE
Operations in General — Chloroform — Ether — Causes of Death after Operations —
  Incisions —Sutures —Dressings —After Treatment.....       36

                           CHAPTER  II.

Amputations and  Disarticulations — Stumps — Structure and Dressing of—Dis-
  eased Stumps — Statistics of Amputations.......36-47

                           CHAPTER  III.

Special Amputations — Amputations of Fingers, Thumb, Wrist, Forearm,  Arm,
  Shoulder,  Toes, Great-toe, Little-toe, Foot — Chopart's, Hey's, Pirogoffe's, and
  Syme's Operations — Leg, Knee, Thigh, Hip......47-67

                           CHAPTER  IV.
Increased Vascular Action — Congestion — Determination — Inflammation — Its
  Nature and Treatment—The Effusive, Adhesive, Suppurative,  Ulcerative, and
  Gangrenous Forms of Inflammation........67—105
DIVISION  SECOND,
                       SURGICAL  INJURIES.

                            CHAPTER V.
Effects of Injury— Shock — Traumatic Delirium, Varieties and Treatment of .   106-108

                           CHAPTER  VI.
Injuries of Soft Parts — Contusion — Wounds — Incised — Modes of Union of In-
  cised  Wounds — Treatment—Contused and  Lacerated  Wounds — Traumatic
  Gangrene — Amputation in..........109-121 
X
CONTENTS.
                            CHAPTER VII.

Gun-shot Wounds — Apertures of Entry and Exit, Symptoms and Treatment of
  Resection and Amputation in........•
                           CHAPTER  VIII.

Punctured and Poisoned Wounds — Stings of Insects — Snake Bites — Hydropho-
  bia— Dissection Wounds..........131-139
                             CHAPTER IX.

Injuries of Nerves — Wounds of Blood Vessels — Hemorrhage — Transfusion  .   140-142


                              CHAPTER  X.

Wounds of Veins — Air in Veins.........142-148


                             CHAPTER XI.

Injuries of  Arteries — Hemorrhage — Arrest of Arterial Hemorrhage — Surgical
  Treatment of Hemorrhage — Styptics — Pressure — Torsion — Ligature — Col-
  lateral Circulation — Treatment of Wounded Arteries — Traumatic Aneurisms —
  Aneurismal Varix— Varicose  Aneurism — Accidents of Ligature—Secondary
  Hemorrhage — Gangrene..........148-176


                            CHAPTER XII.

Wounds of  Special Arteries — of Carotid — Subclavian — Axillary — Brachial__
  Radial — Ulnar — Palmar Arches — Femoral and  its Branches — Tibial, and
  Plantar.............176-183


                            CHAPTER  XIII.

Injuries of Muscles and Tendons—Sprains nd Strains— Ruptures of Tendons and
  of Tendo  Achillis.........            183-184


                            CHAPTER XIV.

Injuries to  Bones —Bending of  Bone — Fractures — Causes, Varieties, and Signs
  of—Union of Fractures —Treatment of Simple Fractures — Starch and Plaster
  Bandage — Accidents  in Treatment of  Fracture— Spasm —Extravasation —
  QMema—Gangrene — Complications — Compound Fractures, Treatment of__
  Amputation  in —Resetting  of  Fractures — Ununited  Fractures  and False
  Joints.............184-208


                             CHAPTER XV.

Special Fractures — of Nose — Malar and Maxillary Bones — Lower Jaw__Clavicle
  — Scapula — Humerus — Forearm — Elbow,  Wrist,  and  Fingers__Pelvis__
  Femur — its Neck and Shaft — Patella — Leg — Ankle — Foot__Ribs   .  .   208-236 
CONTENTS.
XI
                            CHAPTER  XVI.

Injuries of Joints — Contusions —Wounds — Traumatic Arthritis — Dislocations —
  Reduction of Dislocations — Complication  with Fracture — Spontaneous  and
  Congenital Dislocations..........236-246
                           CHAPTER  XVII.

Special Dislocations — of Lower Jaw — Clavicle — Shoulder Joint — Elbow — Wrist
  — Fingers —Hip — Knee — Ankle, Foot, and Pelvis.....246-272
                           CHAPTER XVIII.

Injuries of Head — Cerebral  Disturbance — Concussion — Compression — Ence-
  phalitis— Treatment of these Injuries—Suppuration within Cranium—Inju-
  ries  of Scalp — Cephaloematoma — Wounds  of  Scalp — Fracture  of Skull—
  Contre-Coup — Fracture of Base — Discharge of Blood and Serum  from the
  Ears — Depressed Fractures — Punctured Fractures — Extravasation of blood
  — Wounds of the Brain —Trephining........272-296
                            CHAPTER  XIX.

Injuries of the Spine — Division and Compression of Cord — Dislocations of the
  Spine — Injuries of the Face — Nose — Ears — Foreign Bodies in — Injuries of
  Orbit— Eye-ball— Tongue and Mouth —Injuries of the Throat— Cut Throat —
  Asphyxia — Drowning — Hanging — Artificial Respiration — Foreign Bodies in
  Air Passages — Scalds of Air Passages — Injuries of GSsophagus      .    .   296-318
                             CHAPTER  XX.

Injuries of the Chest — Wounds of Lung — Emphysema — Pneumonia — Empyema
  __Hernia of Lung — Wounds of Heart and Large Vessels  ....  318-324
                            CHAPTER  XXI.

Injuries of Abdomen and  Pelvis — Rupture  of Viscera — Wind  Contusions —
  Buffer Accidents—Wounds of Intestines — Traumatic  Peritonitis — Injuries of
  Bladder, Urethra, and Rectum — Foreign Bodies in those Canals — Laceration
  of Perineum............325-335
                           CHAPTER XXII.

Effects of Heat and Cold — Burns and Scalds — Frost Bite   ....  335-340 
xii
CONTENTS.
DIVISION   THIRD
                       SURGICAL  DISEASES.

                         CHAPTER  XXIII.
Abscess —Varieties —Diagnosis, and Treatment of—Sinus and Fistula   .   .  341-348
                          CHAPTER  XXIV.

Ulcers — Healthy — Weak — Indolent — Irritable — Inflamed — Sloughing — Va-
  ricose and Hemorrhagic..........349-351


                           CHAPTER  XXV.

Mortification — Varieties  of—Causes and Treatment — Spontaneous and  Senile
  Gangrene — Amputation in   .........       352-360


                          CHAPTER  XXVI.

Gangrenous Diseases — Bed Sores — Sloughing Phagedena — Hospital Gangrene—
  Cancrum Oris — Boils — Carbuncle........360-364
                         CHAPTER XXVII.

Erysipelas — Causes, Varieties, and Symptoms — Cutaneous—Cellulo-Cutaneous,
  Phlegmonous and Cellular — of Newly-born Infants — Head and Face — Scrotum
  — Pudenda — Fingers — Whitlow — Internal Erysipelas — Erysipelatous Laryn-
  gitis— Arachnitis—Peritonitis.........365-381
                        CHAPTER  XXVIII.

Purulent  Infection or Pyemia — Visceral  Abscesses — Theories  of__Treat-
  ment.............382-387
                          CHAPTER  XXIX.

Tumors—Innocent  and  Malignant — Encysted  Tumors — of Scalp__Horns__
  Cysts — Simple and Compound — Hsematoma — Cheloid — Sarcomata__Wens__
  Polypi —Fatty and Fibro-cellular  Tumors — Fibrous — Malignant Fibrous —
  Recurring  Fibroid — and  Fibro-Plastic Tumors — Enchondroma__Malignant
  Tumors — Cancer Scirrhus — Encephaloid — Melanosis — Colloid__Treatment
  of Cancer by Compression — by Caustics — by Operation — Epithelial Cancer__
  Ecraseur — Operations for the Removal of Tumors    .....  388-418 
CONTENTS.
xiii
                            CHAPTER XXX.

Scrofula — of Tissues and Organs—Tubercle — Causes and Treatment of Scro-
  fula   ..............  418-425
                           CHAPTER XXXI.

Syphilis—Primary Syphilis — Chancres — Varieties and Treatment  of—Mercu-
  rial  and  Non-Mercurial  Treatments  compared — Consecutive  Symptoms —
  Chancrous Induration — Bubo — Venereal Warts — Constitutional or Secondary
  Symptoms — Causes and Treatment of—Syphilitic  Diseases of the Skin,  Hair,
  and Nails — Mucous Membranes — Lips — Tongue — Throat — Larynx — Nose
  — Periosteum and  Bones — Nodes—Necrosis — Iritis — Sarcocele — Infantile
  Syphilis — Symptoms and Treatment of.......424-456
                          CHAPTER XXXII.

Diseases  of  the Skin  and  its Appendages — Warts  and  Corns — Onychia —
  Ingrowing of the Nail — Cheloid and  Fibro-vascular Tumor — Lupus Non-exe-
  dens, and Exedens — Cancer of the Skin — Varieties of    ...    .  456-463
                         CHAPTER  XXXIII.

Diseases  of  the  Lymphatics and  their Glands — Inflammation  of—Adenitis —
  Enlargement of.........•            464-467
                         CHAPTER  XXXIV.

Diseases of Veins — Phlebitis — Adhesive — Suppurative — and Diffuse — Patho-
  logy and Treatment—Varix, operations for......467-473
                          CHAPTER  XXXV.

Diseases of Arteries — Arteritis, Adhesive and Diffuse — Spontaneous Gangrene —
  Structural Diseases — Plastic and Fatty Deposits — Atheroma — Calcification  of
  Coats — Ulceration — Rupture—Contraction and Occlusion  ....  473-481
                         CHAPTER  XXXVI.

Aneurism — Varieties of— Structure of Sac — Pressure-Effects — Symptoms —
  Suppuration and Sloughing of Sac — Spontaneous Cure—Diagnosis — Causes
  — Medical Treatment — Surgical Treatment — Hunterian and Distal Operations
  — Accidents after Ligature — Recurrent Pulsation — Suppuration and  Slough-
  ing  of Sac — Gangrene — Treatment  by Compression — Comparison  between
  Ligature and Compression — Manipulation — Galvano-Puncture .     .    .  482-514 
xiv
CONTENTS.
                         CHAPTER  XXXVII.

Aneurisms of the Lower Extremities — Inguinal  Aneurisms — Ligature of Exter-
  nal Iliac Artery — Ligature of Common Iliac — Ligature of Aorta and of Inter-
  nal Iliac — Femoral and Popliteal Aneurisms — Ligature of Femoral Artery —
  Accidents following it— Amputation in Popliteal Aneurism — Ligature of Tibial
  Arteries.............514-529
                       CHAPTER  XXXVIII.

Aneurisms of the Neck and  upper  extremity — of Innominata Artery—Distal
  Operation for — Aneurism of the Carotid — Diagnosis of—Ligature of  Carotid
  Artery — Ligature of both  Carotids — Distal Ligature of Carotid — Aneurism
  of Internal Carotid — Aneurism of Subclavian —Ligature of Innominata — Liga-
  ture of Subclavian, in different parts of its course — Aneurism of Axillary —
  Ligature of Subclavian — Accidents that follow — Ligature of Axillary Artery —
  Aneurisms of Arm, Forearm, and  Hand — Ligature  of  Brachial,  Radial, and
  Ulnar Arteries............529-563
                         CHAPTER XXXIX.

Aneurism by Anastomosis—Treatment of—Nevus—Varieties of—Mode of Liga-
  turing — Hemorrhagic Diathesis.........564-570
                             CHAPTER  XL.

Diseases of Nervous System — Neuritis — Neuralgic — Tic — Division of Nerves in
  — Neuroma — Tetanus — Symptoms and Treatment.....571-578
                            CHAPTER  XLI.

Diseases of Bones — Periostitis — Osteitis — Suppuration of Bone — Abscess in
  Bone —Trephining —Caries, its Nature, Symptoms, and Treatment — Operations
  for Caries—Necrosis — Symptoms — Pathology — Formation of New  Bone__
  Treatment of—and Operation for......                 579-593
                           CHAPTER  XLII.

Structural Diseases of Bone —Hypertrophy —Rickets, Mollities, and Fra<nlitas
  Ossium — Tubercle in  Bone —Tumors of Bone— Exostosis — Enchondroma —
  Cystic Tumors - Spina Ventosa - Hydatids - Osteo-C ancer - Osteo-Cephaloma
  — Osteo-Aneurisma — Diagnosis and Treatment of                  #       5
593-607
CHAPTER  XLIII,
Diseases of Joints - Synovitis — Hydrarthrosis — Arthritis — its Pathology  Causes
  and Treatment —Strumous Diseases of Joints — White Swelling — Anchylosis
  or Stiff Joint     .                                                   J  "
                           ..........  607-620 
CONTENTS.
XV
                           CHAPTER  XLIV
Excision of Diseased Joints — of Shoulder — Elbow — Wrist — Ankle — Astragalus
  — Os Calcis — Knee Joint — Influence of Phthisis on these Operations — Ampu-
  tations — Loose Cartilages in Joints — Neuralgia of Joints ....  620-640
                            CHAPTER  XLV
Diseases of the Spine — Angular Curvature — Caries — Psoas and niac Abscess —
  Lateral Curvature — Symptoms and Treatment of—Spina Bifida     .     .   641-650
                           CHAPTER  XLVI.
Disease  of the Hip Joint — Symptoms, Pathology,  and Treatment — Excision of
  Head  of the Femur — Chronic Rheumatic Arthritis.....650-661
                          CHAPTER  XLVII.
Diseases of the Bursae—Inflamed and Enlarged  Bursae — Bunion — Ganglion —
  Inflammation of Tendons..........661-665
                         CHAPTER  XLVIII.
Strains, Contraction and Retraction of Muscles — Tenotomy — Squint — Wry-neck
  __Club Foot — Talipes Equineus, Varus, Valgus, Calcaneus, and other Varieties
  —Weak Ankles — Knock-Knee — Contraction of the Knee — Deformities of the
  Arm and Hand............665-678
                           CHAPTER  XLIX.

Diseases of the Head and Neck—Fungus of Dura Mater — Fistula Lachryma-
  ls—Extirpation of Eyeball — Otitis — Ear-ache — Otorrhea — Epistaxis — Plug-
  ging the Nostrils — Ozena, Nasal Tumors, and Polypi — Mode of Removal—Dis-
  eases of Frontal Sinuses and Cheeks — Salivary Fistula—Hare Lip — Operations
  for — Cancer  of  the  Lips — Operation  for — Plastic Surgery  of  the Face —
  Rhino-Plastic Operations — Cheilo-Plastic Operations — Blepharo-Plastic Opera-
  tions— Diseases of the Tongue — Tongue-tied — Prolapsus, Fissures and Cancer
  of the Tongue — Operations for Cancer of the Tongue — Ranula .     .    .  679-708
                              CHAPTER  L.

Diseases of the Jaws — Epulis — Dropsy,  Suppuration, and Tumors of the Antrum
  __Operations on the Antrum — Removal of the Upper Jaw — Diseases, Tumors,
  and Removal of the Lower Jaw.........708-715 
xvi
CONTENTS.
                              CHAPTER  LI.

Diseases of the Throat —Cleft Palate—Staphyloraphy —Diseases and Excision of
  the Uvula  and Tonsils —Diseases of the Pharynx —Diseases of the Oesophagus
  — Spasmodic and Organic Stricture of—Diseases of the Larynx —Acute and
  Edematous Laryngitis — Aphonia — Chronic Laryngitis — Cauterizing the La-
  rynx— Necrosis of the  Laryngeal Cartilages—Polypi  in  the Larynx — Opera-
  tions on the Windpipe — Laryngotomy — Tracheotomy — Difficulties in and Com-
  parisons between—Trachea Tubes —Diseases of the Parotid — Parotitis or
  Mumps — Tumors of the Parotid — their  Extirpation — Hydrocele of the Neck
  — Bronchocele — Treatment of.........715-743
                             CHAPTER  LII.

Diseases  of the  Breast — Supernumerary Breasts — Neuralgia — Hypertrophy—
  Abnormal Secretion of Milk — Inflammation  and Abscess of the Breast — En-
  cysted Abscess — Tumors of the Breast — Non-Malignant — Chronic, Mammary,
  Adenoid,  Cystic — Sero-Cystic, Cystic  Sarcoma, Scrofulous and Hydatid — Ma-
  lignant Tumors — Scirrhus — Encephaloid  and Colloid — their Diagnosis  and
  Treatment — by Compression and Amputation — Question of Operation in Dis-
  eased Breast considered — Amputation of the Breast — Tapping the Chest and
  Pericardium.............743-766
                            CHAPTER  LIII.

Hernia—Structure of a Hernial Sac — Contents of Sac — Symptoms of Hernia—
  Nature and Treatment  of Reducible Hernia — Radical cure of Hernia — Irre-
  ducible Hernia — Inflamed,  Incarcerated  and Strangulated Hernia—Seat of
  Stricture in  Strangulated Hernia — Symptoms,  Diagnosis, and Treatment of
  Strangulated   Hernia—The Taxis  and  Operation—State of Intestine and
  Omentum — Wounds  of Intestine—Wounds  of Arteries — Accidents of Ope-
  ration— Artificial Anus —Faecal  Fistula — Operation  without  opening  Sac__
  Reduction in  Mass — Hydrocele  of  Hernial Sac—Inguinal Hernia — Oblique
  and Direct —Diagnosis of—Operation  for —Caecal Hernia—Congenital and
  Infantile Hernia — Femoral  Hernia — Diagnosis and Treatment of—Operation
  for —Umbilical, Ventral,  Obturator, Perineal, Vaginal,  Pudendal,  Sciatic and
  Diaphragmatic Hernia........                 766-813
                            CHAPTER  LIV.

Intestinal  Obstructions,  Acute  and Chronic —Symptoms —Diagnosis—Causes
  and  Treatment—Gastrotomy —Formation  of  Artificial  Anus  in  Lumbar
  ReSion..............813-822
                             CHAPTER  LV.

Diseases  of  the Large Intestine  and Anus — Congenital Malformation of Anus
  and Rectum —Stricture and Cancer of Rectum — Cancer of Anus — Spasmodic
  Contraction of Sphincter — Ischio-Rectal Abscess — Fistula in Ano—Varieties 
CONTENTS.
xvii
of,  and Operations  for — Piles—Varieties — Causes — Diagnosis  and  Treat-
ment  of—Operation for, by Ligature, Excision,  and by Caustics—Prolapsus
Ani — Operation for Recto-Vesical  and Recto-Vaginal Fistula—Tapping  the
Abdomen.............823-850
                             CHAPTER  LVI.

Diseases of Bladder and Prostate — Cystitis — Vesical Catarrh — Cysts  in Bladder
  — Irritability of Bladder — Tumors and Paralysis of Bladder—Retention and
  Incontinence of Urine — Extroversion of Bladder — Prostatitis — Enlarged Pros-
  tate— Retention of Urine from — Tapping of the Bladder  ....  850-865
                            CHAPTER  LVII.

Diseases  of  the  Urethra — Urethritis — Urethral and Perineal Abscess — Gonor-
  rhea— Nature, Symptoms, and Treatment of—Complications of Gonorrhea —
  Chordee — Dysuria — Hemorrhage — Sequences  of Gonorrhea — Impotence —
  Inflammation  of  the  Testes and Eyes — Gonorrheal Rheumatism and  Erup-
  tions— Gonorrhea  in the Female — Stricture of the  Urethra — Spasmodic,
  Congested,  and  Organic — Treatment   by  Dilatation — Catheterism — False
  Passages — Division  of Stricture — Perineal  Section—Operation  for  Imper-
  meable Stricture—Complications of Stricture — Retention and Extravasation
  of Urine — Urinary Abscess and Urinary Fistulas — Vaginal Fistulae — Urethro-
  vaginal  and  Vesico-Vaginal  Fistulae — Tumors  of the  Urethra — Urethro-
  plasty ..............   865-899
                           CHAPTER  LVIII.

Stone in the Bladder — Diseased Conditions of the Urine — the Lithic, Oxalic, and
  Phosphatic  Diatheses — Cystine — Xanthine — Structure  of  Calculi — Renal
  Calculi—Vesical Calculi — Encysted Calculi—Symptoms of Stone — Sounding,
  difficulties in — Operation for Stone — Lateral Operation of Lithotomy — Instru-
  ments  required  for — Mode of Performing—After-treatment — Lithotomy in
  Children — Difficulties and  Dangers during and after Lithotomy — Causes of
  Death  after Lithotomy— High or Supra-Pubic Operation — Median and Bilate-
  ral Operations—Urethral and  Prostatic Calculi — Lithotrity — Mode of Per-
  forming and Instruments required for — Accidents and  Dangers of Lithotrity —
  Comparison  between Lithotrity and Lithotomy — Recurrence  after Operation —
  Stone in Women.............899-
                             CHAPTER  LIX.

Diseases  of  the  Penis  and Scrotum — Hypospadias — Epispadias — Phymosis—.
  Circumcision — Paraphymosis, operation for — Balanitis—Warts and Cancer of
  Penis — Amputation  of  Penis — Hypertrophy of  Scrotum — Chimney Sweep's
  Cancer..............948-954
       2 
xviii
CONTENTS.
                             CHAPTER  LX.

Diseases of the Testis and Cord — Malposition of the Testis —Neuralgia of the
  Testis — Orchitis and Epididymitis — Hydrocele — Spermatozoa in Hydrocele of
  the Cord — Hematocele — Varicocele, operations for — Tumors of the Testis —
  Simple,  Strumous, Syphilitic, and Cystic Sarcocele — Cancer of the Testis—^
  Operation of Castration — Diagnosis of Scrotal Tumors   .     .    .    •   954-974
                            CHAPTER  LXI.

Diseases of the Female Genital Organs — Introduction of the Speculum and of the
  Female Catheter — Hypertrophy of the Labia—Condylomata — Cystic Tumors
  — Imperforate Vagina, and  Hymen — Enlarged Clitoris — Prolapsus Vaginae —
  Cystocele —Vaginal and Uterine Discharges — Displacements — Tumors —Polypi
  and  Cancer of the Uterus — Ovariotomy — Mode  of  Performing the  Ope-
  ration ..............  974-984 
LIST   OF  ILLUSTRATIONS.
  All  the Illustrations in this Volume have been drawn from nature, with the exception
of those against which a name is placed in the following List, and some of the diagrams.
In this List mention is also made whenever the subject has been taken from the Museum
of University College (U. C. M.)
Fig.                               page
 1. Position of saw in amputations   .  39
 2. Artery in stump (U. C. M.)   .   .  40
 3. Nerve in stump (U. C. M.)  ...  40
 4. Sequestrum from stump (U. C. M)  41
 5. Aneurismal varix in stump   .   .  42
 6. Amputation of phalanx    ...  47
 7. Amputation of middle finger  .   .  48
 8. Amputation of index finger   .   .  48
 9. Result of  amputation  of index
      finger........49
10. Result of  amputation  of  middle
      finger   ...*....  49
11. Result  of  amputation  of little
      finger........49
12. Amputation of left thumb  ...  50
] 3. Amputation of right thumb  .   .  50
14. Result of amputation of thumb   .  50
15. Result of amputation of two fingers  50
16. Result of  amputation  of three
      fingers........50
17. Amputation at wrist.....51
18. Amputation of forearm    ...  51
19. Amputation of upper arm  ...  52
20. Amputation at shoulder, 1 st stage  52
21. Amputation at shoulder, 2d stage  53
22. Result of amputation at shoulder  53
23. Amputation of toe.....54
24. Amputation of great toe   ...  54
25. Amputation  of  fifth metatarsal
      bone.........55
26. Line of Hey's amputation  .  .   .  55
27. Line of Chopart's amputation    .  56
28. Sole flap in Chopart's amputation  56
FIG.                               PAGE
29.  Chophart's amputation from dor-
      sum  .........56
30.  Lines of incisions on foot ...  56
31.  Line  of disarticulation at ankle-
      joint .........57
32.  Disarticulation at ankle-joint, 1st
      stage.........57
33.  Disarticulation at ankle-joint, 2d
      stage.........57
34.  Stump of ditto......57
35.  Pirogoff's amputation   ....  58
36.  Amputation through upper third
      of leg, 1st stage.....59
37.  Amputation through upper third
      of leg, 2d stage.....60
38.  Amputation through knee-joint  .  61
39.  Amputation  of  thigh in  lower
      third.........62
40.  Amputation  of  thigh  in middle
      third.........62
41.  Amputation of thigh  by making
      posterior flap first   ....  63
42.  Amputation at hip-joint, left side  G3
43.  Amputation at hip joint, right side  64
44.  Amputation at hip-joint, 2d stage  65
45.  Irrigation in inflammation ...  79
46.  Mode of passing a seton  ...  86
47.  Healthy pus-cell......93
48.  Pus-cell from pyemia   ....  93
49.  Pus-cell in phlebitis.....93
50.    Ditto    ditto......93
51.  Pus from scrofulous abscess  .  .  93
52.  Serre-fine........114
(xix) 
XX
LIST  OF  ILLUSTRATIONS.
FIG.                                  PAOE
53.  Bullet-wound,  aperture of entry
      (U. C. M.).......123
54.  Bullet-wound,  aperture  of  exit
      (U. C. M.).......123
55.  Temporary tourniquet  .   .   .  .126
56.  Bullet-screw.......127
57.  Bullet forceps.......127
58.  Bullet extractor......127
59.  Bullet   in   head   of  humerus
      (U.C.M.).......129
60.  Fine forceps.......131
61.  Mode of tying an artery in stump 157
62.  Artery forceps......158
63.  Reef-knot........158
64.  Ligature of artery  in continuity,
      1st stage........159
65.  Ligature of artery  in continuity,
      2d stage........159
66.  Ligature of artery  in continuity,
      3d stage........159
67.  Femoral artery 56 hours after am-
      putation ........160
68.  Brachial artery 10 days after am-
      putation .......161
69.  Femoral artery  six weeks  after
      amputation.......161
70.  Partial absorption of coagulum  . 161
71.  Defective coagulum after  pyemia 161
72.  Collateral circulation   .... 163
73.  Traumatic aneurism of palm  .  . 167
74.  Varicose aneurism at bend of arm 169
75.  Varicose aneurism dissected out . 169
76.  Varicose   aneurism  laid   open
      (U. CM.).......170
77.  Structure of varicose aneurism  . 170
78.  Longitudinal fracture   .... 188
79.  Application of starch bandage  . 195
80.  Clippers for starcfc bandage   .  .196
81.  Cutting up  starch bandage    .  .196
82.  Starch  bandage  for  compound
      fracture........196
83.  Gangrene of arm from tight band-
      aging (U. C. M.).....198
84.  Screw probe for ununited fracture 207
85.  Clavicle fractured at acromial end
      (U. CM.).......210
86.  Healthy clavicle......210
87.  Fox's apparatus for fracture of the
      clavicle........212
88.  Fracture of lower end of humerus
      (U. C M.).......216
89.  Fracture of lower end of radius  . 218
90.  Impacted   fracture   of   radius
      (U. C M.).......218
91.  Impacted   fracture   of   radius
      (U. C M.).......219
92.  Pistol-splint.......220
FIG.
 93.

 94.
 95.

 96.
 97.

 98.
 99.

100.
101.
102.

103.
104.

105.

106.
107.

108.

109.

110.

111.


112.


113.

114.
115.

116.
117.
118.

119.
120.
121.
122.

123.
124.
125.

126.
Bond's splint for fracture of the
  radius........220
Fracture of neck of femur  .  . 223
Extracapsular fracture of neck of
  femur (U.  CM.).....226
Section of impacted extracapsular
  fracture  of  neck   of femur
  (U. C M.).......227
United extracapsular fracture of
  neck of femur (U. C M.)  .  . 227
Long splint, bracketted  .  .  . 229
Fracture  through  condyles  of
  femur (U. CM.).....230
Fracture of patella.....231
Pott's fracture, (U.  CM.)   .  . 234
Treatment  of fracture of the os
  calcis.........234
Clove-hitch knot.....242
Dislocation  of humerus down-
  wards   ........249
Dislocation of humerus, forwards
  and and inwards.....249
Dislocatien of humerus, inwards 249
Dislocation  of humerus, back-
  wards and downwards  .  .  .  249
Dislocation  of humerus under
  clavicle........250
Reduction of dislocation of  hu-
  merus into axilla.....252
Dislocation of both bones of fore-
  arm,  backwards.....254
Position  of  arm flexed in dislo-
  cation  of  radius   forwards
  (U. C M.).......255
Position  of  arm  extended  in
  dislocation  of radius forwards
  (U. CM.).......255
Dislocation  of  radius forwards,
  position of bones.....255
Reduction of dislocated elbow  .  256
Dislocation  of  wrist  upwards
  (U. C M.).......257
Dislocation of wrist  downwards  257
Dislocation of thumb  (U. C M.)  258
Dislocation  backwards  of  first
  phalanx of thumb  .   .  .      .259
Mode of  reduction of same  .   .  259
Dislocation of finger  (U. C. M.)  260
Dislocation of hip, backwards   .  261
Dislocation of hip, backwards and
  downwards.....        £61
Dislocation of hip, downwards  .  261
Dislocation of hip, upwards  .   .  261
Reduction of dislocation of hip  ~
  backwards......     Qfia
Reduction of dislocation of hip
  downwards......     9(54 
LIST  OF  ILLUSTRATIONS.
xxi
 no.                                  PAGE
 127.  Reduction of dislocation of hip
        upwards.......265
 128.  Dislocation of foot outwards .  . 268
 129.  Dislocation of astragalus(U.CM.) 271
 130.  Fracturing of skull, showing splin-
        tering of outer table (U. C. M.) 286
 131.  Improved ear-scoop   .... 302
 132.  Split sheet for artificial respira-
        tion  .........310
 133.  Suture for wounded intestine  . 332
 134.  Quilled suture for lacerated peri-
        neum.........335
 135.  Multiple psoas abscess (U. C. M.) 343
 136.  Suction-trochar......344
 137.  Abscess-knife.......346
 138.  Seton passed through abscess  . 347
 139.  Arteries  plugged  in senile gan-
        grene (U.  C. M.).....355
 140.  Foot in gangrena  senilis  .   .  . 355
 141.  Microscopical characters of con-
        tents of encysted tumor.   .  . 390
 142.  Horn on nose.......390
 143.  Ulcerated encysted tumor of scalp 391
 144.  Microscopical  characters of fi-
        brous tumor......396
 145.  Microscopical  characters of en-
        chondroma.......398
 146.  Enchondroma of index finger  . 399
 147.  Enchondroma of fingers   .   .  . 399
 148.  Microscopical characters of scir-
        rhus  .........401
 149.  Microscopical characters of ence-
        phaloid ........401
 150.  Microscopical ditto of epithelioma 414
 151.  Microscopical ditto  of chimney-
        sweeper's cancer.....414
 152.  Concentric globes of epithelicoma 415
 153.  The ecraseur.......415
 154.  The  ecraseur applied (Chassai-
        gnac)........416
 155.  Scrofulous ulcer of leg    .  .  .  420
 156.  Scrofulous disease of finger .  .  420
 157.  Microscopical characters of tu-
        bercle   ........421
 158.  Microscopical ditto of pus  .  .  421
 159.  Syphilitic onychia.....458
 160.  Microscopical characters of lupus  460
 161.  Cancer of leg.......463
 162.  Ligature of varicose  veins   .   .  472
 163.  Plastic  deposits in arteries  (U.
       C M.)........473
 164.  Adhesive arteritis  (U. CM.)   .  474
165. Microscopical characters  of athe-
       roma .........476
166.  Microscopical ditto ditto  .  .   .  476
167. Microscopical ditto ditto  .  .   .  477
168. Annular calcification of arteries   478
 FIG.                                 PAG 3
 169. Laminar calcification of arteries  478
 170. Aneurism of leg  expanding pos-
        terior tibial nerve   .... 487
 171. Aneurism of  aorta eroding spine
        (U. CM.).......489
 172. Aneurism of aorta bursting into
        oesophagus.......493
 173. Aneurism of aorta bursting into
        pericardium......493
 174. Diagram of Anel's operation .  . 497
 175. Diagram of Hunter's ditto   .  . 497
 176. Diagram of distal ditto   .  .  .497
 177. State  of  femoral  artery after
        ligature  for popliteal  aneu-
        rism .........499
 178. Obliteration of popliteal vein by
        pressure of an  aneurism (U.
        CM.)........506
 179. Sac  of aneurism  cured by com-
        pression (U. C.  M.) .  .  .  . 508
 180. Sac of aneurism  cured by com-
        pression (U. C. M.)  .... 509
 181. Compressor for groin  .   .  .  .510
 182. Compressor for thigh  .... 510
 183. Obliteration of femoral vein by
        inguinal aneurism   .   .   .  .516
 184. Aneurism  of profunda ....  521
 185. Aneurism  of  innominata  (U.
        CM.)........531
 186. Diagram of aneurism of innomi-
        nata treated by ligature of sub-
        clavian only......532
 187. Diagram of aneurism of innomi-
        nata treated by ligature  of
        carotid only......532
 188. Diagram of aneurism of innomi-
        nata treated by ligature of sub-
        clavian and carotid  ....  532
 189. Aneurism  of  aorta  simulating
        carotid aneurism .   .  . . .  .  538
 190. Ligature of subclavian, 1st part of
        course (U. CM.).....550
 191.  Ligature of subclavian and caro-
        tid  for  subclavian  aneurism
        (U. CM.).......550
 192.  Syringe for perchloride of iron
       injection.......560
 193.  Ligature of nevus,  1st stage .  .  567
 194.  Ligature of nevus,  2d stage  .   . 568
 195.  Ligature of narrow nevi, 1st stage 568
 196.  Ligature of narrow nevi, 2d stage 568
 197. Elastic ligature of nevi   .   .   . 569
 198. Neuroma of posterior tibial nerve
       (U. CM.).......574
 199. Diffuse suppuration of humerus  580
200. Circumscribed abscess in head of
       tibia bursting into joint    .   . 581 
xxii
LIST  OF ILL
USTRATIONS.
FIG.                                 PA<lli
201. Trephine for circumscribed ab-
       scess of bone......581
202. Mr. Marshall's osteotrite .   .  . 584
203. Necrosis of tibia, showing internal
       sequestrum (U. C M.)  .   .  .588
204. Necrosis  of  tibia, imperfect for-
       mation of new bone (U. C. M.)  589
205. Bone forceps, oblique cutting  . 590
206. Bone forceps.......590
207. Gouge forceps......590
208. Bone forceps, straight cutting  . 590
209. Saw for necrosis.....591
210. Necrosis forceps......591
211. Sequestrum forceps   .... 591
212. Tubercle in head of tibia .   .  .597
213. Tubercle in bone magnified 250
       diameters.......697
214. Tubercle in bone.....698
215. Spina ventosa (cystic tumor)  of
       bones of knee-joint (U. C. M.)  600
216. Encephaloid of head of humerus  602
217. Encephaloid of head  of humerus
       laid open,  showing cartilages
       unaffected.......602
218. Aneurism by anastomosis of pari-
       etal bone.......604
219. Interior of  knee disorganized by ,
       inflammation......611
220. Perforation  of cartilage incrust-
       ing head of tibia consequent on
       caries of subjacent  bone   .  . 612
221. Anchylosis, complete, of hip (U.
       CM.)........619
222. Butcher's saw......623
223. Excision of head of humerus   .  624
224. Result of excision of head of hu-
       merus, five years after operation 624
225. Excision  of  elbow, lines of inci-
       sion .........625
226. Excision of elbow by longitudinal
       incision........626
227. Result of excision of elbow,  three
       years after operation   .   .  .  627
228. Excision  of radius,  six months
       after operation.....628
229. Excision of os calcis   ....  633
230. Excision of astragalus ....  634
231. Excision of knee.....635
232. Articular end of femur, excised . 636
233. Articular end of tibia, excised  .  636
234. Angular curvature of spine from
       caries (U. CM.).....640
235. Lateral curvature of spine (U. C
       M.).........645
236. Lateral curvature of spine'Shaw) 647
237. Tavernier's belt......649
238. Chronic disease of hip-joint  .  .  654
FIG.                                  VAdt
239. Head of femur after excision    . 656
240. Chronic disease of hip, position of
       limb.........656
241. Excision of hip-joint  .... 658
242. Position of limb after excision of
       hip.........658
243. Chronic rheumatic arthritis of hip
       (U.C.M.).......659
244. Bunion.........663
245. Tenotome........666
246. Talipes equineus (U. C M.)  .   . 670
247. Talipes equineus, bones of (U. C.
       M.).........670
248. Talipes calcaneus (U. C. M.)  .   . 670
249. Talipes varus......671
250. Talipes varus, bones of (U. C M.) 671
251. Talipes valgus......671
252. Contracted knee, tibia  displaced
       backwards.......674
253. Contracted knee straightened   . 675
254. Apparatus for straightening con-
       tracted knee......676
255. Operation for fistula lachrymalis 680
256. Melanosis of eyeball   .... 681
257. Plugging nares......683
258. Malignant tumor of cheek    .   . 687
259. Harelip operation.....689
260. Cheek-compressor for hare-lip   . 690
261. Hare-lip, projecting  intermaxil-
       lary portion......690
262. Hare-lip,  projecting  intermaxil-
       lary, side view.....690
263. Diagram of  rhinoplasty  opera-
       tion  .........696
264. Depressed nose......697
265. New nose, 2d day.....697
266. Patient before  rhinoplasty ope-
       ration   ........698
267. Patient after rhinoplastic  opera-
       tion, some months  .... 698
268. Cheiloplastic operation   .   .  . 699
269. Lines  of  incision  for cheilo-
       P\asty........700
270. Cheiloplastic  operation   .  .  . 700
271(a). Operation for repair of lower
       eyelid........70o
271(6). Operation for repair of upper
       eyelid........70o
272. Lower  eyelid deformed by cica-
       trix  .........701
273. Lower eyelid after operation .  . 701
274(a). Operation for symblepharon . 701
274(6). Operation for ptosis   .  .  .701
275(a). Operation for entropium  .  . 701
275(6). Operation for ectropium  .  . 701
276. Patient with opening into ante-
       rior nares.......ygj 
LIST  OF  ILLUSTRATIONS.
xxiii
FIG.                                  PAGE
277. The same case closed by ope-
       ration   ........701
278. Cork-screw needle.....705
279. Operation for cancer of tongue . 705
280. Operation for cancer of tongue in
       mylohyoid space.....706
281. Removal of  tongue by ecraseur
       (Chassaignac)......706
282. Ranula (Guerin)......707
283. Epulis.........708
 284. Antrum perforator.....709
 285.  Cleft palate.......718
 286.  Cleft  palate  with edges  pared,
        palatal arch snipped across and
        muscles divided (Sedillot) .   .718
 287. Sutures  applied   to  preceding
        figure (Sedillot).....718
 288. Appearance after  union has taken
        place (Sedillot).....718
 289. Uvula scissors......718
 290. Tonsil guillotine......719
 291. OLdema glottidis......723
 292. Throat probang......725
 293. Laryngeal syringe.....730
 294. Polypus of larynx (U. C M.)   . 731
 295. Operation of tracheotomy   .   . 735
 296. Trachea-hook......735
 297. Trachea-forceps......736
 298. Mr. Thompson's tracheotome   . 736
 299. Trachea-tube, side view   .  .   . 739
 300. Trachea-tube, front view  .  .   .739
 301. Laryngeal tube......739
 302. Parotidean  tumor.....740
 303. Hypertrophy of breast in girl of
        fifteen........745
 304. Trochar for paracentesis thoracis 765
 305. Operation of tapping the chest  . 766
 306. Hydrocele of hernial sac  .  .   . 768
 307. Instrument for Wutzer's opera-
        tion  for  the radical  cure  of
        hernia.......772
 308. Femoral hernia strangulated  by
        neck of sac.......775
 309. Operation for hernia, 1st stage . 781
 310. Operation for hernia, 2d stage  . 781
 311. Hernia director......782
 312. Hernia knife.......783
 313. Position of hands and knife in di-
        vision of the stricture   .  .   . 783
 314. Gangrene  of intestine  strangu-
        lated eight hours.....786
 315. Dupuytren's enterotome  .  .   . 791
 316. Application of the enterotome  . 791
 317. Double inguinal  hernia on same
        side (U. C. M.).....798
 318. Double  direct inguinal  hernia
        (U. C M.).......798
no.                                 PAGE
319. Congenital hernia.....802
320. Infantile hernia......802
321. Femoral hernia (U. C M.)   .   . 804
322. Femoral hernia, anatomy of (U.
       C M.)........805
323. Femoral hernia, turning upwards
       (U. C. M.).......806
324. Diaphragmatic hernia .... 812
325. Intestine  strangulated  by  aper-
       ture in  omentum (U. C M.)  . 814
326. Operation for  artificial anus  in
       left  lumbar region,  diagram
       showing the line of operation . 820
327. Colon  drawn forwards, fixed  to
       wound and opened   .... 821
328. Two-bladed speculum ani .   .   . 829
329. Speculum for fissure of anus .   . 829
330. Knife  for fistula in ano   ... 833
331. Diagram  of operation for fistula
       in ano........834
332.  Open-bladed forceps for piles   . 844
333. Bushe's needle for piles .   .   . 844
334. Speculum ani for  caustics   .   . 845
335. Prolapsus ani......846
336. Organic deposits in urine .   .   .851
337. Cyst in bladder......852
338. Pathological  sequences of  en-
       larged prostate (U. C M.) .   . 860
339. Enlarged middle lobe of prostate
       (U.  CM.).......862
340.  (a). Puncture of  bladder  above
       pubes........864
340. (6). Puncture of bladder through
       rectum........864
341. Caustic catheter......873
342. Bridle stricture (U. C. M.)  .   . 880
343.  Stricture from effusion into cor-
       pora cavernosa (U. C M.)    . 880
 344.  Stricture in anterior part of ure-
       thra (U. C. M.).....880
 345.  Lancetted stylet for  division  of
       strictures.......886
 346.  Shouldered  staff for perineal sec-
       tion .........887
 347. Urethroplasty, Nelaton's opera-
       tion .........896
348. Urethroplasty......896
349. S-shaped female catheter .  .  .898
350. Bozeman's  operation for vesico-
       vaginal fistula, 1st  stage  .  . 898
351. Bozeman's  operation for vesico-
       vaginal fistula, 2d stage   .   . 898
352. Lithic acid  deposit.....900
353. Lithate of ammonia deposit .  .  900
354. Oxalate of lime deposit  .  .  .  901
355. Ammoniaco-magnesian phosphate
       deposit........902 
XXIV                 LIST  OF  ILLUSTRATIONS.
FIG.                                  PAGE
356. Cystine.........902
857. Vesical calculus composed  of
       several renal ones agglomerated
       together........904
358. Encysted vesical calculus, seen
       from the outside.....905
359. Encysted vesical calculus, seen
       from within......905
360. Sounding for stone behind pros-
       tate  .........907
361. Sounding  for stone  above the
       pubes........908
362. Hollow sound.......908
363. Sounding for encysted calculus  . 909
364. Lithotomy knife......911
365. Lithotomy probe-pointed knife  . 911
366. Lithotomy forceps.....912
367. Lithotomy forceps curved .  .   . 912
368. Lithotomy scoop in handle   .   .912
369. Lithotomy scoop......912
370. Lithotomy staff......912
371. Searcher........912
372. Hollow-bladed lithotomy forceps 912
373. Position of  patient,  line of in-
       cision in lateral lithotomy .   .913
374. Finger in groove of staff .  .   . 914
375. Knife in groove of staff   .   .   . 914
376. Position of  hands and  knife in
       second stage of lithotomy  .   . 915
377. Arteries of  perineum and deep
       fascia (U.  C M.).....915
378. Incision in  prostate  in lateral
       lithotomy  (U. C M.)   .   .   .915
379. Position of  knife in  lithotomy,
       Fergusson.......916
380. Position of  knife in  lithotomy,
       Liston........916
381. Position of  knife in  lithotomy,
       Author........916
382. Diagram of  direction  of forceps
       in extraction of stone   .   .   .918
383. Position of  finger and scoop in
       extraction of stone  .... 919
384. Lithotomy-crushers for breaking
       up large stone in bladder  .   . 923
FIO.
385.

386.
387.
388.
389.
390.
391.

392.

393.

394.

395.
396.
397.
398.
399.

400.
401.
402.
403.
404.
405.
406.

407.

408.
409.

410.
411.

412.
413.
414.
415.
416.
417.
                                PAGE
 Line of  incision  in  bi-lateral
  lithotomy (Dupuytren) .   .   .931
 Lithotome cache"......931
 Urethral calculus (U. C M.)    . 932
 Prostatic  calculus.....933
 Lithotrite........936
 Civiale's scoop......936
 Position of hands in using litho-
  trite for crushing.....936
 Position of hand in using scoop
  for crushing......936
 Position of lithotrite  in seizing
  stone.........937
 Position of lithotrite in crushing
  stone........938
 Urethral lithotrite.....939
 Urethral forceps......940
 Phymosis........948
 Circumcision.......949
 Phymosis  with  sloughing  of
  prepuce........949
 Paraphymosis......950
 Reduction of paraphymosis   .   . 950
 Warts on penis......951
 Hydrocele (U. CM.).   .   .   . 959
 Dissection of hydrocele   .   .   . 959
 Tapping in hydrocele  .... 960
 Spermatozoa from  encysted hy-
  drocele  ........962
 Spontaneous  hematocele  with
  fibrine in interior.....964
 Vidal's needles for varicocele   . 967
 Varicocele   included    between
  needle and silver wire (Vidal)  967
Varicocele twisted up (Vidal)   . 967
Scrofulous  testis  with   fungus
  protruding (U.  C M.)  .   .  .969
Cystic disease of testis (U. C M.) 970
Operation of castration    .   .  . 972
 Malignant sarcocele,  hydrocele
  of tunica vaginalis and of cord
  (U. C M.).......973
Reflecting speculum vaginae   .  . 975
Bivalve  speculum vaginae  .   .  . 975
Caustic-holder for uterine disease 978 
DIVISION    FIRST.

     FIRST  PRINCIPLES.
                            CHAPTER I.

         GENERAL CONSIDERATIONS  ON OPERATIONS.

  Manual dexterity is necessarily of the first  advantage to a surgeon, and he
should diligently endeavor to acquire the  art of using his instruments  with
neatness, with rapidity, and with certainty;  but manual dexterity must not be
mistaken for professional skill, and desirable as it doubtless may be to be able
to remove a limb, or to cut out a stone, in so many seconds; important, in a
word, as it is to become a dexterous operator, it is still of far greater importance
to become a successful one.  The object of every operation is the removal of
disease that either threatens  the  life, or that interferes with the comfort  and
utility of existence;  and the more certainly a surgeon can accomplish this, the
better will he  do his duty to his patients, and the  more successful will he be in
his practice.   Success then,  in the result of an operation, whether that result
be the preservation of life, or the removal of a source of discomfort, is the thing
to aim at.   To  this, dexterity and rapidity in operating are in  a high degree
conducive; but there are various other considerations equally or still more neces-
sary, the solution of which can only be afforded by an intimate general acquaint-
ance with the  science of surgery and of medicine.   The diagnosis of the nature
and extent of the connections of the local disease has- to be made;  lurking vis-
ceral  affections  must be detected,  and, if possible, removed.  The constitution
of the patient must be prepared for the operation; the best time for its perform-
ance  seized; and, after its completion, the general  health must be attended to
in such a way as shall best carry the patient through the difficulties he has to
encounter,  and  any sequelae  or complications that arise must be met  by, and
must be subjected to, appropriate treatment.  These, as well as the simple per-
formance of the operation, are the duties of the operator; and on the manner in
which these are performed, as much, or even perhaps  more, than on the mere
manual dexterity displayed in the  operation itself,  will the fate  of  the patient
depend.  It is well known that the result of operations  differs much in the prac-
tice of different surgeons of  acknowledged dexterity, and this variation in the
proportionate  number of recoveries cannot be accounted for by any difference in
the degree of manual skill displayed in the  operation itself; but must rather be
sought in  the greater attention  that is  paid by some surgeons to the constitu-
tional treatment of their patients  before and  after  the operation, and to  their
more perfect  acquaintance with  the  general science and  practice of surgery.
Indeed, success in operative surgery depends  greatly upon the selection of
proper cases.   The practice of operating in notoriously hopeless  cases with the
                                                              (25) 
26                      OPERATIVE SURGERY.
view of giving the patient what is called a last chance, is much to be deprecated,
and should never be done.   It is by operating under such circumstances, espe-
cially in  cancerous diseases, that much discredit has  resulted to surgery, for in
a great number of instances the patient's death is hastened  by the procedure;
which, instead of giving him a last chance, only causes  him to be dispatched
sooner than would otherwise have happened.
  The condition of a patient that principally determines the result of an opera-
tion is the state of his general health.  Indeed, the state of the patient's consti-
tution  influences the success of an operation far more than the mechanical dex-
terity with which the surgeon performs it.  It is no uncommon circumstance to
see patients sink  after  the most dexterously performed  operations for hernia,
stone, the ligature of arteries, &c, owing to some morbid condition of the blood
or the  system that disposes to diffuse inflammation; whilst, on the other hand,
some  patients will make the most  remarkable  and rapid recoveries  after they
have been mutilated with but little  skill.  Persons of an  irritable  and  anxious
mind do  not bear operations as well as those of a more tranquil  mental consti-
tution.   Those also  of a feeble and irritable  habit of body, especially nervous
and hysterical women, with little power of circulation, cannot  bear up against
6evere  surgical procedures, being apt to  become depressed, exhausted, and to
sink without rallying.  That combination of  debility and of  irritability,  the
consequence of want, of dissipation, and especially of the habitual  excess of
alcoholic stimulants, which is so commonly met with in the inhabitants of large
towns, renders them peculiarly unfavorable subjects  for operations, which are
consequently less  successful amongst them  than in the more healthy  and
temperate  inhabitants of country  districts.   The condition of the  patient's
heart should also  be carefully looked to before an  operation  is  undertaken.
Fatty degeneration of this  organ, as indicated  by its feeble action, by irregu-
larity and want of power  in  the circulation, by breathlessness, and by a  dis-
tinctly-marked  arcus senilis, should make the surgeon careful  in  undertaking
any operation attended with much loss of blood, or shock to the nervous system;
though it need not be a bar to its performance, if the disease for which it is to
be practised  would  otherwise be fatal.   Disease of the lungs, of a  phthisical
character,  when active or  advanced, is  incompatible with  the success of an
operation, but under certain circumstances, as will be explained when speakin°-
of diseases of the joints,  and fistula  in ano, an operation is justifiable  and
proper, even  though  the patient be consumptive.   Perhaps the most serious
constitutional  affection, and the one that more than any  other militates  against
the success of an operation, is a diseased  state of the kidneys, with albummuria
or diabetes, the inflammatory action  that is set up is apt to run into a low diffuse
and  sloughing form, and this is  especially the case in all operations about the
genito-unnary organs.   The contamination of the patient's system by malignant
disease must always  prevent our operating, as a return of the affection  will
most certainly speedily take place.  And, lastly, no operation, save of the most
urgent necessity, and to rescue the patient from immediate death  as for the
suppression of arterial hemorrhage,  should  ever be performed whilst he  is
laboring  under  erysipelas, phlebitis, or any  diffuse  inflammation;  and  even
during the epidemic prevalence of  these affections, operations that are not of
immediate necessity, as for the removal of  simple tumors,  especially about
the head, should  be postponed until a more  favorable season.   Operations in
very old people, if of a severe  character, and attended by much shock to the
system, are commonly fatal;  thus, amputations in individuals above the ase of
seventy,  are very rarely successful.                                      5
   The causes of death after operation are partly dependent  upon the operation
itself,  but in  the  great  majority of cases, they are  more connected with th*
hygienic influences  by which  he is surrounded, than with  the local iniurv in
footed during the operation.  How often do we not see patients carried off by 
CAUSE OF  DEATH AFTER  OPERATIONS.          27
fatal diseases supervening on the most trifling operations, as the removal of a
finger  or  toe, or of small encysted  tumors of the scalp, from  some condition
of the system  that is unconnected with the injury that has been inflicted; a
condition  that only required the local  disturbance of the operation to call it
into activity.
   The conditions that are most to be dreaded by the surgeon, and  that  most
commonly tend to a fatal result after operation are, shock, hemorrhage, and sur-
gical fever,  with its local complications.
   The shock of an operation may prove fatal in various ways; from the  severity
of the mutilation, as in a case of double amputation;  from the nervous centres
being implicated, as in the  removal of large  tumors from the face, that  have
connections with the base of the skull; from fear, or from the state of nervous
depression in which the patient has previously fallen,  causing him to feel the
influence of an  operation disproportionately to its severity; these various effects
of shock  have,  however,  been  much lessened since chloroform has been gene-
rally administered in operative surgery.   Chloroform, however, does not remove
the  physical impression produced on the  system  by a severe mutilation, hence
the  influence of a serious and  prolonged operation is still manifested in the pro-
duction of shock, although the patient may have experienced no suffering.
   Hemorrhage, if very copious, may destroy the patient by inducing  syncope
that may be immediately fatal; or, by increasing the influence of the shock,
so that he cannot rally;  or it may be attended by serious  after-consequences,
 such as the  supervention of hemorrhagic or  irritative fever.  When occurring
 a few hours, or a day or two  after  an operation, it usually proceeds from the
imperfect ligature of the vessels, or from  arteries bleeding  after the setting-in
of re-action, which had  not furnished blood whilst the patient was under the
influence of the shock of operation.  On recovery from chloroform also, it not
unfrequently happens that arteries begin to spout, that yielded little or no blood
 whilst the patient was in a state of anaesthesia.  Under  these circumstances,
it is of far less moment, and less frequently fatal, than when occurring at a
 later period, arising from some morbid condition of the wound or system, and
usually associated with a typhoid condition, in consequence of which the proper
 formation of plastic matter is  interfered with.  During the  performance of the
 operation hemorrhage should,  as much as possible, be  prevented; the operation
itself  is a cause of  depression, and  any great loss of blood would only greatly
 aggravate this.
   Surgical fever, of an irritative type, associated with cerebral symptoms, may
 set  in with unusual violence;  but it never proves fatal without the manifesta-
 tion of some local inflammatory mischief.  These local inflammations are indeed
 the most frequent causes of death after operations; they are all of  a  diffused,
 congestive, or adynamic character, and  are  frequently connected with  a pre-
 vailing epidemic constitution at the time.  They are  of two distinct kinds;
 the first, taking their origin from a wound as from a  central starting-point, are
 the various forms of erysipelas, diffuse inflammation  of the cellular tissue, in-
 flammation of veins, and absorbents, hospital gangrene, and diffuse suppuration
 of bone.   The others are those  secondary affections which  fall upon some in-
 ternal organ, as for example, the lungs, liver, brain, or gastro-intestinal mucous
 membrane.   The most frequent and fatal of these various complications, is con-
 gestive inflammation  of the  lungs; which is an almost invariable accompani-
 ment, if  not a cause of  death  in surgical fevers.  The membranes of the brain
 in other instances  are found  inflamed;  and more rarely the gastro-intestinal
 mucous surface is affected.   These various causes of death are necessarily most
active amongst the  poorer inhabitants  of  large" towns, whose vitiated constitu-
tions render them far less able to bear up against the depressing influences of
a severe  surgical operation, than those whose days are  passed in the purer air
and healthier occupations  of  a country  life.  Internal organs may also have 
28
OPERATIVE  SURGERY.
been so injured by the accident or disease, that necessitates  the operation, as
to be unable to recover themselves, and falling into a state  of inflammation or
gangrene, may destroy life.   This we see happen in the intestines  in  cases  of
hernia, and  in the brain in injuries of that organ.
   The surgeon being convinced  of the  necessity of having recourse  to opera-
tion, should proceed fully and unreservedly to lay before his patient  the state
of the case, and if necessary state the reasons that render an operation impera-
tive, in order to obtain his consent, and that of his family.   In the event  of
the patient refusing  to submit, what course  should the surgeon pursue ?   In
this he must be  guided partly by the nature of the  proposed  operation; and
partly by the state of the patient, and his capability of  forming a correct judg-
ment of his case.  If the operation be one of expediency, merely for the relief
of an infirmity or the removal of an ailment, that does  not directly jeopardize
life, most certainly  no surgeon would think of undertaking it without the full
consent of his patient.  If on the other hand it be an operation that is impera-
tively necessary  for the preservation of life, in which the delay of a few minutes
or hours may be fatal to the patient, as in the case of the proposed ligature  of
a wounded  artery, or the relief  of a strangulated hernia, and in  which  the
patient not being aware of, or capable of being made to understand the neces-
sity for immediate action, is  unwilling to assent to the proposal, the surgeon
truly will be placed in a dilemma  of  anxious  responsibility; between allowing
the patient to fall a sacrifice to his  ignorance or timidity, and attempting, per-
haps unsuccessfully, to rescue him from inevitable death against his own  con-
sent.   I believe the  proper course for the  surgeon to  pursue under such  cir-
cumstances, is to judge  for  the  patient in  a matter  on which he is  clearly
unable to form an opinion, and to  compel him, so far as practicable, to take the
necessary steps for the preservation of his life, or to put him under chloroform,
and when narcotized, to perform any operation that may be  necessary.   In the
event of the patient being insensible, as after an  injury of the head, the sur-
geon must necessarily take upon himself to act as the case requires.   Children
cannot be considered capable of  giving  an opinion as  to  the propriety of  an
operation, the  consent of the parents is here necessary, and  quite sufficient,
and in their absence, the case being an urgent one, the surgeon must stand in
loco parentis, and take all responsibility upon himself.
   These points then having been determined, the patient  should be  prepared
for the operation, if the  case be  sufficiently chronic to admit of the necessary
delay.   This preparation  must not consist in any routine  system of purging
and starving, which  is ill-calculated to support the constitution against the call
which will be made upon its powers:  but by adapting our  means according to
the condition of the patient  to support the powers of  life.   The tendency to
erysipelas, pyemia,  and low  and  diffuse inflammation  generally, is materially
lessened by supporting the patient's  strength, by means  of a nutritious diet,
previous to the performance  of the operation.  Indeed, in many of the more
severe cases of compound  fracture and  disease of the joints, it is only by the
use of a nutritious diet, and by the administration of stimulants, often in lar^e
quantities, that the  patient can  be brought  into a condition to bear the shock
and consequent depression of the operation.  It may even be found necessary
to administer from  half-a-pint to a pint of  brandy, with perhaps a considerable
quantity of  wine, together with eggs, beef-tea, and other nourishment, for some
days before  the operation can be  undertaken.   This is more particularly the
case with hospital patients of bad constitution, who have met with serious acci-
dents, attended by much suppuration  and irritative fever.   In the more chronic
cases, the time should  be seized for the operation when the secretions are free
the tongue clean, and the action  of the skin and kidneys in a healthy state •
and above all the mind should be  kept tranquil and hopeful, being allowed to
dwell as little as possible upon the impending event. 
PREPARATIONS FOR OPERATION.
29
  The immediate preparations for the operation should always be superintended
by the surgeon himself.   He must see that the  table is solid, and of a conve-
nient height, well  covered with blankets, and provided with pillows;  and that
the light of the room is good.  There must be  a sufficient  supply of sponges
and of basins, with hot and cold water; and if the operation be likely to be at-
tended by much hemorrhage, a tray filled with sand or saw-dust should be pro-
vided, in order to catch the blood.   The surgeon must then look over his in-
struments, comparing them, if the operation be  complicated, with a list previ-
ously made out; he must see that they are  arranged in the order  that they are
wanted,  and  properly covered with a towel.  Much  of the successful  perform-
ance of an operation depends on the attention and steadiness of the assistants.
Of these there should be enough, but not too many.   In all  capital operations
three or four will  be required.  One for the administration  of the chloroform,
another  to command the artery, a third immediately to assist the  surgeon, and
the  fourth to hand sponges, instruments,  &c.  The duties of the assistants
should be performed in silence, and each man must carefully attend to his own
business, and not neglect this, as is too often done, in  his anxiety  to crane over
and see what the surgeon  is about.   There should be no unnecessary talking
when once the patient is on the table, the surgeon's directions being conveyed
by a brief word or two, a look, or a sign with the hand.   _
   The surgeon himself must  always feel the heavy  responsibility that hangs
over him during the performance of a great operation—" at that moment when,"
as Dr. Grant has elegantly said, " death everywhere surrounds his  knife, and he
is endeavoring to  convey all his knowledge  to its point."   But having carefully
considered each successive step of the operation,  provided for every emergency
that can by any possibility arise in the course of it, and trusting  in Him, from
whom all knowledge is derived, to strengthen his judgment and guide his hand
aright, he will proceed to  the performance of his duty with self-reliance, and in
the full confidence that he will be able to accomplish all that art can do.
   The introduction of anaesthetics into surgery is undoubtedly one of the great-
est boons ever conferred upon mankind.  To the patient it is invaluable in pre-
venting the occurrence of pain, and to the surgeon by relieving him  from the
distress of inflicting it.   Anassthesia is not, however, an unmixed good.  Every
agent by which it can be induced produces a powerful impression on the sys-
 tem, and may occasion dangerous consequences when too freely or  carelessly
 given, and  even with every possible care it appears certain that the inhalation
 of chloroform is in some cases almost inevitably fatal.   We cannot purchase
 immunity from suffering without  incurring a certain degree  of danger.   There
 can, however, be little  doubt that many of the deaths that have followed the in-
 halation of chloroform have resulted  from want of knowledge, or of due care, on
 the part of the administrator.  Yet, whatever be the precautions taken, there
 is reason to fear that a fatal result must occasionally happen.   This immediate
 risk, which is but very trifling, is more than counterbalanced  by  the immunity
 from other causes  of death during operations which used formerly to occur.
   There is, however, another question in relation to chloroform which deserves
 the most serious consideration on the  part of the surgeon;  viz:  Does it influ-
 ence the rate of mortality after operations ?  On this  point there is conflicting
 testimony.   Dr. Simpson  has published statistics  to  show,  that  the  mortality
 after operations has lessened since the introduction of chloroform.   Dr. J. Ar-
 nott, on the other  hand, adduces figures to prove  that it has materially increased,
 in amputation by  12, in lithotomy by as much as 28  per cent.  I am inclined
 to believe that the rate of mortality has increased since the use  of chloroform
 in operative surgery.  But is this increase altogether due to any effect produced
 on the system by the inhalation of chloroform ?   May it  not, in  some measure
 at least, be owing to operations being  often performed in very doubtful or ex-
 treme cases, now  that they can be done painlessly, when formerly the suffering 
30
OPERATIVE  SURGERY.
inflicted would have deterred  the surgeon from  proposing, or the patient from
acceding to  their performance?  A surgical operation was  formerly, from  the
pain attending it, looked upon as a  more serious affair than it is at the  present
day, and surgeons were not willing  to inflict suffering unless  there were a good
prospect of a successful issue.   Now, however, that the most serious operations
can be performed without any consciousness to suffering, the surgeon, in  his
anxiety to give his  patient a chance of life, may not unfrequently operate  for
disease or injury that  would otherwise necessarily and  speedily be fatal, and
which formerly would have been left without an attempt at relief.
  Making, however, all allowance for the extension of operative  surgery to ex-
treme cases that were formerly not  thought to come within  its range, I cannot
but think that chloroform does exercise a noxious influence on the constitution,
and does lessen the  prospect of recovery in certain states of the  system, more
especially when the nervous power is enfeebled or the blood is in an unhealthy
state; under such circumstances the depressing influence of chloroform  appears
to me to act injuriously, the  patient does not rally well  after the operation for
which  it is administered, and  immunity from suffering  is purchased by a les-
sened chance of recovery.
  Anesthesia by the administration of chloroform is best commenced before the
patient leaves his bed.   It should never be given but by a person accustomed
to its use, and in  whose capability the surgeon has full reliance, as nothing em-
barrasses him more, during the operation, than to have any doubt about the
chloroform being properly administered.   The following is  the  way in which
chloroform may, I think, most conveniently and safely be administered.  On a
piece of folded lint, about two inches  square, and consisting of three doubles,
about 3j of chloroform is poured, and the lint is then held at a distance of about
three inches  from the nose of the patient,  so as to  permit of the very free  ad-
mixture of air with the first few inhalations of the vapor.  After the lapse of
about half a minute, the lint is brought nearer to the patient's nose, to within
a distance of perhaps an inch, being never allowed to touch;  at the same time
a porous towel, not  doubled, is lightly laid  over the face  of the patient  and the
hand of the operator, so as to prevent the  escape of the  chloroform vapor, but
not to interfere with the admission of air.   During the whole time it is the duty
of the administrator to keep his hand on the pulse, to watch the breathing, and
occasionally to examine the pupils of the patient.
  The principal points to be attended to during the inhalation  of this potent
agent are, that it should  not  be given too suddenly, or in too concentrated a
form, and that whilst under its influence the  patient be not raised up off the
couch or table.   If the lint is too much saturated with it, and be held  too
closely applied to the mouth and nostrils, the patient will not be able to  get
sufficient  atmospheric  air,  and  may speedily  become  partially asphyxiated,
choking violently, struggling to get free, and becoming purple in the face, with
a full, slow pulse.  Care should be taken not to compress the abdomen in  holding
the patient, for as the  respiration becomes chiefly or wholly diaphragmatic, it
may be seriously interrupted by any pressure on  the abdominal  wall.   Whilst
under  its influence the patient  should never be raised up, as  has just been
stated; for as this  agent exercises a powerful sedative action  on the heart,
sudden, and  perhaps fatal, syncope may ensue,  by putting  the  patient in  the
erect position.  Hence also it is dangerous to administer it in those operations
that require to be performed whilst the patient is in  the erect position.  It is
well to caution the  patient not to  take anything to eat  for two or three  hours
before its administration, lest it induce vomiting of the partially digested meal
With due caution  it  may be  given with perfect safety to individuals of  ali
ages.  I have operated on infants  less than a month old* as well as on octo-
genarians, under its influence.  In administering it to young children, Dr  Snow
recommends that it should be diluted with rectified spirit.  The first influence 
CHLOROFORM.
31
of chloroform appears to be exercised upon the nervous system.  The patient
becomes excited and talkative, and a state of unconsciousness is induced, the
muscular system at the same time being rendered rigid and tense. At this time
the heart's action is usually quickened, and more forcible than natural.  As the
administration of the chloroform continues, however, complete paralysis of sense
and motion is induced.   The  patient becomes altogether unconscious to all ex-
ternal impressions, the muscles become relaxed, and the action of the  heart slow
and feeble.   This diminution  in  the power of the heart's action is well marked
in the lessened force of the jet  of blood  from  cut arteries.   The respirations
become shallow and feeble in  proportion  as the sensibility of the nervous system
and the energy  of the muscular movements are lessened, and the blood  in the
arteries becomes dark; in fact, a semi-asphyxial state sets in.  When thus fully
anaesthetized, the patient is on the very  verge of death, and  requires the most
careful  watching on the part of the person who administers the chloroform ; his
fingers  should never be  off the pulse, or his eyes taken away from the counte-
nance of the patient.   The breathing should be very carefully watched :  when
it becomes embarrassed the chloroform  must be given sparingly, and when it
becomes stertorous it should be discontinued entirely.  In this state the inhala-
tion of a small additional quantity of this potent agent, the application of the
vapor in too concentrated a state, or the sudden  raising up of the patient, might
occasion a fatal result from paralysis of the heart.
   If the inhalation of  chloroform has  been suspended, great care  should be
taken when  its  administration is recommenced,  lest the already enfeebled heart
be suddenly overpowered by the  sudden exhibition of too large a volume of
vapor in a concentrated form.
   It should be borne in mind that it is not  necessary in all operations to
administer chloroform to the same  extent.  In all the greater operations, as
amputations, lithotomy, and  the ligature  of  arteries, enough  should be given
to completely paralyze muscular movement, as well as to suspend sensibility and
 consciousness.  In operations for hernia, also, and all  other proceedings impli-
 cating  the abdominal walls, if  complete muscular  relaxation be not induced,
 great inconvenience and not a little danger may result.  So, also, in very painful
 operations about the anus and genital organs, a full dose of chloroform should
 be given.  But  for the removal of many tumors about the trunk, or in many of
 the minor operations on the extremities, and about the head and face, muscular
 relaxation is not so necessary, and  it will be sufficient to give enough  chloroform
 merely to  suspend sensibility and consciousness to pain.
   In certain diseased conditions of the system the administration of chloroform
 requires much care, but, as a general rule, it may be stated that whenever the
 constitutional disease has not advanced to such a degree as to contra-indicate an
 operation, chloroform may be given.  In the  early stages of phthisis it may
 usually be safely inhaled, but in some cases of  bronchial irritation the vapor is
 apt to produce  troublesome cough.   When the  heart  is diseased great caution
 is necessary, more  particularly when its muscular substance has undergone fatty
 degeneration; the sedative influence of the  chloroform being apt  to produce
 a sudden depression or arrest of the heart's  action under these  circumstances.
 In many,  perhaps  the majority, of the cases of death from chloroform, the fatal
 event has  been traced to this cause.   In valvular disease of the  heart I believe
 that  it  may be more safely given.   In persons  who are epileptic, and in  those
who  suffer from congestion of the brain, it requires to be cautiously administered,
as in the  earlier stages of anaesthesia  much cerebral excitement is apt to be
evinced.  In hysterical subjects chloroform is said  to induce a tendency to
laryngeal spasm.  The most dangerous condition in which to administer chloro-
form is that in  which, in consequence of renal disease, the blood is loaded with
urea: in such cases epileptiform convulsions are  readily induced, with lividity
of the  face,  and a  tendency to stertor and coma. 
32
OPERATIVE  SURGERY.
  Should chloroform be given in operations rendered necessary by severe inju-
ries, during the period of the continuance of the shock of the accident, as  in
primary amputations ?  Under such circumstances, its use has been objected to
on the ground that it would act injuriously by still further lowering the already
depressed vital powers of the patient;  and that the pain of the operation, it
performed without it,  would prove a good  stimulant, and thus serve  to rouse
the patient.   But would this really be so?  Is the pain  of an operation a
stimulant?   In order to answer this question, let us observe the condition of
a patient immediately after  the performance of a severe amputation — as an
amputation — without his having been  anaesthetized, and we  shall find, that so
far  from having  been restored or stimulated, he will have been seriously de-
pressed by  it.  The pulse will be small, feeble, and slow; the surface cold; and
the mind, perhaps, scarcely conscious;  in fact, though a slight degree  of pain,
as a pinch or a  prick, may act as a stimulant, very severe suffering is a most
powerful depressing agent, capable of itself of destroying life.  The pain of an
operation performed soon  after  the occurrence of a  severe injury, so  far from
rousing the patient, appears to me to act most injuriously, by inflicting  a second
shock upon the system before, perhaps, it has fairly recovered from the depress-
ing effects  of the first; and it is by preventing this, that chloroform is of such
inestimable advantage in these cases.
  Death from chloroform may occur in three different ways; viz., from coma,
asphyxia, and syncope; through the brain, the lungs, or the heart.  When by
coma, the patient will be heard suddenly to breathe stertorously; he  becomes
livid in the face,  and is convulsed; the heart continues to beat until the last
moment of life, and death appears to  result primarily from the circulation of
dark blood  through the nervous centres.  This form of death chiefly occurs in
individuals who are epileptics, or whose blood is loaded with urea. When death
occurs by asphyxia, it is  the fault of the administrator, sufficient  air not being
admixed with the chloroform vapor to  maintain the respiratory function.   The
symptoms are those of asphyxia, consisting of lividity of the surface, distension
of the jugulars, struggling for breath, and speedy cessation of the heart's action.
In some cases, death is not immediate,  but  a low form of congestive pneumonia
sets in, the blood never becomes properly aerated,  and death ensues  in a few
days  without  perfect  recovery having  taken  place.   In death from cardiac
syncope, the patient, after a few inspirations, suddenly becomes pale and faint;
the pulse  beats  in a  flickering manner a  few times and then ceases, though
respiration  may continue; the fatal event being evidently due to paralysis of
the heart.  This is an accident, that may occur to individuals who are depressed
either by mental  emotion, or by physical debility before taking the chloroform,
and that is not unfrequently connected with a fatty heart.   It is best guarded
against by giving the  patient a little stimulant,  as brandy or ammonia, before
commencing the inhalation.
   The treatment  of an overdose of chloroform is conducted on two principles:
lstly,  the  establishment  of respiration, either  natural or artificial,  so as to
empty the  lungs of the vapor contained in  the air-cells, and to aid the  oxygen-
ation of the  blood; and  2dly, the stimulation of the heart's action,  and  the
maintenance of the circulation.
   The  first principle  of  treatment — that  of re-establishing  respiration__is
most serviceable in the asphyxial form; the other, that of stimulating the heart,
when  the  syncopal symptoms  are present.  But in all cases  they°may most
advantageously be employed in combination.
   The  treatment to be adopted on the occurrence  of dano-erous symptoms  or
of apparent death from chloroform, is as follows:
   1.  The administration of the vapor must at once be discontinued.
   2.  The tongue should be  seized with the fingers,  with a hook or forceps, and
drawn out  of the mouth; and  the larynx pushed up so that the glottis may be
opened. 
CHLOROFORM.
33
  3. Fresh  air should  be admitted around the patient by opening door3 and
windows, and by preventing bystanders or spectators from crowding round.
  4. All constriction should be  removed  from the patient's throat and chest,
and these parts freely exposed.
  5. Artificial  respiration must  at  once  and without delay be  set up, whilst
these other measures are being carried out, either by the surgeon applying his
mouth to the patient's  lips and thus breathing  into the  chest;  or,  what is
preferable, by the alternate and steady compression and relaxation of the walls
of the patient's chest.
   6.  Electricity should be applied freely over the heart and diaphragm through
to the spine, by means  of the Electro-Magnetic, or other convenient apparatus.
   7.  Friction may  be  employed to the  extremities; a  little  brandy rubbed
inside the mouth;  and cold water dashed on the face, as  accessory means.
   The administration  of ether is effected  by the application over the nostrils
of a hollow sponge, saturated with the best washed ether.  This mode is pre-
ferable to the  use of  any of the  complicated inhalers, inasmuch as by  the
admixture in the  sponge of a sufficient quantity of atmospheric air with  the
ethereal vapor, all  danger of asphyxia is  avoided.   To prevent the pungent
effects of ether on the cutaneous surface, Dr. Warren has proposed the anoint-
ing of the face with some protective unguent.  The first effects of the inhalation
are resistance on the part of the patient, and some slight irritation  of the air
passages, the pulse is  increased in rapidity, rising to one hundred pulsations
per minute, the face  becomes flushed, and the movements and speech of the
patient excited.   This stage of excitement soon passes, and  full etherization is
then effected;  the pulse falls to sixty or seventy, the countenance becomes pale,
insensibility to pain is produced, and  the whole  muscular  system  is  relaxed.
The  indications  of this state are the dropping of the  upper eyelid,  and  the
inability of the patient to sustain his arm when raised.  This is the period
most favorable for  the  performance of operations, and especially for the reduc-
tion of dislocations, and of fractures attended with shortening of the limb. The
time required for the induction  of  the anaesthetic state varies,  averaging, per-
haps,  about five minutes, a longer period than is required in the administration
of chloroform, and attended with slightly more excitement.  The fatal  conse-
quences which have attended the employment of chloroform, has  caused  the
American surgeons almost entirely to trust to ether in preference.   Certainly
 ether is a safer agent than  chloroform,  no death having as yet resulted from its
administration; and the only argument in favor of the use  of chloroform over
 ether is, chloroform is  the most convenient  agent, its  effects being  produced
 more  quickly, and no  disagreeable smell being left behind, as is the  case with
 ether. In fact, we use chloroform in preference to ether, on the same principle
 that induces us to  incur the increased risk of an express, rather  than submit to
 the slower but safer progression of a parliamentary train.
   Local Ancesthesia, by means of the application  of  a frigorific mixture  of ice
 and  snow, as introduced by Dr. J. Arnott,  may very conveniently be employed
 in many cases in  which the internal administration of anaesthetics is  either
 inadmissible or inconvenient.  It can only be produced with  certainty, however,
 in those cases, in which the incisions merely implicate the skin and subcutaneous
 structures, as in opening abscesses, slitting up sinuses, avulsion  of toe-nails, or
 removing small  and superficial tumors.   For all such purposes, however, it is
 extremely valuable.
   The mode of using the frigorific  mixture is as follows : — About a tumblerful
 of rough ice is put into a strong canvass bag and finely pounded with a mallet.
 It is then poured out on a sheet of paper, and half its  bulk of salt is quickly
 mixed with it by  means of an ivory or wooden paper knife.  The mixture is
 then put into a muslin or gauze bag, suspended from a wooden ring, and applied
 to the part for from five to ten minutes.   So soon as the skin  becomes  white,
        3 
34
OPERATIVE  SURGERY.
 opaque, and  hard, anaesthesia is produced, and  the incisions may be made
 without any pain being experienced.  The frozen part speedily recovers itself,
 no inconvenience resulting.
   The incisions for the operation itself should be carefully and properly planned,
 so as to give sufficient  space, with as little mutilation as possible, and in some
 cases they must be arranged with the view of subsequent extension, should the
 state of things discovered at the operation require it.   They should be made
 freely without tailing.   The  point of the knife being entered and withdrawn
 perpendicularly, and made to cut with a rapid sawing motion, due  attention
 being at the same  time paid to the resistance of the tissues, so that the surgeon
 does not, by using too  much force, plunge or  jerk his scalpel or bistoury into
 the  part.  The scalpel  should be set on a smooth ebony handle, which is less
 slippery than  an ivory one,  when wetted with blood, and admits  of  greater
 delicacy of touch; it should be light in the blade, nearly straight-backed and
 slightly bellied on  the cutting edge.   When very free and  extensive incisions
 are  required, as in the removal of large tumors,  &c, Liston's spring-backed
 bistoury, of proper size and  shape, is a  most convenient instrument.   Whilst
 the  incisions are being made, care must be taken that too much blood is not
 lost.   This may be prevented most conveniently by the use  of the tourniquet,
 or by an assistant compressing the  main  artery in the groin or axilla.  If the
 seat of the operation be such as not to admit of this, the assistant must com-
 press the  bleeding vessels, as they are  divided during the  operation;  and  as
 soon as it is concluded, he must remove  his  fingers from them one by  one, to
 admit  of their  being ligatured.  If oozing continue, after  all jetting  vessels
 have been tied, this  may be  arrested by exposure  to the air,  or by pouring a
 stream of cold water upon the wound.  In some cases the pressure of pad a°nd
 bandage, and in others  that  of a sand-bag will arrest this bleeding, but in the
 majority of instances position and coaptation of the flaps will suffice.
   The  sutures should be introduced at the time of the operation, whilst the
 patient is  still under chloroform, but should  be left to hang loose, and  not be
 drawn tight until the wound is dressed.   In this way the patient is  saved the
 pain, which is always much complained  of, of introducing  the sutures  at the
 time of  the  dressing.  They should be  made  of dentists' twist, of moderate
 thickness, so as not to cut  out readily, and need only be very fine in case of
 plastic operations, when scarring  is objectionable.   In some cases, where much
 tension is exercised or great accuracy required, hare-lip pins are preferable  to
 ordinary sutures.                                              r

 1,J^/\t\rUnd™-Sma11'  a,nd a11 00zinS has ceased> its lips may at onoe be
 brought together.   This may  also be done even when large, if the patient be
 of a very irritable constitution and sensitive to pain, the whole dressing being
 performed whilst he is still under the influence of chloroform.  But in fenerah
 when the wound is extensive, as in cases of amputation, I  prefer, and  aimos
 invariably adopt, the  plan  recommended by Mr. Listen, of  leaving the  wound

 untH TJ V ?leCe v \Gt lmt in\^Td between its HPS for ^ oAhree  hours^
 until its surface has  become  glazed;  the lint is then carefully removed  any
 Zo\ZTLS:fJ  f" a7ay'anVhe »*» of the incision brou^t'^
 apposition,  the sutures being drawn tight and tied.   Lon- strins of r,lUpr of
 moderate width should now be applied*; these may either°be  o?kl, iatt or
 the common adhesive kind, both having advantages that recommend  them hi

 Ci&Ji^^^P0,ldi,,? drdVantaSe"that -ludTtlm in  others
 ine  isinglass  plaster  is  clean, unirntating, and, being  transparent   allows   a
good view  of subjacent  parts, but it  has the disadvantage oToLin/and
 stripping off when  moistened by the discharges or dressing wS nft  S
 ders  it a very inefficient snnnnrt    Tko „„         dressings, which often ren-
 . ..      ,  ,y luewi,iuu support,   lne common adhesive nWpr i<s mnr0  ir-,-^
tating and dirty, but it  is much  stronger and holds tiX?     I  ,      •
readilv when mnWt^oA    T„ i    Dtlu,,oer ana noids tighter, not  loosening as
reaauy when moistened.   In large wounds, as in those of amputation, I prefer 
              AFTER-TREATMENT  OF  OPERATIONS.           35

the isinglass for the first dressing, and leave it on until  loosened  by the dis-
charges, and then  use the common adhesive plaster for subsequent applications,
when less irritation is likely to be induced.  In some cases in which the wound
is in such a situation as to admit  of it, and more particularly if it be  a deep
though clean cut—as after the  extirpation  of tumors, — great advantage will
be  found after the sutures have  been introduced and the plasters applied, in
padding the part externally with a firm compress of lint, and then applying a
roller tightly but evenly over all.   In this way will not only all oozing be pre-
vented, but direct coalescence and union of the  opposed surfaces may be secured.
  The position of the  part should be carefully attended to, so that the edges
and surfaces of the incision be brought into  proper contact; more may be done
in this way, without pain or uneasiness to the patient, than by any amount of
traction and pressure that can  be exercised.   The  part should be so arranged
that one end of the incision may be the  most dependent,  so as to facilitate the
escape of discharges.   One end of the ligatures should  be  cut  off short, the
other left of a moderate length  to hang  out of the lowest part  of  the  wound,
provided that by  so  doing it  do not cross  its whole line.  A narrow strip of
water-dressing should then be applied along the edge of the incision.  The first
dressings need not  be changed until about  the third day after the operation,
unless they become loose or are  too tightly applied, when they may be snipped
across.   About this time, or earlier in many cases, a serous bloody fluid will be
discharged from between the strips of plaster and the sutures.  The escape of
this must be facilitated by removing any  obstacles that are in its way.  If, how-
ever, the sutures do not interfere with the escape of the discharges, and  are not
producing undue irritation or excessive traction, they may be left in  for a few
days  longer.   In  amputations, especially in cachectic subjects, they may fre-
quently be left undisturbed for six or eight days, with much advantage.
  If union  do not  take place by adhesive  inflammation, and suppuration has
commenced, with much tension and heat  about  the  part, the substitution of a
poultice for the water-dressing will  be advantageous.   When suppuration has
fairly set in, these applications should be changed at least twice or thrice in the
twenty-four hours.  The neglect  of this precaution often gives rise to much irri-
tation, and retards the healing process by the accumulation of discharges in and
around the wound.  Care should  also be taken that there is a free escape for the
pus, which may sometimes be pent up by the two early cohesion of the edges,
without a corresponding agglutination of the  deeper  surfaces of the wound.  As
granulations spring up, it may become necessary to  substitute astringent dress-
ings for the emollient ones, and the parts must be well supported by bandages,
especially in amputations, and in  all cases where there is a tendency to bagging
of matter.
  The constitutional after-treatment of operations demands as much  attention
on the part of the surgeon, as the  management of the wound itself.   Imme-
diately after the operation, and before the effects of the chloroform have passed
off, the patient should be comfortably arranged in bed, with the clothes sup-
ported  by a cradle, or other  contrivance, away from  the part  implicated; an
opiate should then be  administered, or a  little wine  and water, if there is faint-
ness, and the patient kept as quiet as possible.
  With regard to  the diet after the operation, this must depend entirely on the
patient's constitutional powers, his age, and upon the severity of the operation to
which he has been subjected.  If the patient's strength  be  good, not  having
been broken by previous  disease  or suffering, and  if  the  operation be a slight
one, as the amputation of a finger, or the removal  of a  small  tumor, he may
have  half his usual diet allowed for a  few days, but without any stimulants.
If the operation  have  been  more severe, but  not  capital, no solids should be
allowed, but broths and  nourishing liquids alone given.   If the operation be a
capital one, the patient's health and strength being  otherwise good, he may be 
36
AMPUTATIONS.
 restricted to farinaceous slops  and beef tea until suppuration has come on;  in-
 deed, up to this time, the febrile reaction will usually prevent the patient taking
 solids.  Some light pudding may then be  added, and the  diet may, as the case
 progresses, be gradually  improved by the  successive addition of fish and the
 lighter kinds of meat, with a moderate quantity of stimulants, as required, until
 it reach  the  normal standard.  It  not unfrequently happens, however, that a
 totally different course must be pursued. If the patient have been much reduced
 by long-continued suppuration, or other depressing causes before the operation;
 is old and weakly in constitution, or has been in  the habit of taking a very con-
 siderable quantity of stimulants, it will be absolutely necessary to depart from
 the routine plan, and to adopt  a tonic and  stimulating mode of treatment.  In-
 deed, in hospital practice especially, I find this by far the most useful mode  of
 treating patients after severe  operations;  without it, many would have  sunk,
 whom  I have seen saved by the free administration of large quantities of brandy,
 wine, porter, eggs, and beef tea, from the very time of the operation;  that stimu-
 lant  being given to which the  patient  is  accustomed in a  state of health.   I
 believe also that this plan of  treatment is the best preventive to those low and
 diffuse forms  of inflammation  that  are so commonly fatal in these cases, and
 when they come on  I know of  no better remedy than the brandy and egg mix-
 ture  of the Pharmacopoeia, freely administered.   In all this, however, the sur-
 geon must be guided by the patient's pulse, his previous habits, and the power
 of his  constitution ;  and nothing requires greater judgment than the adminis-
 tration of stimulants, according to these particulars.   The  great importance of
attending scrupulously to the general cleanliness  of the patient, and to the ven-
tilation of the ward or room in  which he is lying, as the best means of prevent-
ing the occurrence of the lower forms of  inflammatory mischief, need scarcely
be insisted on, as these hygienic precautions are universally recognised as being
of the first importance under such circumstances.
   The various special operations will be considered when treating of the several
injuries and diseases for which they are required; but as  amputations do  not
readily fall under any special head, being required for a vast variety of different
conditions, it will be more convenient to consider them here.
                           CHAPTER  II.

           AMPUTATIONS AND DISARTICULATIONS.

  The term  "amputation" properly means  the separation of a limb from the
body, but it is sometimes applied to the removal of other parts, as the breast or
penis.  The frequency of amputations of the limbs has much lessened of late
years; other  and less  severe modes of treatment being now successfully had
recourse to in many cases of diseased joints, of aneurism, and of compound frac-
tures, that  were formerly submitted to the  knife.  But yet,  amputations are
amongst the most frequent  operations in  surgery, and will continue to  be so as
long as the human body is liable to severe mutilations, to gangrene of the limbs
and to malignant and other incurable diseases of the bones and joints   It has
been somewhat the fashion  to decry amputation; and to speak of this operation
as an opprobrium to curative surgery.   But  though no surgeon can deprecate
unnecessary amputations  more strongly than I do, yet I cannot admit  that the
removal of a limb differs from other operations, which are only attempted when all 
            AMPUTATIONS  AND  DISARTICULATIONS.          37

other means have failed in curing the diseased part, or saving the patient's life.
And surely, it is rather a subject of just pride than the reverse, for the surgeon
to be able with ease, and by a single operation, to  save the whole of the body,
though he sacrifice a limb that has  been utterly and  incurably disorganized or
spoilt by disease or injury.   In  the performance of an amputation, also, much
dexterity may frequently be  displayed,  and there  is  commonly great scope for
surgical skill in the constitutional treatment of the patient, both before and after
the operation.
   An amputation may be done in the continuity of a bone;  or at a joint, when it
is called a disarticulation.   In  either case, hemorrhage during the operation is
the great danger which must be carefully guarded  against.   As a general rule,
it is better to prevent this  by the application of a  tourniquet, than  by trusting
to the compression of the  artery by an  assistant; the tourniquet  arresting the
flow of blood through the collateral vessels as well  as the main trunk, whilst an
assistant can only stop the  current of blood that passes  through the latter.
When the tourniquet is applied, the pad  should  be carefully placed  over the
artery, and  the band buckled pretty tight, but the instrument should not be
screwed up until the moment of the operation, lest venous congestion take place
on the limb, and an inordinate quantity of blood be lost.   So soon as the main
arteries have been tied, after the  removal of a limb, the tourniquet may be
unscrewed, and 1?he band  taken off, the  assistant, however, keeping his finger
on the artery, lest a ligature slip; for if  it be only left half loosened, it  will
often happen that venous hemorrhage continues abundantly from the stump,
in consequence of the pressure of the instrument being still sufficient to prevent
the  return of the blood through the veins.  This will at once cease on taking
the  tourniquet completely off, and  elevating the cut surfaces.
   In  amputations and  disarticulations, the  surgeon has  the choice  of  three
operative procedures: — by the  circular method — by flaps — or, by a combina-
tion  of the  two, the formation of skin-flaps with a circular cut  through the
muscles.   It is not my intention  to enter into a discussion as  to the relative
merit of these  procedures, for which I would refer to  the writings  of Liston and
Velpeau.  I believe  that  by either the circular or the flap method an equally
good stump may ultimately be  formed; but  that  much will depend upon the
special dexterity  that the  surgeon may  have acquired, by  the  habitual  per-
formance of one or other of these operations.   Educated in the doctrines of Mr.
Liston, who invariably amputated  by the flap method, and who certainly1 did
this with wonderful rapidity and precision, I have been in  the habit of perform-
ing  this operation in preference to  the  circular, over which it certainly possesses
the  special advantages of greater celerity in  performance, more perfect coapta-
tion and smoothness of the opposite sides of the wound, and a greater tendency
to union of the stump by the first  intention.
   The surgeon should always stand so that he may support and grasp the limb
to be removed, his left hand being placed on  the outer side, in amputations of
the  left limbs — on the inner side,  in those of the  right.
   The amputating instruments must be in proper order, and of good construc-
tion.  For the smaller amputations, straight  spring-backed bistouries, in ivory
handles, will be required, narrow or broad in  the blade, according to the size of
the  part to be removed.   Scalpels also, not too broad in  the blade, are useful
in those  cases in which the bistoury, from its length, might be  inconvenient.
Cutting-pliers, with long and strong handles  and  short blades, either straight
or curved, as may be  most  convenient, are especially required  in amputations
about the hands  and feet.   The knives for the larger amputations should have
smooth ebony handles, and be well balanced.   The  back of the blade should run
straight to the point, and be well rounded.  The edge should taper off towards
the  point, with a good convexity.   The breadth of the blade should vary from
the Ath to the |th of an inch, and  its length must be proportioned to the thick- 
38
AMPUTATIONS.
ness of the limb  to be  removed.  As a general rule, «  <^« to ™,£? £
sweeping cut, so as to form a well-rounded and  smooth flap, the  blade snou u
be in length equal to about double the thickness of the limb.   The f»w should
be strong'in the blade and back, so as not to bend in  cutting.   lne+°Ja°* ^
be of good breadth, and, in order not to hang  as it works its way through the
bone, must be  somewhat broader at the  cutting edge than  elsewhere   ino
teeth should  not  be too fine, and must  be set crossways.  The artery torceps
may either be of the ordinary "bull-dog"  make, or they may be broad towaids
the point, so as to allow the knot more  readily to be slipped  over the point to
be deligated.                                      ,    .     ,      ,  ,
  The flaps may be made either by cutting from without inwards, or  by trans-
fixion—cutting from within outwards.   Transfixion should  be  preferred  in
fleshy parts, as  the thigh or arm; but cutting from without inwards will  be
found to afford  the best result, and is indeed the only mode of forming the flap
in some situations where the bones are thinly covered, as  on the  outer side  of
the fore-arm, the anterior part of the leg, or just above the ankle-joint.  When
the patient is extremely  muscular, and the amputation has to  be done in  the
arm, thigh, or leg, it will be found  to be  most  convenient to have skin-flaps,
made by cutting from  without inwards, dissecting up  the integuments  from the
fascia to a sufficient extent, and  then making a circular cut through the muscles
down to the bone, thus  only leaving a skin covering.  The advantage of this
procedure over  the ordinary flap or circular operation is very great under cer-
tain  circumstances.  In  both cases, but more  especially  in flap  operations  on
stout muscular subjects,  a large  pad  of muscle  is apt  to be  left in the stump.
This, which at first sight might  appear an advantage, as an additional  covering
to the bones, is a decided disadvantage, inasmuch as  it usually projects by the
retraction  of the skin  covering it, sloughs, and interferes with the proper union
of the flaps.  If the limb have  been the seat of much suppurative action, the
muscles become softened and do not retract, and are  apt  afterwards to project
between the skin-flaps, giving rise to much trouble and delay in the healing of
the stump.  This pad is also disadvantageous after cicatrization  is completed,
as it then  forms a soft flabby and bulbous  end  to the stump instead  of a firm
hard cicatrix.
  So soon as  the incisions have been made through the soft parts, the bones
must be cleared for the application of the saw.   This is best done, when  there
is only a single bone, by a firm  circular sweep of the  knife  from  heel to  point
round the under segment  of the bone, and then another round the upper sur-
face, in the opposite direction.   If there be two bones, care  must be taken in
clearing them not to direct the  edge of the knife upwards into the interosseous
space higher than the line to which  the saw is  to be applied, lest any  artery be
cut high up in  this situation, where it is always difficult to  secure it, owing to
its retraction above the membrane.
  The bone having been properly cleared, the  flaps must be forcibly retracted
by an assistant, in order to admit of the proper application of the saw, which
should always be made opposite the highest point to which the incision is carried
through the soft parts.  For the purpose of retraction the assistant's  hands are
quite sufficient, though some surgeons are  still in the habit of using retractors,
made of split pieces  of linen  cloth or of wash-leather.  In  order to saw the
bone quickly and steadily, there are several points  deserving attention.   The
first cut should be made so as  to form a deep groove to  receive the  teeth, by
pressing the left thumb on the  bone, and applying  the heel  of the   saw, held
horizontally, along this,  by which it is steadied; the  instrument  must then be
drawn  fairly and  sharply along  the whole line of its teeth from  heel to  point.
The groove thus formed  receives the edge of the saw, and  the bone may then be
quickly cut through  by  long, light and  sweeping  movements of the instru-
ment from point to heel, the position being gradually changed from  the hori- 
INSTRUMENTS.   FLAPS.   SAWS.
39
\____1J
zontal  to  the  vertical as  progress  is  made.   The  surgeon must, with his
left hand, support the part to be  removed;  and care must  be taken not  to
bear upon this, so as to snap
the bone as it is weakened by                      Fig. 1.
the action of  the  saw; nor
should it be so much raised as
to run the risk  of locking the
saw.   When there  are two
bones  in the limb  of equal
strength, as  in  the  fore-arm,
they should be  cut through at
the same time; but in the leg,
the fibula, being the weakest,
should always be first divided.
Should the division  be made
irregularly, and splinters of
bone  project, these must be
snipped off with cutting pliers.
   After the  limb has been re-
moved, the ligature should be
applied. The main and larger
arteries must first be tied. For
this purpose, fine compressed
whipcord is  the best material.
The  ends of these  ligatures
knotted together must be left long, so that they maybe distinguished.   Usually
from two to  four or six smaller vessels require to  be tied, and they should be  se-
cured with ordinary ligature thread; but sometimes, either from the existence of
malignant disease in the limb, or when extensive suppurative action has been going
on in  the limb, the stump  is  excessively vascular, and a very large number  of
ligatures may be required.   I have more than once had occasion to apply between
twenty and thirty ligatures  to vessels in  the arm  and thigh under these circum-
stances.  As union always takes place by granulation in such cases as these, it sig-
nifies  little how many are put on, the smaller ones separating early.  Sutures must
then be introduced  through the edges of the  wound, but may be left loose; and
wet lint applied between the surfaces and over the outside, the  dressing of the
wound being deferred for a few hours until the surfaces  are  glazed.   At least
this is the  plan, introduced  by Mr. Liston, that I  think should be generally
followed, more particularly  in  cases of primary amputation, and in all wounds
where union by adhesion may be hoped for.  But in amputations for disease,
when patients  are in a low  and irritable condition, I think it is better  to apply
the dressings immediately after the performance  of the amputation, before the
 effects of the chloroform are recovered from.   Before doing this, it is desirable
 that all oozing should have  ceased, and with this view, after the  ligatures have
 been applied, I commonly pour a jug or two of cold water over  the face of the
 stump, and then proceed with the dressings, which must be conducted in  ac-
 cordance with the general  principles to be laid  down when we come to speak
 of wounds.  The stump should not be bandaged until the third or fourth day,
 unless it is very fleshy and  heavy; and at first the roller should not be brought
 over its face, but merely by circular turns, as far  as the line of incision.  When
 suppuration is subsiding, and cicatrization going on, the  bandage may advan-
 tageously bo brought over the face of the stump.  As a general rule, it will be
 found that a narrow roller will adapt  itself better than a broad one.  After cica-
 trization is completed, the patient should be allowed to go about on crutches,
 but must  not  wear  an artificial  limb  for several months, until  the parts have 
40              %           AMPUTATIONS.
Fig. 2.
become firmly consolidated; during the whole of this time the stump should be
kept carefully bandaged, and not exposed to injury.             _ .    ~ornnva]
   Simultaneous or synchronous amputation of  two limbs,  requiring  w™°™
for severe injury or for gangrene, has occasionally been successfully practised
either by two sur-eons performing the two amputations at the same time  or oy
the same surgeon^doing first one and  then the other; the vessels of the nrs,
limb being secured by an assistant, whilst the  second limb  is being removed.
The object in synchronous  amputation when the removal  of  two limbs is
required, is, to lessen  the  continuance of shock to the system, by throwing, as
it were, that of the two operations into one.  In doing this, however, the sur-
geon  must  necessarily be  guided by the circumstances of  the> cases.   It the
patient be very greatly depressed, the infliction of so severe an injury as a double
amputation might probably extinguish life at once; and if possible to wait after
the removal of the first limb, and before the second was amputated, it might be
desirable to do so, until the shock of the first operation had  passed  off; but if
the patient were not too much depressed, the  double  simultaneous  amputation
would probably be the safe course.
   On  examining  the  structure of. a stump, after  a year or two have elapsed
                             from the  time of its formation, it will be found
                             to be composed of a mass of fibro-cellular tissue,
                             the muscular and tendinous structures that enter
                             into the  formation  having become thus  trans-
                             formed.  The ends of the bones will be found to
                             be rounded, and  the medullary canal filled up,
                             the  vessels being obliterated up  to the nearest
                             collateral  branch (Fig. 2).   The ends  of the
                             nerves  are thickened,  and commonly assume a
                             bulbous  appearance  (Fig.  3).  On  examining
                             these rounded or oval tumors, they will be found
                             to be fibro-cellular masses having nervous fibrillae
                             thinly scattered throughout.
                               The proper adaptation of  artificial limbs is  a
                             matter of considerable  consequence,  and the
                             ingenious mechanical contrivances that are at the
                             present day adapted to stumps, leave  little to be
                             desired.  The surgeon had better leave the  details
                             of these  mechanical  contrivances to the instru-
 ment-maker;  but he  should  see that they are made light,  consistently with
 sufficient strength and support, and that the end of the stump is never pressed
 upon by them.1  Thus, after amputation of the thigh, the artificial limb should
 take its bearing point from the lower part  of the pelvis and  hip.  In amputa-
 tion immediately below the knee, this joint should be  bent and received into
 the socket of the instrument, and  if the  amputation be  at a lower point than
 this,  and the stump be extended into the artificial  limb, its end must be pro-
 tected from injurious pressure.  Even in the case of disarticulation at the ankle-
 joint, where the soft tissues of the heel are left,  pressure can seldom  be  borne
 upon the end of the stump.
   Morbid conditions  of stumps. — It not unfrequently happens that  the end of
 the bone in a stump necroses.   This occurs either in  consequence of the injury
 inflicted by the jarring of  the saw, or happens in  those stumps  that  unite by
 the second intention, and where the bone consequently lies  bathed in pus for a
 considerable time, being exposed between the  flaps, and thus at last losing its
  1 [The most perfect of all the artificial limbs we now possess, is the one invented by
Mr. Palmer, Chestnut Street, Philadelphia.  This piece of mechanism received the prize-
medal at the London Exhibition of 1851.  It merits the entire confidence of the surgeon."] 
DRESSING  AND STRUCTURE  OF STUMPS.          41
vitality.   This is especially apt to happen in persons of feeble constitution in
whom the limb has, previously to the operation, been the seat of abscess that
denudes or otherwise injures  the vitality of the bone.  In these cases a fistulous
opening will be left leading  down to the necrosed bone,
which  usually separates three or four months  after the        Fig. 4.
operation  in the shape of a complete ring, with irregularly-
spiked prolongations stretching from its upper part (Fig. 4);
after this has been removed, the  stump  becomes  firmly
consolidated.
   Conical or sugar-loaf stumps,  as  they are  called, com-
monly form in consequence of the flaps having originally
been cut  too short, but in  other cases  they may  occur,
though the stump may have been  skilfully  fashioned, in
consequence of the soft parts which have been the seat of
inflammatory action and suppuration before the amputation,
retracting during the granulating process, so as to denude
the  bone.   In such  cases as these, great retraction and
contraction  of the flaps are apt to go on  during cicatriza-
tion, so that the  bone may never be covered at all,  but be
exposed at the bottom of an  irritable ulcer;  or if the soft
parts do coalesce, the cicatrix will be unable to support the
slightest  pressure without  becoming  ulcerated.   Under
these  circumstances, the  only  remedy consists in  laying
open the  stump,  and  cutting off about three  inches  of  the
bone.
   If the stump be too long and projecting, so as constantly
to be  in  the  patient's way, there  is  no remedy  but to
perform a second  amputation higher  up.   This is espe-
cially  required in badly fashioned stumps  of the   leg where the  limb has
been removed too far below the  knee, so that it  projects  backwards in an
awkward  manner, and is constantly liable to accident when the patient uses  a
wooden pin.
   Painful  and  spasmodic stumps. — The nerves in a stump naturally become
somewhat expanded and bulbous; and  no material  inconvenience results from
this condition. But it occasionally happens that a distinct tuberose enlargement
forms  in  connection  with  one  of them, attaining  the size  of a cherry or  a
walnut, and this  being pressed against the  end of  the bone, or implicated in
the  cicatrix, becomes  the  seat of intense pain of a neuralgic character, more
particularly whenever it is touched.   Under these  circumstances excision of
this bulbous  extremity of  the  nerve is necessary, and  will  effect a cure.   But
besides this  form of painful stump, which may happen in the strongest and
healthiest subjects, and is  entirely dependent on losal causes, there  is  another
condition in which the stump  becomes not only the seat of  intense pain, but
usually of convulsive twitchings.   This form of  painful stump arises from con-
stitutional causes, and invariably occurs in females, more particularly in  those
of the hysterical temperament, and who are subject to neuralgic pains elsewhere.
In these cases the general  cutaneous sensibility of the stump is increased; it is
often the seat of convulsive  jerkings or twitchings, and the pain  is  of a more
or less  intermittent character, being increased  under the influence of various
emotional and constitutional causes.  In cases such as these, the  treatment
should be conducted on the general principles that will be fully discussed  when
we come  to speak of neuralgia.   No excision of the nerves  of the  stump, or
even amputation  higher up is of any avail: the disease being constitutional, will
certainly return in each successive stump, until at last the shoulder or hip may
be reached without any permanent benefit accruing to the patient.
  Aneurismal enlargement of the arteries of a stump is of extremely rare occur-
 
42
AMPUTATIONS.
rence.   The  only  case  with  which  I  am  acquainted, is one ™orde<Tby■Mr
Cadge, in which an aneurismal varix formed in a stump after disarticulation at
the ankle-joint (Fig. 5 a).
Fig. 5.
   Strumous or malignant degeneration may occur in a stump, presenting the
ordinary characters of these affections met with  elsewhere.  In the strumous
stump  secondary amputation may advantageously  be performed, but  on the
recurrence  of  malignant disease, it is seldom justifiable, as there  is probably
deposit in internal organs or contamination of the lymphatics.
   The fatty degeneration of the muscles  of a limb, arising from their disuse,
gives rise to a peculiar appearance in the stump.  During the  amputation, the
muscles look like pieces of yellow wax, and are firm : no atrophy, so far as size
is  concerned, having taken  place; the fat being deposited between the muscular
fibres, producing  atrophy of them by its pressure, and occupying their place;
the general size of the limb and fulness of the  stump being consequently pre-
served.  Union takes place  under these circumstances, though somewhat slowly;
at least in several cases in which I have observed this condition it was  so.  In
one of these I amputated the leg for disease of the foot of nine years' standing,
and in another the thigh for disease of the knee  of fourteen years'  standing.
   Mortality after amputation. — The  general causes of death after operations
have  already been  considered, but we must now consider some special points
connected with the relative mortality after amputations of different kinds; and
the cause  of the difference that exists.  The principal causes of death  after
amputation are the influence of shock, the occurrence of secondary hemorrhage,
of erysipelas, phlebitis,  pyemia, and  congestive pneumonia; besides these, hos-
pital gangrene and sloughing of the  stump,  occasionally carry off the patient.
   The circumstances which most influence the general result of amputations, as
well as the particular cause of death  after  the operation, may be divided into
two classes. 1. Those that  have reference to the  general constitutional condition
of the patient.  2. Those  that are connected with the operation itself.
   1.  To the first class may be referred the influence 1, age ; 2, general health ;
and 3, hygienic conditions.
   1.  Age  exercises a material  influence on the  result of amputations.  As  a
general rule it may be stated that the younger the patient the  greater the like-
lihood of a successful result.  At early periods of life also  there is a great ex-
emption from low secondary diseases of the erysipeloid type, and if death occurs
it is usually from exhaustion or intercurrent visceral mischief.
   2.  The general health of the patient previous to the operation exercises  neces-
sarily a more important influence on the  chances of recovery.   The result of
amputations  is necessarily widely different, according as  the operation is prac-
tised on the  healthy inhabitant of a country district, or on  the cachetic and
 debilitated denizen of a large town.    The causes of death also differ  in  these
 cases.  In the country hemorrhage or acute inflammation, in  towns erysipeloid
 diseases and pyemia commonly lead  to the fatal  result.
   3. The  hygienic conditions  that  surround the patient  after the  operation
 exercise, perhaps, an equally important influence, not only  on the rate of mor-
 tality, but on the cause of death.   Exposure  to an impure  atmosphere want or 
MORTALITY AFTER AMPUTATIONS.
43
bad  quality of  food  after an  amputation,  lessen  materially the prospect of
recovery by disposing the patient to the worst forms of erysipelas, pyemia, and
hospital gangrene.
  2. The circumstances connected with the operation itself that influence mate-
rially its results, are, 1. The seat of the amputation.  2. The structure of the
bone sawn.  3. Whether the operation is done for injury or disease.   4. If for
disease, the nature of the affection.  5. If for injury, the time that has elapsed
before the limb is removed.
  1.  With regard to the influence of the seat of amputation on the result of the
operation, it may be stated as a general rule, that the  risk is greater in propor-
tion as the size of the part that is amputated increases, and as the  line of am-
putation approaches the trunk.  In  the  larger limbs, more  especially  in  the
thigh, every inch appears  to make a difference in  this respect.   Thus  in  our
army in the East, of 178 amputations of  the thigh 44 were in the upper third,
and of these 38, or 86 per cent,  proved fatal;  68 were in the middle third, of
these 41, or 60 per cent, died; whilst in  the  lower third the mortality out of
66  cases was 37, or 56 per cent.  It needs no formal argument to show, that the
amputation of the toe, or of  the foot, is less hazardous than that of the leg, or
of the thigh.   The statistics collected by  Malgaigne of amputations of all kinds
in the Parisian hospitals, exhibit clearly this increase  in  the  ratio ol mortality
as the operation approaches the trunk.  Thus, in 26 cases of amputaion  of  one
of  the smaller toes, there was 1 death.   In 46 cases of amputation of the great
toe, there were 7 deaths, or 1 in  6.   Of 38 partial amputations of the  foot, 9
proved fatal, or about  1 in 4.  Of 192 cases of amputation of the leg, 106 died,
about 56  per cent.  And in  201 amputations of the thigh, there were 126
deaths, or 62  per cent.
   I am informed that in  the British army  in the  Crimea the per centage of
death was, after amputation of the fore-arm 7, of the upper arm 19, of the
shoulder joint 35; of the foot 16, of the leg 37, of the thigh 64, and  of the
hip 100, figures most creditable to the  skill of the surgeons employed,  but
showing the progressive tendency to increase with the size of the limb removed.
   Not only does the size  of  the part removed, and its proximity to the trunk,
influence materially the general mortality after amputation ; but these conditions
also influence  the particular cause of death.   Thus, after the smaller amputa-
tions, as of a toe, for instance,  death only occurs in unhealthy states of the con-
stitution, from the occurrence of erysipelas, or of some of the various forms of
diffuse inflammation.  Death after the larger amputations more  frequently re-
sults from causes connected with the operation itself, as, for instance, secondary
hemorrhage, shock or exhaustion from the  abstraction of the large quantity of
blood contained in the limb, as well as by that lost during the operation.  After
the removal of the whole of a limb, as in  the case  of amputation of the hip-
 joint, it is possible that the  cause suggested by Mr. Cox, viz., the removal of a
limb in which the blood  undergoes changes of importance to the rest of the
economy, and consequently causing a return of  imperfectly altered blood to the
heart, may materially  affect the result.
   2. The part of the bone that is sawn through may influence the result.   Thus
amputations through the  cancellous ends  of long bones are less dangerous than
those through  their shafts, in consequence of the medullary canal not being
opened when the section is  made near the  articular end, and thus the liability
of  diffuse suppuration of this cavity, and of consecutive  phlebitis  and pyemia
are avoided.
   3. The nature of the disease for which  the  amputation is performed influ-
ences its  mortality.   Thus  amputations  for malignant  disease are more  fatal
 than those for caries of bone or diseased joints.  In cases of diseased joint there
 is a greater tendency to recover when the affection is of a simple than when it
is of a tuberculous nature.  The period at  which the amputation is performed 
44
AMPUTATIONS.
after the setting in of the disease serves but  little to influence the mortality,
provided it be not deferred to too late a stage,—when the patient s constitution
is worn out by hectic.                                          ,.    ,   .  fl
  4. The mortality resulting from amputations is perhaps more  directly lnnu-
enced by whether the operation is done for injury or disease, than by any othei
cause, being  far greater in corresponding limbs after injury than disease,   in
the following table may be seen the results of 174 cases of amputation performed
at University College Hospital.

       RESULT OF AMPUTATIONS IN UNIVERSITY COLLEGE HOSPITAL.
	Injury.		Disease.	
SEAT OF AMPU»*TION.	CASES.	DEATHS.	CASES.	DEATHS.
Shoulder and Arm	23 17 7 6	14 3 2 0	46 48 16 11	9 8 5 0
( Total.	53	19	121	22
  Of these  amputations, 66  occurred in the Hospital up to 1841, and  are re-
ported by Mr. Potter in a paper published in  the " Medico-Chirurgical  Trans-
actions for that year.   They  were performed by the several surgeons of the In-
stitution at that time.   Of the remaining 108, 41 were performed by Mr. Liston,
between 1841 and his death, in 1847;  5 by his immediate  successors; and 62
by me.   Mr. Quain's cases are not included.
  Malsaigne's statistics from  the Parisian hospitals illustrate this matter in as
clear a"point of view, as will  be seen by reference to the following tables.
	Injury.		Disease.	
SEAT.	CASES.	DEATHS.	CASES.	DEATHS.
Thigh......	46	34	153	92
Leg......	79	50	112	55
Foot......	9	6	29	3
	30	17	61	4
  The shock inflicted by the injury, with its subsequent evils, appears  to be
one of the principal reasons of the greater frequency of the mortality after am-
putations for injury than of those for disease.   After amputation for injury, also,
there is a greater liability to the occurrence of gangrene of the stump, and pye-
mia and its secondary effects, than in the case of the removal of a limb for dis-
ease; in which the principal causes of death usually appear to  be exhaustion,
and  the supervention of disease of the lungs.   In  amputation in cases of dis-
ease, it  will  be found, that those  patients do best in whom the disease is most
chronic.  This is especially observable in cases  of  disease of bones and of the
joints.
  5.  In amputation  in cases of injury an important question has to be deter-
mined,  viz., the influence exercised by the  time that  has  elapsed  from the in-
fliction  of the injury to the performance of the amputation, on its results.   Not
only is  the rate of mortality influenced  by the period at which the operation is
performed, but the conditions that immediately occasion the fatal event • as Mr.
James,  of Exeter, has shown in a most excellent essay on the causes of  death
after amputation. 
          PRIMARY  AND SECONDARY AMPUTATIONS.       45

  Amputations for injury are commonly divided by surgeons into primary and
secondary ; the primary being those that are performed during the first twenty-
four or thirty hours, before any inflammatory action in the  part injured has
taken place.   By secondary amputation, many surgeons mean those operations
that are practised after the first twenty-four hours; whilst others again restrict
the term to those that are done after suppuration has set up in the limb, calling
those amputations intermediate that are performed  between these two periods,
viz., from the twenty-fourth hour to the occurrence of suppuration,  and  which
consequently occupy a very  extensive range.  I think, however, that this dis-
tinction is a somewhat trivial one, and not very easily applied in practice; and
it is better to  include under the  term secondary, all amputations performed
after inflammatory action has been set up in  the injured part.  In civil prac-
tice, the mortality after primary amputations, as  will be seen by  the annexed
tables, somewhat exceeds that following secondary operations.  It is more espe-
cially primary amputations of the lower extremities, and particularly those of
the thigh, that are attended by very fatal results.  Of the 44 cases of primary
amputation of the thigh, recorded by Malgaigne, 34 perished.  And of 24 cases
recorded by South, Laurie, and Peacock, as occurring at St. Thomas's Hospital,
at the  Glasgow  Infirmary,  and  the  Edinburgh  Infirmary, every  one  proved
fatal.  This similarity of result occurring in different institutions, shows clearly
that this operation is one of the most fatal in  surgery, and that  the great mor-
tality attending it is inherent to it, and not dependant upon local  or accidental
circumstances.   This danger of amputation of the thigh for injury is increased
in  proportion as the  limb  is severed high up.   It  is least in those cases  in
which the operation is  done for injury of the leg or knee joint, and greatest
when it is performed for compound fracture of the femur, recovery from which
is rare indeed.
Primary Amputations.				Secondary Amputations.			
Thigh. A	CASES.	DEATHS.	James. South. Laurie. Steele. Hussey.	Thigh. J	CASES.	DEATHS.	James. Steele. Laurie. Hussey.
	13 5 11 32 6	8 5 11 21 5			15 18 24 2	5 15 16 0	
Leg . .)	18 9 22 53 13	7 2 15 22 0	James. South. Laurie. Steele. Hussey.	Leg . .)	5 19 5 2	1 13 3 0	James. Steele. Laurie. Hussey.
Shoulder J and arm j	19 6 26 49 16	3 0 13 15 3	James. South. Laurie. Steele. Hussey.	Shoulder ) and arm 1	4 16 14 1	1 9 7 1	James. Steele. Laurie. Hussey.
Fore-arm <	18 1 15 . 35 15	0 0 0 1 1	James. South. Laurie. Steele. Hussey.	Fore-arm .	1	0	- Hussey.
 
46
AMPUTATIONS.
RESULTS OF PRIMARY AND SECONDARY  AMPUTATIONS IN CASES OF INJURY,
                   AT UNIVERSITY COLLEGE  HOSPITAL.
	Primary.		Secondary.	
SEAT.	CASES.	DEATHS.	CASES.	DEATHS.
Thigh..... Leg...... Shoulder and arm Fore-arm ....	7 11 4 5	4 3 1 0	16 6 3 1	10 0 1 0
Total . . .	27	8	26	11
  In  military practice the case is  different; secondary amputations being  by
far more fatal than primary.  This is the experience of army surgeons from the
time of Faure, Larrey, and the Peninsular officers, to those of the late Crimean
campaign.  Thus,  Faure  only  saved 30  out  of 300  secondary amputations,
whilst  Larrey saved  three-fourths of those in which he amputated primarily.
In the Peninsular war, the mortality after secondary amputation of the  upper
extremity was twelve times, and after secondary amputation of the  lower limb,
three times as great as after primary amputation of these parts.  I am informed
on high authority that in the British army in the Crimea, from the 1st of April
to the close of the war, the  relative rate of mortality per cent, after primary
and secondary amputations, was as follows:
  After primary amputations at the shoulder,  27; of the arm, 17;  of the fore-
arm, 3; of the thigh, 62;  of the leg, 30; and of the foot, 17.
  After secondary amputations  the  deaths per  cent, were—at the shoulder, 66;
of the arm, 31; of the fore-arm, 28 ; of the thigh, 80; and of the leg,  76.   Or,
for the upper extremity, the whole rate of deaths after primary was 15, against
41, after secondary amputations; whilst, for the lower extremity, excluding the
foot, it was 46 for the primary, against 78 per cent, for the secondary.
  To what is this  difference between the results  of primary and secondary
amputations in civil  and  military practice owing ?  Why are the results  of
amputations reversed in civil and military practice ?   Why are primary ampu-
tations more  fatal in civil, and  secondary  amputations in military practice ?   I
think we  may explain this difference in respect to primary amputations, partly
by the circumstances under which the injury of the limb has been received, and
partly by the difference in the nature of the  accident.   As has already been
stated, the shock to  the system is the main cause of death after primary amputa-
tions, and this is  felt less severely by the soldier than by the civilian.  A soldier
struck in  the heat of action, when his spirits are raised, and his courage  is
high, treats his wound almost with indifference, or looks upon  it, perhaps, as a
glorious accident of  his profession; whilst the civilian, whose  limb is crushed
by the wheel of  a carriage, or the fall of a scaffold, is not only mentally unpre-
pared for such an accident, but  is depressed by the magnitude of the  calamity
that has unexpectedly overtaken him, in which he sees, perhaps, his own ruin
and that of his family.  Hence, the depressing influence  of the shock  of the
injury is seriously increased by the mental distress accompanying  it and the
chances of recovery are proportionately diminished.                  '
  In secondary amputations the influence of shock is no longer felt but the
chief danger arises  from  the  occurrence of  gangrene, diffuse inflammation,
secondary hemorrhage,  and all  those  morbid conditions  that are apt  to  be
induced by defective hygienic circumstances, and in these respects  the civilian
is more favorably situated than  the  soldier.   If an injured limb  be  not
removed on the field, the soldier is often conveyed to a  crowded hospital neces-
sarily overfilled with wounded comrades, and rife with pestilential influences 
AMPUTATIONS OF  THE  FINGERS.
47
where, if amputation is performed, he has little prospect of escaping infection.
The civilian, on the other hand, who is struck down by accident, is placed in a
state  of cleanliness and  comfort — probably greater than he  has  ever before
experienced — can  be  successfully guarded  against all noxious influences, and
consequently has the best possible chance of recovery afforded him.  In addition
to this, amputations are  not uncommonly very properly done on  the  field, in
cases in which an attempt would be made in civil practice to save the limb, and
as the injuries are  frequently produced by musket-shot, there  is less mangling
of the limb, and  consequent shock to the system, than when a member is
crushed by those accidents  in  mines, on  railways, and  by waggons, for which
primary amputation is  commonly required in civil life.
   As  has already been observed, not only does the rate of mortality  differ in
primary  and secondary amputations,  but also  the  cause of death.  Primary
amputations  are  most frequently fatal from shock  or exhaustion, although
death from secondary diseases  of a low  type is by  no means of unfrequent
occurrence in these cases.   Secondary amputations for injury most commonlv
carry off the patient by the supervention  of diseases of a low type.  Amongst
these secondary affections that are, according to my observation  at the University
College Hospital, of most frequent occurrence, gangrene of the stump stands
in  the first place, especially after amputation of the  thigh, and more  particu-
larly if the limb has previously been in a similar condition before the  amputa-
tion.  Then again phlebitis with pyemia, secondary hemorrhage, and some  of
the low forms  of visceral inflammation, or  congestion, as pneumonia, pleurisy,
and diarrhoea, are of  frequent occurrence.  Pyemia and congestive pneumonia
are the most frequent  causes of death after secondary amputation of the leg and
arm.  Secondary  hemorrhage to such an extent as to  prove  fatal is not  of
common occurrence;  when it does happen it is usually associated with some
diseased state of the blood that interferes with the formation  of a plastic plug
in the artery.   The treatment of this condition will be considered in discussing
injuries of arteries.
                           CHAPTER III.

                      SPECIAL AMPUTATIONS.

  Amputations of the Hand.— The fingers not unfrequently require ampu-
tation  for injury or disease, more
especially as the result of bad whit-                  Fig. 6.
low.  In  many cases  the  ungual
phalanx  requires removal, having
become necrosed.   This may usu-
ally most readily be done  without
amputation by making an  incision
through the pulp of the finger, and
then extracting the diseased  bone,
thus saving the nail and pulp, which
will form an excellent  end to the
finger.   Yet, in other cases ampu-
tation will be  required.  This may
either be done by cutting into the
joint from its  dorsal  aspect  with
 
48                   SPECIAL amputations.
 a narrow-bladed bistoury, running across it lightly, touching the lateral ligaments,
 and  making the flap from the palmar aspect; or the flap may conveniently be
                                  made from the palmar surface by transfixion,
                                  and then cutting cross the joint (Fig. 6).'
                                  In doing this, care must be taken not to get
                                  too far backwards, and to mistake the de-
                                  pression above the head of  the second pha-
                                  lanx for the  articulation, which would lead
                                  to a little embarrassment.   Some little diffi-
                                  culty is occasionally experienced  in finding
                                  the joint, and surgeons have endeavored to
                                  be  guided to it by attention to the  folds in
                                  the integument  covering  it;  but in these
                                  there  is no  constancy, and no correlation
                                  exists between the joint and the folds  in the
                                  skin over it.   When the  amputation is per-
                                  formed from  the dorsal  aspect  the  finger
                                  should  be  flexed, when the  joint will be
                                  found  immediately under the apex of the
                                  triangle formed by the phalanges.  In ope-
                                  rating  from  the   palmar  aspect, the  finger
                                  should be forcibly extended as soon as the
                                  flap  is made, when if the knife be applied
                                  to the  lateral ligaments the synovial surface
                                  will show itself;  but,  as a general rule, am-
                                  putation should  not be performed between
                                  the proximal and second phalanges;  because
                                  as no flexor tendon is  attached to the proxi-
                                  mal phalanx, it is apt to remain permanently
extended, and  a  good deal m  the  patient's way.   In  the case  of the  index
finger, however, it will be better to  leave  the proximal phalanx, the stump of
                                             which forms a useful opponent
                                              to the thumb.
                                               Amputation  is  frequently
                                             required at the metacarpopha-
                                             langeal  articulations.    Here
                                             it may be done in  two ways;
                                             either  by lateral  flaps, or the
                                             oval method.  If  by lateral
                                             flaps,  the adjoining  fingers
                                             should be well separated from
                                             the  one about to  be  removed,
                                             by an assistant who grasps the
                                             hand, so  as to put the  integu-
                                             ment on  the dorsum upon the
                                             stretch. The point of a bistoury
                                             should then be entered about
                                             three-quarters of an inch above

bone; it is then carried forwards to a point oppj^he^terfi^l w T?^
across the side of the finger, and then carried Rme^jiT^^^l^
process is performed upon the opposite side, the iuJdi^erted down h    f
touches of the knife, the extensor tendon divided theS„    7  H I*™
ticulation  performed.'  The oval method, whmh f thfnk I tK  ♦'    ■  ^'
not wound  the palm, consists  in entering  ^U^.^^^ d°6a
i For the conservative surgery of the band, vide Chapter XLIV.
as in 
AMPUTATIONS OF THE FINGERS.
49
the last case, carrying it as far as the web, drawing  it across  the palmar aspect
of the finger, and then obliquely  backwards to join  the  starting-point of the
incision.  By a few touches of the point of the knife the oval flap is turned
back, and the articulation opened.   As a general rule it is better to remove the
head  of the metacarpal bone together with  the finger, as otherwise a wide  gap
will be left in the situation of the  finger that has been amputated, and  much
deformity of the hand result.   This  may be done by cutting the metacarpal
bone  beyond its head across with bone-forceps in  a transverse direction, if
it be  either the  middle or ring-finger that  is removed (Fig. 7).   If it is the
index or little finger, the bone  should be cut obliquely from without inwards,
so as  to shape the bone to the tapering form of the hand (Fig. 8).   If it be cut
directly across,  an  ugly and  inconvenient  square protuberance will always be
left, which will  be  much in the way, and liable to constant  injury.  In some
employments, however, in which great strength and breadth of  hand are required,
and where appearance is of little consequence, the head of the bone may advan-
tageously be left.
   The after-treatment of these cases is extremely simple.   The hand should be
put upon a splint, the wound  covered with  a piece of water-dressing, and the
ends  of the fingers, with a small piece of lint interposed, tied  together by means
of a  tape, care being taken, however, that they do not overlap.  The shaft of
the metacarpal  bone that is  left will gradually atrophy, and thus a very taper
and shapely hand eventually be left (Figs. 9, 10, and 11).
Fig. 9.                    Fig. 10.                    Fig. 11.
   Amputation of the Thumb. — In  disease or injury of the thumb as little as
possible should be removed  by amputation, for if even but a very short stump
of the metacarpal bone  is left, it will serve as a useful opponent for the other
fingers.  When  the thumb requires amputation, it  may most conveniently be
removed by Liston's method.  The point  of a long narrow bistoury should be
introduced well on the palmar aspect of the carpo-metacarpal articulation, car-
ried over this, which it opens (Fig. 12), and the dorsum  of  the  hand as far as
the web;  the  point  of the knife should then be pushed downwards through
the ball  of the  thumb, transfixing this and issuing where  the  incision com-
menced.   It is next made  to  cut  outwards, keeping close  to the metacarpal
bone, which is readily twisted out, the remaining attachment being  separated
by a few touches  of  the knife.   A oval incision will be left,  which comes toge-
ther closely by a narrow line  of cicatrix.  In amputating the right  thumb, it
will be necessary for the surgeon if he adopt the method just described, either
          4 
50
SPECIAL  AMPUTATIONS.
to use his left hand, or to cross his hands in an awkward manner.  In order to
avoid doing  this, he  may reverse the steps  of the  operation with advantage;
first transfixing the ball, and making the anterior flap, then  cutting over the
dorsum, opening the joint, and turning out the bone (Fig. 13).
Fig. 12.
Fig. 15.
Fig.  16.
   The metacarpal bones, with or without the fingers  supported by them, occa-
sionally require removal for disease or injury.   For these operations, which are
not of a very regular kind, it is difficult to lay down definite rules;  but in per-
forming them, care should be taken to make good square flaps of sufficient size,
but to avoid cutting into the palm if possible.   It is well not to disarticulate
the lower end of  the bone, so as to open the wrist-joint, but rather to cut it off
with bone-forceps a little above this.   In injuries from the explosion of powder-
flasks or gun-barrels, when the hand is much shattered, it is of great conse-
                           quence to avoid cutting up the
                           palm to  too great an extent,
                           and it is well,  in these cases,
                           to  save  a finger  if  possible,
                           which will be  more of use to
                           the patient than any artificial
                           limb,  however  ingeniously
                           constructed (Figs. 15 and 16).
                           When only one finger is left,
                           as  the index or little finger,
                           with the thumb, in  cases of
                           partial amputation of the hand
                           after injury or  for disease, the
                           digit that remains  not only
                           becomes  more mobile  than
                           formerly, but greatly increased
                           in  size  and much  stronger
                           than before, so that its util-
                           ity  becomes materially aug-
                           mented.
  Amputation  at the wrist is  not  very often required.  In  performing dis-
articulation  at this  joint, its  peculiar  shape with the convexity looking  up.
wards  must be borne in  mind.   The  integuments being  well retracted  an
 
OF FOREARM  AND ARM.
51
arched incision should  be made from one styloid  process to the other, across
the  back  of the joint,  with  its  convexity looking  forwards  (Fig.  17).
The articulation  having been opened,
and  the  lateral ligaments divided, the                Fia. 17.
knife  is  carried  forwards  so  as  to
make  a  well-rounded flap  from  the
palmar surface;  in  doing  this,  care
must be taken not to cut against the
pisiform  bone; which projects a  good
deal beyond the other carpal bones.

   Amputations of the Arm.—Am-
putation of the forearm is  not  unfre-
quently required for disease or injury of
the wrist or hand.  In performing this
operation,  as  long  a  stump should be
left as possible, so as to give  the patient
more power over any artificial limb that
may be fitted to  it.   The flaps  should
be about a couple of  inches in length,
and well rounded, the hand being  placed in a midstate between pronation  and
supination.  The dorsal flap is best made by  cutting from without inwards; the
line of incision commencing just at the palmar aspect  of the under part of the
ulna, being  carried forwards for  a little  distance  parallel  to this bone,  and
then across the arm  in a slightly  curved manner, until it reaches  the palmar
aspect of the radius; it must then pass along  this, until it reach a point oppo-
site to that at which it commenced, and be dissected back.   The palmar flap is
next made by transfixion (Fig. 18).  As soon as it is cut, the bones are cleared
Fig. 18.
 by a couple of sweeps  of the knife, and the interosseous membrane divided;
 they are then sawn together.  The vessels will be found to be cut long at the
 end, and on either side of the palmar flap.
   Amputation of the arm is most readily performed by lateral flaps made by
 transfixion from  before backwards; the bone is then well cleared by a couple
 of sweeps of the knife  and sawn across.   In  clearing the bone, care must be
 taken fairly to divide the  musculo-spiral nerve by a firm sweep of the knife
 round  the back of the bone  (Fig. 19), if the amputation is performed  in that
 part of the  arm where  this  nerve winds round the  humerus.   If  the  limb ia
very muscular, skin flaps and the  circular section of the muscles will probably
give the best result.
  Amputation at the shoulder-joint may be required for injury of the  arm or 
52
SPECIAL  AMPUTATIONS.
disease of the humerus;  in the first case it is best performed by transfixion; in
the other, by cutting from without inwards.   The subclavian artery should be
Fig. 19.
Fig. 20.
compressed as it passes over the first rib; though, if the assistant be steady and
well up to his duties, this may be dispensed with.
                                      The  operation,  for so severe a  proce-
                                   dure, is very successful; of 60 cases that
                                   occurred  in  the Crimea in the British
                                   army 41 recovered.
                                      In operating  by  transfixion, a long
                                   narrow-bladed knife should be  used.   In
                                   this operation, one  assistant must have
                                   charge of the limb; another should raise
                                   the flap; and  to  a  third  should  be en-
                                   trusted  the important duty  of  following
                                   the knife as it cuts behind the  humerus,
                                   and grasping the  posterior flap with the
                                   axillary  artery, so as to prevent hemor-
                                   rhage from  this  vessel.   The assistant
                                   holding the arm away from  the body, so
                                   as ^ to relax  the  deltoid somewhat, the
                                   knife, instead of being entered by a punc-
                                   ture, should make a small cross-cut about
                                   an inch in extent, at  the point  at  which
                                   transfixion is to be practised, so as  to pre-
vent that jagging of the integuments  by the heel  of the instrument  which
would  otherwise occur.   If the  operation be on  the  right  side, the surgeon
stands  before the  patient, and the point of  the knife should be entered about
an inch in front of the acromion  (Fig. 20); and being carried  directly across
the joint  and  capsule, should pass out at the posterior border of the  axilla.
If on the left side, the surgeon stands behind, and the point of the knife must
be  entered well behind  the spine  of the scapula, at the posterior border of
 
AT  THE  SHOULDER.
53
&
the axilla, carried  across the anterior aspect  of the joint, and brought out to
the inner  side  of the coracoid  process.  In  either case the large flap con-
taining the deltoid
muscle must  then                         Fig. 21.
be  cut by a sweep
of the knife down-
wards, and  as soon
as made, raised by
another  assistant.
The  heel  of  the
knife  is now to be
laid on the head of
bone, the capsule of
the joint cut across,
and the attachments
of the  muscles to
the tuberosity  di-
 vided.   In  order
 to  facilitate   this
 part of the opera-
 tion, it is generally
 recommended that
 the arm should be
 carried forcibly in-
 wards  across  the
 chest.   This  may
 readily be done in
 the dissecting-room
 where  the limb  is
 entire; but in the
 case of comminuted
 fracture of the humerus, with extensive laceration of soft parts, it cannot be
 accomplished.   In such cases as these, the  head and  upper end of the  hu-
 merus being broken off from the shaft, the lever-
 like action of  the bone cannot be put in force,           Fig. 22.
 and it is sometimes not such an  easy matter as
 might at first appear, to detach  its head from
 the glenoid cavity.   In order to  do this, I have
 in cases of comminuted fracture of  the hume-
 rus, in which I was amputating at the shoulder-
 joint, found it necessary, after opening the cap-
 sule,  to seize hold of the upper fragment and to
 draw it forcibly downwards and inwards, by in-
 serting the fingers between the head and the
 glenoid cavity, in order to divide the  muscles
 inserted into it.  After the head  of the bone
 has been turned out  of the glenoid  cavity, the
 knife must be passed  behind it, and carried down
 for a distance of about three inches close to the
 bone  at its inner side.  The surgeon then cuts
 across the soft parts, so as to form the posterior
 flap.   In doing this, the assistant, to  whom  this
 duty is entrusted, must follow the knife with
 his hands, grasping firmly the whole thickness
 of the posterior flap, so as to compress  the ax-
 illary artery, and  thus prevent the occurrence of hemorrhage (Fig. 21).  The
 
54
SPECIAL  AMPUTATIONS
Fio. 23.
 surgeon should not cut the flap across until the assistant tells him that  he
 holds the vessel firmly, and then he must be cautious not to injure his assistant's
 fingers.   The artery will be found to be cut long in the middle of the posterior
 flap, and a few smaller branches may be required  to  be tied at its  inner angle
 and in  the deltoid.  The stump, after it is healed, will present the appearance
 in Fig. 22, taken from my last patient.
   In those cases in which this  operation requires to be performed for disease,
 especially for tumors  of the humerus, by which the soft parts are thinned  or
 condensed, it may very conveniently be done by making the anterior flap by dis-
 secting it up from without  inwards, using of  course for this purpose a short
 knife;  a broad bistoury is most  convenient.  The joint is then opened, and the
 posterior flap formed  in  the usual way.  In  this way I  have easily performed
 amputation at the shoulder joint for large tumors of the head  of the humerus.

   Amputations of  the Foot— The phalanges of the toes -seldom require
                       amputation; when they  do, they may be removed  in
                       the same way as the corresponding parts in the hand—
                       by the formation of a flap on the plantar surface, either
                       by cutting from above  downwards, or by transfixion.
                         In  removing a bone at the metatarso-phalangeal ar-
                       ticulation the oval method should  always be practised
                       so that  the sole of the foot may not be cut into.   In
                       doing this, it must  be remembered that the articulation
                       is situated considerably above the web of the toes, and
                       the incision must therefore be commenced proportion-
                       ately far backwards.  As a general rule it will be found
                       that the articulation is about the same distance above
                       the web as the point of the toe is below it.
                         The metatarsal bone of the great toe occasionally re-
                       quires removal in whole or in part.   If the  disease is
                       limited  to  the anterior  part, the shaft of the  bone
;♦* h«ai i «.  <•     xi. •    .ld be cut across with a Pair of  bone-nippers, and
its head left; for as this  gives  insertion to the peroneus  longus, its  removal
will  materially weaken the foot.  The whole of the bone may be readily removed
                 p                     in  the following way: the  point of
                                       a strong broad bistoury should be en-
                                       tered on the dorsum of the foot in
                                       the interspace between the first  and
                                       second metatarsal bones, as far back
                                       as possible; it should then be  car-
                                       ried  forwards  upon the ball of the
                                       great toe, to a point opposite to the
                                       web  between the  toes,  and thence
                                       made to sink  into  the sole of  the
                                       foot in a line parallel with the outer
                                       margin of the bone (Fig. 24);  the
                                       flap thus formed should be dissected
                                       back, its plantar aspect being  kept
                                       as thick and fleshy  as possible   The
                                       surgeon next  passes the  knife be-
                                       tween the first and  second metatarsal
                                       bones  and cuts  directly  forwards
                                       through the centre of the angle be-
                                       tween the great and the second tpes

                                       that  ih8 'S18' C3re mUSt  be  ta^n
directed too much towards the metatarsal bone  oAhtfreatf £?, itf^hitch
 
amputations  of  the  foot.
55
against  one of the sesamoid bones.   The surgeon next seizes the extremity of
the toe, and, pressing it well inwards, passes the point of the  bistoury deeply
into the angle of the wound  (Fig. 24), where, by the division of some tendinous
and ligamentous fibres that constitute the key of the joint, he opens the articu-
lation and  detaches the bone by lightly touching its  ligamentous attachments.
By keeping the edge of the knife well against the  side of the bone, he may
avoid wounding the dorsal artery of the foot, the bleeding from  which would be
troublesome.  When the bone is to be partially removed, the operation requires
to be performed in the  same way, the incisions, however, not being carried so
far backwards.
   The metatarsal bone of the little toe may conveniently be removed by an oval
incision, so as to avoid wounding the sole  of the foot.  This  is best done  by
entering the point  of the knife just behind the tubercle of the bone, carrying
it forwards and inwards in  the line  of its articulation with the cuboid, to the
centre  of  the fourth digital interspace, and thence forwards to the web of the
toe; the knife is  next carried round the  plantar surface  of this, the incision
being continued obliquely into  that which has been made on the dorsum of the
foot (Fig.  25).  The small flap thus formed is well dissected down, the knife

                                  Fig. 25.
Fig. 26.
passed round the under surface of the bone, and the joint opened by the toe
being forcibly drawn outwards, and its  ligamentous connections lightly divided.
  The whole of the metatarsal bones may be  removed  from the tarsal,  by the
operation  originally planned and  executed by
Mr. Hey.   This consists in, first of all, making
a large convex flap in the sole of the  foot, one
horn of which commences at the tubercle of the
fifth metatarsal  bone,  whilst  the  other  termi-
nates at that of  the first, or rather opposite the
projection  of the  scaphoid.   A  small flap  is
then made on the dorsum  of the  foot, and the
articulations exposed.   These must  then be
opened with some care, as they are very irre-
gular (Fig. 26); the  second metatarsal bone,
especially, being sunk  into a kind of pit in the
middle cuneiform, and  the  articulation  of the
fifth  with  the  cuboid  being very  oblique.
This operation is seldom practised, disease being
rarely limited to the metatarsal bones; their disarticulation also from the tarsus
is very troublesome, on account of the irregularity of the  line  of articulation,
hence it is better to saw through the metatarsus just in  front of the tarsal articu-
lations, rather than to attempt to disjoint the  bones.
  Amputation through the tarsus  may conveniently be performed by Chopart's
operation, which consists  in disarticulation in the  line between the os calcis
and astragalus behind,  and the cuboid and scaphoid in front (Fig. 27).   This
operation  may be perfortned either by first making the flap from the sole of
 
56
*  S
special  amputations.

                          Fig. 28.
Fig. 27.
1  \X
'*«
the foot, and then disarticulating (Fig. 28), or the procedure may be reversed,
and the joints having been cut through  from the dorsum, the flap may after-
wards be made (Fig. 29).  I prefer the first plan, as it enables the surgeon to
make a better and more correctly-fashioned flap.
  In operating on the left foot, the knife, a stout bistoury, should be entered
well behind the tubercle of the scaphoid, and carried forwards for at least three
                                     inches, to about
Fig. 29.
Fig. 30.
                                           the head of the
                                           metatarsal bone
                                           of  the   great
                                           toe, then  right
                                           across the sole
                                           and down  the
                                           outer side of the
                                           foot,  as far as
                                           half an inch be-
                                           hind the  fifth
                                           metatarsal bone.
                                           On the  right
                                           foot, this line of
                                           incision is re-
                                           versed   by the
^ £ knife being entered half an inch behind the metatarsal
   .;' bone of the little toe, carried forwards to the root of the
     toes across the sole, and down the inner side to behind
     the tubercle of the  scaphoid (Fig.  30,  2).  This flap
     should be made broad, especially at  the inner side, but
     well rounded  at  the  angles, and should consist of the
     whole  thickness  of parts in the sole of the foot, which
     must be well dissected out from the concavity under the
     metatarsal bone.  A convex incision  is then made along
     the dorsum from one horn  to  the other of the  plantar
     flap;  the parts  well retracted,  and  the  articulations
     opened by the surgeon bearing firmly upon the  anterior
     part of the foot, and lightly touching the ligamentous structures with the point

     eie'of£Vl  lD ^ T86 ,°f f&  °perati°n>  Care ™st be taken tit the
     edge of the bistoury be  not mchned too much  backwards, lest it slip over the
     astragalus and open the ankle-joint;  or too far forwards, lit it pass anterior to
1. Line of amputation of
    great toe.
2. Line of Chopart's ope-
    ration.
3. Lines  for excision of
    os calcis. 
amputations  of  the  foot.                57
the scaphoid—between it and the cuneiform bones.   After disarticulation has
been produced, the projecting head of the astragalus should be sawn or clipped
off.  The result of this operation is extremely favorable, the patient, by the aid
of a properly constructed  boot, being able to walk, and even  dance with very
little appearance of lameness.  In some cases where the muscles of the calf are
very strong, and calcaneum  projecting, the heel becomes  drawn  up, and the
centre edge of the stump made  to  point down in such a way that the patient
is rendered lame  by walking on the  anterior  sharp  edge of the calcaneum,
which irritates the flap.  This  condition is  best  removed by division  of the
tendo Achillis.
   Disarticulation of the foot at the ankle-joint was first reduced by Mr. Syme to a
regular operation.  By its performance amputation of the leg may often be avoided,
the patient being left with an exceedingly useful stump, which, as its covering is
ingeniously taken from the heel, constitutes an excellent basis of support (Fig. 34).
The operation is performed by making an incision from the anterior part of one
malleolus downwards and  backwards, across the plantar surface of the heel, to a
corresponding point in the opposite malleolus (Fig. 31).  This flap is well dis-
sected back, the knife being kept close  against the bone, especially when it
passes towards the inner side of the os calcis, in  the neighborhood of the plantar
arteries (Fig. 32).  An incision is next made
across the dorsum of the foot, from the upper            Fig.  31.
extremity of the sole flap on one side, to that on
 the other, and the joint opened from the front.
The lateral ligaments should now be touched
with the  point of the bistoury, and the tendo
 Achillis divided by pressing the foot forcibly
downwards and  cutting  from before  back-
wards (Fig. 33) by some twisting and dissec-
 tion ;  at  the  same time the os calcis is com-
pletely separated from its soft  attachments,
 and the  foot  removed; the  two malleoli must then be sawn off, the  plantar
 arteries tied, and the flap brought up.   A well-formed rounded stump will thus
 be left as represented in Fig.  34.
Fig. 32.
Fig. 33.
Fig. 34.
  In performing this operation, care must be  taken that no button-hole aper-
tures are made through the posterior part of the heel flap.  This may commonly 
58                    SPECIAL  amputations.
be avoided readily enough whon the soft structures in this situation are greatly
thickened  and infiltrated by plastic matter, as the result of chronic disease;
but if the  operation be required for injury of the foot, great care is required in
digging out the heel, the integuments at the posterior part of the  os  calcis
being very thin and adherent to the bone.  It is  also of importance that the
incision across the heel should be  carried well back over its point (Fig. 32).
Unless this be done a large cup-shaped flap will be left, in which blood and pus
will accumulate, and the  cicatrization of the stump will be much retarded.  The
principal point, however, to be attended to is, that the plantar arteries are cut
long; unless care be taken to do  this, the flap will be insufficiently supplied
with blood, and sloughing, especially of its outer angle, to which there is in all
cases a tendency, will be particularly liable to occur.  As union takes place by
granulation, there will  be a tendency to bagging in the stump, but this may be
prevented by proper bandaging.   The tendency to sloughing and to undue sup-
puration chiefly occurs in those cases in which the  amputation has been per-
formed  as  a primary operation for a  crush of the foot.  In one case, in which
I had occasion to perform it for an  injury of this kind, a good deal of trouble
resulted from this cause,  though eventually the case did perfectly well, and the
patient now walks with scarcely any difficulty.
  Various  modifications of Syme's amputation may at times be practised with
advantage, in consequence of the soft part covering the heel  being  more or less
ulcerated or disorganized, so as not to admit of forming a good basis of support.
Under these circumstances, the flaps may be fashioned from the sides instead
of from behind;  and in this way I have more  than  once formed  an excellent
covering to the end of the stump.  These lateral flaps should not,  however, be
made in any case that admits of disarticulation  at  the  ankle in  the ordinary
way.  In no case do they afford so great a basis of support as the integuments
of the heel, which are  far more dense and elastic.
  Pirogoff's modification of  Syme's operation consists in the preservation of
the posterior portions of the os calcis which  is left in  the heel flap.   The opera-
tion is performed  in in the following way: — the incision  is  carried across the
                                             sole of the foot, from one  mal-
                                             leolus to  another; but the flap
                                             thus   formed  is  only dissected
                                             here about two lines.  Disarticu-
                                             lation of the  astragalus  is  then
                                             effected in  the usual way by an
                                             incision across the  front of the
                                             foot.   A narrow saw is now ap-
                                             plied  to  the  upper  and  back
                                             part of the os calcis behind the
                                             astragalus  (Fig. 35),  and  the
                                             bone  cut  obliquely  downwards
                                             and forwards; the  malleoli are
                                             then removed and  a thin  slice
                                             of the articular  cartilage  taken
                                             off.    The advantages of   this
                                             operation  over  the  ordinary
                                             mode  of  disarticulation consist
                                             in the stump being larger and
                                             better adapted for pressure,—in
                                             the readiness  of the union of the
two applied osseous surfaces,—and in the less likelihood of the vascular supply
in the posterior flap being interrupted, as  its vascular communications are not
much disturbed, and the  posterior tibial artery can always be cut long
   The Subastragaloid amputation  is another mode  of disarticulating the foot
In it the heel  flap is made as in Syme's operation, and the articulation between
Fig. 35.
 
AMPUTATIONS OF THE  LEG.
59
the astragalus  and scaphoid  being opened  (the  ankle-joint left intact), the
bistoury is passed under the astragalus, between it and the  calcaneum, which,
together with the rest of the foot, is removed. In this amputation a good, long,
useful stump results; but the cases requiring it must be few, as it does not often
happen that the calcaneum, together with the anterior range qf tarsal bones are
diseased, without the astragalus also being involved.
   In cases of caries of the tarsus requiring amputation, it occasionally happens
that the surgeon cannot determine with certainty,  whether the morbid  action is
limited to the anterior range  of tarsal bones, or extends so far backwards  as
seriously to implicate the astragalus and calcaneum, and is  consequently unable
to decide whether the foot admits of removal by Chopart's operation, or requires
disarticulation at the ankle-joint.  Under these circumstances all doubt will be
cleared, and the proper operation performed, by making an incision  across the
dorsum of the foot in the line of the  astragalo-scaphoid and calcaneo-cuboid
articulations;  these are then opened, and the state of the bones  examined.  If
the astragalus and calcanenm be sound, or but slightly diseased on their anterior
aspect, Chopart's  operation may  be  done,  and any carious bone left behind
gouged away. If, on the contrary, these bones be found to be deeply implicated,
the  flap may be dissected back for  about  an inch, and disarticulation at the
ankle-joint proceeded with. It may also be well to bear in mind, that the tarsal
articulations may have become so  anchylosed, as the result of old disease, as to
require the application of the saw.

   Amputation of the leg may be performed in three situations;  either just
below the knee, in the middle, or in the lower third of the limb. The  selection
of the line of amputation must depend  upon the extent of the disease, but,
wherever practicable, the amputation  should be performed  low down;  the mor-
tality diminishing in proportion as the limb is removed near to the ankle.  Of
106  amputations in this situation done in  Paris  there were only  13 deaths.
Surgeons used formerly, even where  the disease  or injury was limited to the
foot, to amputate immediately below the knee;  in  all  those cases in which the
patient would be obliged to wear  a common wooden  pin, the long leg stump

                                  Fig. 36.
being highly inconvenient when the patient rested  on his bent knee;  whereas
to those individuals who could afford the expense of a well-constructed  artificial
limb, the amputation was done in the lower part of the leg.  But this difficulty
has of late years been removed by the introduction of a  short wooden pin, in
the socket of which the stump is fixed in the extended position; and amputation
in all admissible cases should consequently, even amongst  the poorer classes, be
done at or below the calf.
   The flap amputation of the leg may be performed in the following way.  The
tourniquet  having been applied to the artery in the  popliteal space (Fig. 36), 
60
special  amputations.
the assistant, whose  duty it is to retract  the  flap, takes his stand in this, as in
all  amputations  of the  lower extremities, opposite to the surgeon.   In the left
limb, the point of the knife is entered at the posterior edge of the tibia, carried
forwards for a distance of one inch and a half, then across the anterior part of
the leg to the posterior border of the fibula, up which the incision is made to
extend to a corresponding distance.   In the right leg, the same  incision com-
mences on the fibular side of the limb, and terminates on the tibial.  The flap
thus formed, which should be broad and well  rounded, is next dissected up by
a few touches  of the point of the knife, and  transfixion of the limb made by
passing the blade across behind the bones, from one angle of the incision to the
other.   The posterior flap is then  formed by cutting obliquely downwards and
backwards, and should be about three inches long.   The bones are next cleared
by a double sweep of the  knife, and the interosseous soft parts divided by car-
rying the instrument in a figure of  8 way between the bones.   In doing this,
especial care must be taken not to direct the edge upwards, so as to split either
of the tibial arteries,  more particularly  the  anterior: for as this vessel retracts

                                 Fig. 37.
above the membrane, its ligature when divided too high, is no easy matter   In
sawing the bones, the fibula should always be cut firlt/as otherwise it will be
pretty sure to be splintered.  This bone  may be best divided on the leftside
by sinking the hand below its level of the limb, and using the heel of the saw
and  on  the right, by holding the  hand above'the limbfand^ cutting^ with the
end of the instrument (Fig. 37).                       '     ^wng witn tne
  If the limb be very muscular, a  large pad of the muscles of the calf will be
left in the posterior flap;  this  will usually be a  trood HpaI  in +\1 ™  T •
treatment; it may 8l„aghP/a„d thus interfere with  pTpe/ l" t ZetS
I have advantageously removed  at  one sweeD of  th* lrnifi, +1.      T         ,.'
the muscular mass  thus  left, thus leaving ifttlemore than *1*"?*' Pf * °f
order to avoid this, the best operation consfsts' n sS casesV, W  P V     1D
skin-flaps on the anterior and posterior aspec softheS Jlten"  T^
circular  cut through the muscles.   In  this way thendTof the  t        S '
but a thin covering; but this matters little if th^operation tvlrZVT™
below the knee, for the patient bearing upon the Si" rft^ J
exercises no pressure upon its cicatrix  when an artificial limb is adnr!^ f  7'
  Amputation through the knee-joint, originally  t*\Z£^§^ ''nd 
amputations  of the knee and  thigh.        61
practised by Velpeau  and other Continental surgeons, has recently found favor
in this country and America.
   The operation may readily be performed in the following way.   An incision
is made  directly across the knee-joint above the centre of the patella.   The
skin-flap thus formed is dissected back, and the joint being opened above the
patella, and the ligaments divided by a few touches of the knife, a long posterior
flap is cut from the upper part of the calf of the leg, by passing the knife behind
the  tibia and carrying it downwards for a suitable distance.  The exposed
articular surface of the femur is then  to be  sawn off.   The only large vessel
requiring ligature  will be  the popliteal.   Some surgeons prefer making a long
anterior skin-flap and a transverse cut through the soft structures  of the ham.
The anterior flap falls  over the end of  the femur, and  being composed of the
tough and extensile integument of the  knee,  constitutes an excellent covering
to the bone well adapted for pressure.
   This amputation may sometimes conveniently be varied by being done through
the condyles without  previously opening the knee-joint.  The  anterior  flap  is
fashioned as before, the posterior flap is then  made  by transfixion behind the
joint, and the bone being so cleared, the  saw is applied immediately above the
articulation, and the limb thus removed
(Fig. 88).   The .result is the same in               Fig. 38.
whichever way the operation is  done                          fT\
The  advantages of this  operation  over                         / /
amputation of the thigh higher up are     ^\.              / /
undoubtedly great.  The limb being re-          ^^\^       £/
moved  at a greater distance  from  the                 /l^^B^bk
trunk, the shock  to the  system will be                /RSIR^Il^
less, and the rate of mortality diminished.                /JF^1»J|mm|
The medullary canal  of  the femur not              /&%   Sj**m
being opened there will be less likelihood              $fm^iipP  !S§fl
of osteomyelitis;  fewer ligatures will be    ^^^^Mi^aj^fjP^^^jjjr^
required, and if desirable these may be               f/\5<    ^^^f^
brought out through  an  opening made              Mr   | \       ^%k
in the centre of  the posterior flap, as              Mr    I  \          ^m.
Blandin recommends; and lastly, a longer            m     \ j           ^m
stump will be  left, the  movements of                   \j            ^
 which are more under the control of the
 patient than a shorter one, owing to the  proper muscles of the femur not being
 divided,  and thus all the movements  of that  bone being  preserved in  their
 integrity.  There  is a little  point of practice that I have found  useful in this
 amputation, viz., to round off with the  saw the sharp edge left on the condyle
 after the removal  of its  cartilaginous surface, and which otherwise  may press
 injuriously upon the flap.  Dr. Markoe finds that out of 40 cases in which this
 operation has been done,  there have been 17 deaths:  a rate of mortality equal to
 37 per cent.
   Amputations of the thigh are commonly required, both for accident and for
 disease;  they may be performed  in three situations: immediately above the
 knee, in  the middle of the limb, or in its upper third.   In the amputation in
 the lower and middle third, a tourniquet may be applied high on the limb: but
 when  the operation is done in the upper third there  is no space for the applica-
 tion of this instrument, and the surgeon must then trust to an assistant com-
 pressing the artery as it passes over the brim  of the  pelvis.  This is best done
 by grasping the great trochanter with the fingers of the  right hand, and then
 applying the thumb firmly over the artery; upon this the other thumb is then
 pressed as firmly as possible, and  thus  all chance of letting the vessel slip is
 prevented.
   Amputation  above the knee, or Vermale's operation, is best done by lateral
 flaps.   In performing this operation, the outer flap should always be made first. 
62
SPECIAL  AMPUTATIONS.
The point of the knife being entered in the middle of the thigh, about three
inches above the upper border of the patella, is carried close round the bone and
brought out through the  centre of the ham;  the flap  is  then cut downwards
and outwards; the knife  being entered again in the upper angle of the incision,
is carried close round the bone to its  inner side, and the  inner flap made by a
sweeping cut (Fig. 39).  Unless the blade be kept in contact with the bone in
Fig. 39.
Fig. 40.
 this situation the femoral artery is very apt to be split; the flaps being then re-
 tracted, the bone is cleared  by two sweeps of the knife, and sawn  about four
 inches above its articular surface.
   In the middle and upper  third of the thigh,  the  antero-posterior flap opera-
 tion is to be preferred.   In  ordinary cases the anterior flap may first be made,
                                  and the posterior one subseqently fashioned
                                  by transfixion (Fig. 40).   If, however, the
                                  patient be very much emaciated, it is dif-
                                  ficult to  get a good cushion from the ante-
                                  rior part of the thigh in this way, and  it
                                  is consequently  preferable  to  follow the
                                  plan recommended by Mr. Luke, of making
                                  the  posterior flap first by transfixion, and
                                  the  anterior one afterwards  by cutting
                                  from without inwards (Fig. 41).   In  some
                                  instances in which the tissues at  the  pos-
                                  terior part of the thigh are much diseased
                                  or injured,  whilst those on  the  anterior
                                  aspect of the limb are sound, a very good
                                  stump may be fashioned by making a long
                                  square anterior  flap  by transfixion,  and
                                  then  cutting at  one stroke of the knife
                                  through  the soft part  at  the  posterior
                                  aspect of the limb in a somewhat oblique
                                  direction from below upwards.   The ante-
                                  rior  flap  when  laid down  will form  the
                                  cushion at the end of the stump.   If the
                                  patient be excessively muscular,  and the
                                  amputation be a primary one, I think it is
                                  better to  make  skin-flaps with  a  circular

I„ thi, wav the harge gaping fleshy ^£^£tZ£ff£
into unhealthy suppunmon and sloughing, and lead to the death oHhe patie™°
 
            AMPUTATIONS OF THE  THIGH  AND  HIP.          63

  Amputation through  the trochanters may sometimes be advantageously prac-
tised, either in severe compound fractures of the lower part of the thigh, or in
cases of those malignant cartilaginous or osseous  tumors of the lower and mid-

                                  Fig. 41.
die third of the femur, and thus the more severe and dangerous  operation of
disarticulation at the hip avoided.  Indeed, should it be found after section of
the bone that this is so much injured or diseased as to require removal at the
joint, this  may readily enough be done by dissecting the head out of the ace-
tabulum  with a strong scalpel or bistoury.
   Amputation at the hip-joint has been performed in a variety of ways, which
it is not  necessary to detail.  The simplest and speediest consists in  making a
large and thick anterior flap by transfixion, and a short posterior one from the
gluteal region and back part of the thigh.  In order to perform this  operation
properly, the patient's  body must be brought well forward upon the edge of the
table, so  that the nates project beyond it, with the sound limb tied to the leg
of the table.   One assistant, whose duty it is to raise the anterior flap and com-
press  the arteries  as  they are cut, should stand behind the surgeon; another
must have  charge of the limb and  impress such  movements on it, as to bring
the head of the femur into the best position for the proper performance of the
operation.  The duties of both these assistants are of the utmost  importance,
and should only be entrusted to fully competent persons.   The  pelvis and body

                                  Fig. 42.
must  be well steadied by two or three others.   The knife, which must have a
blade twelve inches long, requires to be entered  and the flap to be made in dif-
ferent ways, according to the  side of the body on which the operation is per- 
64
SPECIAL  AMPUTATIONS.
formed.  If it be on the left side, the knife should be entered about two fingers
breadth below the  anterior superior spine of the ilium, and carried deeply in
the limb behind the vessels, and directly across the joint;  its point being made
to issue just above  the tuberosity of the ischium (Fig. 42).   In transfixing, care
must be taken not  to carry the point of the knife too high, lest it enter the thy-
roid foramen.   The anterior flap must then be rapidly cut downwards and for-
wards, about five inches in length.   The limb which  had, during this stage of
the operation, been raised and slightly flexed upon the abdomen, must now be
forcibly abducted and everted; the capsule of the joint is then to be opened by
a firm cut with the point of the knife.   So soon as this is done, the head of the
femur must  be pushed up, so that it may start out of the acetabulum; the heel
of the knife is then  passed behind it, the remainder of  the capsule cut across,
and the posterior flap rapidly fashioned by carrying  the knife  downwards and
backwards through the thick muscles in this situation.  When the amputation
is performed on the right side, the anterior flap is  made by entering the knife
just above  the  tuberosity  of the  ischium,  and bringing it out two  fingers'
breadth below the anterior superior spine of the ilium (Fig. 43); the remaining

                                 Fig. 43.
steps of the operation being performed as in the last case.   In those cases in
which amputation  at the hip is performed  for a severe  compound fracture of
the thigh  high up, it may be somewhat  more difficult  to get the  head of the
bone out of the acetabulum, as the surgeon is deprived of the long lever afforded
by the limb by which the head is tilted upwards and forwards.  In such cases
as these, he must seize  the  broken fragment  and draw this down  at the same
time that he pushes forwards its head and cuts firmly and fairly upon it  In a
case in which I amputated at the hip for compound fracture of the thigh two
inches below the trochanters, I found it necessary to use much force in depress-
ing the lower end of the fragment, and thus elevating and turning out its head
 m In amputation at the hip-joint, the great danger to be apprehended  is exces-
sive hemorrhage, the  incisions being made so high up that no tourniquet can
be applied, or pressure of the artery in the groin trusted to.   It is therefore of
great importance to  perform the  operation with as  much rapidity as  possible,
and the  disarticulation ought to be effected  in, at most, thirty or forty seconds!
The arrest of the  hemorrhage during the  operation must  be  entrusted  to an
assistant who can be fully relied on.   His business should be to compress the
artery above the brim of the pelvis, and then to follow the knife in the first in
cision, and as the anterior flap is being made, slip his fingers under  it and grasp 
AMPUTATIONS  AT  THE HIP.
65
it firmly above and  below, so as  to compress the  femoral aftery in it, which  is
divided as the knife cuts its way out (Fig. 44).   By grasping the flap tightly,

                                  Fig. 44.
there will be but little risk of undue hemorrhage from the femoral artery;  but
lest it should slip, or the assistant whose duty it is to attend to it by any chance
fail in holding it properly, it may be well to direct one of the assistants, whose
business it is to  steady the trunk, to have his thumb well pressed down into the
iliac fossa, so as to compress the  artery against the brim of the pelvis.   As the
posterior  flap is being made, the bleeding from the gluteal and  sciatic vessels,
which is  often very free, may be arrested by two assistants being in  readiness
to cover  and compress  them with the fingers  or  sponges.   The arteries may
then  be ligatured one by one, as  the assistant raises his fingers from them.   If
he have good hold of the femoral, the vessels in the posterior flap may be tied
first; but if the femoral be insecurely held, it must first  be tied.  The femoral
arteries, both superficial and  deep, will be  found to be cut long and to project
from the muscles by which  they  are surrounded, so as very readily to be seized
by the  fingers or forceps, pulled  out and ligatured.  The arteries in the poste-
rior flap and on the inner side of the joint will be found in  the intermuscular
septa.  Another point of importance in this operation, in making the first punc-
ture across the  thigh, is to avoid wounding the opposite  limb, the  scrotum or
the obturator foramen; this may  be  done by keeping these parts out of the  way
of the  knife, and carefully guiding its course parallel to, but not  against the
pelvis.
   Amputation at the hip-joint has been performed, so far as I can ascertain, in
126 cases; of these 76 died.  In 47 instances it was for injury;  of these 35 proved
fatal.   In 42 cases in which it was  done for chronic  disease, 24 recovered and
18  died.  According to Dr. S.  Smith, the mortality from  this  operation has
been much less of late years than was formerly the case, and  this is  doubtless
true so  far as amputation at the hip-joint for disease is concerned; but in cases
of injury the procedure is still a highly unsatisfactory one.  In all the 12 cases 
66
CONGESTION.
in which it was  done in  the Crimea  it proved  fatal.   The  diminution of late
years in the mortality when this operation  is practised  for disease, is doubtless
in a great measure due to the better selection of cases, but especially  to the em-
ployment of anaesthetics, by which the severe shock to  the system that usually
results from so severe a mutilation is necessarily materially lessened.
CHAPTER  IV.

  CONGESTION.
   Congestion plays an important part in surgery, it occasions  serious structural
changes, and runs into inflammation.   Congestion is always a passive and me-
chanical condition, hence the term active congestion should  not  be employed.
Indeed, what has  been described as "active congestion" is in reality a variety
of the inflammatory process.
   Congestion  is a true  hyperaemia; in it we find  not only that the blood is
greatly increased in quantity, but that it circulates  languidly  through the part,
and is of a darker color than natural.  The arteries are at most of their normal
size, perhaps even contracted;  the  veins and capillaries  are  greatly distended
by the slowly-moving fluid. When the circulation in the congested part becomes
completely arrested, stagnation is said to have occurred.
   The symptoms of congestion are  well marked when the part affected  can be
seen or felt; when occurring in an  internal  organ they are often very obscure.
Congestion of an external part, may be recognized by the changes it induces in
the color, the feel, the size, the sensibility, the temperature  and  the functions
of the part that it affects.  The color of a congested part ranges  from purplish
red to a dusky brown; its size is increased; it feels soft, and pits  under the
pressure of  the finger.  The  patient is often conscious of a heavy, dull,  achin<*
sensation in it, scarcely amounting to pain, but  yet attended with uneasiness°
The  temperature is never above, but often below, the natural  standard, and the
functions are lessened in activity.
.   The existence of congestion in an internal organ may be ascertained by finding
its size increased, its functions modified, with a sensation of weight in it
  The effects of congestion are of much surgical importance.   The first  change
that  usually takes  place is an  effort  in the vessels of the part to  relieve them-
selves by a transudation of the more watery constituents of the blood into the
surrounding cellular tissue.  Hence distension of the cells of  this tissue by the
enused iiuid, giving rise to adema.                                      J
  If  the turgidity of the vessels be great, and  their walls at the  same time
weakened rupture will occur and hemorrhage on to  the surface, or into the sub-
stance of the part, ensue.                                   ;
  In  consequence of the infiltration of the cells of the part, softening takes
place  nutrition  becomes less  and less perfectly performed,  and  ulceration at
ast occurs.  These changes we not unfrequently see in the integuments of the
legs of old people.  In other cases the vessels becoming permanent^dilated
the part  assumes habitually a redder or darker tint, becom^TwX^anS tftt
be a  mucous surface, it may be roughened and papillated, as is often observed
in a congested conjunctiva.                                      ^" uuntnou
  The causes of congestion, always mechanical, may be divided into two -reat
classes, which we often find conjoined.  1st. Those causes that act by obstruct- 
DETERMINATION  OF BLOOD.
67
ing the return of the venous blood; 2d. Those that act by enfeebling the walls
of the capillaries and veins, so that they are no longer able to withstand the
outward pressure of the contained blood.   Amongst the first set of causes may
be  specified, any condition that directly and immediately interferes with the
proper return of blood through a vein ; in this way the pressure of a tumor upon
such a vessel produces congestion of the part from which it carries off the blood.
   Venous obstruction does not always act in so direct a manner as this, for  it
not unfrequently happens that obstruction to the return of blood from one organ,
will occasion a congestive condition of the vessels  in a distant one.  Thus we
find that some forms of congestion of the eye-ball are due to obstruction in the
branches of the portal veins.
   The long-continued dependent position of a part may occasion its congestion
by the blood mechanically gravitating into  it, and  overcoming, by the pressure
thus brought to bear upon the vessels, the onward movement of the fluid within
them.   Thus we see congestion of the legs from long-continued  standing;  of
the hemorrhoidal veins from an habitually sedentary life;  and of the posterior
part of the lungs  of those who have been long  confined to the recumbent
position.
   Amongst the most common causes of congestion  that act by enfeebling the
vessels, we find  the  debility of old age, acting partly by lessening the tone  of
the vascular system generally; and partly by inducing a diminution of the pro-
pulsive power of the heart. So also cold, by lessening  the vitality and retarding
the circulation  of a part, produces congestion  of it.   Certain typhoid, or ady-
namic states of the system, favor the  occurrence  of congestion  in  the  more
dependent parts.  And lastly, inflammation may terminate in this  condition.
   The  obstructive causes are  especially apt to induce congestion when they
occur in connection with  a feeble condition  of the vascular system.
   The treatment of congestion has strict reference  to  its cause.
   The first indication consists in the removal of any source of obstruction  to
the return of blood  from the part, as by unloosening a ligature,  or elevating a
part that has been too long dependent; or,  less directly, as in the case of many
internal congestions, by restoring the freedom  of the circulation  through the
larger viscera.   Thus, a congested  eye or pile may be relieved by the removal
of hepatic or portal obstructions.
   The  next indication consists in lessening the quantity of blood  in the con-
gested part.  The mere removal of the obstructing cause may effect this.  In
other cases, the  direct  removal of the  blood by scarification, as  in a congested
conjunctiva, or by leeches, as around a turgid pile,  affords  immediate relief.  In
some  parts again, the judicious application of a  bandage will prevent or remove
congestion.  With this view the hand and arm are bandaged before the  apparatus
for a fractured clavicle is  applied : and in varix the leg is supported by an elastic
stocking, to lessen the pressure of blood in  the dilated veins.
   The third indication in the treatment of congestion, consists in constringing
the dilated vessels by the direct application of an astringent to them; thus we
habitually apply  nitrate of silver to  a  congested mucous  membrane, and cold
douches to many external forms of the  disease.
                           DETERMINATION.

  Increased vascular action lies at the bottom  of most surgical processes;  few
important surgical actions taking place without it.  No process by which the
separation of dead parts is effected, or by which the repair of wounds or ulcers
is carried out, can occur without an increased activity of the vessels of the parts
concerned.   Every tissue is susceptible of it; and the surgeon often excites it
intentionally as one of  the  most efficient of his therapeutic  means;  hence an 
68                         INFLAMMATION.
 acquaintance with the elements and the details of the process, with  its nature,
 symptoms, causes, results, and  terminations, is of the first moment.
    Increased vascular action  is of two distinct kinds: 1st. Determination ;  2d.
 Inflammation.  These two conditions, though in practice most commonly found
 more or less conjoined, require to be studied separately.
    In determination, the blood is increased in quantity, of a bright arterial color,
 and  circulates through the parts with great rapidity.   This condition, which is
 often called " increased action," consequently  resembles congestion in the blood
 being in excess, but differs from it in every other respect.
    Determination of blood is a vital  process, often of a very transitory character,
 and frequently occurs as  a normal action  in those  conditions  of the  system in
 which, for temporary purposes, an increased afflux  of  blood is called for by par-
 ticular organs.  The enlargement of the mamma  before lactation, and  the turgor
 of the erectile tissues, afford familiar illustrations of this act.  The surgeon often
 employs determination of blood for  therapeutic purposes.   Under these circum-
 stances, therefore, it cannot be  considered a disease.
    When determination of blood is  of a chronic or continued character it may
 lead  to such changes in  the  appearance,  structure, and  functions  of a part as
 materially to modify its nutritive and secretory activity,  and then it  becomes
 truly a disease.  Under these circumstances the part is often said to be in a state
 of "  chronic irritation."
   The symptoms that  characterize  determination  of  blood to a part, are those
 that we should expect  to  result from an  increased  quantity of blood rushin*
 with  increased velocity through the  affected  textures.  There is redness  of a
 bright scarlet hue,  swelling from turgescence  of  the vessels, heat cognizable to
 the surgeon as well as to the patient, a feeling of fulness and of throbbing, with
 an increase in the  quantity of the  secretions of  the part;  in  fact,  alf those
 symptoms that characterize inflammation in  its milder forms, but in a minor
 degree, and of a less persistent  character.
   The effects of determination of blood, when acute,  consist  either of rupture
 of the affected vessels,  and a natural relief by the hemorrhage which ensues  as
 may happen in  piles after a dose of aloes  has been given ;°or, in the  pour'ino-
 forth of the secretions of the  part, if  a free surface  or gland, considerably
 augmented in quantity  and deviating somewhat perhaps  from their  normal  cha-
 racter, asm lachrymation after the introduction of a grain of snuff into the eye
 \V hen this occurs within shut serous sacs,  dropsical accumulations may ensue.
   The more remote  effects of chronic determination of blood  to a part, consists
 in permanently increasing its nutritive activity and thus  leading to induration
 and hypertrophy   Or,  determination of blood  may result  in true inflammation.
   Ihe causes of determination of blood are three-fold-
   First,  An external irritant  directly applied to a  part will induce  it, as when
 a grain of dust is blown upon the conjunctiva.   Secondly, internal irritation, as
 an  increased use of a  part, will determine an increased flow of blood to it
 Ihus  using the eyes much in  microscopical investigations  may produce redness
 watering and irntation of those organs.  To this clS* of causeVmay be rrfer  d
 the various forms of normal determination.                      *    lbltiIIt;u

anJther^ ^ °f CaUS6S C°QSiStS " ^ rePercussion of bl°°d from one part to

   The treatment of determination of blood is nearly identical with  that of the
mi der forms of inflammation;  hence we  shall reserve the co^ration of it
until we come to treat of that disease.                     consideration oi it


                           INFLAMMATION.

A'l^V^7^^  inflammatory Process is one  of  the  most  complex and
difficult on which the surgeon can enter,  but  the  labor required to masteMts 
INFLAMMATION.
69
details is well bestowed, inasmuch as an acquaintance with its nature, symptoms,
and progress, gives an insight into a great part of the science of surgery.  The
management of  inflammation as it affects different tissues and organs, and thus
constitutes distinct diseases, comprises a great part of the  duties of a surgeon.
The theory of inflammation is a purely  physiological and pathological  study,
and however interesting its investigation  may be, yet  as the  discussion of this
subject belongs  rather to the domain of general pathology than to that of prac-
tical surgery, it cannot  consistently be entered  upon here; but regarding the
subject from a surgical, rather than from a  physiological or pathological point
of view, we must discard all hypothesis, and  confine ourselves to the results of
trustworthy observation.
   We have  seen that in congestion  the quantity of blood is increased, but
the  rate  of its motion is lessened;  in determination we have  everything
augmented, there is an increased size of  the  vessels, and an increased quantity
of blood within them, circulating through them with increased velocity.  In
inflammation we have a combination of these conditions; we have an increased
size of the vessels, an increase in the  quantity and rapidity of the motion of
the blood, but  conjoined  with this we  have a  tendency  to  its arrest, to its
stagnation at points.   In  studying the  phenomena of inflammation in the
web of the frog's  foot  under the microscope, we observe that  the first  change
on the application of a stimulus is the  momentary contraction followed by dila-
tation of the artery; the flow of blood through it and the  capillaries is at first
accelerated,  retardation from congestion then ensues, and lastly, stagnation  at
points.
   At  these  centres of commencing stagnation, it will be seen  that the blood
appears  to  ebb  and flow,  oscillating  to  and fro, and then  stopping at last;
the  immediate  stagnation taking place in those capillaries, which are  not  in
the  direct line  of passage from an artery into  a vein, and  the arrest  taking
place  by the adhesion of the  red  corpuscles  coalescing by  mutual adhesion
into masses, which, after  being  carried  bodily up  and down  more and more
slowly, at last  appear  to  block  up the vessel, partly by overcrowding and
distending it, and partly by becoming  adherent to  its walls; this adhesion
usually commencing at the angle of union between  two capillaries.  Around
the  stagnant part  the  vessels are  crowded  by an aggregation  of the red cor-
puscles, which appear to be more closely packed in  consequence of the draining
away of the liquor sanguinis.   The blood does  not enter the part of the vessel
in which stagnation has  taken place, but  passes off by a  collateral branch
(W. Jones).
   At this part also, where the circulation is retarded, the white corpuscles may
be seen to be increased in quantity, and appear to be adherent to the wall  of
the vessel, along which they are either stationary, or at most roll but languidly.
Around tbe whole of this area, in the centre of which there is stagnation with
retardation of the blood, there is that increased rush of an increased quantity
of blood, characteristic of determination.
   These are the  general phenomena  presented  by an  inflamed part when
studied under  the  microscope.  In  order  to  become  acquainted  with the
elements of this  process, we must analyze the  condition of the vessels  and  of
the blood.
   First, as  to the Vessels: — The arteries, capillaries, and veins are all enlarged,
not only in  the part inflamed, but those  around and leading to it, so  that more
blood is conveyed with greater rapidity to the seat of disease.  Is this enlarge-
ment  of the inflamed vessels primary or not ?   This would appear to depend
greatly upon the  stimulant that excites the inflammation, and perhaps on other
circumstances that we  cannot readily appreciate;  thus, if a weak solution  of
salt, or if ice-cold  water or spirit of wine be applied to the web of a frog's foot,
 there  is a momentary constriction of the arteries and  retardation of the flow  of 
70
INFLAMMATION.
 blood, followed by rapid dilatation and accelerated flow.   In other  cases again,
 as W. Jones has observed, the dilatation may be  primary, no  contraction pre-
 ceding it, as happens when a strong solution of salt or of sulphate  of copper
 and  vinum opii is applied to the part.   The  solid  sulphate  of  copper produces
 speedy, complete, and permanent contraction.
   Though the vessels  generally are enlarged, the arteries  especially become
 dilated, and  this dilatation implicates  the  afferent  vessels to a considerable
 distance, which can be felt, by the volume of their pulsations, to be increased
 in bulk.  That the coats  of  those  vessels leading  to the  inflamed parts are
 dilated in  consequence of being  relaxed, is evident from  the fact that the
 pulsation  in  them is stronger and more forcible  than  in  other  parts of the
 arterial system, though equally dependent upon the  heart's action, to which
 their diminished tonicity offers less  resistance.  This may be readily observed
 in the pulsation of the  digital arteries in a case of whitlow.  That the vessels
 convey more blood  through as well  as  to the inflamed  part, is proved by the
 observation  of Lawrence, who found that in bleeding a  patient, with whitlow
 of one hand, in both arms, more  blood flowed from the inflamed than from the
 sound limb, in the same space  of time.
  In consequence of the dilatation  of the smaller arteries  and capillaries of
 the  part, red corpuscles  are admitted in  crowds where single  files  could  only
 penetrate before; hence an appearance of new vessels  is presented, though none
 are in reality formed.  It is in this way that the surface of the conjunctiva may
 in a  few hours be brightly reddened, not by  the formation of new vessels, but
 by dilatation and accumulation of blood in previously existing ones.
  Besides this dilatation of the smaller vessels of the part, the arteries become
 elongated, tortuous   and waved, increasing in length as well  as  in  diameter.
 The  German pathologists — Kolliker, Hasse, and Bruch, whose views are  con-
 firmed by Paget and W. Jones—have observed that the arteries of the inflamed
part  have a tendency to become dilated at points, so as to present small varicose,
or aneurismal pouches projecting from their walls, or fusiform dilatations of
their whole  diameter.   These  changes would appear to arise from  one of two
causes; either that  the vessel is  constricted  at points between which it main-
tainsits normal width, and thus that  the dilatation  is apparent and not real- or
 that  it is actually dilated where it appears to  be so.                        ;   ;
  I shall not enter upon the question as to the causes of these  changes in the
 vessels; how a stimulant acts in giving rise to them, and what share the nerves
of the part may have in their production; as these are points out of the scope
of this work, and which, indeed, appear as yet to be altogether undecided
 _ The changes that the blood  undergoes in inflammation are fully of as ffreat
importance as those  presented  by the vessels.                                  „
  The most apparent physical  change met with in  this fluid, is, that it appears*
to have become thinner, as  was long  ago pointed out by Hewson.   But there
are other  changes that can only be  appreciated by chemical and microscopical
research.  These we must study as they affect the  different constituents of the
 blood.
 _ The red particles  have been shown by Andral and Gavarret to be increased
in quantity in the early stages of inflammation, but as the  disease continues,
they speedily-diminish in number; falhng below the  natural standard in  this
respect  as A\ . Jones and himon  have pointed out.   No other apparent change
takes place in these particles, except the tendency to their a<Watior.into
clusters by the cohesion of  their flat surfaces.  ThiJ  cluster ng^ltfe red par
fades, first pointed out by W  Jones,  takes place in  the vessels*well aoufof
them, and is considered by its  discoverer,  and by Henle, to be owing to inspis-
sation of the plasma.                                        v,„m0 w Uii,j,ib.

  The white corpuscles have excited much attention of late years in connection
 with the arrest of circulation  in inflammation.  Dr. Williams has  shown  that 
LOCAL  SYMPTOMS.
71
they appear in increased numbers in the inflamed part, and by their adhesion
to the walls of the vessels, become one principal source of the  arrest of the cir-
culation.  There are several questions, however, with reference  to  the  white
corpuscles,  lstly. As to their actual increase; 2dly. As  to the  cause of this
increase in their numbers; and 3dly.  As to their greater disposition to adhere
to the vessels.   Their increase in inflammation  is  stated by W. Jones  to  be
partly relative, owing to the diminution in the red particles; and  Paget, as well
as other observers, is of opinion  that it is only in  sickly and young animals,
kept for the purpose of experiment, that this increase has  been observed,  never
being met with in healthy animals, or in the human  blood taken from inflamed
parts.   Hence  he infers  that they are only met with in large numbers in  in-
flammation, when existing numerously elsewhere.  Their  appearance in large
numbers  in the vessels of the inflamed part, and their accumulation here, is
ascribed by W. Jones simply to retardation of the circulation; this  condition
being consequently the effect, and not the cause of the obstruction which, how-
ever, they may mechanically increase when it has been once induced.
   The  natural adhesiveness of the white corpuscles to the sides of the vessel is
such as to require a brisk  current to sweep them along, hence when the force
of this is lessened, as is  the case in an  inflamed  part, they are  not readily
detached; but, as it has been shown that the tendency to cohesion is increased in
the red corpuscles, it is but  reasonable to  believe, with Dr. Williams, that the
adhesiveness of the white ones may also be augmented.
   The liquor  sanguinis undergoes  important  changes in inflammatory  blood.
 Quesnay, Hey, Thackrah,  Babington, and Grainger,  have  all observed that the
quantity of fibrine in it increases, and Andral and Gavarret have  shown that it
may rise from 2i per 1000 as high as 10 per 1000.   This  superfibrination of
the blood probably results from waste or oxidation of the  tissues, and its aug-
mentation must not be looked upon as an increased development of nutritive
power.  It is in fact the consequence of changes taking place in  the blood and
parenchyma of  the diseased  part.
   The proportion  of albumen and of saline  matter is  somewhat below the
natural standard, whilst that of the water is increased above it.
   When inflammatory blood is drawn from the body it coagulates more  slowly
than healthy blood;  the coagulum  also is harder and smaller, and the quantity
of serum apparently greater.  The  surface of the  coagulum  is  commonly
 covered by a tough layer of yellow fibrinous  matter, the  bvffy  coat; and its
upper surface is depressed in the centre, having elevated  edges,  being cupped,
as it is usually termed.  By  this  "buff" and "cup" the practitioner commonly
 estimates the intensity of the inflammation;  but it must be borne in mind that
buff may occur in certain  conditions of the system,  as in  plethora, pregnancy,
 or after exercise, without the occurrence of inflammation ; and that the  tissue
 affected, rather than the severity of the inflammation, influences its  quantity:
 thus, it is greatest if the fibrous or serous  tissues, and least when the mucous
 or tegumentary, are inflamed.  The cupped shape of the clot may likewise be
 owing, in some  degree, to the kind of vessel in which the blood is received,
 being most evident  in those  which are rather narrow and  deep.
   These are the principal changes  met with in the vessels and blood of the
affected part, but it  must  not be supposed that the inflammatory process consists
simply in these  changes; the  nerves and parenchyma doubtless  exercise an
important influence, the  precise nature and extent of which can  scarcely at
present be appreciated, though the observations of Paget and  W.  Jones demon-
strate  its existence.
                  SYMPTOMS  OF  INFLAMMATION.

   The symptoms of inflammation are local and constitutional.   In  order that
these should occur, so as to establish the existence of the inflammatory process, 
72
INFLAMMATION.
it is necessary that those actions that constitute  it continue for some length of
time; as they gradually pass from determination and congestion into  inflamma-
tion, it is difficult to say, except by the persistence and  intensity of  the symp-
toms,  that  the physiological state has ended, and  the  pathological one com-
menced.                                                        .    7
  The local signs of inflammation may be referred to five heads; viz.,^alteration
in color; alteration  in size; modification of sensation;  increase of tempera-
ture, and modification of function of the part  affected.   Each  of these  con-
ditions may separately occur, or two or more be associated together without the
existence of inflammation.   But  it is the peculiar grouping  together of them
all that characterizes the presence of  this pathological condition.
  The relative intensity of these changes varies greatly, according to the tissue
that is the seat of  the inflammation ; thus, in inflammation  of mucous mem-
branes and of the skin, the alteration in color is most marked; in  inflammation
of the cellular tissue, the change  in  size always attracts special attention, and
when  a fibrous tissue is inflamed, its sensibility becomes greatly increased.
  Alteration in color is an invariable, and one of the earliest and most  striking
local signs  of inflammation; parts that are naturally perfectly pale, as the ocular
conjunctiva,  assuming the most vivid crimson  color when  inflamed.^ Some
parts, though they change in color, do not become  red.   Thus, the iris, when
inflamed, assumes a greyish or brownish  tinge, and the  mucous membrane  of
the bladder, and of  a portion of intestine, often  becomes  slate-colored.   The
redness of  inflammation varies from a bright  crimson to a dull purple,  the tint
depending greatly upon the state of the constitution, and upon the presence  of
more or less congestion.  The duller and  darker  the tint, the  more local  con-
gestion or  constitutional depression  do we usually find.   The redness is evi-
dently due  to the increased quantity of blood in  the inflamed structure; and in
the earlier  stages of the  disease, it is owing to the increase of the size of the
vessels, the admission of new red corpuscles by which  they are distended, and
by the draining away of the plasma.  In some  low or  asthenic forms of the
disease, the coloring matter of th.e blood  appears to undergo changes that allow
its ready transudation  through the walls  of the vessels;  and  in  more  chronic
cases the vascularization of the products of inflammation tends to render it more
permanent.
  Alteration in Size.—Dilatation of the vessels being an essential element  of
the inflammatory process, swelling must  be  an  invariable accompaniment  of
this disease.   In the  early stages  this is due to  the dilatation of the  vessels;
in the more advanced conditions, chiefly to the occurrence of effusions  of
various kinds.
  The swelling varies greatly in different localities.  It is greatest in those
which are of a loose texture, and least in those which are firm and dense. Thus,
for instance, in inflammation of the cellular tissue of the scrotum, the swelling
is much greater than in the same disease affecting the testes.  The inflammation
of the conjunctiva occasions great swelling, that of the sclerotic but little.
  The swelling  of chronic inflammation  may terminate  in permanent hyper-
trophy, or thickening of  the affected  parts, partly in consequence  of  persistent
dilatation of the vascular system of the  part, but chiefly from the deposition
of plastic matters in the  substance of its tissues.
 _ Modification of the sensibility of the Part, owing partly to  increased sensi-
bility  of the nerves, but chiefly to  the  pressure exercised on their terminal
branches by the dilated blood-vessels, manifests itself  by the occurrence  of
pain, or by some alteration in the special nervous sensibility of an  or^an:  thus
in the eye, by the patient perceiving flashes of  light, and in the earthy noises
of various kinds; in the bladder, by a constant  desire to expel the urine  and
in inflammation of the kidney, by a desire to urinate.
  Pain is one of the most prominent  symptoms  of inflammation, and its exist- 
LOCAL SYMPTOMS.
73
ence serves a useful  purpose by preventing the patient  using  or moving the
inflamed part.   The  intensity of the pain depends  more upon the structure
affected than on the violence  of the inflammation.  As a general rule, it may
be observed that the intensity of the pain is in the inverse ratio  of the swelling
of the  part  affected.   Thus, the pain  of inflamed  bone or fibrous  tissue  is
excessive; that of cellular membrane trifling.  In erysipelas of the scalp, most
pain is experienced in the ears; the pain of the inflamed sclerotic is far greater
than that of a conjunctiva similarly affected.
   In some forms of inflammation pain can scarcely be said to exist, though the
disease may assume the most destructive form.  Thus, in certain inflammatory
affections of the throat and of the peritoneum there is little or no pain.  Inflam-
matory pain is always increased on pressure.   The  character of pain varies
according  to  the seat of the  inflammation.  Thus, when mucous membranes
suffer, it is often of a gritty,  itching, or burning character, as in conjunctivitis;
when the serous membranes  of the chest  or abdomen are attacked, it is of a
lancinating or  stabbing  character; aching  in bones; throbbing when pus is
about to form;  sickening when the testis is affected.   When the pain is prin-
cipally elicited by pressure,  the  part is said to  be tender.  This tenderness is
of great service in a diagnostic point of view; it may be elicited by direct pres-
sure upon the part, as by squeezing an  inflamed testis, or by pressing two sur-
 faces  together, as  in an inflamed joint.  In inflammatory  pain, especially  of
 osseous and fibrous tissues, there is very commonly nocturnal exacerbation.
   It is important to  bear  in  mind that inflammatory pain is often not seated
 merely in the part affected, but radiates  extensively along the course of  the
 nerves, the terminal branches of which are implicated to a limited extent perhaps.
 Thus, in inflammation of  the testis we have pain in the loins and groins.   In
 deep-seated ophthalmia there may be exquisite pain along the branches of  the
 Fifth Nerve over the whole side of the head or face, in consequence of the ciliary
 branches of the nasal, which are distributed  to the iris and choroid,  becoming
 compressed or stretched.
   The temperature of an inflamed part  usually rises  above its normal standard
 Hunter has, however, remarked that it does not increase  above that of the  left
 ventricle: thus, in a case of hydrocele, he found the tunica vaginalis at 92°
 Fahr. before inflammation had been excited in it, and at  98|° after it had been
 set up.   In a case of extravasation of urine, with severe inflammation, I found
 the temperature in the incision made in the perineum 98° Fahr. It is probable
 that there is always a local  increase  of  heat in  inflammation.  This, however,
 appears to the sensations of  the patient to be far greater than it is  iif reality.
 Travers truly remarks, "that the nerves measure the sensation, and not  the
 degree of heat."  In many cases the sensation to the patient is that of burning
 in the part, though the actual rise in temperature may be but trifling.  This is
 owing to the exalted sensibility of the nerves.
   The cause of the increase of temperature is interesting.   In  all processes in
 the economy in which  determination of blood takes place, as  in blushing or
 parturition,  the temperature rises.   This  can  clearly  not be owing to  any
 production of heat during respiration, which may account for the general heat
 of the blood, but not for its  local increase.  It is  more probable that, as the
 ordinary and general supply is  derived from the waste of the  tissues, so that
 of inflammation may be due to increased destruction of organic  matters in the
 part inflamed.
   Modification of Function, Use, or Nutrition, invariably occurs in inflamma-
 tion, and  furnishes important local  symptoms.   The functional activity of an
 organ is increased  in the  earlier  stages  at least of inflammation, and  the
 character of the secretions from the  part materially modified.  Thus, when the
 mucous membrane of the urethra is inflamed, there  is copious discharge from
 it, and this is not mucous, but purulent. 
74
INFLAMMATION.
  The use of the part affected is greatly interfered with; thus, the bladder can
contain no urine, the eye  cannot  bear the light, nor a joint  be moved when
inflamed.
  The nutrition of the inflamed tissues is modified or arrested; hence, wasting,
softening, or contraction, are common accompaniments of this process.
   Constitutional Symptoms. —The severity of the constitutional symptoms de-
pends on the intensity and the extent of the disease, or on the  vital importance
of the part affected by it;  on  the amount  of local irritation, and whether it is
owing to external or internal causes.  Thus, a moderate degree of inflammation
in a part of no vital importance, as the skin, and  occasioned by an external
cause, as an abrasion, gives rise to  no appreciable  constitutional  disturbance.
But if the inflammation  be wide spread, as that of diffused  erysipelas^ or if it
arise from constitutional  causes, or if there be  much local tension, as in whit-
low, or  if the part affected be of great importance, as the  larynx or the eye,
then the general symptoms become proportionally severe.
  The constitutional disturbance  in inflammation  always  assumes  the form
of fever — inflammatory or symptomatic fever, or Pyrexia.   It  is  invariably
secondary, being consecutive to the local affection.  It is the true surgical fever,
no febrile disturbance occurring in surgical practice except as a consequence of
local disease or injury.   This fever appears to  result primarily from deteriora-
tion of the blood by the local  inflammation, and from  consequent reaction  on
the circulatory and nervous systems.  Andral states  that increase of the fibrine
of the blood in inflammation is simultaneous with  the  accession of the fever,
and that when  once this increase of fibrine has taken place, the spread and
intensity of the inflammation is increased by it.   He has further observed that,
in inflammation without fever, there is no increase of fibrine, and that when
the fever ceases  the  proportion of fibrine falls  to its normal standard.   Thus,
the local inflammation occasions the superfibrination of the blood, and this the
general fever.
  Inflammatory fever, or  pyrexia,  presents,  however,  an  infinite variety  of
forms; the type which it assumes being finally dependent: 1st, on the state of the
the blood; 2d,  on  the  condition of the nervous system; and, 3d, on the  oc-
currence of certain  local or specific  symptoms, dependent on the seat of the
inflammation.    These varieties  in  the type of  the fever arrange themselves
practically into  three classes.  1. Sthenic, or typical  inflammatory fever.  2.
Asthenic, or  typhoid fever.  3. Irritative,  or  nervous fever.   In all these
forms of fever, there are three distinct stages: that of invasion, exacerbation,
and decline.
  The sthenic form of.inflammatory fever, true pyrexia, occurs in individuals of
healthy constitution, young, or middle-aged, in connexion  with those forms  of
inflammation that are of an active, acute character, and not unfrequently conse-
quent upon injury.
  In  this form of fever, the stage of invasion  is very slightly marked, though
it always occurs.   There are rigors, with some slight depression of the nervous
system;  but these  symptoms  may  be so transient as to  escape observation
entirely, and speedily terminate in the stage of febrile reaction,  la  the majority
of cases, it is not until  the constitutional disturbance has  reached  this stage
that it attracts attention.   The skin  is now hot, and  usually dry;  the pulse full,
bounding, or thrilling,  and quickened by thirty or forty  beats' in the  minute
above  its normal rate;  its  character depending greatly on the tissue or or°-an
affected.  If this  be the mucous  membrane, skin, or a glandular  structure" as
the testis or mamma, it is compressible, though full; if a serous membrane'be
inflamed, it  is  small, incompressible, and wiry;  if a fibrous  tissue be the  seat
of disease, it is hard and  full.  The secretions are arrested or diminished in
quantity; hence the urine is high-colored and acid, the  bowels confined   the 
INFLAMMATORY  FEVER.
75
tongue coated with a white fur, and the mouth clammy, usually with much thirst;
there is a feeling of great languor, and the head is often heavy and hot.
  As the fever declines, if a favorable termination occur, the system  not un-
commonly relieves itself by a critical evacuation; — from the skin, by abundant
acid perspiration; — from the kidneys, by the free deposition of lithates in the
urine;—from the bowels, by diarrhoea;—and from some of the mucous surfaces,
by  hemorrhage.   The  tongue  cleans, the pulse  subsides  in frequency and
strength,  the secretions become freer, the thirst lessens, and  strength and appe-
tite  return.  Should  the fever not take a favorable course, death may ensue by
the  occurrence of  serious  visceral  complications; the lungs  and  brain being
especially apt to  suffer, becoming the seats of fatal  inflammatory mischief; or
the sthenic form  of the disease may gradually merge into those types that are
characterized by  debility and irritation.                         «
   The  asthenic form of  inflammatory fever  principally  occurs  in  those  indi-
viduals whose  constitutions are broken by privation, dissipation, or  by any of
the general depressing causes of disease, as grief,  anxiety, or long  residence in
a vitiated atmosphere.
   In constitutions  such as these, so frequently met with in all  classes, but espe-
cially amongst the poorer  residents in  large towns, inflammatory fever almost
invariably assumes a  low form.   There  is also, in  this variety of the disease, a
special tendency to its complication with visceral mischief; the lungs being pecu-
liarly apt to  become affected by a low form of pneumonia.               •
   The asthenic form of the disease may come on  as a sequence of the sthenic
variety that has just been described;  the  symptoms gradually merging into
those of a low form, and being characterized by debility rather than by strength
of action, the pulse becoming weaker though its frequency is  kept up, the tongue
becoming brown  and dry, with a tendency to  the early supervention of delirium
of a muttering kind.
   When  the fever assumes the asthenic form from the very first, the period of
depression is strongly marked, and often prolonged for many hours,  reaction
coming on  gradually and  imperfectly, alternating with the  depression  against
which  the system  is struggling.   Even when fully established, the symptoms
of this stage of reaction are not of a very active character;  there is throughout
an  appearance of heaviness or stupor about the patient, with little activity of
the  intellectual  faculties,  and an early tendency  to delirium of  a  low form,
especially at  night: the pulse is feeble, though quick; the  skin either moderately
hot,  or else  pungent and  burning;  the tongue brown  and  dry,  with sordes
rapidly accumulating about the lips  and teeth;  the cheeks are often flushed,
and the eyes bright  and  staring.   As the third stage comes on, if the  patient
recover, critical  evacuations, often of a hemorrhagic  or diarrhoaal  character,
come on : the pulse subsides, the tongue gradually and slowly cleans from the
sides and tip, and the patient slowly  and imperfectly  regains his strength;
the  convalescence  being  often interrupted by intercurrent disease, and the
powers of the constitution  being frequently broken for months, or for life.  If
the  disease take  an unfavorable course, the weakness of pulse, and  dark incrus-
tation of  tongue increase;  the skin  becomes cold; hiccup, subsultus, dyspnoea,
or coma,  supervene;  and death occurs from exhaustion, or as the result of vis-
ceral complication.
   The  irritative fever is of a less specific type.   It is usually associated with
the  asthenic form, the nervous system being especially implicated.  It occurs
in individuals whose mental powers have been overwrought, or whose  nervous
systems have been  irritated and shattered by intemperance.   It is characterized
by irregularity in its actions, sudden  exacerbations,  and  a rapid decline.  The
several febrile symptoms run high in the early stages.   The pulse soon becomes
sharp and small; there is high delirium of a furious kind, wildness of eye, and 
76                        INFLAMMATION.
heat of head.   But these symptoms soon give way to signs of debility and
exhaustion, and death takes place from coma and cerebral irritation.

       TERMINATIONS AND EFFECTS  OF  INFLAMMATION.

  There are  two ways in which inflammation may terminate without leaving
any traces of its presence in the part affected; these are by Resolution, and by
Metastasis.
  The termination by resolution simply means a return to health.   The pain
and heat first subside, the swelling lessens, and lastly the redness passes away:
the constitutional symptoms also disappear.   With  regard to the more intimate
changes  in the part itself, it will be seen that the  dilated vessels contract, the
stagnant masses of blood-discs are pushed on and broken up by streams finding
their way into and against them.   Absorption, which had  been held in check
during  the continuance  of inflammation,  comes into  play and  removes  the
extravasated  matters, and secretion becomes  more active, and  helps to unload
the part.  Resolution may in this way be complete, or it may go on to a certain
point and then stop, leaving one or other of the effects that will immediately be
mentioned.
  By metastasis is meant a change in the seat of the inflammation, its sudden
and complete disappearance in one  part and  reappearance in  another.  This is
of extremely rare occurrence; it is occasionally seen however, as in the inflam-
mation  of the testis, that suddenly supervenes on the disappearance of a gonor-
rheal discharge.
  Besides these true  terminations, inflammation  commonly passes from  the
ordinary and primary condition into some other form of the disease.   Thus, for
instance, when plastic matter or lymph is thrown out, adhesive  inflammation is
said to have occurred.   When  it terminates in the production of pus,  we have
suppurative inflammation.  When  an ulcer forms, ulcerative  inflammation is
said to have set in, and when the inflammatory action is of  such intensity as to
cause the death of the part affected, gangrenous inflammation has occurred.
These different conditions  of the inflammatory process differ so widely from its
ordinary forms, and from each  other, as  to  constitute distinct  diseases, and as
such to require separate and distinct consideration.
   When inflammation has  once been set up in a  part it may extend  to other
portions of the system in four distinct ways.  1st.  By local extension; this
may occur by the inflammation spreading along the tissue  affected in its con-
tinuity ; as, for instance, along the skin, cellular or mucous membranes.
   2d. It may  also spread by contiguity  of tissue, passing from one affected
structure to  an adjacent healthy one; thus we see the opposite surfaces  of an
inflamed joint involved in disease at opposing points.
   3d. Inflammation may extend to distant  parts through the  medium of the
blood.  This  fluid being altered and depraved, and increasing the liability to
inflammation  in other parts, as  in some  of the erratic forms of erysipelas;  or,
conveying pus  to a distance, as  in  phlebitis, and thus giving rise to numerous
centres of inflammation.
   4th.  Inflammation may be  carried to a  distant  part by  metastasis, as  has
already been stated.
 _ Effects of Inflammation. — Closely allied to the local symptoms of inflamma-
tion^ are the  local effects  of this disease.   These consist first, of changes in the
consistence  of  the part inflamed,  which may be  of two kinds.  Induration
chiefly as a consequence  of chronic  inflammation, occasioned  by the tumescent
state of the vessels of the part, or the effusion of plastic matter within it.
 Softening, chiefly after acute inflammation, depending partly on the infiltration
of effused  liquids into the textures, and partly on  a disintegration of the sub-
stance,  and thus a lessening of the  consistence even of the hardest tissues  by 
THE CAUSES  OF INFLAMMATION.
77
impairment of their nutrition:  thus an inflamed bone may be  cut and pared
down with a knife, or the ligaments  of an  inflamed joint become so soft as to
admit of  spontaneous dislocation.  This  softening may ultimately lead to the
interstitial absorption of a part, which becomes shrunken and contracted  after
inflammation.   Ulceration, as will hereafter  be fully stated, is not an unfrequent
consequence of this softening and atrophy conjoined with rigidity, as we see in
these joints that have undergone inflammation.
   In chronic  inflammation we  not  unfrequently  find  that increased nutritive
activity of the part  leads to an increase in  its size and growth, partly owing to
actual augmentation in  bulk  of the tissues of the part;  in many cases, however,
being rather  dependent on  effusions into the cellular  membrane.  Instertitial
absorption and gradual  wasting of a part without previous softening, often occur
as an effect of inflammation.  Thus, a blow on the hip will occasion absorption
and shortening of the neck of the femur.
   Loss of transparency in structures that are normally  translucent is a common
effect of  chronic inflammation, as  may every day be observed in the cornea or
in the capsule of the  crystalline lens; in some cases this rather depends upon
a modification of nutrition than upon the deposit  of new matter upon the part.
In other  cases, again, it proceeds from  the deposition of plastic matter in or
upon it.
   The  symptoms, terminations, and effects  of inflammation that have just been
described, are those which characterize the more ordinary forms of the disease.
In practice, however, we recognize  many important varieties of this affection.
These  may be referred to three  heads, as they affect its  duration, its intensity,
or its character.
   1st.  As to  duration.   The disease may be acute or chronic, varying from a
few days  to many years, being especially persistent in  those structures that are
naturally least vascular, as, for instance, bones and joints.
   2d. As to intensity.   When the symptoms are well  marked,  the redness and
heat great, the tension considerable, and perhaps the pain severe, with corre-
sponding constitutional disturbance, the  inflammation  is said  to  be active or
acute ;  when  of a less intense character, it is termed sub-acute ;  and when there
is merely redness and  swelling, with little or no pain, and but slight constitu-
tional disturbance, the  disease is said to be  of a passive kind.  The duration of
the  inflammation commonly  influences its intensity,  which is usually less in the
more chronic  cases; but very frequently we find the reverse, and that when of
but short duration it may be sub-acute or passive, whereas some forms of a very
chronic character may retain great activity,  and  are especially liable to recurrent
active attacks.
   3d. As to  character.  If the inflammation is  circumscribed, occurring in a
healthy constitution, and tending after a moderate  time  to terminate in resolu-
tion, it is called healthy or phlegmonous.   If the  vessels  become distended and
dilated, the blood slowly circulating, the redness of a purplish tinge, and the
swelling  considerable, with  but  little heat, the disease is said to be congestive.
Of  unhealthy inflammation  there are numerous varieties;  the  diffuse having a
tendency to spread widely unchecked; the strumous being modified by scrofula;
and the specific inflammations, that arise from special causes, and are frequently
capable of self-propagation.

                 THE  CAUSES  OF INFLAMMATION.

   The  causes of inflammation  may  be divided like those of all other diseases,
into predisposing and exciting, and these again  may either be of a strictly local
character, or  act locally, through the medium of the constitution.
   Local predisposing causes. — Though every tissue of the body is susceptible
to inflammation, yet some parts are more  liable  to it than others.   This cannot 
78
INFLAMMATION/'
be owing to any greater degree of vascularity, for we find that the tissues linin0
the interior of a joint more readily  and more violently inflame, though they are
almost extra-vascular,  than a portion  of  the mucous membrane which is so
abundantly supplied with vessels.   Indeed, serous and synovial membranes are
more liable than most other tissues  to inflammatory excitement.   Y\ natever the
reason of  this may be, there are two sets of causes that more especially predis-
pose tissues to inflammation.                                      .    ,
   Thus, habitual over-use or over-stimulation of a part, by producing determi-
nation of blood to it, may readily drive it into inflammation.
   When a part having once been  the seat of inflammation, has  been left in a
weakened or impaired  state, it will  be more liable to the occurrence of a second
attack of inflammation,  having less resisting power;  hence,  also, subsequent
attacks are induced by less active exciting causes than were required to call the
first disease into action; we see this in the inflammatory affections of eyes and
joints.  Then, again,  a tendency to local  congestion  or stasis will dispose to
inflammation, very slight over stimulation inducing the disease when the ves-
sels of the part are already overloaded; this is often seen in the case of varicose
veins, the congested skin readily running into inflammation.
   It is of great consequence to ascertain whether any constitutional predispo-
sition to inflammation  exists, and if so, what its precise nature is, for the pro-
gress of the local affection will in a great measure be  dependent on the amount
of constitutional predisposition.   The constitutional predisposing causes  are of
two kinds.
   1st. Inflammation is predisposed to by a state of general over-stimulation of
the vascular and nervous systems.  This condition may be hereditary, as in the
sanguine temperament, or dependent on youth and sex; or it may be acquired
by habitual indulgence at table; the induction of plethora, producing an inflam-
matory habit of body.   And inflammations occurring in this habit of body are
usually of the sthenic variety, though not unfrequently accompanied in the case
of those accustomed to alcoholic stimulants, by fever of an irritative form.
   A directly opposite condition of  the system equally  disposes the person to in-
flammatory attacks.   Thus a state  of vascular and nervous depression,  by les-
sening the  reacting power of the constitution, causing a loss of tone in the vas-
cular system, with ready tendency  to dilatation of the vessels,  and to stagnation
of blood, disposes to inflammation.   In this way inflammatory actions are espe-
cially apt  to occur in  scrofulous'patients, in  whom  the general powers are en-
feebled, and in such individuals they occur under the influence of minor exciting
causes than in those in whom  nutrition is more actively carried  on.  Here in-
flammation usually assumes the passive, congestive, or asthenic forms.
   The  exciting causes of inflammation are very numerous and simple in their
action.   Commonly, mechanical injuries are those that occasion surgical  inflam-
mations, which are, indeed, set up  by nature  as  the means of repairing the
effects of the injury.
    Chemical agencies, as the application of caustics, and undue extremes of heat
and cold, are  also amongst the most common exciting causes.  The application
of the virus of certain morbid poisons, as of syphilis and the malignant pustules,
 directly occasion it.   And lastly,  certain  states of the blood  give rise  to it, as
we observe in those conditions of the system  in which boils, carbuncles, &c. are
 produced.

                  TREATMENT  OF INFLAMMATION.

    The Treatment of Inflammation may be divided into the preventive and the
 curative.
    The preventive treatment can only be employed in inflammations supervening
 on injury.  In it the  principal point  to  be  attended to is, the removal of the
 local and  constitutional causes of  irritation.  By doing this, the occurrence of 
           TREATMENT OF ACTIVE INFLAMMATION.         79

inflammation in a part that has been injured, or otherwise disposed to its acces-
sion, may be entirely prevented, or, if this be  not accomplished, much lessened
in severity.
   The local preventive treatment of inflammation is  best  carried out by the
removal of all sources of irritation, by absolute rest of  the part, and by the free
application  of cold.   If the  injury be superficial, and  not very severe, lint
dipped  in cold water, frequently renewed, may  be  applied; or, if the skin  be
unbroken, an evaporating lotion may  be used.   Should  a limb or joint  be
severely injured, the  cold  irrigation will  be a preferable  mode of reducing  its
temperature.  This may most conveniently be done by suspending over the. part
a large wide-mouthed bottle, full of water, in which a  few pieces of ice may, if
necessary, be put;  one end of a skein of cotton, well wetted, is then  allowed to
hang in  the water, whilst the  other is  brought over the  side  of the  bottle.
This, acting as a syphon, causes a continual  dropping upon the  part to which
the cold is to be applied.   (Fig. 45.) In some cases the application of pounded
ice in a bladder or of cold evaporating lotions, may be preferred to the irrigation.

                                  Fig. 45.
  At the same time all constitutional irritation must be removed by abstinence,
rest, and a free aperient.
  In undertaking the curative treatment of inflammation, the surgeon must not
allow himself  to be guided by the name of the affection that he has to do with,
but he must be influenced in the means that he adopts by the  actual condition
of the patient, and the state of  the  diseased part; for nothing  presents greater
variety than the management of  the inflammatory process, in different conditions
of the patient, and in the different phases of that affection.  We shall accord-
ingly consider the treatment of inflammation as applied to the acute  and sthenic,
the chronic, and the asthenic varieties of the disease.
   Treatment  of acute Inflammation with fiver of the Sthenic type. — In  the
treatment of this  variety of the disease, active and- energetic measures must
early be had recourse to, especially if the patient be young and strong.  There
is no affection that is more  under the control of the surgeon  than this when
occurring in a healthy constitution,  and  in which more can  be done by active
means early employed.   It is consequently of the first importance that precious
time be not lost by the employment of inefficient measures, otherwise important
local changes and  irremovable alterations of structure may ensue.    It is also of
great consequence to remove the  disease fully; not only to subdue it, but to
extirpate it, lest it degenerate into some of the more chronic,  passive, and in-
tractable forms.
  The first thing to be attended to in the treatment  of the sthenic, and of all
the  other varieties of inflammation, is the removal  of the cause.   Thus rest 
80
INFLAMMATION.
must be afforded to a diseased joint, light removed from an inflamed eye, and a
foreign body taken  out of the flesh in which it is lodged.
  The next great indication is to lessen the determination  of blood to the part.
The measures  for accomplishing this comprise what is termed the antiphlogistic
treatment.   This consists of constitutional and local means.
   Constitutional antiphlogistics. — The most  powerful and efficient  that we
possess is certainly blood-letting, and when the inflammation is  sufficiently  ex-
tensive  and severe, and  the patient's  powers warrant it, we may have recourse
to the abstraction of blood.  Now, blood  can easily be taken away, but it cannot
readily be restored  to a patient,  and we should never remove it unnecessarily,
lest permanent ill effects to the health ensue.  It is certainly not often required
in the treatment of surgical inflammations; and should be especially avoided in
very young and very old subjects; in the inhabitants of large towns generally;
or  in  those in whom inflammation of  a specific character occurs:  hence  in
hospital or private practice it is  now often found advisable to have  recourse  to
other means in its stead.  It should never be had recourse to unless an organ of
great importance to the economy, as the  lung or brain, for instance, be inflamed,
or so injured  that inflammation  of it is imminent; or unless a tissue, like  the
transparent structure of the eye, be affected, in which it is absolutely necessary,
at any risk, to cut short an inflammation before it give rise to change of struc-
ture, which, however slight, would be fatal to the  after utility of the part.  The
quantity of blood that should be taken  necessarily varies  greatly, according to
the age and constitution of the  patient,  and the nature of his disease; and it is
of  importance to bear in mind that when blood-letting is  required, the system
tolerates the loss of the vital fluid in a way that it does not otherwise do.   The
effect produced on the  pulse and on the system should be the guide to  the
quantity to be taken away.  A decided impression should be produced by blood-
letting, not so much on the frequency of the  pulse, as on  its  character; that
should guide us, and not the number of ounces drawn.  The point to be obtained
is the greatest effect upon the system with the least loss  to the patient, hence
the blood should be taken from  a large orifice in the medium basilic, or cephalic
vein, the  patient sitting upright.  In  repeating the  venesection we  must  be
guided by the impression that has been  made upon the disease and by the state
of  the pulse.   Purgatives should always be given early, except in some special
cases of acute inflammation of the abdominal organs.   They clear the intestinal
canal, free the secretions, and equalize  the circulation.   In general, it will be
found most advantageous to administer  a  mercurial, followed by a brisk saline
purge, and this should be repeated from time to time during the progress  of
the case.
   Diuretics and diaphoretics require to be administered frequently  during the
day.   If the  skin is  hot and dry, antimonials should be given in small and
repeated doses;  these may advantageously be conjoined with,  or replaced by,
salines, such as the citrate of potass, the acetate of ammonia, or nitre.   In this
way the force of the heart's action is  lessened,  and the skin and kidneys are
called into  active operation.   It is also probable that the salines alter  the con-
stitution of the blood, dissolving the fibrine and lessening the quantity of water,
both of which constituents are in excess in inflammation.
   In many forms of sthenic inflammation, especially in those which affect the
serous  and fibrous  membranes, we do not possess a more efficient  agent  than
mercury administered, not  as a purgative, but as an  alterative  to  the system.
 Mercurial  remedies are of  special  service in aiding  the operation  of other
 medicines.   Diuretics, diaphoretics, and  purgatives  will  frequently  not act
 properly unless conjoined with  a mercurial.  In inflammation the preparations
 of mercury act as direct antiphlogistic agents, lessening the quantity of fibrine
 in  the blood, and equalizing the circulation.  They  are  of especial value in
 promoting  the absorption of exudation matters,  more especially of lymph  as 
           TREATMENT OF ACTIVE INFLAMMATION.         81

we  may see happening under  their influence  in  certain diseases  of the  eye.
They appear to do this rather by lowering  the vascular action of the part, and
thus allowing the absorption to  be carried on, which  had been  arrested during
the persistence of the inflammation, than by any specific influence exercised
over the effused fibrine.   Care, however, is required in  the  administration of
this mineral.  In irritable or cachetic  constitutions  it should not be given at
all, or not without great caution.   It is best borne by strong constitutions, and
in acute inflammation of the serous and fibrous tissues.
   Calomel, blue pill, and mercury and chalk, are  the preparations usually em-
ployed when the mineral is given by the mouth.   When administered endermi-
cally, the  mercurial ointment  is preferred; and the use of  the mineral is in
general continued until the gums become spongy, and a red line is formed at
their edge; the patient experiencing a coppery  taste  in the  mouth, and the
breath becoming fetid.   It is not necessary to induce profuse salivation.
   It is especially the combination  of calomel with  opium  that produces  the
most beneficial effects in the treatment of surgical  inflammation.  Two grains
of calomel, and a third or half a grain  of opium, every fourth or sixth hour,
tranquillize the system and lessen vascular action in  a remarkable manner.
    Opium  is not only of use  in the way that  has just  been indicated, but is
of essential service  in allaying the pain and  irritability that often accompany
inflammation, especially in many inflammatory affections of the bones and joints.
 In the form of Dover's powder it is of especial value in this respect.
    In the treatment of active inflammation, it is  of essential consequence that
 the patient should be kept at rest in a well regulated temperature on low diet;
 in fact, the more complete the abstinence in this respect is, the  more  rapidly do
 therapeutic means act and the  febrile  symptoms cease.
    The local treatment of inflammation is of the utmost importance, as it directly
influences the vessels that are  deranged  in action.   It consists of means of the
most varied and  opposite  character; heat and  cold;  iced water and poppy
 fomentations; astringents and  sedatives, are all employed, and  all with success,
 but each only in  certain stages and forms  of the  disease;  and  the  art in con-
 ducting the local treatment of inflammation consists in adapting  the various
means at our disposal to the particular condition of  the case  before us.
    Local bloodletting is the most efficient means we possess in directly lessening
vascular action in a part, as by it we take the blood  directly  from the inflamed
and turgid vessels.   It may be used in addition to, though it is  now very com-
 monly employed  in  preference  to, general bloodletting;  especially if the inflam-
 mation be not severe, if it occur at either of the extremes of life, in women,
 and in persons generally of feeble  power.
    Blood  may be taken locally by punctures, scarifications,  incisions, or  by
 leeching  or cupping.
    Punctures  and  incisions can only be practised in inflammation of the  cuta-
 neous and exposed  mucous surfaces, due attention being had to subjacent  parts
 of importance.   They constitute a very efficient  means of  relief to the part;
 as not only is blood removed, but an  exit is afforded for effused matters;  ten-
 sion and pain are consequently materially lessened, and the tendency to slough-
 ing and other after-consequences perhaps prevented.  The punctures should be
 made with  a fine lancet, in parallel rows over the  inflamed surface, and should
 not exceed a quarter of an inch in depth.   The incisions must always be made
 in the axis of the limb, and should be so arranged as to afford  the greatest pos-
 sible relief to the tension of the parts.   Their extent superficially and in depth
 must vary according to the seat of the inflammation.   Thus, in the inflamed
 conjunctiva they must  of course  be very  limited  in  this respect, whilst in
phlegmonous inflammation of a limb they may  be of much greater  extent.
Care, however, must always be taken not to wound superficial arteries or veins.
 A modification of puncture is  sometimes practised by opening  the veins in the 
82
INFLAMMATION.
neighborhood of the inflamed part at several points at once.  Thus, in inflam-
mation of the testis the scrotal veins may advantageously be punctured.   The
bleeding from punctures and incisions should always be encouraged by warm
fomentations.
  Leeches are usefully applied  to the neighborhood of inflamed parts, but
should  not  be put upon  the inflamed surface  itself, as their  bites irritate.
There  are certain  situations  in which  leeches  should not be placed, as over a
large subcutaneous vein, or in regions where there is much cellular  tissue, as
the scrotum  or  eyelids, lest  troublesome  hemorrhage  or  ecchymosis result.
So also they should not be applied near a specific ulcer, lest  their bites become
inoculated  by the discharge.   The bleeding from a  leech-bite should be
encouraged by warm poulticing or fomentations for some time after the animal
has dropped off.   In this way from half an ounce to an ounce of blood  may
be taken by each leech.  There is usually no difficulty in arresting the  hemor-
rhage from the bite; should there be so, continued pressure with some scraped
lint, felt, matico,  or  powdered alum,  will accomplish  this.  If this  do not
succeed, as  may happen in some situations where pressure cannot  be conve-
niently applied, as on  the  neck and abdomen, particularly  in young  children,
a piece of nitrate of silver  scraped to a point, or a heated wire introduced  into
the bite, previously wiped dry, or a twisted  suture over and around it, may be
required.
   Cupping is the  most efficient local means of  removing blood that we possess,
and the quantity extracted  may be regulated to a nicety in this way.  It  can-
not, however, be employed  upon the inflamed surface itself, on account of the
pain and irritation that would be occasioned, and  is  consequently chiefly appli-
cable to internal inflammations. As the scars made by the scarificators continue
through life, cupping should  not be practised upon exposed  surfaces.
   The inflamed part should always be  placed  in such a position as to facilitate
the return of blood from it.  Unless this be done,  the pain is greatly increased,
and the congestion augmented.  Hence, it requires  to be elevated on  a  level
with, or above, the rest of the  body.   All motion and  use must likewise be
interdicted,  as favoring determination and increasing pain.
   In cold and heat we possess two most important  local means of controlling
inflammation.   They cannot, however,  be employed indiscriminately.
   Cold:—There are two stages of inflammation in which cold may be employed
with especial advantage; first, during the very early stages, rather with a view
of preventing or limiting the inflammation,  so that it may not pass beyond the
bounds of adhesive action; and next when  acute  inflammation has passed off,
the vessels of the  part remaining relaxed  and turgid:  the application of  cold
acting as a powerful agent in restoring  the tone of the parts.
   Cold should never  be had recourse to  when these stages have passed, and
when suppuration  is coming on, or has  set in; still less should it be employed
when there is a tendency to  mortification.   Its long-continued and  incautious
use may indeed give rise to extensive sloughing of the inflamed part.
   The modes of  applying cold vary  according to  the  part affected.  If the
surface be inflamed, evaporating spirit lotions, to which sedatives may some-
times be advantageously added, are the best.  If  it be wished to influence the
whole  substance of a limb, irrigation with cold water should be adopted. (Fi°-. 45.)
If it be intended that the effect of the cold penetrate deeply, as  in inflam-
mations of the head, spine, or chest, it may be applied  by means of pounded
ice; to which, if an extreme  degree of cold be  required, salt may be added.
The ice is best applied by being placed in a bladder, gut, or a Mackintosh  ba°\
partially filled.
   Warmth  and moisture conjoined are of  the utmost service in  the treatment
of inflammation.   By these means, tension is  relaxed, effusion is favored  and
thus the over-distended vessels are relieved.  If continued for too Ion"' a time 
          TREATMENT  OF  CHRONIC  INFLAMMATION.        83

however, these means favor congestion, and sodden the parts.   Warm applica-
tions are especially serviceable in all  cases of inflammation attended by much
pain, more particularly if this occur from tension; and they are especially use-
ful when suppuration is threatening, or has come on;  and in many cases where
there is a tendency to slough.
   When abscess threatens, or the  surface is broken, nothing affords so much
relief as a well-made poultice, either of linseed meal or of bread; this made
soft and smooth, and not spread too thickly on the cloth containing it, should
be applied as hot as  the patient can bear it.
   Water-dressing, consisting of doubled lint, well soaked in tepid water, and
covered by oiled silk, or thin gutta percha, extending  from half an inch to an
inch beyond it on all sides, may be advantageously substituted for a poultice if
the sore be small, and the inflammation limited.
   Fomentations of warm water, or of  decoction of poppy and camomile flowers,
applied by means of flannels wrung out of these liquids, or of bags containing
the boiled plants, well soaked in the decoction, squeezed out, and applied  hot,
are very useful in extensive superficial inflammations.   The flannels and bags
should  be well covered with oil-silk  or Mackintosh cloth, so as to retain the
heat, and to  prevent evaporation.  Spongiopiline may be used as a substitute
for ordinary fomentations in cases in which the surface is unbroken.
   These are the  means by  which acute  active inflammation is  arrested  and
cured.  In their  employment, we must endeavor to proportion the activity of
our measures  to the  age, constitution, and vigor of the  patients,  the seat  and
intensity of the local disease, and  continue them until the inflammatory action
is not only arrested,  but  has entirely subsided,  the part being  restored to its
ordinary healthy state.

         TREATMENT OF CHRONIC INFLAMMATION.

   The treatment of chronic inflammation is far more difficult and requires much
more attention than that of the acute form of the disease.  Chronic inflamma-
tion is so frequently complicated with various unhealthy conditions of the system,
and with an impaired state of the general health, by which, indeed, it is often
kept up, that much practical tact and skill are required in carrying out the  the-
rapeutic indications properly.
   In the treatment of chronic inflammation we have not only to subdue inflam-
matory action, but also to remove structural changes and other effects induced
by it.   Hence, our object is not to produce a great and  sudden impression on
the system, as we are often required to do in the treatment of the acute affec-
tion.   In  this way chronic inflammation can  never  be cured, or its  effects
removed.  The patient might be bled to death,  and still the increased vascular
action  would go on in the inflamed part, so long as  there  was a drop of blood
circulating in his vessels.   It is true that the  same antiphlogistic means are
employed in arresting the chronic, as in  cutting short the acute form of the
disease, but in a less  energetic manner; our object being to induce a gradual
and continuous improvement in the  state of the system and  of the. diseased
part.   Local nutrition is always modified in chronic inflammation,  and this can
only be restored to its  normal condition  by close attention  to all the circum-
stances that  tend to improve the patient's general health, as well as by  pro-
ducing an impression on  the part itself  by appropriate local means.  Hence, in
the treatment of  chronic inflammation hygienic  measures are of the first  con-
sequence.  In most cases nothing can be done without proper attention to these •
and much by these that cannot be effected by any more direct medicinal means.
The treatment of this form of inflammation  must likewise be varied according
as it is of an uncomplicated character, occurring in an otherwise  healthy  con°
stitution, and assuming a sthenic type; or as it occurs in a cachectic and feeble 
84
INFLAMMATION.
system, assuming a congestive or passive character, or  as it is  met with in  an
unhealthy constitution, and affects a specific form.
  In  the management  of these various forms  of chronic inflammation  the
patient must be kept at rest, and, if the disease be at all extensive, be confined
to bed.   He should be in pure air, and, as a general rule, be put on a light and
unstimulating  diet.  The regulation of the  diet  is  of much consequence, and
the amount  and quality of the nourishment afforded must  be carefully propor-
tioned to the age, strength, and previous habits of the patient, as well as to the
degree and the seat of the inflammation, and  the form of constitutional fever
that accompanies it.   In the  more acute form of chronic inflammation, farina-
ceous slops,  at most beef tea, and light puddings, can be allowed.  In  the less
active forms occurring in feeble constitutions, with depression of general power,
animal food may be given, of  a light kind, and  the scale  of  nourishment in-
creased until stimulants, as beer, wine, or brandy, are allowed.   Nothing requires
greater nicety in practice than to proportion the diet, and to determine the cases
in which stimulants are necessary.   It may be stated  generally that  the more
the disease assumes the asthenic and passive forms, the more are stimulants re-
quired; until,  at last, in the truly typhoid type of inflammatory fever, our prin-
cipal trust is in  these agents; and large quantities of wine,  brandy, and am-
monia are required to maintain life.
  Mercury is of essential  service in the more  active forms of chronic inflam-
mation, but  in all cachectic  and strumous constitutions it should, as much  as
possible, be  avoided.  It is not only of great  use in arresting  the further pro-
gress of the disease, but  especially in  causing the  absorption of some  of the
effusions that  result from it, and in removing some  of the  other effects of
chronic inflammation, such as thickening, hardening, and opacity of the parts.
It should be given in small doses for a considerable length of time  until the
gums are slightly affected.  In many cases of depressed power it may be very
advantageously conjoined  with bark or sarsaparilla.  The most useful  prepara-
tions are calomel in half grain or grain doses, the iodide of mercury in the same
quantities; or if a gradual and continuous effect  be required, the bichloride  in
doses of from  Jgth to ^th of a grain.
   The iodide of potassium is an alterative and absorbent of the greatest value,
especially in chronic inflammations of fibrous or  osseous tissues, more particu-
larly when occurring in strumous  constitutions, in which it may often be sub-
stituted with great advantage for mercury, and given  in those cases in which
that mineral would otherwise be administered.  In many cases it is of essential
service after a mercurial  course.  Some days should, however, be allowed  to
elapse after  the mercury is discontinued  before the iodide  is given, otherwise
profuse salivation or even sloughing of the gums  is apt to result.
   Sarsaparilla is a very valuable remedy if obtained good, and forms an admi-
rable vehicle for  the preparations of mercury or iodine.  The  fluid-extract of
red Jamaica sarsaparilla,  carefully prepared, is  that to which I give the prefer-
ence ;  and where the  inflammation  is associated  with want of power, its value
is certainly very great.
   The cod-liver oil is of the very greatest value in the various  strumous forms
of chronic inflammation;  in debilitated, emaciated, cachectic, and strumous sub-
jects ; it may be given  in  some vehicle, such as orange-wine,  or juice, that
covers its taste.   In some cases it is advantageously conjoined  with the iodide
of potassium, or, when there  is much want of power, and strumous  anaemia ia
present, with  the preparations  of  iron.   It  is more  particularly in  children
and young people that it  is of service in removing the various effects of chronic
inflammation.
  Purgatives are often required in  chronic inflammation.   In robust subjects
in whom the disease is active, salines may be  employed; to which, if there  be
a rheumatic tendency, colchicum may advantageously be added.   As a general 
          TREATMENT OF  CHRONIC INFLAMMATION.        85

rule, warm aperients, such  as the compound decoction  of aloes, with Bochelle
salt, answer best; and in children a powder composed  of one part of mercury
and chalk, two of carbonate  of soda, and four of rhubarb will be found very
serviceable.
        LOCAL TREATMENT OF  CHRONIC INFLAMMATION.

   In chronic inflammation our  local means of treatment are much more varied
than in the acute form of the disease.
   Local blood-letting is  often  required with a view of directly unloading the
vessels of the part, and this  is  accomplished by scarification, leeching, or cup-
ping.  Scarification is principally employed in  chronic inflammation  of the
mucous membranes.  Leeches  may very usefully be employed, in some forms
of  chronic inflammation, by applying two or three at a time and repeating this
application every second or third day.
    Warmth and moisture are not so serviceable in chronic as  in  acute inflam-
mation, and care should  be  taken that they be not  continued   for so long a
time as to sodden the parts.  An astringent or stimulant, such as liquor plumbi
or  spirits of wine, may often advantageously be added  to the warm application.
    Cold is seldom required in any but the  advanced stages  of chronic inflam-
mation, in which there is debility and passive congestion of the vessels of the
part.  In order  to remove this state of things, its application should  not be
continuous, but be  made twice or thrice a day, so as to  occasion a sudden shock,
and produce a constringing effect upon  the enfeebled  circulation  of the part.
This is best  done by pumping or  pouring cold water from  a  height, or by
douching, and should be followed by active friction with the hands.
    Friction is often of great service in some of the forms of congestive inflam-
mation, and in the removal  of the  thickening, stiffening, and induration  that
results.   Friction may be practised either with  the  naked hand  or with some
embrocation of a stimulating or absorbent character.
    Counter-irritants are amongst the most energetic local means that we possess
for combating chronic inflammation.   Rubefacients, in the shape of stimulating
embrocations, to which absorbents, such as mercurial ointment may often advan-
tageously be added, may be usefully employed as adjuncts to friction.
   By means of blisters applied either directly over the inflamed part, or at a
little distance from it, the surface being kept raw and exuding by some stimu-
lating application, effusions and those chronic structural changes that accompany
the more advanced stages of inflammation may be absorbed.
    In the latter  stages of chronic inflammation, the pyogenic counter-irritants
may be very advantageously  employed.   By these a  powerful  derivative action
is  induced, and chronic thickening, may be melted away.
    Issues  are of especial  service in chronic inflammation of the  viscera, joints
and bones; they should be applied in the soft parts over the affected structures,
and may be kept open for a  very considerable length  of time.  They are  best
made in the following manner: — A piece of common adhesive  plaster, about
 two inches square, having a hole the size of a shilling cut in its middle, is fixed
upon the part where the issue is to be made; a piece of potassa fusa, about the
size of half a cherry stone, is then placed on the surface left uncovered by the
circular central aperture, a square piece  of plaster  being laid over all.  The
patient experiences a burning pain for about two hours, when it ceases; on re-
moving the plasters a black slough corresponding in  size to the central aperture
will be found. This must be poulticed for a few days until it separates, and the
raw surface then dressed with savine ointment, or stimulated  by an issue-bead.
As it shows a tendency to heal, it may be kept open by the  occasional applica-
tion of the potassa fusa.
   A seton when counter-irritation is to be  applied over very deep-seated parts,
is more useful than an issue. The seton may most conveniently be made in the 
86
INFLAMMATION.
following way (fig. 46) : —A fold of skin about two inches or more ii) breadth
is pinched up, and its base transfixed  by a narrow-bladed  bistoury.  The blunt
end of an eyed probe, threaded with the seton, is next pushed  along the back

                                 Fig. 46.
of the blade from heel to point, which being withdrawn as the probe is carried
onwards, the seton is left in the wound.   A poultice should then be applied.
   The actual cautery is especially successful in  deep-seated chronic inflamma-
tion, as of joints, when a deep and prolonged action  is required  to  be  set  up.
The cauterizing irons may be of various shapes.   They should be heated to a
dull red heat and then quickly drawn in lines, crossing one another, over the part.
  Astringents directly applied to the inflamed parts are  of extreme service in
those forms of congestive  or passive inflammation in which the circulation is
sluggish and the capillaries loaded, affording relief in these cases by inducing
contraction of the vessels.  In order to ensure their proper action they must be
employed of sufficient strength,  for if too weak they irritate, and increase rather
than relieve the congested  condition.  The  nitrate  of silver is the astringent
that is commonly preferred, and  this  applied either solid  or  in  solution, of a
strength from ten grains to one  drachm  of the  salt to the ounce of distilled
water, will produce a very marked beneficial influence  in  congestive inflamma-
tion of the mucous and cutaneous surfaces.
   Pressure by means of well applied bandages, elastic webbing, or strapping,
is of essential service in supporting the  feeble vessels in congestive inflamma-
tions. In many cases pressure may be advantageously conjoined with absorbents
and rubefacients,  as mercurial and camphor  liniment, or the plaster of mercury
and ainmoniacum.   This treatment, by removing congestion and promoting the
absorption of inflammatory effusion, is especially useful in chronic forms of in-
flammation accompanied by thickening of parts, as in the joints and testis.
   Having now discussed the treatment of ordinary sthenic inflammation in its
acute and chronic forms, we must next say a few words on the  management of
the asthenic and irritative varieties  of the disease.   These forms of inflamma-
tion derive their peculiarities more from  the character  of the constitutional
disturbance  that accompanies them,  than  from any  peculiarity in the local
affection.  Hence it is not in the topical treatment of the disease, but  in  the
management of the constitutional condition, that the principal  difference exists
between this and the other varieties of inflammation.
   In considering this part  of our subject, it is of especial importance to banish
the term " antiphlogistic;" for the same treatment that would be anti-inflam-
matory in one form of the disease, would certainly favor its progress in another.
Here we must be entirely guided in the means that we adopt  by the condition
of the patient and the character of  the symptoms.   If these from the first par-
take of  the asthenic or irritative type, we cannot at any period  have recourse to
the treatment that has been  recommended in  sthenic inflammation.   If the
disease commence in an active  form,  the fever progressively assuming a lower 
TREATMENT OF LOW  INFLAMMATION.           87
and lower character merging into the asthenic and irritative conditions, so must
we gradually alter the nature of our general treatment, which is always a deli-
cate procedure, requiring much caution.  Though  the  inflammatory fever may
at first assume the sthenic form, if there  is reason to believe, from the broken
constitution of the patient, or from the congestive or passive  character of the
local inflammation, that the constitutional symptoms will  not  long continue of
this type, we must be extremely cautious how we  lower  the  patient by active
depletion; for however high the fever may at first run,  and in  these cases there
is often febrile disturbance of  a very active character for  the first few days, the
disease speedily expends its force and rapidly subsides into a low form.  In such
cases as these, which are of very common occurrence in London practice, more
particularly in hospitals, we  should never bleed,  but  content ourselves, after
clearing out the bowels, with  keeping the patient quiet on a moderate or low
diet, and administering diaphoretic salines.  As the  symptoms gradually merge
into the typhoid type, the pulse with increasing frequency diminishing in power,
the tongue  becoming dry  and  dark, and the other symptoms of asthenia begin-
ning to show  themselves,  we must begin to give some stimulant in combination
with the salines.  The carbonate of ammonia in five to ten grain doses, or even
more, may be given in an effervescent form, with fifteen grains of the bicarbon-
ate of potass  and a sufficient quantity of citric acid,  every third or fourth hour.
The nourishment  must be increased; and wine or alcoholic stimulants must be
conjoined with it in proportion as the symptoms of debility become more  and
more urgent.   In effecting this change we must be careful not to run into the
error  of over-stimulating our patient;  this maybe avoided  by observing the
influence exercised on the pulse and tongue by the change in  treatment.
   In the majority of cases this  stimulating plan is not well  borne during the
first few days after the  setting in of an inflammation; but when the more active
symptoms show a tendency to subside, when the bowels have been well cleansed
out and the skin is beginning to assume  a slight degree of moisture, then it may
be resorted to with every success.
   In  many cases, however, it happens that the symptoms so rapidly sink into,
or, from  the very first,  assume so  asthenic a character, that the only treatment
that  holds  out a chance of saving the  patient's life consists  in the early and
 free  administration of tonics and  stimulants, with  mild  nourishment; such  as
 ammonia and bark, wine, brandy, or porter, with beef-tea and arrowroot, and
 of these, large quantities  may be required in the four-and-twenty hours; the
 patient  evincing a  tendency  to sink whenever  their use is interrupted.   The
 brandy and egg mixture of the  pharmacopoeia, if well  made, combining as it
 does  nutriment and  stimulus, is the best remedy that can  be administered in
 many cases.
    Under this plan of treatment the tongue will be found to  become moist, the
 brown sordes to  clear oft' from  the inside  of the mouth, the pulse to become
 steady and full, sleep to be procured, and the strength maintained.   The more
 I see of surgical inflammation the more  confidence do  I feel in this stimulating
 plan of treatment,  which is the only method of carrying patients through those
 low forms of inflammation  that are so frequent in hospital  practice.  The lia-
 bility to these  inflammations will also be materially lessened by the early em-
 ployment of a stimulating plan of treatment after injuries and operations.
    As the asthenic  passes into the irritative form, we may find it necessary to
 conjoin opiates with the general treatment.
    In  the lower forms of inflammatory fever, congestive pneumonia and asthenic
 bronchitis  frequently supervene.   In this complication, the following draught
 may be advantageously given  every third  or fourth hour :—R  Tinct. Camph.
 comp., )|p  20 to 30, Ammouiae  Carbonatis gr.  v. to x.,  Decocti  Senegae, 3iss.,
 with rubefacients, blisters, or dry cupping to the chest.   The diarrhoea that not
 unfrequently occurs, must be met with opiates  and astringents;  and if the
 urine cannot  be passed, it must be drawn off by the catheter. 
88
INFLAMMATION.
            SECONDARY  FORMS  OF INFLAMMATION.

  Inflammation, if it do not terminate by resolution, passes from the forms that
have just been described, into  others of a secondary character.   These are :
1st, the Effusive; 2nd, the Adhesive;  3rd, the Suppurative;  4th,  the Ulcera-
tive; and, 5th, the Gangrenous  inflammations.
  Effusive Inflammation.—-Effusions are not invariably  the  consequences of
inflammation; serum and blood are often poured out independently^' it.   In a
natural and healthy state, effusion or transudation of a watery fluid is constantly
going on in all parts of the body through the walls of the capillaries, this plasma
serving an important purpose in the nutritive actions of the tissues which it
bathes.   It  is only when this is increased in quantity and  altered in composi-
tion, that it becomes a diseased product, constituting oedema when occurring in
the cellular  tissue, and dropsy when accumulating in serous or synovial cavities.
The fluid that is thus exuded in sufficient quantity to accumulate, is of a watery
character, being neither liquor sanguinis  nor serum, not containing the fibrine
of the one, or the proportion of albumen and salts of the other.   Its transuda-
tion is generally dependent upon venous  congestion.  Thus, if the veins of the
leg are compressed, oedema of the foot will occur; if those of the liver suffer
pressure, ascites will result; or  if the renal veins  are obstructed,  albuminuria
will ensue.
  If the pressure on the vessels be still greater, the capillaries may become dis-
tended till they rupture, giving rise to effusion of blood, as in  some forms of
epistaxis and hematuria.
  Now, in inflammation, an increased degree of pressure exists in the inflamed
parts, the vessels being over-distended as well as dilated, and  blood continuing
to be pumped with augmented  activity against  those that  are already turgid;
hence there is a mechanical tendency to the occurrence of some effusions, and
a disposition for the inflammation to relieve itself by the distended vessels pour-
ing out some of their contents.   But though effusions in inflammation are partly
mechanical, they are not by any means wholly so; for, in many cases, organizable
matter and  organisms appear,  which did not previously exist, and which are
produced by the local actions of the part.
  The proper effusions of inflammation are—1st, blood; 2nd,  liquor sanguinis;
3rd, serum; and, 4th, secretions of tissues or organs.   These  effusions are in a
great measure mechanical,  depending on the dynamic state  of the vessels;
though, doubtless, in  many  instances, modified by other causes of a vital charac-
ter.  Fibrine, or lymph, though usually spoken  of as an inflammatory effusion,
differs so remarkably  in its vital characters from  the rest, and is so evidently a
new formation, that I shall  consider it separately.
   The  frequency with which one or other form of effusion occurs in different
tissues, or organs, varies greatly.  Paget  observes, " each  tissue has its  proper
mode and products of inflammation;" hence particular kinds of effusion are very
rare in some,  although of common occurrence  in other parts.
   1.  Effusion of Blood often occurs  in  small quantity, tinging the other pro-
ducts  of inflammation.   When this is the case, the coloring matter is broken
down and dissolved, a condition indicative of a low state of the constitutional
powers.   In other cases, the hemorrhage may be abundant, the character of the
blood  being but  little changed.  This effusion is dependent upon over-disten-
sion of the vessels, with softening of the tissues, giving rise to rupture of the
capillaries, without which it cannot  occur, there being no  such thing as trans-
udation of blood in  inflammation.   Hemorrhage of this kind most frequently
occurs from mucous surfaces, which readily bleed when inflamed.  It may also
happen from the rupture of new vessels in freshly-deposited lymph.
   2.  Effusion of Liquor Sanguinis. — In this case the fluid parts of the blood 
ADHESIVE  INFLAMMATION.
89
transude, leaving the red corpuscles behind.   It is occasionally met with in
so-called serous  effusions, into the tunica vaginalis, for  instance; so also the
serum  contained in the bleb of a blister is really liquor  sanguinis; and Paget
has found that in this there is  more  fibrine when there is  most strength of
constitution.   This fluid  is not uncommonly met with in  the subcutaneous and
submucous cellular tissues; about the glottis, and in the  scrotum, for instance,
giving rise to a gelatinous semi-transparent swelling of the part.  In these cases,
the more fluid portions are sometimes absorbed, leaving the fibrine behind, then
constituting the  condition termed solid oedema.  The fibrine in this effusion
often does not coagulate  so long as it is retained in the body, but when  once it
is removed solidification ensues.
   3.  Serous or  albuminous effusions are very common in inflammations of a
slight  or subacute form, of serous and cellular tissues, giving rise to dropsies
and oedema.  They most frequently  contain  a  small admixture of  fibrine,
approaching  somewhat to the characters of the last-mentioned effusion.  The
quantity of the  fibrine contained in them is usually a measure of the degree of
the  inflammation.   These serous accumulations  form and are  absorbed with
great rapidity, and their absorption is  usually most rapid when the fibrination
is least.
   4. Secretions of tissues and organs undergo changes in quantity and quality,
under the influence of inflammation.   The quantity is at first increased; but
during the active stage  of the inflammation, when there  is much tension, it
becomes diminished, the  part  being almost dry;  as  the inflammatory action
subsides, and relaxation  of the vessels  ensues, it again becomes increased.
   The alteration  in quality in  secretions from glands, is chiefly due  to the
admixture of morbid secretions  from  the mucous membrane.  When a serous
membrane is inflamed, the secretion not  only accumulates in greatly  increased
quantity, as in acute hydrocele, but it becomes turbid by the admixture of flakes
of lymph, which are sometimes so abundant as to give it a puriform appearance.
In other cases true pus is formed, as in inflammation of the  anterior chamber
of the  eye,  terminating in hypopium.
   In  inflammations of  the cellular  tissue,  the  quantity of fluid  is either
simply increased, or it becomes  fibrinous, occasioning solid  oedema and indu-
ration.
   In inflammation of the mucous membranes, the most important modifications
of secretion  occur.  The first  effect is to cause the transudation  of a serous
fluid from the  mucous  membrane, the secretion  becoming  clear, watery, and
abundant.   As the inflammation increases, exudation-corpuscles and large quan-
tities of epithelial scales are thrown off, and mixing with the  mucus, make it
viscid and tenacious, ropy as it  is termed.  In the more advanced stages, we
find  pus,  and  exudation-corpuscles,  with  epithelial  scales,  constituting the
various forms of muco-pus, and of true purulent secretion.

                    ADHESIVE  INFLAMMATION.

   The adhesive is that form of inflammation which terminates in the  effusion
of fibrine, lymph, or plastic matter; it may hence be termed fibrinous or plastic
inflammation.
   The study of the products of this  form of inflammation is of great import-
ance, not only because they form the  basis of adhesive action,  but  that they
are the media from, by,  and in which all the reparative effects of inflammation
take  place, and the reconstruction  of destroyed tissue is effected.   Lymph,
the  material of repair employed by nature, has an  independent and inherent
vitality by  which  it is  organized,  irrespectively of  the forces  of  the parts
around it.   It is  capable  of development into various tissues, and of  degene-
ration into structures lower in the scale of organization.   Many of the ulterior 
90
INFLAMMATION.
products of inflammation being but instances of the development or degenera-
tion of lymph.
  Although lymph is usually observed by the surgeon in a semi-solidified form,
lience often termed " coagulable lymph," it must necessarily be separated from
the vessels in a fluid state.   This separation  is not a mechanical act, but a vital
phenomenon, analogous  perhaps to the process of nutrition, by which a living
organized fluid, possessing within itself the  power of self-development, and of
organization into tissues, is separated  or  eliminated from the blood.  It is this
fibrine, lymph,  or plastic matter that  plays so important a part as a reparative
agent in  surgery;  that is seen as a covering to  the surface of recent wounds,
glazing them in a few hours, and causing speedy union  to take  place  between
their opposed sides through  its intervention.
   Characters of Lymph.—The plastic (Williams) or fibrinous (Paget), and the
aplastic  (Williams), croupous (Rokitansky) or corpuscular (Paget), are the two
varieties under which lymph is presented to  the  surgeon.
   The fibrinous or plastic,  is the true healthy coagulable lymph.  When first
poured out it is liquid, but it speedily  coagulates into a whitish, greyish, or
yellowish-white, elastic, semi-transparent substance, somewhat resembling the
buff'  of  coagulum.   Chemically considered, it  is not composed of pure fibrine,
but contains an admixture of oily and saline matters, which are necessary for
its development.  This form of lymph is only met with in healthy and  vigorous
individuals, usually as the result of inflammation consecutive upon cleanly-cut
wounds.   Under the microscope  it appears filamentous in structure, being made
up of delicate interlaced fibrillae.
   The corpuscular, aplastic, or croupous lymph  differs remarkably  from the
variety that has just been  described.  In this, coagulation does not take place,
but corpuscles  float free in a thin, clear,  serous liquid.  This variety of lymph
is met with in,  and is indicative of, cachectic  states of  the  system.  The cor-
puscles  which  characterize  it, commonly go by the  name  of exudation-cells;
they resemble in general characters the white  corpuscles of the blood, or those
met  with in the fluid  contained  in  the lymphatic vessels.  Gulliver states,
however, that exudation cells are larger and more irregular in size and shape
than  these, and usually exhibit from  two to  three nuclei  when treated with
acetic acid.   They form in about four-and-twenty hours after inflammation has
been  set up;  and may either  develop, passing upwards  through fibro-cells,
caudate-cells, &c,  into  filaments;  or,  degenerate into pus-corpuscles,  granule-
cells, granular matter, and debris.
   These  two  primary forms of lymph, the  fibrinous and the corpuscular, are
almost always  found  together, but existing  in various proportions  in the same
exudation mass; the relative quantity of the one or other element determining
whether it shall undergo  development or degeneration.  Paget  observes that
"the greater  the proportion'of  fibrine in any  inflammatory exudation, the
greater  is the  likelihood of its  organization."   This preponderance of fibrine
being indicative of adhesive inflammation.  And "the  greater  the proportion
of  corpuscles,  the greater  the  probability  of suppuration  or  of degenerative
process."  The preponderance  of corpuscles  indicating suppurative inflam-
mation.
   Why  does lymph at  different times assume  different forms, fibrine prepon-
derating in some,  corpuscles in other cases ?   Or, in other words, why have we
a tendency to adhesive  inflammation  in  some, to suppurative inflammation  in
others ?   This question, which  has been closely investigated by Hunter Bichat
Rokitansky, and Williams, has been very clearly replied  to by Pa-et as refer-
able to  three causes.  1. The state of the blood;  2. The seat of the inflamma-
tion; 3.  The degree and character of the inflammation.
   1.  State of  the Blood. — Paget  applied blisters to thirty different patients
and collected the sero-fibrinous fluid that accumulated in  the  blebs.   In those 
DEVELOPMENT  OF LYMPH.
91
who were suffering from purely local diseases, the constitution being otherwise
healthy, the fibrine was firm, filamentous, and elastic ;  in cachectic or phthisical
patients it was almost wholly  corpuscular, with every intermediate variety,
according to the condition  of the  system.   As  a  general rule in young per-
sons, and in those of sound  constitution, the fibrine is plastic;  hence it is  in
these individuals that we may chiefly look for the union of wounds by adhesive
inflammation.
   -. The seat of inflammation modifies its product  very considerably, as Bichat
and Hunter long ago pointed out.   Serous membranes are prone to fibrinous —
the  mucous to suppurative inflammation; and in cellular tissue, both fibrine and
corpuscles are found.   This general rule, however, is  subservient to the state
of the constitution, and to the influence of certain  specific diseases.  Thus  in
diphtherite and croup, lymph is poured  out on the mucous  membrane  of the
throat; whilst in empyema, pus  is formed in the cavity of the pleura.
   3. The  degree  and  character of the  inflammation  modify considerably the
product.  In slight inflammations it is almost always corpuscular; in the more
acute and active, of a fibrinous  character.   Certain forms of inflammation are
always attended by specific products.   In pyemia, for instance,  all the products
have a suppurative tendency,  even  when serous membranes  are  inflamed.  In
croup, on  the  other hand,  there is a disposition to plastic effusion even on
mucous surfaces.
   After-changes in lymph.—Lymph that has been  poured out is susceptible of
three important changes, viz., absorption, development, and degeneration.
   When lymph undergoes  absorption, it probably  breaks up and  dissolves  in
the  fluids of the part, being carried  off by the vessels; these  changes we not
unfrequently see taking place in an inflamed eye.
   Development of lymph. —In  a healthy constitution  and with a healthy local
condition,  lymph  evinces an  upward  tendency in the scale of development,
becoming vascular, and being converted into a fibro-cellular  material.  This
development may be arrested by the three following conditions:  viz., the state
of the patient's health; the continuance of the inflammation; and a congestive
state of  the part itself.
   If the health be impaired  or broken, all development ceases; this  process
being  essentially dependent upon  constitutional  force  and vigor.  Hence the
necessity of maintaining the patient's powers  if we look for healthy and com-
plete reparative action  in a part.
   The  continuance of  inflammation beyond a certain  point in intensity, pre-
vents the development  and  proper  organization of  lymph.    Thus, in an  ulcer
which becomes inflamed, all reparative action is at once arrested, and the lymph
already deposited  may retrograde or become absorbed.   This property in local
inflammation of imprinting a retrograde course upon  lymph that has already
been deposited, is taken advantage of by the surgeon, who dissolves away a hard
and chronic thickening of a part by exciting inflammation  in the centre of  it
with potassa  fusa.
   Local congestion of  a part effectually prevents the deposit of lymph.   Thus,
no reparative action takes place in  an ulcer seated on a congested limb.
   In undergoing development, lymph always passes into the fibro-cellular state,
beyond which it very frequently does not proceed.  This fibro-cellular tissue so
formed, is the common connecting  medium of wounds, and the tissue of  which
cicatrices are composed; we see  it  on the face  of a stump binding together all
the  tissues, muscles, nerves, and vessels in  one common bond.  It  is  of this
fibro-cellular  substance that adhesions, bands, false membranes, thickenings
and  opacities  are commonly formed.
  Plastic matter may also be developed into bone, passing through a fibrous, or
fibro-cellular  transformation; and,  lastly, we  see it developed  into  epithelial
scales,  such as are commonly found in cutaneous cicatrices. 
92                         INFLAMMATION.
   Vascularization of lymph. — In lymph  that undergoes development, blood-
vessels are seen to make their appearance at an early period.   With regard to
the precise time of their  formation, Dupuytren and Villerme state, from their
experiments on dogs, that twenty-one days are required; and Travers, from his
experiments on the frog's web, fixed the same period as that in which red blood
begins to pass.   In the human subject, however, the lymph on the surface of
an ulcer or wound certainly appears to become vascular long before this.
   How are the new vessels formed? —by development  in the lymph?  or  by
extension from surrounding parts?  Hunter and Rokitansky  incline to  the
former  opinion.  Travers  and Quekett, who have recently investigated  the
matter fully, believe that the vessels are always projected into the  lymph from
neighboring parts; and  Paget  agrees  with these  observers.  Travers  states
distinctly, as the result of his observations, which are borne out  by the results
of the experiments of  the late Dr. Todd, that " there is no such thing as inde-
pendent vascularization, the whole business of organization is of and from the
margin  of the wound."
   According to Travers, the following are the periods of development of vessels
in a frog's web which had been wounded :—
   Up to the fourteenth day, there is stasis in the vessels adjoining the wound.
From the fourteenth to the  twenty-first day, channels are opened in the plastic
matter,  at first  colorless,  then  admitting single blood-corpuscles;  from  the
twenty-first to  the  twenty-eighth day, the circulation is more active, the vessels
enlarging and  anastomozing; in  the fifth week, transparent capillaries pass
across from the colored arteries  to veins; and in  the sixth week there is  the
formation of new vessels  in  loops, half-circles, &c.
   The steps by which this interesting process is accomplished, are the following.
At first, small lateral dilatations  or  pouches appear at  some points on the
walls of the nearest old vessels; these grow out into the plastic mass, bend towards
each other, coalesce, and form a loop or fork.  These loops give rise to secondary
vascular outgrowths; and thus the vascularization of the lymph is completed.
   Travers states that these vessels are visible, like fine striae, before the circu-
lation can be detected in  them.  A single globule of blood first enters, this  is
followed by others, which for some time have a see-saw or oscillatory motion,
which progresses gradually towards the  nearest vessel, and the blood  entering
this completes the  circulation, which becomes continuous and equable.
  The degeneration of lymph has been especially studied by Paget.   He observes
that it may wither and harden, forming dry,  horny masses or vegetatious;  that
it may undergo fatty degeneration, and become converted into granular matter.
These two last forms  of degeneration are frequently met with in the coats of
diseased arteries.   Besides these changes,  it may calcify, being converted into
aninorganic earthy material; it may undergo pigmentary changes; and, lastly,
it is very frequently converted into pus.

                 SUPPURATIVE  INFLAMMATION.
  The suppurative is  that  form  of inflammation which gives rise to  the  pro-
duction  of pus; and  pus never occurs except as  the result of this  form of
inflammatory action.
  Pus presents considerable variety in its  general  character, according to the
nature of  the constitution of the patient, or the condition of the part fn which
it is formed.
  When formed in a  person  of healthy constitution, as the result of sthenic
inflammation, it is an opaque, creamy fluid,, thick, smooth, and slightly o-lutinous
to the touch; of a yellowish-white color, with a greenish tin^e, havin* a faint
odor, and an alkaline reaction.  Chemically, it is  composed of water containing
albumen, fibrine, saline, and  fatty matters in solution and admixture, and usually
gives  off a small quantity  of ammonia.   Pus presenting these characters is
termed  healthy or  laudable. 
CHARACTERS  OF  PUS.
93
  When admixed and tinged with blood, it is said to be sanious.   When thin,
watery, and acrid, ichorous; when containing cheesy-looking flakes, it is termed
curdy ; and when diluted with mucus or serum, it is frequently called muco-pus,
or sero-pus.  Besides these, pus presents many other varieties.  Thus, for in-
stance, when formed from  bone,  or  in the  neighborhood of  the alimentary
canal,  it has a peculiar fetid odor.   Its chemical composition may likewise vary
under different circumstances; thus, ordinary pus formed in the soft parts, contains
merely a trace of phosphate of lime, whereas that which is formed in connection
with diseased bone has been found by B. Cooper to contain 2^ per cent, of this
salt.   Sometimes animalcules are found in pus;  vibriones are met with in some
kinds of pus from the genital organs.   Pus presents  other peculiarities, which
are only cognizable by their effects on the system; thus, the pus from  specific
sores  possesses  contagious properties, though in chemical, microscopical, and
physical constitution, it does not differ from other  forms  of  that fluid.
  On  examining pus under  the microscope,  it is  found to consist of corpuscles
floating in  a homogeneous fluid, the " liquor puris."   These corpuscles appear
to be modifications of the exudation-cell, being composed of a semi-transparent
cell wall, containing two or three nuclei, which are rendered very apparent by
acetic  acid.  Besides these, a large quantity of granular matter, of particles of
fibrine, of  disintegrated  exudation-cells, are usually  found admixed with it.
The greater the quantity  of corpuscles, the richer and more creamy is the pus.
   In  many cases,  the  microscopical  characters of pus differ,  however, from
those  that have  just been given.   Thus, in the thin, greasy, yellowish-looking
pus, somewhat resembling melted  butter, that we find in the joints in pyemia,
the  pus-corpuscles are irregular in outline, and not so distinctly nucleated;
and in some forms of chronic abscess, when the pus is thin  and curdy, the
pus-corpuscles present a somewhat similar appearance, undergoing fatty degene-
ration.
  Fig. 47. Healthy pus-cells.  Figs. 48, 49, 50. Various forms of pus-cell from
phlebitis and pyemia.   Fig. 51. Pus from a scrofulous abscess.
Fig. 47.                                  Fig. 49.
 
94
INFLAMMATION.
  Pyogenesis, or the formation  of pus, is  an interesting  study.   The  older
surgeons believed  that this fluid was formed by the breaking up or disintegra-
tion  of the  solid  tissues, or that it was the result  of  their liquefaction  or
saponification  by the acid products  of inflammation.  Quesnay and Haller
exposed the fallacy of these opinions, and modern pathologists look upon pus
as a direct product of inflammation.
  Pus-cells have been shown by  recent observers to be modified or degenerated
exudation-corpuscles,  and  the  fluid  in which they float  to be of  a serous
character.  In many cases the transition from lymph to  piis-cells can be seen
to take place; thus Paget has observed that the fluid contents of  thevesicle of
herpes, which are corpuscular exudation-matters, become purulent  in  twenty-
four hours.   So, again, every surgeon must have repeatedly observed  that,  in
cutting  into  some forms of  abscess in their  early  stages,  a sero-plastic fluid
escapes, which, in the course of a day or two, becomes purulent.   So  likewise
in amputating in  the vicinity of an inflamed part, the  tissues  appear  to be
infiltrated with  gelatinous exudation-matter,  which, in the  course of a few
hours becomes converted into pus.
  Pus may be formed on the free surface, or in the substance of parts.   The
first constitutes a purtdent secretion;  the second an abscess.
  When formed on a free surface, whether this be serous or mucous, the pus
cells appear to be modified exudation-corpuscles floating in the watery  effusions
of the inflamed part.
  When pus forms in  the  substance of a tissue, or organ, constituting an
abscess, there is in the first place a high degree of inflammatory  action.   Sero-
plastic exudation is thrown out, infiltrating the tissues, and in  the centre of
this, where  the  inflammation attains  its greatest intensity, the exudation-cells
become  transformed into pus-corpuscles.  A drop of pus  is thus  formed in the
inside of the exudation-matter already effused, or at the moment of its evolution,
as the result of changes imprinted on it by contact  with  the inflamed  parts.
Around the  pus thus formed, the lymph deposited in the  substance of the
tissues,  and filling  up their interstices, forms a consolidated mass, which plays
an important part in limiting the further extension of the suppuration.  As the
suppurative action advances, the corpuscles composing the  innermost layers of
this plastic mass, gradually transform into pus-cells; the blastema degenerating
into  liquor puris.  The purulent accumulation thus  formed, constituting an
abscess, is always  retained in healthy states of the  system, by  an  external
boundary of consolidated lymph, which extends  itself on  its outside by fresh
deposits, and by the liquefaction and metamorphosis of its interior, as the central
accumulation of pus increases.
   This  boundary of lymph has been  termed  the Pyogenic  membrane, and was
supposed by Delpech to be  the  secreting organ of pus.    This,  however, it is
not;  and that it is not necessary for the secretion of pus,  is shown by  the facts
that it is not found in the  early stages  of suppuration;  that on free  surfaces
suppuration occurs without it, and that it is absent in certain kinds of abscesses,
the diffused  and the metastatic.   A better term for it would  be  the " limiting
fibrine," as it limits or bounds the spread of suppurative action.  Its absence is
usually indicative  of a  want of power in the system; the  suppuration  then
becoming diffused, extending itself indefinitely through the cellular tissue.
   The  diagnosis of pus is usually easy, but some fluids resemble pus so closely
to the naked eye, that the microscope becomes necessary  to establish their true
characters.   From healthy mucus there is no difficulty in distinguishing pus
but when  mucus  has been  thickened  and rendered  opaque by fnflammation,
and is mixed with exudation-cells, it  is impossible, and can never be necessary
to distinguish it from pus.
   Turbid serum, containing broken-down and granular fibrine,  frequently met 
CHARACTERS OF  PUS.
95
with in serous sacs, closely resembles pus; here  the  diagnosis may be effected
by the absence of cells.
   Seftened fibrine,  as in clots and inflamed vessels, often closely resembles pus
to the naked eye, but the microscope reveals the true nature of the fluid  by the
absence of exudation-cells.
   Atheroma may be distinguished from pus  by the presence of cholesterine,
granules and fat, and by the non-existence of the characteristic  pus-corpuscle.
In tubercle and cancer the  absence of the true pus-cell, and the presence  of
appearances characteristic of these morbid products, establish the diagnosis.
   When  admixed with blood the detection of pus  is often  very difficult, and,
indeed, cannot  in  many cases be satisfactorily accomplished;  the white cor-
puscles have sometimes  been mistaken for its cells, to which they have  a great
resemblance.
   When  diffused in milk, as in some forms of lacteal abscess, the corpuscles  of
this fluid will be seen to be smaller  and clearer, with a more  defined  outline
than those of pus.
   Suppuration  varies greatly as to duration.   Inflammation very  commonly
terminates in the formation of pus, in the course of about three days; at other
times a much longer period than this is required, the inflammatory action being
 of a passive and languid character.  When once suppuration has been set up, it
 may continue for an indefinite time, pus becoming, as it were,  the  established
 secretion of the part.  It  is  not uncommon to find  purulent discharges from
 mucous membranes continuing for years.
    The characters of suppurative inflammation vary according as  it is healthy,
 unhealthy, or specific.
    The  Symptoms of suppuration are  local  and  constitutional.   The  local
 symptoms differ as the suppuration occurs on a mucous surface, or in an internal
 cavity, or organ.
    When an inflamed mucous surface is about to suppurate, the  membrane pre-
 sents the ordinary characters of active inflammation, being swollen, red, and
 often painful; to these a discharge is  speedily superadded.
    When suppuration  is about to take place in the substance of tissues or organs,
 the local symptoms of inflammation undergo  certain modifications indicative of
 the supervention of this action.   The pain becomes throbbing, the part swells
 and becomes tense, but after a time softens;  and fluctuation or undulation may
 be detected in it.   The skin becomes  glazed,  red, shining, and cedematous.   In
 other cases, again, suppuration occurs without any evident local sign of inflam-
 mation, the presence of the pus revealing itself by swelling and fluctuation only.
    Constitutional Symptoms. — On the supervention of extensive suppuration,
 the ordinary symptoms  of inflammation subside, and are usually interrupted by
 the occurrences of chills, alternations of heat and cold; or if the formation of
 pus be extensive, by severe and  long-continued  rigors. The fever often assumes
 a somewhat intermittent character, and its intensity lessens, the pulse becoming
 soft,  though continuing quick.  If pus be formed in sufficient quantity for its
 discharge to act as a  severe drain on the constitution, another set of symptoms
 speedily sets in, dependent on the loss that is going on.   The patient becomes
 weak, his nutrition is impaired,  and hectic is  established.
    Hectic does not come on unless there is a discharge of pus from  the  system.
 No hectic occurs so long as an abscess, however large, continues unopened;  but
 it supervenes with great rapidity when once its contents are discharged.  I have
 known a large abscess exist unopened for two years, without any constitutional
 disturbance, but  so soon as it  was  opened,  well marked hectic set  in, which
 speedily carried off the patient.
  _ Hectic is essentially a fever of debility, conjoined with irritation.   Emacia-
 tion and general  loss of power invariably accompany it.   The  pulse, which is
 quick, small, and  compressible, rises from ten to twenty beats above its normal 
96
INFLAMMATION.
standard; the tongue becomes red at the edges and tip; the cheeks are often
flushed, and the eyes glistening, with a dilated pupil; all these symptoms have
a tendency to  exacerbations after meals, and  towards evening.   There  is also
increased action, either of the skin, bowels, or  kidneys.  Thus profuse sweating,
copious purging, and abundant red deposits in  the urine  take place;  thei'e dis-
charges often  alternate with one another, melting the patient away, and hence
are termed colliquative.   The debility gradually increasing, the  patient rapidly
wastes, and at last  dies  from  sheer exhaustion, the  conjoined result of fever,
mal-nutrition,  and wasting discharges.
   In some cases of extensive  suppuration, especially in children, hectic does
not occur, but marasmus  or atrophy takes place instead,  the child wasting away
without fever, and being carried off  at last  by exhaustion or some intercurrent
disease.
   Inflammation  tends to suppuration  under the influence  of  conditions very
similar to those  that give rise to  the formation of corpuscular rather than
fibrinous  lymph.   Indeed it must  be  borne  in mind  that there are no very
definite limits between these two products of inflammation,—exudation corpuscles
and pus cells.   We see that, in a sore,  the same action  will generate cells that
very closely resemble one another.  Some  of these  are exudation,  becoming
organized; others again are  pus-corpuscles, and become  eliminated.
   1st.  The state of the patient's health exercises a great influence on the pro-
bable tendency  to  suppuration.   The sounder  the  constitution  the less the
chance of inflammation  running into  the suppurative  form.   And indeed we
may often, in surgical practice, look  upon the suppurative tendency of wounds
as a measure of the state of  the patient's health.  Thus, in scrofulous constitu-
tions, the inflammation  that is excited by a trivial  injury, as the sprain of a
joint, for instance, is very apt to run on to  suppuration.   So again, in certain
cachectic states of the system, slight wounds suppurate, or fester, as it is termed.
   2nd. The specific character of the inflammation often determines the super-
vention of suppuration; some diseases, such as gonorrhoea and purulent ophthal-
mia, consisting essentially in the secretion of pus by a free  surface.
   3rd. The seat  of inflammation also  exercises  considerable influence.  Thus
mucous membranes when inflamed  almost invariably suppurate, the  transition
from their normal secretion to pus  being very readily effected.   Serous mem-
branes do so  but rarely; the puriform fluid secreted by them when inflamed
being in most  cases nothing  but turbid  serum.
   4th. The more intense  the  inflammation  the greater the liability to the
formation of pus; hence pus  usually  forms  in  the centre of inflamed parts.
When the inflammation is of an active sthenic character in a healthy constitu-
tion, it requires  considerable intensity  to give rise  to suppuration.  It is only
where the system is strongly predisposed  by struma or cachexy  that very slight
inflammations terminate in this  way.  The degree of inflammation required^for
the formation of pus varies greatly, but it is always greater than that necessary
for plastic exudation.
   5th. The local condition of the part influences the probability of suppuration.
Thus a subcutaneous wound, as in tenotomy, does  not suppurate; but if it be
opened, and its  interior  exposed to the air,  then  degeneration  of  exudation-
cells, which constitutes  their conversion  into  pus, takes place.  For the same
reason  all ulcers suppurate.  The lodgment of foreign  bodies, as of urine, a
piece of  bone, or a  bullet, by  exciting intense  and continuous inflammation,
almost inevitably leads to suppuration, which  is indeed  the means adopted  by
nature for their removal from the system.
   The treatment of this  form of inflammation is divisible into local and consti-
tutional.
   The Local Treatment presents three  indications. 
ULCERATIVE  INFLAMMATION.
97
  First, the removal of the cause; as by extracting a piece of dead bone from
the bottom of a sore.
  Secondly, lessening inflammatory action by appropriate antiphlogistic means,
and thus either removing the inflammation entirely, or confining it within those
limits that are compatible with the effusion of plastic matter.
   The third indication consists in facilitating  the escape  of  the  pus, if it be
lodged in tissues or deep cavities, and in moderating or arresting  the  amount
of  its discharge, when  it is poured out from a free  surface  by the use of as-
tringents of various kinds, or by the proper employment of pressure.
    Constitutional Treatment.—With  the view of preventing the occurrence of
suppuration, a general antiphlogistic  treatment must be  employed in the earlier
stages of inflammation; but as the drain on the system  may eventually be con-
siderable, we must be careful not to push these measures with too much activity.
After the discharge has taken place, nourishing, tonic, and  even stimulating
treatment will be required in proportion  to the amount of debility that  is in-
duced.   Amongst the most useful medicinal agents are mineral and vegetable
tonics, the mineral acids, and cod's liver oil.  Attention to hygienic conditions,
with change of air and residence at the sea side, are also most valuable.   When
 hectic comes on,  the same general  tonic plan must be adopted, whilst we have
 recourse to means adapted to meet the special  symptoms.   Thus, acids are re-
 quired to check the sweating, astringents to arrest the diarrhoea, and as much
 mild nourishment as the patient will bear, to support the strength.

                   ULCERATIVE  INFLAMMATION.

    The Ulcerative, is that form  of inflammation which terminates in the forma-
 tion  of an ulcer.   An  ulcer may be  defined to be a solution of continuity, with
 loss of substance; a cavity or hole slowly produced by some action going on in
 the part itself, or suddenly, by chemical agents,  destroying  the  textures, and
 attended by the secretion of pus.  It is that process by which nature separates
 parts that have,  from whatever  cause, lost their vitality,  and is  diametrically
 opposed  to adhesive inflammation,  being attended by an  absorbing, and not a
 depositive action.  There are two distinct stages  described as constituting the
 process of ulceration, attended  by the most opposite  phenomena; viz., 1st, the
 period of destruction;  2nd, the period of reparation.   To the first only can the
 term be properly  applied, the stage  of repair being one of deposition.  The pro-
 cess  of  ulceration must always be confined to the surface, and  cannot occur
 within the texture or substance of parts.  It is most common  on the cutaneous
 and  mucous surfaces, but likewise occurs on the lining membrane of blood-ves-
 sels and  on serous membranes.
    In what does ulceration essentially consist ?   Is it simply an arrest of nutri-
 tion ; a cessation  of the deposition of new materials, whilst the  old ones are re-
 moved,^ passive  state  in which absorption is normal,  and deposition imperfect?
 Or, is it an  active condition of the absorbents, deposition being  normal, but
 absorption being  carried on with too great vigor ? or, lastly,  is  it a process  of
 disintegration,  of elimination,  of ejectment of spoiled  and  dead  matters;  a
 detachment of the disorganized  soft tissues, as we see  occurring in sloughin«
 ulcers or in the removal of carious bone, in its disintegration  by pus ?   Prob£
 bly all these conditions enter  into  ulcerative  action, but more especially the
 latter. _ It might  be supposed  that the precise  share that each takes could be
 determined by a  reference to the agency by which ulceration is affected;  whe-
 ther by the absorbents or by the veins; but this cannot be determined at pre-
 sent; and that ulceration occurs independently of either set of vessels is evident,
 from the fact that it is met with in parts, as the cornea and in  cartilage, where
 neither  exist.  Doubtless, in many  cases ulceration  consists  essentially in the
 disintegration, softening, breaking down, or, as it has been termed, the " mole- 
98
INFLAMMATION.
cular death " of the tissues, and the detachment of these spoilt matters by a
peculiar action of the subjacent living structures.
  There are  certainly two  conditions in which  ulceration may occur;—with,
and  without, inflammation.   Inflammation  may give rise  to  ulceration in two
ways:—1st, by directly softening and disorganizing the structures; and thus
occasioning the more rapid  or acute forms of ulceration, that  are accompanied
with  much sloughing and  signs of active  inflammation, great pain, heat, and
redness.   2d, by chronically modifying nutrition, inducing induration and plas-
tic  infiltrations, which,  under the  continuance  of the inflammatory process,
soften and break down, becoming converted into ill-organized pus,  mixed with
the debris of the part.
  Tissues that have been  congested for a long time are apt  to inflame under
the influence of some trivial exciting cause, and  rapidly to run into ulceration.
This  usually commences in the centre of the part, where the  nutrient action is
lowest; here a small sore forms, which exudes thin unhealthy pus,  and rapidly
extends.  So long as the sore is inflamed, it continues to spread, and reparation
cannot go on in it.   It would appear as if  a moderate  degree of inflammation
were too  intense for the vitality of chronically  congested  tissues,  or  those  in
which lowly-organized fibrine has been  effused.   The more the vitality of a
tissue is  reduced, the less  appears  to  be the degree of  inflammation that is
required to produce disintegration and ulceration of it.  Indeed, if the vitality
of a  part be sufficiently lowered, it may fall into a state of ulceration without
the  occurrence of  inflammation, or with so slight a  degree  as scarcely to be
appreciable;  the  ulcerative action appearing to  arise from  disintegration de-
pendent upon the want  of nutrition.  Thus, for instance, in scrofula and  in
other diseases, as scurvy or  syphilis, where there  is an  imperfect nutritive force,
a tendency to softening and breaking down  of structure, and consequent ulcera-
tion occurs; and these tendencies are much increased by the occurrence of con-
gestive or subacute inflammation  in the part.
  Ulceration is so  intimately allied with  sloughing  and  gangrene, that it is
very  difficult to  separate  the  causes  of  the  one from   those  of the other
conditions.
  The predisposing causes  of ulceration  are chiefly found in those conditions
that  interfere in any way with  the  nutrition of a part.   A feeble  circulation,
such as  often exists in  the lower limbs, the alae of the  nose, and in newly-
formed  or recently-cicatrized  parts, tends to the formation of ulcers.  As age
advances, nutrition becoming impaired, and the  circulation  less active, slight
causes suffice to disintegrate the structure  of a  part, and  mal-nutrition, or loss
of innervation from any cause, by lessening the  vitality and resisting power of
tissues, has a tendency to give rise to ulceration.  Hence  we  so commonly see
ulcers of the legs, in elderly people, more particularly  amongst  the poorer
classes, arise from slight irritation  or  pressure.   In  the   dogs that Magendie
starved by feeding them  on  sugar, gum, or oil, and distilled water, ulceration of
the cornea occurred.   This must have been the  result of simple  mal-nutrition,
rather than of inflammation.
  Ulceration may be directly excited by the intensity  of  the inflammation at
once destroying or disintegrating a part.  By a severe mechanical injury, lona-
continued pressure, or the  application of a  chemical  irritant, producing direct
breach  of surface.  And, lastly, by the influence of  certain specific  diseases,
which are accompanied by want of nutrition,  as scurvy  and some scrofulous
affections, the peculiar character of which consists  in the  ready production of
ulcerative action.
   Ulceration may commence in several distinct ways on the cutaneous and mu-
cous surfaces.
   1st,  There may  be such a degree  of acute  local inflammation as rapidly
gives rise to "molecular death" of the part.   If the action  be  not a  very 
CAUSES OF  ULCERATION.
99
acute one, and the destruction of the tissues not very rapid or extensive, the
disorganized matters, become  mixed with pus, and are discharged in the form
of a dirty, brownish,  puriform fluid.   If the  action be more violent than this,
complete  disintegration  does  not take place in the  affected  part, but  shreds
of the  spoilt tissues  continue attached for some time to the ulcerated surface,
giving it a very ragged appearance.   If the inflammation be of a more intense
character,  layers of  disorganized tissue, constituting "sloughs," are formed,
and remain  in  contact with  the ulcerated surface, often covering it in com-
pletely,  and  invading  with  considerable  rapidity  the  neighboring healthy
structures.   Thus, some of the forms of phagedenic,'or sloughing  ulcer, are
constituted.
   2d. Chronic  inflammation  may give rise to ulceration, by so interfering with
the nutritive actions, that the balance of absorption and deposition  is disturbed
in  favor  of the former.   The  ulcerative effects of  chronic  inflammation  are
especially marked in  parts that have been chronically congested; the congestion
having given rise to such softening and loosening of tissue as facilitates mate-
rially ulcerative action.
   3d. Ulceration sometimes commences in the  crypts or follicles which open on
 the mucous surface, some modification of structure taking place in their  epithe-
 lial linings, which leads to the formation of circular depressed ulcers, as may
 often be observed about the tonsils.
   4th. A vesicle or  pustule forming on the cutaneous surface, and  shedding its
 contents, very commonly gives rise to an ulcer, as in Rupia and Pemphigus.
   5th.  Suppurative inflammation not unfrequently occurs in the subcutaneous
 or submucous cellular tissues, and by undermining and consequently destroying
 the vascularity of the skin and mucous membrane, and thus arresting its nutri-
 tion, gives rise  to ulcer.
   6th. In some specific cases, we find that ulceration is preceded by the forma-
 tion  of a morbid growth, tubercle, or tumor, in which inflammation  and disin-
 tegration of tissue, and consequent lesion of substance occurs.
   In whatever way  ulceration  commences, it  presents  three distinct  stages:
 1st, the period  of extension, or of slough;  2d,  the period of arrest, or of plastic
 deposit;  and 3d, the period of granulation and of cicatrization.
   1st.  When the ulcer is spreading, there  is always a circle of inflammation
 around  it, as  evinced  by redness, heat, and  a burning, throbbing pain;  its
 edges  are  jagged, eroded, or sharp cut; its  surface, which is more or less of a
 circular  or oval shape, spreading pretty equally from  one starting  point, and
 being covered with a greyish or yellowish, soft, adherent slough.   In ordinary
 cases this is thin and shreddy, but in some forms of ulceration it is soft, pulta-
 ceous, and elevated above the surrounding parts.  There is either no discharge
 at all, or else a bloody, ill-conditioned fluid,  hardly deserving the name  of pus,
 drains from the surface.
    2d.  In the next stage of ulceration, that of arrest, the symptoms of inflam-
 mation diminish, and a layer of plastic matter  is deposited  in the tissues form-
 ing the base and sides of the ulcer.   This not only  serves to  arrest or limit the
 further process of ulcerative action,  but becomes the  medium of its ultimate
 repair.   The surface  begins to clean, the  grey adherent slough separating in
 fragments,  and dissolving away in  the  discharge,  which gradually loses its
 sanious tinge,  assuming more  the characters of healthy pus, though still very
 scanty in quantity.  The surface continues flattened, its  sensibility diminishes,
 and  the edges  are often elevated and  indurated.  In this  stationary condition
 an ulcer may remain for many months;  and it is that in which we commonly
 find chronic sores.
   3d.  The last stage, that of repair, is characterized by the formation of granu-
 lations, which may be looked upon as the turning-point in ulceration.  Until
 granulations are formed, ulceration  is a wasting process, or at most stationary; 
100
INFLAMMATION.
so soon as they are formed, it becomes  reparative.  Instead of a tendency to
increase, to erosion, and to concavity, we now have a disposition to contraction,
to deposition, and to convexity of surface, which assumes a bright-red hue, of a
vermilion or scarlet tinge, appearing  to  be studded with minute  papillae; the
edges become rounded and  smoothed down towards  the surface, losing  their
sharp cut appearance, and the discharge  assumes the characters of  healthy pus.
   We now proceed to study the changes that occur in an ulcer during the stage
of repair, — the process of granulation, and of cicatrization.
   1st. As to granulations,  their mode of formation, structure, and use.
   So soon as inflammation and extension of ulceration are checked, the surface
of the ulcer, as has already been stated, becomes covered by a layer of plastic
matter.  This plastic layer, separating the  ulcer from surrounding and adjacent
tissues, forms a basis to it, from which the granulations, the organs of repair,
spring up.   Before this plastic basis can be deposited, it is necessary that the
inflammation be  reduced within those  limits that are compatible with plastic
effusion.  So long as  inflammatory action  exceeds this  limit around the edge
or at the base of the ulcer, no lymph is effused.  But so soon as this undue action
is checked, lymph is thrown out, which becomes vascular by vessels shooting
into it from below;  and assumes a granular form from its deposition in papillae,
or granulations, which are consequently composed of exudative  matter which
has  become  vascularized in  the way that  has  already been  described.  In the
great majority of cases,  granulations are only  formed on surfaces exposed to
the  air and  secreting pus;  but they may  be  formed without exposure to the
air or the formation of pus,  as  Hunter and Paget have shown to occur in some
cases of fracture, the  ends of  the bones  being covered by a distinct layer of
florid granulations.  That these granulations are in reality composed  of lymph
that  has become vascular,  is evident from the interesting fact  observed  by
Hunter, and which every surgeon  must have  had  repeated  occasion to verify,
both in wounds and compound fractures;—that a portion of bluish-white, semi-
transparent lymph effused on the surface of the sore or denuded bone is seen to
become vascularized, and to be converted into true granulations, in from twenty-
four to forty-eight hours.
   The microscope shows  that  granulations are composed of cells heaped  up
without much, if any, apparent order, and connected  by but little intermediate
substance.   When single, they are  colorless;  when  in  clusters, they  become
ruddy.  It is interesting  to observe how these cells undergo different changes
in different parts of the same ulcer.
   Those situated at the  base nearest the  attached surface  of the granulation,
 constituting its  deeper layers,  undergo development into filaments and  fibro-
 cellular tissue.   Those on the surface  are either thrown off in a rudimentary
 form, or degenerate into pus-cells;  whilst  those at the edges become converted
 into  epithelial scales.  Thus we see the  same action giving rise to exudation
 corpuscles, to pus, to epithelium, and to fibro-cellular tissue.
   The development of vessels in granulations — a most wonderful and beautiful
 process, by which thousands  may form in a day on a healthy granulating surface
 —is identical with their general development in lymph, which has already been
 described.   A series  of loops and  arches being formed as  outgrowths from
 neighboring vessels.
   The sensibility of granulations  varies considerably, being  often greatest  in
 those which spring from  tissues that are  naturally the least sensitive, as bone,
 for instance. No nerves have been traced in granulations, hence their apparent
 sensibility would appear to depend upon that of the subjacent inflamed tissues.
   The characters of granulations afford important indications to the surgeon as
 to the condition of the  surface from which they spring, and the state°of the
 patient's general health.  Granulations indicative of a healthy local and con-
 stitutional condition, are small, florid, pointed, close-set, and bathed with healthy 
CICATRIZATION.
101
 pus; the use of which  appears to  be to cover and protect the tender surface
 with a soft lubricant coating, into which the granulations may sprout without
 being dried by the air, or readily damaged in any other way.
   In a weak state of the sore, or of the constitution, the secretion of pus dimi-
 nishes, and it loses its healthy  character; the granulations become large, pale,
 and flabby, appearing to be cedematous from infiltration of serum, and assuming
 a glassy or semi-transparent look, with a purplish hue.   Occasionally hemor-
 rhage takes place into them, and they become  broken down and sloughy.  If,
 whilst a sore is healthily granulating, morbid  action is set up in it, or in  the
 economy — as by the supervention of erysipelas, or fever — the granulations
 and pus-cells  degenerate at once; the granulations becoming rapidly absorbed,
 and the surface of the sore  assuming a greyish,  sloughy look, and the formation
 of pus  being  arrested.
   2d. The healing process, or  Cicatrization, is that by which  the ulcer closes
 and becomes  covered by an integumental investment.   Two distinct processes,
 though carried on simultaneously, are necessary for the accomplishment of this.
 These consist in the granulations assuming a  healthy character, and covering
 themselves with new cuticle; and in the contraction of the surface of the sore.
   The  first change that takes  place  in  an ulcer that is about to undergo  the
 healing process, is, that the granulations become florid,  and are bathed with
 healthy pus;  the  edges and surface of the sore then assume the same level —
 the  granulations  rising, and the edges subsiding.   So  long  as  there  is any
 inequality  in  this  respect, the process  of cicatrization  cannot  go on.   The
 granulations  nearest the edges become  smooth, cease  to pour out pus, and
 become glazed over with a thin, whitish-blue pellicle, which is  the first appear-
 ance of new  skin,  composed of granulation-cells developing into epithelium.
 As cicatrization advances,  the  part of the sore immediately inside this bluish-
 white line will be seen to  be occupied by a red zone, which, in  the course of
 four-and-twenty hours, becomes, in its turn,  new epithelium, and appears to be
 the link between granulation and true cuticle.
   At the  same time  that  these changes are going on, contraction of the sore
 takes place.   This  would appear to be entirely a mechanical  process, and not  a
 vital action; and is owing to the conversion  of the exudation-cells of the granu-
 lations into the filaments of cicatricial tissues, which being more closely packed,
 and becoming drier, occupy less space (Paget).  This contraction commences
 as  soon  as the sore presents a tendency to cicatrize, and continues for a con-
 siderable time after this  is completed.
   Cicatrization  advances with greatest rapidity  around the edges  of the  sore;
 the centre  taking  the longest  time to heal, in consequence of the activity of
 the process appearing to diminish the farther  the  new skin extends from the
 old tissues.  Indeed, if  the ulcer be large, there may not be sufficient force  for
 the cicatrization of its centre.   A sore of a circular shape usually takes a longer
 time to  heal  than an oval,  elongated one; the reason appearing to be that the
 new skin is only formed at the edge, and never  in  the centre of an ulcer;
 unless it happen that islands of  old skin are left there undestroyed, which serve
 as  centres of cicatrization.  It would appear to  be necessary  for the healin"1
 process, that granulations have  some  of the old textures to be modelled upon,
 the characters of which they then, and only then, appear to assume; receiving
 an impulse from the plastic  force of the old tissues on which they are deposited,
 that causes their development into analogous structure.
   The changes taking place in  a cicatrix do not cease with its formation: two
 processes continuing for  a very considerable length of time afterwards; viz. the
gradual contraction and the development of the cicatricial tissue.
  We have seen that granulations tend to  contract during the healing of  an
ulcer, and that the  diminution in surface thus produced, facilitates greatly its
cicatrization.  Hence a  scar is  never  so large as the original sore.   This con- 
102
INFLAMMATION.
traction continues, however, and  does  not attain its maximum until long after
the completion of cicatrization, often occasioning great puckering or deformity.
The degree of contraction depends partly on the seat of the scar, but principally
on the agent that produces the ulcer; if the scar be seated on a part where the
skin is very tense, the contraction will be slight; if the skin be naturally loose,
it will be considerable.   The contraction that takes place in scars which result
from burns, is  greater than in those which occur from  any other cause, often
producing serious deformity and great distress to the patient.   These results do
not supervene in their fullest extent  until after a lapse of some weeks or months
from the infliction of the injury.   This contraction would appear in some cases
to be due, not  only to the consolidation of the texture  of the  scar, but to the
development in it of  yellow elastic tissue.
   Two  great changes are wrought  by time in  the texture of a  cicatrix;  its
tissue assimilating  more and  more  to  the normal structure of the part, and
its deep attachments becoming more movable.   When first a scar  is formed, it
is thin,  reddish, or bluish and shining, being composed of imperfectly-developed
filamentous  tissue, covered by a  thin epithelial layer.    As it becomes older, it
assumes a dead-white color, and becomes depressed, and gradually, but slowly,
many years being required for the change, it " wears out;" that  is  to  say,  its
structure more closely resembles that of the texture of  the part on which it is
seated.   It never,  however, becomes developed into true skin, as  neither hair,
nor sebaceous or sudoriferous glands form in it.
   In structure  cicatrices are composed of a fibro-cellular  tissue, rather sparingly
supplied with blood-vessels, and  covered  by a  thin epithelial covering, usually
smooth  and glistening, but sometimes  nodulated and  rugose.   The  sensibility
of the cicatrix  itself is lower than that of the skin generally, but it will usually
be found that  the edges of the integument, when in contact with  the cicatrix,
are more highly sensitive than are the integuments on  other parts of the body.
When tough and irregular cicatricial bands, or " bridles," stretch across a part,
it will usually be found that they are devoid of sensibility.
   Coincident with these changes, the scar loosens its deep attachments, so that
it can be moved more freely upon subjacent parts.  It  is a  long time before the
scar attains the vitality of the older structures, if ever  it  does so  completely;
and  the larger  it is, the less its power will usually be.  Under  the  influence of
scurvy or syphilis, an old scar is apt to open up again; so  also  if a fresh ulcer
is formed on the old cicatrix, it will take a longer time to heal than the original
one.
  The diagnosis of ulcers is readily made when seated on the skin, where no art
is required to  recognize a sore.   On  the mucous surfaces, however, it  is not
always easy to do so;  enlarged follicles and crypts, or aphthae,  being constantly
confounded with ulcers.   The  difficulty here proceeds from the  circumstance
that muco-pus  may be poured  out from a simply inflamed  surface, or from one
in which the abraded epithelium  and open crypts are mistaken for  ulcers.
  In the local  treatment of ulcers, the following points  should be particularly
attended to:—lstly. To subdue inflammation ;  for until  this be done no proper
reparative action can go on.  This is accomplished by the ordinary local anti-
phlogistic treatment.   2dly. Position and  rest are essential, in order that con-
gestion  or  determination of  blood  may not take place.   3dly.  Proper local
applications adapted to the nature of the case,  of an emollient, sedative, astrin-
gent, or stimulating  character, must be  employed frequently, conjoined with
pressure upon,  or support to, the  weakened vessels of the part.
  The constitutional treatment must be carefully attended to.  Unless this be
done, the best regulated local plan may be employed in vain.   Attention to the
digestive organs, and improvement  of the constitution, if it be  strumous  or
syphilitic, will  do more in these cases than any other means can accomplish. 
GANGRENOUS  INFLAMMATION.
103
                   GANGRENOUS  INFLAMMATION.

  Gangrene may result either from the intensity or from the specific character
of an inflammation.
   The intensity of the inflammation may be so great as to kill the part directly,
however healthy its texture, or sound  the  constitution  of the patient may be.
More commonly, however, it is not so much the actual as the relative  intensity
of the inflammation that destroys the part; there being  some debility, local  or
constitutional, by which its resisting or preservative power is lessened.  It is
this occurrence  of inflammation in a part or system in which the vital force is
defective, that is especially apt  to result in gangrene; and it is remarkable to
observe what slight injuries will induce gangrenous inflammation under these
circumstances, especially in  the residents in towns and in those who are debili-
tated.   The greater the general and  local debility, the greater  will be the
liability to gangrene.   The nature of the tissue exercises, however, considerable
influence; thus, with a moderate amount of inflammation, some tissues, when
inflamed, very readily run into gangrene, the cellular membrane especially being
apt to do so; whilst others, as the proper tissue of glands and organs, are seldom
so affected.
   The specific character of  the inflammation  influences greatly the disposition
to gangrene;  some forms, as the carbuncular, invariably resulting in the loss  of
vitality of the part.  In some states of the constitution, the blood appearing to
be diseased, there is a great liability to gangrene.
   When a part has been violently inflamed in consequence  of injury, or some
such cause, we look upon gangrene as impending, if we find that  the redness
becomes of a dusky or purplish  hue;  that bullae filled with dark fluid rise upon
the surface;  that the swelling,  at first hard, tense, and brawny, becomes of a
pulpy  or doughy character;  that the pain is of a dull, heavy, or burning kind ;
and that the temperature of the part, at first greatly increased, gradually sinks.
We  know that gangrene has taken place when  there is total  loss of the  sensi-
bility of the  part even to pricking  or pinching; that the motion of the part
itself  ceases; that its color changes to  a peculiar mottled, purplish-red,  or
greenish-black hue, unlike  anything else in  the body;  that the temperature
falls to a  level with that of surrounding  parts; or jf the  surface affected  be
extensive,  may even feel colder, owing to evaporation from it.  There is like-
wise  an odor evolved differing, from that  of ordinary decomposition, and
evidently  depending upon gaseous exhalations from the part that  has lost  its
vitality.
   These signs constitute moist or acute gangrene, occurring as the result  of
inflammation.  Death and putrefaction are simultaneous in this case, the putre-
faction being  evidently the result of changes  effected in the tissue by the in-
flammatory act, and not by post-mortem chemical decomposition, the part bcini*
decomposed at the same time that it  is killed.  The extent  of tissue affected
may vary from a mere spot to the implication of the greater portion of a limb,
and  the gangrene appears to be finally arrested by the inflammation expending
its force as it  radiates from the centre, and reaching a part where there is suffi-
cient vitality for  adhesive inflammation to be set up.
   The constitutional symptoms, always of  a low type, vary according to circum-
stances.   If the  blood be healthy, and  the constitution sound, the gangrene
occurring as the consequence of severe injury, the symptoms will  present the
ordinary character of inflammatory fever,  though even in these cases there is a
great tendency to asthenia.   If the  constitution be broken, or the blood in a
diseased state, the constitutional symptoms will rapidly run  into the  irritative
form.
  The  progress   of gangrenous inflammation would  be indefinite were  it not 
104
INFLAMMATION.
arrested by the adhesive process which limits it, just as it bounds the suppura-
tive  inflammation.   So soon as  the  gangrene reaches a part, the vitality oi
which is too active to be destroyed  by the inflammatory action; and where in-
flammation consequently takes  on that form, which it  always  does m healthy
tissues—the adhesive; or, if the inflammation, gradually lessening in  seventy
as it extends from its gangrenous centre, subsides to that degree which is com-
patible with the formation of lymph, the line of demarcation,  as it  is termed,
is formed.   This line is a kind  of barrier or septum of plastic matter, poured
out into the interstices of the healthy tissues at their extreme  limits next the
gangrene;  the line, indeed,  along which the dead  and  living parts touch.  It
extends along the whole depth  of the  gangrene, completely surrounding it on
all its attached sides.  The  inflammation  does  not  cease abruptly in this line,
but fades away in the healthy parts beyond it.
   So soon as the gangrene is arrested, nature endeavors to throw off the spoilt
part.  This is effected by a  process of ulceration, extending through  the line
of demarcation, and loosening  the  slough by the  absorption of that  layer of
living tissues which  lies next to it.  This line  of ulceration  is  termed the line
of separation, and extends  itself along the extreme margin of the living  tis-
sues; the dead parts being removed solely by actions going on in the  contiguous
living structures, except where  they may be partially disintegrated by the pus
that is thrown out.
   This process of separation commences at the edge of the slough, which gra-
dually loosens, and slowly extends downwards  to the whole  depth of  the gan-
grene ;  if this affect the entire thickness of a limb, the ulceration will find its
way completely across  it.   If  the  slough be  more superficial, the ulcerative
action passes underneath it, detaching it gradually.  The line  of  separation is
usually oblique, the soft parts being first divided, and the  hard tissues then
ulcerated through, until the ligamentous, or osseous structures  are  reached,
which are slowly acted upon by it.   This action is most rapid in the soft parts,
 and in  young subjects.
   After the separation of the gangrenous part, a more or less ragged,  irregular
 ulcerated  surface is left, which, if not  too extensive, will undergo  ordinary
 cicatrization.   As ulceration extends across the limb, the largest arteries  and
 veins  are cut through by it, without hemorrhage resulting, owing to a mass of
 plastic matter being poured out in their interior, and blocking them  up from
 the line  of separation to the  nearest  large collateral  branch  above  it.  The
 period required for the detachment of gangrenous parts varies according to their
 extent.   Small sloughs may be detached in a few  days, whilst many weeks are
 required for the separation  of a limb.
   In the  treatment of gangrenous inflammation, antiphlogistic remedies must
 be  very sparingly used, the patient's condition being usually not of  such  a
 nature as to bear lowering.   It is very easy to knock down the inflammation by
 energetic measures; but, at the same  time, the reparative power of the  system
 is destroyed, and the  patient  may not be able to rally.  Inflammatory fever,
 however high it may be in the early stages, rapidly sinks after  gangrene has
 set in, symptoms of an asthenic, or  an  irritative type, ensuing.   Hence it is only
 before the occurrence, and  during the spread of gangrene, that  antiphlogistic
 remedies can be employed; for when  once gangrene has ceased to extend,"how-
  ever high the action  may have been that accompanied its  progress, all the
  powers of the constitution will be required to maintain  the process of separation
  of  the sloughs, if  they be  extensive and deep.
    Venesection is  never required  in  any form  of gangrenous  inflammation.
  When blood requires to be taken,  local blood-letting should be had recourse to
  as a preventive  means.  And, in  this way, when  conjoined with measures for
  the relief of  tension, and consequently of that strangulation  of the  tissues
  which is such a fertile cause of gangrene, in some forms of inflammation, it 
GANGRENOUS  INFLAMMATION.              105
becomes an extremely important adjunct to the treatment.   In these cases, free
incisions into the inflamed and tense parts, by which the vessels are relieved of
the blood, and the tissues of effused fluids, will often prevent gangrene.  This
is more especially the case when  loose cellular tissue, as that of the  penis or
scrotum is inflamed, or indeed in any part in which much tension is  conjoined
with the inflammation.   In  some forms of inflammatory sloughing, nature re-
lieves the part by free hemorrhage, as from the dorsal artery, in cases  of acute
gangrene of the penis, and it is not until this has taken place that the gangrenous
action becomes  arrested.  In this way, also, irritant  effusions and infiltrations
are discharged, and thus one cause of sloughing removed.   Punctures are  not
sufficient for this  purpose, but free incisions from  two to three inches long
should be made,  which by gaping widely allow the escape  of blood and other
fluids, and thus effectually relieve tension.  Mild local antiphlogistic treatment
of an ordinary character is  likewise required.  When  the  gangrene  has been
arrested, the foetor of the sloughs must be diminished by antiseptic applications,
such as the solutions of the  chlorides, charcoal, and yeast poultices.   The se-
paration of the sloughs  should be left as much as possible  to nature, which is
always fully able to accomplish this, if  the patient's strength can be kept up.
Any attempt to hasten this process only irritates  the parts, and causes the gan-
grene to spread when it might otherwise have been arrested.   The vitality of the
tissues in the proximity of, and  above  the line  of separation, is very low, and
may readily be destroyed by any fresh action set up in them, there being always a
 danger of exciting inflammation to such a degree as to exceed  that which is
 necessary for the adhesive,  and to cause it to run into the gangrenous form.
 Hence no attempt should be made to pull away sloughs not already separated,
 nor should stimulants be applied to the  living tissues.  It matters  little as to
 what is done  to parts already dead, which, when  loosened, may be cut away,
but we must not meddle with those that are living.   Hemorrhage  seldom occurs
before the separation of the sloughs, but there is always danger of its happen-
ing during that  process.   If it  occur, pressure  or the_actual cautery, will be
found the best  means  to  arrest it.  And if these  fail, ligature of the artery
higher up, or amputation, when practicable, might be required.
   The parts that are already gangrenous should be enveloped in lint  soaked in
 the chlorides of zinc, or lime, or in creosote, or dusted with charcoal powder.
 No poultices should be applied if the sloughs  are large, heat and  moisture
 hastening their decomposition;  but if small, yeast, carrot,  or charcoal poultices
 may be  advantageously applied.
   Parts that are quite dead, but that do not  readily separate, such  as tendons,
 ligaments,  and  bones,  may be  cut through  with  scissors, pliers, or  saws, and
 thus many weeks or months saved in their separation.  It may occasionally be
 necessary in doing this  to encroach on  the  living tissues; this  should be done
 as carefully as  possible, for reasons already stated.   They  do not bleed much,
 owning to their infiltration with  lymph.
   The line of separation should be dressed with  water-dressing, or with some
 mild detergent lotion or ointment, in order to keep  the surface clean, and free
 from absorption of gangrenous  matters.  If  sloughs are not readily  separated,
 the balsam of Peru, either  pure, or diluted with yolk of egg, or very dilute
 nitric acid, and  opiate lotions, are the most useful applications"  After the sepa-
 ration of the sloughs the ulcerated surface must be treated on general principles.
    The constitutional treatment of gangrenous inflammation requires  to be con-
 ducted upon the principles that  guide  us in the management of the asthenic
 and irritative forms of inflammatory fever;—by attention to hygienic measures,
 and the moderate  employment of antiphlogistic  remedies  in the early stages;
 by support of the  system, by means of light tonics, nourishment, and stimulants,
 as the^disease  assumes anasthenic form; and by the administration  of  opiates
 as it sinks into' the irritative type. 
DIVISION   SECOND.

      SURGICAL  INJURIES.
                           CHAPTER V.

                       EFFECTS OF  INJURY.

  The effects of an injury, if at all severe, are twofold, constitutional and local.
  The constitutional effects are immediate and remote.
  The immediate constitutional effects,  or slwck, consist in a disturbance of the
functions of the  circulatory, respiratory, and nervous systems, the harmony of
action of the great organs of the body becoming disarranged.   On  the  receipt
of a severe injury the sufferer becomes  cold, faint, and trembling;  the pulse is
small and fluttering;  there  is great mental depression  and disquietude; the
disturbed state of mind revealing itself in the countenance, and in incoherence
of speech and thought;  the  surface becomes covered by  a cold sweat; there is
nausea, perhaps vomiting, and relaxation of the sphincters. This condition lasts
for  a variable period, its duration depending on the severity of the  injury, and
on the nervous susceptibility of the patient.  In extreme cases, the depression
of power characterizing shock may  be so great as to terminate in death.  In the
great majority of  instances, however,  reaction comes  on, and the disturbed
balance in the system is gradually restored. Not unfrequently the reaction runs
beyond the limits necessary for this, and a febrile state is induced.
  Is this state the result of fear and nervous susceptibility? or is it occasioned
directly by the physical  lesion ?  In many cases, doubtless, the effect is entirely
mental. Thus persons have been frightened to death without any local mischief.
That there is great difference in the mental fortitude of individuals is notorious;
some suffering excessive shock from the mere apprehension  of injury, whilst
others may be the subjects of the severest injury, and  show but slight  sign of
suffering.  If the injury be sudden and unexpected, the shock is usually greater.
When the feelings are roused, as in the heat of action, injuries  often pass un-
noticed by those who receive them.  Hence it is evident, that the state of mind
at the time of the receipt  of the injury materially influences its immediate
effect on the constitution.   There  can  be little doubt, however, that different
individuals manifest very different degrees of susceptibility to pain, some having
more acute  sensations than others.  Instances of this kind must  have fallen
under the observation of every surgeon.
  The sudden occurrence of a severe injury will  induce a physical impression
independently  of any mental emotion.  Thus if a  limb of one of the lower
animals be suddenly crushed by the blow of a hammer, the force and frequency
of the heart's action immediately becomes considerably lessened.   Here there
can be no mental impression.  So in man, it is found that the severity and the
continuance of the shock are usually proportionate to the severity of the injury.
The surgeon not unfrequently employs this fact as an accessory means  of  diag-
nosis.  Thus, if  a man break his leg, and at the same time strike his abdomen,
                                                             (106} 
SHOCK.
107
and the  shock be very serious, and  long-continued, without sign of rallying,
the probability is that some severe injury has  been inflicted upon an  internal
organ ; injury of the viscera occasioning greater severity and longer continuance
of shock than a wound of a less vital part.
   The remote effects of shock give rise to serious constitutional disturbance,
as has been  pointed  out  by Hodgkin and James, which often do not manifest
themselves for weeks or months after the infliction of the injury.   Some change
appears to be induced in  the condition of the blood, or  in the action of the
nervous  system, that is  incompatible  with  health; severe febrile diseases,
usually of a  low form, supervening.  Perhaps, as  Hodgkin  supposes, the part
locally injured becomes incapable of proper nutritive action, and thus a morbid
poison results, in consequence of some peculiar  combination of the chemical
elements of  the part, by which  the whole system is influenced.   Be this as
it may,  the  fact remains  certain, that constitutional  disturbance may con-
tinue for, or  supervene, at a  considerable  time after  the infliction  of a local
injury.
   The direct local effects of  injury comprise contusions, wounds of all kinds,
fractures, and dislocations :  these we shall immediately proceed  to consider.
   The remote local  consequences of  injury are not so obvious.   But there can
be little doubt  that  many structural diseases owe their origin  to this  cause.
The nutrition of a part may be modified to such an extent by a blow or wound
inflicted upon it, as to occasion those alterations  in structure which constitute
true  organic disease.  Thus we occasionally find,  on death  resulting  some
months after a severe injury,  that extensive local mischief, usually of an inflam-
matory character, is disclosed, which has evidently been going on  in an insidious
manner from the time of  the  accident.
   In other cases again, a blow may give rise to severe and long-continued neu-
ralgic pains  in  a part, or it may be the direct occasioning cause of structural
disease in bones, joints, or blood-vessels;  and, lastly, the origin of many cases
of cancer can be distinctly referred to external violence.
   Treatment of Shock.—If the disturbance be chiefly of a mental character,
the  patient  will usually  rally speedily by being spoken to  in  a kind  and
cheering manner, or by having  a  little wine and water, or ammonia, admin-
istered.  If  the shock be of a  more severe character, and be the result of
considerable  injury, the patient  should be laid in the recumbent position, and
the  injured  part arranged  as comfortably as possible;  he should be wrapt up
in warm blankets, hot bottles should be  applied to  the  feet, and friction to
 the  hands and  surface;  a little warm tea, wine, or  spirit, and water, may be
 administered, provided the insensibility be not complete; if so, it should not
 be given, as the fluid might then find its way into the larynx.   Under these
 circumstances, ammonia should  be applied  to  the nostrils, and  a stimulating
enema administered.  When there is  much pain associated with the  shock a
few drops of laudanum may  advantageously be given.   By treatment  such as
this,  the energies of the nervous and  vascular systems  are gradually restored,
and then reaction speedily comes on.
   A  question of considerable importance frequently occurs  to the surgeon in
these cases,  viz., whether an  operation  should be performed durin°- the con-
tinuance of  shock.   As a general rule, it certainly should be  deferred  until
reaction  comes  on,  as  the additional  injury inflicted  by the  operation would
increase the  depression under which the patient  is suffering.  In some  cases,
however, the presence of a  crushed  limb appears to prolong  the shock, and
thus  prevents  the  patient  rallying,  notwithstanding the  administration  of
stimulants.    Under  these circumstances,  the surgeon  would be justified in
operating before reaction came on.  Here the administration of chloroform is
extremely beneficial  by preventing the  pain  and dread  of the  operation  from
still  further  depressing  the vital  energies.  In  these cases of long-continued
shock, great  care is required in ascertaining  that  there is no internal injury 
108
EFFECTS  OF INJURY.
giving rise to the depression, but that the shock is really dependent upon the
mangled limb.
  After the  immediate  effects  of the shock have  entirely passed  away, we
must  adopt means  to prevent the remote consequences.  With this view   if
the patient can  bear it — blood-letting is of  essential  service, and, I think, far
too much neglected at the present day.  In  addition to this, the  patient's diet
and habits of life should be carefully regulated, over-stimulation being especially
avoided;  his  bowels should be kept freely opened, and  his  general health
attended to.  After the immediate effects of shock have gone off, the reaction
which ensues may not pass  the limits of health; but if the injury be severe
from its extent or from the implication of important parts, the local inflamma-
tion, which is necessary for its repair, gives rise to a general febrile state.  This
inflammatory fever assumes one  or other  of the types characterizing that which
accompanies ordinary inflammation, and requires  to be treated on the principles
that guide us in the management of that affection.
   Traumatic delirium not unfrequently occurs in cases of severe injury in indi-
viduals with  an irritable  nervous system; particularly in those who had been
drinking  freely before, or were  intoxicated  at the time of  the  accident.  It
usually comes on  about  the third or fourth day, but not unfrequently earlier
than this; and most commonly declares itself during the night.   This disease
presents two distinct types — the one inflammatory, the other irritative.
   In inflammatory traumatic delirium there is a quick and bounding pulse, hot
skin and  head,  flushed cheeks, glistening eyes,  much  thirst, and  high febrile
action generally.   The delirium is usually furious; the patient, shouting, sing-
ing, tossing himself about the  bed,  and moving the injured limb  regardless
of pain.  The  treatment of  this form of the  disease is strictly antiphlogistic.
Bleeding  from the arm, with leeches and ice  to the head, purging, and  low diet,
will subdue it;  but in many cases it is speedily fatal.
   The irritative, or nervous delirium, usually occurs in persons of  a broken
constitution; and closely resembles ordinary delirium tremens; sometimes it is
preceded  by a fit of an epileptic character.   In  this form of the disease the
pulse is quick, small, and irritable; the  pupils dilated; the  surface cool; the
countenance pale, with an anxious, haggard expression, and bedewed with a
clammy sweat.   The tongue  is white, and there  is sometimes tremor of it and
of the hands; but this by no means invariably occurs.   The delirium is usually
of a muttering and suspecting character; the patient is  often harassed by spec-
tral illusions, but will answer rationally when spoken to.  This form of disease
is sometimes very rapidly fatal.   I have known it destroy life in cases of simple
fracture in less than twelve hours.
   The treatment of irritative traumatic delirium  consists essentially in the ad-
ministration of opium until  sleep is procured, or the pupil becomes contracted.
For this purpose, large quantities are frequently  required; and the drug should
be given  in full doses, and repeated every second or third hour.
   If there be much depression, it will usually be expedient to administer the
opiate in  porter, or in that stimulant to which the patient — if a drunkard__
has habituated himself.   The administration of  the  opiate should be preceded
by a free  purge and an aperient enema, so that  all source of irritation may be
removed  from  the  intestinal canal.   A  strait-waistcoat is commonly necessary
in all cases of traumatic  delirium, in order to prevent the  patient injuring the
wounded  part.
   After  sleep has  been  induced, the quantity of the opiate  must be lessened;
but it will be found necessary to continue it for  some time, as  there will be a
tendency to the recurrence of the delirium at night.
   These  two forms of traumatic delirium, the inflammatory and the irritative
are often found more or  less conjoined; a modification  of the treatment then
becomes requisite—the surgeon depleting with one hand, and allaying irritation
by opiates and giving support with the other. 
INJURIES  OF  SOFT  PARTS.
109
                           CHAPTER  VI.

                    INJURIES OF  SOFT  PARTS.

   Contusion. — In a contusion the skin is unbroken, but there  is always  some
laceration of the subcutaneous  structures.   Indeed, great disorganization of
these occasionally takes place, though the skin continues entire, owing to its
greater  elasticity and toughness.   Hence a contusion may be  looked upon as
being a subcutaneous lacerated wound.
   Contusions may  result  from direct pressure — as, when a  part  is forcibly
squeezed; from a direct  blow,  usually  by a hard,  blunt body; or, from an
indirect blow, as when the hip-joint is  contused by a person falling  on his feet
from a height.
   Compression of the parts injured is always necessary to constitute a contusion.
This  compression may occur between the force on  one side, and a bone as the
resisting medium on the other; or the part injured maybe  compressed and
contused between two forces in  action—as when  the hand is  caught between
two wheels  revolving; or between a force in action and a passive medium — as
by a wheel passing over the limb and crushing it against the ground.
   Contusions are of various degrees; they may be arranged as follows:—lstly,
of the  skin simply; 2dly, with extravasation into the cellular tissue;  3dly,
with subcutaneous laceration of the soft parts; and 4thly, with subcutaneous
disorganization of the soft and hard parts.
   In all cases extravasation of blood is the chief characteristic of  contusion.
In the first degree the blood is merely effused into the skin, producing  ecchy-
mosis or bruise;  the color of which varies from purplish-red to  greenish-brown;
being dependent upon changes  that take place in the  extravasated blood as it
undergoes absorption.
   In the second degree,  a bag of blood can often be felt fluid and  fluctuating
under the skin, in which state it may remain for weeks or even months without
undergoing any  material  change, provided it  be  excluded from the air.  In
other cases it gradually becomes absorbed; or, if it communicate with the air,
the bag being opened in  any way,  it may undergo disintegration, suppuration
taking place within or around it, and the clots discharging through an abscess.
In some cases it would appear from the observations of P. Hewett and of Paget,
that the  clot  resulting from  extravasated blood may become organized and
finally penetrated  by blood-vessels.  The French pathologists have described
 the formation  of a cyst containing serous fluid in the site of the extravasated
blood.   These cysts are composed of a fibrous structure, but without cells; they
 have  no distinct  lining  membrane, and in their interior serous or grumous
fluid, composed of disintegrated blood, is found.   In other cases the serous or
 fluid parts are  absorbed, and the fibrinous matters forming cheesy concretions are
 left behind.  Lastly, extravasated blood may give rise to a  sanguinous  tumor,
 Hematoma, the blood — continuing for years fluid, but still not unchanged —
becoming darker, treacly, and more or less disintegrated, being intermixed with
various products of inflammation.
    In the third and fourth degrees of contusion, the laceration and disorganiza-
tion of structures  usually lead to fatal internal hemorrhage, to sloughing and
suppuration, or to rapid gangrene of the parts.
    The diagnosis of contusions is not always easy.  The minor degrees may be
mistaken for  incipient gangrene;  the  discoloration  not  being very dissimilar,
but that the part, when simply contused, preserves its temperature and vitality.
In some  cases  the extravasated blood has a hard, circumscribed border, and is 
110
INJURIES OF  SOFT  PARTS.
soft in the centre, thus resembling somewhat a depression in the subjacent bone.
This is especially the case in some bruises about the scalp.
  The diagnosis of  old cases of extravasation, leading to Hematoma, from
abscess or malignant  disease, is not  always  easily made by tactile examination
only, but the history of the case, exploration with a grooved needle, and examin-
ation of the contents of the tumor under the microscope, will always clear up
any doubt that may exist.
  Treatment.—In the two first degrees of contusion our great object should be
to excite, as speedily as  possible, the  absorption  of the extravasated blood.
Here  cold applications are of especial service; lotions composed of one part of
spirits of wine or of  tincture of arnica to eight or ten of water should be con-
stantly applied.   Of the value of arnica  in these cases I entertain no doubt; I
have employed it largely in the most extensive extravasations, and have rapidly
promoted their absorption  by its use.  Leeches — so commonly  used in these
cases — should not be applied to a bruised part, they cannot  remove  the  blood
that has  already been  extravasated, and often  set up  great irritation, that
leads to its suppuration.   The bag of blood should  never be opened, however
soft and fluctuating it may feel, so long as there is any chance  of procuring its
absorption by discutient remedies; but if signs of inflammation occur around it,
the parts becoming  red, hot, and  painfully  throbbing, free  incisions should at
once be made, the blood — already disorganized  and mixed with  pus — be dis-
charged, and  the cavity  allowed  to  granulate.    Purging and  general anti-
phlogistic treatment will often be found of use in promoting absorption  of the
extravasation.
  In the third and fourth degrees  of contusion it is useless to attempt to save
the life of the injured part.  Here  poultices  must be applied to hasten suppura-
tion and  the  separation of  the sloughs;  the ulcer that results being treated on
general principles.   In the worst cases of contusion, where  the  structures of
the limb are disorganized, amputation is the sole resource.
  Contusions  of  internal  organs are  always  of  a very serious character, and
require  special treatment  according to the part that is affected, and the  extent
of its injury.

                               WOUNDS.
  A wound may  be  defined to be a  solution of  continuity suddenly produced
by the incision, rupture, or fracture of a  part.
  Surgeons universally divide wounds  into incised, lacerated, contused, punc-
tured, and poisoned.
  Incised wounds may  vary in extent,  from a  simple  superficial  cut  to the
incisions required in the  amputation at the hip-joint.   Incised wounds are
usually open, communicating freely with the  air; occasionally, however, when
made by the  surgeon they are sub-cutaneous, only  communicating externally
by a small puncture; they may be simple, merely implicating integument and
muscle, or, complicated with injury of the larger vessels  and nerves, or  of im-
portant  organs.   In  all cases they  give  rise to three symptoms;  viz. pain,
hemorrhage,  and separation of their sides.
  The pain in an incised wound is usually of a  burning, cutting, or smarting
character.  Dr. J. Johnson  compared his own sensations to the pain experienced
by a stream of melted lead falling  upon the part.  Much depends, however, on
the extent and the situation of the wound; and  also whether the cut is  made
from  the cutaneous  surface, inwards, or  from within outwards;  being  oreater
in the former than in the latter case, owing to the section of the nerves&beino-
made from the branches towards the trunk.   When the cut is from within out
wards, the  trunks being_ first divided, the branches are paralyzed, and do not
feel the subsequent incisions.
  The amount of hemorrhage  necessarily depends  upon the vascularity of the 
HEALING  OF WOUNDS.
Ill
part, as well as on the size of the wound.   The proximity of the part wounded
to the centre of the circulation, or to a large vessel, also influences  this very
considerably—different parts of the same tissue bleeding with different degrees
of facility. Thus, the skin of the face pours out more blood when cut than that
of the leg.  The same  parts will, under different states of irritation, pour out
different quantities of blood.  Thus the tonsils have bled, after their excision, to
such an extent as to occasion death, though usually but a few drops are lost.
   The  separation of the lips of the wound depends  on their tension, and the
position of the  part, as well as on the elasticity and vital contractility of the
tissues.  It is greatest in those parts that are naturally most elastic, or that possess
the greatest degree of tonicity; thus, the muscles, when cut, will retract to a dis-
tance of some inches;  so also the arteries and skin gape widely when divided;
whereas in the ligaments  or bones no retraction takes place.
   Incised wounds  may unite in the five following ways: — lstly, by the direct
growing together of their opposed  surfaces; 2dly, by  scabbing; 3dly, by the
opposite surfaces uniting  through the  medium of coagulable  lymph;  4thly, by
granulations springing up from the sides and bottom, and  covering  themselves
with an epithelial coating; and, 5thly, by the growing together of two granu-
lating surfaces.
   1st.  The direct growing together of opposite surfaces was termed by Hunter
 "union by the first-intention," though this term is not employed in this accep-
 tation by modern surgeons, most of whom extend it  to the union by adhesive
 inflammation.   When wounds unite in this way, it is by the simple and  direct
 coalescence of the opposed  surfaces; and  not, as Hunter had supposed, by the
 interposition of a layer of effused blood becoming the bond of union; or, as others
 have imagined, by lymph being poured out, which unites the opposed surfaces.
 Dr. Macartney, who pointed out the error of these doctrines, has shown that in
 this kind of union there  is  no intervention of blood  or of lymph; the process
 consisting essentially in clean-cut parts, laid in apposition, uniting and growing
together directly in the course of a few hours, without inflammation  of any of
its products being required  to effect the union; hence he termed  it " immediate
union."
   The conditions necessary for direct union appear to be the perfect coaptation
of the  cut surfaces — a  healthy constitution and the absence of all inflamma-
 tory action.   It is not often in surgical practice  that such  a simple and  direct
result can be obtained, though in some of  the plastic operations about the face,
 we not uncommonly succeed in securing it.  After some  of the larger opera-
 tions, also, this kind of union  occasionally takes  place.   Thus Paget records a
 case of amputation of the breast, in which the flaps contracted immediate and
 direct union with the subjacent parts;  and on the patient  dying at the end of
 three weeks of erysipelas, the  union was  so perfect that it was impossible to
 discover  by microscopical examination that any inflammation  had existed, or
 exudative matter been poured out.  In some flap operations, the surgeon may
 be successful  in attaining union by this means.   Thus, in amputations of the
 thigh and arm, we occasionally find that  nearly the whole, or  a considerable
 portion of the flaps, are united together at the  expiration of about eight and
 forty hours.
   2d.  Healing by scabbing consists in the direct adhesion of the lower part
 and sides of a wound  under a crust of dried blood, hair, etc. which  forms an
air-tight covering.  The absence of inflammation is necessary for  healing by
scabbing; if inflammatory effusion occur,  the scab will be thrown off, and  air
getting admitted, an ulcer forms, upon which granulations will spring up.  This
kind of union  is extremely rare in man, owing to the readiness with which
inflammation  is excited; but is common  in the lower animals, inflammation
being not so readily induced  in them.   This  natural process is sometimes 
112
INJURIES OF  SOFT  PARTS.
imitated  by the  surgeon closing a wound with a piece of lint steeped in blood
or in collodion, under which union takes place.
   Analogous to  healing by scabbing is  the process  of  cure  in  subcutaneous
wounds, as in Tenotomy; in these, union takes place without any  inflammation,
though  this is sometimes  excited by the  injury;  the reparative  material,
"nucleated  blastema," not being an  inflammatory product.
   3d.  Union  by the adhesive inflammation,  the "union  by the first-inten-
tion " of modern surgeons, or "primary adhesion," as it is termed by Paget,
consisting in the effusion of lymph between  the opposed surfaces, is  more fre-
quently obtained than the direct union.  In order that it should take place, it is
of great importance that no blood be interposed between the sides of the incision;
hence it is facilitated by all oozing being allowed to cease, and by the  surfaces
being allowed to become glazed by the exudation of lymph for some hours
before they are brought in contact. If any blood be interposed, it acts as a bar-
rier to the cohesion of the opposite layers of plastic matter, invariably becoming
disintegrated,  breaking  down, and being washed away by the suppuration ex-
cited by its presence; hence in the dressing of surgical wounds, such as stumps
after amputation, in which it is desirable to  procure union by adhesive inflam-
mation, the cut surfaces  should  not be brought together for a few hours, until
all oozing of blood has ceased, and the fibrinous layer thrown out.
   The union by adhesive inflammation in an incised wound  takes place in the
following manner:  After  all  hemorrhage  has  ceased, the  surface  becomes
"glazed," being covered with a film of the fibrine of the liquor sanguinis, with
which a large  quantity of white corpuscles are found intermixed,  a sero-sangui-
nolent fluid draining away.  This layer of fibrine rapidly becomes thickened by
the deposit of exudative matter, and ultimately becomes vascular, undergoing
development into fibro-cellular tissue,  which constitutes the  bond of union, its
exposed  surface  becoming  gradually covered by an epithelial  layer, as has
already been described in speaking of the development of lymph and its cicatri-
zation.   The  adhesive  layer forms with varying  rapidity on different surfaces;
thus, in a stump, after amputation, it will be  found that the muscles, fasciae, and
cellular tissue  are covered with fibrine in the  course of a few hours;  it is not
until about the third or fourth day that the subcutaneous fat becomes  coated in
the same way;  and  eight  or  ten days  elapse  before the  adhesive  lymph  is
thrown out upon the cut surface of the bone;  and here it shows  itself first on
the medullary canal, afterwards on the cancellous texture, and lastly upon the
hard bone.
   For the  production and  organization  of this lymph  a certain  amount of
inflammation is  absolutely necessary, but the  inflammation must be  confined
within proper  limits.  If too violent,  the adhesive may pass into the suppura-
tive inflammation; and if too long-continued, its development may be interfered
with; for though inflammation be necessary for the formation of the  bond of
union, none is required  for its organization, or its ultimate development  into
fibro-cellular tissue.
   4th.  In those cases  in which union by direct  cohesion,  or by the adhesive
inflammation fails, either by the interposition of blood, by the  excitation of
undue inflammation, by the wound being left open to the air, or by any other
disturbing cause, granulations are thrown out, and union by " the second-inten-
tion," as it is termed, occurs;  and one may often see in the same incised wound
one portion healed by direct union, another  part  by the adhesive inflammation
and the remainder by granulation.  Union by granulation, or the second-inten-
tion, has  already been described when  speaking of the repair of ulcers  with
which it is identical (p.  101).  A layer of plastic exudation  is deposited  which
gradually increases  in  thickness, becoming vascular: accumulating in masses
of pointed and ruddy granulations, throwing off pus and effete corpuscles from 
MANAGEMENT  OF WOUNDS.
113
its surface, and developing in the  deeper parts  into fibro-cellular tissue, whilst
the more superficial portion undergoes epithelial transformation.
   5th. It not unfrequently happens that although granulations have sprung up,
union between the opposed surfaces has not taken  place.  We must endeavor
to accomplish this, by bringing the granulating sides of the wound together,
when they will cohere, thus constituting union by " secondary adhesion."   In
some amputations, and in many plastic operations, cases of hare-lip, cleft-palate,
&c, this mode of union is occasionally established.
   Management of Incised Wounds.—In the treatment of an  incised wound, we
must always  endeavor to  procure  union directly or by adhesive  inflammation
between a portion, if not the whole, of the surfaces;  if union in this way be
obtained, we save the patient much time and trouble.
   The probability of procuring adhesive union  depends  greatly upon the con-
stitution  of  the patient,  as well  as on the management of the wound.  The
sounder the constitution,  the more readily will union by  the first-intention take
place; and in all cases, it is disposed to by the removal of all sources of irrita-
tion from the system.   Thus  in  those  operations, the plastic, for instance, in
which it is necessary that the union be as  direct as possible, the constitution of
the patient should be prepared, by his being kept for some time previously upon
a nourishing but unstimulating diet, chiefly consisting of milk and light animal
food, having regular exercise, and his bowels acted  on by saline aperients:  we
should also look specially to the  state of the digestive and urinary organs, and
remove any  source of irritation in connexion with them.  In  cases of accidental
wound, if we wish  to secure union  by the first-intention, we must purge the
 patient,  keep him quiet,  and employ a moderately antiphlogistic regimen, avoid-
ing especially all stimulants, which have a great tendency to  interfere with this
 desirable result.   It must be borne in mind, that the great object is to limit in-
flammation ;  if this be carried beyond what is necessary for plastic effusion, sup-
purative action will certainly occur.   With regard to local antiphlogistic treat-
ment, nothing is required beyond simplicity of dressing, and  keeping  the part
cool by means of wet lint, or, if the wound be very extensive, and inflammatory
action threaten to run high, by irrigation (Fig. 45).
   There  are three  great indications  in the local  management  of an incised
wound.
   The first is the arrest of hemorrhage.  If the bleeding be general from the
surface, it may be stopped by position, by  coaptation of the sides of the wound,
and by the application of cold and styptics.   If it be  of an  arterial character,
 ligatures will be required to the bleeding points.
   The next  indication consists in the removal  of foreign  bodies  of all kinds;
 such as dirt, pieces  of stone, glass, &c, including coagulated blood  from between
 the lips of the wound.   In doing this, care should  be taken not to wipe the
 wound too roughly; a piece of soft lint, a triangular bit  of sponge, or a stream
 of cold water poured over the surface, should be the means employed.
   The next and most  important indication to fulfil, is the coaptation  of the
 opposed surfaces  as accurately as possible.   This can only be maintained  by
attention to  position, and by the application of sutures, plaster, and  bandages.
   As a general rule, the sides should not  be  brought together until all hemor-
rhage has ceased.   If, however, there be but slight oozing, this may be arrested
by the approximation of the  surfaces.  If the wound be  extensive, it may be
advantageous to wait for  a few hours,  until its sides are  glazed over by a layer
of fibrine.   The parts should  now be brought  gently in contact, due attention
being paid to relaxing them as much as possible, by position,  so that there may
be no gaping of the lips, or tension on the sides #f the wound.  They must be
kept in position by sutures, plasters and bandages.
   Sutures are commonly employed when there is more tendency to gaping than
can be overcome by position or plasters.   The  material  that is generally used 
114
INJURIES OF  SOFT  PARTS.
for this  purpose is well-waxed dentist's or twisted silk of various^ degrees of
fineness, introduced  by means of a curved  needle.   Sometimes silver wire is
employed.   In wounds of the limbs,  especially in  those cases in which  some
traction may be expected, the  suture  should be  composed  of soft thick silk-
twist; whilst in those cases in which it is of importance that as little deformity
as possible be left, it should consist of the finest silk or thread that is compatible
with the requisite strength.
   Sutures may be of various kinds: the interrupted, consisting of a number of
single stitches, applied at distances varying from half  an inch to an inch and
a half, is the one most commonly had recourse to in all the  cases  involving the
integument.   In applying this suture the needle should never be carried deeper
than the integumental structure, except in some  of the parts  about  the  face,
such as the lips and  eyelids.   The suture should be tied by means of the reef-
knot, and the ends be cut short.
   The continuous suture, never used  on the cutaneous surface, is principally
employed in incised  wounds of the intestines.
   The quilled suture is applied in cases, as in rupture of the perineum, in which
the sides of a deep wound are required to be brought  into contact throughout.
It consists of a double interrupted suture  passed  deeply, and tied tightly over
pieces of elastic  bougie, laid parallel  to, and at the distance  of half  an  inch
from the edges of the wound.
   The beaded  suture is rarely employed at the present day: in it the knot is
made over a large bead, or a split  shot, strung upon either  side  of the suture,
which thus diffuses the pressure over a greater extent  of surface.
   The twisted or figure of 8 suture is very commonly employed in surgery; it
consists in the introduction of a slender pin, made of soft iron, with a steel point,
across the lips of the wound, and the application of soft silk-twist over this in
the manner of a figure of 8, care being taken  not to draw it too tight,  or to
compress the soft parts between the  needle and suture, lest sloughing result.
   Sutures, of whatever  kind, act as irritants along  the tract through which
they are applied, hence they should always be withdrawn as soon as they have
accomplished their object — that of procuring union  of the opposed surfaces.
Every minute that they are left in beyond this is  detrimental to adhesion, and
is  attended  with a risk  of the excitation  of undue action.   In general  they
should not be left in beyond eight-and-forty hours; but in some cases they may
advantageously be retained for a considerably longer  period, provided they do
not excite irritation.   When they  are withdrawn, care  should be  taken not to
disturb the adhesion in their neighborhood by improper  traction.
   The serrefine (Fig.  52) may be used in  some  cases, especially when  very
 Fig. 52. accurate union of the lips of a wound  is required, as in cuts upon
         the face.
   i£||      Plasters serve to maintain the approximation of the opposed surfaces.
  \  \   Tney are °f various kinds; but the resin, soap, and isinglass plasters
  CW   are those that are most commonly employed.   Each of these possesses
    J    peculiar properties that fit it  for  particular cases.   The resin plaster
         has the advantage of being the most adhesive, and of not being readily
loosened by discharges, but it  is  irritating, sticky, difficult  to remove, and, in
consequence  of the  lead that it contains, leaves a dirty-looking incrustation on
the part.
   The soap  plaster is less irritating, but at the same time is  less adhesive, and
is  consequently seldom employed in the treatment  of wounds.  The  isinglass
plaster is doubtless the most cleanly and least irritating of all, and being trans-
parent, possesses the advantage of enabling the surgeon to see what is passing
beneath it.   It has, however, the disadvantage of being readily loosened by the
discharges of the part, or by the necessary, dressings.  The plasters should be 
COLLODION.
115
cut into strips of sufficient  length  to  support the sides as well as to compress
the edges of the wound, and should  be applied between, but not upon  the points
of suture, all hairs having  been removed from the part on which they are laid
down, and the surface being thoroughly dried.  In removing them,  both ends
should be loosened at the same time, and the strip thus taken off without either
lip of the wound being unduly dragged upon.
   Collodion may often be advantageously used instead of plasters, either alone
or in  addition to sutures, being painted  over the wound with  a camel's hair
brush, and thus  bringing the lips into more accurate coaptation, at the same time
time that it excludes the air.
   [An effectual and neat application of the collodion  dressing for wounds may
be made in the following manner: — Strips half an inch or an inch in breadth,
should be cut from some light, strong material  of open texture.   The  fabric
which for this purpose answers best, is that known in the shops as Donna  Maria
gauze, a variety of silk "illusion."  Theso strips should  be laid  transversely
across the wound, and their extremities fastened  to the integument  by the ap-
plication of a collodion containing in solution about y^th its  bulk  of Venice
turpentine.   The turpentine increases the adherence of the collodion, although
of a slightly irritant nature  when applied  upon raw surfaces.  In case, therefore,
the surgeon  desires entirely  to exclude  the air  from the  wound,  turpentine
should be omitted and  simple  collodion employed; or else collodion  containing
a small portion  of castor oil.   The advantages of this mode of dressing over
the ordinary adhesive strips, or isinglass plaster, consist in its not being loosened
by heat or moisture;  the perfect freedom offered to the discharges; the ability
of the surgeon  to dispense  with sutures to a great degree;  and  also the facility
afforded for  the daily examination of the lips of the wound.   When it shall
become desirable to  remove the dressing a sponge moistened with ether should
be passed over the extremities of the strips, which can then be raised without
difficulty.  This method of uniting wounds is especially applicable  to injuries
of the face, and to  plastic operations, and was,  we believe, first employed  by
Dr. Goddard, of this city.]
   After coaptation has  been  effected  by position, aided by the  application  of
sutures and plasters, a strip of water-dressing may be  laid along the line of the
wound, and a piece of wet  lint over  the  whole surface, which should be kept
as cool as possible. If any ligatures have  been.applied to bleeding vessels, they
must be left hanging out  at  the   most dependent angle.   The first dressings
should be  left unchanged for two  or three days, the sutures may  then  be
 removed, and the plasters as they become loosened; care being taken to support
 the sides, and after a time to  bandage the part properly by circular  turns of a
 narrow roller.   In many cases the direct union  of clean cut wounds may be
 much facilitated by bandaging the part, so that firm pressure is  exercised upon
 it from the very first. This requires to be done carefully and with due attention
 to the proper support of the  deeper parts, lest infiltration of sero-sanguinolent
 fluid occur in them, which will readily lead to suppuration.
    Union may be readily accomplished in  many slight incised wounds, by cover-
 ing the edges of the cut with a piece  of  soft lint soaked in collodion.  Direct
 cohesion, by a process analogous to scabbing, taking place under this dressing.
  ^  If union by the first intention fail, or if the wound occur in such  a constitu-
 tion that it is useless to attempt it, inflammation  takes place in  and around it
 the lips swell and become red, a sero-sanguinolent discharge, gradually assuming
a puriform character, exudes; and, at the same  time, if the wound  be an ex ■
tensive one, suppurative fever sets  in.  Under these circumstances, the sutures
should be immediately removed: the  strips of plaster, if continued, should be
used  merely for support and  not for union; a large soft  linseed-meal  poultice,
or a thick piece of warm water-dressing, should be applied; and the patient put 
116
INJURIES OF  SOFT  PARTS.
 upon a moderate antiphlogistic regimen.  When suppuration has fairly set in,
 and granulations have sprung up, the treatment must be conducted in accord-
 ance with those general principles that guide us in the management of ulcerated
 surfaces.   The  suppuration must be  moderated,  the process of  cicatrization
 facilitated by the application of a bandage, the  general health attended to, and
 the strength of the patient supported.
   Union by " secondary adhesion" may sometimes be accomplished, after that
 by the first-intention has failed, by bringing the granulating surfaces together a
 second time by means of  sutures, harelip-pins, or plasters.
   Faulty cicatrices often  give rise to  great disfigurement, and require  some
 operative means to remedy this inconvenience.  These plastic operations will be
 described more  fully hereafter, but it may be stated here that much benefit will
 occasionally result by the excision of  the cicatrix, and then  bringing together
 the opposite edges of  the wound in a uniform line.   Should it be too large for
 this, if flat it must be left, but if angular it may be divided down to the second
 structures  beneath,  and the  gap thus resulting, filled  up by a flap of sound
 integument dissected up from the neighboring parts and twisted into it.

               CONTUSED  AND  LACERATED  WOUNDS

   May be  defined to be wounds that  are conjoined with more or less bruising
 about the edges and sides;  presenting  every possible variety in  the degree of
 contusion and of wound, from a cut on the shin  to a limb crushed and lacerated
 by a cannon-shot.  They  are  commonly inflicted by blunt cutting  instruments,
 as in chops by a hatchet, or by stones, bludgeons, &c.  Lacerations by machinery,
 in which parts are torn off or crushed; the bites and gorings  of animals, and
 gun-shot injuries of all kinds, come under this denomination.
   Whatever their mode of infliction, these wounds present certain characters in
 common, by which they differ from all  other injuries.  Their lips are irregular
 and torn, less gaping than in incised wounds, but surrounded by more  or less
 ecchymosis and contusion, with a tendency to slough on their sides.  There is
 usually but little hemorrhage, and the pain  is  of an  aching or dull character.
• In consequence of the sloughy state of the lips and sides, these wounds always
 unite by the second intention.
    Contused and lacerated wounds present peculiarities according to their mode
 of infliction.
    When occasioned by the bite of a large animal, the part injured becomes very
 painful and inflames extensively, the  wound being  lacerated, much contused,
 and often  penetrating  deeply.   It sloughs in consequence  of the  pressure to
 which it has been subjected, and of the  animal shaking and tearing the  part
 seized.  When the wound is inflicted by the tusk or horn of an animal, it is
 extensively lacerated rather than  contused, and often partakes of the nature of
 punctured wound.
    When a part  of the body is torn off, the wound presents peculiar characters,
 which differ, however, according as the separation is effected  at the part struck
 or seized,  or at a distance from  it.
    In the  first  case — as when  a cannon-ball carries off a  limb, or an arm is
 caught in  a steam-mill or rag-tearing  machine and crushed or torn off, the stump
 presents a very ragged surface, the  skin being stripped  away higher than the
 other parts, the tendons  hanging out, and the bellies of the muscles that  are
 torn across being swollen, protruding, and apparently constricted by the lacerated
 integument.  A most important condition in these wounds is that of the vessels;
 these are  separated lower  down than the other  parts,  for beino-  elastic they
 elongate and pull out before  they give way.  There is no hemorrhage, because
 the inner and  middle  coats of the artery breaking off short, allow the'external
 one to be dragged down and twisted  over its mouth in such a way as to offer  a 
       CONTUSED WOUNDS. — TRAUMATIC  GANGRENE.     117

complete barrier to the escape of blood.  The bone is crushed off at the end of
the stump, of which it forms the conical apex.
   Occasionally when parts are pulled off, they are separated at a distance  from
the point seized.   Thus fingers that have been torn off by machinery have  their
extensor tendons  separated higher up, at  their junction with the belly of the
muscle, and not at the part seized; the tendon being drawn  out of its sheath,
and hanging on to the separated end in a ribbon-like manner.
   In  the progress  of  a contused or lacerated wound  there are  two  distinct
periods : — 1st, that of the separation of the slough produced by the contusion;
and -dly, that of repair by granulations of the chasm left.
   The extent of  the slough  depends  not only upon the extent, but also  upon
the situation  of the injury.   If the parts around the wound be much bruised,
then  superficial sloughing to a great extent may occur; if the wound be  deep
though not extensive, there will always be  danger of troublesome sloughing,
leading to suppuration, and burrowing of matter, and in some cases to secondary
hemorrhage.   Those wounds that are situated immediately over bony points —
as the shin and elbow — are especially tedious, as the slough frequently impli-
cates  the fasciae.   The scalp, however, has a less tendency to slough than any
other  part of the cutaneous  surface.   This  is  owing to its great vitality, and
the large  supply  of blood it receives from  closely subjacent arteries.  In all
cases  of contused and lacerated wounds — but more especially in those of the
scalp — there is great danger of the supervention of erysipelas.   But the chief
 danger to be  apprehended in wounds  of this description is the supervention of
 gangrene.  In these cases gangrene may occur in three  ways: —
   lstly.  The contusion always kills a thin layer of tissue, which forms a slough
 on the sides or lips of the wound; but in some cases the violence done to the
 part  is so great  as directly to kill its whole substance.  Thus  if a finger  is
 crushed to a  pulp  by  machinery, all circulation  is  completely  and  at  once
 arrested, and the  vitality  of the part destroyed outright.  If the violence  be
 not quite so great  as this, the vitality of the part may be so lessened, and its
 resisting power diminished to such an extent, that the  inflammation necessary
 for the  repair of the injury terminates in gangrene.  This is a local traumatic
 mortification, evincing  no disposition to spread beyond the  part injured, but
 being bounded by a line of demarcation along which it will separate.   It is not
 always easy to distinguish this direct form of gangrene  from such discoloration
 and disorganization of a  limb  as is still compatible with life.  In all cases of
 doubt the  surgeon must  wait, and  a very short time — a few hours — will be
 sufficient to declare whether the vitality of the part can be maintained or not.
 In cases of much doubt there can be no objection to make an incision into the
 part,  and thus ascertain  the true state of  things.   But  this  should not  be
 done  if it can possibly be  avoided.
    2dly.  The injury may be chiefly inflicted upon the great vessels of the  limb,
 damaging, them to such  an  extent as  to interrupt completely the circulation;
 gangrene being thus induced  indirectly in the parts  supplied  by them.  This
 form  of gangrene we shall have occasion to treat of fully when speaking of
 injuries of the arteries.
    3dly.  The  true  traumatic  or " spreading  gangrene," the  most fatal variety
 of mortification, may occur from  comparatively slight wounds, in consequence
 of some constitutional disorder;  but most commonly it is the  result of severe
 contused and lacerated injuries, and fractures.   It has a tendency to spread
 rapidly, especially through the cellular  planes of the limb, often involving the
 whole member in  less than twelve hours after its invasion.   Its occurrence is
 indicated by the  injured limb  becoming cold, being greatly swollen and readily
 pitting, afterwards  by much  tension  and oedema of the subcutaneous  cellular
 tissue, causing the part  to assume a brawny hardness; — there  is  sometimes
 crackling from the generation of gas. The skin is at first  of a dull, tallowy- 
118
INJURIES OF  SOFT PARTS.
white or bluish color, mottled or marbled  by bluish-green streaks in the course
of the veins, but speedily assumes a yellowish-hue, bullae containing dark fluid
often rising upon it.  The constitutional  symptoms set in very early, are for a
short time  indicative of much  febrile action,  but  very speedily assume  an
asthenic form.   Death usually occurs in the  course of from  thirty-six hours to
four days; and always very shortly after the  gangrene has reached the trunk.
  The peculiarities of this form  of gangrene consist in  the rapidity of its pro-
gress, its great fatality, and  the  tendency it has to affect and spread along the
cellular tissue of the  limb in preference to any other part.  It is truly a consti-
tutional affection, depending rather on the state of the  blood than upon the
local injury.   Thus in some cases we see it follow comparatively slight contused
wounds, whilst in others the  most serious  crushes and injuries may occur with-
out it.  It appears to be closely associated in its occurrence with those conditions
of the system that dispose to the  supervention of erysipelas, phlebitis, and other
inflammatory diseases of a diffused  or spreading character; and hence its great
fatality.   From the other varieties of traumatic gangrene it differs remarkably,
not only in the rapidity of its extension and the general appearance presented
by the parts affected,  but more especially in the little disposition it manifests to
limit itself by a line of demarcation or by  any adhesive action.
   Treatment of contused and lacerated wounds. — In  the  treatment  of the
slighter forms of these injuries we must bear in mind the occurrence of the two
periods; those of sloughing  and of granulation.   There is  also in all injuries
of this description a special tendency to the  occurrence of erysipelas and allied
diseases.
  In these cases care must be taken to clean the parts thoroughly from foreign
bodies that are frequently impacted or ground into them.   However contused
and torn a flap of skin may be, it should never be separated, provided it main-
tain  any attachment to  the neighboring tissues, but always be replaced  on the
chance of its vitality  being preserved.  If it live, as it will often do, especially
about  the scalp,  under apparently the most  discouraging circumstances, much
will  be gained;  if it  slough, no harm can result from the attempt to preserve
it.   There are even cases on record, in which  parts that have been completely
separated  have become  attached  by being  immediately reapplied to the surface
from which they had been torn.   Whether  this be actually the case  or not, it
is at all events certain thaf a very small tongue of skin is sufficient to maintain
the vitality  of a part.  This we see exemplified in the operation for the restora-
tion  of a lost nose; and cases  have occurred to me in which the nose, nearly cut
off, being only retained  by a portion of one ala, has readily  united on  being
replaced;  so likewise in bad cases  of compound dislocation of the fingers, the
part has been saved, though merely attached  by a narrow bridge of  skin.
After a part has been replaced in  this way,  it should be retained in situ by a
few points of interrupted suture,  with a piece of lint soaked in  collodion applied
to the line of wound.  The sutures must  be left in for a somewhat longer time
than usual,  until good union  has  resulted^
   In ordinary cases of  contused  or lacerated wounds, whether superficially ex-
tensive or deep, we must facilitate the separation of the  sloughs by the applica-
tion of poultices, which also  serve to subdue  local inflammation.  About the
period at  which the slough begins to be loosened, there  is danger of the occur-
rence  of  hemorrhage if a large artery have  been implicated  in the  injury.
M hen hemorrhage  occurs in  this way it usually sets in from  the sixth to the
twelfth day  and may be speedily fatal.   After the sloughs  have separated, an
ulcer is left, which must be treated on general principles
   In the more  severe  cases  of  contused  or lacerated wounds any attempt at
saving the part  may  be hopeless, and  the  patient's only chance lies in amputa-
Sv«- 1«?i! Tv!mnS    ^Pedie"cy.of°Pe^on, two questions present them-
selves . lstly. Ihe nature of the cases in which  amputation should be performed ; 
AMPUTATION  IN  CONTUSED WOUNDS.          119
and, 2dly. The time at which it should be done, whether immediately after the
infliction of the injury, or at a subsequent period.   It is difficult to lay down
more than very general rules as to the kind of cases  that require amputation,
so much depending on the age, constitution, and previous habits of the patient.
In all  cases the surgeon should be careful  not to condemn a limb that admits
of a fair chance of being saved; and, if the patient should happen to die, as he
often may, from the after-effects, such as erysipelas or phlebitis, of a contused
wound that admitted of a fair prospect of recovery, the surgeon  may justly con-
sole himself with the reflection, that, with the  constitutional disposition leading
to these diseases, the injury inflicted by the amputation would in all probability
have been equally fatal, and that thus the  patient has been saved the pain of
an operation that would have been unsuccessful in its result.
   As a general rule, severe injuries are more readily  recovered from in the
young than in  the old, their vitality and elasticity of constitution being greater,
with less tendency to consecutive diseases.   Much will depend  upon the habits
of the patient, or upon the existence of visceral disease at the time of the injury.
In persons who have been free livers, and who have that peculiar irritability of
system conjoined with deficient power, so commonly observed in such subjects;
and more especially if there be already existing disease of the liver or kidneys,
 contused and lacerated wounds are apt to be followed by the worst forms of ery-
 sipelas and traumatic gangrene, and  thus to be speedily fatal.  Injuries of the
 upper extremity are less  serious than those of the lower; its  supply of blood
 being proportionably greater and more uniformly distributed.   In some badly-
 contused wounds, also, of the arm and hand, as in bad lacerations with fracture
 about the shoulder, elbow, or metacarpus, resection of the injured part may be
 performed instead of amputation of the limb.
   Though  there may always be this doubt as to the cases  that should  not be
 amputated, there are certain conditions in which the  surgeon need never hesi-
 tate to perform this operation,  as the only chance of saving the patient's life.
   The following  are the  cases of severe contusion and laceration in which the
 limb should be amputated; either with the view of preventing the  occurrence
 of gangrene, or in order to remove a mortified part from the  body, and thus to
 save the life of the  patient at the expense of the injured limb :—
    1st. If a limb has been torn off by machinery, carried away by a cannon-ball,
 or  cut off  by the passage of a railway train over it, the irregular and conical
 stump should be amputated, so as to leave a more useful and healthy one to the
 patient;—
    2d. If the  whole thickness of a limb—the  soft parts and the bones—be tho-
 roughly disorganized and crushed, it must  be  removed;—
    3d. If the  soft parts are extensively stripped  away from the  bones, though
 these be entire, so much sloughing and suppuration  would ensue as to leave a
 useless limb, and amputation should be performed.  It is in  these cases that  it
 is often  especially difficult to  estimate the amount of injury that cannot  be re-
 covered from, this depending so much upon the age and constitution of the suf-
 ferer.  I believe that surgeons, in their anxiety to  save  a  limb, often lose  a
 patient under these circumstances.   I have more than once had reason to regret
 having attempted to save limbs injured in this way, and believe that if the skin
 of the lower extremity be extensively torn down and the muscles much lacerated,
 so  as to slough away, there is but little  chance for the patient — unless  he be
 very young, and of a remarkably sound constitution—except in  amputation.  In
 the upper extremity it is different; there  recovery may take  place under the
 most  adverse  circumstances.
    4th.  If  the bones are  extensively comminuted and crushed at the same time
 that the soft parts  are much lacerated, there  can be no question about the pro-
 priety of removing  the limb.
    5th.  So also if the knee be largely opened, with laceration of the soft parts, 
120
INJURIES OF  SOFT  PARTS.
and  perhaps  fracture of the contiguous bones, the limb must be amputated.
Corresponding injuries of the ankle, shoulder, and elbow joints, may, as has
already been stated, admit of resection rather than of amputation.
  6th. Bad crushes of the foot have a great tendency to run into gangrene, and
hence require amputation.   In  the hand, on the contrary, very extensive inju-
ries  are often  recovered  from, without this operation being  necessary; and in
many cases partial resection  may be substituted for it.
  7th. In those cases in  which a large artery, as the femoral, is lacerated at the
same time that the soft parts are  extensively injured,  and the bone  fractured,
amputation is required in order to  prevent the occurrence of gangrene.  In the
more local form of traumatic gangrene, in which the disease is confined to the
part directly crushed and injured, no good  can come of  delay, and amputation
should be performed so  soon as  mortification has declared itself; and the limb
must be  removed  at a sufficient distance from the seat of mischief.   Thus  if
gangrene of the foot or ankle come on in  consequence of a smash of these parts,
the upper part of the leg or thigh  should be amputated.   When the mortifica-
tion results indirectly from  injury  of the vessels, the limb should also be imme-
diately removed in a line with the  wound, unless this be  too high up; then the
most favorable point must be seized,  as will hereafter  be explained.  Amputa-
tion under these circumstances is by no means a very  unfavorable  operation,
and one  that I have several times successfully performed, provided  it be done
sufficiently early, before the constitution becomes poisoned by the absorption of
morbid matters from the gangrenous limb.   It is scarcely necessary to warn the
surgeon to be certain of the existence of gangrene before he  operates; and also
that it be not a mere limited slough, but sufficiently extensive to jeopardize the
patient's life.
  In all  cases in which  the true  traumatic or rapidly spreading gangrene has
set in, the surgeon will  be  placed in a great difficulty which  ever way he act.
If he leave the patient to nature, in the hope of a line of demarcation forming,
he  will almost  certainly  be  disappointed, the gangrene rapidly spreading up to
the trunk; and if he amputates, he will probably lose  his patient by the stump
becoming affected.  Yet amputation  should, in my opinion, be performed  at
once.  For although this operation is necessarily very unfavorable, when prac-
tised in these cases, in consequence of the  gangrene not being a local affection,
but dependent on constitutional causes, yet it must be remembered  that if the
surgeon wait for the line of demarcation, or trust to other means, such as inci-
sions or general treatment, the patient will almost to  a  certainty die.   The
patient's safety in these cases lies  in amputating  early, and removing the limb
high above the  part affected; thus in spreading  gangrene  of the arm, at the
shoulder-joint; and of the leg,  in the upper part of the thigh.  The necessity
for high amputation in these cases is owing to the gangrene spreading more
extensively in the cellular tissue than it does in the skin; and hence in reality
invading the limb to a higher point than it appears externally to do.   A prin-
cipal source  of danger, and  of  death, after amputation  in these  cases, is the
great disposition  to the recurrence of  the morbid condition in the stump.   Out
of  ten cases  in which I have seen  or done amputation for this disease, this
recurrence happened in five instances.  This tendency will be  increased by the
proximity of the line of amputation to the  gangrenous limit.  But even under
the most unfavorable circumstances recovery will  sometimes  take place.  Thus
I have seen  the flaps in amputation for spreading gangrene  infiltrated with
gelatinous looking fluid, and yet  recovery  take place.   In a  man whose arm
I amputated at the shoulder-joint for  spreading gangrene of the limb, the infil-
tration had extended as high as the  scapula, but yet he made a very excellent
recovery.
   Much of the success of the case will depend on the after  treatment.  Li"ht
dressings to the stump, the  administration  of full doses of liquor opii, and  the 
GUN-SHOT  WOUNDS.
121
early and free administration of nourishment and stimulants, are the  principal
points to be attended to; and  attention to  these will often bring the patient
through, though usually not without much difficulty and  great constitutional
disturbance.
  The next question, as to the  period at which  amputation should be performed
in contused wounds, has already been considered at page 44.   It may be gene-
rally stated that the sooner a condemned limb is taken off, the less is the suffer-
ing, and  the better the chance of recovery to the patient, and that, consequently,
primary amputation should be  practised in these cases.   For notwithstanding
the higher  rate of mortality in primary than in secondary amputations, it is
absolutely necessary in many cases to remove the  injured limb within the first
twenty-four hours.   This higher mortality may partly be dependent on the acci-
dents that  require  primary amputation being more severe than those  in which
it has been thought justifiable to attempt to save the limb ;  and certainly of the
two alternatives of leaving a badly-crushed  and  mangled limb on until suppu-
ration is set up, and thus  exposing the patient to  all the risks of gangrene,
erysipelas, pyemia,  &c,  or  removing it at once, the  latter is the one  attended
with least danger to the patient.
                           CHAPTER  VII.

                         GUN-SHOT WOUNDS.

   Amongst the special varieties of contused and lacerated  wounds, none are
 of more interest than the different forms of  gun-shot injury.  Though  compa-
 ratively and fortunately rare in civil practice in this  country, yet they are of
 sufficiently frequent occurrence to render an acquaintance with them  indispen-
 sable to the general surgeon.  To the military surgeon their study is necessarily
 one  of  peculiar interest and importance, and to him I wo«ld specially recom-
 mend the perusal of the works of Hennen, of  Guthrie, of Ballingall,  and of
 other surgeons who  have had  unusual opportunities of studying the nature of
 these injuries upon the field of battle, and by whom they have been treated with
 all the minuteness of  a speciality.  I purpose  in  the following  observations
 rather  to confine  myself to such  a general  discussion of the subject as is re-
 quired  by the civil practitioner, than to enter into it with all the minuteness of
 detail that may be thought  necessary to the military surgeon.
   Gun-shot injuries constitute a species  of contused  and  lacerated wounds,
 characterized in some  cases by the peculiar appearance presented by the color,
 shape, and  size of'the  orifice; and  in others, by the extensive injury inflicted
 to parts, both  superficial and deep-seated, in consequence of which they may
 prove immediately or rapidly fatal.  If the sufferer survive,  high inflammatory
 action,  with much pain and tension, with profuse discharge, deep-seated suppu-
 ration, and other after-consequences of a serious  and very protracted character,
 are apt  to set in.  These peculiarities were at different times  attributed to the
 parts being burnt  by the ball, to the  poisonous nature of  projectiles,  and to
 electricity, developed by the bullet in its passage through the  air, or by its fric-
 tion  against  the barrel.  All these opinions, however, have been  shown to be
 erroneous, and  every peculiarity presented by these injuries can be accounted
for, by the bluntness of  the contusing body, the rapidity of its course, and the
force with which it is driven.  That the sloughing which always occurs in the 
122
GUN-SHOT  WOUNDS.
track of a bullet-wound is due to the injury being inflicted by a blunt body  is
evident from the  fact, that sharp splinters of shell have  been known to inflict
clean-cut wounds.                                                  .   ..
  Gun-shot wounds vary greatly according  to the  nature of the projectile,  to
the force with which it  is driven, and to the direction in which it strikes.
  As to the nature of the projectile : — Gun-shot injuries of a serious character
may be inflicted  by weapons charged  only with powder.   This may injure by
the mere concussion of the explosion; thus a pistol charged with powder, and
discharged with the muzzle resting against the chest of a man, has been known
to kill  by concussing the heart.   In other cases a portion of  the powder unex-
ploded may be driven into or through the skin by that which is exploded behind
it.   In this way  very troublesome and  disfiguring marks are  not unfrequently
inflicted on the face, and other parts of the  body, by the charcoal of the powder
being  driven into  the  skin.   That a weapon  so charged  may  actually  kill,
appears from a case related by Dupuytren, in which a fowling-piece  charged
with powder only, and fired at the distance of two or three feet from the abdo-
men, pierced the belly with a round  hole  and killed the man.   The force of
the explosion only will  sometimes produce  serious lacerations.  Suicides occa-
sionally forget  to put a  bullet into the pistol, and  discharging it into their
mouths, blow open the cheeks and injure the pharynx and glottis by the explo-
sive force.   Some years ago, a man was brought to University  College Hospital,
who had discharged the tube of an  Italian iron loaded with powder only, into
his mouth, and died in consequence of  the injuries  he  received.  In another
case that occurred in the same institution, a man  died on the fifth day after
firing a pistol into his mouth, from sloughing of the  pharynx and inflammation
of the  glottis and larynx, in consequence of the scorch of the explosion inter-
fering  with respiration,  and thus producing suffocation.
   Wadding  and  soft materials, as  pieces of clothing, will occasionally inflict
serious wounds by the force with which they are driven.   These injuries often
happen on  the stage, at reviews, fairs, &c.  Taylor relates several  instances of
the kind,;—a girl killed by having a gun charged with paper pellets discharged
at her; also, that  of a man who was killed by a kid-glove fired from a blunderbuss.
   Small  shot often inflict serious injuries, and these are most commonly met
with in civil practice.  If the person wounded be within a few feet of the muzzle
of the gun, a terribly torn and lacerated wound, of a very serious character,
even worse than that occasioned by a .bullet, will  be  inflicted; for the  shot not
being scattered, is driven through the body in a solid compact  mass, tearing the
tissues to a great  extent.
   The shot  scattering as it flies, produces  at a greater  distance a less serious
injury, usually lodging in the subcutaneous  cellular tissue, where it may remain
for years, requiring to be picked out with a lancet, or it may give rise to suppu-
ration.   Occasionally, the  shot, by penetrating an important  part, may cause
serious or fatal results; thus, a single shot penetrating the eye-ball will destroy
vision; or, lodging in the heart, or the  femoral vein, has been known to  give
rise to rapidly fatal results.  A patient was brought to Univerity College Hos-
pital, who  committed suicide by firing  a pocket-pistol loaded with small  shot
into the mouth;  after  death, the shots were found to be deeply lodged in  and
to have penetrated the anterior portion of the vertebral column.
   Splinters of various  kinds, of metal, wood, or stone, carried by the force of
the  explosion, as in blasting and mining operations, inflict  perhaps the worst
forms  of gun-shot  injury that are met with in civil practice.  In naval actions
the force with which splinters  of wood  are driven, when struck and scattered
by cannon-shot, is so great as to inflict the most serious and fatal  mischief.   A
particular form of injury, not unfrequently met with in civil practice, and which
belongs to  this class, is the wound  of the right  eye-ball, by  the explosion and
splintering of faulty percussion-caps. 
             APERTURES  OF ENTRY  AND  OF  EXIT.          123

  Bullets, slugs, and  grape-shot  occasion more serious wounds  than any that
have yet been described;  lacerating  soft parts, fracturing and crushing bones,
tearing asunder vessels and  nerves, perforating the viscera, and  occasionally
cutting off parts, as a finger, the nose, or an ear, and thus giving rise to every
possible variety of injury.
  In the majority of cases, a bullet traverses, and the wound has two apertures,
one of entry, the other of exit;  occasionally it happens, however, that in conse-
quence of the ball being  spent, or of the piece not being efficiently loaded, or
of the  oblique direction with which it strikes the part, it merely leaves a contu-
sion or dent, rebounding or glancing off.  In other cases, there  is only  one
aperture, and here the bullet has probably lodged in the soft tissues, in a bone,
or in the cavity of a hollow organ, as the bladder.  It sometimes happens, how-
ever, that the ball drops out through the aperture at which it entered, as when
a spent ball strikes a  rib; or, that it carries a pouch of clothing before it, which
enables the surgeon to withdraw it.  One bullet may even make more than two
apertures; thus, a ball has been known to split against the  sharp  edge of the
tibia, and to have one aperture of entry and two of exit; or it may pass through
both thighs, or both calves, and thus occasion four apertures, and cases  have
been recorded in which five wounds even have  been made  in the  same person
by one bullet.
   The direction of these openings is often  of  importance, in a medico-legal, as
well as in a surgical  point of view.   Thus, Sir Astley Cooper, by  attending to
this circumstance in  a case
of  murder, ascertained  that                    Fig. 53.
the fatal  shot  must have
been  fired by a left-handed
man, and  thus  led  to the
detection of the criminal.
These   apertures,  though
usually opposite  to one an-
other,  when a ball traverses,
will sometimes  take  a very                     Fig. 54.
remarkable course, the bul-
let being deflected by meet-
ing with   obstacles  from
bones,  or  by the elasticity
of the skin.   Thus, a bullet
has been known to strike a
rib  and  to  be  deflected,
running under  the skin  to
the opposite side  of the
body; so again, striking one
temple, it has been carried under the scalp to the other side of the head, where
it has  passed out; thus giving the appearance of having penetrated important
cavities which in reality were not wounded.
    The apertures of entry and of exit, made by a round bullet, deserve attentive
consideration. Much discussion has arisen as to whether there is any difference
between these apertures,  and if  so, to what it is owing.   That there is a differ-
ence in the great majority of cases there can be no doubt.   The hole made by
the entrance of the ball being small, depressed, and circular, scarcely admitting
the introduction of the little finger (fig. 53), whilst that made by  its exit  is a
large,  somewhat everted,  and  irregular aperture into which two or  three fingers
may be freely passed (fig. 54).   In  some cases, however, it is equally  certain
that there is no appreciable difference between the two, and in others that the
aperture of entry is larger than that of exit.
 
124
GUN-SHOT  WOUNDS.
  There can be no doubt that Mr. Guthrie has given  the correct explanation
of these discrepancies when he states, that the amount of the difference in the
two apertures will depend partly on the momentum of the  ball, and partly on
the resistance it  meets with.  If the ball strikes shortly after its discharge,
when at the maximum of its velocity, it will  make but a small round hole;  not
so much shattering the parts as separating them.  If it traverse a part composed
of soft tissue, meeting with but little resistance in its passage, it loses but little
of its momentum, and  passing out of the body with nearly the same force with
which it entered, it makes an aperture of  exit that differs but slightly, if at all,
from that of entry.   If the ball strikes a bone on its passage through the  limb
or body, and thus, by meeting with much resistance, have its momentum mate-
rially lessened, the  aperture of exit will  be torn, large  and ragged, differing
materially from that of entry.  So also we find in all bullet-wounds the entrance
aperture is actually less in diameter than the  bullet itself, provided it  be made
whilst the ball is moving with  its full velocity; if it have  nearly lost its  mo-
mentum before it strikes,  then the entrance-wound will always  be large  and
ragged.  In this there is nothing peculiar to  the tissues of the living body, the
same happens when  any elastic material, as a piece of green timber, is struck.
Much, however, will also depend on the period at which the wound is examined.
In the  early stages, for the reasons mentioned, the wound of entry is smaller
than  that of exit, but as the eschar which forms in the wound of entry is larger
than that at the exit aperture,  the  former may, in a later stage, appear larger
than the latter.   This difference in the size of the two wounds  I  saw well ex-
emplified in the case of a young man, shot through the  neck in  a  duel.  The
aperture of entry, which was at first the smallest, appeared on the second day
the largest, in consequence of  the extrusion  of a black eschar;  though  it con-
tinued more regular in shape than that of  exit.
   [The characters of the wounds inflicted by the Minie ball, and by the conical
ball thrown from our own Sharp's rifle, differ materially in appearance  from
those described in the text as produced by the ordinary round bullet.
   According to the reports of MM. Baudens and Scrive, French military sur-
geons in the Crimea, the wound of entrance  made by  the conical projectile, is
most frequently oval, and sometimes linear, as if it had been produced by the
point of a sabre.   The wound of exit does  not differ ordinarily  from that of
entrance, save  in its increased size, and in its irregular appearance.   The rela-
tive position of the two wounds is always that of a straight line,  as the ball is
never deflected from its course when it has once entered the body.  All tissues,
whether muscle, aponeurosis, or bone, between these two points, are alike pene-
trated.   The soft parts are consequently torn and lacerated to a very great ex-
tent, and the bones  frequently present badly  comminuted fractures.
   As the result of such extensive lesion, violent  traumatic  inflammation  com-
monly sets in, extending over  a vast  surface, leading in many instances to gan-
grene, and frequently  imposing upon the  surgeon  the necessity of amputation.]
   Cannon-balls inflict two  kinds of injuries.   They may contuse a part without
destroying the integrity of the skin, the  ball striking  obliquely, or  rolling over
the surface of  the body.   The elasticity of the skin prevents this from injury,
though all the subjacent  textures, bones, muscles,  and vessels, may be totally
disorganized and crushed into  a pulp, if a limb be struck; if the trunk itself
be injured, the vertebral column and lumbar muscles may be disorganized, and
the liver, kidneys,  spleen, stomach, and intestines ruptured, without any breach
of surface.   These  injuries, formerly erroneously attributed to the action of the
current of air  set  in  motion  by the  ball, go by the name  of ivind contusions.
In some of these contusions gangrene of the limb sets in, apparently, as Mr.
 Guthrie has pointed out, from  the rupture of the principal vessels.
   Cannon-shot more commonly carry away the whole thickness of a part, tearing 
TREATMENT OF  GUN-SHOT  WOUNDS.           125
and shattering a limb, carrying off the thick and fleshy parts of thigh, calf, or
shoulder; or they may inflict the most fearful injuries, by smashing the trunk
and head.
   In gun-shot injuries, the shock to  the  nervous  system is always very great
where  parts of  importance, as the head, chest, and abdomen, or large joints as
the knee, are opened, and the severity of the shock is indicative of the amount
of mischief inflicted.  Thus if a bullet appears to  have traversed the  chest,
but in reality has been deflected under the  skin,  the comparative absence of
shock  will  serve, to a certain extent, to prove the absence of visceral mischief.
In some cases the shock alone appears to be sufficient to kill;  thus, a man  shot
by a pistol-bullet, which traversed the distended stomach, died in a few seconds
from shock, there being no bleeding of importance, or other cause of immediate
death  discernable  (Taylor).   In some cases,  however, that are  mortal, the
symptoms  of shock are but slight.
   Gun-shot wounds being contused, do not in general bleed much, when merely
fleshy or muscular parts are  perforated or even carried away.  But in many
cases,  patients  lose their lives from immediate hemorrhage; the larger arteries,
when  cut across by a bullet,  bleeding as freely as if  divided with a knife.
   Gun-shot wounds always inflame, with much swelling and tension of the part.
The pain which, at the moment of infliction, may not have been severe, becomes
 extremely acute when inflammation  has set in, owing principally to  the great
 tension that takes place.  This, indeed, is one of the most remarkable phenomena
 of gun-shot injury, and, by giving rise to strangulation of the tissues, is often
 the cause  of serious mischief.  The inflammation speedily terminates in  suppu-
 ration, not only in the track of the ball, but widely diffused through the neigh-
 boring parts.  A period of great danger in gun-shot wounds is that about which
 the sloughs begin to separate, usually from the twelfth to the twentieth days;
 and up to  this time it is  often impossible  to  know  the precise extent  of the
 disorganization.  At this period, also, " consecutive hemorrhage" is very apt to
 come  on, after  very slight exertion,  without any warning.  This  may be  sud-
denly fatal, and is always more  dangerous than the  primary hemorrhage, not
only on  account of the difficulty  of arresting it, but  likewise from the patient
being already weakened  by  inflammatory and suppurative action.  At a  still
 later period than this, the patient,  if  his limb be  saved, may have to undergo
 long and tedious processes of exfoliation of dead bone, and to run  the risk, of
 intercurrent attacks of erysipelas, hospital gangrene, and visceral mischief.
    Treatment.—Some of the slighter forms of gun-shot injuries, those of a purely
 superficial character, merely require  to be treated on  the  ordinary  principles
 that guide us in the management  of contusions and lacerations.   When  they
 affect the head, chest, and abdomen, they present so many circumstances of
 special importance that we must  defer their consideration until we  come to treat
 of injuries of  those  regions.  Gun-shot wounds of  the  extremities may be
 divided into two great classes in reference to  treatment. 1st.  Those that do not
 require  amputation.   2d.  Those in which amputation is necessary.
   In  all cases  of gun-shot wound, whether amputation be ultimately required or
 not, certain immediate attentions are necessary in  order to place the sufferer in
 some  degree of comfort and  safety.  Thus, if a  person  be shot through the
 fleshy part of a limb,  no bone or vessel of importance  being  injured, the  part
should be  covered with wet cloths, and placed in an  easy position.  If there be
abundant venous hemorrhage the limb should be raised, and if this do not arrest
the bleeding, a compress used. If the hemorrhage  be arterial, a tourniquet must
be applied.  So, also,  a tourniquet  should be applied if there be rapid dripping
of blood, even though the bleeding be not in a jet.
 _ If a limb be smashed, or torn  away,  a tourniquet  should  be applied  very
tightly upon the stump, which must be covered up in wet cloths.  The pressure
of the tourniquet will not only arrest hemorrhage, but will stay that spasmodic 
126
GUN-SHOT  WOUNDS.
quivering of the muscles  of the mangled limb, which  is so  painful  to the
sufferer.
  If the head or neck be wounded, cold wet  pledgets should  be applied, and
hemorrhage, whether venous  or arterial, arrested by pressure with the fingers.
  If the chest be shot through, the patient should be laid on the injured side,
and cold applied. If emphysema occur, or if air freely pass through the wound,
a body bandage must be tightly applied.
  If the abdomen be wounded, the patient should be laid on the injured side,
if the aperture  be a lateral one.  If central, on his back, with  the knees
bent over a log or  knapsack.   If the intestine  protrude, wash and quickly
return it.
  In  addition to these immediate attentions, which may be bestowed upon
sufferers from gun-shot before they are sent to the hospital for more methodical
treatment, the influence of the  shock should be  counteracted by the adminis-
tration of a little brandy-and-water, and plenty of cold water be  given to allay
thirst.
  1st.  Those cases of gun-shot injury  that do  not require  amputation, must
be treated on the principles that  guide us  in  the  management of all  contused
and lacerated wounds, the surgeon, however, bearing  in mind that these inju-
ries are  especially apt to  be followed by  extensive and  intense inflammatory
action, and that sloughing will  inevitably result  in  every part that has been
touched by the ball.
  The first point to be attended  to in these cases is the arrest of hemorrhage.
In general this may not give much trouble; but if a large vessel be injured,
                                    the loss of  blood will rapidly prove fatal,
                                    unless  stopped.  This  is  done, in the
                                    first  instance,  by  direct  pressure with
                                    the fingers on the bleeding part, followed
                                    by the application of the  tourniquet, or,
                                    if this  instrument  be not at  hand, by
                                    some  simple substitute, such  as rolling
                                    a pebble,  about the size  of an egg,  in
                                    the   middle of  a  pocket-handkerchief,
                                    laying  this  over  the  artery,  knotting
                                    the ends of  the  handkerchief  round the
                                    limb, and   then twisting  it  up tightly
                                    with  a  piece of stick,  or  the  hilt of a
                                    sword,  passed under it (Fig. 55).   The
                                    wound in  the artery may  be  of such a
                                    kind as to  require amputation of the
                                    limb; if not, hemorrhage  must be  per-
                                    manently arrested  by an  incision being
                                    made down to the bleeding vessel, and a
                                    ligature  applied on either side of the
                                    wound in it; for reasons that will be fully
                                    stated when we  come to speak of injuries
                                    of arteries.
                                      The next point to be attended to is the
extraction of foreign bodies, such as splinters of bone, shot, slugs  or bullets,
wadding, pieces  of clothing that have been carried in with the ball, and other
matters of a like kind.  These will generally be found near the aperture of exit.
Splinters of bone  require  special attention.  Those  that are quite loose and
carried away from the shaft must be taken  away, as they will necrose  and  pro-
duce the same irritation that  other foreign  bodies  would.   If splinters are still
attached to  soft parts, though  carried considerably away from the portion of
bone to which they were attached, they must also be taken out; but if they
 
TREATMENT  OF  GUN-SHOT WOUNDS.           127
Fig. 56.
continue attached in the vicinity of the fracture, they must be left, becoming
enveloped  in  and tending  to  consolidate the callus that is thrown out for its
repair, and thus adding eventually to the strength of the limb.
   If the bullet lodge, it, together with foreign  bodies accompanying  it, such
as pieces of clothing, must  be  cut out by a  counter opening.   If anything is
very tightly fixed, so that it cannot readily
be removed, it must be left till loosened  by
suppuration.   In searching for bullets and
other foreign  bodies, care should be taken
not to probe the wound unnecessarily from
mere curiosity, or so as to excite irritation:
in many cases, the introduction of the finger
is far more useful than that of the probe.
Various  instruments are used  for the  re-
moval  of bullets and other foreign bodies.
The accompanying wood-cuts (Figs. 56, 57,
and 58) represent the best forms of bullet-
screws and forceps.   The probes are usually
made much larger and  stronger than those
in ordinary use.
   In those cases in which small  shot are
lodged  under the skin, they may be turned
out  by being cut down upon with  a  fine
scalpel.
   Our next object should  be the treatment
of the wound itself.  This, as has  already
been  stated, will always  inflame  violently
and  slough along  the whole  track of the
ball.  The principal points to  be attended
to are, consequently, to limit the  inflam-
mation,  and  to facilitate  and  watch  the
suppuration of  the  sloughs.
   In order to  limit  the  inflammation,  it
was  a common practice  with military sur-
geons, and still is  so with the French,1 to
dilate, by incision, the wound  made by the
ball,  with a  view  of  preventing  tension
and  strangulation  of  parts.    Since  the
time, however,  that John  Hunter pointed
out that an incision could  not alter the nature of a contused wound, and  only
superadded another injury to  the one already inflicted by the bullet, British
surgeons have only employed the knife in the early stages  of gun-shot wounds,
for the purpose of securing bleeding vessels, or to facilitate the extraction of
foreign bodies.   In  the  more  advanced  stages, however, free incisions, which
should be made in the direction of the axis of the limb, are commonly required,
in order to lessen inflammatory tension, to prevent  the  extension of sloughing,
and to favor the escape of matter.
   The best mode of lessening inflammation in a  gun-shot  wound is  by cold
irrigation (fig. 45), conjoined with  position  and rest;  to  which water-dressing
and poultices, useful as they may be, are far inferior.   As suppuration conies
on, we must substitute warm applications  for the  cold, so as to hasten the for-
  1 [In Baudens' Treatise on Military Surgery, already quoted (Paris, 1858), this custom
of the dilatation of gun-shot wounds by incision is most strongly reprobated.  As long
ago as the year 1836, this writer had already stigmatized the  process  as  "useless  and
barbarous;" and he now adds that,  during the Crimean war, he had observed with satis-
faction that the practice possessed not a single defender.] 
128
GUN-SHOT  WOUNDS.
mation of matter and the separation  of the  sloughs.  Free  incisions will also
now be required.  These should not be delayed too long; they may be practised
when the part has  become  swollen with much tension, in order to prevent the
deep mischief that must otherwise ensue.   At the period of  the loosening and
separation of the sloughs  there  is always especial danger of the supervention
of consecutive  hemorrhage.   The patient, consequently, at this time requires
to be carefully watched:  if the wound be  in the vicinity of large vessels, he
should have a tourniquet placed  loosely round the limb, so as to be screwed up
at a moment's notice;  and he must, on the supervention of bleeding, have the
artery ligatured, if possible at the seat of the wound; if this be not practicable,
in the most convenient situation above it; and if this  do not arrest the bleeding,
amputation should be had  recourse to.
   After-consequences of  a  serious character, such  as abscesses,  profuse dis-
charges, necrosis, and the  separation of splinters of bone, must be looked for in
many cases;  and these consequences may be prolonged for a considerable series
of years, at last perhaps wearing  out the patient if the cause of irritation be not
removed.   Thus  General  Bern required to  have a  bullet removed  by Liston
from the external condyle of his femur nineteen years after it first lodged there;
and Marshal Moncey died forty years after the receipt of a gun-shot wound,
from its effects.
   2d. The cases of gun-shot injury that require amputation are of a very similar
kind to those of contused wounds generally, in  which the same  operation is
necessary, and the surgeon must exercise the same  amount  of caution not to
condemn  a part too hastily; for a part that looks much shattered and injured
when covered with coagulated blood and dirt, before  being cleaned and put up,
presents a very different appearance after the fracture has been reduced, splin-
ters of bone removed, and the soft parts brought properly together.
   Amputation, however, is  required  when  the  whole  limb  is  carried  off, a
ragged stump merely being left;  so, likewise, if the limb is completely crushed
and disorganized, whether by direct blow or  by a wind contusion, though still
left adherent.  Again, if  the  principal vessels and soft parts be carried away,
though the bone be uninjured, the limb cannot be  preserved.  Amputation is
especially necessary in some of the more serious injuries of the lower extremity;
thus, if a bullet divide the femoral vessels, or the sciatic nerve, and splinter the
thigh bone, or if the sciatic nerve and soft parts  at  the back of the thigh be
carried away, although the vessels and  bone be left uninjured, the case is  one for
amputation;  and, indeed, it  may be stated generally, that compound fractures
of  the thigh occasioned by gun-shot, require amputation.  The mortality, how-
ever, after amputation of the upper two-thirds of  the thigh for gun-shot injury
was so great in the Schleswig-Holstein war, that it became a question with many
of the German and Danish surgeons whether this operation should be continued,
or whether the patient would not have  a better chance if the injury were treated
as a compound fracture.  At the siege of Sebastopol the mortality after ampu-
tation of the  upper third of the thigh was so great in  the Russian army that the
surgeons  abandoned the operation; nearly one-third  of the cases in which the
lower and middle third were  amputated are said to have recovered in the British
army in the Crimea (p. 43).   The amputations in the  upper third were fatal
in the ratio of 86 per cent., those of the middle of 60, whilst of the lower  third
the mortality was reduced  to 56 per cent.  In gun-shot wounds of the joints of
the lower  extremity, removal of the limb becomes necessary;  thus, if the head,
neck, or trochanters of the femur are shattered by a bullet, it  is generally
considered necessary to remove  the limb at the hip-joint.   But  Mr/Guthrie
has recommended excision of  the injured head and neck of the bone  instead.
This operation has been successfully performed by Mr. O'Leary in  the Crimean
war.  In  those  cases in which  the knee or  ankle-joints are  perforated and
smashed  by balls, or in which  longitudinal  fractures of the  tibia or femur 
AMPUTATION  IN  GUN-SHOT  WOUNDS.          129
extend into them, amputation is imperative.  In  some  instances, when the
bones are not  too much disorganized, though the joints are traversed, the limb
may be preserved.  In some cases of gun-shot wounds, implicating the shoulder
and elbow-joints, removal of splinters and  excision of the injured portions of
bone may be advantageously substituted for amputation, the
injury in the soft parts being treated on ordinary principles,
as in the  case represented in Fig. 59, of a bullet lodged in
the head of the humerus.  The value of excision of joints
in  cases of gun-shot  injury has been established  by the
experience of German,  French,  British,  and Russian  sur-
geons, during the recent wars  on the Continent  and in
the  Crimea.   It is especially  in  gun-shot injuries  of the
shoulder  and  elbow-joints  that these operations  have been
attended  by satisfactory results.   M. Baudens  states  that
he saved 13  out  of 14  cases  of excision  of the shoulder.
According to Mr. Thornton, in  the British army  in  the
 Crimea, the shoulder  was  excised 12 times with 2  deaths;
 the elbow in  17 cases, of which 2 were fatal, and partially
 in 5 other cases, all  of which were successful.  These results, which reflect
 the highest credit on  the skill  of our army surgeons, were more successful than
 those  that followed the amputation of corresponding parts.  Of 66 disarticu-
 lations at the shoulder, 19  were fatal; and of 153 amputations of the  arm,
 29 died.   In the lower  extremity excisions are not so successful after gun-shot
 injuries as for disease.  Of 6 cases in which  the head of the femur was  excised;
 only 1 case,  Mr. O'Leary's, recovered; and  in  2  cases  in which portions  of
 the femur were removed, and in 1 in which  the knee-joint was  excised, death
 ensued.
   In the Russian army  conservative surgery was also extensively practised, and
 in it, according to Messrs. Mouat and Wyatt's Report, of 20 cases of  excision
 of the elbow, 15 recovered.
   Gun-shot wounds  of the  foot, if serious,  require its  removal,  either at  or
 above the ankle.  Those  of the hand are  of special  interest  from their fre-
 quency, in consequence of the bursting of guns, or of  powder-flask explosions.
 In these cases, however extensive the  injury may be that is inflicted upon the
 hand, fingers being blown away, the thumb thrown back, and the metacarpal
 bones splintered, we  must endeavor, if possible, to save a portion of it, if it
 be only one or two fingers; and, owing to the great reparative power possessed
 by the hand, we  shall often, in the worst-looking cases, be able  to accomplish
 this.  If the thumb,  with one finger as an  opponent,  can be preserved, it will
 be of more service to the patient than any artificial contrivance, however  inge-
 niously made (Fig. 16).  It not unfrequently happens that amputation may be
 required in the more advanced stages of gun-shot injury, in consequence  of
 mortification  supervening.  Under these  circumstances, it must  be practised
 without  delay, and without waiting for the  line of separation.   If, in conse-
 quence of long-continued  suffering and discharge, the patient's health becomes
 worn out, and the limb  remains  a useless  appendage, amputation will at last be
 imperative.
   The question as to  the  period at which amputation  ought to be performed
 after the infliction of  these wounds, is one of great  importance, and has  given
 rise to a  corresponding amount of discussion  among surgeons.   The older mili-
 tary surgeons, Wiseman, Ledran, Ranby, &c, taking a common-sense view of the
 question, advocated the removal  of the hopelessly-injured limb  so soon as the
 shock to  the system had subsided, the pulse  had regained its volume, and the
 warmth  of surface had returned.   After the Battle  of  Fontenoy, in the middle
 of the last century, professional opinion underwent a change upon this  subject,
 and Faure wrote a thesis, which  obtained the prize of the French Academy  of 
130
GUN-SHOT  WOUNDS.
Surgery, recommending delay in amputating in certain cases.   Hunter, Percy,
and other surgeons of repute, promulgated similar views, until Bilguer, the sur-
geon-in-chief to Frederic the Great's armies, went to the absurd and dangerous
extent of condemning amputation entirely.   These extreme opinions necessarily
occasioned a reaction, and the experience gained in the wars of  the French Re-
volution  and Empire, has finally enabled surgeons to settle this question defi-
nitely.  It is more particularly by the  labors and observations of John Bell,
Larrey,  Thomson, Guthrie,  S. Cooper, and Hennen, that the necessity of having
recourse  to immediate amputation in all  cases of gun-shot injury, requiring this
operation, has been established.
  In  determining this point we must be guided, partly by surgical experience
on the  result of such cases left to nature, and  partly by an  appeal^ to facts.
In appealing to experience  we must, to use the forcible language of Sir Charles
Bell,  contemplate what shall be the condition of the  parts  in twelve  hours, in
six days, and in three months:  " In  twelve  hours  the inflammation, pain and
tension  of the whole limb, the inflamed countenance, the brilliant eye,  the
sleepless and restless condition, declare the impression the  injury is making  on
the limb and on the constitutional  powers.   In  six days, the limb  from  the
groin  to the toe, or from the shoulder to the finger, is swollen  to  half the size
of the body; a violent phlegmonous  inflammation pervades the whole; serous
effusion has taken  place in  the whole limb, and abscesses  are  forming in  the
great  beds of cellular texture  throughout the whole extent of the extremity.
In three months, if the patient has labored  through  the  agony, the bones  are
carious;  the abscesses  are  interminable sinuses; the  limb is undermined and
everywhere unsound, and the constitutional strength ebbs to the lowest degree."
  If  we appeal to facts, we shall find  that of 300 secondary amputations re-
ported by Faure, after the battle of Fontenoy, only 30 were successful; whereas
Larrey saved three-fourths of his primary amputations.   In  the Peninsular
War,  the comparative loss after secondary amputations  of  the  upper extremity
was, to that following the primary, as twelve to one; and of the lower extremity,
the loss after secondary amputation was  three  times  as great as after primary.
During  the  siege  of Sebastopol, out of 80,000 wounded  Russians there were
3000  amputations.   Of the primary amputations  of  the upper extremity, leg,
and foot, about one-half recovered; and  of the lower and  middle third of the
thigh, about two-thirds died; but of all  the secondary amputations more than
two-thirds died.  Primary amputation, therefore, should always be performed.
But if an unsuccessful attempt at the preservation of the limb be made, and if
occasion for its subsequent  removal should arise, the surgeon must wait until
suppuration has set in before  he operates, the period of acute  inflammatory
action being allowed  to  pass by.  The cases that most commonly require
secondary amputation, are those in which traumatic gangrene has set in; here
the limb must always be removed without delay, in accordance with the prin-
ciples laid down in speaking of this subject in reference  to contused wounds.
If profuse hemorrhage  occur  from the  wound that does not admit of suppres-
sion by  the ordinary means, secondary amputation may become  necessary.  So,
also, when the bones do not unite, the patient being worn out by discharges and
the irritation of necrosis and caries, and  left with a wasted, shattered, and use-
less limb, its removal is the only means  of saving life. 
PUNCTURED  WOUNDS.                    131
CHAPTER  VIII.
              PUNCTURED  AND  POISONED WOUNDS.

   Punctured wounds, made by narrow sharp-pointed instruments, vary greatly
in extent, from the prick of a needle in the finger to a sword-thrust through
the body.  Not  unfrequently punctured wounds are somewhat  contused, being
made by a triangular or wedge-like weapon, as a bayonet or lance blade.  Hence
they partake of the general  character of contused wounds, having a tendency
to unite by granulations from the bottom, and  to  be accompanied  by much in-
flammatory  fever.  When deep, they are of  a  most  dangerous  character —
wounding blood-vessels, traversing the great cavities, and injuring the contained
viscera.
   In the treatment of punctured wounds, the  principal points are  to arrest the
hemorrhage, and to facilitate union.
   The hemorrhage must be arrested by pressure  properly applied by means of
compresses  or pads, so as to approximate the sides  of the  puncture;  by the
application of cold; or by cutting down on the injured vessel if it be a large
one, and ligaturing it above and below the  perforation in it.
   In the majority of cases, unless the injury be  a slight one, suppuration  and
union by the second-intention will take place.   This must  be promoted by
poulticing;  and undue inflammation must be guarded against by local anti-
phlogistics.   In many cases union by adhesion is  obtained : and in others  that
are allowed  to suppurate, there can be little doubt that  the same favorable  ter-
mination  might be secured if proper attention were paid to the injury.  In
former  days when  duels with the  small  sword were of frequent occurrence,
persons called " suckers," who were often  the drummers of a regiment, were
employed to attend the wounded  combatant.   Their treatment, which was con-
ducted with a certain degree of mystery, consisted in sucking the wound  till
all blood ceased  to flow; then applying a pellet of chewed paper or a piece of
wet linen to the orifice; in this way it would  appear  that many sword-thrusts
traversing the limbs were  healed in a few  hours  or days.  The
process of suction cleared  the wound thoroughly of all blood, and    Fig. 60.
drawing the sides into close  apposition, placed the parts in the
most favorable condition  possible for union by adhesion.   This
practice might,  perhaps, in many cases, be advantageously imi-
tated at the present day with a cupping-glass and  syringe.
   Amongst the  varieties  of punctured wounds  that are  most
commonly met with in ordinary practice, are those that are occa-
sioned by needles penetrating into, and breaking off in the body.
These accidents  chiefly occur in the fingers and  about  the nates,
and  though of a trivial character, are often  extremely trouble-
some, both to  surgeon  and patient.  When the surgeon is called
shortly after the occurrence of the accident, he must endeavor to
remove the fragment left behind, by cutting down upon it.   In
doing this he will be guided by  the  situation  of  the puncture,
and  by the seat of  the pain, and  sometimes by feeling the point
projecting under the skin.  In many cases this is a sufficiently
simple proceeding; in others, however, a deep  and troublesome
dissection may be required,  especially when  the fragment  of
needle gets into or under the sheaths of a  tendon.  I have had
occasion to  undertake  somewhat troublesome  dissections between the  biceps
tendon and the brachial artery,  or in the close  proximity of the ulnar artery, for
ft
P 
132
POISONED  WOUNDS.
the removal of fragments of needles lodged in the bend of the arm and the wrist.
For the  purpose of extracting needles, thorns, splinters of wood,  and other
foreign bodies of small size  and pointed shape lying in narrow wounds, the for-
ceps shown in  the  annexed woodcut (fig. 60) will be found  most serviceable,
as they have very fine, but strong and well-serrated points.
   In many cases if the needle  have been  lodged for  some days, the surgeon
will fail  in  his endeavors to extract it;  and  unless the_ indications of  its
presence be very clear, I think the wiser course is to leave it undisturbed, and
to trust  to nature for  its elimination from the body, as it will seldom be found
when sought for, and  indeed, may not exist,  although supposed to be  present.
The following  plan  of ascertaining  whether a portion of needle be  really im-
pacted has been suggested by Mr. Marshall.  A powerful magnet is  to be held
upon the part for  a quarter  of an  hour, so  as  to  influence the fragment; a
finely-hung polarized  needle  should then  be suspended over it, when if any
iron be present, deflexion will ensue.


                         POISONED WOUNDS.
   A very important variety of punctured wound is  that  in which a poison ig
introduced into the puncture.   The  most  important of these poisoned wounds
are those inflicted by the stings of insects, the bites of snakes or of  rabid ani-
mals, and injuries received in dissection.
   The stings of insects, as of bees, wasps, &c, though painful, seldom  produce
any serious inconvenience ; yet occasionally they may do so, and even prove fatal,
by inducing  erysipelas in some  unhealthy  constitutions,  or  by giving  rise  to
intense irritation by  the multiplicity  of the stings; as by bees swarming upon
and  stinging a person  in great  numbers; or  they may be dangerous in conse-
quence of an important part  being  stung,  as the eye, or  the interior of the
mouth, or pharynx, as  has  happened by swallowing a bee in a piece  of honey-
comb.  Some insects, as scorpions or the tarantula in Italy, give rise to serious
and even fatal disturbance by their bite.   A peculiar  train  of nervous  pheno-
mena is said to follow the bite  of the tarantula, hence  called " tarentismus," a
disease that is generally stated to be  peculiarly influenced  by music, though this
has recently been denied by M. Gozzo.
   In the treatment of  stings of insects the  application of cooling lotions, of a
cold poultice, or rubbing the part with olive oil, will be found  the  most useful
means of allaying  irritation.   In some  cases,  touching  the part stung  with
ammonia, gives immediate relief.
 ^ Snake bites are seldom fatal in this country, venomous reptiles, such as the
viper and adder, not  possessing  a  sufficiently  energetic poison to  destroy a
healthy adult, though  they might possibly kill a child or a very delicate and
weakly person.   They  are said  to be most active in warm weather and during
the season of procreation, and their bites are most dangerous if inflicted  through
a vein or glandular part, or near the  centre of  the circulation, or about the neck
and  face.  In  tropical countries  the  bite  of the rattle-snake,  of the Cobra
di Capella, the puff-adder, or the Tobacco-pipe snake is often fatal; and it occa-
sionally happens in  this country that the surgeon has an  opportunity of seeing
wounds inflicted  by these fearful reptiles in  menageries.   Thus Sir E. Home
has recorded a fatal case of rattle-snake bite occurring in this country.  A
similar instance lately occurred at St. George's Hospital, and  another in Paris,
to showmen.  The most remarkable case of this kind with which I am acquainted
occurred  recently at the University College Hospital, affording an opportunity,
rare in this country, of witnessing the effects of the bite of a Cobra di  Capella.
The patient, a keeper at the Zoological Gardens, was bitten in the bridge of the
nose, the poison fang  having  apparently penetrated the  angular vein.   When
brought to the  hospital, about half an hour after the accident, he was apparently 
POISONED  WOUNDS.
133
dying, being unable  to  speak,  swallow, or support himself; the pupils were
dilated, face livid, heart's action feeble, and he was scarcely conscious.   After
death, which took place in  little more than an hour from the time of the  inflic-
tion of the wound, the veins of the brain and the  cerebral sinuses were  found
congested with blood, as were also the lungs to an immense extent, and the solid
abdominal viscera.  The right cavities of the heart were loaded with dark blood,
the  left being  empty;  indeed the phenomena of asphyxia were strikingly
marked.  In this case death would  appear to have resulted from  the poison
paralyzing the medulla oblongata, and those portions of the nervous system that
are instrumental in carrying on respiration, at the same time that the blood was
disorganized by  the action  of  the virus.
   Snake-poison  when introduced into the system may  kill in  two ways;  either
by its direct depressing influence, somewhat resembling that produced by some
narcotic poisons; or,  by  exciting a kind of diffuse inflammation of the cellular
tissue of the limb or  part.
   The first mode of death only occurs when the poison is either very powerful,
or the animal bitten small.  Thus the poison of the Tobacco-pipe snake is said
to be so virulent that it will kill a full-grown  man  in less  than a quarter  of an
hour.  The rattle-snake,  and the Cobra di Capella, will kill a small animal  in the
course of a few seconds; and a  man lately bitten by a  rattlesnake in Paris, died
in nine hours; the Cobra bite just related was fatal in less than one hour.
   In other cases again,  the poison  acts by exciting diffuse inflammation, sup-
puration, &c, of the cellular  tissue.  Thus in  the case which occurred  in St.
George's, the patient died  on the 18th day after the bite of a rattlesnake, with
large abscesses in the arm  and in the axilla, and with  sloughing of the cellular
tissue of  the limb.
   The symptoms occurring after a poisonous snake-bite, consist in great depres-
sion and prostration of the  system, a feeble and intermittent pulse, dilated pupils,
usually slight delirium, speedy stupor, insensibility, and  death. The part  bitten
swells and becomes livid in a  few hours;  and, if the patient survive sufficiently
long, diffuse inflammation and gangrene occur in its neighborhood; involuntary
evacuations take place;  asthenic symptoms set in, which may eventually  termi-
nate fatally in the way that has  already been mentioned,  or end slowly, and after
a lapse of time, in the  recovery of the patient, whose health may long  suffer
seriously  from the effects of the accident.
   The treatment of these injuries is local and general.
   The local treatment  presents two great indications: lstly,  to prevent the
absorption of the poison into  the  system; and 2dly, to treat the diffuse inflam-
mation and sloughing that may subsequently occur.  The first  indication may be
fulfilled by tying a ligature so tightly round the limb  at a little distance  above
the injured part as to arrest all  circulation through it.    In this way the absorp-
tion of the poison may be prevented ; the wound should then be freely cauterized
with a red-hot  iron  or  cinder, or  better still, be  excised, and a cupping-glass
applied over the cut surface, so as to withdraw the blood  in the  neighborhood
which may have become contaminated by the poison.  If a cupping-glass be not
at hand, or if the part bitten  be so situated as  not to  admit of its application,
there can be no objection to the employment of suction by the mouth after free
excision; the poison not being absorbed by an unbroken mucous  membrane.
In using  suction, the mouth should be rinsed with  brandy.  With the view of
lessening the swelling, tension,  and pain of the limb, frictions with olive oil are
said to be advantageous.   After diffuse inflammation  has set in  this must  be
treated on general principles — by fomentations and free incision.
   The constitutional treatment consists in the early and free  administration of
the most  powerful stimulants, with the  view of combating the depression that
exists.  For this purpose, brandy, wine, ammonia, or ether must be freely given. 
134                    POISONED WOUNDS.

The eau de luce—which enjoys a high reputation in some  tropical countries—
owes its efficacy to the  ammonia which it contains.   Should  drowsiness  come
on, the patient must be walked about, and artificial respiration with galvanism
may be resorted to as a last means of maintaining  life until the  effects of  the
stimulants may overcome those of the poison.  Large doses of arsenic have been
recommended  as a kind of specific, and the "Tanjore pill," a celebrated Indian
remedy, owes its activity to this mineral;  but care must, of course, be taken in
administering  this, lest the remedy prove as  fatal as the  injury for which it is
administered.
   [The experiments recently  made by  Dr. Hammond, U. S. A., and  Mr. De
Vesey, of California, as to the prophylactic and curative powers of Bibron's anti-
dote to the bite of the rattlesnake seem to go far to prove its efficacy.   As this
subject is one so  pregnant with interest to the American surgeon, we give the
formula in detail, as furnished to Mr. De Aresey, by Prince Paul, of Wurtem-
burg, the celebrated naturalist: " R. Potassii Iodidi,  gr. iv.; Hydrarg. chloridi
corrosiv., gr. ij ;  b.romini, £v. — M.   Ten drops  of this mixture diluted with
a tablespoonful or two of wine or brandy, constitute a dose ; to be repeated if
necessary.   It must be kept  in glass stoppered vials well secured."
   In two or three cases in  which the antidote was administered to the human
subject, when bitten by the  serpent, an  almost immediate amelioration of the
symptoms was experienced ; and in the series of experiments practised upon dogs
the results  appeared to be satisfactory. — Vide the  American Journal of the
Medical Sciences for January  and April, 1858.]
   The bite of rabid animals gives rise to the disease so much dreaded and so
often spoken of, but fortunately so seldom seen in man in  this country, termed
hydrophobia.
   This disease invariably occurs in man, and, most commonly, in  the  lower
animals, as the result of contagion.  The wolf, the fox, the jackal, and the cat
are  most liable to  it.   When  originating de novo, its causes are excessively
obscure.  It has  been  attributed to the influence of season; thus Eckel finds it
most common  in  the months  of February and May;  but want of  water, sudden
changes from  heat to cold, bad food, and unsatisfied sexual desires have all been
assigned as causes of its occurrence in  animals.  Dogs more frequently become
rabid than bitches;  thus, of  a hundred and forty-one cases collected by Eckel,
only fifteen occurred in bitches; and amongst dogs it is most  common in those
of a mongrel  breed, seldom affecting those that are of pure blood; or that have
been castrated.   In the human subject it never appears  except as the result of
contagion either  by a bite, or by the  rabid  animal licking a raw surface, as an
abrasion on the hand  or lip.   The bite of a rabid animal is most  dangerous
when inflicted on a naked part, as on the hand or face. A person bitten through
clothing often escapes any ill effects, in consequence  of  the teeth being wiped
and the poisonous saliva arrested by the clothes.   Hence a number of persons
may be bitten by the same rabid  animal, and but a very few take the disease;
not more, perhaps,  than one  in ten, or  one in twenty.
   The period that intervenes between the bite and the occurrence of the disease
is  usually  considerable.  Meade  has related the  case  of a lady who  got  the
disease fifteen months after the bite.   Elliotson says that the  average time that
elapses between the injury and  the symptoms is from six weeks to three months.
The Duke of  Richmond, who was bitten by a tame fox, took the disease between
six and seven weeks after the injury.   Writers, however, in stating that  six,
seven, twelve, and even fifteen years have intervened between the infliction of
the wound and the manifestation of the symptoms, have  evidently committed
an exaggeration  or fallen  into error,  having very probably confounded  othel
nervous affections that closely resemble hydrophobia with it.
   Symptoms.—The wound has generally cicatrized long before  any symptoms 
HYDROPHOBIA.
135
of hydrophobia declare themselves, and no peculiar appearance is presented by
the scar. Shooting pains, twitching and itching sensations have, however, occa-
sionally been experienced in the site of the wound before the supervention of
the attack; and it  is probable that in all cases some  process analogous to a
zymotic action takes place within it before the disease comes on.   The precise
nature of this, however, requires to be elucidated by further observation.
   The general symptoms are usually ushered in by some antecedent phenomena
for two or  three days;  according to  Perry, for five or six.  These  initiatory
symptoms  consist of giddiness, chills, and heats, and a general feeling of dis-
comfort.  The  more  special  symptoms never  manifest  themselves until the
disease becomes fairly established;  they consist  of extreme nervous irritability
and apprehension, with convulsions, induced by  various  external influences,
whether acting on  the surface  of the body, or on the fauces, or may be occa-
sioned by mental impressions, and speedily end in exhaustion and death.  These
more special symptoms may be  arranged under three  heads: consisting of a
spasmodic affection  of  the muscles  of  deglutition and  respiration;  of extreme
sensibility  of the surface and of the senses; and of excessive mental terror and
agitation.
   In consequence of the spasmodic affection of  the muscles of deglutition, the
act of swallowing commonly excites convulsions; hence the patient  experiences
a horror of all  liquids; and, in  attempting to drink, gulps down the fluid with
a strong mental effort.  In some cases, solids give rise to the  same  difficulty in
deglutition as  liquids; but  occasionally, though rarely,  patients  have been
known to  swallow  perfectly  well throughout the disease.  This  difficulty in
swallowing is certainly owing to an excessive sensibility about the pharynx and
throat, in consequence of which  every effort at deglutition induces violent reflex
movements.
   A catch in the breathing, resembling what often occurs when a person goes
into a cold bath, is  met with as one of the earlier symptoms, taking place in the
midst  of conversation, and before the patient's  mind is directed to the  nature
of  the disease.   This catch is due to the spasmodic descent of the  diaphragm,
and gives rise to severe pain at the pit  of the stomach, or a feeling of suffoca-
tion, and a return of the convulsions.
   An extreme  degree of sensibility of the surface, and of some of the senses,
is characteristic of hydrophobia.  The cutaneous nerves  b*ecome so  sensitive
that a blast of  cold air, the rustling of the bed-clothes, the slightest  touch of
or movement on the skin will bring on  convulsions.  The nerves of sense become
equally excitable, so that a sudden  flash of light before the  eyes, as the  reflec-
tion of the sun from a looking-glass,  or a sudden noise, as the slamming of a
door, will produce the same effect.  The noise produced by liquids being poured
from  one  vessel  to another is peculiarly distressing to the patient;  and Dr.
Elliotson mentions  a patient with hydrophobia  being thrown into violent agita-
tion by hearing the dresser, who sat up with him, make water.
   The sufferings and  convulsions that patients experience when they attempt
to drink, appear to be owing  to  this excessive  sensibility of the nerves  of the
mouth and pharynx, and the recollection of these  sufferings makes them afraid
to repeat the attempt; hence the fear of liquids, from which the disease derives
its name.
   One of the earliest symptoms  of hydrophobia, and one of the most persistent,
is an  extreme  degree of mental agitation and  terror, a vague sense  of dread
and horror at  the  impending fate.  Delusion sometimes occurs  of a spectral
character,  the patient supposing himself to be surrounded by animals, by horrid
forms, or by gaping, ghastly, and grinning countenances.   The first symptom
in the Duke of Richmond's case was, that he fancied some poplar trees opposite
his  bed-room window were men looking in.   These delusions may  alternate
with fits of delirium and frenzy.   In these it is said that the patient barks like 
136
POISONED  WOUNDS.
a dog, and endeavors to bite; but this is a popular error — the pretended bark
is merely the catch in breathing, and the attempt to bite is nothing but move-
ments of the tongue and mouth, induced by the clamminess of the viscid and
ropy  mucous saliva.   Occasionally  the  symptoms subside  completely before
death;  the sensibility  of the surface  disappearing, the mental agitation  or
delusion being removed, and  deglutition  and respiration  being quietly per-
formed.   Thus Dr. Latham relates  the  case of a man laboring under this dis-
ease, who sat up quietly in bed, and  drank a pint of porter half an hour before
he died.
  I am not acquainted with any authentic case of recovery from hydrophobia,
after  the  disease has fairly set in.  The disease may prove fatal in four-and-
twenty hours, or life may be prolonged for  six or seven days;  death generally
occurring from the second to the fourth day, and  being apparently induced by
exhaustion.
  The appearances found after  death throw  no light whatever upon the  disease,
and indeed may often be supposed to be the  effects rather than the causes of the
spasmodic  irritation.  The tongue, the fauces,  the  throat, the  glottis, and the
larynx, the stomach and oesophagus, the brain, the medulla oblongata, and spinal
cord,  have all been found congested  and inflamed;  there is  nothing, however,
in the appearances presented by these parts that affords a clue to the true nature
of this inscrutable and terrible  malady.
  The treatment must principally be of a preventive and palliative character;
we cannot speak of  curative treatment in  hydrophobia; for, after the disease
has once  set in, the utmost that  can be done will  not accomplish more than
to lessen  the  sufferings of the patient, and  stay for a few  hours the fatal
termination.
  When a person is bitten by a dog that is mad, or even by one that  is sup-
posed to be so, the surgeon should always adopt  energetic  means to save the
patient from the invasion of  a disease  that is necessarily fatal.  In  having
recourse to preventive treatment, it  should  be  borne in mind  that  the larger
proportion  of persons actually bitten by rabid  animals do  not fall  victims to
hydrophobia; the probability of the  occurrence of the disease depending partly
upon  the animal that bites, and partly upon whether the bite is inflicted  upon
the naked or clothed parts of  the  body.   Thus Watson  states that,  of 114
persons bitten by mad  wolves, 67 died  of  hydrophobia; whilst, according to
Hunter and Vaughan, only 1 out of  20  or 30 bitten by mad dogs take tb/dis-
ease.   This latter estimate may possibly be somewhat lower than the truth, but
yet the fact remains certain that wolf-bites are far more dangerous than dog-
bites, and this is probably owing to the circumstance of wolves always flyin^ at
the face and naked parts.   It is in consequence of this small proportion of per-
sons  taking the disease  out of the total  number bitten,  that so many popular
remedies and superstitions have obtained an unmerited reputation for preventing
the disease.  The only  preventive means that  can  be trusted  to by a surgeon
are, excision and caustic.
  Excision of the part  bitten  should be carefully  and freely  performed —no
half  measures being had  recourse to.  Hence it is better to remove too much
of a comparatively unimportant tissue  or part, than to allow the sufferer to
run any risk of falling a victim to this fatal disease.  In order to excise every
part that has been touched by the tooth,  the surgeon, after washing the wound
and contiguous surface, should  make a circle with ink, or  tincture of iodine
completely round the injured  part   He must then pass a probe to the bottom
of the wound, and excise the whole  by scooping out a conical  piece of  the tis-
sues  taking care to go beyond  the furthest limit to  which the probe is  passed.
If there be any doubt of the whole of the injured parts  having been removed,
potassa fusa should be applied.   If the lip  is bitten through, a portion  should
be cut out, and the wound brought together, as in hare-lip operations- if it be 
DISSECTION WOUNDS.
137
a finger that is injured, amputation of it should be performed.  In those cases
in which the wound is  so  situated that excision cannot readily be performed,
potassa fusa, or strong nitric  acid, or nitrate of silver, as recommended by Mr.
Youatt, should be freely applied to every corner of it.
   If the bite have already cicatrized, the  place  should be excised at any time
after the injury, provided the dog is known to have been, or to have become
mad, for it  is not improbable that the occurrence of some of the remoter cases
of the disease is dependent upon, or connected with, some peculiar action set up
in the wound, which might possibly be  averted by the  removal of the cicatrix.
I forbear to speak of any other means of preventive treatment than excision and
caustic, as I consider them utterly undeserving of confidence.
   After the disease has  once  set in,  nothing  can be  done  but  to palliate
symptoms  and to prolong life.   Every possible  remedy that the  ingenuity of
man could  devise, from warm water to viper and ticuna-poison, has been  tried,
and been found utterly useless.   The  only plan of  treatment that  holds out
a hope of eventual success, and which, whether  it succeed or not in curing the
patient, at  all  events mitigates his sufferings, is that  which has been recom-
mended by Drs. Marshall Hall  and Todd.   It consists, in  the first  place,  in
removing all external irritation, whether mental  or bodily; putting the patient
 in a darkened  room, as much removed as  possible from all noise and the  intru-
 sive curiosity of strangers,  and  surrounding his bed  with gauze curtains  or
 screens, so  as to prevent the disturbing influence even of a draught of cold air.
 Measures  must then be adopted to lessen the excitability of the  spinal cord.
 This may be done most efficiently, as Dr.  Todd suggests, by the application of
 ice  in a piece of gut laid along the whole length of the spine, and,  lastly, the
 surgeon must bear in mind that he has to  treat an exhausting disease, and that
 he  must consequently support the patient by wine, beef-tea, and such nourish-
 ment as can be taken.
   Dissection-wounds.—The  majority of wounds  received in dissection are  not
 dangerous.   Every student in anatomy frequently punctures and cuts himself
 in dissecting in the course of his studies, and it is but rarely that we see any
 ill consequences following these  injuries.   In some cases,  however, the most
 serious results, terminating  in permanently impaired health, or even in death,
 ensue.  The  result depends  partly on  the state of health of the person  punc-
 tured, and  partly on  the condition of the body from which the puncture  is re-
 ceived.   If the health be broken by any cause, whether excess of study or dis-
 sipation, very serious effects  may follow  that would not  occur if the patient had
 more resisting power;  hence it is of much importance  to those engaged in the
 practical study of anatomy not to allow the  health to  become impaired to too
 great an extent.
   The deleterious influence exercised  by the dead body may be attributed  to
 three different causes.   Thus it may be supposed to result from the  mere ordi-
 nary irritation of the wound; or, it may  arise from the inoculation  of putrid
 matter; or, lastly,  be dependent upon the introduction of a specific  virus into
 the system.  I think it is probable that each of these causes may exercise  an
 influence, but that the worst effects of dissection wounds are dependent on the
 inoculation of a peculiar virus.
   That ill  effects sometimes result from the  simple irritation of the puncture is
 evident from the fact, that  we see mere  scratches or  punctures with splinters
 of wood, or other harmless substances, give rise to considerable local disturbance
in certain states of the constitution; so also we find that those dissection-wounds
 that are ragged and torn, such as are made by spiculae  of bone or the tooth  of
a saw, are attended by  peculiarly troublesome consequences.
   Putrescent  matters  must always  be injurious when introduced  into  the
economy, but, at the same time,  it is a remarkable fact, that the worst  dissec-
tion-wounds have been received  before putrefaction had set in, and that they 
138
POISONED  WOUNDS.
more commonly occur in post-mortem inspections than in dissecting-room inves-
tigations.                                                           .fl
  That the worst forms of dissection-wounds are dependent upon a specinc virus
is evident from the fact, that it is especially after death from certain diseases,
especially of an erysipelatous type, that these consequences ensue.  Most danger
is to be apprehended from punctures received  from the bodies of those who die
of erysipelas, phlebitis, and  the diffuse forms of peritonitis following parturition
or the  operation for hernia.   That the  poisonous influence fromsuch bodies is
transmissible to others by  contact or  infection,  cannot  be denied, and  such
accoucheurs and operating surgeons should abstain as carefully as possible from
performing post-mortem  examinations  on patients dying from such diseases,
lest the poisonous influence be carried to and  excite similar morbid action  on
their own patients. The mere contact of such a body is occasionally dangerous.
Thus, I have known a subject in the dissecting-room seriously infect in different
ways six students  who were working at it. Two had suppuration of the^ cellular
tissue, under the  pectorals  and in the axilla;  one was seized with  a kind of a
maniacal  delirium; a fourth  had typhoid fever; and  the remaining two were
seriously, though not dangerously, indisposed.
  From all this it would appear that there are two distinct kinds of mischief
resulting from these injuries.
  The milder form is not of a specific  character, but proceeds from the simple
irritation  of  a scratch  in a broken  constitution,  or from the inoculation  of
putrescent matter.  In these cases the part  punctured  becomes painful, hot,
and throbbing,  in  from twelve to twenty-four hours after the injury, the finger
swells  and inflames, the absorbents of the arm  are perhaps affected, and the
glands in the axilla become enlarged.   There  is general febrile disturbance of
an inflammatory character, ushered in  by rigors, and a feeling of  depression;
suppuration takes place about the puncture, and  also, perhaps, in the inflamed
glands, the case presenting  the ordinary characters of  whitlow with inflamma-
tion of the absorbents.
  In  the mere severe  form of dissection-wound, the  patient is  seized, about
twelve or eighteen hours after the puncture, with rigors, anxiety of countenance,
and  depression of the  nervous system:  with  a quick pulse, and with febrile
reaction of an  inflammatory character;  on examining  the  finger, a pustule, or
vesicle, with an inflamed areola, will be observed in the situation of the puncture;
from this a few red lines may be  observed stretching up towards the arm-pits,
with swelling and tension in this region.   Diffuse inflammation of  the cellular
tissue  of the limb sets in  about  the fifth  or  sixth  day, extending up to the
shoulder, and down the side of the chest to the flank.  Abscesses, usually of a
somewhat diffuse  character, the pus  being mixed with  shreds  and  sloughs,
form,  often  with  much pain, in these  situations.   The  general symptoms
gradually assume an asthenic  type; the  tongue becomes brown, sordes accumu-
late  about the  lips and gums, low delirium sets in with a rapid, feeble pulse,
and  death occurs  in from ten days to three weeks.  When incisions are made
into the brawny tissue, it is  found infiltrated with sero-pus, and in a sloughy
state.   If the patient live, large circumscribed abscesses  form under the pecto-
rals, in the axilla, and above the clavicle, with much exhaustion and depression
of the system,  convalescence being tedious and prolonged, and the  constitution
being often shattered for life.
  It is this form of the disease that resembles diffuse inflammation of the cellu-
lar tissue arising from other causes; and  indeed there can be little doubt that
it is a cellular erysipelas dependent on a toxic agency.  That  this  form of
dissection-wound is of a truly erysipelatous character, is  evident from  the fact,
that patients laboring under it will communicate fatal erysipelas to their nurses
and  attendants; as happened in  the case  of the late Mr. Potter,  whose early
death is so much to be lamented.   It is also this kind of dissection-wound that 
INJURIES OF  TISSUES AND  ORGANS.           139
is especially apt to occur after punctures received from patients who have died
of diffuse inflammation of the serous membranes.
   Treatment. — On the receipt of a  puncture in dissection, the best mode to
prevent injurious consequences,  is, to tie a string tightly round the finger above
the injury, thus causing the blood  to flow, and perhaps to wash out the virus
with  it.   The  part should then be well-washed in a stream of cold water at a
tap, and sucked for some  minutes; in this way any poisonous matter that has
been introduced may usually be got rid of. I think that, in general, it is better
not to apply  caustics  in  these cases; they only irritate and  inflame  the finger,
and can  do but little good.   If any caustic be employed, it should be a drop of
nitric acid let fall into the wound.   The  nitrate of silver, which is  commonly
employed, can  never do much good, as it does not penetrate to a sufficient depth
to be of service.  Dissectors should bear  in mind the great influence that the
state of  the  constitution exercises upon the effects of the puncture, and that in
proportion as the health is sound there is less likelihood of any injurious conse-
quences ensuing.
   In the slighter forms of dissection-wound, attended by a moderate  amount of
 inflammation, the part must be poulticed, leeches should be applied, and the
 arm put in a sling.   If  the  absorbents become inflamed, chamomile  and poppy
 fomentations must be  diligently  used,  the  early opening  of  abscesses  had
 recourse to,  and free incisions should be practised wherever there is  much  ten-
 sion,  even  though  matter have not already formed, with a view to prevent
 suppuration.  The  general  treatment of  clearing  out the bowels with a  free
 calomel purge, followed by  moderate  antiphlogistics in the  early stages must
 be adopted; but support will soon be required; and if there  be much constitu-
 tional irritation, opiates may advantageously be  administered.
   The treatment  of the more severe forms of dissection-injury consists princi-
 pally in fomentations, and in early and  very free  incisions  into  the finger or
 other parts  that  become tense  and brawny.   In the  constitutional treatment
 our great reliance, after clearing out the intestinal canal with a free purge,
 such as  five  grains of calomel and fifteen grains of jalap, consists in the admin-
 istration  of  bark, ammonia, camphor, wine, and  brandy, with such nourish-
 ment as the  patient can take; the case being treated as one of the lowest forms
 of asthenic  inflammation.   If the  patient survive, he must be  sent  as soon as
 possible into the  country, and  must devote  some  months  perhaps  to  the  re-
 establishment of his health.  The  part that has been punctured often continues
 irritable  for a great  length  of time, even  for many years, remaining  red,
 inflamed, and desquamating, with perhaps the occasional  formation of pustules
 upon it.  This condition is best remedied  by the occasional  application of the
 nitrate of silver.
                           CHAPTER,  IX.

               INJURIES  OF  TISSUES AND  ORGANS.

   We next proceed to the consideration of injuries of particular tissues and
organs, and we shall take these in the following order: lstly.- Injuries of nerves
2dly. Of blood-vessels.  3dly. Of  the  organs  of locomotion, including those
of bones, joints, muscles, and tendons; and 4thly. Injuries as they affect par-
ticular regions of the body.                                             ^ 
140          INJURIES  OF  TISSUES  AND ORGANS.
                       INJURIES  OF NERVES.

  Nerves are often contused, the injury producing a tingling sensation at their
extremities, and pain at the part struck, which  usually pass off in  the course
of a few minutes or hours; but in certain  conditions of the  system,  more es-
pecially in the hysterical  temperament, this  may last  for a considerable period,
and even give rise to neuralgia of a more or less permanent character.
  If a  nerve  be punctured, unpleasant  consequences sometimes result, more
particularly in delicate  women.   Thus, I have more than once seen  a  puncture
of one  of the digital branches  of the ulnar nerve  produce a  kind of painful
paralysis of its trunk, rendering the arm nearly useless.  I have seen  the same
effects happen in the median nerve from  so  slight a cause  as^ the puncture of
a finger with the needle.   It occasionally happens in venesection at the bend of
the arm, that a branch of the internal cutaneous is pricked with the  lancet, and
that very persistent neuralgia occurs in consequence.
   When a nerve is completely cut across, immediate paralysis of sense and
motion occurs in all the  parts  supplied  by it.   Consequently, if the  integrity
of the nerve be essential  to life, as of the pneumogastric, death  must ensue.1
There is well-marked loss in temperature and modification of nutrition in some
cases of cut nerve.   This is probably owing to the dilatations of the smaller
arteries, and consequent slowness of circulation, that haS been found in animals
to follow the section of the nerve of a limb.  Thus in a patient who applied at
the  University College Hospital twenty-one weeks after the  ulnar nerve had
been accidentally divided, and who had  paralysis of  the parts supplied  by it,
I found the temperature between the ring and  little fingers of the injured side
to be 9° Fahr. below that of the same spot on the other hand.
   If a cut nerve be examined shortly after the injury, it will be found to have
become slightly bulbous at the extremity, nervous matter having escaped  from
the neurilemma, and fibrine being thrown out and around between the two ends.
Restoration of the continuity of the nerve evidently takes place, as is shown by
the fact, that in the course of a few months its functions gradually become re-
established in its  lower  part, the  paralysis slowly  disappearing.  If, however,
a portion of the  nerve has been  actually excised, there is no restoration of
function, as was shown  long ago by Haighton.   Schwann and Hasse have found
the return of sensibility and motion in the lower part of the nerve to be owing
to nerve-tubes forming in the uniting medium, and thus serving to establish the
continuity of the nerve.

         CUTS AND WOUNDS  OF BLOOD-VESSELS, AND HEMORRHAGE.
   The characters of the  bleeding or hemorrhage differ according to the nature
of the vessel from which the  blood  escapes.   When a vein  is  wounded, the
blood that is poured out is of a dark color, and flows  in a uniform stream; the
 force with which this is  projected  depending  on  the conditions in which the
 wounded vein is placed.   If  there be any pressure between the wound and the
 heart, as of a ligature  upon the vessel; or if the position  of a part be such as
 to favor the gravitation of the  blood  towards the wound;  or  if the muscles of
 the limb be made  to contract, the force of the  flow of blood will be increased.
   1 [That division  of the pneumogastric nerve does not necessarily result  fatally, is
 proved by a case reported by Dr. J. H. B.M'Clellan, of this city.  In an operation for the
 removal of the parotid gland, Dr. M'Clellan found the nerve in question involved in the
 diseased mass, as well also as  the spinal  accessory and portio dura.  The tumor was
 excised, and with it a portion of the pneumogastric, two inches in length.  Strange to say,
 Bcarcely any impediment  to respiration was experienced,  and the patient recovered.
   To the best of  our knowledge no other such instance is on record, but the case adduced
 proves beyond all doubt,  that in the living subject, the important functions of this pair
 of nerves may be executed fully by one alone.  Vide M'Clellan's Surgery, p. 336.] 
        EFFECTS  AND  TREATMENT  OF  LOSS OF BLOOD.    141

  When an artery is wounded, the blood that escapes is of a bright vermilion
or scarlet color.  It flows  by jets, synchronous with  the  contractions of the
left ventricle; and  between  each jet the flow does not cease, but  the stream
becomes continuous.  In the great majority of cases  the jet only comes  from
the proximal  aperture,  dark blood issuing from the distal  opening in a con-
tinuous and trickling stream; but in some situations a jet  of blood, of an arte-
rial character, may  issue from the distal as well as the proximal end of the cut
vessel, as in wounds of  the palmar and plantar arches, or of the arteries of the
forearm.  As the blood flows the jet lessens in height, in consequence of the
weakening of the heart's action.   The height  and  force of the jet in all  cases
depend greatly on the size  of the vessel;  thus the jet from  the  femoral artery
is stronger  than that from a muscular branch of  the  thigh.   When  a small
arterial branch is wounded near to its origin from the main trunk,  the jet will
always be forcible and free;  so also  the proximity to the centre of  the circula-
tion will influence materially the force with which  the blood is propelled  from
the wound in the vessel.
   When the blood is not poured out on the surface, but escapes from a wounded
vessel into the cellular tissue of a part, the  substance of organs, or internal
cavities, it is termed an extravasation.   In these cases there are not the ordi-
nary  local  signs of hemorrhage, but we judge of  the escape  of blood by the
general effect produced upon the system by its loss.
   The constitutional effects of hemorrhage depend  upon the quantity of blood
lost, on the rapidity with which it is poured out, and on the state of the patient's
constitution.
   When a large quantity of blood is suddenly lost, as when a main  artery is
cut across  or an aneurism bursts,  the patient may  die  forthwith; falling  down
in a state of syncope, with a pale cold  surface, lividity about the lips and eyes,
and a few gasps, sighs, great restlessness, and convulsive movements of the limbs
before he expires.   If  the  quantity lost  be not  so great  as to produce death,
but is yet very considerable, the patient becomes faint and  sick, with coldness
and pallor of the surface, great restlessness and agitation, thirst, noises in the
ears,  and failure or complete loss of sight.  If the quantity lost, though con-
siderable, be  not so great as this, or be spread over a greater interval of  time,
so that the patient is enabled to  rally between the recurrences of the hemor-
rhage, a state of anemia will be  induced, characterized by pallor of the skin
and of the mucous membranes, palpitation of  the heart, rushing noises in the
head, amaurosis, a  tendency to syncope when in the erect position, oedema of
the extremities, and general debility of the system.
   After excessive  loss of  blood, the patient  may gradually rally,  and, as the
vital  fluid is reproduced in  his system, he may recover without any  bad effects;
or he may fall into a  state of anemia, which may  perhaps never be completely
recovered  from, and be  associated with various  forms  of local debility and
disturbance of  functions.   After very abundant loss  of blood, "hemorrhagic
fever" is apt to set in,  characterized by a tendency to reaction in the system,
with  extreme irritability of the heart and arteries.   It is irritative fever con-
joined with anemia.   There is but a small quantity of blood in the  system, and
the heart and arteries make violent efforts to drive  it forwards.  This  condition
is marked  by the  symptoms of extreme  loss of  blood, alternating with periods
of intermittent reaction, the pulse becoming much hurried, fluttering, jerking,
and irregular in force and  frequency;  slight flushing of the face and brilliancy
of the eyes, rapidly passing again into pallor  and  syncope; and if the hemor-
rhage eventually prove fatal, delirium and convulsions, with excessive  restless-
ness,  usually precede  death.   The  body of a person  who  has died  from the
effects of hemorrhage presents  a peculiarly blanched, semi-transparent, waxen
look;  the  lips,  alas of the  nose, and  finger-nails, having  a  somewhat  livid 
142
WOUNDS  OF  VEINS.
appearance,  contrasting strongly with the clear,  yellowish-white hue of  the
general surface.                                                „    ,   fl
  The general treatment of hemorrhage is sufficiently simple.  After the flow
of blood has been  arrested by  proper  local  means, such as  will hereafter  be
described, the effects of its loss are usually speedily recovered from by rest and
good nourishment.  In some cases, however, the nutrition of the system becomes
permanently impaired, and a state  of chronic  anemia is induced, which, not-
withstanding the administration of chalybeate preparations, may continue through
life, and terminate in cachexia, phthisis, or diarrhoea.
  When the loss of blood is considerable, and is  attended  by symptoms  of
much prostration, it may be necessary to have recourse to immediate  measures,
in order to prevent the syncope being fatal.  With this view the patient should
be laid recumbent,  with the head low, and pressure  may be exercised upon the
abdominal aorta or  the main arteries of the limbs, so as to confine the blood as
much as possible to the nervous and circulatory centres.  If death appear immi-
nent from the effects  of the hemorrhage, as happens in some  cases of flooding,
transfusion  of  blood  maybe had recourse to;  the  influence  of_which, in re-
storing the  failing  powers of the heart and nervous system, is immediate and
most striking, and  has been unquestionably determined by the observations  of
Dr. Blundell and other obstetricians.
   The operation of transfusion  is one of some delicacy,  and requires care, lest
mischief be occasioned  by the  injection of air together with the  transfused
blood — an  accident  that  would probably prove  fatal to the patient.  If the
proper transfusing apparatus, such as Higginson's or Blundell's, by which the
blood may be injected without the risk of admixture of air, and of a proper
temperature, be not at hand, an ordinary hydrocele syringe capable of holding
about  six ounces,  and  fitted  with stop-cock  and canula, may be used.   An
opening of  sufficient  size  having been made in one of the larger veins at  the
bend of the arm or about  the instep, and the canula having been introduced
for about an inch,  the syringe, previously warmed, should be filled,  and  about
twelve ounces  of freshly-drawn  human blood slowly but steadily injected, the
limb  being placed in such a position as to favor its  transmission to  the  heart.
In performing this operation, the  principal  points  to be attended to are, the
proper introduction of the canula into  the vein with as  little injury  as possible
to its  coats, the perfect  freedom of the whole  apparatus from bubbles of air,
and the steady but rapid performance  of the  operation, so as to avoid coagu-
lation and  deterioration of the  blood.   If  transfusion  be determined  on,  it
should not be delayed until  the last moment, when the agony  of  death  has
already commenced, as then the actions  of the nervous and circulatory systems
may be so impaired that  the  patient is no longer recoverable, or if temporarily
so, will speedily relapse into a state of fatal disease.
   CHAPTER  X.

WOUNDS  OF  VEINS.
  Veins  are  very  commonly wounded  suicidally, accidentally, or in surgical
operations, but unless they are deeply seated, their injuries are seldom attended
by any serious consequences.  There are, however,  three sources  of danger
in wounds of veins:  1st, from  loss  of blood;  2d,  from the occurrence  of 
ENTRY OF  AIR  INTO  VEINS.
143
diffuse inflammation of the vessel; and, 3d, from the entrance of air into the
circulation.
  A vein is known to be wounded when dark blood  flows in a rapid and uni-
form stream from the seat of injury.  If the vessel wounded be one of consi-
derable magnitude, or be in close proximity to the centre of the circulation, the
flow of blood may be rapidly fatal, more especially if its escape is favored by
the dependent position of the part.
  The  hemorrhage from  a wounded vein may,  if the vessel is superficial, be
arrested by position, and the pressure of a compress, by means of a few turns of
a roller.   If the vein be one of considerable magnitude, as the internal jugular,
for instance, or if it be so  situated that pressure cannot  be brought  to bear
upon it, it may require the application of a ligature: this, however, should, if
possible, always be avoided, inasmuch as it is apt to occasion dangerous inflam-
mation of the vessel.
   The wound in a vein is healed by slight inflammation taking place about the
lips of  the incision, and giving rise to the formation of a distinct cicatrix.   In
some cases, from  the irritation of the  simple wound, and in others from the
application of  the ligature, a diffuse form of inflammation  of the  vein takes
place,  which usually proves fatal.  This variety of phlebitis will be described
when we  come to speak of the different kinds of venous inflammation.
   The  entrance of air into a wounded  vein, though an accident of  rare occur-
rence,  is one  that occasions  such peculiar  and alarming  symptoms, that  it
becomes necessary to be acquainted with the circumstances attending  it; and
its study  is the more interesting to the  practical surgeon, as it is chiefly in the
course of operations that this condition occurs.
   It has  long been  known to physiologists  that the forcible  introduction of
air into the circulation  would kill an animal; and Morgagni, Valsalva, Bichat,
and Nysten, have  made this a subject of observation and  experiment.  The
death  of  the  animal in these cases appears to  be dependent  partly upon the
quantity of air injected, and partly on the rapidity with which it  is thrown in.
Bichat supposed that a single bubble injected  into  the circulation killed the
animal with the rapidity of lightning;  but this  is erroneous, as shown  by Nys-
ten.  I have on several occasions injected two or three cubic inches of air into
the jugular vein of a dog without  producing  death, though much distress  re-
sulted.   The rapidity with which the air is thrown in exercises a considerable
influence  upon the result.   If blown in quickly, a small quantity  may kill; if
thrown in slowly  and  gradually, a large quantity may  be injected without
destroying life, the blood appearing to dissolve and carry away the gaseous fluid.
   In surgical practice, we do not meet with the  forcible introduction of air, but
have only to do with its spontaneous admission  into the circulation.  This was
first observed in the year 1818, in a case in which  the internal  jugular vein
was opened during the removal of a large tumor from the right shoulder by M.
Beauchesne.   The investigation of this subject is consequently  a comparatively
recent  matter, in  which the labors of the Commissioners  of the  French Aca-
demy are conspicuous,  and the names of Magendie,  Amussat, Cormack,  and
Wattman, are distinguished.  As cases  of the entry of air  into the veins com-
paratively seldom occur in man, it is necessary to study the phenomena accom-
panying it, on  the lower animals.   In  experiments which I have made on this
subject, I have observed the following phenomena:—On exposing the internal
jugular vein low in the neck, and puncturing it at a place where  the  flux and
reflux of  the blood are  plainly discernible, there is perceived in the first inspi-
ratory effort made  by the  animal  after the wound, a peculiar  lapping, or gur-
gling liquid, hissing  sound; the nature of the sound depending partly on the
size and the  situation of the opening in the vessel.   At  the same  time a few
bubbles of air are seen to be mixed with blood at the orifice in the vein.  The
entrance of the air is immediately followed by a struggle  during the deeper 
144
WOUNDS  OF  VEINS.
inspirations, in which fresh quantities of air gain  admittance, the entrance of
each  portion  being attended by the  peculiar sound, above  described   On
listening now to the action of the heart, a loud churning  noise will  be heard,
synchronous with the ventricular systole, and the  hand will, if applied to the
parietes of the chest, perceive at the same  time a peculiar bubbling, thrilling,
or rasping sensation, occasioned by the air and blood being, as it were, whipped
together between the columnse carneae and cord.ne tendineae.   As the introduc-
tion of air continues, the circulation becomes gradually more feeble and languid;
the heart's action, however, being fully as forcible, if not more so, than natural.
The animal soon becomes unable to stand: if placed upon its feet, rolls  over on
one side, utters a few plaintive cries, is convulsed, extrudes the faeces and urine,
and dies.  If the thorax be immediately opened, it will be seen that the heart's
action is continuing regularly and forcibly, and that the pulmonic cavities,
though filled, do not appear distended beyond their ordinary size.
   Death occurs, as I have shown,  in a  paper on this subject, published in the
158th number of the "Edinburgh Medical and  Surgical Journal," in conse-
quence of  the air and  blood being  beaten up together in  the right cavities of
the heart into a spumous froth, which cannot be propelled through the pulmo-
nary vessels; hence there is a deficient supply of blood to the brain and nervous
centres, and fatal syncope comes on, attended usually by convulsions.
   The spontaneous entry of air into the veins of man is attended by two distinct
sets of phenomena, one of a local, the other of a constitutional character.
   The local  phenomena consist in a  peculiar sound, produced  by the entrance
of the air,  and in the appearance of bubbles about  the wound in the vein.   The
sound is of  a hissing, sucking,  gurgling, or lapping character, and never fails
to indicate the dangerous accident that  has occurred.  When once heard, whe-
ther in man  or the lower animals, it can never be mistaken.  It has fortunately
only fallen to my lot to hear  this sound in the human subject on one occasion;
that of a patient who had attempted  suicide by cutting his throat.  The inter-
nal jugular being wounded, was  being raised for the purpose of having a liga-
ture  passed  under it; at this moment  a loud hissing and gurgling sound was
heard, some  bubbles of air appeared about the wound, the patient became faint,
and greatly  oppressed in his breathing.   The ligature was immediately tight-
ened, the faintness gradually passed off, and no bad consequences ensued.
   The effects produced upon the constitution are usually very marked.  At the
moment of the entry  of  the air, the patient is seized with extreme faintness,
 and a sudden oppression about the chest;  he usually screams out, or exclaims
 that he is dead or dying, and continues moaning or whining; the pulse becomes
 nearly imperceptible, and the heart's action laboring, rapid, and feeble;  death
 commonly results,  but not instantaneously, in many cases at least.  Thus Beau-
 chesne's patient lived a quarter of an hour after the occurrence of the accident;
 Mirault's between  three and four hours; and Clemot's several hours.  Amongst
 the other recorded fatal cases I have not been able  to find any but vague state-
 ments as to  the length of time the patients survived.
    If the patient survive the immediate effects of the accident, he may probably
 recover without any bad  symptoms, as happened  in the  case to  which I have
 referred, as  occurring  at  the University College  Hospital, and in an  instance
 recorded by B. Cooper.   The presence of the air in the pulmonic capillaries
 would appear in some cases to act as an irritant, and induce fatal pneumonia or
 bronchitis, as happened to the patients of Roux and Malgais;ne.
    The cause of the spontaneous entry of air into  the veins has been very com-
 pletely investigated and determined  by the French Commission.  If we open a
 large vein at the  root of a dog's neck, near  the thorax, in which the venous
 pulse, or flux and  reflux of the  blood is perceptible, we shall see that air rushes
 in at each inspiration—but only at this time—never gaining entry during expi-
 ration.  This is owing to the tendency to the formation of a vacuum within the 
            CAUSES OF  ENTRY OF  AIR  INTO  VEINS.         145

thorax, more particularly in the pericardium, during inspiration.   This suction
action, or "venous inspiration," is confined to the large vessels in and  near the
thoracic cavity, being limited,  by the collapse of the coats of the veins, at a little
distance  from this.   If the veins were rigid  tubes, it would  extend throughout
the body, but as they are not, it ceases where their coats collapse.  It is indeed
limited to that part of the root of the  neck  and the axilla, where the venous
flux and reflux are perceptible, and the space in which it occurs has been termed
the "dangerous region."   But under  certain circumstances air may spontane-
ously gain admission beyond this.
   It is well known that what is called by the French writers the " canalisation "
of a vein, or its conversion into a rigid uncollapsing tube, is the  condition of
all others which is most favorable to the introduction of the air into it.  Indeed,
except in those situations in which there is a natural  movement of  flux and
reflux of the blood in the veins, this accident cannot occur  unless these vessels
be canalised,  or, in  other words, prevented from collapsing.  This canalisation
of the vessel may be occasioned in a variety of ways.  Either the cut vein may
be surrounded by indurated  cellular tissue,  which will not allow it to retract
upon itself, but keeps it open, like the hepatic veins; or the coats of the vessel
may have acquired, as a consequence  of  inflammation  or hypertrophy, such  a
 degree of thickness  as to prevent their falling together when  divided.   Then
 again, the  principal veins at the root of the neck have, as  Berard has pointed
 out,  such  intimate connections with the neighboring  aponeurotic  structures,
 that they are constantly kept in a state of tension, so that  their sides are held
 apart when they are  cut  across.   The contractions of the platysma and  other
 muscles  of the neck may likewise, as  Sir  C. Bell  has  shown, have  a similar
 effect.   In removing a tumor also, that  is situated about the neck, the traction
 exercised upon its pedicle may, if this  contain a vein, cause it  to become tem-
 porarily canalised; and the incomplete section of the vessel, especially in a trans-
 verse direction, must prevent the approximation of the  sides of the incision in
 it, which will be rendered open and gaping by the retraction of the surrounding
 tissues.   This patency in the incision in the vein, is apt to  be increased by the
 position that is necessarily given to the head and arm in all operations of any
 magnitude about the  shoulders and neck.   Lastly, the  introduction of air into
 a vein will be favored by the vessel being divided in the angle of a wound, the
 vein being, when the flaps that form that angle are lifted  up,  rendered  open-
 mouthed and gaping.
   On looking over the reports of cases  in which air gaiued  admittance into the
 veins during operations, it will be found that these vessels were always in one
 or other of the above-mentioned  conditions.  Thus, in  Beauchesne's case, air
 was  introduced in consequence of incomplete division of the external jusrular,
 immediately above the right  subclavian, whilst in a state of tension, during the
 removal of a portion of the  clavicle.   In a case that occurred to  Dupuytren, a
 large vein connected with the tumor, and communicating with the jugular, was
 cut at the last stroke of  the  scalpel, whilst the tumor was being forcibly drawn
 up.   The vein was found to  be adherent to the sides of  a sulcus, so that it re-
 mained gaping when cut.  In a case by Delpech, there was hypertrophy of the
 axillary vein, causing it to gape like  an  artery.  In Castara's case there was
 incomplete section of a vein, which opened into  the  subscapular, whilst the
 tumor was being raised up.   In Roux's  case, a vein in  the neck was opened,
 whilst a tumor, which was being removed from that region, was being forcibly
 raised, in order to dissect under it.  Ulrick  saw the accident occur  in  conse-
 quence  of the incomplete division  of the internal jugular vein, which was im-
 plicated in a tumor in the neck.  A similar case happened to Mirault of Ano-ers
 the  internal jugular being  divided to half its extent.  A case occurred to
 Warren, in which the air entered by the  subscapular vein, the coats  of which
 were  healthy, but in a state  of tension, in consequence of the  position of the 
146
WOUNDS OF  VEINS.
arm;  and another, in which the same accident happened from the division of a
small transverse branch of communication between  the  external and internal
jugular, whilst in  a state of tension.   Mott, whilst removing a tumor of the
parotid gland, opened the facial vein, which was in a state of tension in conse-
quence of the position of the patient's head, when air was introduced.  A case
is related by Malgaigne in which the accident  happened  in consequence of the
incomplete section of the external jugular vein, which was enveloped in a tumor
that was  being removed.   M. Begin  also relates a case in which the accident
happened, in consequence of the  puncture of the internal jugular whilst  he
Was removing a tumor from the neck.
  These  cases, which are all that I have been able to meet with, in which  the
condition of the Wounded vein was particularized, show clearly what is the state
of the vessel and of the  surrounding parts  that is most likely to favor  the
occurrence of the accident, and consequently what  the  surgeon should pecu-
liarly guard against in the  removal  of tumors  about the neck and shoulders;
viz., incomplete division of the veins, and the employment of forcible traction
on the diseased mass at the moment  of using the scalpel.   In removing tumors
from  the  neck and  shoulder, it is in many cases impossible  to  avoid drawing
them forcibly upwards or forwards, in order to get at their deeper attachments;
but if this be necessary the chest should, for reasons that will immediately be
pointed out, be tightly compressed, so that no  deep inspirations may be made
at the moment that the knife is  being used,  or before a divided or wounded
vein can be effectually secured.
  Preventive Treatment.—When  a patient is under the  knife, the respirations
are  generally shallow and  restrained, the breath being held, whilst every now
and then  there is a deep gasping inspiration,  at which  moment, if a vein  be
opened in which  the pulse is perceptible, or that is canalised, air must neces-
sarily be  sucked in; and, as has already been said, in quantity and force pro-
portioned  to the depth of the inspiration.   This, then, being the  case, the mode
of guarding against the introduction of air into the veins  is obvious. The chest
and abdomen should be so tightly bandaged with broad flannel rollers or laced
napkins, as to prevent the deep gasping inspirations, and to keep the breathing
as shallow as possible, consistently with the  comfort of the  patient.  I have
often found, that the entrance of air into  the veins of a dog could be arrested
by forcibly compressing the chest of the animal, so as to confine the respiratory
movements, but that as soon as  a deep inspiratory effort was made, the compres-
sion having been removed, a rush of  air took place into  the vessel.  If, there-
fore, during an operation about the root of the neck or summit of the thorax,
the chest be bandaged, as here  recommended, the surgeon must be careful  not
to remove  the compression until the  operation is  completed, and  the  wound
dressed;  for if this precaution be not attended  to, the  patient will, most pro-
bably, on the bandage being loosened, make a deep inspiration, and air may be
sucked in at the very moment that all appeared safe.
  Curative  Treatment.—Different plans have been  recommended by surgeons
for  the treatment of those cases  in  which air  has already gained  admittance
into a vein; but, from the very fatal  nature of this accident,  it does not appear
that much benefit has resulted from any of them : the recovery of the patient,
in some of the cases, appearing to be rather due to the quantity of air that was
introduced being insufficient to cause death, than to any effort  on the part of
the surgeon.  The two principal modes of treatment that have been  recom-
mended, consist in the suction of the  air from  the right auricle, and the em-
ployment of compression of the chest.  Thus, Amussat and Blandin  advise us
to introduce the pipe of a syringe, a female catheter, or a flexible tube, into the
wounded vein, if it  be large enough to admit the  instrument, and if not, to
open the right jugular, and pass it down into  the auricle, and thun to employ
suction, so as to empty the heart of the mixture of blood and air.  At the same 
TREATMENT OF  AIR IN  VEINS.
147
time that this is being done we are, say they, to compress the chest as forcibly
as possible, so as to squeeze more of the air out of the heart.  Magendie  and
Rochoux advise suction  alone;  and Gerdy recommends us to be content with
compression  of the chest.  Warren (of Boston)  directs us according to the
condition of  the patient, to have recourse to bleeding in the temporal artery,
to tracheotomy, or stimulants.
   The indications that present themselves in the treatment appear to me to be
threefold:
   1st. To keep a due supply of blood to the brain.
   2d. To maintain the powers  of the  heart until the obstruction in  the  pul-
monic capillaries can be overcome or removed.
   3d. To remove, if possible, the obstruction in the capillaries of the lungs.
   We shall  now see how far the means already mentioned, viz., suction, com-
pression, &c, can fulfil these indications.   And, first, with regard to suction, it
would no doubt be highly advantageous if we could, by this or any other means,
remove the  air that has gained access to the heart, and thus prevent the pul-
monic capillaries from being still farther obstructed.   But, putting out of con-
sideration the difficulty of finding the wounded vein, the still greater difficulty
of introducing  a suitable tube  a sufficient distance into it — the danger  of
allowing the ingress of a fresh quantity of air  whilst opening the sides  of the
incision in the vein, so as to introduce  the tube, and  the  risk there would be,
if the patient  recovered  from the effects of the accident, of having  phlebitis
induced;—putting all these circumstances aside, which appear to  me to be most
serious objections, it becomes a  question,  according to Amussat,  who is one of
the  strongest advocates  of this mode  of practice, whether by suction with  a
syringe, or even by the mouth, any material  quantity of air can be removed.
He  says that even when  the tube is  introduced into the right auricle, much
more blood than air is constantly withdrawn. These considerations, then, should,
I think, make  the surgeon hesitate before having recourse to such a hazardous
mode of procedure.
   The next  plan, that of circular compression of the chest, however valuable
it may be in  preventing the ingress of air, can, when that fluid has  once been
introduced into  the veins, have no effect  in removing it from the circulatory
system.  We cannot by any compression that we  may employ, squeeze the air
out of the heart.  But compression may not only be productive  of no positive
good, but may even occasion much mischief,  by embarrassing still farther the
already weakened respiratory movements, and thus interfering  with  the due
aeration of the small quantity of blood that may yet be traversing the  lungs.
   Bleeding from the temporal artery can by no possibility be productive of any
but an injurious  effect, by diminishing the already too small quantity of blood
in the arterial  system.   Opening the  right jugular  vein may,  perhaps,  to  a
certain extent, be serviceable, by unloading the right cavities of the  heart,  as
Dr. Reid has shown it to be capable of doing,  and it has been recommended by
Dr. Cormack on this account.  Lastly, tracheotomy cannot be of  any particular
service, as the arrest of the respiratory function is secondary and  not primary.
   What, then, are the measures that a surgeon should adopt in order to prevent
the occurrence of a fatal termination in those cases in which air has accidentally
been introduced into the veins during an operation ?  Beyond a doubt, the first
thing to be  done is to prevent the  further ingress of air, by compressing the
wounded vein with the finger, and, if practicable, securing it by a ligature. At
all events,  compression with the finger  should  never be omitted,  as it has been
shown by Nysten, Amussat, Magendie,  and others, that it is only when the air
that is introduced exceeds a certain quantity,  that death ensues. All further
entry of air  having thus been prevented, our next object should  be to keep up
a due supply of blood to the brain and  nervous centres, and thus maintain the
integrity of  their actions.   The most efficient means of  accomplishing  this
• 
148
INJURIES  OF  ARTERIES.
would probably be the plan recommended by Mercier, who believing that death
ensues in these cases, as in prolonged syncope, from a deficient supply of blood
to the brain, recommends  us to employ compression of the aorta and  axillary
arteries, so as to divert the whole of the blood that may be  circulating in the
arterial system to the encephalon.  This appears to me to be a very valuable
piece of advice, and to be the most effectual way of carrying  out the first indi-
cation, that of keeping up  a due supply of blood to  the brain and  nervous
centres.  The patient  should, at the same time that the  compression is being
exercised on his axillary arteries and aorta, or, if it be preferred, as more conve-
nient and easier than the last, on his femorals, be placed in a recumbent position
as in ordinary fainting, so as to facilitate the afflux of blood to the head.  The
compression  of the  axillary  and femoral arteries  may readily be made by the
fingers of two of those assistants that are present  at every operation.
   For the  fulfilment of the  second indication, that of maintaining the  action
of the heart until  the obstruction in the capillaries of the lungs  can be over-
come or removed, artificial respiration should be resorted to, as  the most effectual
means of keeping up the action of that organ.
   For the purpose  of keeping up artificial respiration, the Humane  Society's
bellows, if they be  at hand, might be used, or, if they cannot readily be pro-
cured,  the  surgeon must  inflate with his mouth.   Before inflating the lungs it
will  be necessary to remove everything that  can compress the  chest, or interfere
in any way with the free exercise of the respiratory movements.  Friction with
the  hand  over the  prascordial region, and the  stimulus of ammonia to the
nostrils, may at the same time be resorted to.
   The third indication — that  of overcoming the  obstruction in the pulmonic
capillaries — would probably be the best fulfilled by the means  adopted for the
accomplishment of  the second, viz., artificial inflation of the  lungs.  That the
action  of respiration,  if kept up  sufficiently long, will enable  the capillaries
of the lungs to get rid of the  air contained in them, appears to be the case;
for I have several times observed that, if a certain quantity of air  be spon-
taneously introduced into  the jugular vein of a dog, and artificial respiration be
then established, and be maintained for half or three-quarters of an hour, but
a very small quantity indeed, if any, will be found, on killing  the animal, in
the  cavities  of the  heart or in the branches of the pulmonary  vessels.   I am
aware  that this is  not altogether conclusive of the fact, as  the air might be
dissolved  in the blood, or  might still exist in  the capillaries of the lungs,
although none might be found  in the larger branches of the pulmonary artery;
but still it  seems to me that  we can hardly account for the  large quantity of
air that will  disappear when  artificial respiration  is  kept up,  in  any other way
than that some, if not all of  it, passes  out of the  capillary vessels into the air-
cella of the lungs.
                           CHAPTER, XI.

                      INJURIES  OF ARTERIES.

  An  artery may be  bruised, torn, punctured, or cut.   A slight bruise of an
artery is not attended by any bad consequences, but if the contusion be severe, .
obliteration of the vessel may ensue from adhesive inflammation some days after
the accident.  Thus,  a patient was admitted into University College Hospital, 
             RUPTURE  AND  WOUNDS  OF  ARTERIES.          149

under Mr. Quain, with a contused wound in the axilla, received by falling upon
some iron railings;  no change took place in the circulation of the arm for two
days, when  pulsation in  the radial  artery ceased,  the  injured vessel having
evidently become obliterated by adhesive inflammation.
   An artery may be torn either partially or completely across.  When partial
rupture occurs, the  internal and middle coats only give way, the toughness of
the external coat preventing its laceration.  This  accident is especially apt  to
occur as a consequence of  blows or strains upon diseased or weakened vessels,
and thus may possibly lay the foundation for aneurism.  In other cases the
ruptured portion of the coats becomes turned down into the inside of the vessel,
and, acting  as a valve, prevents the further progress of the  blood through  it,
thus giving rise to gangrene of the limb.   In some cases the partially ruptured
vessel becomes blocked up by plastic  matter, occluding its interior, but without
gangrene resulting.
   The  complete rupture of an artery may occur either in  an open wound or
under the integuments.  When an artery is  torn across in  an open wound, as
by the  avulsion of a limb  by  machinery, or by a cannon-shot carrying it off,
there is usually but little hemorrhage, even from the arteries of the magnitude
of the  axillary or  femoral, and though  the vessel hang out of the wound,
pulsating to its very end.   This absence of bleeding is owing to  the  internal
and middle coats, which are fragile, breaking off short  and contracting  some-
what;  whilst the external  coat and the sheath of the vessel, being elastic, are
dragged down and  twisted over the torn end of the  artery, so as completely to
prevent the escape of blood.
   When the  laceration of the artery is subcutaneous, as occasionally happens
in the attempted reduction of  an old dislocation of  the  shoulder, either exten-
sive extravasation,  or one or other of the varieties of traumatic aneurism, may
be produced.
   Wounds  of arteries may be  divided into those that do hot penetrate  into the
interior of  the vessel, and those by which it is laid completely open.
   Non-penetrating  wounds of arteries are very  rare.  Mr. Guthrie, however,
relates  the  case of  a gentleman who cut  his throat, and in whom  the carotid
artery was exposed and notched through the external and  middle  coats only;
the vessel finally gave way on  the eighth day, fatal hemorrhage  ensuing.  A
case also lately occurred at the London Hospital, in which a suicidal wound  of
the throat  had exposed the carotid artery.   After  death it was found  that the
inner and middle coats of  the  vessel  had  been  divided  by the pressure of the
 knife, which was blunt, but the  external  coat had  been left entire, and under
 this a dissecting aneurism  was  found.
   In penetrating wounds of an artery, we have always hemorrhage of an arterial
 character, unless the puncture be made with so fine an instrument as  to  be
 closed  by the mere elasticity  of the  coats of the vessel.   Thus, Maisonneuve  x
 has shown   that an artery may be punctured with  a fine needle without any
 hemorrhage or other unfavorable result occurring.   If, however, the puncture
 be larger than this, being  made by a tenaculum or hook, it does not commonly
 close in this way;   and if hemorrhage do not  take place immediately, it will
 probably come on  in the  course of a few hours or days, from ulceration of the
 vessel.   If the wound be  larger than this, there is always an  amount of hemor-
rhage proportionate to its  size, and to that of the vessel.
   The elirection of the wound  in the artery influences materially its characters.
 If the  cut  be parallel to the axis of the vessel, there is less tendency to gaping
of the  edges  than if it  be oblique.   In transverse wounds of arteries, the
retraction of the coats is so great as to cause the wound  to assume somewhat of
a circular appearance.   If the artery be cut completely across, there is always
a less degree of hemorrhage than  when it is partially divided, for the retraction
and contraction of the cut ends may then be sufficient to close the vessel, which 
150
INJURIES  OF  ARTERIES.
is not the case when it is merely wounded.  When the wound in the artery is
subcutaneous, communicating only by an  oblique and narrow  aperture with the
surface, but  little, if any, external hemorrhage takes place, but  extravasation
of blood  occurs.   The extravasation may  either  be poured into one  of the
serous cavities, or it may be diffused  in  the cellular tissue of the limb or part,
infiltrating it deeply and extensively; and perhaps  by its pressure giving rise
ultimately to gangrene; or it may be effused in a more  circumscribed manner,
giving rise to one or other of the forms  of traumatic aneurism.
                     ARREST  OF  HEMORRHAGE.1

   The  arrest of arterial hemorrhage is perhaps the most important topic that
can  engage  the surgeon's attention, as on the safe accomplishment of this the
success of every operation is necessarily dependent.   In studying this subject,
we must first investigate the  means that are adopted by nature for the supres-
sion of the hemorrhage;  and,  secondly, how these may be imitated by art.
   The  natural  arrest of arterial  hemorrhage is effected by means that are in
the  first  instance of a temporary, but afterwards  of a  permanent character.
The means which secure temporarily  the  flow  of blood from  an  artery, and
which,  if the vessel  be of a small size, as the facial or  radial,  are sufficient in
many cases  to stay the hemorrhage without  the interference of the  surgeon;
and  by which, whatever be its size, his operations are materially assisted, and
nature  makes an  effort, though it may be an  unsuccessful one, to prevent a
fatal escape of blood, are  threefold.  They  consist —
   1st.  In an alteration in the constitution of  the blood.
   2d.  In a diminution of the force of  the  heart's action, and consequently of
the pressure on the inner  coat of the vessel.
   And 3d.  In certain changes effected  in and around the artery.
   1st.  The alteration that takes place in the blood consists in an increase of its
plasticity as  it flows.   The blood  that  escapes from a wounded  artery has from
the first a tendency to glaze and coagulate about the cut  vessel,  so as to offer a
mechanical obstacle to the further escape of  blood  from it.  This  of itself is
sufficient in the  smaller vessels to arrest the hemorrhage, the more so, as has

  1 The  history of the investigations into the means adopted by nature for the arrest of
hemorrhage, is full of interest to the surgeon, and is excellently  given in Jones's work on
hemorrhage.   No subject in surgery affords a stronger  evidence  of  the advantage of the
application of "Experimental Pathology" to practice,  than this, as  our knowledge of it
has been wholly gained by experiments on the lower animals.
  Petit,  who published several memoirs on this subject  in 1731 and following years, states
that hemorrhage is arrested by the formation of two clots—one  outside  the vessel,' which
he calls  the "Couvercle;" the other inside,  the " Bouchon"— the first being formed by
the last  drops of blood that issue, the second by the few drops that are  retained.  These
clots by  their adhesion stop the bleeding.  AVhen a ligature is applied, a similar clot forms
above and below it.  He recommends compression, and the support  of the clot.
_  Morand, in  1736, added much of  interest.  He admitted the formation of coa<rula, but
insisted  on the change  in the artery itself; which he showed  became corrugated,  con-
tracted,  and  retracted.   Morand entertained erroneous views  as  to the structure and
functions of arteries, but he  established the great  fact that changes occur in the artery

  Kirkland, in 1763, wrote an excellent treatise on the subject, and his views were adopted
and supported by White, Gooch, Aiken, and  other surgeons of his day.   He showed  that
hemorrhage was lessened by swooning; and, that an artery contracted up its nearest col-
lateral branch, and was of opinion that coagulum did not arrest  the bleeding.
  J. Bell took  a retrograde step on this subject, by denying the retraction and contraction
ot the artery,  and the importance of the internal coagulum, and  by  attributing the arrest
ol hemorrhage solely to the injection of the surrounding cellular tissues with blood
  It was not until 1805 that Mr. Jones, by a series of admirably conducted investigation*
nnally determined  the mode  in which the arrest of hemorrhage takes place.  Since his
time but little has been added to the subject, so complete has been his examination of it 
            TEMPORARY  ARREST  OF HEMORRHAGE.         151

been pointed out by Hewson,  in  consequence of the last flowing blood being
more coagulable than the first.
   2d. The diminution in the force in the heart's action exercises a very mate-
rial influence in arresting  the flow  of blood from an artery.   The  forcible
manner in which the jet of  blood is propelled at each systole of the ventricle,
is the principal obstacle to the coagulation of the blood around and within the
cut vessel;  for not only does the movement  of the blood prevent  coagulation,
but so long  as the jet is more powerful than the cohesion of the clot, it will
certainly wash the coagulum away.   As the blood flows and the heart's impulse
becomes gradually  lessened in force, the jet becomes  lower and lower,  until
at last, when faintness comes on, it is almost  entirely arrested,  and time is
afforded for the formation and the deposit of a coagulum in the vicinity of the
wound.
   3d.  The  changes  that  take place  in and around the vessel itself are those
upon which the final arrest  of the  bleeding is dependent.   They consist in the
retraction of the artery within its  sheath, in the contraction of the cut ends,
and in the formation of a, coagulum  around  its exterior, and in its interior.
   When  an artery is cut across, it immediately  retracts within its sheath, the
interior of  which is left rough and uneven.   Through  this uneven channel the
blood  is projected,  either flowing freely externally or being extravasated into
the neighboring cellular tissue, according  to the  direction  and state of the
wound.   As  the blood flows over the roughened  surface of  the sheath, it
becomes entangled in the fibres, and  tends to  coagulate upon  them; this ten-
dency to  coagulation is favored by the increased plasticity of the blood  as it
flows, and by the diminution  of the propulsive  force with which  it is carried
on.   By the conjoined operation of these causes a coagulum is formed, which,
though lying within the sheath,  is outside to, and extends  beyond the artery;
and is lience termed  the  external  coagulum.   It  is  usually of a somewhat
cylindrical  shape, and  often  looks like a continuation  of  the vessel, being at
first perforated by a hollow track, through which the stream of  blood continues
to flow.   As it increases, the  hollow  becomes closed by the concentric deposit
of coagulum.  The hollow  track leading  from the surface  of the  coagulum to
the wound in the  artery,  has been  especially  described  and  dwelt upon  by
Amussat.   This coagulum  acts  mechanically by blocking  up  the end of the
artery, and also by compressing the vessel within the sheath; thus constituting
 the first barrier to the hemorrhage.  The formation  of  the external coagulum
 is thus in a great measure dependent on  the retraction  of  the artery within its
 sheath.
   The next  changes that  take  place  in  the  artery, and, indeed, that are to a
 certain extent simultaneous with those that have just  been  described, are, its
 contraction and the formation of the internal coagulum.
   The contraction of the cut artery commences immediately after its division,
 and may of itself be sufficient to close the  smaller arteries.   Thus, during an
 operation, we may  often see an artery which, when  first cut, jetted a stream of
 blood as  large as a straw, gradually contract in size until it cease to bleed, owing
 simply to this contraction.  In the larger arteries this process  is  not  sufficient
 to close  completely the vessel, but merely gives its cut end  a conical shape,
 diminishing greatly the aperture and converting  it into a kind of pinhole at the
 end of the artery.
   In proportion as the open end of the artery is  obstructed  by the external
 coagulum and contracts in  diameter,  the  blood is propelled  with more and more
 difficulty through it, until  at last it escapes in but a small and feeble stream,
 or even becomes completely at  rest, allowing its fibrine to be  deposited in a
 slender coagulum, which plays a more important part in the permanent than in
 the temporary arrest of the bleeding.  To the formation of this internal coagu-
 lum  the  contraction of the  vessel is  subservient.   This  coagulum is slender 
152
INJURIES OF  ARTERIES.
and of a conical shape, the base being attached to the margins of the aperture
in the vessel, and the apex extending upwards.  It has no point of attachment
except by its base, the apex  and sides  being perfectly free;  it is at first com-
posed entirely of coagulum, though of a firm fibrinous character, no exudative
matter entering into its composition at this period, though after-changes of an
important character occur within it.   The importance of the internal coagulum,
as a temporary means of  arresting hemorrhage, though great, has, I think, been
over-estimated.  In many cases it is not formed at all; this  happens in certain
states of the blood when that fluid  is devoid  of  plasticity, and in some  cases
the proximity of a collateral  branch to the cut end of  the vessel appears, by
preventing the stasis of the blood within it, to interfere with  its coagulation;
even when it is formed, it is  but of little service, so far  as  the primary arrest
of the hemorrhage  is concerned, not being deposited until after  the flow of
blood has been checked  by other means, such as  the  deposit of the  external
coagulum and the contraction of the vessel.  After it is formed, it is useful in
acting as a damper,  and in breaking the force of the wave of blood against the
cut end of the vessel.  It is in the permanent arrest of hemorrhage  that the
internal coagulum is of great importance.  After the hemorrhage from the cut
artery has been  arrested  temporarily  by  the means that have been indicated,
nature proceeds to secure the vessel by permanently occluding it.
   The permanent closure of  a cut artery is effected by two processes:
   1st.  By the adhesive inflammation  set up in the vessel  and  the surrounding
parts.
   2d. By the continued  contraction of the artery
   A few hours after the division of the  artery, lymph is found  to have  been
poured out both  within and on the outside of the injured vessel.  The lymph
that is thrown out within the vessel forms the most important part of the  in-
ternal coagulum, and tends materially to the permanent closure of the wound.
It is effused from the cut surface of the internal and middle coats  around  and
immediately within  the contracted orifice  of the vessel, forming a small nodule
projecting into  its  interior.   If an  internal clot have  already formed,  this
plastic nodule is deposited underneath it, or is effused into its  base; if no tem-
porary clot have formed, a conical  mass of coagulum will be deposited  upon
this  nodule, in obedience to that  law of pathology by which blood  tends to
coagulate upon inflamed points.  When fully formed this coagulum differs ma-
terially in structure at different points.   At its base it is firm, of a brownish or
buff color, and is composed principally of fibrine;  above  this  it becomes dark,
morone colored, and ends in a long  tail-like  projection  of  simple clot, which
extends up to the nearest large collateral branch.   The  important part of this
coagulum, pathologically  speaking, is its plastic base; the rest, however long it
may be, is of no use in the permanent closure of the vessel;  but, like the  in-
ternal clot already described,  merely serves to break the shock of the blood.
   Coincident with these  changes in the interior of the vessel,  important pheno-
mena occur on its exterior.   Inflammation takes place in the sheath and in the
surrounding parts, a round or ovoid mass of fibrine being here effused, which is
at first mixed up with the external coagulum; the coloring matter of this, how-
ever, gradually becomes  absorbed, leaving the plastic matter  accumulated in  a
mass, and completely blocking up the end of the vessel from the outside.
   Under the  influence of the  inflammation set up within  and around it, the
artery goes on contracting, until it embraces the included coagulum so firmly
that it would appear as if it  were  adherent to every part of it, and some diffi-
culty is experienced in  separating them.   That they are not  adherent, I have
ascertained by finding, on careful  dissection,  that the transverse strise of  the
lining membrane of the  artery are always visible, although  the coats of  the
vessel are often stained  nearly black by the  imbibition of the coloring matter
of the  blood.   The contracted vessel usually assumes a  conical shape, but in 
PERMANENT ARREST  OF HEMORRHAGE.         153
some cases I have seen the contraction commence suddenly, and the narrowed
part to be perfectly cylindrical for the distance of about an inch.
   The changes  that have just been  described are those that take place in the
proximal  end of the artery.   In the  distal or inferior end, occlusion is effected
by the same processes essentially, but  the retraction and contraction of the vessel
are not so complete and  extensive, and  the coagulum  is usually smaller  both
inside and out;  in some cases, indeed, the internal coagulum is deficient.  The
less perfect closure of the distal end may, as Mr. Guthrie suggests, be the cause
of the more frequent occurrence of hemorrhage from it.
   The  ultimate change that takes place in  the divided  artery, is, the trans-
formation  of  its cut extremity up to the first collateral branch, into a dense
fibro-cellular cord.   This is effected by the plastic effusion inside and  outside
the artery, with the cut and contracted vessel in the centre, developing  into
fibro-cellular tissue.
   The arrest of hemorrhage from a punctured or partially divided artery is
 effected in a somewhat different manner to what has been just  now described;
 the difference consisting in the changes  that  go on in the neighborhood of the
 wound.   If the wound  in  the  soft parts covering the artery be of small size,
 and  oblique  in direction,  so that the  blood does not escape  with  too  great
 facility, it will be  found that the  temporary arrest of the hemorrhage  takes
 place by  an extravasation of blood occurring  between the artery and its sheath,
 by which the vessel  is  not only compressed, but the relations between the
 wound and the aperture in the sheath are altered.  This stratum of coagulated
 blood extends for some distance within the sheath, above and below the wound,
 opposite  to which it  is  thicker than elsewhere.  Coagulum may  likewise be
 formed in the tissues of the part outside the sheath,  by which the vessel is still
 further compressed, and the tendency to the escape of blood  proportionately
 lessened.
    The permanent closure of the puncture is effected by the adhesive inflam-
 mation.   Lymph may be effused in such  a way as to be sufficient  merely to
 plug the  wound in the coats, or else it may be in sufficient quantity to obliterate
 the whole of the interior of the artery, producing complete occlusion of it.  In
 order that the wound in  the artery should unite without obliterating the cavity
 of the vessel, but simply by the formation of a cicatrix in the coats, it is neces-
 sary that it be below a  certain size; but  this  size will vary according  to its
 direction.  If  the  wound  be longitudinal or slightly oblique, it will  be more
 likely to unite  in  this way than if transverse.   Mr. Guthrie states that  in an
 artery of the size of the temporal, a small longitudinal wound  may sometimes
 heal without  obliteration  of  the vessel, though this very rarely  happens in
 arteries  of larger size.   If a vessel the size of the femoral  be opened to the
 extent of one-fourth of its circumference, there is no proof that the wound can
 heal without obliteration of the cavity of the artery;  but when the  longitudi-
 nal wound is very small in a large  artery, little  more than a puncture, closure
 may possibly take place simply by its cicatrization.  The plastic matter forming
 the cicatrix is  thrown out by the external coat of the artery.   The internal and
 middle do not  unite strongly, the aperture in them  being merely filled up by a
 plug of  lymph; hence the artery always continues weak at this point, and may
 eventually become aneurismal.
    If an  artery of the second or third magnitude, as the axillary or femoral, be
 divided  to one-fourth or more of its circumference,  either fatal  hemorrhage
 or the formation  of a  traumatic aneurism will usually take place.   In those
 comparatively rare cases, however, in which the hemorrhage is  arrested without
 these consequences ensuing, it will be found that it is so, by the vessel becoming
 obliterated by a  plug of lymph, which is poured out at the wounded part, and
 gradually encroaches on the cavity of the artery,  until complete obliteration is
 produced, and  the vessel at the seat of obstruction becomes converted  into a
 fibro-cellular cord. 
154
INJURIES  OF  ARTERIES.
      THE  SURGICAL  TREATMENT  OF HEMORRHAGE FROM
                         WOUNDED ARTERIES.

  The object of the surgeon, in any means that he adopts for the suppression
of arterial hemorrhage, is to imitate, hasten, or assist the natural processes, or to
excite analogous ones.   All his means act by increasing the retraction and  con-
traction of the arterial  coats in forming an  artificial coagulum, or in exciting
adhesive inflammation in and around the vessel.
  The danger from arterial hemorrhage, and the measures that must be adopted
to meet  it, vary according to the size of the vessel.  Under all  circumstances
the surgeon should bear in mind the excellent  advice  given by Mr. Guthrie,
never to fear bleeding  from any artery on which  he can lay his  finger; the
pressure of this readily controlling the bleeding from the largest vessels, pro-
vided it can be fairly applied, or the cut end of the artery seized between the
finger and thumb.   Thus, in  amputation at the hip and shoulder joints, the
assistant readily controls the rush of blood from the femoral and axillary arte-
ries  by  grasping them between his fingers; above all, the surgeon should never
dread hemorrhage, or lose his presence of mind by its occurrence.  If effectual
means for its suppression are had recourse to, it can always be, at least, tempo-
rarily arrested.  And least of all should  any surgeon have  recourse to inefficient
means to stop it, and endeavor, by covering up the wound with rags, handker-
chiefs, &c, to prevent the escape of blood.   These means only hide the loss that
is going on, and by increasing the warmth of the parts,  prevent the contraction
of the vessels, and favor the continuance of the bleeding.  Under all circum-
stances, therefore, bleeding  wounds should  be opened up, the  coagula gently
removed from their surface, by means of a piece of soft sponge or a stream of cold
water, and the part well  cleaned.   In  this way " you look your enemy in the
face," and can adopt efficient means for the permanent arrest of the hemorrhage.
  The flow of blood through a limb may be controlled for a temporary purpose,
as during an operation, by the compression of the main artery by the hands of
an assistant.   This may be done in the lower extremity by pressing  the femoral
artery against the brim  of the pubes, and in the upper  extremity by compress-
ing the  subclavian against the first rib,  or the brachial against the shaft of the
humerus.  The  pressure should be made by grasping the limb with  one hand
in such  a way that the index and  middle fingers  bear  upon the artery,  and
press it directly against  the  subjacent bone.   If the limb be large, or if long-
continued pressure  be  required, the same fingers of the other hand should be
firmly applied upon those that  are  already compressing  the vessel.  In some
cases, especially when the subclavian or external iliac requires to be compressed,
the handle of a large key, or the end of a desk seal covered with leather, will
be found the most convenient instrument for applying the pressure.
  In most cases, however,  in which temporary  compression  of the  artery  is
required, the tourniquet should  be  employed.  It is far safer to trust to this
instrument than  to  the  hands of  an  assistant, however steady and  strong
\Y hen the tourniquet is  applied with a sufficient degree  of tightness, the whole
circulation through the limb may be completely arrested.  This can never be
done solely  by the compression of the main trunk,  the  collateral and  minor
supplying-vessels conveying blood into the limb independently of it   Then
again if the operation  be unexpectedly protracted  from any cause, the finders
of an assistant may tire  or stiffen,  and,  by relaxing the steadiness of their
pressure, allow hemorrhage to  ensue.  For  these reasons, surgeons almost in-
variably employ the tourniquet in amputations; and even the late Mr.  Liston,
who at one period of his career discarded this instrument, commonly employed
it during the latter years of his  life.   There are three tourniquets used by
surgeons: —Petit s consists of two  plates attached to  a band that is buckled
round the limb over a pad that has previously been applied above the artery  to 
        APPLICATION  OF COLD. — DIRECT,PRESSURE.     155

be compressed (fig. 18).  By the action of a quick  screw the plates can  be
separated,  the band tightened, and  the  pad forced against the artery.   In
applying the tourniquet, care should be taken not to screw it up until the very
moment that the  compression  is required, and then to do so quickly and with
considerable force, lest venous  congestion of the limb take place, by the veins
being compressed  before the circulation in the arteries is arrested.   The horse-
shoe, and Signorini's and Skey's tourniquets appear to me to have no advantage
over the  one described, and they possess the disadvantage of not compressing
the collateral vessels, and consequently of commanding the circulation in a less
perfect manner than the ordinary instrument.
   The  different means that may be  employed  for the permanent  arrest  of
hemorrhage are  the application  of cold, styptics, cauterization with the hot
iron, and pressure, or the employment of torsion and ligature.
   The  application of cold is sufficient to arrest that general  oozing  of arterial
blood that is always observed on a cut surface.   The mere exposure of a wound
that has bled freely, so long as  it has been covered up by pledgets and bandages,
to the cold air, is  often sufficient for this purpose.  When this does not succeed,
the application of a piece of lint, soaked in cold water, will  usually arrest the
flow of blood.  When it is necessary to do  this speedily, as in some  operations
about the air-passages, a small  stream of cold water  may be allowed to drip into
the wound, and thus  cause  rapid contraction of  the vessels, and  consequent
cessation of bleeding.   In cases of bleeding into some of the hollow cavities of
the body, as the rectum, vagina, or mouth, the application of ice is advantageous.
   Styptics influence powerfully the  contraction of the vessels, and by increasing
the rapidity of formation, and  the firmness  of  the coagulum, tend to arrest the
hemorrhage; they are  principally used in  bleeding from  spongy parts,  from
cavities or organs, to which other applications cannot readily be  made.  The
great objection to their employment in some wounds consists in their tendency
to modify the character of the surface, and to prevent union by the first inten-
tion.   The most useful styptics  are the  tincture of  the sesquichloride  of
iron, spirits of turpentine, gallic acid,  and  matico; the  application of alum, or
touching a bleeding part with  a  pointed stick of the nitrate of silver, is also
serviceable.
   Cauterization  by means  of  the red-hot  iron was almost  the  only mode  of
arresting arterial hemorrhage that was known to the aridients.   It  is  now com-
paratively seldom  had recourse  to, but yet in many cases it  is of  the  most
unquestionable utility, and superior to any other means  that we possess;  more
particularly in those cases in which the hemorrhage proceeds from a soft and
porous part that will not hold a ligature, or a surface  from which  many points
appear to be bleeding at the same time.  A somewhat conical  iron  should  be
used of sufficient size, and the hemorrhage will  often be staid more  effectually
if it be applied-at a black, than at a red or white heat.  As  the  actual cautery
 blocks  up the artery by a thick slough or  eschar, there  is  always  danger of a
recurrence of the  bleeding when this separates, and the surgeon must be on his
guard about the sixth or eighth day lest it break out again.
   Direct pressure  upon the  bleeding part is a  very efficient mode of arresting
hemorrhage from  small arteries.   It is not, however,  applicable  to all parts of
the body,  as it is necessary that the vessel  should  have a bone subjacent to it,
so as to afford a point of counter-pressure; hence it cannot readily be employed
in soft and moveable parts, as the throat or perineum.   Pressure may be  prac-
tised in various ways; sometimes the mere  uniform compression of  a bandage
is sufficient to arrest the hemorrhage; thus oozing  from a wound may often be
stopped by laying  down the flaps, and applying  a bandage  pretty tightly over
them.   Sometimes a weight applied upon this will tend still further to arrest
the bleeding; as,  for instance,  by means of a sand-bag laid upon the part.   In
the case of bleeding from hollow  cavities, as the  rectum, vagina, or nares, the 
156
INJURIES OF  ARTERIES.
hemorrhage may be arrested by the pressure of a plug of sponge  or lint,  to
which  sometimes a styptic  may advantageously be added.  AY hen  the hemor-
rhage proceeds from the puncture of a small or moderate-sized artery, as of the
temporal or brachial, pressure should be made against the adjacent bone With a
graduated compress and bandage, and be continued for one, two, or three weeks,
until complete consolidation of the wound takes  place, the vessel becoming
obliterated.  The  grailualed compress should be at least an inch in thickness,
and made of a series of pledgets of lint of a circular shape, gradually diminishing
in size.  It should be applied with its pointed end resting over the wound in
the vessel.   In  applying it, a piece of adhesive plaster should be laid over the
part on which the pressure is to be exercised,  and a thick slice of a  phial cork,
or a  fourpenny piece, wrapped in  lint, being  placed  on this, the graduated
compress should be bandaged tightly over the whole.   When" applied in this
way, pressure always acts by inducing adhesive inflammation ancLobliteration
of the vessel at the point compressed.
   The torsion of arteries for the arrest of hemorrhage, mentioned by Galen,
and  revived  by Amussat, Velpeau, and Thierry, has never found much  favor
amongst surgeons in this country.   It may be practised in various ways.  Thus
Amussat recommends that  the artery be  drawn  out for about half  an inch by
one  pair of forceps;  that it then be seized at its attached point with another
forceps, and the end be twisted off by about half a dozen turns.  Fricke advises
that the ends be  not  taken off, but merely*twisted  for six or eight times,
according to the size of the  vessel.   Thip*ry simply seizes the artery and twists
it.   There  can  be  no doubt that hemorrhage from the  largest vessel may be
efficiently stopped by its torsion, the artery being placed in the condition of one
that is lacerated or torn through.  The internal and middle coats are retracted,
and  the  external one twisted into  a kind of valve beyond them.   A coagu-
lum next  forms within  the vessel, blocking up  its extremity;  inflammation
then takes place,  gluing together  the  coats of  the artery;  the twisted end
sloughs off, and the vessel becomes occluded up to the nearest collateral branch.
The advantage  that torsion is supposed to possess over the ligature is, that no
foreign body being left in the wound, there is  less suppuration, and  a greater
prospect of union  by the  first intention.   This advantage, however,  is more
fanciful than real; the  twisted end  acts  as a foreign body, and is  as likely to
interfere with union as the  pressure of a ligature.   Torsion possesses the great
disadvantages of being less safe, and less readily practised  than the ligature,
on the larger  arteries.  Occasionally in operations, however, small  arteries, as
muscular branches, may advantageously be pinched or twisted once or twice in
such a way as to arrest the bleeding from them.
   The ligature is the means that surgeons commonly have recourse to for the
arrest of hemorrhage from wounded arteries.
   The ligature had been occasionally and partially employed by the later Roman
surgeons, but with the decline of surgery fell  completely  into  disuse, giving
way to such barbarous and inefficient modes of arresting the hemorrhage as the
employment of  the actual cautery, the performance of  opefctions with red-hot
knives, the application of boiling pitch, or of molten lead, to the bleeding and
freshly-cut surface.   About the middle of  the sixteenth century it was revived
or re-invented by that great luminary of the French school of surgery, Ambrose
Pare\   But so slowly did the ligature make way amongst surgeons, that Sharpe,
surgeon to Guy's Hospital,  writing in 1761, two centuries after its introduction
into practice by Pare, found it necessary, in his well-known work, entitled, "A
 Critical Enquiry into the Present ^tate  of Surgery,"  formally to advocate  its
employment for the arrest of hemorrhage from wounded arteries, in preference
to styptics or the cautery, on the ground  that "it was  not  as  yet  universally
practised amongst surgeons residing in the more distant counties of our king-
dom."  What, it may be asked, was  the  reason that it took two centuries to 
LIGATURE.
157
promulgate the use of the simplest  and most  efficacious means we possess  in
surgery, — a means that no surgeon could now for a day safely dispense with ?
The reason simply was, that surgeons were totally ignorant of the means em-
ployed by nature for the occlusion of arteries, that they consequently knew not
how to apply a ligature to these vessels, or what kind of ligature should be used ;
and that, in their anxiety to avoid the recurrence  of secondary hemorrhage, and
to make  all safe,  they fell into the very errors  they should have avoided, had
they been acquainted with the physiology of the processes that nature employs
for the closure of the artery and the separation of the thread.
   Between twenty and thirty  years after the time at which  Sharpe wrote, we
find that Hunter introduced that great improvement in the surgical  treatment
of aneurism,—the deligation  of the artery at a distance from the sac, and in a
healthy part of its course: but  this great accession to the treatment of a most
formidable disease was but coldly received, and ran some  risk of being lost  to
the world in consequence of the ill-success that attended  the earlier operations.
In  Mr. Hunter's first operation, four ligatures were used,  all of which were ap-
plied so slackly as merely to compress the artery for some  distance, and to avoid
too great a degree of pressure  at any one point; the artery was denuded, so that
a spatula could be passed under it,; and, although in his  subsequent operations
Mr. Hunter  contented himself with employing  but one ligature, yet in some of
these the vein was included in this; and he Sid not draw the noose tightly, for
fear of injuring the coats of the vessel,  in accordance with the doctrine of the
day;—surgeons generally at this time being haunted with this dread of injuring,
and thereby weakening, the coats of the artery; and in order to avoid doing so,
adopted  modes of treatment that almost infallibly led to ulceration of the vessels
and consecutive hemorrhage.  The application of several ligatures of reserve,
applied slack—the use of broad  tapes—the interposition of plugs of cork, wood,
agaric, or lead — of rolls of lint or plaster between  the  thread  and the vessel,
were some amongst the plans  that were in common use.   And how can we be
surprised that the patients perished of hemorrhage, and that the ligature of the
vessel was nearly as inefficient and fatal a means of arresting bleeding as the use
of a cautery, or of a button of white vitriol.
   It was not until Mr. Jones, by an appeal to  experiment, and by means  of a
series of admirably conducted investigations, showed that  the very point that
surgeons were anxious to avoid — the division  of  the coats of the vessel by the
tightening of the noose — was  that
on which  the  patient's safety  de-                  Fm. 61.
pended; pointed out  the form and
size of ligature  that  was most  safe,
the degree  of  force with which it
should be applied, and the processes
adopted  by nature  for  the occlusion
of  the vessel — that a more rational
practice  was introduced, and  that
surgeons at length had full confidence
in the use of the ligature.
   The mode of application  of  the
ligature, and the kind of ligature to
be  used, vary according as the  cut
end of the artery has to be tied in an
open wound, or as the vessel  has  to
be  secured in its continuity.   When
a ligature has to be  applied  to the
divided vessel in an open wound, as
after an amputation, the  mouth of the artery must  be seized and drawn forwards
(fig. 61).   For this  purpose a tenaculum, or sharp hook, is  not unfrequently
 
158
INJURIES OF  ARTERIES.
used, and in many cases answers the purpose  exceedingly well.   There are,
however, some  objections to this instrument; thus, it occasionally seizes other
tissues with the artery, and as it draws the vessel  forwards by perforating its
coats, it has happened that an  accidental  puncture having been made by'it be-
hind  the part to which  the  ligature is applied, ulceration  of the vessel and
subsequent hemorrhage of a fatal character has ensued;  as I have seen happen
in one case.  The most  convenient  instrument for  the purpose  of drawing
forward the artery, and one to which  no objection whatever applies, is Listen's
bull-dog  forceps.  These  have been  conveniently  modified  of late by  having
the blades expanded just above the points (fig. 62), so that the ligature can be
slipt over the end of an artery  that is deeply seated, as  between  bones or close

                                  Fig. 62.
to the interosseous membrane of the leg — a situation in which it is sometimes
troublesome to tie a vessel by any other means.  In  some  cases the  bleeding
point may be  so  situated that the ligature is  most conveniently passed under
and round it by means of an ordinary curved needle.
   The kind of ligature used must vary according to the size of the vessel.  If
this  be small, full round twine; if large,  dentist's silk, or compressed smooth
whip-cord, should  be  employed; I always  employ the latter in ligaturing the
main artery of the limb.   Before being used, the ligature should be well waxed,
so that  it may not be  too limp; its strength should  be  tested by knotting it
with a jerk, and if found efficient it may be cut up  in pieces eighteen inches  in
                              length for use.   In applying the ligature, care
            Fig. 63.            must be  taken that it be put well  beyond the
                              cut end of  the  artery, that it clear  the forceps'
                              points, and that it  be tied  tightly with a reef
                              knot, which does not slip (fig. 63).  One end
                              of the ligature should then be cut off about a
                              quarter of an inch from the knot, and the other
                              left hanging out  of the wound.  The ligature
that secures the main  artery should have both  its ends knotted together byway
of distinctive  mark.  It is always better to leave one end  of the ligature;  if
both be cut off, the noose and  knot left are apt to become enveloped by granu-
lations or adhesive matter, and after the healing process is well advanced,  or
perhaps completed, to give rise to suppuration  in and  re-opening of the wound.
   When  the  artery has  to be  ligatured in its  continuity, but at the  point
wounded, it must be exposed by as careful a dissection as the state of the parts
will  admit.  If a surgeon determine to apply a ligature at a distance  from the
injury, his anatomical knowledge will guide him to  the vessel.   This is usually
done by cutting through the  tissues  in  the course of the vessel-;  Hargrove,
however, recommends that in  ligaturing arteries, the incisions  should not be
made parallel to the course of the vessel, but in an  oblique  or transverse direc-
tion over it, and this  suggestion appears to me to be  deserving of attention  in
some situations, more  particularly in the  ligature of the brachial at the bend
of the  arm, or of the carotid at the root of the  neck.   The surgeon is usually
guided to the vessel by some fixed line or point, as the edge of amuscle, which
has a determined  and constant relation  to the artery.   Thus in exposing- the
brachial, he  cuts  along the  inner  border of the  biceps.  In  some cases^how-
ever, as in the ligature of the  i*ac arteries, no such  certain anatomical guide
exists,  and then an imaginary line is drawn between two fixed points —as the
 
LIGATURE.
159
Fig. 64.
umbilicus and  the centre of Poupart's ligament, which  becomes  the  guide to
the course of the vessel.   These " directing lines" should be carefully studied
and kept in mind.
   In  making the first incision,
the skin should be  put on the
stretch with  the fingers of the
left hand, or by those of an as-
sistant.   If the artery is super-
ficial, or if there are parts of
importance  in  its vicinity, the
incision  should not penetrate
deeper than the skin.   But if
the vessel be deeply seated and
no parts of importance intervene, it may be carried at once
through  the subcutaneous cellular tissue, until  the  fascia
covering the artery is exposed.   This must then be pinched
up with the  forceps, and opened by the  edge of the scalpel
laid horizontally.   Through this opening a grooved director
may then be passed, and the fascia incised on it, without risk
to subjacent parts.   The sheath of the vessel is now exposed
by a  little careful dissection; and  the  next step of the  ope-
ration, which consists in exposing the  artery and separating
it from its accompanying vein, is one of great delicacy.  This is done by pinch-
                  ing up  the sheath with the  forceps and applying the knife
                  horizontally (fig. 64).   The  point  should  never be used, or
                  the blade turned downwards against  the artery, as an incau-
                  tious movement  or the mere pulsation of the vessel might
                  cause it to be wounde"d.  The artery having thus  been ex-
                  posed, the surgeon seizes one  edge of the  sheath  with the
                  forceps, and putting it on the stretch, gently  separates the
                  artery from its accompanying vein by teazing through the
                  cellular connections with the end of  the aneurism needle, or
                  with a  director; being careful  not to expose it to a greater
                  extent  than is absolutely necessary for the passage of the
                  ligature, lest subsequent sloughing of the vessel ensue,  as a
                  consequence of the destruction of the vascular connections
                  between it and the sheath (fig. 65).
                     In opening the sheath,  care should be taken  not to wound
any small  branch, lest  the collateral supply be interfered with, and  danger of
secondary hemorrhage induced.   The
edge  of  the  opening in  the sheath
being held tightly in the  forceps so as
to be rendered tense (fig. 66), the liga-
ture  should then  be carefully  passed
between  the vein  and artery,  taking
care to include only the latter, and espe-
cially not to transfix and include a por-
tion of the vein; an accident that often
terminates fatally by phlebitis or gan-
grene.  So also the surgeon must be on
his guard not to mistake any contiguous
nerve for the artery, as has happened to
the most experienced  operators;  and
also to  avoid  transfixing  and tying a
portion of the  thickened sheath instead of th'- vessel, as I have known happen
to a most  excellent surgeon.   The best material for the ligature  when applied
 
160
INJURIES  OF  ARTERIES.
 to the continuity of an artery, is  the  dentist's silk or compressed  whip-cord,
 well waxed, and tied in a reef-knot, as  represented in fig. 63.  Much ingenuity
 has been expended in devising instruments for passing it under the artery.  In
 the majority of cases the common aneurism needle — well ground down, but
 rounded  at  its  extremity — is all that  is required.   Occasionally it may be ad-
 vantageous to  use a needle with a small curve.   Many ingenious contrivances
 have been devised by Trant, Weiss, Coxeter, and others for seizing and drawing
 forward the noose from the bottom of the wound.   After the ligature has been
 passed under the vessel it should be tied tightly with a reef-knot, and both  its
 ends left hanging out of the wound.  The limb should then be elevated and be
 lightly covered  with a piece of flannel, or of cotton wadding;  care being taken
 not to apply pressure of any kind.
   The immediate effects on an artery of the application of a firm round ligature
 with a proper degree of force, is the division of the internal and middle coats
 of the vessel, and the constriction of its  outer one.   If we examine the ligatured
 vessel a few days after it  has been  tied, we find that the  coats are contracted,
 that there is an  internal pyramidal coagulum, composed of plastic matter at its
 base, and  fibrinous clot towards  it  apex (Fig. 67);  and that the ligatured por-
 tion of the vessel is surrounded by a quantity of lymph.   If the artery be exa-
 mined at a still  later period than this — at the end of two or three months, for
 instance — it will be found  to be converted into a fibro-cellular cord  as high as
 the  first collateral branch above  the ligature (Fig. 69).  Now these are analo-
 gous appearances to those met with  in an artery that has been cut  across and
 occluded without the application of a ligature, and  are evidently the result of
 inflammation of the vessel.   The question arises, how this inflammation is set
 up when a ligature is applied.   Is it by the pressure  of  the  noose, or by the
 division of the coats  of the artery  ?  That it  is not the  mere pressure of the
 ligature that excites the occluding inflammation, is evident from the experi-
 ments of Jones  and  of Travers, who  found that if the  ligature be removed
 shortly after its  application, sufficient inflammatory action had been  excited in
 the coats of the artery to lead to its  complete occlusion.   And though any in-
 flammation set up in the external  coat  may cause an effusion of lymph inside
 the vessel, yet that which is  required  to repair the breach  occasioned by the
 division of the internal and middle coats, is  the principal  source of the plastic
 deposit.   The changes  that take place  in the vessel after the  application of a
 ligature require, however, to be more  carefully studied.
   The division of the internal and middle coats should be done evenly, smoothly,
 and  completely, so as to leave  a wound  that  will readily take on  the adhesive
 inflammation.  This is  best  done by a  small round  ligature, applied  with such
 degree of force that the surgeon feels  the coats give way under his finger.   The
 adhesion between the coats is  much facilitated by the pressure of the ligature,
 which also acts as a support to the vessel.
   The formation of the internal coagulum in the proximal end is
 the most important part of the process.    For the  first four-and-
 twenty hours after the application of the ligature there is little, if
 any, appearance  of this.  Usually about this time, if opportunity
 offers to examine an artery in the  human subject, it will be found
 that a small nodule of lymph, of a yellowish or buff color, has been
deposited in the  bottom of  the cul-de sac that is formed by the
retraction and contraction of the cut ends of the inner and middle
coats, so as to close up the extremity of the artery.   About  the
second or third day, this coagulum will be found to have assumed
a conical shape (Fig. 67), the base being composed of decolorized v  '
fibrine and  exudation-matter firmly adherent to  the lower end T^ ^
of the artery; the middle and terminal portions of the coagulum, af^ alu
composed of fibrinous clot,  and  of  a  dark purple or morone tton.   P
 
LIGATURE OF  ARTERIES.
161
Fig.
  Brachial  artery,
ten days after am-
putation.
Fig.
color, lie  loose and floating in the artery, extending  up as high  as  the  first
collateral  branch.  About the tenth day, the  inflamed end of the vessel will
be found to be tightly and firmly contracted upon the  inclosed plug (Fig.  68),
                 the  dark-colored portions of which now begin to
                 undergo a process of absorption.  Between this pe-
                 riod and the sixth week, the contraction of the ves-
                 sel and the absorption of the free part of the plug
                 go on simultaneously (Fig. 69), the interior of the
                 artery becoming darkly stained  by imbibition  of
                 the  coloring matter of the coagulum.   Lastly, the
                 plastic base of the plug becomes incorporated with
                 the  contiguous arterial coats, and undergoes even-
                 tual transformation into fibro-cellular  tissue.
                   In some cases (Fig. 70), there is an imperfeet
                 formation  of the internal plug,  or  even total ab-
                 sence of it, and not unfrequently secondary hemor-
                 rhage occurs as a consequence.   This condition
                 may arise  either from  want of plasticity in the
                 blood, from an absence of due adhesive inflamma-
                 tion, or from the coats  not having been properly
cut through.  In other cases, in consequence of suppurative action
being set up in  the artery, a kind of disintegration  or liquefaction
of the plug takes place after it has been formed.  This I have seen
happen in a case of  ligature of the carotid artery, in which death
occurred from visceral disease ten weeks after the operation; and in  the femoral,
in cases of pyemia (Fig. 71).  In the distal cul-de-sac of the ligatured artery
                I have never seen any very distinct coagu-
                lum  formed, either  in  the human subject
                or in dogs on which  I have experimented,
                but merely  small detached fragments of
                coagula  and some plastic effusion.
                  The changes that take place in the ex-
                ternal coat  are of the most important 'cha-
                racter.   After the internal and middle coats
                have been cut through  by the ligature, the
                external would not be able to resist the im-
                pulse of the blood were it not strengthened
                and  consolidated by the  adhesive inflam-
                mation.   The necessary  inflammation is
                occasioned partly by the dissection required
                to expose it, and partly  by the pressure
                and  irritation of the ligature.   Lymph is
                thrown  out  between  the vessel  and  its
                sheath,  matting  together these parts,  and
                often enveloping the noose and knot in an
                ovoid mass.  Progressively with the effu-
                sion of lymph and consequent strengthening
                of the coats, the pressure of the noose causes
                gradual sloughing and ulceration  of  the
                part included in it.   The mode  in  which
                the noose  ulcerates  its  way through  the
                external  coat is of  much importance,  as on this depends in a
                great measure the success of the ligature.  There are two sources
of danger in connection with this process; either that the sloughing may be too
extensive, or that  the ulceration through the artery may take place before the
adhesive plug is properly and firmly  formed.
        11
  Partial absorp-
tion of coagulum
in femoral, four-
teen  days  after
amputation.
  Femoral arteries, ten
days after amputation
of thigh.  Death from
pyemia. 
162                 INJURIES  OF ARTERIES.

  The chance of the sloughing being too extensive, principally arises from the
artery  being isolated, and  separated  from its  sheath to too great an extent
during the dissection required to expose it, in consequence of which, its nutri-
ent vessels beino; divided in great'numbers,  that portion of the  coats of the
vessel, deprived of its vascular supply, becomes sloughy; hence the danger of
passing a spatula, large probe, or the handle of a scalpel under  the artery, and
also of applying several ligatures.  Premature ulceration of the vessel  most
commonly occurs from the patient's constitution being in too debilitated a state
to admit of healthy reparative action.
  So soon as the ligature has ulcerated through that portion of the artery which
is included in its noose, it becomes loosened and separates; frequently being
thrown off with the  discharges, or becoming detached on the slightest traction.
The period of the separation of the ligature depends upon the size of the artery
and the thickness of its coats.  From the radial, or ulnar, it is usually detached
by the eighth day; from the  femoral, iliac, or subclavian, about the  sixteenth
or twentieth days.  In some cases the ligature will continue attached for a much
longer period than this, owing to the inclusion of a bit of a nerveor of muscular
substance within its  noose.  In  order  to hasten the  separation  in  these cases,
moderate traction and occasional twisting of the ligature may be practised.
                   COLLATERAL  CIRCULATION.

  When the main artery  of a limb has been  ligatured, or  in  any other way
occluded, it is  only the direct flow of blood that is  interrupted;  the  indirect
supply which is conveyed  into the  limb,  or  part,  by the free inosculations
between the anastomosing vessels of the different portions of the arterial system,
being sufficient to preserve its vitality, and  to  prevent the occurrence of gan-
grene.  So free and ready are the communications kept  up between different
portions of the arterial system, that after the largest  arteries in the body, such
as the subclavian, iliac, and aorta,  have been ligatured, sufficient  blood to sup-
port life is at once conveyed into the parts supplied by them.   This collateral
circulation is most active and most  readily maintained in  early life, when the
vessels are pliant and elastic, readily accommodating themselves to the increased
quantity of blood that they are required to  convey.   As age advances, the vas-
cular system becomes less elastic, and  there  is  a  greater  difficulty in the  es-
tablishment and maintenance of the  collateral circulation.   The anastomosing
vessels that serve this purpose are invariably furnished by arteries contiguous
to that which is ligatured,  and come off from the same side of the body.  Thus,
for instance, after the ligature of the superficial femoral,  it is by the profunda
artery that the supply of blood is  carried to the lower extremity.   Thus also,
when the common carotid is ligatured, the circulation to the parts it supplies is
not maintained through the medium of the opposite carotid, although the inos-
culations between the ultimate branches of the two  vessels is so free upon the
throat, upon the face, and within the cranium; but it is by means  of the infe-
rior thyroid and vertebral arteries (branches  of the subclavian on the same
side), which become greatly enlarged, that  the  supply  of blood  is kept  up to
the parts on the outside, as well as in the inside of the cranium.
   The supply of blood that is sent to a limb, after the deligation  of the main
trunk, is at first but small in quantity; being  merely sufficient for the main-
tenance of its vitality, but not enough for the continuance of  the usual actions
of the part.   Hence, although the life of the limb may be preserved after the
ligature of its artery, it becomes cold, and the  patient  is unable to move it for
some time, the muscles appearing  to be  completely paralyzed; gradually, how-
ever, the supply of blood  increases, until,  having  reached its usual standard,
their normal vigor returns. 
COLLATERAL CIRCULATION.
163
  By what mechanism is this accomplished?   It is  due to changes  taking
place in the  capillaries; in the anatomical anastomosing branches, and in the
trunk itself.
  The capillaries are the first to enlarge; and this they appear to do by a vital
process, and  not in consequence of the mere increased pressure of the blood,
the temperature of the limb  often rising, in  the course of a day or two, to its
normal standard, and  sometimes to two or three degrees beyond  it; whilst a
great sensation of heat is experienced in it by the patient.   This  period extends
over several weeks, and if opportunity be afforded of examining the limb during
its continuance, the tissues generally will be found to be preternaturally vascu-
lar, admitting injection freely.
   Coincident with this increase of activity in  the capillary system, the  anas-
tomosing vessels of the part  enlarge,  becoming serpentine, tortuous, and waved,
forming circles of an interlaced net-work,  During this enlargement much pain
is often experienced, owing to their pressure upon neighboring  nerves.   This
form of collateral circulation commences by a general enlargement of all  those
muscular and subcutaneous  secondary vessels of the limb, which can normally
be readily distinguished  by the naked eye.  After this  general  enlargement
has  continued for some weeks, it tends to localize itself in  a few of the princi-
pal anatomical inosculations, until at last it is through their medium that the
circulation is chiefly maintained.   Thus  for instance, after the  ligature of the
common carotid, the supply of blood is ultimately conveyed by the inosculations
between the superior and inferior thyroid  arteries, and by the vertebral and
basilar.  When the subclavian is tied, the circulation of the upper extremity is
carried on by the anastomoses between the posterior and supra-scapular, and
the branches of the axillary artery distributed  to the vicinity of the shoulder;
and when  the external iliac  is tied, the  blood is conveyed to the lower limb by
the inosculations between  the mammary and lumbar arteries, with the  epigas-
tric and circumflex ilii.
   Jones pointed  out  the  curious  circumstance,  that  when  two anastomosing
branches approach one another they  split, before inosculating,
into two or  three ramusculi, which  by uniting form a circle
of anastomoses.   Besides this  kind  of collateral circulation,
Maunoir,  Porta, and  Stilling, have noticed vessels running
directly between the  extremities  of  the obliterated  trunk,
 forming species  of arterial shoots, springing from the stump
of the vessel.
   The change  that takes place in  the  trunk  consists in  its
 conversion into a fibro-cellular cord, from the point  to which
the  ligature'  has been applied to the first large collateral branch
below it  (Fig. 72): here it  becomes pervious  again, and  re-
ceiving the' blood poured into it through the different  anasto-
 mosing channels, becomes again subservient to the purposes
of circulation.   Porta and  Stilling  have shown that, after a
time, down  the  centre of this fibro-cellular cord a small tor-
tuous central canal becomes developed, uniting the two dis-
tant ends  of the divided artery.  This is  probably the  last
change that  takes place in the establishment of the collateral circulation.
   The collateral circulation  is occasionally not sufficiently free to preserve the
integrity or  vitality of the parts supplied by it.  As  a consequence of this,
gangrene  not  uncommonly   results,  or  the limb may become paralyzed or
atrophied.   This  condition is most frequently  met  with in old people,  from
ossification and  rigidity of the arterial system;  or it may happen as the result
of copious hemorrhage,  or  of an extensive transverse wound of the  limb
dividing many of the  anastomosing vessels.   It more  rarely happens that we
find  too great  freedom of the anastomoses,  so  as to lead  to a  failure of the
 
164
INJURIES  OF  ARTERIES.
 purposes for which the ligature  has been applied, by the rapid admission of
 blood into the distal end of the vessel, and thus perhaps occasioning secondary
 hemorrhage.

   PRINCIPLES  OF  TREATMENT  OF  WOUNDED  ARTERIES.

   The whole  of the doctrine of the  general treatment of wounded  arteries  by
 the ligature may be included in two great principles : lstly, To cut directly down
 on the wounded part, and to tie the vessel there; and, 2dly, To apply a ligature
 to both ends, if it be completely divided, or to the distal as well as the proximal
 side of the wound, if it be merely punctured.
   These principles of treatment  were distinctly laid down by John  Bell;1 but
 although this great surgeon inculcated forcibly  these rules of practice, surgeons
 appear to have been led away by  the erroneous  idea of applying the Hunterian
 principles in  the  treatment  of aneurism to that  of  wounded  arteries, until
 Mr. Guthrie,  by his practice and precepts, and by adducing an overwhelming
 mass of proof to bear  on  this important question, has recalled the attention
 of the profession to the  proper and rational treatment of wounded arteries.
   1st.  The  principal  reason in  favor of  cutting down  directly  upon the
 wounded part of the injured vessel is, that the  ligature of the main  trunk only
 stops  the  direct supply of blood  to the limb,  but does not interfere with the
 anastomosing  circulation, which  finds its  way readily into  that portion of the
 vessel which  is below the  ligature, and consequently  continues to  escape  by
 the distal aperture in  the artery.   Thus, though bright arterial  blood may
 no longer jet from the upper  part of the wound, blood which has become of a
 dark color, in  consequence of the  changes  to which it  is subjected in  its
 passage  through the vascular net-work  of the  limb, will continue to well out
 from the lower aperture in  the artery, entailing the necessity of further opera-
 tive procedure to restrain its flow; and unless this be done, the patient will die
 of hemorrhage as surely, though perhaps not quite so speedily, as if no ligature
 had been applied.   Thus, if a surgeon  endeavors to arrest  the flow of blood
 from a wound of the ulnar artery  near the  palm by ligaturing  the brachial in
 the middle of the arm, and, when the blood bursts forth as furiously as ever,
 applies successive ligatures  to the  arteries of the fore-arm with as little success:
 he will at last, by the continued  recurrence of  hemorrhage, be forced to adopt
 the simple expedient that  ought to have been had recourse to in the first in-
 stance—of ligaturing the  vessel  at the point  wounded, and  thus  at  len-th
 succeed  in arresting the bleeding.
   Another reason  for the  practice now advocated is, that  in  some  cases the
 surgeon  cannot possibly know what  artery is injured unless he seek for it in
 the wound itself.   A large artery may apparently be wounded,  from the direc-
 tion of the stab and the impetuous flow of blood that has followed it, when-in
 reality it is only a minor branch   that has been injured.   Thus, for instance,
 in hemorrhage from a stab  in the  axilla, which  proved fatal, notwithstanding
 he ligature of  the subclavian artery for supposed wound of the axillary, the
 long thoracic was found  to be the  vessel  divided; so also the external iliac has
 been  ligatured for supposed wound of the common femoral, when in reality it
 was the superficial external  pudic  that was  injured

 oJ^\nTUl-°£ T[US  ^ °.nnthe injUred  Part of the  artery applies to all
 cases  in  which the wound is still open, whatever be its condition    However
 £SS|in?r   '  "1  aUH  J th\rUnd;  hoWever  ^-conditioned  and  infil-
 eenef,17^JZ\iv.     neiShbonnS Parts  ™J K it may be stated  as  a
 fhrthernn^ tn  ♦ ft'      7!' I   u  ^"^ eXCePti<™> that will be noticed
Ind Zc\I ,}' th     t^1S n°? ft*0 the Patlent Unless the vesseI be «* down upon
and tied at the part injured.  Ihis must always be done at any period after the
            1  " Principles of Surgery," vol. i. pp. 350, 390.  8vo. edit. 
TREATMENT OF  WOUNDED  ARTERIES.          165
receipt of the injury, so long  as there is an external wound communicating
with the artery.   An operation of this kind is often attended with the greatest
difficulty, not only owing to the hemorrhage that usually accompanies  it and
obscures the parts,  but also in consequence of the altered condition of the
tissues in the wound. In order to moderate the hemorrhage, the pressure of an
assistant's fingers  on the artery high up  in the limb must  not be trusted to;
but  a tourniquet  should be applied so as completely to arrest the circulation
through  the  limb, and  thus to facilitate the search for exposure of the injured
vessel, the wound being dry.   A large probe  should then be passed to the
bottom of the wound, and,  taking this  as  the  centre, a free incision should be
made in such a direction as may best lay open the cavity with the least injury
to the muscles and  other soft  parts. After turning out any coagula contained
within it,  and clearing it  as  well  as possible,  the  wounded vessel must be
sought for.   The  situation of this may sometimes be ascertained at once by the
gaping of the cut  in its coats.   In many cases, however, it is necessary to relax
the  pressure upon the artery, so as to allow a jet of blood to escape, that may
indicate the position of the aperture.   The ligature may then be  applied by
passing  an  aneurism needle under the vessel, if it be partially divided;  or, if
it be completely cut across, by drawing forwards the  end and ligaturing it, as
in an open wound.   In doing  this, care must be taken that the ligature be
really applied to  the vessel, and that a portion  of the sheath infiltrated with
blood, or thickened by adherent coagulum,  be not  mistaken  for  the artery.
The incisions down to the wounded artery should be made on the side of the wound
itself, and through the wound  in the soft  tissues covering it.  Guthrie advises,
that in those cases in which the wound passes indirectly to  the principal artery
from the back or  outside of the limb, the surgeon need not  follow the track  of
the  wound, but may cut  down on  the vessel where  nearest the surface, and
then, passing a probe  through the wound, the  spot  at which  the artery has
probably been wounded will be pointed out, which must then be ligatured in
the usual way.  No operation should be undertaken unless  the hemorrhage be
actually continuing.  If the bleeding have been  arrested,  however furious it
may have been, the  surgeon should never go in search of the wounded vessel,
or undertake any  operation, unless it burst forth again.  A man was brought to
the University College  Hospital with a deep stab  in  the  groin directly in the
course of the external iliac artery; a very large quantity of arterial  blood
had been lost, but the  hemorrhage  ceased  on his admission, by the application
of pressure, etc.   From the great  and sudden  loss  of blood, it  was supposed
that  the external iliac had been punctured, but it was not thought advisable
to perform any operation unless hemorrhage recurred.  The bleeding did not
return, the wound healing without any further trouble.
   2nd.  The second  great principle in the treatment of wounded arteries is, that
the ligature  should be applied to both ends of the vessel, if it be cut completely
across, or on both sides of the aperture  in it, if it  be only partially divided.
The reason for this rule of practice  is founded on physiological grounds as well
as on practical experience.  If the anastomoses of  the  part  be very free, as  in
the arteries of the palm or fore-arm, bleeding may continue from the distal end
uninterrupted by  the ligature on the proximal side of  the wound.  If less free,
it will probably issue in a stream of  dark venous-looking blood in  the course  of
two or three days.  After  the collateral circulation has been sufficiently  estab-
lished, bright scarlet blood will burst forth  from the distal aperture.  Expe-
rience has shown  that it is in this way that secondary hemorrhage from wounded
arteries commonly occurs, the bleeding coming from the distal and not from the
proximal end of the vessel.  In some cases the distal end  is so retracted and
covered in by surrounding parts, that it cannot be found to be ligatured.  Under
these circumstances  the best practice has resulted by plugging the wound from
the bottom with a graduated sponge  compress. 
166
INJURIES OF  ARTERIES.
  Although advocating strongly the importance  of the  distal as well  as  the
proximal ligature in all cases of wounded artery, I am aware that  instances  are
on record in which the proximal ligature alone, and that even at a distance from
the wound, has proved successful in arresting the hemorrhage; but I cannot do
otherwise than regard these cases as accidentally successful, the distal end having
been better plugged than usual with coagulum;  and I am  strongly of opinion
that the rule of practice should be that which is laid  down by John Bell, and
so forcibly and copiously illustrated by Mr. Guthrie,  viz.:—That both ends of a
wounded artery be sought for, and tied in the  wound itself.

                      TRAUMATIC  ANEURISMS.

  We  have hitherto  discussed  the  treatment of an injured artery having an
open wound communicating with it.   It often happens, however, that the  case
is not so simple as has been described, but that in addition to the  wound in the
vessel, we have a subcutaneous  extravasation  of  blood with more or less pulsa-
tion, thrill, and bruit, from the projection into  it of the blood from the wounded
vessel.  These traumatic aneurisms are of  two kinds,  the diffused and  the
circumscribed.
  1st.  The diffused traumatic aneurism consists of an effusion of  blood poured
out by, and communicating with the wounded artery;  limited in extent by the
pressure  of surrounding parts, and partially coagulating 'in the meshes of  the
broken down  cellular tissue.   Its boundary, which  is  ill defined, is composed
partly  of this  coagulum,  and partly of plastic  matter, effused by  the  tissues
into which  it  is poured  out,  and has a constant tendency  to extend  by the
pressure  of the fluid blood, which continues to be projected into the centre of
the tumor.
   This form  of traumatic aneurism is indicated by  a subcutaneous, soft, and
fluctuating tumor, often of considerable size, composed of extravasated blood.
At first the skin covering it is of  its natural color, but it gradually becomes
bluish, and is  thinned by  the  pressure to which it is subjected.  If the wound
in the vessel be rather large and free, there will be  a distinct pulsation  in  the
tumor synchronous  with  the beat of  the heart, accompanied by  a thrilling,
purring,  or jarring sensation, and often a distinct and loud bruit. In  other cases,
again,  if the injured  artery be small, or if the wound  in  it be oblique, and of
limited size, there will be  no distinct pulsation or bruit; the tumor being either
indolent  and semi-fluctuating, or having an impulse  communicated to it by the
subjacent artery.
   These tumors, if left to  themselves, never undergo spontaneous cure, but they
either  increase in size until the integument covering  them sloughs  and ruptures,
or the external wound which had been temporarily plugged by coagulum, gives
way; or else they inflame and suppurate, pointing at last like an abscess, and
when bursting, giving rise to a sudden gush of blood, which may at once, or by
its  rapid recurrence, prove fatal.  In some cases, a subcutaneous breach is made
in the coagulated and plastic boundary, and the blood  becoming infiltrated into
the  cellular tissue  of the limb  or  part, gives rise  to syncope, gangrene,  and
death.
   The treatment of these cases must be conducted  on precisely the same plan
as that of an  injured artery communicating with an  external wound, the only
difference being, that in the case of the diffused  traumatic aneurism, the aper-
ture in the artery opens into an extravasation of blood instead of upon the surface.
We must especially be upon our guard not to be led  away by the term aneurism
that has been  applied to these cases, and not to treat such a condition, resulting
from wound, by the means that we employ with success in the management of
that disease.  In a pathological aneurism the blood is contained within a sac,
which, as  will  hereafter  be  shown, is  essential  for  the occurrence of those 
TRAUMATIC ANEURISMS.
167
changes that are necessary for the cure  of the disease.  In  the  diffused trau-
matic aneurism there is no sac, properly speaking, and hence these changes to
which a sac is necessary, cannot take place. I doubt whether there is a case on
record in which the  Hunterian operation for aneurism, applied to the condition
now under consideration, has not terminated in danger or death  to the patient,
and in disappointment to the surgeon.
   The proper treatment of these cases  consists in  laying open the tumor by a
stroke of the scalpel, removing the coagula, dissecting out the  artery, and liga-
turing it above and below the wound in it.  This operation, easy  in description,
is most difficult and  tedious in  practice.  The bleeding is often  profuse, the
cavity that is laid open is large, ragged, and partially filled with coagula.   It is
with much difficulty often that the artery is found under cover of these, and in
the  midst  of infiltrated and disorganized tissues, and when found  it is not
always easy to get a ligature to hold.   In performing this operation,  the artery
must, if possible, be compressed between the  tumor and the heart; if it cannot
be so commanded, the surgeon must be ready to apply his  finger to the wound
in the artery at the moment that the sac is laid open, in order to arrest the gush
of blood that takes place from the open orifice.  The application of a ligature
to  the  distal end of the vessel, if completely divided,  is especially difficult.
Here the application of the  actual cautery, or pressure, by means  of a sponge-
tent, or graduated compress, will be  found  the  best means  of arresting the
hemorrhage.
   2nd.  The circumscribed traumatic aneurism differs entirely from the diffused
in its pathology and treatment, inasmuch as it possesses a distinct sac.
   There are two varieties of this form of aneurism;  in the first, a puncture is
made in an artery, or the vessel is ruptured subcutaneously, as perhaps in the
reduction of an old  dislocation, an extravasation of blood takes  place into the
tissues in the neighborhood of the wound, and if there is an external aperture,
this cicatrizes.  The blood that is extravasated becomes surrounded and limited
by a dense  layer of  plastic matter poured  out into the areolae of the neighbor-
ing tissues, and forming a distinct circumscribed sac, which is  soon lined by
layers of fibrine deposited from the blood that passes through it.  This tumor,
usually  of moderate  size,  and of tolerably  firm  consistence,  pulsates syn-
chronously with the beat of the heart, and has a  distinct bruit, both of which
cease when the artery leading  to  it  is  compressed.  This form  of circum-
scribed  traumatic aneurism most  commonly occurs from  punctured wounds
of small arteries, as the temporal, plantar, palmar, radial, and ulnar.
   The treatment  to be adopted depends  upon the
 size and situation of the artery with which the tumor         Fig. 73.
 is connected.  If the artery be small, and so situated
 that it can  be opened without  much after-inconve-
 nience  to the patient, as on the temple  or in the
 fore-arm, it should be laid open, the coagula turned
 out, and  the vessel  ligatured above and below the
wound  in it. If the tumor be so situated, as in the
palm, that it would be difficult and hazardous to the
integrity of the patient's hand to lay it open, the
Hunterian  operation  for aneurism  should be per-
formed, as  was successfully done  in the case (Fig.
73) in which the brachial was ligatured for an  aneu-
rism of this kind in the ball of the thumb, follow-
ing serious injury to the hand from a  powder-flask
explosion.
   It is but  rarely that this form of traumatic  aneu-
rism is connected with a large artery; when it is, the
vessel may  be  ligatured above, but close  to the sac, in the same way as in the
 
168                  INJURIES OF ARTERIES.
next variety.  If this  form of traumatic aneurism  have increased greatly in
bulk, so that the skin becomes thin and discolored, or inflammation ensues, and
symptoms of impending suppuration take place around it, then  it would be use-
less  to ligature the  artery above the tumor, as  this would  certainly give way,
and  secondary hemorrhage  ensue.   Here the proper course  is to lay open the
sac, turn out the contents, and ligature the artery above and below the part that
is wounded.
  The next form of circumscribed traumatic aneurism is of  rare occurrence,
and  usually arises from a small puncture in  a large artery, as the axillary or the
carotid.   This bleeds freely, but the hemorrhage being arrested by pressure, the
external wound and that in the artery close.  The cicatrix in the artery gradually
yields, forming, at the end of weeks or months, a tumor which enlarges, dilates,
and  pulsates eccentrically, with distinct  bruit,  having all  the symptoms that
characterize an aneurism from disease, and  having a sac formed by the outer
coat and  sheath  of the vessel.   It is at first soft  and compressible on being
squeezed, but becomes harder and firmer, and cannot be so lessened after a time.
It consists of a distinct circumscribed sac, formed by the dilatation of the cica-
trix in the  external coat and sheath of the artery, no  blood being effused into
the surrounding tissues.   The treatment in  these cases consists of the ligature
or compression of the artery leading to the sac, in  accordance with the princi-
ples that  guide us in the treatment of aneurism from disease;  though from the
healthy state  of the coats  of the vessel, the artery may be  ligatured as near as
possible to the sac.

                    ARTERIO-VENOUS  WOUNDS.

   The wound in the artery may communicate with a corresponding one in a con-
tiguous vein, giving rise to two distinct forms of disease — aneurismal varix
and varicose  aneurism.   These preternatural communications, which were first
noticed and accurately described by W. Hunter, most commonly happen at the
bend of the arm, as a consequence of the  puncture of the brachial artery in
bleeding, but they have been met  with  in  every part  of the body in which an
artery and vein lie in  close juxta-position, having been found to occur as a con-
sequence of wounds of the subclavian, radial,  carotid, temporal, iliac, femoral,
popliteal, and tibial arteries.  The  two forms  of disease to which the preter-
natural communication between arteries and veins give rise,  differ so completely
in their nature, symptoms, effects, and  treatment, that a separate consideration
 of each is required.
   1st. Aneurismal varix results when a contiguous  artery and vein having been
 perforated, adhesion takes place between the two vessels at  the seat of injury,
 the communication between them continuing pervious, and a portion of the arte-
 rial blood  being projected directly into  the veins at  each  beat of the pulse.
 Opposite to the aperture of communication  between  the two vessels, which is
 always rounded and smooth, the vein will be found to be dilated into a fusiform
 pouch, with thickened coats.   The veins of the part generally are considerably
 enlarged, somewhat nodulated, tortuous, and thickened.  The artery above the
 wound is dilated ;  below it is. usually somewhat contracted.  These pathological
 conditions  are evidently referable to a  certain quantity of the  arterial  blood
 finding its way into the vein, and  distending  and irritating it by its presence
 and pressure, and less consequently being conveyed by the lower portion of the
 artery.
   The symptoms consist of a tumor at the seat of injury, which can be  emptied
 by pressure upon the artery leading to it, or by compressing its walls.  If sub-
 cutaneous, this tumor is of a blue  or purple color, of an  oblong shape,  and will
 be seen to receive the dilated and  tortuous  veins.  It will be  found to pulsate
  distinctly  with  a tremulous jarring  motion,  rather  than  a  distinct impulse. 
VARICOSE  ANEURISM.
169
Auscultation detects in it a loud and blowing, whiffing, rasping or hissing sound,
usually of a peculiarly harsh character.  This  sound has very aptly been com-
pared by Porter, to the noise made by a fly in a paper bag, and by Liston, to
the sound  of  distant  and complicated  machinery.   The thrill  and sound are
more distinct in the upper than in the lower part of the limb, and are most per-
ceptible if it be allowed to hang down so as to become congested.   Besides these
local symptoms, there  is usually some muscular weakness  and diminution in the
temperature of the part supplied by the injured artery.
   As this condition, when once formed, is  stationary, all operative interference
should be  avoided, an elastic bandage  merely being applied.   Should a case
occur in which more than this  is required, the artery must  be  cut down upon
and ligatured  on either side of  the wound in it.
   2d.  Varicose Aneurism. — In  this case the opening in the  artery and vein
do not directly communicate (see Figs. 75 and 77), but an aneurismal  sac is
formed between the two vessels into which the blood is poured  before passing
into the vein.
   The pathological condition of this form of injury consists  of a circumscribed
false  aneurism, communicating on  one  side with the artery, and on the other
with the vein which is always in  a state of varix, as represented in the annexed
cuts from drawings of Sir C. Bell's, in the Museum of University College, re-
presenting a varicose  aneurism before and after it has been opened (Figs.  74 to
76).  In this case there appears to have been  a high division  of the  brachial
and a communicating branch below the  wound, between the  radial and ulnar, in
consequence of which, as  Mr. Shaw informs me, the tumor  pulsated as forcibly
after the operation  as before, the blood  finding its way back through the aneu-
rism into the  veins, caused gangrene of the hand and arm.

                                  Fig.  74.
   In the  symptoms of varicose  aneurism, we  have  a combination of  the
characters  of aneurismal varix, and of the circumscribed traumatic aneurism;
there is a pulsating tumor,
at first soft  and compres-                     Fig. 75.
sible, but after a time, as-
suming a more  solid con-
sistence, in consequence of
the  deposition  of  fibrine
within it; above this tumor,
the vein that has been punc-   W.        mlWi^^^fW  <&jm&B   ^*y*i
tured is dilated into a fusi-
form pouch, presenting the
ordinary characters of va-
rix.   The  sounds   heard
in these tumors are of two distinct kinds:  there is the peculiar buzzing thrill
that  always exists where there is a preternatural  communication between an
 
170
INJURIES  OF  ARTERIES.
artery and vein; besides this, there is  a  blowing or bellows  sound dependent
on the aneurismal disease.   These  signs are most perceptible when the limb is

                                  Fig. 76.
in a dependent position, and the sounds can often be heard in the veins at a
considerable distance from the  seat of injury.   There is also some impairment
in the nutrition and temperature of the parts supplied by the injured vessels.
As  the disease advances, the aneurismal tumor lying between the artery and
vein continues to increase in size, and to become hardened by the deposition of
laminated fibrine.   If left to itself, it would probably continue to enlarge until
sloughing of the integuments covering it, followed by hemorrhage, took  place.
In  some  cases, the  aperture  of communication  between  the  vein and  sac
becomes closed, and the  aneurism is converted into one  of the false, circum-
scribed variety.
  The treatment of this disease must be conducted on different principles from
                                            those that  have been  laid down
                   Fig. 77.                   as required in the ordinary cir-
                                            cumscribed traumatic  aneurism;
                                            the  difference depending upon
                                            the  fact, that  in  the varicose
                                            aneurism there is always a double
                                            aperture in the sac, and that thus
                                            the  proper deposition of lami-
                                            nated fibrine necessary for its oc-
                                            clusion  cannot take place.   The
                                            sac of such an aneurism may be
                                            compared to one  that  has been
                                            ruptured, or accidentally opened,
                                            in which we could consequently
                                            not  expect  the occurrence of
those  changes  that are  necessary for  the cure  of aneurism by the Hunterian
operation.
   In a varicose aneurism, consequently, the sac must be freely incised, and the
artery tied  on  either side of the puncture  in it.  Now  this procedure may,
unless the surgeon be careful, and  properly understand  the pathology of this
disease, be attended by some difficulty.   (Fig. 77.)  After the first incision has
been made through the integuments, the dilated vein  will be laid open, and an
aperture will be seen at the bottom of the vessel, from which arterial blood may
be made to issue.   If an attempt be made to find  the artery immediately below
this aperture, the surgeon will be disappointed, for the sac of the circumscribed
aneurism intervenes between the two vessels.  That this aperture  leads into
the  sac, and not into  the artery, may readily be  ascertained by introducing  a

  Note.—Figs. 74 and 75 represent a varicose aneurism at the bend of the arm unopened.
Figs. 76 and 77,  the  same  tumor laid open, showing the circumscribed  false aneurism
between the two vessels.
 
SECONDARY  HEMORRHAGE.
171
probe into it, which will be seen  to be capable of being carried sideways, as
well as upwards and downwards, to  a considerable  extent,  and in  dift'erent
directions, altogether out of the course of the artery.   In order to expose this
vessel properly, a probe-pointed bistoury must be introduced into  this  opening,
and the sac of the  false aneurism slit up to its full extent, the coagula turned
out, and the puncture in the artery sought for at the bottom of the cavity that
has been exposed;  this may now readily be made visible by the escape of a jet
of arterial blood on relaxing the  pressure  on the upper part of  the  artery; a
ligature must then  be passed above and below the wound, and the cavity lightly
dressed with lint.

                   ACCIDENTS AFTER  LIGATURE.
   The  accidents that may follow the  application of the ligature to wounded
arteries are, secondary hemorrhage,  and gangrene of the limb.
   By  Secondary or Recurrent Hemorrhage, is  meant bleeding from  any cause
after  the application of a ligature.   This accident may arise from a variety of
circumstances, which  may be divided into two great  classes: — 1st, those that
are dependent  upon the vessel or ligature;  and 2d, those that are connected
with some morbid  condition of the constitution or of the blood, in consequence
of which  those changes which are  necessary for  the occlusion of the artery do
not take place.
   Amongst the first class  of causes may be mentioned  any imperfection in the
application of the ligature; as, for instance, its being  tied too loosely, or with
the inclusion  of a portion of nerve, vein,  or muscle; so also the accidental
puncture of the artery above the  point to which the ligature  is applied.
   The rush of blood through a neighboring trunk, or  collateral  branch  imme-
diately above the  ligature, has been considered as likely to interfere with the
formation of the internal plug; but  too much importance should not be attached
to  this, for  Porter has tied the  carotid  successfully  within  one-eighth  of an
inch  of the  brachio-cephalic  artery.   Bellingham has ligatured the external
iliac  close  to  its origin;  and Key, the  subclavian in  the  vicinity of a large
branch, without secondary hemorrhage ensuing.   I think, however, that the
presence  of a collateral  branch  in close  proximity to the  distal side  of the
ligature — more especially if it be one  that serves to carry on  the anastomosing
 circulation — will  be found  to have  a  decided  tendency in preventing the
 formation of an internal coagulum.
   The wound of a collateral branch immediately above the ligature, though it
 do not give rise to troublesome hemorrhage at the time, will, as I have seen,
 cause furious bleeding as the collateral circulation becomes established.
    A diseased state of the  coats of the artery at the point deligated, will occasion
 rapid sloughing and unhealthy ulceration  of  the vessel;  those plastic changes
 which are necessary for its occlusion not  going on within it.   It has happened
 that  fatal secondary hemorrhage has occurred from a large artery, such as the
 femoral,  in consequence  of a  small atheromatous  or calcareous  patch  having
 given way immediately above  the ligature a day or two  after its application.
    The constitutional causes  of secondary hemorrhage act by preventing the
 formation of a clot within, and the deposit of plastic matter without, the artery;
 or if  formed, causing their  absorption in a  few days.   (Figs. 70  and 71.)
 Amongst the most common of these  causes are those  unhealthy states  of the
 system in which inflammation  of a diffused or erysipelatous character sets in,
 which is incompatible with plastic effusion.   In these cases  either no internal
 coagulum at all is formed, or if any is deposited it is  weak, imperfect, and
 unable to  resist the  impulse  of  the blood; or if it have already formed, it
 speedily becomes absorbed or disintegrated, offering no resistance  to the impulse
 of the blood, and  being washed away.
    The occurrence  of erysipelas, phlebitis, or sloughing  of the stump or wound, 
172
INJURIES OF  ARTERIES.
will  prevent or arrest the  necessary  adhesive inflammation.  Besides  these
conditions, there are certain states of  the  blood in which from  disease, as
albuminuria, it has lost its plasticity, and cannot yield the products of adhesive
inflammation.  Secondary hemorrhage is especially  apt to  occur in  cases of
pyemia, provided that disease assume a somewhat chronic character.   The con-
ditions of the blood in pyemia being incompatible with the formation of a firm
and plastic coagulum  within  the artery, the vessel continues or becomes open,
and secondary hemorrhage will certainly  occur.
   The occurrence of secondary hemorrhage is usually somewhat gradual, and
not without warning.   The  blood  does not burst forth in a  gush at once, but
appears at first in a small quantity oozing  out of the wound and staining the
dressings;  it may then  cease to flow for a time, but breaks out again in the
course of a few hours, welling-up  freely  in the wound, and either draining the
patient  by  repeated  losses, attended by the phenomena  that characterize
hemorrhagic fever, or else exhausting him so that he falls a victim to some
asthenic disease, such as pneumonia, erysipelas,  or phlebitis.  In  other cases
again, after a few warnings, it may burst out in a gushing  stream that at once
destroys life.
   The opportunities that I have had of  examining the state of  the vessels in
several  cases of fatal secondary  hemorrhage, lead  me fully to  concur with
Guthrie and Porter, that the blood in the great majority of instances comes
from the distal, and not  from the  proximal, side of  the wound.   The greater
tendency in the distal end  of the vessel to bleed, appears to arise  partly from
the less perfect occlusion of this portion of  the artery, and partly  from its
greater liability to slough, in consequence of the ligature interrupting its supply
of blood through the  vasa-vasorum.  It is no objection to this opinion that the
fatal hemorrhage is  often of an arterial character; for, though  it is true that
the blood which  is  carried to the distal end, is, for the first  few days after the
application of a ligature,  of  a venous hue;  yet after the collateral circulation is
once established, it gradually assumes  a  more  scarlet tint, and at last becomes
completely arterialized.
   Secondary hemorrhage may come on at any time  between  the application of
the ligature and the closure  of the wound.   There are, however, three periods
at which it is particularly apt to occur: — lstly, a few days  after the  ligature
has been applied; 2dly, about the period of the separation of the ligature; and
3dly, at an indefinite time after its  separation.
   The hemorrhage which occurs a few days after the application of the ligature,
arises, either from some imperfection in the tying of the ligature; from disease
in the arterial coats, causing them to  give way; or from  want of adhesive
inflammation on the face  of a stump:  when from the latter cause, there is a
general  oozing or dribbling  of blood from  many points of the surface rather
than a gush from one orifice.   In those cases in which the artery has been tied
above the wound only, hemorrhage is very apt to occur at this time.
   When hemorrhage  occurs about  the time of the separation of the  li-ature, it
may arise from any of the causes already specified that interfere with  the due
formation of an internal coagulum, or that occasion  sloughing of the coats of
the vessel.
   Lastly in some cases in which the ligature has separated, but the  wound has
remained open, the  hemorrhage may take place either from  the cicatrix in the
artery being too weak  to support the impulse of the blood; or from the coagulum
being obsorbed  in the way already mentioned.  The continuance of the open
state of the wound after  the separation  of the ligature, is, I think,  not impro-
bably dependent upon a  morbid condition  of the coats of  the  vessel, which
eventually leads to hemorrhage.  The length of time that will sometimes elapse
between the separation of the ligature and the occurrence of hemorrhage is very
remarkable   thus there is a  preparation in  St. Thomas's  Hospital of a carotid 
SECONDARY  HEMORRHAGE.
173
artery from which secondary hemorrhage took place in the tenth week after
ligature; and South mentions a case of ligature of the subclavian, in which the
thread separated on the twenty-seventh day, the fatal hemorrhage occurring in
the thirteenth week.
  The Treatment of Secondary Hemorrhage must be considered, as the bleed-
ing takes place; lstly, from a stump; — and 2dly, from an artery tied in  its
continuity.
  In all cases of ligature of arteries, care should of course be taken to prevent,
if possible, this  accident, by keeping the patient perfectly quiet, giving  no
stimulants, having the bowels kept open, and the secretions free, and avoiding
any undue traction on the ligature itself.
  lstly, The treatment  of secondary hemorrhage from a stump will depend in
a great measure on the degree of union that has taken place between the flaps.
  When the hemorrhage occurs  a few days after amputation, if there be but
slight oozing, elevating the part, applying cold, and bandaging it with a roller,
so as to compress the flaps, will sometimes arrest the bleeding.  If it continue,
however, or  become  more severe, the flaps which will  have been disunited  by
the effusion  of blood, must  be separated, and the bleeding vessels sought for
and tied. In some cases the ligatures will not hold;  under these circumstances
the application of the actual cautery will arrest the flow of blood.  If the oozing
appear  to be pretty general from a number of points, the flaps being somewhat
spongy, I have succeeded in arresting the hemorrhage by clearing their surfaces
thoroughly of all coagula, and then  bringing them tightly together  by means
of a roller.
   If the hemorrhage occur at a later period,  after the eighth or tenth day, when
tolerable union has taken place,  and appears  to  proceed from  the  principal
artery of the part, an effort may be made to arrest it by the application of the
horse-shoe tourniquet, which occasionally will stop  all further loss of blood;  or,
if the union that had taken place  between the flaps has been  broken through,
the stump may be fairly opened up, the coagula turned out, and the bleeding
vessel sought for and  tied.  If, however, several weeks have elapsed, or  if,
notwithstanding  the hemorrhage, the union  between the flaps  continues sound
and firm, then the choice lies  between ligaturing the artery in the stump itself,
by making a fresh incision, or continuing the old one up;  or else  in  ligaturing
 the artery at some distance  above the stump.   I prefer the former method, as
 in  this  way the  surgeon is  led directly to the  open and  bleeding vessel, and
 the patient  escapes  the  dangers of  a second formal operation.   But if this
 cannot be done, it will  be  necessary to tie  the main  artery  of the limb just
 above the flaps, or wherever it can be most readily reached;  thus, in  amputa-
 tion of the  leg, the superficial femoral may be ligatured; after  removal of a
 thigh,  the same artery, or the external iliac; and in disarticulation of the arm
 at the shoulder-joint, the subclavian  artery must  be tied, either above  or just
 below the clavicle.
   2dly. When the hemorrhage occurs after a ligature  has been  applied to  the
 continuity of the vessel, whether  for injury or disease, pressure  must first  be
 tried.   With this view the wound should be  plugged, and a graduated compress
 should be very firmly and carefully applied by means of a ring tourniquet over
 the point from which the blood proceeds, which in this way may occasionally be
 stopped.  Not unfrequently, however, this will prove ineffectual, the bleeding
 recurring from underneath it.  When this is the case, what course should the
 surgeon pursue ?  He may re-apply the compress once  more with great  care,
 after clearing away coagula, and  drying the parts thoroughly;  but should it
 again  fail in arresting  the  bleeding, it is useless to trust to it again, as the
hemorrhage will certainly recur, and valuable time and much blood will be lost
in these fruitless  attempts at checking it.   The course that the surgeon should
pursue in such a case as this, is a most anxious  consideration, but one on which 
174
INJURIES OF  ARTERIES.
his mind snould be clearly and decidedly determined, as there is but little time
for reflection or consultation, and none for referring to authorities. ^
   If the artery be situated on the trunk, as the subclavian, carotid, or one of
the iliacs, there is  nothing to be done but to trust to the plugging of the wound,
and in the  great majority of these cases the patient will die  exhausted  by re-
peated hemorrhage.
   When the artery is situated in one of the  limbs, more efficient procedures
may be had recourse to.   If it be one of  the  arteries of the upper extremity,
the wound should be opened up, and  an  attempt made to tie both ends of the
vessel  again in this; should this fail, or not be practicable, the artery must be
deligated  at a  higher  point than that at which it had been previously tied;
should  the hemorrhage  still continue, or  be re-established, amputation  is the
only resource left.
   In the lower extremity, the treatment of this form of secondary hemorrhage
renders the case replete with difficulty.  Here I believe it to be useless to tie
the artery at a higher point than that to which the ligature has been already
applied, as gangrene invariably follows this double  ligature of  the  arteries of
the lower  extremity:  at  least  in  the two or three cases that I have seen in
which this practice has  been  had recourse to,  mortification of the limb has
ensued; and in all the reported cases with which I am acquainted, a similar
result  has  occurred.   Under these  circumstances, therefore, I  should be dis-
posed to recommend the surgeon to cut down on the bleeding part of the vessel,
treating it as a wounded artery, and applying a ligature above  and below the
part already deligated;  an operation that would necessarily be fraught with
difficulty.   Should this  be impracticable, or not  succeed  in  checking the
hemorrhage, I think that we should  best consult the safety of the patient by
amputating at  once on a level with the ligature.   Although  this is a severe
measure, it is  infinitely  preferable  to allowing him to run  the  risk of the
supervention of gangrene, which will require  removal of the  limb under less
favorable conditions.   If the hemorrhage occur from a wounded  artery, to which
ligatures have  already been applied  above and  below the  seat  of wound, the
same treatment must be adopted as  in those cases in which the bleeding  takes
place from the  application of the ligature to the continuity of the vessel.
               GANGRENE  FOLLOWING  LIGATURE.

  After the ligature of the main artery of a limb, the collateral  circulation is,
under all ordinary circumstances, sufficient to maintain the vitality of the part
supplied  by the deligated vessel.  In some cases, however, it happens that the
condition of the circulation  in  the parts  below the  ligature is  not  compatible
with their life.   The occurrence of gangrene in this way  is influenced  by the
age of the patient, the  seat of the operation, and the various conditions in which
the limb  may afterwards be placed.
  The influence of age  is not, however,  so marked as might be supposed; for
although there can  be no doubt  that there is a less  accommodating power in
the arterial system to varying quantities of blood at an advanced period of life,
and that, there would  be greater difficulty in  maintaining the vitality of the
limb after ligature of the artery in a man of sixty than  in one of twenty-five;
yet I find, that of thirty cases  in which gangrene of the  lower extremity fol-
lowed the  ligature either of the  external  iliac or femoral arteries, that  the
average age of  the patient was  thirty-five years, as  nearly  as possible the mean
age at which these  operations, according to Norris's  Tables, are generally per-
formed.  Of these cases of gangrene, 2 occurred under twenty years of age, 11
between twenty and  thirty, 8 between thirty and forty, and 9 above forty.
  The seat of the operation influences greatly the liability to gangrene, which ia 
GANGRENE  FOLLOWING  LIGATURE.
175
much more frequent after the ligature of the  arteries in the lower, than in the
upper extremity.
  Besides  these predisposing causes, gangrene after ligature may be  directly
occasioned by a deficient supply of arterial blood.
  In some  cases this may arise  from the collateral vessels being unable, in
consequence of the  rigidity of their coats, to accommodate themselves to the
increased quantity of blood they are required to transmit; or they may be com-
pressed  in  such a way by extravasation as to be  materially lessened  in  their
capacity.  In other instances again, the existence of cardiac disease may inter-
fere with the proper supply of blood to the part.
   Great loss of blood, either in  consequence of secondary hemorrhage, or in
any other way, before or after the application of the ligature, is often  followed
by gangrene, and is almost  certain to be attended  by this  result if  a second
ligature has  been applied  to a higher point in  the lower extremity.   That a
diminution in the quantity of blood circulating in the system  may, under the
most favorable circumstances, become a cause of gangrene  after the ligature
 of the artery, is illustrated by the statement of Hodgson, that soon  after the
 introduction of the Hunterian operation into Paris, it was the custom to employ
 repeated venesection in  the cases  operated on,  the  consequence of which was
 that mortification was of frequent occurrence.
    A more common cause of gangrene is the difficulty experienced by the venous
 blood in its return from the limb.  This difficulty always exists even when no
 mechanical obstacle impedes its return,  being dependent  on the want of a
 proper vis d tergo influence to drive it on.   The propulsive power of the heart,
 which is  the main agent  in the venous  circulation, is  greatly diminished by
 being  transmitted  through the narrow and  tortuous channels of  the anasto-
 mosing vessels.   This difficulty to the onward passage of the venous blood may,
 if there exist any cause of obstruction in the larger venous trunks, be readily
 increased to such an extent as to choke the collateral  circulation, and so cause
 the limb to mortify.  This mechanical obstacle may  be dependent upon the oc-
 clusion of the vein by inflammation excited within it opposite  the ligature, by
 its transfixion with the  aneurism needle, or by its  accidental wound  with the
 knife in exposing the artery.   When such an injury, followed by inflammation,
 is inflicted on a vein, which, like the femoral, returns  the great  mass of blood
 from a limb, gangrene is the inevitable result.
    The supervention of erysipelas in the limb after the application of  the  liga-
 ture, though  fortunately not of  very frequent occurrence, is a source of con-
 siderable danger, being very apt  to give rise to gangrene by the tension  of the
 parts  obstructing the anastomosing  circulation    I  have  in  this way, on two
 occasions, seen gangrene of the fingers follow the  ligature  of the vessels of the
 forearm.
    The abstraction of heat from the limb, either directly by the application of
 cold, or indirectly, by the neglect of sufficient  precaution to keep up the tem-
 perature of the  part, often occasions gangrene: thus Sir A. Cooper  has  seen
 mortification follow the application of cold  lead lotion, to a  limb in which the
 femoral artery has been  tied; and Hodgson has witnessed  the same result when
 the operation was performed at an  inclement season of the year.
    The incautious  application  of heat may, by  over-stimulating the  returning
 circulation  of the limb,  especially about that period when the rising  tempera-
 ture is an indication of increased action in  the  capillary vessels, occasion mor-
 tification.   In this way the application of hot  bricks and bottles to the feet
 have given rise to sloughing; and Liston was compelled to amputate the thigh
 after  ligature of the femoral artery, for  gangrene,  induced by fomenting the
 limb with hot water.
    The  application of a bandage, even  though very cautiously made,  is apt to
 induce sloughing  and gangrene.   I have seen this happen when a roller was 
176
WOUNDS  OF  SPECIAL  ARTERIES.
applied to the leg after ligature of the femoral, with a view of removing the
oedema.
  The period  of  supervention of gangrene  of the limb  extends over the first
three or four weeks after the ligature  of the vessel.   It seldom sets in before
the third day, but most frequently happens before the tenth.
  The gangrene  from ligature of an artery is almost invariably of the moist
kind, on account of  the implication  of  the veins.  The limb first becomes
cedematous. vesications then  form, and it assumes a purplish or greenish black
tint, rapidly extending up to the seat  of operation.   In some cases, though they
are rare, simple  mummification  of the  limb comes  on,  the  skin assuming a
dull yellowish-white hue, mottled by  the streaks that correspond to the veins,
and becoming dry, horny, and shrivelled,, about the extensor tendons of the
instep.
   Treatment of  Gangrene following Ligature. — Much may be done with the
view of preventing this.  Thus:  the limb should  be elevated,  wrapped  up
loosely in flannel  or cotton wadding, and laid on its  outer side after the opera-
tion.   If the weather be cold, hot water bottles may be  put into the bed, but
not in contact with the limb.  Should there be any appearance of stagnation of
venous blood, the plan recommended by Mr. Guthrie  of employing continuous
and methodical frictions  in a direction upwards  for twenty-four hours, so  as to
keep the superficial veins emptied, may be practised.
  When mortification has fairly set in, amputation  of the limb should be had
recourse to at once as the only chance of saving  life, in all those cases in which
the patient's constitutional powers are sufficiently strong to enable him to bear
the shock  of the  operation.   The limb should be  removed at the seat of the
original wound, or opposite  the point at which  the  artery has been tied.   In
those cases, however,  in which the  gangrene follows injury  of  the femoral
artery just  below Poupart's  ligament, Guthrie advises  the amputation to  be
done below the knee, where it usually stops for a time.  If the gangrene spread,
with oedema or serous infiltration of the limb, the  amputation  should be  done
high up;—at the shoulder-joint, or in the upper-third of the thigh.  In these
cases a large number of vessels  usually require ligature, having been enlarged
by  the collateral circulation.
                         CHAPTER  XII.

                 WOUNDS OF SPECIAL  ARTERIES.

 _ Carotid.—Wounds of the carotid artery, and of its primary and secondary
divisions, are of more frequent occurrence in civil practice than similar injuries
of any other set of arteries in the body, in consequence of the neck being so
frequently the seat of suicidal attempts.   The hemorrhage from wounds of the
main trunk is so copious as often to be immediately fatal.  In  the event of a
surgeon being at hand, both ends of the  bleeding vessel must be  at once liga-
tured.   In consequence of the speedy fatality  of wounds of the carotid artery
and of its primary branches, traumatic aneurisms  are  rarely met with in this
situation; they do, however, occasionally occur, and the records of  surgery con-
tain at least  five instances of this kind, in all of which the common carotid was
tied, and the patient ultimately recovered.
^  Aneurismal  Varix of the internal jugular vein dependent on punctures  of
it,  or of the  carotid artery, usually the  result of sword-thrusts in the neck, are 
      WOUNDS OF SUBCLAVIAN AND AXILLARY ARTERIES.  177

apparently of more frequent occurrence than traumatic aneurism in this region;
probably owing to the  close proximity of the vein rendering it difficult for the
artery to be wounded  on  the outer or anterior sides, without  first perforating
that vessel.   The symptoms presented by these cases, though offering the gene-
ral characteristics of aneurismal varix, yet have several points  that are worthy
of special remark.   The wound of the vessels was in every instance followed
by the effusion of a large quantity  of blood into the loose cellular tissues of the
neck; the extravasation acquiring even the size of a child's head, and threaten-
ing immediate suffocation.  As this  extravasation  subsided, the ordinary cha-
racters of aneurismal varix began to manifest themselves.  The period at which
these symptoms first made their appearance, varied somewhat  in  the different
cases, but they always occurred within four or five days  of the receipt of the
injury.  In none of the cases did the disease appear to shorten life, or to have
occasioned any dangerous or inconvenient effects, with the exception  of some
difficulty in lying  on  the affected side, and occasional giddiness or noise in the
head on stooping.
    Varicose aneurism  does not appear to have been met with in this situation.
No operation  is admissible in these affections.
    Traumatic aneurisms of the temporal artery, and of its branches, occasionally
occur as the result of  partial division of these vessels in cupping on the temple;
two cases of this kind I have met with, in both of which the disease was readily
cured by laying the tumor open, turning out its contents, and tying the artery
on either side of it.
    Subclavian. — A  wound of the subclavian artery may almost invariably  be
looked upon as fatal, though in consequence of the manner in which it is pro-
tected  by the clavicle these injuries can scarcely occur except from gun-shot
violence.  From the rapidly fatal  nature of wounds of the subclavian artery,
traumatic aneurisms in  this situation are not met with; but  when the  artery
passes into the axilla below the margin of the first rib, they are not of unfre-
quent occurrence.   Aneurismal varix of the subclavian vein resulting from
wound of the artery in this situation, has, however, been seen, notwithstanding
the separation that exists between  the two vessels until they reach the  acromial
angle of the subclavian space.   These  injuries have likewise  usually been the
result of sword-thrusts, and do not admit of any surgical interference.
    Axillary.—In open wounds of the axillary artery, and of its branches, the
 rule of practice consists, in cutting down upon the bleeding vessel wherever it
 may be situated, and  ligaturing it on  either side  of the wound.  It  must  be
 borne in mind, that the arterial branches given off between the  lower  edge  of
 the first rib, and the fold of the axilla being very numerous, a punctured wound
 of the axilla  or side of the chest may injure one of these vessels, though from
 its course, and the free flow of arterial blood that has followed the stab, it may
 be supposed that the axillary artery itself has been punctured.  The particular
 vessel injured can only be ascertained by following up the wound and ligaturing
 the artery that furnishes the blood.
    In some cases, however, the state  of the parts may be such, that  it may be
 impossible  to trace the artery at  the depth at which it is situated,  or even to
 expose it in a mere superficial  situation, as in the stump after amputation at the
 shoulder-joint.  Under these circumstances, the rule  of surgery, of ligaturing
an artery at the seat of injury,  may be departed from, and the main trunk should
be tied either above or below the clavicle; and the success of this operation has
been sufficient  to  justify our  having recourse to  it  rather than  exhaust the
patient by  any prolonged attempts at the ligature of the vessel  in  the open
wound, though I think that this ought first  to  be  attempted.   Of 15 cases in
which  the  artery  has been ligatured  either above or below  the  clavicle,  for
hemorrhage from wounds in the axilla or from stumps, I find that 9 were cured
and 6 died.   Although the success is about  equal in whichever situation the 
178
WOUNDS  OF  SPECIAL  ARTERIES.
vessel be  tied, I should certainly give the preference to the supra-clavicular
operation, owing to the greater facility of its performance, and the comparative
absence of collateral branches at the seat of ligature.  In some cases, however,
especially after amputations at the  shoulder, the clavicle is pushed up  at its
acromial end, and then the artery might be  best reached  below the clavicle,
under or through the pectoral muscles.
   Traumatic Aneurisms in the Axilla are not of unfrequent occurrence, arising
directly from gun-shot wounds, or from the thrust  of a knife, sabre, or other
pointed weapon.   In some cases the injury arises from a subcutaneous rupture
of the vessel, the patient stretching out and straining his arm in an attempt to
save himself from falling, and feeling a sudden snap in the axilla, which is
followed by the formation of a rapidly diffused aneurism.
   There are several cases on record  in which axillary aneurism has resulted
from violent attempts made by the surgeon in  the reduction of old standing dis-
locations of the head of the humerus.  Thus  Pelletan mentions a case of this
kind, in which  the tumor being supposed to be emphysematous, was opened, and
the patient perished of hemorrhage.  Warren relates a case of diffused axillary
aneurism resulting from rupture of the artery, in  consequence  of  the  surgeon
attempting to reduce a dislocation of the humerus by using his foot as a fulcrum
in the axilla, but without taking off his boot.   Gibson has  related three cases
of axillary aneurism following rupture of the  artery, in the attempt  to reduce
old standing dislocations with the pulleys.   These cases are of much interest to
the surgeon, as showing the necessity for great caution in the  use  of powerful
extending force in the reduction of old dislocations,  adhesions having probably
formed  between the  artery and head of the bone.
   Some of these traumatic axillary aneurisms have a tendency to diffuse  them-
selves with great rapidity, filling up the whole of the hollow of the armpit, and
extending  under the pectorals, even up around the shoulder.   In other cases
again, when more circumscribed,  the disease may get well  spontaneously,  as
happened in cases recorded by Van Swieten, Sabatier, and Hodgson.   In  other
instances  again,  the disease has remained stationary for years, or has  even
undergone spontaneous cure.  It cannot however be considered sound practice
to leave a traumatic  aneurism of this artery without surgical interference, after
the ordinary dietetic and hygienic plans of treatment have  failed in effecting a
cure, for it may at any time become rapidly diffused, or inflame and suppurate.
   The treatment of  traumatic axillary aneurism must  have reference not only
to whether it  is diffused or circumscribed; but if  diffused, whether it  be of
recent origin,  or have originated from puncture or subcutaneous rupture of the
vessel.
   When  a diffused  traumatic aneurism of recent origin, rapid formation, and
dependent upon puncture of the artery, is met with in the axilla, the treatment
must be conducted in the same way as that  of a wounded artery, without ex-
travasation, in  this situation.  The tumor should be laid open, the artery sought
for, and,  if possible, ligatured where  wounded.  If this be impracticable, it
may be deligated above the clavicle.  There  is, however, the danger after this
operation,  either of  secondary hemorrhage coming on from  the  seat  of wound,
by blood conveyed  through the collateral vessels,  which  open into the sub-
scapular and  circumflex arteries; or  else, of the limb falling into  a state of
gangrene.   In either case amputation at the shoulder and through the aneuris-
mal extravasation is the only practice that can be had recourse to.
   In those cases of diffused traumatic aneurism of the axilla  that arise from
subcutaneous  rupture of the artery, the condition  of parts  is essentially the
same as in a case of punctured wound of the  vessel, with the exception of the
existence of no external  aperture  in the integuments.   In these cases there is
a tumor of considerable size, hard  or fluctuating, according  to  the  state of
coagulation of  its contents, with  thrill, pulsation, a gushing,  hot sensation, 
TRAUMATIC  AXILLARY  ANEURISMS.
179
much oedema of the arm, tendency to inflammation, suppuration, and gangrene
of the sac.
  In such a case the choice would lie between treating the injury as that of a
wounded artery, by direct incision, or ligaturing  the vessel above the clavicle.
The first  plan, by direct  incision, has never to my knowledge been  practised,
and would present so many difficulties as scarcely to be a  justifiable  procedure.
The ligature of  the vessel above tfie clavicle has  been done three times, and
of these only one recovered, two of the patients dying of gangrene and second-
ary hemorrhage.  In the successful  case, secondary hemorrhage  had occurred,
and gangrene of the arm, which threatened,  was prevented, and the patient
saved, by having amputation at the shoulder-joint performed.
   Circumscribed traumatic  aneurisms  of the axillary artery are not uncom-
monly of slow  formation, existing for several  months  or years before  they
require operation,  although resulting from punctured wound  of the armpit.
In  chronic cases such as these, the aneurism is necessarily provided with a firm
and distinct sac, and  approaches closely in its  characters to the pathological
form of the disease. The treatment here  cannot  be conducted on the principles
that guide  us in the  management of  a  wound,  or of a diffused aneurism  of
recent occurrence  of this artery; for not only is  the circumscribed  aneurism
provided  with a sac, but the vessel, at the point injured, would very probably be
found to have  undergone changes that  would render it little able to admit or
 to  bear the  application of the ligature.   It would be softened, thickened, and
 lacerable, with perhaps a wide funnel-shaped aperture leading into  the sac,
 which would be closely incorporated with the  neighboring parts.  But indeed
 the treatment of this form of  circumscribed traumatic aneurism by the ligature
 of the artery on the proximal side of  the  sac, has been found  to be attended
with remarkable success.  In  eight recorded cases in  which this operation has
been performed, not one fatal  result has been noted.  In all, the aneurism  arose
 from  stabs  or gun-shot wounds, and had existed  for various periods, between
 two weeks and  four years.   In four of the cases  the artery was ligatured above,
 and in four below, the clavicle; and in one  case of each category there was
 suppuration of  the sac.
   The particular point at which the artery should be ligatured  must depend
 upon  the condition of the  tumor.   If this be of large  size, or arise from the
 upper part of  the  axillary  artery above or immediately below the pectoralis
 minor muscle,  there is  no  choice  but to deligate the vessel above the clavicle.
 Should, however, the  principal increase  in the tumor take place in a direction
 downwards and forwards under the  great pectoral muscle, the portion of the
 artery immediately  below the clavicle  appearing to be free  from disease, the
 question  would arise as to whether this part might  not be selected for the appli-
 cation of the ligature; and  as the results of both operations have hitherto been
 equally favorable, this  must rather be determined by the peculiarities in each
 case,  than on more general  grounds.   Most surgeons, I think, would  however
 prefer ligaturing the  artery above  the clavicle,  as being a simpler proceeding,
 than  tying it below that bone; which, moreover, has  the  disadvantage  of
 bringing the scalpel into very close proximity with the sac, which, were it to
 stretch upwards under the  pectoralis minor to  a  greater extent than could be
 discernible externally,  might possibly be  opened  by the knife, as has even hap-
pened in operating  above the  clavicle.   It has been recommended to apply the
ligature between the  sac and the origins  of  the  sub-scapular, and  posterior
circumflex  arteries, above the former  and below  the latter; but  this  is  an
anatomical  impossibility if the aneurism be situated above the lower border of
the axilla.
   Compression  of the artery on the distal side of the tumor  has succeeded in
curing the disease in a case  that was under Dr. Goldsmith,  of Vermont. 
180
WOUNDS  OF  SPECIAL  ARTERIES.
  The Brachial Artery and its Branches.—The hemorrhage from wounds
of the brachial artery may sometimes be arrested by the employment of metho-
dical compression, but usually it requires  ligature in the ordinary way on each
side  of the  aperture.  This  vessel may occasionally be the  seat of traumatic
aneurism, in consequence of a puncture received in venesection.  This accident,
which was formerly of frequent occurrence, when venesection was practised by
professed phlebotomists,  now very rarely  happens.   Should a  surgeon be so
unfortunate as to puncture the brachial  artery in this  way, he may prevent
injurious  after-consequences  by keeping up a proper degree of  pressure, by
means of a graduated compress applied immediately on the occurrence of the
accident.   With this view, the fingers, hand, and fore-arm,  having been very
carefully  padded and bandaged,  a well-made graduated  compress should be
firmly applied over  the seat of puncture, and retained there for at least ten
days or a fortnight.   Should  the aperture in the artery not be closed in this
way, either a circumscribed  false aneurism, a varicose aneurism, or an aneu-
rismal varix will form, according to its situation in relation to the vein.
   In the Circumscribed Traumatic Aneurism at the bend of the arm, following
a wound of the brachial artery, we have the usual soft or  semi-solid pulsating
tumor, which can readily be emptied on  pressure, and possesses more or less
bruit.   This disease may be treated in one of three ways : by compression upon
or above the tumor;  by  ligaturing the  artery leading to it;  or by cutting
through the sac, and deligating the vessel on either side of the aperture in it.
   The compression  of the tumor has  often been successfully practised.  It
may be done  by means of a graduated compress, or the application of a ring
tourniquet — the  tumor  becoming  consolidated, and  gradually  undergoing
absorption.   Should  this  plan not succeed, we must be guided in our ulterior
measures by the particular conditions of the case.  If the tumor be of recent
origin, soft and compressible; or, though  of longer duration, large, with a thin
sac, it should be treated by direct incision, and the artery be deligated on either
side of  the  wound  in it.  Should, however,  the tumor  be small, or but of
moderate size, and the sac be tolerably thick and firm, so as to admit  of the
deposit of laminated  fibrine, we may treat it by deligation of  the brachial
artery, either in the middle of the arm, or, as Anel  did  with  success, imme-
diately above the tumor.  In  the event,  however, of the  disease not being
cured in this way, incision of the sac must be had recourse to, as I have known
to be necessary in  a case in  which the  brachial artery  was tied above the
tumor, which was large,  with a thin sac, the pulsations returning in a few
days, and the tumor continuing to enlarge.
   Varicose Aneurism, at the  bend of the  arm, presents the  ordinary character
of the disease. ^  Occasionally, though rarely, it would  appear that the aperture
of communication between the aneurismal  sac and the vein becomes closed,
and thus the varicose is  converted into  the ordinary circumscribed traumatic
aneurism.
   The treatment of this affection must be conducted on different principles from
that  of the ordinary circumscribed variety, for whatever be  the density of the
sac, it is never, as has already been explained (p. 169), a perfect one, having
always an opening into the vein which would prevent its proper closure by the  .
deposit of laminated fibrin.  In 4 cases related by Sabatier, which were treated
by Anel's operation, amputation became necessary in 2, and in the other cases,
the operation by incision of the sac was required before a cure could be effected.
 The sac must therefore be laid open, and the vessel tied on either side of it in     a
 the way that has been recommended in the treatment  of that disease, and with
 the caution there laid down.   If the varicose aneurism be converted, after a few
 days, into the circumscribed form, the aperture into the vein becoming occluded,
 the ligature  of the artery above the sac may be successfully employed, or com-
pression succeed in  curing the disease. 
WOUNDS OF  THE  PALMAR  ARCHES.
181
  In aneurismal varix of the arm, a roller and compress  are all that  can be
required.
  Arteries of the Fore-arm and Palm. — These vessels are very commonly
wounded by pieces of glass, earthenware, or knife-cuts.   In every case the
bleeding-point must be cut down upon, and both ends of the vessel tied.  This
rule is peculiarly imperative in  this situation, on account of the freedom of the
anastomosis through the palmar arches.   In many of these cases the bleeding is
at first very free, but, being arrested by pressure, does not break out again until
eight or ten days have  elapsed, when,  the  arm being much infiltrated with
blood, inflamed, and swollen, double ligature of the vessel, at the seat of injury,
has to be practised under somewhat difficult and unfavorable circumstances.
   Traumatic Aneurism of the Radial and Ulnar Arteries usually assumes the
circumscribed form, owing to the pressure employed at the  time of injury, con-
fining the extravasation.   If it  be small and recent, and situated superficially
at the lower part of the fore-arm, or if it  be in any way diffused, the better plan
is to cut down upon and through the tumor at once, ligaturing  the vessel on
either side.  If, however, the aneurism  be deeply seated amongst the mass of
muscles at  the  upper part of  the fore-arm, near the elbow joint, the wound
having  healed, and the soft parts covering it being healthy  and firm, the advice
given by Mr. Liston appears to be most judicious :—rather than cutting through
the muscles, and detaching their connections, he recommends that the aneurism
should  be left  to  attain  some consistence,  and then that the brachial artery be
secured in the mid-arm.
   Wounds  of the Palmar Arches not unfrequently occur from the breaking of
glass or bottles in the hand, or stabs from some pointed instrument,  and are
always  troublesome to manage.   If the surgeon see  the case shortly after the
infliction of the wound, he might endeavor,  by enlarging the aperture to a mode-
rate extent, and with due attention to the tendons and nerves of the  part,  to
secure,  the bleeding vessel.  Should he  fail  in doing this, which he certainly
would if it be the  deep arch that is injured, a graduated compress must be well
and firmly applied from  the bottom of the wound; and that artery above the
wrist which appears most to  correspond  with the arch wounded, or better still,
the brachial itself should  be compressed with a ring tourniquet, or the elbow
may be forcibly flexed, and cold assiduously applied.  If the case be not seen
until several days  have elapsed, when secondary hemorrhage has  occurred, and
the palm has become  infiltrated and  swollen, pressure can  no longer be borne
upon the seat of  injury, and it is useless to endeavor to search for the  injured
vessel in the midst of sloughy and infiltrated tissues, through a narrow wound
which cannot be  enlarged without danger of disorganizing the hand.  Under
these circumstances, it is necessary to deviate from the ordinary rule of practice
in wounded arteries, and  both  arteries should  be tied,  immediately above the
wrist;  should hemorrhage occur after this, as  might happen in the case of an
enlarged interosseous artery, the surgeon  must try compression or ligature of the
brachial.
   Circumscribed  Traumatic Aneurism in the Palm is by no means of frequent
occurrence.  It may however follow wounds of the palmar arches.  In such a
case as  this, it would  be  clearly out of the question to lay  open the sac, and  to
search for the injured vessel in  the midst of the aponeurotic and tendinous struc-
tures of the hand.  It would consequently  be necessary, either to tie the radial
and ulnar arteries  immediately above the  wrist, or to ligature the brachial in the
upper arm.   The  latter plan  should be  preferred;  as, were the  first  mode of
treatment put into practice, the sac might continue to be fed by the interosseous
artery, as happened in a case of Roux's, in which the patient died of hemorrhage
from the palmar aneurism  after the ligature  of both  arteries of  the  fore-arm.
In the  case represented (fig. 73),  Liston successfully ligatured the brachial in
the mid-arm, after compression  upon it had failed to effect a cure. 
182
WOUNDS  OF  SPECIAL  ARTERIES.
    Femoral Artery and its Branches. — The hemorrhage from these arte-
  ries when wounded is always very profuse.  In all cases, ligature of the wounded
  vessel should be practised at the seat of injury.  If a diffused traumatic aneu-
  rism have already formed, the artery should be commanded by a tourniquet, as
  it passes over the  brim of the pelvis, the sac laid open, and the bleeding vessel
  sought for and  tied.  Mr. Guthrie has collected a great number of cases, which
  prove  incontestably that the general  principles of treatment in wounded arteries
  must not be departed from, when the arteries of the groin or thigh are wounded.
  On the contrary, the facility with which in most  cases the circulation  is kept
  up, and the readiness with which secondary hemorrhage comes on  as  a conse-
  quence of the free anastomosis in this situation, renders the rule  of practice of
  applying a ligature on both sides of the wound in the vessel peculiarly stringent
  in all recent  arterial wounds in this part of the body.   Secondary  hemorrhage
  and gangrene of the limb are the great sources of danger here.   When gan-
  grene is imminent, or has come on, amputation  is necessarily the  sole resource.
  With regard  to secondary hemorrhage, supervening after ligature of the artery
  at the seat of injury, there is, I think, no safe  course but removal of the limb
  Where the artery has been tied higher up, as for instance when  the external iliac
  has been ligatured for recent wounds or traumatic aneurisms in the groin  or
  upper  part of the thigh, the hemorrhage appears to have returned, or gangrene
  to have supervened in all the cases.  If the traumatic aneurism have assumed a
 circumscribed character,  it must be treated on the principles laid  down for this
 form of the disease, the supplying artery being ligatured above the tumor; and
 cases are not  wanting in proof of the success of this practice.
   It occasionally, though rarely, happens that a varicose aneurism is formed  in
 the groin or upper part of the thigh, as the result of wound of artery and vein
 in this situation.   It usually presents the  ordinary characters of this  disease
 but some peculiarities have occasionally been met with.   Thus, in a case related
 by Mr. Horner, there was a wavy motion in the femoral vein on the uninjured
 side, arising  from the blood in  the  wounded  vessel  communicating  a 'thrill
 upwards to that contained in the vena cava.  In a case related  by Dr Morrison
 it is stated that a tumor as large as the human uterus at the third month of
 pregnancy, communicated with the injured vein.
   The  treatment of this  disease is exceedingly unsatisfactory; of 4 cases in
 which  the external iliac artery was tied, a fatal termination occurred in  every
 instance 2 of the patients dying of gangrene of the limb, and  the remaining 2
 or secondary hemorrhage and consecutive pneumonia.  It has conseauentlv been
 proposed by Mr. Guthrie  that the tumor be laid open, and tie artery Jen
 above and  below the aperture in it.   As this plan has never been fairiy put in

 K?n V°J i PwapS. be US6lelS  t0  SpeCulate on  the  chances  of success
 of this kindTn thV     J   WG mUSiiGar in  mind> that la?in? open an aneurism
 of this kind in the groin is a very different matter from  adopting the same pro-
 cedure at  the  bend of the arm, or in a situation  where the surgeon can^eadily
 command the  artery on the proximal side of the sac.   The guS of bloodTom
  o large an artery as the common femoral, would be so great, that with wliateve^
 rapidity the operation were performed, there would be cons derable risk of the
 patient  suffering a fatal hemorrhage, before the vessel mnttlS Ha•        !  S
 is it wnnU K«  Z;fk o      j-       ,      ,, ,e vessel, matted and incorporated
 as it would be, with surrounding parts, could be separated and secured ■ and the
 ligature of the vein would probably be followed by gangrene of the limb

 the^TrteZte W STf° ^^ ? * d^ ^, ~ni^ with
 the arteries of the leg and  foot, require to be treated by the free  exposure of
 the bleeding orifice in the vessel, and its inclusion between two Latures  In

sZlo  Slf wT^ V^rf ?,the.rteH0r tibkl or PernK e y, t
su geon will have to  cut freely by the side of or through the muscles of the
calf.  This he must do in  the direction of their fibres, injurint them by trans
verse mcision as  little as possible, and by taking the track ofXTwin? as his 
             INJURIES OF  MUSCLES AND  TENDONS.         183

guide, the bleeding vessel will at last be reached, and  must then be tied in the
usual way.   In such cases as these, surgeons have often attempted to arrest the
hemorrhage by the ligature of  the superficial femoral or popliteal arteries;  and
though  they have occasionally  been successful, as happened  in a case in which
I saw the popliteal ligatured  for a wound of one of the arteries of the leg, yet I
fully concur with Mr. Guthrie in deprecating this practice, as contrary to good
surgery, and, with him, regard  the success that has occasionally  followed these
operations as purely accidental.
   Small circumscribed aneurisms are occasionally met with in the foot, in con-
sequence of the wound of one of the plantar arteries, as in operations for club-foot.
If pressure have failed in preventing or curing the disease, the only course left
to the surgeon is to lay the tumor open, and to ligature the artery on either side
in the usual way.
                         CHAPTER  XIII.

             INJURIES OF MUSCLES  AND  TENDONS.

   Sprains, or strains, of  muscular parts without rupture of fibre, are of very
common occurrence,  especially about the shoulder, hip, and  loins,  and are
accompanied by much pain,  stiffness, and  inability to move the part.   When
occurring in rheumatic subjects,  these injuries  not  uncommonly give rise  to
severe and persistent symptoms.   In  some  cases painful atrophy, rigidity,  or
local paralysis of the injured  muscle being induced.
  In  the treatment  of these  accidents, when  recent, it will  be found  that
kneading or  rubbing the part with a stimulating embrocation, the application
of dry cupping, or, if the pain be severe, the abstraction of a few ounces of
blood by cupping, together with rest, is most efficient.   If the  injury occur  in
a rheumatic constitution it will be found useful to give colchicum and Dover's
powder in the  following form: R Extr. Colchici Acetici, gr. i.   Pulv.  Ipecac.
comp., gr. x.   Extr. Coloc. comp. gr. iv., f. pil.  iij.   If the pain continue, the
application of the "thermic  hammer" is exceedingly serviceable, and  if local
paralysis or atrophy ensue,  the use of the electro-magnetic apparatus will be
beneficial.
   The subcutaneous  rupture of muscles and tendons not unfrequently occurs,
not so  much  from any external violence, as by the contraction of the muscle
rupturing its own  substance.  In  the majority  of cases,  when  rupture takes
place, it is the tendon that gives way, most commonly at its point of attachment
to the  muscle, which opposes itself, by its vital contractility,  to that forcible
extension which  must necessarily precede  its rupture.  Sedillot found that in
21 cases, the  rupture occurred at the point of origin of  the tendon 13  times;
and  in  the remaining 8,  the  muscle itself was  torn.  It occasionally happens
that the muscular sheath is  ruptured, so that the belly of the muscle forms a
kind of hernial protrusion through the aperture; or the tendon may be displaced
by rupture  of its sheath.  This usually  happens with  the long head  of the
biceps,  or the extensor tendons of the fingers.
  These ruptures most commonly occur in middle-aged  people, who have lost
the elasticity of youth, though their physical strength be  unimpaired.   At the
moment of the rupture taking place, the  patient usually experiences a sudden
shock, as if he had received a blow, and sometimes hears a snap.  He becomes
unable to use the injured  limb, and at the  part where the rupture has occurred 
184
INJURIES TO  BONES.
finds a hollow or pit, produced by the retraction of the end of the torn muscle,
which is contracted into a hard lump above this.
   These accidents, though troublesome, are seldom serious.   The tendo-achillis,
the  quadriceps-extensor of the  thigh, the  triceps of the  arm, the biceps, the
deltoid, the rectus abdominis, are the tendons and muscles that most commonly
give way, with the relative frequency of the order in  which they are placed.
   The  mode  of union of these injuries has  been  well described  by Paget.
When a tendon is cut or torn across, an ill-defined mass of nucleated blastema
of a greyish-pink tint is effused into the cellular tissue and sheath, between the
cut ends.   About  the 4th  or 5th day, this has become more defined, forming a
distinct cord-like uniting mass between the ends of the tendon;  in the course
of two  or three more days, this mass has  become tough and filamentous;  the
tissue gradually perfecting itself, until it closely resembles tendinous structure,
though for some time  it remains dull white and more cicatrical in appearance.
The strength of this bond of union is marvellously great; Paget found that the
tendo-achillis of a rabbit, six days after its division, required a weight of 20  lbs.
to rupture it.   In  ten days the  breaking weight was  56 lbs.   Divided muscles
unite in the same way as tendons, but less quickly, and by a fibrous bond.
   Treatment.—The principle of treatment  in these cases is extremely simple:
it consists in relaxing the muscles by position, so as to approximate the divided
ends; and maintaining  the limb for a sufficient length of time in this position
for proper union to take place.  If relaxation be  not attended to, the uniting
bond will  be elongated  and weak.   Stiffness and weakness  are often left for a
length of time—for many months, indeed—after union has taken place.   Warm
sea-water douches, followed by methodical friction, will greatly tend to restore
the suppleness of the parts.
  When the tendo-achillis  is ruptured, the best  apparatus  consists of a dog-
collar placed round the thigh above the knee,  from which a cord is attached to
a loop in the back  of a  slipper;  by shortening  this cord, the leg is bent on  the
thigh, and the footextended, so that the muscles of the calf become completely
relaxed.  After this simple apparatus has been used for two or three weeks,  the
patient may be allowed  to go about wearing a high-heeled shoe for some weeks
longer.
  When partial rupture of one of the extensor muscles of the thigh takes place,
the patient's limb must be kept for some little time in the same position as for
fractured patella, and  then he maybe allowed to walk about with a leather
splint behind  the  knee, so as to present flexion of this joint.   In muscular or
tendinous ruptures of the  arm,  a sling is all  the  apparatus  required, but it is
especially in these injuries  of the deltoid that  paralysis and  atrophy are apt to
result.
  CHAPTER  XIV.

INJURIES TO  BONES.
  A bone may be bruised, bent or fractured.   Bruising of the bone and peri-
osteum  often occurs, and is usually of no great moment, but if severe, or hap-
pening  in bad  constitutions, or in old people, it may give rise to serious conse-
quences
Jit «? contusion be severe the vitality of a layer, or even of the whole sub-
stance of the bone, may be destroyed, as happens  sometimes from the graze or 
FRACTURES.
185
 contusion of a bullet.   Even a moderate  contusion of a bono that is but thinly
 covered, as the shin, or elbow, may give rise to troublesome symptoms  from
 inflammation of the periosteum.  In old people, the contusion of a  bone is fre-
 quently followed by its atrophy and shortening, as happens in the  neck of the
 femur; and in strumous constitutions, serious disease of the bone may be  attri-
 buted to this cause.
   In  the  treatment of bruised bone,  leeches and  fomentations are  the  most
 important means  that  we possess;  the after-consequences will  be  considered
 when we  come to speak of necrosis.
   Bending of bone may occur in  two  conditions, with  or  without  fracture:
 independent of fracture, it is most commonly met with in  very young subjects,
 before the completion of ossification, the  bone being  healthy, but naturally soft
 at this period of life.   It occasionally takes place  after  the adult age, but is
 then the result of some structural change, by which the natural firmness of the
 osseous tissue is diminished.  The bending  most commonly occurs  in the long-
 bones, especially the clavicle, the radius, and the femur, but sometimes is met
 with in the flat bones, or those of  the skull, in which  depression  takes place
 from a blow without fracture having occurred.   In many cases of bending both
 of long and flat bones, there is  partial fracture on the convex side.
   The treatment is simple: the surgeon  gradually  straightens the  bone, by
 applying a splint on its concave side, towards which the bone is pressed  by a
 bandage and a pad, applied upon its greatest convexity.

                               FRACTURES.

   The management of fractures constitutes one of the commonest duties of
 the surgeon, and hence the consideration of all that relates to their  nature  and
 treatment is of the very utmost importance.
   Fractures are  almost invariably the  result of external  violence.   This  may
 act  in two ways:  directly or indirectly.
   The worst forms of fracture are  occasioned by direct external violence, the
 blow crushing and splintering the bone, as by the passage  of a heavy  wheel, or
 a gun-shot injury.  When the  bone is broken by direct violence, the fracture
 is always at the seat of injury,  and  is often  complicated with considerable mis-
 chief to the soft parts, the result of  the same force that breaks the bone.  Indi-
 rect violence may break a  bone in  two ways.   One that is more commonly
 talked of than seen is by " contre-coup," in which,  when  a blow is inflicted on
 one part, the shock that is  communicated expends its violence on the opposite
 point, where the  fracture consequently occurs.  This  form of injury  is chiefly
 met with in the head;  and  although its  occurrence  has been denied, I cannot
 doubt it,  as I have seen unequivocal instances of this kind of fracture.
   In the next form of indirect violence occasioning fracture, the bone is broken
 by being snapped, as it were, between a resisting  medium on one side, and the
 weight of the  body on the other.  Thus, a person jumping from a height, and
 alighting on his feet, may break his  legs by their being compressed between the
 weight of the  body above and  the  ground below.   The long bones are those
 that are most frequently fractured in this way, and the  fracture  occurs at  the
 greatest convexity, or at their weakest  point.  When a person jumps from  a
 carriage that is in motion, although  the height of the fall be not great, yet its
 force is considerable, the  body coming to the ground with  the same  velocity as
 that with  which it was being carried onwar'ds in the vehicle.   Hence, fractures
 received in  this way are usually  severe,  and  often compound or comminuted.
  Muscular action is not an unfrequent cause of fracture  of those  bones  into
which powerful muscles are inserted.  This is  especially the  case with  the
patella and some  of the  bony prominences, such as the acromion,  which are
broken in  the same way that a tendon is ruptured,— by the violent contraction 
186
FRACTURES.
of the muscles attached to them  tearing  them asunder.   It is not often that
the long bones are so fractured, but it has happened that the humerus has been
broken  by a person striking at, but  not  hitting another;  or that  the  clavicle
has been fractured by a rider giving his horse a back-handed blow.  In these
cases, however, muscular action may not have been the  sole cause, the weight
of the limb also tending to fracture the bone.  Those bones that do not offer
attachment to any powerful muscles, as the cranial, for instance, cannot.be frac-
tured in this way.
   The predisposing causes of fracture are numerous and varied.
   Some bones are especially liable to be broken in consequence of their serving
as points  of support.   Thus, when a person falls upon the hand, the shock is
transmitted  from the wrist-joint through the radius, humerus, and clavicle, to
the trunk; the radius and clavicle being the weaker bones, are especially liable
to be fractured under these circumstances.   So again, the  situation of  a bone
irrespective  of use, or any other circumstance, may predispose  it to fracture;
the  prominent position of the  nasal bones, and  the exposed situation of the
acromion, render these parts  peculiarly liable to this injury.   The shape  of
some bones disposes them to  fracture; thus, a  long bone is necessarily more
readily  broken  than a short  and thick one; hence,  fracture of the  tibia and
femur from falls on the feet are more common than of  the os calcis.   Certain
parts of bone are more commonly fractured than others.   Those points espe-
cially into which  powerful muscles  are inserted, or that are in  exposed situa-
tions, and hence liable to injury, or to receive the weight  of the falling body,
are often  broken.  Hence, the  acromion,  the olecranon, and the neck of the
femur, are commonly fractured.
   Age  exercises  considerable influence, not only on the  general  occurrence  of
fracture, but on the  peculiar liability of certain bones.   Though fractures may
occur at all ages,  even in intra-uterine life  (Chaussier having dissected a foetus
that had 113 fractures), yet, bone being elastic and  cartilaginous in .early age,
is less readily broken than when it has become brittle and earthy, as  in advanced
life.  In  children,  fractures most commonly occur  in the shafts  of the long
bones;  or, at the point of junction between the shaft and epiphysis, where
ossification has not as  yet taken  place.   This separation  of the epiphysis in
children,  the detachment as it were of the terminal points  of ossification, is not
unfrequently met with, and occurs chiefly at the lower end of the humerus and
femur, sometimes in the radius and other bones.  As age advances, the compact
tissue of the shaft becomes denser and harder, but the cancellous structure of
the extremities more dilated, and looser, hence fracture of the neck of the femur
is especially common in old people.  In young persons also, the bone is  usually
simply broken transversely, but fractures taking place at a more advanced period
of life generally assume an oblique direction, and become  comminuted; so also
they more  commonly extend into  joints  than when occurring in early age.
Occasionally fracture termed " spontaneous," happens without any very direct
occasioning  cause, or under the influence  of a degree of  violence that would
usually be insufficient to occasion it.  This may happen  in consequence of the
texture of the bone being weakened or rendered more brittle by disease, such
as mollifies or fragilitas ossium, by the cancerous cachexy, by syphilis, by the
presence of cancerous growths within the substance of the  bone  itself, or by the
pressure upon, and absorption of it, by some neighboring tumor.  In other
cases,  again, it occurs without any apparent disease, local or  constitutional.
This usually happens as the result of the brittleness and weakening induced by
age.  I have  known  a  gentleman  little  above fifty,  apparently in  perfect
health, break his thigh with a loud snap whilst turning in  bed.   In these cases
union rarely takes place, or not without much difficulty.
   Sex necessarily influences the liability to fracture, men being more frequently
exposed to the causes of this injury than women.  In women  the bones that 
VARIETIES OF  FRACTURES.
187
are most frequently fractured  are the  clavicle, the tibia, and the neck of the
femur.  In men, the shafts of the long bones, the cranium, and pelvis, are most
frequently broken.
   From  statistical  accounts it would  appear that  the right limbs are  more
frequently broken than the left, being more  exposed to the causes of fracture.
It has been supposed that the bones are more brittle in winter, and hence break
more readily  than  at other  seasons, but this  is altogether a mistake,  though
fractures may be common at  this period of the year, from falls being  more
frequent.
   Fractures present important varieties as to their nature and their direction.
The varieties  as to  nature depend upon the  cause of the fracture, its seat, and
the age of the patient.
   Varieties as to Nature.—Fractures are divided into  two great classes, accord-
ing  as they are  accompanied  or not by an open wound.  When the bone is
merely broken across, the fracture is  a simple one.  When one fragment is
wedged into another, the compact tissue being driven into the cancellous struc-
ture, it is said to be impacted.  When the bone is broken into several fragments,
it is comminuted.
   When the  soft parts covering the broken ends of bones  are torn through, so
 that the fracture communicates by a wound with the surface of the body, it is
 said to be  compound.  The fracture may be rendered compound in two  ways,
 either by the same  injury that breaks the bone lacerating the soft  parts, as
 when a bullet traverses a limb, and fractures the bone; or else by the protrusion
 of one of the extremities  of the broken fragment through the integuments
                                             O           C"           o
 covering it;  this necessarily most frequently happens  when  the  fragments are
 sharp and  pointed, and the coverings thin, and may be  occasioned either by
 muscular contraction driving the fragment through the skin, or by some incau-
 tious movement on the part  of the patient, forcing it through.
   A fracture is said to be complicated when the injury to the bone is conjoined
 with other  circumstances which are perhaps of more importance than the mere
 fracture itself, the complication constituting perhaps  the most serious part of
 the injury, and  influencing greatly the general result of the  ease.  Thus,  a
 fracture may be complicated with injury of an important  internal organ, as,
 of the brain, lungs, or bladder; the injury to the organ being inflicted by the
 projection against it of one  of the broken fragments.  So also a fracture is not
 unfrequently complicated with the  wound of one of the  principal  arteries of
 the part, as  happens especially in  the  leg, where the tibial arteries,  being in
 close contact with  it, are often torn  by the broken bone.  In other cases, again,
 the fracture  is associated with injury of a joint, or  dislocation of it.   Besides
 these varieties of fracture, it occasionally happens that a bone is only cracked,
 or partially broken.   This especially occurs in the bending of bone in children,
 in which  cases  the fracture  may be partial or incomplete, merely extending
 across the convexity of the  curve made by the bone.  Intra periosteal  fractures
 have  been described, but this  is  an anatomical refinement of little  practical
 value.
   The direction assumed by fractures varies greatly, and depends materially
 on the cause of the  injury,  as well as upon the bone that is fractured.
   The line of fracture may run through  a bone  in  three different  directions:
 either  transversely, obliquely, or longitudinally to its  axis.   The transverse
fracture is  the simplest, and is seldom complicated with injury to  the neigh-
boring parts.  It chiefly occurs in children, and very frequently in the  articular
extremities or processes  of  bones;  it  unites  readily,  and  is attended by  but
little displacement;  it is most  commonly the result of direct violence, but it
may arise from muscular action, as  in the case of the patella, which is usually
broken in this way.
   The oblique fracture commonly occurs  from indirect violence; the breaking 
188
FRACTURES.
force being applied to the ends, and not across the shaft.   Itoften runs a long
way, more than half the distance of the shaft of a bone, and is more dangerous
              than the transverse, owing to the obliquity of the fracture causing
    Fig. 78.    the ends  of the bone to be sharply pointed (Fig. 78, a),  and thus
              frequently to puncture the  skin, or to perforate an artery.   It is
              tedious in its cure, owing to the fragments being less  directly in
              apposition; hence, also, there is a greater liability to  shortening
              of the limb; it is principally met with in the shaft of  the long
              bones of adults, and elderly people.
                 The longitudinal fracture consists  of  a splitting of a bone in
              the direction of its axis (fig. 78, 5), and  has a great tendency to
              run into  a joint, and to separate the articular ends of the bone.
              It most  commonly results  from gun-shot injury, especially from
              Minie balls,  but I have  seen  cases of its occurrence from very
              slight violence.  The great danger of longitudinal fractures is
              the implication of the neighboring articulation, but in some cases
              it extends a little distance  up  the shaft of a bone, stopping short
              of this.
                 The signs of fracture, taken individually and  singly, are all
              more or  less equivocal, and may arise from other conditions of
              the part, being common to various injuries.  It is rather by their
              simultaneous occurrence that we consider them as pathognomonic
              of the existence of a broken bone.
   Amongst the more equivocal signs may be mentioned the  occurrence of pain
 in the limb, which may be  owing either to the  laceration  of the  soft parts by
 the broken fragments, or to the general injury inflicted upon  it.  So also the
 existence of increased or diminished swelling is observed  in different cases of
 fracture; the augmented swelling being owing  either to  the  extravasation of
 blood into the limb, which  often takes place  to a very considerable extent, even
 without the wound of any principal  vessel;  or, to  the approximation  of the
 attachments  of  the muscles, by the shortening of the part.  Diminished swell-
 ing, or flattening,  occurs in some  cases, in  consequence of the weight  of the
 limb drawing the part down,  and thus lessening natural rotundity.
    The more special and peculiar signs of fracture are three in number:  1st, A
 change in the shape of the limb ;  2d, Mobility in its continuity;  and 3d, The
 existence of grating between the broken ends  of bone.
    1st. The change in the shape of the limb, due to the displacement of portions
 of the broken bone, is perhaps the most important sign of fracture;  it manifests
 itself by a want of correspondence between the osseous points on opposite sides
 of the body, by an increase or diminution of the natural curves of the limb, by
 angularity, shortening, or swelling.
    In investigating the  existence and extent of displacement  in a case of frac-
 ture, the surgeon should always strip his  patient, compare  the points of bone on
 the opposite sides of  the  body, and  their relative situation to some  fixed and
 easily distinguishable neighboring prominence on the  trunk or injured part of
 the limb.   From this the  measurements may be taken, by grasping the injured
 part and  the corresponding  portion of the healthy limb in  either  hand, and
 running the  fingers lightly over the depressions and  elevations, marking any
 difference that  exists;  or, if  greater accuracy be required, measuring  by means
 of a tape. In some cases the measurement must not be made between the trunk
 and the limb injured, or even from one extremity of the limb  to the other, as
 shortening of the whole member might  depend on  other causes than fracture,
 such as wasting, diseases of joints, or dislocation, but the measurement must be
 taken between  different points of the bone actually injured.
    The displacement of a broken bone may be the direct result  of  the violence
 which occasions the fracture, the fragments  being driven  out of their position,
 
SIGNS  OF  FRACTURES.
189
as when a portion of the skull is beaten  in; or it  may result from the weight
of the limb dragging downwards the lower fragment, as  in a case of fractured
acromion.  In some cases, it is either occasioned,  or greatly increased, by the
direction of the fracture.   Thus, in several cases of broken tibia which have
been under my care, the line of fracture  being oblique from above downwards,
and from before backwards, I found the upper end of the lower fragment pro-
ject considerably forwards, sliding,  as it were, along an  inclined plane in the
upper one, and in one  of these cases  that  I had an opportunity of dissecting
after  amputation, the  direction of the  fracture, rather,  than muscular action,
appeared to  be the cause  of  displacement.  In transverse fractures  there  is
always but slight displacement.
   Muscular  contraction is, however, without doubt, the most frequent cause
of displacement; hence, it  has been found that in paralyzed  limbs  that are
fractured, there is but little deformity.  The contraction of the muscles of the
part approximating their points of  attachment, owing  to the  support or resist-
ance offered by the bone being removed, draws the  most  movable fragment out
of its normal position.  The other  causes that have just been mentioned, tend
greatly to favor this kind of displacement;  but  in  some  cases, as in fractured
patella, the displacement is entirely muscular, and  in all fractures of the long
bones it is chiefly due to muscular  contraction.
   The direction of the displacement is principally influenced by the direction
of the fracture, the position of the limb, and muscular action; it may be angu-
lar, transverse, longitudinal, and rotatory.
   In the angular displacement there is an increase of the natural curvature of
the limb;  the  concavity of the angle being on the  side of the  most powerful
muscles; thus, for example, in fracture of the thigh, the angle projects on the
anterior and outer side of the limb, because the strongest muscles  being situated
behind and  to  the inner side, tend, by their contraction, to approximate the
fragments on that aspect.   This  displacement principally occurs in oblique and
comminuted fractures.
   The transverse or lateral displacement occurs when a bone is broken directly
across,  the  fragments often  hitching one against  another, and  so  being,
as it were,  entangled  together.  In this case  there is often but  very little
deformity.
   In the longitudinal displacement there may be  either shortening or elonga-
tion of  the  limb.  When  there is shortening,  as  most commonly happens  in
oblique fractures, it is dependent on muscular contraction, the broken ends of
bone being drawn together so as to overlap  one another, or "riding."   In other
 cases, the shortening may be owing to the impaction of one fragment in the
 other.   In some cases  there is preternatural  separation  of the  fragments, the
 weight of the  limb tending to drag the lower one downwards, or muscular con-
 traction drawing the upper one away from it.
   The rotatory displacement is owing to  the  contraction of particular sets of
 muscles twisting the lower  fragment on its axis, as well as producing shortening
 of the limb.   Thus, the external rotators in fractures of the neck of the thigh
 bone, and the supinators  in  some fractures of the radius, have a tendency to
 twist or rotate the  lower fragment in an outward  direction.
   2d. The occurrence of preternatural  mobility in the continuity of a bone
 cannot exist without fracture, and separation of the fragments from one another;
hence, its presence may always be looked upon as  an  unequivocal sign  of the
bone being broken.  It occasionally happens, however, that fracture may take
place,  and,  owing to  the  impaction or  wedging  together  of  the  fragments,
mobility not be perceived;  hence, its absence cannot in  all  cases  be  construed
into a proof of the non-existence of fracture.
   3d. Another sign of much value in practice is the occurrence of crepitus, or
rather of the grating together of the rough surfaces of the  broken bone, which 
190
FRACTURES.
  can be felt as well as heard on moving the limb.   This grating can only occur
  when the fragments are movable and  in  contact, and is  especially perceptible
  when the rough ends of the broken bone  are directly rubbed against  one an-
  other, and not the  smooth periosteal surfaces merely opposed, or overlapping.
  It  is not, however, an  invariable accompaniment of fracture, being absent in
  some cases, in which the fracture is firmly impacted, or when the fragments are
  widely separated.   It must not be confounded with  crepitation that occurs in
  the limbs from other causes, as from emphysema, or the effusion of serous fluid
  into the sheaths of the tendons, which  gives rise to a peculiar crackling sensa-
  tion, very different  from the rough grating of a fracture.
    It will thus be seen that each of  these symptoms, taken individually,  is more
  or less equivocal, and that it usually requires a combination  of at least  two of
  them to determine whether fracture exists.  In ascertaining the existence of a
  fracture, the  surgeon should make the necessary manipulations with  the utmost
  gentleness, but yet effectually, so that no uncertainty may be allowed to remain
  as to the seat and nature of the injury,  more especially when  it occurs in the
  vicinity of a  joint.   The increased mobility may be ascertained  by fixing the
 upper fragment, and rotating the lower portion  of the limb; the  grating, by
 drawing down the lower fragment, so as to get the rough surfaces in apposition
 and then grasping the limb at the  seat of fracture  with one  hand, rotating it
 gently with the other.  The displacement must be ascertained by measuring'the
 limb carefully in the way that has been directed, and by comparing the injured
 with the sound side.
  _ A fractured bone  is ultimately united by being soldered together by the depo-
 sition of new bone  around, within, and  lastly between, the  broken  fragments.
 In exceptional cases, as in fractures occurring within the capsule of a joint, and
 in those of the patella and the olecranon,  union  is effected  by fibrous or fila-
 mentous tissue.  In some instances  that will hereafter be considered, owin^ to
 peculiar, local, or constitutional circumstances, new bone is not formed, but^the
 uniting medium is of a fibrous character.
   The new bone that constitutes the bond  of union is termed callus.   In many
 cases,  a larger quantity of this is temporarily deposited than is permanently left.
 This temporary formation of bone goes by the name of the " provisional callus."
 It is formed partly external to the fracture, incasing the broken  ends, and partly
 in the medullary canal, so as to include  the fragments between layers of new
 bone and thus maintain  them in contact.   That which  is permanently left, and
 which intervenes between the broken ends, is called the " definitive callus."
   The production of callus has been  studied with  much care by Haller  Duha-
 mel, Bordenave and  Hunter, by Dupuytren, Breschet and Villerme, and more
 recent y by Stanley and  Paget.   From  the observations of these pathologists,
 it would appear, that the union of a broken bone takes place through the medium
 oi_ plastic matter deposited by a process of adhesive inflammation set up  in the
 injured bone itself, its periosteum, and the neighboring soft parts;  the lymph
 thus formed gradually undergoing development into osseous tissue.   The whole
 process, indeed, is strictly analogous  to that which  takes place  in the ordinary
 healing of a wound by adhesion, and the development  of the  cicatrical tissue
 The broken fragments are at first movable, and surrounded by a considerable
 extravasation of blood. In the course of ten or fourteen  days this has ordinarily
 undergone absorption to a considerable extent; the periosteum and the medul-
 hrirf ^V^ v6 V1Cimtj °f thG fracturMhe tissues around it and the
 broken bone  itself become  very vascular, and  pour out a quantity of lymph
 thtt Zft arT\the  fragmen^^ll  as within the medullary ca/al, lo
 111  Jil T     f &T1 ensheathed by a reddish  gelatinous  mass of a fusiform
 morPe cinS d \T°S1^   ' "*' °? "^   This Sradually beco™s more and
 more consolidated, and in proportion as it becomes firmer, the  mobility of the
fragments lessens, and the ends of the  bone becoming smooth by the* pa ti 
UNION OF  FRACTURES. — CALLUS.
191
deposit being adherent to, and interposed between them, grating is less distinct.
From the third to the fourth week the lymph has  assumed a sufficient degree
of firmness to keep the fragments in apposition, though the bone  still yields
readily at the  seat of fracture.   This lymph, which  is poured  out  not only by
the periosteum and bone, but by all the soft parts in the neighborhood of the
fracture, gradually undergoes ossification, the bony matter being  first  deposited
in a granular manner, but in sufficient quantity by the sixth or eighth week to
unite, the fracture pretty firmly.  The callus, which  is at first soft and spongy,
and differs from old bone in its microscopic as well as ordinary physical charac-
ters, gradually assimilates to old bone, both in hardness and in structure; osseous
corpuscles and vascular laminated canals forming in it;  and it becomes smooth
on  the surface, being invested  by a  dense cellulo-fibrous  periosteum, until, by
the  end of six or eight months, ossification is perfect.  The last process in the
consolidation of the fracture is the formation of  new bone between  the broken
ends.  This does not take place definitely until a considerable period after the
ensheathing  callus has  been formed.   This bone  is deposited in  the plastic
matter effused between the fragments, which undergoes  ossification in the  same
way as the external callus  does.  By the time that  this intermediate or defini-
tive callus is fully formed, that portion of the ensheathing or provisional callus
which is not required for  the  preservation of the  permanent integrity of the
bone, has been gradually removed, or has moulded  itself closely to the  shape
and condition in which it will ultimately remain, the medullary canal having
again  become free, and the ends of the fracture  rounded off. In some cases the
medullary cavity is not restored to its former condition for a considerable  time,
continuing to be partially  occluded by a thin septum of  callus.
   According  to Paget, the plastic  matter that is effused around and between
the bones undergoes ossification in various ways.  Those  fractures that ossify
quickly do so most commonly through nucleated blastema, a fine closely-granular
ossific deposit taking place in  the blastema, and  becoming converted into the
laminae of the cancellous tissue, the  nuclei becoming probably  converted into
bone corpuscles.   In other cases again, the nucleated cells  of  granulations and
plastic effusions ossify by being transformed into  bone.  Then, again, the new
bone may be formed  by the plastic exudation passing, first of all, through the
stages of fibrous tissue, of cartilage of the purest foetal form, or through  fibro-
cartilage.
   In those fractures  that are transverse, and that remain in steady apposition
during ossification, and more especially if they are but thinly covered  by soft
parts,  the union  appears  to  take place directly and immediately between the
opposed osseous surfaces; there being no appearance of those accessory deposits
of bone  that usually  go by the name of " provisional callus."   If, however, the
fracture occurs in a bone that is thickly invested by soft parts,  masses of new
bone will be thrown out around the fragments, evidently the result of deposition
from the surrounding inflamed tissues, rather than from  the injured periosteum
or  bone.  The influence of neighboring soft parts in determining the deposits
of new bone is well marked  in  the tibia.  In a fracture of this bone we  find,
that at the anterior and inner part, which is thinly covered, union  takes  place
directly  between the broken ends; but at the posterior and  outer  side, where
there is a thick envelopment of tissue, a large  mass of provisional callus will
often be found filling up even the interosseous space.  That neighboring  parts
participate in the inflammation set up around the fracture,  and throw out callus,
is evident by  what takes place  occasionally when one of  the bones  of the  fore-
arm or leg is broken.  Periostitis is then set up in the unbroken bone, opposite
the seat of fracture, and osseous matter sometimes  deposited by it.   We have
specimens illustrating this point in the University College Museum.
   If the  fracture be  not well reduced, the ends  not being in proper apposition,
or if it is comminuted,  it will commonly be found that masses of* new bone  are 
192
FRACTURES.
deposited as buttresses or supports; or,  enveloping the splinters, consolidate
them in this way with the rest  of the  shaft.   So, also, if the fractured bones
are not kept sufficiently quiet during treatment, the neighboring parts become
irritated, and provisional callus is formed.   Hence, as Paget has  remarked, we
commonly find  this deposit in fractures of the ribs, which are kept in constant
motion  by the respiratory actions.  In impacted fractures there  is,  from the
perfect apposition of the surfaces,  but little callus formed.
   From all  this,  I think it clear that in simple  fractures the provisional callus
is deposited principally by the surrounding soft tissues, and  also, to  a  certain
extent, by the periosteum and  medullary canal, its  quantity being dependent
on the amount of irritation set  up in these textures.   The definitive  callus, on
the other hand, is directly and  immediately formed by the vessels of the frac-
tured bone  itself, and the comparative want of vascular supply to this tissue
may account for the slowness of its formation.
   In compound fractures, union takes place by  the ends of the bone,  which lie
bathed in the pus of the wound,  granulating and throwing out plastic matter,
which becomes directly converted  into bone.  There is in many cases but little
provisional callus; but in  most instances a large quantity of accessory osseous
deposit  takes place, more particularly if the  displacement  be  considerable.
The union  of these fractures precisely resembles  that  of a wound in the soft
structures — by granulation — the process occupying a much longer time than
that which is necessary for the union of simple fractures, consolidation  not being
effected for three or four months.  Rokitansky is of opinion  that superficial
exfoliation of that layer of bone which is bathed by the pus, takes place, and
that it is after this has separated that the granulations spring  up,  in  which
the new bone is deposited. I think it admits of very considerable doubt whether
this process of necrosis goes on in  all cases of compound fracture.
   Union of fractures, like all other vital actions, takes place more readily and
much more quickly in the early  periods of life than at a more advanced age,
and is  always  more  speedily accomplished  in  the  upper than  in the lower
extremities.
              TREATMENT  OF  SIMPLE  FRACTURES.

   In conducting  the treatment  of a fracture, the object of the surgeon should
be not only to obtain a sound and strong limb, but one that presents as little
deformity and trace of former injury as possible.  In order to accomplish this,
the  broken  ends of the bone must be brought into as perfect  apposition as
possible, the recurrence of displacement must  be prevented, and the  local and
constitutional condition of the patient properly attended to.
   When the surgeon is called to a person who has met with a fracture, if it be
a severe one of the upper extremity, or  of any kind of the lower limbs, he must
see that the bed, on which the patient  may have to remain for some  weeks, is
properly prepared, by being made  hard, flat, and firm, and, if possible, covered
with a horse-hair mattress. The surgeon must then superintend the removal of
the  patient's clothes, having them ripped  up  the seams, so  that they may be
taken off with as little  disturbance to the injured part as possible.  He next
proceeds to the examination  of the broken limb, using every possible gentleness
consistent with acquiring a proper knowledge of the fracture.  After satisfying
himself upon this point, the limb should be laid upon a soft pillow, until any
necessary apparatus that may be required has been prepared.
   When all has been got ready, the reduction  of the fracture, or the bringing
the fragments into proper apposition, must be proceeded with.   This should, if
possible, always be done at  once, not  only lest  any displacement that exists
may continue permanently,—the muscles, after a few days, becoming shortened,
rigid, and unyielding, not allowing reduction to  be effected without the employ-
ment of much force, — but also  with the view of preventing irritation and 
TREATMENT OF SIMPLE  FRACTURES.          193
mischief to the limb, by the projection  of the  sharp and jagged ends of bone
into the soft structures.  By early reduction we may sometimes prevent a sharp
fragment  perforating the skin, thus rendering a simple  fracture compound, or
lacerating  muscles  and nerves,  inducing  perhaps traumatic  delirium,  and
certainly undue local inflammatory and spasmodic action.
   The great cause of displacement in fractures has already been stated to be
muscular contraction;  hence, in effecting reduction of  a fracture and in remov-
ing the displacement, our principal obstacle is the action of the muscles of the
part.   This must,  and always  may be, counteracted, by properly relaxing them
by position; so soon as this is done, the  bony fragments will naturally fall into
place; but no amount of extension and of counter-extension can get these into
position, and much less retain them there, unless all muscular influence be removed.
   In ordinary fractures no force is necessary for this, or should ever be employed
in accomplishing it; but  attention to  the  attachment of the muscles of the
limb and proper relaxation of them is all that is required.  In impacted fractures
it is occasionally necessary to use  force in order to disentangle the fragments,
but this is the only form of fracture in which  its  employment is justifiable.
In effecting the reduction, not only must the  length  of the  limb be restored,
but its natural curves must not be obliterated by making it too straight.
   After the reduction has been accomplished, means must be taken to prevent
the return of the displacement; for if the parts  be left to themselves, muscular
action, or the  involuntary movement of the  patient, would be certain to bring
about a return of  the faulty position.  In many cases it is exceedingly difficult
to preserve the fracture undisplaced for the first few days after its occurrence,
in consequence of spasmodic movement of muscles of the limb, or of restlessness
on the part of  the patient.  About this, however, the  surgeon  need not be
anxious, as no union takes place for the first week or ten days; at the expiration
of  that  time, the muscles will have probably lost their irritability,  and the
patient have got accustomed to his  position, so that with a little  patience, or by
varying the apparatus  and the position of the limb, good apposition may be
maintained.
   The return of displacement is  prevented, and the  proper  shape and length
of the limb are maintained, by means of bandages, splints, and special apparatus
of various kinds.   In applying these, care should be taken  not  to exert any
undue pressure on the limb.   Pads and compresses  of all kinds should, if pos-
sible, be avoided;  they do no good that cannot be  effected by proper  position,
and often occasion serious  mischief by  inducing sloughing of the integuments,
over which they are applied. Screw apparatus has been invented with the view
of forcing fragments into proper position, but  nothing can be more unsurgical
and unscientific than such barbarous contrivances as these.'
   In cases in  which there  is much  tendency to a return of the displacement, it
has  been recommended to divide the tendons of some of the stronger muscles
inserted into the lower fragment.    This, however, can very rarely be necessary,
and in those cases in which I  have done it, or seen it done, no material benefit
has resulted.
   The  bandages used  for fractures should  be the  ordinary grey calico rollers,
about  three fingers' breadth in width,  and of  sufficient length.  In applying
them, especial care must be taken that the turns press  evenly upon every part,
and  that  the  bandage  be not applied  too tightly  in  the first  instance.   No
bandage should ever be  applied  under the splints.  In this situation they are
not only useless, but highly dangerous, by inducing risk of strangulation.  The
limb should also be examined from time to time, and if the patient complain
of any pain or numbness, or if the extreme  part look blue and feel cold, the
bandage must be  immediately removed;  for though it have not been applied
tightly, swelling  of the limb  may come on from  various causes, to such an
extent as to  produce strangulation, and consequent gangrene of it, as I have
       13 
194
FRACTURES.
seen happen in at least three instances, the limb requiring amputation in both
cases (Fig. 83).  It is remarkable that the whole of a limb will fall into a state
of gangrene  under these circumstances, with  but little  pain,  and often with
very slight  constitutional  disturbance,  the  parts  having  their sensibility
deadened  by the  gradual congestion  and infiltration  of the tissues.  When
such an unfortunate accident happens, immediate  amputation must be had
recourse to.  Before  applying the bandage  in a case of fracture,  and as often
as they are taken off, it is a good plan to sponge the limb with warm soap and
water, which prevents the itching that otherwise occurs, and is  sometimes very
troublesome.
  The splints that are used in cases  of fracture are of various kinds.   Tin,
wood, leather,  and gutta-percha, are  the materials usually employed.  For
some kinds of fracture, special and often very complicated apparatus is very
generally used; but the surgeon  should  never confine himself to one material,
or one  exclusive mode of treating these injuries, as in different cases special
advantages may be obtained from  different  kinds of splints.   Wood and tin
are principally  employed in  the lower extremity,  where  great  strength  is
required to counteract the weight of the limb and the action of its muscles, and
care must  be taken to pad very thoroughly splints made of these materials.
Leather, gutta-percha, and pasteboard  are  more commonly useful  in  fractures
of the  upper extremity, though  they may not unfrequently be employed with
advantage  in the  lower limbs.   In applying them,  a  pattern  should first be
cut out in brown paper, of the proper size and shape; the material must then
be  softened by being well  soaked in  hot water, and moulded  on to the part
whilst soft; so soon as it has taken the  proper shape, it should, if leather or
gutta-percha  is used, be hardened  by being  plunged into cold  vinegar and
water; the pasteboard must be allowed to dry of itself.  Its edges may then
be pared and rounded, and its  interior lined with wash-leather  or lint.  These
splints  have the  advantage  of great durability, cleanliness, and lightness.
The material of which the  splint is composed is of less consequence than its
mode of application.   There are two  points that require special  attention in
this respect:—1st, That the splint is sufficiently broad to extend to the exterior
of the  limb, and not to press into it; and, 2d, that  it embrace securely and fix
steadily the  two joints connected with the  fractured bone; if the thigh, the
hip and knee;  if the leg, the knee and ankle : from want of attention to this,
much deformity often results.
   Special  apparatus should  be employed as little as possible in the treatment
of fractures.   It is scarcely ever necessary in simple fracture,  and is far more
cumbersome  and costly  than the means  above indicated, which are all  that
can be  required.  I  have no hesitation  in saying, that a surgeon  of ordinary
ingenuity and  mechanical skill may be fully  prepared  to  treat  successfully
every fracture  to which  he  can be called, by having at hand a smooth deal
plank half  an inch in thickness, a sheet of gutta-percha, undressed sole-leather,
or pasteboard, to cut into splints as required.
  To these simple means the starch bandage is an invaluable addition. Although
various  plans for  stiffening and fixing the  bandages in cases of fracture, by
smearing them with white of eggs, with  gum, plaster of Paris, etc. have been
employed  at  various times, it is  only of late years that the full value of the
starch  bandage  has been recognized by surgeons, chiefly through the practice
and writings  of M. Seutin of Brussels.
  The  advantages of the starch bandage in the treatment of fractures, as well
as in many other  injuries and diseases, consists in its taking the shape of the
limb accurately and readily,  and maintaining it by its solidity; in being light,
inexpensive, and easily applied, with materials  that are always at hand.   From
its  lightness, it  possesses the very great  and peculiar advantage  in  fractures
of  the lower extremity, of allowing the  patient to remain up and to  move 
STARCH  BANDAGE  IN FRACTURES.
195
about upon crutches, during nearly the whole of the treatment, and  thus, by
rendering confinement to bed  unnecessary, preventing the tendency  to those
injurious  consequences  that  often result from these injuries;  and, by  enabling
the patient to keep up his health and strength by open air exercise, facilitating
the consolidation of the fracture.  In addition to this, the patient will often be
able to carry on his  business  during treatment.   By employing  the  starch
bandage in the way that will be immediately pointed out, I scarcely ever find
it necessary to keep patients in bed with simple fractures of the thigh  for more
than six or seven, or of the leg for more than three or four days, thus saving
much of the tediousness and danger of the treatment.
  The following is the mode of applying this apparatus that is adopted at the
University College Hospital, and which will be found to answer  well.   The
whole  limb is enveloped in  a layer of cotton wadding, which  is thickly laid
along and over the osseous prominences; over this should be laid splints of
thick and  coarse pasteboard, properly shaped to fit the limb, extending beyond
and fixing securely the two joints above and  below the fracture, and  well
soaked  in thin  starch.   The pasteboard should be soft, not milled, and be
double, and torn down, not cut, as in this way the edges are not left sharp.  If
much strength is not required, as in children, or in some fractures of the upper
extremity, a  few  slips  of brown paper, well  starched, may be  substituted for
the pasteboard.  A bandage saturated with thick starch must now be firmly
applied;  and, lastly, this is to be covered by another dry  roller, the inner sides
of  the turns of which may be starched as it is laid on.  During the application
of  this apparatus, extension  must be kept up by an assistant, so as to  keep the
fracture in position; and, until  the  starch has thoroughly dried, which usually
takes from thirty to fifty hours,  a temporary wooden  splint may be applied to
the limb,  so  as to keep  it to  its proper
length and shape.  The drying of the starch
may, if necessary, be hastened by  the ap-
plication of hot sand-bags to the apparatus.
After the bandages have become quite dry,
the temporary splints must be removed, and
the patient may then be allowed to move
about on crutches, taking care, of course,
to  keep the injured  limb well slung up,
and not to bear upon it, or to jar it against
the ground  (fig. 79).   In the course  of
about  three  or  four days after  its applica-
tion, the apparatus will  usually be found
to  have loosened  somewhat, the limb ap-
pearing  to shrink within it.  Under these
circumstances it becomes necessary to cut
it up with a pair of Seutin's pliers, such as
are  represented in the annexed wood-cut
(fig. 80).   This section  must be made along
the more muscular part of the limb, so that
the skin covering the bones be  not injured,
as  represented  in fig. 81, and  after paring
the edges of the splint, it must be reapplied
by  means of tapes or a roller.  It will al-
ways be found  advantageous to adopt the
practice of M.  Burggraeve,  of  Ghent, and
to envelop the  whole limb in a thick  layer
of  cotton wadding  before  applying  the
starched bandage;  this, being elastic, accommodates itself  to the diminution in
the size of the  limb,  and thus  keeps  up more  equable  pressure.  Indeed, of
 
196
FRACTURES.
late I have invariably adopted this practice, and found much advantage from it,
dispensing with any dry roller next  the  skin which there is always difficulty
                                             in applying, and  from  which
                   Fig. 80.                   there  is danger of constriction
                                             or of abrasion.  In  trimming
                                             the  edges  of  the  splint, it
                                             should not  be  removed from
                                             the limb, and, after this  has
                                             been done, the apparatus must
                                             be fixed  together  again with
                                             tapes  or a roller.   If the frac-
                                             ture  be compound, a trap  may
be cut in  the apparatus opposite the seat  of  injury, through which the wound
may be dressed (fig. 82).
                                 Fig. 81.
Fig. 82.
   Although fully recognising the great advantages to be obtained by treating
 fractures on this plan, and employing the starch bandage in almost every case
                         that came under my care, I  did  not think that it
                         was a safe practice to have recourse  to it during the
                         early stages of fracture, until, indeed, the swelling
                         of the  limb had begun to subside.  I therefore never
                         applied it until the sixth, or eighth, or  tenth  day,
                         keeping  the limb properly reduced upon a splint,
                         very lightly bandaged, wet with cold  evaporating
                         lotions until this  time, fearing that if the bandage
                         was applied  at  too early a  period, the inflammatory
                         turgescence of the limb might give rise  to a  slow
                         strangulation of it under the bandages.
                           During the last few years, however, I  have fol-
                         lowed  Seutin's  plan in some hundreds of fractures
                         of all kinds, putting the limb up in  the starch appa-
                         ratus immediately on the occurrence of the injury,
                         and have  found  the practice an  extremely successful
                         one, even in  fractures of the thigh;  so  much so,
                         that at the  hospital I now rarely use any other plan
                         of treatment; and, indeed,  the  more experience of
                         it, the  more satisfied am I with the results obtainable
                         by it.  I  find that the moderate pressure of the ban-
                         dages,  aided probably by the  great  evaporation that
                         goes on during the drying of  so extensive and thick
                         a mass of wet starch, and which produces a  distinct
sensation of cold in  the limb, takes down the extravasation most effectually,
 
        ACCIDENTS  AND  COMPLICATIONS OF FRACTURE.    197

and enables the  patient usually to leave his bed about the third day after the
injury, when the fracture is in the leg or ankle, and about the sixth when it is
the thigh that is broken; so that very commonly we now treat all patients with
simple fractures of the leg,  and many of those of  the  thigh, especially  in
children,  as out-patients.1
   By no other means of  treatment have I  seen  such satisfactory  results  in
cases of fractured  thigh, as by the starched apparatus,  patients  having fre-
quently been cured without any shortening whatever, and with the preservation
of the natural curve of the bone.
   In compound fractures,  also, of the legs  and even of the thigh, I have
obtained  most  satisfactory results by this means.  In compound  fracture  of
the leg, I have seen the patient walking about on crutches as  early as the tenth
or fourteenth day, the  limb being  securely put up in starch; and have more
frequently succeeded in getting union of  the wound, and consequently in con-
verting the compound into a  simple  fracture, by putting up the limb  in this
apparatus, than in any other.
   The plaster  of Paris bandage may sometimes  be advantageously  used as a
substitute for the starch apparatus.   It may be applied in the following way:
A roller of coarse soft muslin must have dry plaster of Paris thoroughly rubbed
into its meshes, some cold water is then to be poured  upon either end of it, so
as to moisten it through.  A dry roller having been  previously applied  to the
limb, the wetted plaster bandage must be smoothly  rolled up it, the surgeon
taking  care  that no reverses are  made.  In order to avoid  these,  it may be
applied in a spiral or figure of 8 manner over the more unequal  parts.  Slips
of the  plaster  bandage should also  be laid on where additional strength is
required, and the whole well  wetted from time to time during the application.
It hardens in the course of a few minutes, and, as it dries, forms a solid, hard,
and light casing to the limb,  affording  excellent support to the fracture.  The
plaster  bandage possesses  the  advantage  over the starch apparatus of being
lighter, and especially of drying and hardening quickly, qualities which render
it invaluable in cases in which it is necessary  to carry patients any distance soon
after the setting of the fracture.
   Various Accidents are liable to occur during the treatment of a fracture;
some of  these  are of a general, others of a  special, character.  Amongst  the
more general  accidents, tetanus, traumatic delirium, and erysipelas, may  be
mentioned as the most common.  Amongst the more special,  the occurrence of
 spasm of the muscles of the limb, abscess, oedema, gangrene, and a tendency
 to pulmonary and  cerebral congestion, are those that have most to be guarded
 against.
   In order to prevent the occurrence of  these conditions, the general health
 must be carefully attended to, the bowels being kept open, the room well venti-
 lated, nourishing diet allowed,  and  long confinement to bed avoided by the use
 of the starch bandage.
   The  treatment of the more general accidents presents  nothing that need de-
tain us here; but those that are more  special and peculiar to fractures, require
consideration.
   Spasm of the muscles of the limb, owing to the irritation produced by the
fragments, is best remedied by reduction, and the maintenance of the fracture
in  proper position, by moderate pressure with a  bandage.   If the spasm be
dependent upon nervous  causes, full doses  of opium will  not  unfrequently
afford relief.   In some cases, it is of a permanent character, producing con-
siderable  displacement of the fragments.   Under these circumstances,  the
division of the  tendons has been recommended, but this practice appears to be

  1 For details of this mode of treatment, I would refer the  reader to Mr. Gamgee's very
practical work on the starched apparatus. 
198
FRACTURES.
an unnecessarily severe one, and  may certainly most  commonly be avoided by
attention to the other plans of treatment which have  been suggested.
   Considerable extravasation of blood is frequently met with in cases of simple
fracture, causing  great  swelling and tension of the limb.  By the continuous
application of cold evaporating  lotions, these collections are  usually readily
absorbed, and the surgeon should  never be  tempted by any feeling of fluid  or
of fluctuation to open them, as he would thereby infallibly convert the  simple
into a compound fracture, and give rise to extensive ill-conditioned suppuration.
In some of these cases  of extensive extravasation,  the limb appears to relieve
itself of the serous portion of the  blood effused, by the formation of large  bullae
or blebs, which burst  or subside, without  any material  inconvenience.  This
extravasation very rarely, indeed, runs  into  abscess; if it do, it must of course
be opened, and treated upon ordinary principles.  It  may lead to gangrene if
deeply effused, by the constriction and  compression it exercises on the muscles
of the limb.
   (Edema and gangrene of the limb, may occur as the result of tight bandaging,
or else by the swelling of the limb consequent upon  extravasation  of blood, or
inflammatory infiltration causing  strangulation of it within a bandage that has
been but lightly applied.  The occurrence of such accidents should make the
surgeon cautious  in applying  a bandage with  any degree of tightness in the
early stages of fracture, or, in those cases  in which there is already  much
swelling;  and the  apparatus should at  once be removed whenever the patient
complain, even of slight uneasiness;  or, indeed,  if any appearance of con-

                                  Fig. 83.
gestion, such as blueness, coldness, or vesications of the fingers  and toes show
themselves.  If  left on beyond  this, gangrene will probably  set  in, slow
strangulation going  on  under the bandages without much, if any, pain.  An
excellent plan of judging of the activity of the circulation in a fractured limb
after it has been put up, is to leave  the ends of the fingers or toes uncovered
by the bandage, when by pressing upon one of the nails, the freedom of the
circulation  may be  ascertained, by noticing the rapidity with which the blood
returns under it.
  In fractures  occurring in old people,  there is a great tendency to pulmonary
and cerebral congestion, partly from determination of the blood, and partly as a
consequence of  the long confinement required; these fractures commonly proving
fatal in this way.   The use of the starch bandage, by enabling the patient  to
get about, is the most effectual prevention to these accidents.
  Fractures may be complicated with various important local conditions.  Thus
the extravasation  of blood into the limb may arise from a wound of some large
vessel, and this may go on to so great an extent as to occasion strangulation of
the tissues; if  not checked by position  and  cold applications, it  may give rise
to gangrene, and  lead to amputation.   In other cases, again, the  soft parts  in
the vicinity of  the fracture may  be contused to such a  degree that they rapidly
run into slough, thus rendering it compound; or a wound may exist, not com- 
           AMPUTATION  IN  COMPOUND  FRACTURES.        199

municating with the broken bone, but requiring much modification of treatment,
and special adaptation of apparatus.
  The most serious complication of simple fractures, consists in their implicating
a joint.   The fracture  may extend  into a  neighboring articulation, and  thus
give rise to considerable inflammatory action, though in some  cases  no incon-
venience  results, even though the capsule be perforated by a  sharp fragment;
but in strumous subjects it may lead to ultimate disorganization of the articula-
tion, requiring excision, which I have several times had occasion to perform in
these cases.
   The complication of  dislocation with fracture often occasions great difficulty
to the surgeon, as it becomes necessary to reduce  the dislocated joint before
the fracture  is consolidated.  In  several cases of this description which  have
fallen under my care, I have succeeded in  reducing the dislocation at once, by
putting up the  limb very  tightly in wooden splints, so as to give a degree of
solidity to it, and to  permit the lever-like  movement of the shaft of the bone
being employed; and then, putting the patient under chloroform, have replaced
the bone without much  difficulty.  Should the surgeon have neglected to reduce
the dislocation in  the  first instance, it will  be necessary for him to wait  until
the fracture has become firmly united, and  then, putting up the limb in splints
or in starch, to try to effect the reduction, which, however, will  then be attended
by very great difficulty.
   In cases of simple fracture occurring in the neighborhood of, or implicating
 large joints, passive motion is very commonly recommended at the end of from
 four or six weeks; I think, however, with  Mr. Vincent, that  this is  often apt
 to do more harm than  good, and is  seldom  required, the natural action of the
muscles of the part  being fully sufficient to restore the movements of the arti-
culation, which may be assisted by friction  and douches.

                        COMPOUND  FRACTURES.

   A compound fracture is that form of injury in which there is an open wound
leading  down  to the broken bone, at the seat of fracture.   These injuries  are
 not only far more tedious in their cure than  simple fractures, but infinitely more
 dangerous.  The tediousness depends upon the communication of the fracture
 with the external air, causing it to unite by a slow process  of granulation,
 instead of by the  more speedy adhesive action that occurs in the simple form
 of injury.   The danger is likewise partly due to the same cause, the process of
 granulation and  suppuration being often attended by such profuse discharge of
 pus, from abscesses or  long-continued exfoliation  of bone; or  by the superven-
 tion of secondary disease, such as hectic, phlebitis,  pneumonia, or erysipelas, as
 to lead to the eventual loss of limb  or life.   Besides these dangers, which may
 be looked  upon as of a remote  kind, the  violence that occasions a compound
 fracture  often shatters the limb  to such an extent, as to lead  to the immediate
 supervention of traumatic gangrene, to the loss of  life  by hemorrhage, or to
 the certain and speedy disorganization of the limb, as the consequence of the
 reactionary inflammation.
   As there are, therefore, not only prospective dangers of great magnitude  to
 be encountered in these injuries, but also immediate risk of a very serious cha-
 racter to be met, the first  question that always presents itself  in a case of com-
 pound fracture is, whether the limb should be removed, or an attempt be made
 to save it.   It is of great  importance to settle this point at once, for, if ampu-
 tation be determined upon, it should be had recourse to with as little delay as
 possible,  there  being no period in the progress of the case so favorable for the
 performance of this operation as the  first  four-and-twenty hours.   Should an
 injudicious attempt have been made at saving the limb, the surgeon must wait
 until suppurative action has been set up before he can remove it;  and then, he 
200
FRACTURES.
will very commonly find that the occurrence of some of the diffuse inflammatory
affections of an  erysipeloid  character will render any operation impracticable;
or the supervention of traumatic gangrene may compel him to have recourse to
amputation under the most unfavorable circumstances.   At a late period in the
progress of the  case, amputation may be required, in order to rid  the patient
of a necrosed and suppurating limb that is exhausting him by the induction of
hectic.
   Though advocating the early performance of amputation in those cases which
imperatively require it, I am aware that  these  operations are very commonly
fatal, especially when practised near the trunk;  but yet, this cannot with justice
be urged as an argument against their performance, as immediate  amputation
should never be had recourse to except in the most severe cases, in which it is
evident that the patient's life  must in all probability  be sacrificed, by the un-
successful attempt to save the limb.   In determining the cases in which  imme-
diate amputation should be performed, no very definite  rules can be laid down,
and much must at last be left to the individual judgment and experience of the
surgeon.  One will attempt to  save a limb which another condemns.  But, in
coming to a conclusion  upon this important question,  he must bear  in  mind,
that though it is imperative to  do everything in his power to  save a limb, yet
that the preservation of the patient's life is the main  point, and that that  course
is the proper one  which offers  the greatest  prospect  of  effecting  this.   In
coming to a conclusion  on a question  of such vital moment as this,  he must be
guided, not only by the nature  and  extent of the fracture, but by the age, con-
stitution, and habits of the patient (p. 119).
   Those fractures must be looked upon as most unfavorable, in  which  the
wound is the consequence of the violence  that  breaks  the bone, and  in  which
there is much laceration of, and extravasation into, the soft  parts; more parti-
cularly if the integuments are stripped off, portions of the muscular  bellies pro-
truding, and the planes of cellular tissue between the great muscles  of the limb
torn up and infiltrated with blood.   Injuries of this description occurring in
the lower extremity always require amputation.   Now the danger to the patient
increases almost in the exact ratio of the proximity of  the injury to the  trunk.
Thus amputation of the thigh for bad compound fractures of the leg,  though a
very serious operation, is sufficiently successful; but when the femur itself is
badly fractured,  and amputation of the thigh high up is required, recovery  can
indeed but seldom be  expected.  In the arm, they are not so serious, and admit
of the member being  saved, unless the bones be greatly comminuted.
   The complication of a compound fracture with the  wound of a large joint,
more_ especially if  there be  crushing or splintering of the bones which enter
into its formation, when occurring  in the lower extremity, is  always a case for
amputation.   When the elbow and shoulder joints are extensively crushed and
injured, amputation of the arm must be practised;  but if the injury be local-
ized, and the soft parts be in a favorable state, resection of the articulation may
be  successfully practised.  These  operations are usually somewhat  irregular
proceedings, being conducted according to the extent  of the wound,  and con-
sisting rather in picking out the shattered fragments of bone, than in metho-
dical excision.
  When one of  the larger arteries of the  limb has been wounded  by the vio-
lence that  occasions the  fracture, or has  been lacerated by  the broken bone,
there may be  copious  arterial hemorrhage externally, as well as extravasation
into the general cellular tissue of the limb.   These cases most commonly re-
quire immediate amputation.  But whilst  the patient is being examined, and
preparations made for the operation, care must be taken that a dangerous quan-
tity of blood be not lost.  This must be prevented by the elevated position and
the application of a tourniquet.  For want of this  simple  precaution I have 
            TREATMENT OF COMPOUND  FRACTURES.        201

seen very large and even fatal quantities of blood gradually lost, by being allowed
slowly to trickle from the wound.
  In these cases it has been proposed, by some surgeons of great eminence, to
enlarge  the wound  in the  limb, or to make an incision down to the  fracture,
and  to  attempt  to  tie the artery where it has been  injured.  In  most cases,
however, this  is scarcely practicable, as  the surgeon would have to grope in  the
midst of bleeding  and infiltrated tissues,  and would experience the greatest
possible  difficulty in  finding the wounded  vessel, after a search which  would
materially tend to increase the disorganization of a  limb.   Even after the re-
moval of a limb in  this  condition it is by no means easy to find the artery that
has  poured out blood; and  how much more  difficult must it not be to search
for it successfully during life ?
   The ligature of the artery at a higher point of the limb  does not  hold  out
much prospect of success,  for the same  reasons that render its employment in-
admissible in  ordinary wounds  of arteries.   If, then,  proper  means  directed to
the wound, such as position, pressure, or perhaps the  attempt at ligature if  the
artery be easily reached, are not successful, no course is left  to the surgeon  but
to amputate the limb without delay.  This is  more especially the case if it  be
the  lower extremity that is injured.   In the  arm there is a  better prospect of
our being able to arrest the bleeding without  having  recourse to this extreme
measure.
   If, however, the  compound fracture  be  unattended by any of the complica-
tions that have just been mentioned, occurring in  a young and otherwise healthy
subject, we must, of course, attempt to save the limb, and shall generally succeed
in doing so.
   Treatment. — In the management of a compound  fracture, special apparatus,
such as M'Intyre's, Liston's, or the bracket-splints, double inclined planes, swing
boxes, and  fracture beds, are often necessary,  in  order to obtain access  to  the
wound, so as to dress it properly, and to place the limb in the best position for
union.   In many cases  the  starch  bandage may very advantageously be used,
but it requires caution, as swelling  and consequent  strangulation  of  the limb
may take place under it.
   The reduction of compound fractures must be accomplished with the same
attention to gentleness as  in that of simple ones. In the majority of cases, no
great difficulty is experienced in effecting this, and after it  has been done, the
limb should be placed on a well-padded splint, properly protected in the neigh-
borhood of the wound with  oiled silk,  so as to prevent soiling of the pads  by
blood and discharge.  In  some cases, however, considerable difficulty arises in
 the reduction, from the protrusion of one of the broken fragments which has
been driven through the skin,  either by careless  handling of the limb in carry-
ing the patient, or  else by the muscular contractions dragging the  lower frag-
 ment forcibly upwards, and thus causing perforation  of the  integument.  The
protruded bone  must, if possible, be gently replaced, by relaxing  the muscles
 of the  limb, and thus bringing the soft parts  over it.  In some  cases,  however,
it is so tightly embraced by the skin, which appears to be doubled in underneath
it, that enlargement  of the wound becomes necessary before it can be replaced.
 In other cases again  it will be  found that reduction cannot be effected or main-
tained, unless the sharp and projecting point  of  bone be sawn off.  This must
be done  carefully  by protecting the neighboring soft parts with  a split card.
The limb, as I have  found in several cases in which it has been necessary to
have recourse to this procedure, is not ultimately weakened by it.
   After the reduction, the great object is, if  possible, to convert the compound
into a simple fracture by  the  closure of the  external wound.  If this  can be
accomplished, the tediousness  and danger of  the case are greatly lessened, the
whole process of suppuration, with  all its attendant evils,  being saved to the
patient.  If the wound be  small, clean cut, and occasioned by the protrusion of 
202
FRACTURES.
the fragment rather than  by the  direct violence which occasions the fracture,
we may hope to succeed in our object by following Sir A. Cooper's recommen-
dation of applying to it a piece of lint soaked in its blood; or,  what is better,
saturated with collodion, and thus obtaining union by adhesion.  If the wound
be large, if a joint have been opened, if it  have been  inflicted  by the same
violence that breaks the bone, or  if there be much bruising of the edges and
surrounding tissues, with extravasation into the  limb, this direct union cannot
be expected to take place.  Under these circumstances it is, I  think, best to
apply from the very first, water-dressing, so as  to allow a vent for the discharges
that take place after the first four-and-twenty hours.
  After the position  of the  limb  has been  thus attended to,  an  endeavor must
be made to moderate the local inflammatory action, and to lessen constitutional
irritation.  The local action  may be moderated by the use  of irrigation (fig. 45),
and by the application of cold  evaporating lotions to the  part, which should be
elevated and but lightly covered, the bed-clothes  being well raised by means
of a cradle, so as not to press on the limb, and to allow space for the evaporation
of the cold lotion; care being taken, at  the same  time, that  the bandages be
applied very loosely, merely with a sufficient degree of force to retain the limb
upon the splint, as inflammatory infiltration that might rapidly induce strangu-
lation of the part is apt to ensue.  The constitutional irritation  must be subdued
by the administration  of opiates, together with  an aperient,  on the morning
following the accident, which must be repeated from time to  time during the
first few days.  Moderate antiphlogistic  regimen must  be had recourse to, and
the patient be disturbed as little as possible. In many cases suppuration rapidly
sets in, and if  the patient be addicted  to  drinking, the  constitutional disturb-
ance  soon assumes the irritative form; under these circumstances, it is  of  great
moment that support,  and even  stimulants,  be freely given;  they must be
allowed from the very first,  and increased in proportion to the  depression  of the
patient's strength, or as symptoms of nervous  irritation come on.
   If there be much  extravasation of blood  into and bruising of  the soft  parts,
great tension of the limb,  followed by unhealthy suppuration and sloughing,
will take place in  the neighborhood of the wound; free incisions  are then
required to remove the tension and strangulation of the  tissues, and by letting
out  the  broken-down  blood and  pus to lessen the risk  of the  occurrence of
gangrene.  So soon as  suppuration is fairly established, a  light poultice or thick
water-dressing, should be applied, and  the  burrowing of matter prevented by
making counter-openings where necessary, by the application of a compress, and
by attention to the position  of the limb.  The fracture apparatus must be kept
scrupulously clean,  especially in summer;  the bandages changed as  often as
soiled, and the pads  well protected with oiled  silk.   During this period various
complications,  such as erysipelas, inflammation of the absorbents and veins, and
low forms  of pneumonia, are apt to occur, requiring special  consideration and
treatment;  so  also, if the discharge be abundant, hectic, with  its sweats and
gastro-intestinal irritation, may come on, requiring full support of the powers
of the system, and the administration of the mineral acids and other remedies,
according to circumstances.  As  the confinement to bed is necessarily very pro-
longed in  these cases, often extending through many weeks  and months, the
state of the patient's back should be attended to, and he should  early be  placed
upon a water-cushion, or hydrostatic bed, lest sores supervene.  As the wound
gradually heals, water-dressing must be substituted for poultices,  so as  not to
sodden the parts and encourage suppuration, and  in time the red  or blue wash
for the water-dressing.   The bone will often be observed  lying white and bare,
bathed in pus, at the bottom of the wound.  But though in this apparently un-
favorable condition,  it may  recover  itself; lymph  gradually being  deposited in
 points on its surface by the action  of its own vessels, and this becoming vascu-
 larized, covering it with a layer of florid granulations.  In other cases, necrosis 
           SECONDARY  AMPUTATION IN FRACTURES.       203

to a greater or less  extent will  take place, and perfect consolidation does not
occur until the bone has separated.   In some instances, a large quantity of pro-
visional callus is thrown out, in which the necrosed bone is implicated, and then
the process of separation becomes extremely tedious  and protracted,  and ampu-
tation may not uncommonly become necessary, from the  powers of the patient
being unable to bear up in so prolonged a struggle.  So soon as some consolida-
tion has taken place, the limb should be firmly put up in gutta-percha or leather
splints, with a starch bandage, so as to enable the patient to be got out of  bed,
to change the air of his room, and thus to keep up his general health. In fitting
these splints, care  must be taken  to make  an  aperture opposite the wound,
through which it may  be dressed (Fig. 82).
   The time required for the proper consolidation of a compound fracture varies
greatly, according to the amount of injury done to the bones and soft parts, the
age and constitution of the patient.  Under the most favorable circumstances,
it requires double or treble the time that is necessary for the union of  a simple
fracture.   Much stiffness of the limb from rigidity of the muscles and tendons
will continue for a considerable length of time;  this may gradually be  removed
by frictions and douches.
   Secondary amputation may become  necessary from the occurrence of trau-
matic gangrene, when it must be done in accordance with the principles already
laid down when speaking of that operation;  but more frequently it  is required
from  failure  of the powers of  the  patient in  consequence of irritative and
asthenic fever, induced by the general disorganization of the limb, or by hectic
resulting from  profuse  suppuration  and slow necrosis  of  the  bones.   Under
these circumstances, the constitution suffers from the  local irritation which is
the source of the wasting discharge,  but by removing this in time,  and seizing
an interval in which constitutional action may have been somewhat  lessened,
the patient's life will in all probability be  preserved; the results  of secondary
amputation for compound  fracture  under these  conditions  being  by no means
unfavorable.  Indeed, it is remarkable  to see  how speedily the  constitutional
irritative and hectic symptoms subside after the removal of the source of irri-
tation, the  patient often  sleeping well, and taking his food with appetite the
 day after the operation.
   The proper period to seize for the performance of secondary amputation  in
 the earlier stages of the injury is often a most critical point.   As a general rule,
 it may be stated, that if the limb be not removed during the first twenty-four
 hours, eight or ten days must be allowed to elapse before the operation is done;
 as during that time constitutional  irritation and suppurative fever are of too
 general and active a character, to render fresh shock to the system  admissible.
 But when once the actions appear to tend  to  localize  themselves,  the  suppu-
 ration becoming more abundant, the  redness extending but slowly, and the con-
 stitutional  symptoms  merging into  an  asthenic form, then the  limb  may be
 removed with the  best prospect of success; the more the action is localized the
 better being the chance of the operation succeeding.
   In many cases the symptomatic  and  suppurative fever so rapidly  merge into
 the asthenic form, that the surgeon must seize the best moment he can  for the
 performance of the amputation.  Under these  circumstances  the operation is
 seldom very successful, the stump becomes sloughy, erysipelas  or diffuse in-
 flammation of the cellular tissues come on, or symptoms of pyemia set in, and
 the  patient speedily dies.   In other cases  again, there is  a  marked interval
 between the stages of the inflammatory and suppurative fever, and the super-
 vention of the typhoid symptoms, lasting for twelve or twenty-four  hours, or
 even  longer.  During this the mischief may  be looked  upon  as in a great
measure of a local character;  the  constitution has  been disturbed by the set-
ting up of  the inflammatory action, but this having terminated in suppuration,
 it has not as yet become seriously depressed  by the  continued irritation of the 
204
FRACTURE S.
discharge from the injured limb, or poisoned by the  absorption of morbid mat-
ters from it.
  The patient's powers must not, however, be allowed to sink to the last ebb
before amputation is performed, as then, if the shock donot destroy life, inter-
current and  visceral congestion, or some low form of inflammatory mischief,
will not  improbably prove fatal.   Much  as "conservative"  surgery is  to be
admired  and  cultivated, and hasty or unnecessary operations to  be deprecated,
I cannot but  think that  the life of the patient is occasionally jeopardized, and
even  lost, by disinclination on the part of the surgeon to operate  sufficiently
early  in cases of compound fracture, and  by too prolonged attempts at saving
the injured limb.
  The success of the operation will in a great measure depend upon  the  after-
treatment of  the case.  Large quantities  of stimulants  and support are often
required in London practice to prevent the patient from  sinking.   I have often
given with the best success eight or ten ounces of brandy, twelve or sixteen of
port wine, with  two or three pints of porter in  the twenty-four hours after
these operations, with beef-tea, arrow-root, or  meat, if the patient will  take it,
and have found it absolutely necessary to  do so lest the patient die exhausted.
  At a later  period than this, when some weeks  or  months have elapsed, and
the fracture  has not united, the  bones necrosing, and  the patient being worn
out by hectic, amputation must be performed at any convenient moment, and is
often  then done with great success if if be  not deferred too  late;  for here
the mischief is entirely local, and the constitution suffering only by the debility
resulting from it, quickly rallies when  the cause of this is removed.
  A fracture is occasionally so badly set that  it becomes necessary to break or
bend  the callus, in order to improve the condition of the limb.  When the dis-
placement is  angular, and the consolidation  not very  firm, this may be done
pretty readily; but  if the displacement  be longitudinal, and much time has
elapsed since the occurrence of the injury, it  will be impossible  to remedy the
deformity.   During the first four weeks the bond of union between the frag-
ments is so yielding, that the angular displacement may he remedied by putting
up the fracture afresh day by day,  by  the employment  of pressure, and by the
application of the roller in the opposite direction to that in which it had been
previously applied.   After this period, the deformity can  only be remedied by
forcibly bending or breaking the callus, and then putting up the fracture again,
when speedy and perfect consolidation  will  ensue.  In  this way  I have several
times remedied fractures that had got into a faulty position, although five or six
weeks had elapsed from the occurrence of the injury.

         UNUNITED  FRACTURES  AND FALSE  JOINTS.

  Some bones when broken never unite by callus or plastic matter, their frag-
ments merely being kept firm by the intervention of the aponeurotic structures
of the part, as is the case with the patella.  This, which is'owing to a want of
apposition of the fragments, and is  dependent on the condition of the part, can-
not be considered a diseased action.
  It happens, however, occasionally in fractures  of  the shafts, or the articular
ends of long bones, that  proper union has  not taken place at the usual time,
or does not take place at all.  This may be owing to one of three circumstan-
ces : lstly, That no uniting material of a stronger kind than fibro-cellular tissue
has been formed;  2dly, That the plastic  matter that  has been thrown out has
only developed into  fibrous tissue,  not having undergone osseous transforma-
tion ;  or, 3dly, That true bony  union has taken  place,  but, owing to some
peculiar state of the patient's health, the  callus has  become absorbed, and the
fracture loosened.
  In  the first and third conditions  we  have an ununited fracture ; the ends of 
        UNUNITED  FRACTURES  AND  FALSE JOINTS.      205

the bone which are rounded  and eburnated being  merely connected by, and
enveloped in, a loose fibro-cellular tissue.
   In the second condition we have a false joint, the ends of the bone being tied
together by strong fibrous bands.  The structure of these false joints, which
has been carefully studied by Rokitansky, presents  two distinct varieties.  In
the first, which partakes of the character of a hinge joint, we find that the ends
of the fracture are smoothed and rounded, invested with a dense fibrous perios-
teum, and united  to one another by thick  bands of ligamentous tissue, in such
a way as usually to admit of considerable lateral movement, though sometimes
they are tolerably firm.
   In the other variety the joint partakes of the ball and socket character, usu-
ally to a very imperfect degree,  but sometimes in a sufficiently well-developed
manner, one end of the bone being rounded and invested by periosteum, the
other, cup-shaped, and  covered  by firm  smooth fibroid tissue.  The bones are
united by a kind of capsule, in which a synovia-like  fluid has  occasionally been
found.
   The form that the false  joint  will assume  depends on the action of the mus-
cles that influence it.   Thus, when occurring in the shafts of long bones, when
it is subjected to movements of  flexion and extension,  it will assume the hinge
form; whilst when it is seated in the articular ends, where it is more subjected
to movements of rotation, it will affect the ball and socket character.
   The causes of ununited  fracture and false joints are  constitutional and local.
   In some cases the constitutional cause appears to be' a cachectic state of the
system, occurring from some debilitating  disease, such as phthisis, scurvy,  or
cancer, or from any depressing cause, in consequence of which there is not suf-
ficient reparative power for the production or proper development  of the plastic
matter, by which  the fracture should be united.   If it have been deposited, it
may, under the influence  of these constitutional causes, again become absorbed,
and the fracture thus  be  loosened; but in many cases no constitutional  cause
can be detected, the patient  being in excellent health, strong, and robust.  In
spontaneous fractures, union  seldom takes place very readily or perfectly.
   Pregnancy is said to have  a tendency to interfere  with the proper union of a
fracture;  this, however, I  consider doubtful,  as I have had under my care, and
have seen a considerable number of cases of fracture in pregnant women, which
united in the ordinary manner.
   Age does not appear to exercise any influence on  the occurrence of disunion
in fractures, which is  indeed most common in the early and middle periods of
life, when fractures are most frequently met  with.   I have on two occasions,  in
my own practice, known very firm and perfect consolidation of fracture of the
shaft of the femur, take place in women of ninety years of age and upwards.
   The local causes are various and important.  The anatomical condition of the
fragments, as regards their vascular supply, is perhaps that on which want of
union is most immediately dependent.   For proper union to take place, it is ne-
cessary that the callus  be deposited from  both sides of the fracture.  If one
fragment is so situated* that sufficient blood is not sent to it  for this purpose,
not only may disunion, but necrosis, occur.   This we  see exemplified in fractures
of the  superior articular ends of the  humerus and femur.  In  intracapsular
fracture of  the anatomical neck of the humerus, the  globular head, being de-
tached from all its vascular connections, may necrose.  In intracapsular fracture
of the neck of the femur,  the head of the bone still retaining some vascular con-
nection through the medium of the ligamentum teres, has sufficient blood fur-
nished to it, to prevent its death, but not enough to form callus—hence fibrous
union takes place.  In  the shafts of the long bones the degree of union will be
dependent  in a great measure on the conditions of  the vascular supply to the
fragments, through the medium  of the nutritious artery.  The influence of the
rupture of the nutritious  artery of the  bone by the line  of  fracture running 
206
FRACTURES.
across it, and thus interfering with the vascular supply of one of the fragments,
has been .investigated by Gueretin;  and the occasional occurrence of atrophy of
the bone after fracture, has been shown by Curling to  be dependent  upon the
supply of arterial blood  through this vessel being interrupted.  Gueretin has
collected cases that tend to prove the direct connection between the occurrence
of ununited fracture, and the want of proper arterial supply to one of the frag-
ments.   Thus in the humerus the course of the nutritious artery is  from above
downwards, and of 13 cases of ununited  fracture, 9 were found to be situated
above  the  canal in  whi#n this vessel  is lodged.   In  the forearm where the
nutritious artery passes from below upwards, of 8 cases of ununited fracture, 7
occurred below this vessel, and only 1 above.  Mr. Adams has, however, shown
that the number and size, as well as position, of the  nutrient arteries varies con-
siderably, and hence the objection that non-union may occur in a fracture of any
part of the shaft of  a long bone, whereas the  nutritious artery is only found at
one spot, can scarcely be  considered a very valid one.   It is certainly owing in
a great measure to this want of vascular supply that intracapsular  fractures
almost  invariably unite by fibrous tissue  rather  than by bone, and that when
bony union  takes place, the callus  is chiefly formed by the surface connected
with the shaft.   In  some cases of intracapsular fracture  of the humerus, no
union whatever  takes place, the detached  fragment necrosing in consequence of
its being entirely deprived of all supply of blood.
  Some bones are much more liable than others to  disunion of their fractures.
According to the statistics collected  by Norris, it would appear that the  femur,
the humerus, the bones of the leg, and of the forearm, and lastly the lower jaw,
are those in which ununited fractures  most frequently occur, and that in the
order which has been given.
  The occurrence of ununited fracture is occasionally attributed to the mobility
or want  of proper apposition of the  fragments, and  doubtless  in some cases it
may be so occasioned : but I believe that these causes are  not nearly so frequent
in their operation as the constitutional and local conditions that have already
been pointed out.  The interposition of a piece of muscle between the fragments,
may occasion disunion.   Of this I saw an interesting instance some years ago,
in which want of union in a fractured femur was owing to the  entanglement of
a portion of the rectus muscle between the fragments.
   The treatment of ununited fracture must chiefly be conducted with reference
to the constitutional cause of  the disunion, though  local  measures must  not be
neglected.  If callus have not been formed, or, after formation, have  been ab-
sorbed under the influence of a cachectic state of the system, the improvement
of the patient's  health, at the same time that the fracture is put up again firmly,
so that the ends of  the bone are brought in close apposition,  may bring about
perfect union.   I have  lately had  under  my care at the hospital,  a man with
ununited fracture of the femur from absorption of the callus four months after
the  occurrence  of the  injury, under  the influence of incipient phthisis and
debility induced by want of food, in whom perfect consolidation of the fracture
has taken place, by giving him cod-liver oil and good diet, with rest in bed and
a starch bandage to the  limb.  If there is no very evident cause for the disunion,
putting  up the  fracture firmly in leather or gutta-percha splints, with a starch
bandage, and  then allowing the patient to move  about upon crutches, so that
his general health may not suffer, at the same time that a tonic plan of treat-
ment is had recourse to, will  occasionally suffice.   This, however,  can only be
useful if but a short time, at most some months, has  elapsed from the occurrence
of  the  injury.   Mr. Smith1  (U. S.) has modified  this  treatment  by putting
the  limb in an  apparatus which combines pressure on  the fracture  with the
power of movement.  This plan, though somewhat tedious, occupying  several
months, appears to be successful, 10 cases out of 14 having been  cured by it,

           1 [Vide Am. Journal of the Med.  Sciences, for January, 1855.] 
TREATMENT  OF  UNUNITED FRACTURES.        207
and has the merit of being unattended by danger.  In some cases the empirical
administration of mercury is attended with success.   In a case of ununited frac-
ture of the humerus that was admitted into the  hospital under Mr. Liston, fif-
teen weeks after the occurrence of the injury, union took place within a month
by putting up the limb in splints, and salivating the  patient.  When the dis-
union arises from malignant disease nothing can be done.
  When the disunion has become very chronic, and a false joint has once
formed, it will be necessary to have recourse to operative procedure before union
can  be attained.   All operations that are undertaken in these  cases are con-
ducted on one or two principles; either with  the view of exciting such  inflam-
mation in the false joint and the neighboring tissues, as will lead to the formation
of lymph capable of undergoing osseous transformation; or else, by removing
the false joint altogether, to  convert the case into  a recent compound fracture,
and to treat it in  the same way that such an accident would be managed.   It
can easily be understood that operative procedures conducted on these principles
are of too serious a character to be lightly undertaken, or to be had recourse to
until other measures have failed, the mortality following  them  being, even
according to public statistics, considerable;  and probably very much  greater
than has been laid before the profession.
   Amongst the first set of operations, — those that have in view the excitation
of  sufficient  inflammation to cause deposit  of proper plastic  matter, — the
simplest procedure consists in the introduction  of acupuncture needles, or  in
the subcutaneous section  of  the ligamentous band with a tenotome.   In this
way I have known union effected in a patient of Mr. Liston's, who had a false
 joint  in the shaft of the femur, though not until after the fracture had been
converted  into  a compound  one,  and  much danger and  suffering incurred.
Four years after the consolidation of the ununited fracture, the  patient was
readmitted into the hospital, under my care, with fracture of the  same bone two
inches lower  down  than  the former  injury, and on this occasion, union took
place in  the usual manner and time without any difficulty.
   The introduction of a seton  across the false joint, though  occasionally suc-
cessful, is apt to give  rise to dangerous and even fatal  consequences, from
arterial hemorrhage, erysipelas,  diffuse inflammation  and  suppuration  of the
limb.  The threads must not be  left in beyond a few days, when sufficient
action will have been induced. A modification of the
seton  consists in passing a  silver wire  around the
fracture,  and by gradually  tightening this, to cut
 through the false joint at the same time that inflam-
 matory action is excited  in  it.   In performing this
 operation it must be borne in mind that large arterial
 branches and even the main trunk, especially in the
 thigh, may become firmly attached  to  the callus,  so
 that unless care be taken they may readily be wounded.
   Dieffenbach has excited the requisite  degree of in-
 flammation by driving with  a mallet, three  or  four
 conical ivory pegs into holes bored by means of a gimlet
 or drill, (fig. 84,) in the ends of the fractured  bone,
which are exposed  for this purpose.  The soft parts
are then laid down  over them, and after a few weeks
the pegs, which  have loosened in consequence of the
removal  or absorption of  their ends, should  be taken
out.  It is not necessary or even desirable to endeavor
to  pin together  the ends of the broken bone, but
merely to introduce the pegs into the extremities of both fragments near  to
the  seat of fracture.  It  is  however, especially  in ununited fractures  of the
femur and humerus that this can be successfully done; the irritation of the pegs
Fig. 84.
 
208
FRACTURE S.
appearing to occasion an  effusion of a large quantity of callus, sufficient for
the consolidation of the fracture.
   The operation  of removing the  false joint may be  performed  by ratting
down upon it, and resecting the  ends of the bones, or  else by destroying the
articulation with  caustic potass.  The excision of a false joint is necessarily a
dangerous operation, and by no means a successful one; erysipelas, phlebitis, and
diffuse suppuration of the bone occasionally supervening.  Of 38 cases collected
by Norris, in which the ends of the bones were either resected or scraped, 24
were cured, 7 derived no benefit,  and 6 died. In those cases that are successful
by this method, some shortening  of the limb must be expected to result, and if
the fracture be very oblique, it would of course be impossible to remove more than
a very limited portion of it, and, consequently, very perfect union could scarcely
be anticipated.  The  application  of caustics to the exposed bones is so coarse
and  uncertain  a  method, as to find but little favor amongst surgeons of the
present day.
   On  reviewing  the  various  methods that  have been  recommended for  the
re-establishment of union between  the  separated fragments, it would  appear
that the excitation of proper inflammatory action, by the  introduction of the
seton, or by driving in ivory pegs, promises the  most satisfactory result.   It is
by no means necessary to  remove the fibrous band that intervenes between the
the fragments in case  of false joint, for if the proper amount  of inflammatory
action  be set up, this  either undergoes  osseous transformation, or a  sufficient
quantity of callus is thrown out around it to consolidate the fracture.   If union
fails to be accomplished, amputation may be required as a last resource.
                           CHAPTER  XV.

                        SPECIAL FRACTURES.

'   In considering the nature and treatment of fractures of particular bones, we
 shall at present confine our remarks to fractures of the face and extremities.
 Injuries of the bones of the  head and spine derive their principal interest and
 importance, from their complication with lesion of some internal and contained
 organ;  hence the consideration of these can with more propriety be  referred to
 that of these  parts.
   Fractures of the Bones of the Face. — The nasal bbnes, being thin as
 well as exposed, are not unfrequently broken.   When fractured they may remain
 undisplaced,  but  are  more commonly depressed; the  ridge  of the  nose being
 beaten  in.   The swelling and ecchymosis  that  usually  attend this fracture
 render  its detection  difficult, and  must be reduced  before  any treatment is
 adopted.  The bone that is depressed should be raised with the broad end of a
 director, or by the  introduction of a pair  of polypus forceps  into the nostril,
 which expand in opening, and push it into proper position.
   If the septum alone be broken, the same treatment must be  adopted towards
 it.   Usually, after  being replaced, the position is maintained; but in some
 cases, where  there is a tendency to  sinking of the nostrils, the introduction of
 a plug into the nares  will  be  required to replace and retain the bones.   The
 hemorrhage,  which is usually pretty abundant, may be  stopped  by the applica-
 tion of cold, but occasionally the nostrils require plugging.  If the lachrymal
 bone be broken, together with the nasal, the ductus ad nasum may be obstructed, 
          FRACTURES  OF THE BONES  OF THE FACE.       209

and the course of the tears diverted.  In an injury of this kind I have seen
extensive emphysema of the eyelids and forehead occur on the patient attempt-
ing to blow his nose.  In some cases the injury  inflicted to the nasal bone
extends through the ethmoid to the  base  of the  brain, and may thus occasion
death.  This I have  seen  happen from a severe blow on the  face with a piece
of wood.
   The malar and superior maxillary bones are seldom broken unless great and
direct violence has been had recourse to, and their fracture is usually accompa-
nied by external wound, as in gun-shot injuries of these parts.  More commonly
the alveolar processes are detached, and the teeth loosened. The treatment then
consists in binding the  teeth together with gold wire.   In some rare  cases all
the bones of the face appear to have been smashed and separated from the skull
by the infliction of great violence.   Thus, South relates the case of a man who
was  struck on the face  with the handle of a crane, and in whom all  the bones
were separated and loosened, " feeling like beans in a bag."   Vidal records the
case of a man who, by a fall from a great height, separated all his facial bones.
In fractures of the  zygoma  the fragments may be driven into the temporal
muscle and produce so  much difficulty to mastication, as to require removal.
   The lower jaw is frequently broken, owing to its prominent  situation; though
 its arched shape enables it to resist all but extreme degrees of violence.   Frac-
 tures of this bone are usually compound, the laceration of the gum causing them
 to communicate with the external air.  And not unfrequently they are commi-
 nuted  as well, but yet from  the freedom of the vascular supply to  the bone,
 rapid and very perfect  union takes place in it.
   Fracture of the lower jaw may occur  in various situations.  I have seen it
 most frequently in the body of the bone, near the symphysis, extending between
 the  lateral incisors; or between these teeth and the canine.   The  symphysis
 itself is not so commonly fractured, the bone being thick in this situation.  The
 angle is  frequently broken, but the  neck  and coronoid process rarely give way.
 The signs of fracture of the lower jaw are very obvious.  The great mobility of
 the  fragments, the crepitus, the irregularity of the line of teeth,  and of the arch
 of the jaw, laceration of and bleeding from the  gums, and dribbling of saliva,
 indicate unequivocally the nature of the  injury.   The displacement and mobility
 of the fracture are greater the nearer  it is to the symphysis.  If the bone happen
 to be broken  on  both sides of this line, the middle fragment is much dragged
 out of place by the depressor muscles of the lower jaw.  In fracture about the
 angle and ramus, the deformity is not so  great, owing to the  muscles, that coat
 and protect either side of the bone  in this situation, preventing the fragments
 being displaced.
   The treatment is  simple enough in principle, though often not very easy of
 accomplishment.   It consists in maintaining the parts in apposition by suitable
 apparatus for four or five weeks, during which time mastication must be inter-
 dicted, the patient living on sop, soups,  and fluid nourishment of all  kinds, and
 talking prohibited.  The apparatus that commonly suffices consists of a gutta-
 percha splint, moulded to the part, properly padded, and fixed  on with a four-
 tailed  bandage; the two  fore-ends  of which are tied behind the  neck, whilst
 the two others are knotted over the top of the head.  When the ramus is broken
 the side of the pasteboard cup splint should be made proportionately long.  Any
 teeth that are luosened must be left in, as they will probably contract adhesions,
 and  fix themselves firmly;  and, if necessary, they may be tied to  the sound
 teeth with gold wire, or dentist's silk.   When  depression, especially near the
 symphysis, is considerable, a clamp apparatus which fixes the chin and the line
 of teeth  has been invented by Mr.  Lonsdale for the purpose of steadying the
 fragments, and answers the purpose  extremely well.
   [The treatment adopted in this country, in those cases of fracture of the lower
 maxillary bone, which  are attended with  but little displacement, consists in the 
210
SPECIAL  FRACTURES.
application simply of retaining compresses and of Barton's or Gibson's bandage
for the lower jaw.  In  oblique  fractures accompanied  with separation of the
fragments, the use of the gutta-percha cup and the same bandage will generally
suffice; the retention of the  fragments  in  coaptation  may also be materially
assisted by the adjustment over the teeth and gums of the silver clamp proposed
by Dr. Mutter.]                                       . .           .
   In  fractures of the body of the lower jaw by gun-shot injury, there is  great
comminution and splintering  of the bone, followed by copious and  fetid dis-
charge, which, being  in parts wallowed, may reduce the patient to a state of
extreme debility.  In these cases, Dupuytren recommends the lower lip to be
cut through, the splinters taken away, and, if necessary, a portion  of the bone
resected, so as  to convert the wound into one similar to what results after the
partial removal of the lower jaw for disease of the bone.
   Fracture of the os hyoides is of very rare occurrence,  and, though usually the
result of direct violence, as a forcible  grasp, has been seen by Oliver d'Angers
to occur  from  muscular action.   The signs  are always very obvious, the frag-
ments forming a sharp salient angle; there is much pain  and irritation, increased
by speaking and deglutition.   There is usually salivation;  and  considerable
difficulty  in breathing may be present.   Reduction is accomplished by pressing
the fragments into apposition, either externally or by passing the finger into the
mouth.   Should one  piece of the bone  be  driven much in, it might possibly
require to be drawn forwards with a tenaculum.  The head should then be fixed
by a  stiff pasteboard collar to  prevent displacement.
   The Clavicle is often broken, partly owing  to its exposure to direct vio-
lence, and partly to its  action in preserving the shoulder  at  a proper distance
from the trunk, and being the only direct osseous support of the upper extremity,
receiving, by transmission  through the  scapula, every  shock that is  communi-
 cated to the hand when the arm is in an extended position; hence blows on the
 shoulder  and falls on the hand are common causes of fractured clavicle.  This
 bone would be more frequently  broken than  it is, were it not that it resembles
 two segments of a circle looking in opposite directions, so as to form an 8 shape,
 which admirably enables it to withstand indirect violence.  The clavicle may
 be fractured in three situations; lstly, and most frequently, the great convexity
 is broken, the bone bending  here when pressed upon  from its extremity, the
 curve becoming increased, and  at last  giving way;  2dly, it  may be fractured
 nearer the acromion under the acromio-clavicular and  coraco-clavicular liga-
 ments ; and 3dly, its tip may be broken off external to the outermost point of
 insertion  of the trapezoid ligaments between it and the acromion.   The signs
 will  depend upon the seat of fracture.  When the bone is broken between the
 conoid and trapezoid ligaments,  there is little, if any, displacement, but pain on
 pressure, some crepitus on moving the shoulders, and slight irregularity in run-
 ning the  finger along the bone.   When  the fracture is  external to the trapezoid
                           ligament, there  is a  remarkably  oblique displace-
            ig^jj.         ment of the scapular fragment, the articular surface
                           of which  is turned forwards and inwards, with  a
                           slight inclination downwards, nearly at right  angles
                           to the rest of the bone, apparently by  the dragging
                            of  the weight of the shoulder, the point of which,
                            with the  scapula, is  rounded forwards (fig. 85).
                            When the fracture occurs  about the middle of the
                           bone, or at any part on the sternal side of the sca-
                            pular ligaments, there is  a  remarkable degree  of
                            deformity, owing to the displacement  of the outer
      86  H^h^Cl  •         fragment in a direction  inwards  and downwards.
              y   av        This displacement is owing  to  two  causes, the
 weight of the arm dragging  the fragment down,  and the action of the muscles
 
FRACTURES  OF  THE  CLAVICLE.
211
that pass from the trunk to the shoulder drawing the scapula and the whole of
the upper extremity, forwards and inwards  towards  the mesial line, when the
support of the clavicle is removed.  The outer extremity of the inner fragment
appears to be elevated, the skin being drawn tensely over it; but this is rather
owing to  the depression of the outer portion of the bone; it is in reality kept
fixed  by the antagonism between the sterno-cleido-mastoid and great pectoral
muscles.  On looking at a patient with fracture of the clavicle in this situation,
the nature of the injury is at once evident.  The flattening  of the shoulder with
its point approximated towards the sternum, the great prominence formed by the
end of the inner fragment over which the skin is tightly stretched, the sudden
depression under this, and the crepitus, which can be easily induced by raising
and rotating the shoulder at the same time that the elbow is pressed to the side,
indicate in the most unequivocal manner the nature of  the injury.  The atti-
tude of the patient is remarkable; he sits, leaning his head  down to the affected
side, so as to relax the muscles, and supports his elbow and forearm in the sound
hand, in order to take off the weight of the limb.
   Fracture of  the  clavicle in infants  not  unfrequently occurs, and is apt to be
overlooked.  The child cries and suffers pain whenever the arm is moved.  On
examination,  an irregularity with  some  protuberance will  be felt about the
centre of the bone.
   Comminuted fracture of the  clavicle from direct violence is often a serious
accident, as the subclavian vein and  subjacent plexus  of  nerves, or the upper
part  of the chest, may be seriously  injured as well.  In  a  case  of this kind
that was  under my care  some time since, the subclavian  vein was apparently
wounded,  great extravasation  of blood taking  place about  the shoulder and
neck, and the circulation through the veins of the arm  so much interfered
with  as to  threaten  gangrene.   The case did perfectly well,  however, by the
continuous  application  of arnica lotions to  the  shoulder, and attention to the
position of  the arm.
   Treatment—When the fracture occurs at the tip of the acromial end of the
clavicle, a figure of 8 bandage round the shoulders, and keeping the arm in a
sling, will prevent the tendency to displacement forwards.
   When the bone is broken underneath the scapulo-clavicular ligaments, there
is but little displacement, and the same treatment will  suffice.   But when the
fracture is situated towards the middle  of the  bone, or indeed at  any point to
the inside of these ligaments, then the management is more difficult, and there
 are three principal indications to be  attended to, in order to correct the triple
 displacement of the scapular fragment.
   By placing a thick, wedge-shaped  cushion with its broad end upwards in the
 axilla, and then bringing the  elbow closely to the side, the  outer  fragment is
 drawn outwards, and by pressing the  elbow well backwards,  the  tendency to
 rotation forwards of the shoulder is removed, and the broken bone brought into
 proper position.   By elevating the shoulder, and taking off  the weight  of the
 arm by means of a short sling  that passes well under the elbow, the displace-
 ment downwards is remedied.   In  applying the necessary  apparatus care must
 be taken to bandage the fingers separately, to pad the  palm of the hand  with
 cotton wadding, and to apply a roller up  the arm as high as the  axillary pad.
 Before applying the roller, the elbow must  always be flexed, otherwise  undue
 and dangerous constriction of the  arm may occur.  The  pad  should be firm,
 made of bed-tick stuffed with bran, six inches long, five broad, and three thick
at its upper part; the sling must support the  elbow, and  the  hand should be
well raised across the chest, so that the fingers rest upon the upper part  of the
sternum.
   The elbow must be kept to the side  by a few turns  of  a roller, or by means
of a padded belt.  In  children, in  whom these fractures  often occur, there is
frequently a difficulty in keeping the bandages properly applied;  under these 
212
SPECIAL  FRACTURES.
circumstances the starch apparatus will  be found very useful, care being taken
to re-apply the apparatus so often as it becomes loose, lest deformity result.   It
                                has been recommended  to  treat fractured
           [Fig.  87.              clavicles occurring in females, to whom any
                                irregularity of union in this situation would
                                be  very annoying, by keeping the patient  in
                                bed for the  first two or three weeks.
                                  [In fig. 87 is given a representation of the
                                well-known  apparatus of Dr. Fox, of Philadel-
                                phia,  for the treatment  of fractures of the
                                clavicle.  This dressing it will be seen is com-
                                posed of a stuffed muslin  collar for the sound
                                shoulder, and of a firm wedge-shaped pad and
                                sling  for the  injured arm.   The  tapes from
                                the sling are attached in front and behind
                                to the  collar, which  serves as the point of
                                resistance.  This apparatus has been subject
                                to many modifications; the most valuable of
                                which  perhaps are those of Drs. Hamilton,
                                Levis, and Bartlett.]
                                  Fractures of the Scapula.—Fracture
                                of  the  body of the scapula is not very com-
                                monly  met with, and when  it  occurs, being
                                always  the  result of considerable direct vio-
                                lence, it  is usually associated  with  serious
injury to the subjacent ribs and trunk.   The  thick layer of muscles overlying
this bone  not only protects it, but prevents displacement, and renders the de-
tection of its fracture  difficult.  The fracture usually  takes place across the
bone, immediately below the spine, but occasionally it  may be split longitudi-
nally  or starred.   If ascertained, it should be  treated by the application of a
body-bandage.

    FRACTURES IN  THE VICINITY OF THE S HO ULD ER-JOINT.

  These fractures are  of common  occurrence, and may  happen either in the
bony  points of the scapula that overhang  this  articulation, or else in the upper
end of the humerus.  Not unfrequently there is double  fracture in the neigh-
borhood of this articulation; thus the acromion may be broken as well as the
neck  of the humerus.  These complications necessarily throw some  difficulty in
the way of the diagnosis of  these fractures.   In many cases, also, the amount
of contusion, and  the rapid swelling that takes place, obscure the nature of the
injury.
  The acromion, forming  as it does  the very tip of the shoulder, is more fre-
quently broken than any other of the bony structures in  this  neighborhood.
The signs of this  fracture  are very obvious; when the  acromion  is broken off
near  its root, the arm  hangs as a dead  weight by the side, and the  patient,
feeling as if his arm were dropping off,  supports it with the other hand.  There
is flattening of the shoulder, which is  most marked  by looking  at  the patient
from  behind; and the head of the humerus can be felt somewhat lower in the
axilla than natural.   On running the finger along the spine of the scapula, a
sudden inequality in the line  of the bone can be detected, and on raising the
elbow and rotating  the arm, crepitus can be felt, the rounded outline of the
shoulder being restored.
   In many cases the tip of the acromion  only is broken off.  When this hap-
pens, the nature of the injury may be suspected  by the patient being unable
to raise his arm to a level  with his head, so  as to touch the  crown, owing to
 
FRACTURES  OF  THE  HUMERUS.
213
some of the fibres of the deltoid having lost their points of attachment; and it
may be determined by the existence in a minor degree of some of the preceding
signs, which prevent the accident being confounded with  paralysis  of the del-
toid from contusion.
   The treatment consists principally in raising the elbow, so as to take  off the
weight of the limb, and to push up the acromion by the head  of the humerus.
At the same time a pad may be placed between the elbow and the side, in order
to direct the arm somewhat upwards  and inwards, and the limb must be fixed
in this position by a bandage and sling.  The union may take place either by
bone or ligament.
   The coracoid process is but seldom broken; never, indeed, except by very
direct violence.   There is in the museum of the University College a prepara-
tion showing a fracture of the base of this process, implicating  and extending
across the glenoid cavity.  The attachment of such powerful muscles as the
pectoralis minor, biceps, and coraco-brachialis would displace the fragment con-
siderably, were it not that it is  kept  in position  by the  ligaments  to which it
gives insertion, and whose fibres are expanded over it.
   The only treatment that can be adopted is to put the arm in  a sling, and fix
it to the side.
   Fracture of the neck of the scapula very rarely occurs,  and there  can be little
doubt that  Sir A. Cooper and Mr. South are correct  in  stating, that cases so
described, are, in reality, instances of fracture of the upper end of the humerus.
There is, according to Mr. South, no preparation in any museum in London
illustrating fracture of the  neck of the  scapula.  Indeed, on  looking at the
great strength of this  portion of the  bone, and the way in which it  is protected
by the other parts about the shoulder, it is difficult to understand how it can be
broken, except by gun-shot violence.
   Fractures of the humerus. —  In studying the fractures of the humerus,
we must divide that bone into three parts, — the upper articular end, the shaft,
and the lower articular extremity.
   Fracture of the upper articular end of the humerus not unfrequently occurs,
constituting an important class of injuries which have been  carefully  studied
by Sir A. Cooper, and more  recently by Mr. R. W. Smith, whose work on frac-
tures deserves the attentive perusal of every practitioner.
   Five  kinds of fracture  of  the humerus  are met with in  the immediate
 vicinity  of the  shoulder-joint.  Two of  these are  intracapsular,  viz., simple
fracture  of  the anatomical neck, and impacted fracture of this  portion of the
bone.   The remaining three are  extracapsular, viz., fractures of the surgical
neck, — simple, and impacted; and  separation of the great tubercle from the
head of the bone.
   Intracapsular fractures of the  neck of the humerus. — When the fracture
occurs at the anatomical neck, the head of the bone is detached from  the  tu-
bercles, a little above,  or, at the line  of insertion of the  capsule.  These frac-
tures are occasioned by severe  falls on the  shoulder, and are most frequently
met with in adults.
   The signs of this injury are  by no means very distinct, though  much light
has been thrown upon them by the recent labors of Mr. Smith.  There is loss
of motion in the shoulder, with some  swelling and considerable pain; but there
is some  deformity about  the  shoulder, and an irregularity, produced  by the
upper end  of the lower  fragment, can be felt towards the inner  side of the
joint; crepitus is  easily produced;  and there is, on measurement from the
acromion to the olecranon, shortening to  the extent of about one-third of an
inch.
   When this fracture is impacted, the upper fragment penetrates the lower one.
In consequence of this, the axis of the humerus is directed somewhat inwards
towards the coracoid process: here also some irregular  osseous swelling may be 
214
SPECIAL  FRACTURES.
detected.   The head of the bone can be felt in the glenoid cavity, but it is not
in the axis of the limb, the elbow projecting slightly from the side, there being
at the same  time a hollow under the  acromion.   There is consequently more
deformity about the joint in the impacted than in the simple intracapsular frac-
ture, with the same impairment of motion, but  only slight crepitus  on firmly
grasping the shoulder and rotating the elbow.
   In fracture of the anatomical neck of the humerus the portion of bone broken
off is truly a foreign body in the joint, and being unconnected with any liga-
mentous structure, may perish, and thus give rise to destruction of the articu-
lation.  When this does not take place it is probable that  impaction of the
fragment has occurred, and that thus its life is maintained; or it may happen,
as Mr. Smith supposes, that its vitality is occasionally preserved in consequence
of some partial union being kept up between  it and the rest of the bone by
untorn shreds of capsule.  In  either  case the principal reparative efforts are
made by the lower fragment, which deposits callus abundantly.
   Treatment.—As there is often much swelling from contusion in these cases,
local antiphlogistic treatment by means of leeches and evaporating lotions should
be had recourse to, for a few days.   A pad may then be placed in the axilla,
and a leather or gutta-percha cap fitted to the shoulder and upper arm, the limb
having previously been bandaged.   The hand must be supported in a sling, and
the elbow fixed to the side.   In examining and reducing  these intracapsular
fractures, no violence should be employed,  lest  the impaction of the fragment
be disturbed, or portions  of untorn capsule, on  which the ultimate osseous
repair of the injury is dependent, be broken through.
   Extracapsular fractures of the neck of the humerus. — In these injuries, the
bone is broken through the surgical neck, or  that portion which  is  below the
tubercles,  but  above  the insertions of the pectoralis  major, latissimus dorsi,
teres major, and deltoid muscles.  This accident may occur in children as well
as in  adults; in the former  the  separation taking place through  the  line of
junction between the epiphysis and  the  shaft of the bone.  In this fracture
there is  double displacement; the  head  of the bone and upper fragment are
rotated outwards, being under the influence of  the muscles inserted into the
great tubercle, whilst the shaft is drawn upwards and inwards under the cora-
coid process, by the muscles going from the trunk to the arm, and by the flexors
of the limb.
   The  signs of this  fracture are sufficiently  obvious.   The  glenoid cavity  is
filled by the  head of the bone, which can be felt in it.  Below this  there is a
depression; crepitus is easily produced, and there is great mobility of the lower
fragment, and  shortening of the limb  to the extent of from  three-quarters to
one inch; but the most remarkable  sign is the prominence formed by the upper
end of  the shaft of the humerus, which projects  under the  integuments, and
can readily be felt under  the  coracoid process, especially when the elbow  is
pushed upwards  and  rotated.  The axis of the bone is also directed obliquely
upwards and  inwards towards  this point.   In consequence of this  fragment,
which is often very  sharp  and angular,  irritating  the nerves  of the axillary
plexus, a good deal of pain is complained of in the"arm and fingers.    This sign,
however, is not met with in children, owing to the  greater smoothness of the
fractured surfaces.
   The  impacted extracapsular fracture of the  neck of the humerus has been
especially treated of by Smith in his very excellent work on fractures.  In this
injury the  superior fragment being penetrated by the inferior one, the  continuity
of the bone and its firmness are in a great measure preserved; lience,  the usual
signs of fracture, such as mobility, displacement, and crepitus, are not readily
obtainable, and indeed the signs of this  injury are chiefly  negative.  Thus,
there is impairment of motion, slight deformity about the joint and upper part 
FRACTURES  OF  THE  HUMERUS.
215
of the arm, and  some crepitus;  but only obtainable with difficulty,  and by
firmly grasping the head of the bone whilst the elbow is being rotated.
   The treatment  usually recommended consists in bandaging the limb, putting
a pad in the axilla, a leather or gutta percha cap over the shoulder, bringing
the  elbow well to the side by means of a bandage, and  supporting the hand
only in a sling, so that the weight of the  arm may be allowed  to  drag on the
lower fragment, and  thus lessen the displacement.
   In the management of  these fractures, I have found a very convenient  r~\
apparatus to  consist of a  leather splint about two feet long by six inches
broad, bent upon  itself in the middle, so that  one half of it may be  applied
lengthways to the chest, and the other half to  the inside of the injured arm,
the  angle  formed by the  bend, which should be somewhat obtuse, being
well pressed up into the axilla.  In this way  the limb is well steadied and
the tendency to displacement inwards of the  lower fragment corrected.
   In some cases  fracture of the neck of the humerus is followed by atrophy of
the bone, though good union has taken place.
   Compound fracture of  the surgical neck of the humerus is not of common
occurrence.  Recently I  had a ease under  my care in  which the accident
happened to a  lad from a fall out of a window.  The fracture was transverse and
the  upper extremity of the  lower fragment  protruded through the deltoid to
the  extent of an inch and a  half.   It was  reduced with  difficulty; as great
irritation was set up around the seats of injury, and as there was a tendency to
protrusion of  the upper extremity of the  lower fragment,  this was turned out
by enlarging the wound, and about an inch and a half of it sawn  off.   Union
took place between the  fragments, and recovery was  effected  with a very
perfect arm.
   Separation of the great tubercle of the humerus occasionally occurs from falls
and blows upon the shoulder;  but more  commonly as the result of the violent
action of the three external rotator muscles, which are inserted into it.   In this
injury  there is a double displacement;   the tubercle is  carried  upwards  and
outwards away from the head of the  bone, and under  and external to the
acromion process;  the head is drawn upwards  and inwards by  the  muscles
passing from the trunk to the arm, as well as by the flexors of the arm, in such
a way that it lies upon the inner edge of the glenoid cavity under  the coracoid
process, and  is indeed almost  luxated.   The consequence of this double  dis-
placement is  a great increase in the breadth of the shoulder, which is nearly
double its natural size; on examination a  rounded tumor, the head  of the bone,
movable on rotating the  arm, can be felt under the  coracoid process, whilst
another osseous mass, the great tubercle, may be felt at the outer and back part
of the joint;  between these a sulcus is perceptible,  and crepitus may be felt by
bringing the two portions of bone in apposition and rotating the arm.  This
accident, which  is  of rare  occurrence, has been most carefully described by
Guthrie and Smith, to whom a knowledge of its pathology is due.
   The principle  of treatment  consists in  an attempt  to bring, and  retain the
detached tubercle in contact with the head of the bone; this may be done either
by mechanical means, or by relaxation of the muscles.
   The treatment by mechanical means consists  in  placing a pad in the axilla,
and  bringing the elbow to the  side so as  to throw out the head of  the  bone, at
the same time  that,  by means of a compress, the tubercle is pressed into proper
position, the arm being supported in a sling.  The treatment by relaxation of
the  muscles  consists in elevating  and  extending the arm from the  trunk; in
carrying .this out, it is necessary that the patient be confined to bed, the arm
being supported on a pillow.
   Fractures of the  shaft of the humerus  are usually somewhat oblique from
above, downwards  and outwards.   The   nature of the  accident  can be  at
once  detected by the great mobility of the fragment, the ready production of 
216
SPECIAL  FRACTURES.
crepitus, and the other ordinary signs of fracture.  The displacement usually
consists in the lower fragment being drawn upwards and to the  inner  side of
the upper one,  which is  often somewhat everted.  The  treatment  is of  the
simplest character, flexing the elbow, bandaging the arm, and the application
of two  or three  well-padded  splints, the  inner  one of which  should be rec-
tangular, being all that is  necessary.  In applying a splint to the inner side of
the arm, care must be taken  that it do not  press upon the axillary vein, lest
oedema of the limb occur.

     FRACTURES  IN  THE VICINITY  OF  THE  ELBOW-JOINT

   May occur through any of the  osseous  prominences in this situation.  They
are very commonly complicated with  dislocation, with  considerable  contusion
of and  injury to the  joint,  or perhaps with  comminution  of the  bones and
considerable  laceration of  the soft  parts  covering  them.   In most  cases
swelling speedily comes on,  tending to obscure materially the  nature of the
injury.
   Fractures of the lower articular end of the humerus.— The sepa-
ration of the lower epiphysis of the humerus in  children before its ossification is
complete, is by no means  an unfrequent  accident, the  fragment being carried
backwards, with the bones of the  forearm connected with it,  so as to  cause
considerable  displacement posteriorly.  It may readily be displaced, but slips
out of its position again, with crepitus, so soon  as it  is left to itself.
   A transverse fracture of the lower end, of the humerus, just above the elbow,
                         occasionally occurs in adults.   In these cases the dis-
                         placement backwards of the forearm and lower frag-
                         ment, the pain and crepitus, indicate the nature of
                         the  accident.
                           Fracture of  either condyle of the humerus  may
                         arise from blows and falls on the elbow.   There is
                         considerable pain about the seat of the injury, but
                         usually not much displacement, unless, as  in fig. 87,
                         there is a transverse fracture as well.  Crepitus, how-
                         ever may readily be felt by rotating the radius, if it
                         be the external  condyle that is injured; or by flexing
                         and pronating the forearm, if it  be the internal con-
                         dyle that has been detached.
                           The treatment of  all these injuries must be con-
                         ducted on very  similar principles.  The swelling and
inflammatory action, which  rapidly supervene, usually require local antiphlo-
gistic treatment, the application of  cold lotions, or of irrigation, the arm being
flexed, and supported in an easy position on a proper splint.   After the subsi-
dence of the swelling,  the fracture, whatever be its precise nature, is best main-
tained in position by being put up  in angular splints, the forearm being kept in
the mid-state between pronation  and supination, and well supported in a sling.
It is in these particular fractures  that passive  motion, if it ever be employed,
may be had  recourse to, a tendency to  rigidity about the joint  being otherwise
often left.  The motion should be begun in adults at the expiration of a month
or five weeks; in children at the end of three weeks after the occurrence of the
accident.
^   [In fractures involving the articulation  of the elbow joint, the main difficulty
in the  treatment arises from the nature of the displacement of the lower frag-
ments of the humerus.  In consequence  of the action of the muscles which
pass from the arm to their insertion upon the forearm, viz., the biceps, triceps, and
brachials anticus, there is a  constant tendency to retraction  upwards of the
forearm, and necessarily a corresponding displacement of the lower fragments
 
FRACTURES  OF  THE ARM.
217
of the fractured bone.   The indication in the treatment  is therefore  evidently
—to keep up a proper degree of extension of the  forearm, and thus to prevent
the displacement above described.  This we believe can best be accomplished by
the use of the splint recommended by the late Dr. Hewson. This splint is angular,
with a flexible joint, and so carved as to fit with accuracy upon the anterior portion
of the arm and forearm.   By this means a sufficient degree of extension of the
forearm is obtained, and at the  same time  all the tendency to excoriation over
the  condyles,  so often  observed after  the application of the lateral angular
splints, prevented.]
   The only fracture of the bones of the forearm  that  commonly  occurs in the
vicinity of the elbow-joint,  is  that  of the olecranon; this may happen from
falls upon the elbow, or  from  muscular action.   The displacement  is usually
considerable, the fragment which is detached being drawn upwards by the
triceps muscle.  Occasionally, however, when the ligamentary expansion of the
tendon of this muscle is not torn through, there is but little separation  of the
fragments.  In  the majority of cases, as it  takes place from direct violence,
there is much swelling  about  the joint, and  not  unfrequently the fracture  is
compound.  The treatment consists in  keeping the  arm extended  for  about
three weeks, by means of a light wooden splint applied along its anterior aspect;
at the end of this time it may be gradually  flexed.   When  the  separation of
the fragments is considerable,  bony union does not take place;  but when the
tendinous expansion of the triceps has  not  been torn, the fracture  unites by
osseous deposit.
   Fracture of the coronoid process is an accident of very rare occurrence, but
would occasionally appear to happen, by falls upon the palm of  the  hand, the
forearm being forcibly driven  backwards.  It  may occur from the contraction
of the brachialis anticus muscle, as in the case of a boy; reported by Mr. Liston,
who, by hanging from a high wall for too long a time, met with this fracture.
When it exists, the forearm is  dislocated  backwards, crepitus being detected  as
it is replaced in position.   The treatment consists in  flexing the elbow, placing
the arm in a sling, and keeping the joint quiet.  Union takes place by ligament
and not by bone.
   Fractures of the middle of the forearm are of very common occurrence, both
bones being usually broken, with much shortening, angular displacement, and
crepitus.  Occasionally one bone only is fractured, from the application of direct
violence.   When this is the case, more attention will  be required in  establish-
ing the precise nature of  the injury.
   The treatment is simple; a splint somewhat broader than the arm,  should be
placed on either side of it,  and a narrow pad  laid along the interosseous  space,
in order that the patency  of this may be preserved; no bandage should be placed
under the splint.  If masses  of  callus  happen  to be thrown out across this
interval, the prone and supine movements  of the hand will be lost, and the
utility of the limb  greatly interfered with.
   Cejmpemnd fractures of the elbow-joint are necessarily serious accidents.  If
the articulation be simply opened  with little laceration of the surrounding soft
parts, and no  comminution  of  the bones, the  limb may very commonly be pre-
served by the employment of active antiphlogistic treatment.   If the bones be
much shattered, the soft parts not  being seriously implicated, removal  of the
splinters,  and more or less complete  resection of the  injured joint, will enable
the surgeon to save the rest of the limb.   But if the  soft parts be extensively
contused and torn, as well as the bones comminuted, amputation of the arm may
be required.
   Compound fractures of the forearm seldom give much trouble or require am-
putation, but they very commonly lead to obliteration of the interosseous  space,
and  thus impair the after utility of the limb.
   Fractures  of the lower extremity of the radius,  near the wrist, are 
218
special  fractures.
Fig. 89.
of common occurrence, from falls upon the palm of the hand, giving rise to very
considerable  and remarkable displacement, which  has often  been mistaken for
dislocation of this joint.   The  importance of these  fractures,  not  only in  a
diagnostic point of view, but also in reference to their treatment, has caused them
to be carefully studied by surgeons, and their nature  and pathology have been
especially investigated by Collis, Goyrand, Voillermier, Nelaton  and Smith.
   The signs  of a fracture of the radius in the neighborhood of this joint are so
                         peculiar, that, when once  seen, they may  always be
                         recognized  without  difficulty  as  diagnostic  of  the
                         injury.  The deformity occasioned by this accident
                         gives  rise to a remarkable  undular distortion of the
                         wrist.   On looking at  the  injured  limb sideways, it
                         will be seen that there is a considerable dorsal pro-
                         minence apparently situated  on  the  back of  the
                         carpus.  Immediately underneath this, on the palmar
                         aspect of the wrist, just opposite the annular ligament,
                         there  is a remarkable hollow or arch  most distinctly
                         marked at, and  indeed confined to,  the radial side of
                         the arm; a little above this,  that  is to say, on the
                         lower part of the palmar aspect of the forearm, there
                         is another rounded prominence, not  nearly so large
                         or distinct however as the one on  the dorsal aspect.
                         On looking at the back  of the  hand it will be seen to
                         be placed somewhat obliquely  to the axis of the fore-
                         arm, the ulnar  border being  somewhat convex, and
                         the styloid process of this bone projecting sharply
                         under the skin  (fig. 89). The  radial side of the wrist
                         is, on  the  contrary, somewhat  concave, appearing to
                         be shortened.
   The pain  about the seat of injury is  very severe, and is  greatly increased
by moving the  hand,  especially  by making any  attempt at  supination.  The
             hand is perfectly useless, the  patient being unable to support it.
             All power of rotating the  radius is  lost, the patient moving the
             whole of  the arm from the shoulder  at once, and thus apparently,
             but not really, pronating and  supinating it.   Crepitus can often be
             felt, but in some cases the most careful  examination fails to elicit
             it,  unless the  hand be very forcibly drawn downwards  and then
             rotated.
               This fracture usually occurs from half an inch to an inch above the
             articular surface of the radius.  The cause of the particular deformity
             that is observed, and  indeed  the general  pathology of the injury,
             has been the subject of much discussion, in a great measure owing,
             I believe, to the opportunity  of dissecting recent fractures of this
             kind  being not very frequent.   Some years ago I had an opportu-
             nity of dissecting and carefully examining the state of a limb in a
             woman who died in University College Hospital, twelve days after
             meeting with  this accident.   On examining the left arm, which
             presented all the signs of this injury in a marked degree (fig. 89),
             a transverse fracture of the  radius was found about an inch above
             its  articular surface.   The  lower fragment was split into three
             portions, between which the upper fragment was so firmly impacted
             to the depth of more than  half an  inch as to require some force
             in its removal.   The three portions into which the lower fragment
          _  was split  were  of very unequal size;  the two posterior ones being
Bmall, consisting merely of scales of bone, the  third fragment, the largest
comprising the whole of the articular surface of the radius, which was souie-
Fio. 90.
 
FRACTURES OF  THE  RADIUS.
219
what tilted upwards and backwards.   To this fragment were attacned the supi-
nator longus, and the greater part of the pronator quadratus; the ligaments and
the capsule of the joint were uninjured.
   This case presented the appearances usually met with in this kind of injury,
the lower fragment being displaced in such  a way that  its  articular  surface
looks slightly upwards, backwards, and somewhat outwards, so as to be  twisted
as it were upon  its axis (figs. 90, 91).  The upper frag-
ment is always found in  a state of pronation, and in many
cases is driven into and firmly impacted in the lower one.
   To what is this displacement  of  the  lower fragment
due ?   Is  it to  muscular action,  or to the peculiar
manner in which the two fragments  are  locked into one
another?   Muscular action cannot, I  think, be considered
the sole, or indeed the chief cause of this deformity, for
although the supinator longus is attached to the lower
fragment, and with the radial extensors would influence
the  position  of  this  portion of the bone, yet it must be
borne  in mind that their antagonists, the  pronator quad-
ratus  and  the flexor muscles of the wrist, are likewise
attached to,  and exercise their action directly upon this
fragment, and would  have a tendency to  counterbalance
the action  of the supinators and extensors.  These mus-
cles also are  by  no means powerful,  and would certainly
not be able  to  withstand  ordinary efforts at remedying
the displacement, which in many cases are unsuccessful.  That the deformity
is the  result  of impaction, I feel convinced, notwithstanding the  elaborate argu-
ment of Mr. Smith in opposition to  this  view, and my conviction is founded on
an examination  of several specimens of consolidated fracture of  the radius pre-
served in  the different collections in  London, upon the dissection of the case
already alluded  to, and upon  the difficulty in any other way of accounting for the
occasional impossibility of properly reducing these fractures.  The great  traction
that is usually  required to remove  the deformity, and the absence of  distinct
crepitus in some cases, until after forcible traction has been employed, also indi-
cate the existence of impaction.   At the same time I do  not doubt  that it occa-
sionally happens that these fractures are  not impacted; this would appear to be
the case in those instances in which crepitus is easily detected, and  the fracture
readily reduced.
   The mode in  which the impaction and  deformity occur, appear to me to be as
follows.   When a person falls on the palm of the hand,  the shock, which is
principally received on  the ball of the thumb, and the radial  side of the wrist,
is not directed  immediately upwards in  the axis of the  radius; but the force
impinging in a direction  obliquely from before  backwards, and from  without
inwards, as  well  as from  below  upwards, has a tendency to  rotate the  lower
fragment on its  own axis, and to  tilt the articular surface somewhat upwards
and outwards.  As  the upper fragment descends, its posterior surface of com-
pact tissue is forced into the cancellous structure  of the lower fragment,  to such
a depth as will admit of the two anterior portions of compact tissue  coming
in contact, and  thus the upper line of compact tissue is driven into the lower
fragment to an  extent corresponding to the degree with which the  fragment is
rotated upwards and  backwards.   If the bone be brittle, or the force be conti-
nued after this  amount of impaction has taken place, the lower fragment will
be splintered.
   The prominence of the styloid process  of the ulna, is the result of the short-
ening  of the radial side of the wrist and hand consequent upon the impaction.
   Besides  this  injury,  Mr. Smith has described a fracture of  the lower end of
the radius in consequence of falls upon the back of the hand, in which the infe-
 
220                    SPECIAL  FRACTURES.
rior fragment is displaced forwards.   In these cases the character of the deform-
ity indicates the nature of the injury.  It can readily be reduced, with a feeling
of crepitation, by traction.
  In  another variety of fracture in this situation, the lower end of the radius
and that of the  ulna are  broken off, resembling very closely dislocation of the
wrist backwards.  But the fact of the existence of grating, of the ready reduc-
tion of the swelling, and of the styloid  processes of the radius and of the ulna
continuing to be attached to, and following  the movements of the carpus, will
be sufficient to establish the diagnosis.
  The treatment of the ordinary fracture of the radius  near the wrist is best
conducted by the apparatus introduced  by Nelaton (fig. 92).   This consists of

                                  Fig. 92.
a pistol-shaped wooden  splint, which is placed along  the  outside of the arm,
reaching from the elbow to the extremity of the fingers.   Forcible extension
and counter-extension  should be practised with  the view of disentangling the
fragments,  and removing  the dorsal prominence.  The  splint, thickly padded
opposite  the  lower fragment should then be  applied  to the outer side of the
arm, and the  hand being well brought down  to its ulnar side, should be band-
aged to the bent part of the  splint.   Another short splint, reaching from the
bend of the elbow to the lower extremity of the upper fragment should now
 e placed along the inside of the arm, after having been well padded along its
radial  border, so as to counteract the tendency to pronation of this part of the
bone.  The arm  must  then be placed in  a sling.   The fracture  unites in the
course of a month or five weeks, and passive motion of the joint may  then be
                                                      commenced,   but   it
                     [Fio. 93.                         wiH be  at least three
                                                      months  before  the
                                                      stiffness of  the  hand
                                                      and wrist  are so  far
                                                      diminished, even  by
                                                      the use of  frictions
                                                      and  douches, as   to
                                                      enable the patient  to
                                                      use the  fingers.   It
sometimes happens that the radius on both sides  is broken at the same time in
this situation, constituting a somewhat serious condition, inasmuch as the patient
is not able  to feed or assist himself in any way during the treatment.
  [In  the treatment of fractures of the lower end of the radius, Dr. J. Rhea
Barton, of this  city, some years  since, recommended the application of two
straight  splints, and of two  compresses, one to be applied  over the lower frag-
 
FRACTURES OF  THE  PELVIS.
221
ment, and the other beneath the inferior extremity of the upper.   Of late, this
dressing has been somewhat superseded by the box splint of Dr. Bond (fig. 93),
in which the palm of the hand rests upon a block, the extremities of the fingers
remaining  free.  By  retaining the  limb in this position  the muscles will  be
relaxed, and no undue pressure exerted upon their tendons. A better chance of
escaping permanent  stiffness will  be afforded;  should this, however, result,
despite the efforts of the surgeon " the hand will not entirely  have lost its uses.
For the hand, thumb, and  fingers being placed very nearly in the position  of
their most frequent  uses,  the interossei, the  lumbricales, and the several short
muscles of the thumb, will, by causing  only a very limited motion, enable the
hand to perform very many of its useful functions."]
   Fractures of the metacarpus and fingers are of so  simple a character in every
way as scarcely to call for  detailed  remarks.   In the treatment, rest of the part
upon a leather or pasteboard splint is all that is requisite.  In compound frac-
ture of these bones,  every effort should be made to save the part; if removal
become necessary, it should be to as limited an extent as possible.

            FRACTURES  OF THE  LOWER EXTREMITY.

   In fractures of  the pelvis, the danger depends not so much on the extent
 of the fracture as on  its complication with internal injury, and the violence with
 which  it has been inflicted.   Fracture may extend  in  any direction  across the
 pelvic  bones, though most commonly it passes  through the rami of the pubea
 and ischium, and across the  body of the ilium,  near the sacro-iliac articulation
 In some cases the symphysis  is broken  through,  and in others  the fracture
 extends across the  body of the pubes.
   It occasionally happens  that a portion of the  crest of the ilium is broken off,
 but this is of little  consequence,  even  though  the bone continues depressed.
 When  the rami of the pubes and ischium, or the whole body of the ilium, are
 broken through, there  is,  of  course, considerable danger from internal injury.
 If the patient escape  this,  the fracture, however extensive it may be, may unite
 favorably.   I had lately a  patient under  my care  at the hospital, with a fracture
 extending through the rami  of the pubes and ischium, and across the ilium, in
 a line parallel with, and close to the sacro-iliac  symphysis, so as completely to
 detach one half of  the  pelvis, but who recovered without any bad consequences
 occurring.
   The nature  of the injury is usually apparent  from the great degree of  direct
 violence that  has  been inflicted upon the part, from the pain that the patient
 experiences in moving  or  in  coughing, with an  impossibility to stand, in  conse-
 quence of a feeling  as if the body were falling to  pieces when he attempts to
 do so,  with mobility  of the part and crepitus on seizing the brim of the  pelvis
 on either side  and  moving it  to and fro.  In examining a patient with suspected
 fracture of the pelvis, care should, however, be taken not to push the investiga-
 tion too closely, lest injury be inflicted by the movement of  the fragments.  In
 those cases, indeed, in which the  fracture does not extend  completely  across
 the pelvis, or in which it is seated  in the deeper parts  of the ischium, an exact
 diagnosis may be impossible.
   In fractured pelvis, the  principal sources of danger arise from injury  to the
 bladder and urethra, with consequent extravasation of urine;  from laceration
 of the rectum, or fracture of the acetabulum;  and  in  examining the pelvis  no
 rough handling should  be  allowed, lest injury to these parts be inflicted by the
 fragments.
   In the  treatment,  the first thing to be  done  is  to  pass a catheter into the
bladder, in order to  ascertain the condition of the urinary apparatus;  if it  be
injured, measures  that will  be hereafter described must be had  recourse to.
The next thing is to  keep  the part perfectly quiet, so  as to  bring about union, 
222
SPECIAL  FRACTURE &.
With this view, a padded belt, or a broad flannel roller, should be tightly applied
round  the pelvis, the  patient lying on a hard  mattress.  The knees may then
be tied together, and  a leather or gutta-percha splint put upon the hip of the
side  affected, so as to keep the joint quiet, and to prevent all displacement  of
the fragment.
   Fracture of the acetabulum is of rare occurrence, and can only  happen when
the pelvic bones have been extensively broken.   There  is a preparation in the
University College Museum, exhibiting a comminuted fracture of this articular
surface as well as of the ilium.   Sanson and Sir A. Cooper have seen the aceta-
bulum separated into its three primitive fragments, and the head  of the femur
driven into the pelvic cavity.
   As some  displacement of the head  of  the femur would occur in these cases,
they might be mistaken for dislocation, more especially as inversion of the foot
has  been noticed.   The crepitus and  free  mobility would  however serve  as
distinguishing signs.
   With regard to treatment, the application of a leather splint and broad padded
belt, with local antiphlogistic means, is all that can be done.
   Fracture of the sacrum is an extremely rare occurrence.   The  only instance
with which I am  acquainted is in  the Museum of the College  of Surgeons.
The coccyx, though more exposed, is also  but seldom broken.  When fractured,
the pain is usually severe, there being much contusion and  inflammation of the
ligamentous expansion that covers this bone, so that the patient is scarcely able
to walk or to sit.   This pain may continue  for months  and even years.  South
relates the case of a gentleman who broke his coccyx by sitting on the edge of
a snuff-box, and who suffered such  severe  pain  that he was  obliged to wear a
pad  on  either tuberosity of the ischium, in order that the coccyx might be in a
kind of pit, and free from all pressure when he sat.
   Fractures of the femur  are  of great practical interest, from their fre-
quency and severity.  They  may occur in  the upper artiqular end of the bone,
in its  shaft, or in its  lower  end.  In these different situations every possible
variety of fracture is often met with.
   Fractures of the pelvic end of the bone may be divided into those that occur
through the neck within the capsule of the joint, — those that occur outside the
capsule, and into those that implicate the  trochanter alone.
   Intracapsular fractures of the. neck of the femur are of two  kinds, the simple,
in which the bone  is merely broken  across, and the  impacted, in which the
lower portion of bone is driven into  the upper fragment.
   The  intracapsular fracture may also be  looked upon as a special injury of
advanced life, being but seldom met with in persons under fifty.  Thus Sir A.
Cooper states that of 251 cases that he met with in the course of his practice,
only 2 were in persons below this age.  It may, however, happen at an early
period of life.  Thus,  Mr. Stanley has  recorded  the case of a lad of eighteen,
who met with this  injury.  Another remarkable  circumstance in  connection
with it is, that it commonly happens from very slight degrees of violence, indeed
almost spontaneously.   Thus, the jarring  of the  foot in missing a  step in going
down stairs, catching the toes under the carpet, tripping upon a stone, or entan-
gling the foot in turning in bed, are sufficient to occasion it.   It is especially in
women that this injury is met with.
   The occurrence of this fracture in old age is owing indirectly to the  changes
in structure, shape, and position of  the head and neck of the femur with ad-
vancing years.  The cancellous structure  of these parts becomes expanded, the
cells large, loose, and  loaded with  fluid fat.  The compact structure becomes
thinned,  and proportionally weakened, especially about  the middle and under
part of the neck, which, appearing to yield to the weight of the body,  is short-
ened ; and instead of being oblique in its direction, becomes horizontal, inserted
nearly at right angles into the shaft.  In consequence of these changes in struc- 
          FRACTURES  OF  THE  NECK  OF THE FEMUR.       223

ture and position, it becomes less able to bear any sudden shock by which the
weight of the body is thrown upon it, and snaps under the influence of very
slight degrees of violence.   When it breaks, the capsule may remain uninjured,
but the  prolongation of it which invests  the  neck of the  bone is usually torn
through.  In some cases, however, this cervical reflexion is not ruptured, the
lower portion of it especially often  remaining  for some length of time untorn,
at last, however, giving way under the influence of  the movements of the limb,
or by being softened by local inflammatory action.   As the  violence occasioning
the fracture is generally but slight, and as the vascularity of this portion of the
bone is trifling in  old people, there is but little extravasation of  blood.
   The fragments  are almost always so separated that the fractured surfaces are
not in apposition: the upper end of the lower fragment is  drawn above  and  to
the outer side of the head of the bone, and at the  same time is twisted so that
its broken surface looks forwards.  The head remains in the acetabulum, attached
by the ligamentum teres, and sometimes preserving a connection with the lower
fragment, through the medium of some untorn portions of the fibrous membrane
investing the neck.   The  capsule is uninjured.
   Mr. Smith has  observed, that  in some  instances the two fragments become
 interlocked or dovetailed as it were into one another, in consequence of the line
 of fracture being irregular and dentated.
    The signs of an intracapsular fracture of the neck of the  femur are altera-
 tion in the shape of the  hip, crepitus  and pain at the seat of injury, inability
 to move the limb, with shortening and  eversion of it.   These we must consider
 separately, as important modifications of each are sometimes noticed.
    The alteration in the shape of the hip is evidenced by some flattening of the
 part, the trochanter not being so prominent as usual.  This process  is also ap-
 proximated  to the anterior superior spine of the ilium, and  on  rotating, the limb
 is felt to move to and fro under the hand, not describing the segment of a circle
 so distinctly as on the  sound side.  The circle  described  by the trochanter  on
 the injured  side is much smaller than that on the sound  side.   In  the  sound
 limb, the trochanter describes the segment of  a circle having a radius equal to
 the length of the head and neck of the bone.   On the injured side, the circle
 has only a radius equal to the length of that portion
 of the neck that still remains attached to the shaft          Fig. 94.
 of the bone.  During this examination crepitus will
 usually be felt, though this occasionally is very in-
 distinct-and even absent, more especially if the  limb
 be not well drawn down at the time it is rotated, so
 as to bring  the  fractured  surfaces in apposition;
 and  much pain is  experienced  by the patient on
 any movement of, or pressure upon, the joint.
    The  attitude of the limb is so peculiar,  as in
 general  to indicate at once to  the  surgeon what
 has happened.   There is  an appearance of  help-
 lessness about it that is  striking.  As the patient
 is lying on  his back  in  bed  it is everted, short-
 ened  somewhat,  with  the  knee  semi-flexed  (fig.
 94);  on  requesting him  to lift it up,  he  makes
 ineffectual attempts to do so, and at last ends by
 raising it with the toe of  the opposite foot, or with
 his hands.  On being taken out of bed and  placed
 upright, the injured limb hangs uselessly, with the
 toes  pointing downwards, and the heel raised  and
 pointing to  the inner ankle of the sound side, the
 patient being unable  to  rest  upon it.  In  some
 cases, however, it happens that  after the fracture has occurred, the patient can
 
224
SPECIAL  FRACTURES.
lift the limb somewhat, but with  much exertion, from  the  couch on which  he
is lying; or can even manage to walk a few paces, or to stand for a few minutes
upon  it,  with  much pain and difficulty.   This is owing  either to the cervical
reflexion of the capsule  being untorn, or else to the fragments not being sepa-
rated, having  become locked into one another;  and it usually occurs  in those
cases in which the other and more characteristic signs of this fracture are not
well marked.
  Eversion of the limb is almost an invariable accompaniment of this fracture.
It is most  marked in those cases  in which  the shortening is most considerable.
This eversion  has usually been attributed to the action of the external rotator
muscles  that  are inserted into the upper end of the lower fragment.  But I
cannot consider this as the  only, or, indeed, the principal cause, of this posi-
tion ;  for,  not only is  it  very  difficult to  understand how these muscles  can
rotate outwards the limb after their centre of motion has  been  destroyed by the
fracture of the neck of the femur, their action being rather in a direction back-
wards than rotatory under these circumstances, but we find  that  the  limb  falls
into an everted position in those cases in which the fracture being in the shaft,
and altogether below the insertions  of these muscles, no  influence can be exer-
cised  by them on the  lower fragment.   I look upon eversion  in  cases of frac-
tured thigh as not a  muscular  action at all, but as  being simply the natural
attitude into which the limb falls when left to itself.   Even in the sound state,
eversion  takes place  spontaneously  whenever muscular action  is relaxed, as
during sleep,  in  paralysis, or in the  dead  body; and in the injured limb in
which there is, as it were, a suspension of muscular action, it will occur equally.
Indeed,  the shortening that  takes  place will specially tend to relax  the  ex-
ternal rotators, and thus still more prevent their influencing the position of the
limb.
   Inversion of the foot in cases of intracapsular fracture has been noticed in a
few cases.   I  have seen  one  instance of this;  Smith, Stanley, and  other sur-
geons, also record cases.  The  cause of this deviation from  the usual symptoms
of  this injury has been a good deal  discussed.  It has been attributed by some
to  the cervical ligament not having been  torn  through at its inner side, but
that, as Stanley observes, may prevent eversion, but cannot occasion  inversion;
by  others,  to the  fact of the lower fragment in these cases being  always found
in front of the upper one.  This circumstance,  which is much insisted on  by
Mr. Smith, appears to  me to be rather the result  than the cause of  the inver-
sion, for any rotation  inwards of  the lower fragment by  the adductor  muscles
of  the thigh would have a tendency to draw the upper end of this fragment to
the anterior, or, in  other words, the  inner side of the upper one.   I  am rather
disposed to think  that  this inversion  is owing, in  some cases  at least, to the
external  rotators  being paralyzed by the violence they receive from  the injury
that occasions the  fracture, and  that thus the  adductors, acting without anta-
gonists, draw  the thigh and leg inwards.   In the instance  that fell  under my
observation, and in some of  those that  have  been  published, the  fracture
resulted  from direct injury to the hip, and was not  occasioned by the patient
jarring his foot, or by any indirect violence operating at the end of the limb.
   The shortening in  cases  of fracture within the capsule  seldom exceeds, in
the first instance, half an inch  to  an inch,  depending  on the extent of the
separation  between the  fragments, and cannot, indeed, in the early periods  of
the fracture, very well  exceed the width of the neck of the bone, as the capsule is
usually not torn through. After the  fracture has existed some time, the capsule
of  the joint may  yield, allowing greater  separation between the fragments, and
then  it may amount to  two, or even two  and a  half inches.  It not uncom-
monly happens that the shortening,  which is at first but very slight, about half
an  inch, suddenly increases to an inch  or  more; this is accounted  for on the
supposition of the  cervical ligament, which  had  at  first not  been completely 
          FRACTURES  OF  THE  NECK  OF THE  FEMUR.      225

ruptured, at last giving way entirely; or, it may be owing to the fragments
which were originally interlocked, becoming separated.   It is in those cases in
which there is but slight  separation  of the fragments, and consequently little
shortening, that the other  signs of fracture are not very strongly marked, and
that the patient preserves some power over the movements of the  limb.
   The  constitutional disturbance in  intracapsular fracture of the neck of the
femur in old people is often considerable, and  the injury frequently terminates
fatally,  from the supervention  of congestive pneumonia, an asthenic state of
system, or sloughing of the nates from confinement to bed  during treatment.
Hence, this injury must always be considered  as  one of a very dangerous and
not unfrequently fatal character.
   The  treatment  of  these fractures  turns in  a  great measure upon  the view
that is  taken of their mode of union, and on the  constitutional  condition of
the patient.   In some cases no union occurs, but the head of the  bone remains
in the acetabulum, being hollowed into a smooth, hard, cup-shaped cavity, in
which the neck, which has become rounded off and polished, is  received, and
plays as in a socket.
   The  union  of the intracapsular fracture of the neck of the femur takes place,
however, in the great majority of cases, by fibrous tissue.   This is owing to
 two causes.   In the first place, to the circumstance that  the fractured  sur-
 faces are  not in  apposition with one another, which I look upon as the most
 important; and,  secondly, that the  vascular  supply sent to the head of the
 bone, consisting only of the blood that finds its way through the vessels of the
 ligamentum teres, is insufficient for the proper production of callus.
   In some cases, however, bony union  takes  place.  This  can only happen
when, in  consequence of the  cervical  ligament being untorn, or  the  fracture
being  impacted, the  surfaces are kept in some  degree of  apposition, and the
vascular supply to the head of the bone is speedily augmented  by the blood
carried  into it through the medium of  the   plastic matter  that is deposited
between the fragments: under no other circumstances is it probable that osseous
union  takes place in these fractures; hence the unfrequency of its occurrence,
there being in all probability not more than eighteen or twenty cases on record
as having thus terminated, in this country.  When bony union has taken place,
the head  will usually be found  to be  somewhat  twisted round, in such a way
 that it  looks towards the lesser trochanter, owing to  the eversion that has taken
 place in the lower fragment.
   As  these fractures do  not unite by bone,  unless the. fragments are in good
 contact, it is useless to confine the  patient to bed for any long period, if the
 signs,  especially  the amount  of shortening,  indicate  considerable  separation
 between the fragments, or if the patient be very aged and feeble.   Under these
 circumstances, lengthened confinement to bed  most commonly proves fatal by
 the depressing influence it exercises on the general health, by the intercurrence
 of visceral disease, or by the supervention of bed-sores.  It is, therefore, a good
 plan to keep  the  patient in  bed merely for two or three weeks, until the limb
 has become somewhat less painful, the knee being well supported  upon pillows.
 After this time, a leather splint should be fitted to  the hip, and the patient be
 got up upon  crutches.   There will be  lameness during the remainder of life,
 but, with  the aid of a stick  and properly adjusted splint, but little inconve-
 nience  will be suffered.
   When  the  fragments  do  not appear to be  much separated, there being but
 little shortening  and indistinct crepitus, and  more particularly if the patient
 be not  very  aged, but  in other respects sound  and well, an attempt may be
 made to procure osseous union.  This may be done by the application of the
 long thigh splint, or, if this cannot very readily be borne, by the double inclined
 plane,  with a padded  belt strapped round the hips.   This apparatus should
 be kept applied for  at least two or three months, when a leather splint may
        15 
226
SPECIAL  FRACTURES.
be put  on, and  the  patient be got upon crutches.   During the whole of the
treatment, a generous  and even  stimulating  diet should  be ordered, and the
patient kept on a water-bed or cushion.  In these fractures of the neck of the
femur, the starched bandage will  often be found to be most useful.  It may be
applied as in fractured thigh, but should have  additional strength in the spica
part, and  indeed may be provided with a small  pasteboard  cap, so as to give
more  efficient  support.   In  old  people,  this  plan  of treatment is especially
advantageous, as  it  enables them to sit  up, or even to walk about, and thus
prevents all the ill effects of long confinement to bed.
   The extracapsular fracture of the neck of the femur is commonly met with
at an  earlier period of life than the injury which has just been described, being
most  frequent  between the ages of thirty and forty.   It  is the result  of the
application of great  and  direct violence  upon the  hip, and occurs equally in
both  sexes.
   This  fracture may be of two kinds, the simple and the  impacted.  In  both
cases  the neck  of the bone is commonly broken at, or immediately outside, the
insertion  of the  capsule  of the  joint.  The fracture is almost invariably com-
minuted : indeed, I  have never  seen a case in which the  great trochanter was
                                 not  splintered  into  several fragments.  In
                                 many instances the  lesser trochanter is de-
                                 tached, and the  upper  end  of the shaft
                                 injured (fig. 95).  This  splintering  of the
                                 trochanter  is  owing  to the same violence
                                 that breaks the bone, forcing the lower end
                                 of the neck into the cancellous  structure of
                                 this  process,  and thus, by a  wedge-like
                                 action, breaking  it into fragments.   When
                                 the neck continues locked in between these,
                                 we have the impacted form of fracture.
                                   The signs of extracapsular fracture vary
                                 according as it is  simple or impacted, but in
                                 both cases  they  partake  of  the  general
                                 character  of those  that  are met with  in
                                 fractures within  the capsule.   The  indi-
                                 vidual  signs,  however, differ  considerably
                                 from these.
                                   The hip  will  usually  be  found  much
                                 bruised and swollen  from extravasation of
                                 blood, which is usually considerable.   The
                                 crepitus is  very  distinct and  loud, being
readily  felt  on laying the hand upon  the trochanter, and  moving the  limb.
The  separate fragments  into which the trochanter is splintered may occasion-
ally be felt to be loose.   The pain is very severe, and  greatly increased by any
attempt at moving the joint, which to the patient is  impossible.
  The eversion is usually strongly marked, and the position of the limb is cha-
racteristic of complete want of  power in it.  Inversion occurs  more frequently
in this fracture than  in that within the  capsule.  Smith finds that of 7 cases of
inversion of the limb in fractures of the neck of the femur, 5 occurred in the
extracapsular fracture; and of 15 cases  of extracapsular fracture, this condition
was met with in three.  When there is much  comminution of the trochanter,
the foot will commonly remain in any position in which it  is placed, but gene-
rally has a tendency  to rotate outwards.
  The shortening of  the limb is very considerable, being never less than from
an inch and  a quarter to two inches and a half, and often extending to three or
four inches.
   The impacted extracapsular fracture of the neck  of the thigh bone  occurs
 
FRACTURES  OF  THE NECK OF  THE  FEMUR.       227
when the upper fragment is driven  into the  cancellous structure  of the  lower
one, remaining fixed  there (fig. 96.)  The signs  of
this form of fracture  are often of a somewhat nega-
tive character, rendering its diagnosis and detection
extremely  difficult.   In many cases  there  is  pain
about the hip, with  slight eversion  of the foot, and
some shortening,  usually amounting to about half  an
inch, but never exceeding one inch.   There is but
little crepitus; in some  cases  none can be detected,
and the patient  can  frequently raise  the  foot for a
few inches off the couch  on which it is laid, and even
walk upon it with a hobbling motion, though with
much pain.   In  consequence  of the  impaction the
limb cannot be  restored by  traction to  its proper
length,  and consequently incurable lameness always results from this injury.
   The  diagnosis  of the different forms of fracture of the neck of the thigh bone
from one another, and from other injuries occurring in the vicinity of the hip
 joint, is a matter of considerable importance, and  often of no slight difficulty.
Between the intracapsular and the ordinary extracapsular fractures there can
be no difficulty;  all the signs of the latter being so much more strongly marked
than those of the former injury, the difference of age  and the degree of violence
required to break the bone being also  important elements in the diagnosis.   It
is more difficult to distinguish  between the intracapsular  fracture and  the im-
pacted  extracapsular fracture.  In  the former case, however, the crepitus and
eversion are  more marked, and the injury usually occurs from less direct violence
than when the fracture is outside the capsule.  In the  latter case, also,  traction
cannot  restore the limb to its proper length as in the  former instance.
   In severe  contusions of the hip there is sometimes eversion of, and inability
to move the  limb, so that at first sight it might be supposed that the bone was
broken.  In  these cases, however, the absence of shortening and crepitus will
always  establish  the diagnosis.  The difficulty is greater,  however, in  those
instances in which the hip-joint having been  the seat of chronic rheumatic in-
flammation, the limb is already somewhat shortened;  here, however, the history
of the case, and the fact of the shortening not being  of recent occurrence, will
be  sufficient  to  establish the  nature  of  the  injury.
The diagnosis of these injuries from dislocations will
be  considered in  a subsequent chapter.
   In the extracapsular  fracture of the neck of the
femur,  death not uncommonly results from  the  se-
verity of the injury, the pain and  irritation of the
fracture and the consequent  shock to the  system.
The great extravasation  of blood into the tissues  of
the limb has  been known to be sufficient to account
for the fatal result.   When the patient lives, bony
union takes  place, large irregular stalactitic masses
being commonly  thrown  out by the inferior fragment,
so as to overlap the  several splinters of bone.  This
callus is most abundant posteriorly in the inter-tro-
chanteric space (fig. 97).
   The  treatment of  the extracapsular fracture may
very conveniently and efficiently be  conducted  by
means of the long splint, a padded belt, if necessary,
being strapped firmly round the hips  underneath  it;
or the plan recommended by Sir A.  Cooper of placing  the patient on a double
inclined plane, with  both feet and ankles  tied together, and a broad belt, well
padded, firmly strapped round the body, so as to  press the fragments of the
 
228
SPECIAL  FRACTURES.
trochanter firmly against one another, will be found an excellent mode of keeping
the limb of a proper length, and the fragments in contact.
  Occasionally the fracture extends through  the trochanter major without im-
plicating the neck of the bone.  Here there is shortening to about three-fourths
of an inch, or an inch, with much  eversion and crepitus readily felt.   This
fracture, which unites firmly and well by bone, must be treated in the same way
as the last.
   Compound fractures of the  neck  of the femur can  only occur from  bullet
wounds.   These cases require amputation at  the hip-joint, unless the  excision
of the injured head of the bone be thought worthy of a trial.
   Fractures of the  shaft of the femur are of very common occurrence; every
possible variety of this injury being  met with here.   They are usually oblique,
except in children, when they are  commonly transverse, and are often commi-
nuted, double, or compound.
   The signs are  well marked.   There is shortening usually to a considerable
extent, with eversion of the  limb, crepitus readily produced, and much  swelling
from  the approximation of the attachments of the muscles.   The lower frag-
ment is always drawn to the inner side of the upper one, and rotated outwards;
and when the fracture  is high up there is  a great tendency to angular de-
formity, in consequence  of  the projection outwards  of the lower  end of the
upper fragment.
   I have lately had an opportunity of ascertaining by dissection the condition
of parts  that leads to the eversion and projection forwards of the lower end of
the upper fragment  in fractures  of the  femur, in the case of an old man who
died about three hours after meeting with a compound comminuted fracture of
the middle and lower thirds of the right thigh-bone, and in whom this condi-
tion of the upper fragment was very distinctly marked.   It was found  that the
gluteus  maximus and medius could be divided without affecting the position of
the bone; but when the  gluteus minimus was cut across, it yielded somewhat.
The pyriformis and  external rotators were now felt to  be excessively tense, and
on cutting these across, the end  of the  fragment could at  once be drawn in-
wards, all opposition ceasing.  The projection  forwards  still remained, however,
and this, which was  evidently due to the tension of the psoas and  iliacus mus-
cles, yielded  at  once on dividing them.   It would thus appear that there is a
double displacement of  the lower end  of the upper  fragments, — outwards,
depending on the action of the external rotators, and  forwards, owing to the
contraction of the psoas and iliac muscles.
   The treatment of fractures of the shaft of the thigh-bone may be conducted
in four different ways; each of which  presents advantages in particular forms
of these injuries; hence  an exclusive plan of treatment should not be adopted.
   1st. The fracture may  be treated by simply relaxing the muscles of the limb.
This is effected by laying it  upon its  outer side, flexing the  thigh well upon
the abdomen and the leg upon  the thigh, and supporting it in this  position  by
an angular wooden or leather splint, extending from the hip  to the  knee, or
outer ankle, and by a short inside  thigh  splint.   This position I usually adopt
in fractures about a couple of inches below the trochanters, in which there is a
great  tendency to the projection outwards of  the lower  end  of the  upper frag-
ment, and find these cases turn out better in  this way  than by any other plan
of treatment.
   2d. Extension, without regard  to muscular relaxation, by means of Liston's
long splint and perineal band, will be found a most successful  plan of treating
fractures in the middle and lower part of the thio-h.
  In  employing the  long splint for the treatment^of  these fractures, care must
be taken that it be of sufficient length to  extend about six inches below the
sole and nearly as high as the  axilla.   The perineal  band should  consist of a
soft handkerchief covered with  oiled silk, and must be gradually tightened.   If 
FRACTURES  OF  THE SHAFT OF  FEMUR.         229
the perineal band occasion excoriation or undue pressure, so as to necessitate its
removal, I have found advantage from keeping  up extension with  a heavy
weight attached to the lower end of  the splint.
   In cases  of  compound fracture, where the fracture exists in the posterior
and outer part  of the limb, I have found a long thigh splint, made of oak and
bracketed opposite the seat of injury, the most convenient apparatus, enabling
the limb to be kept of a proper length, and the wound to be  dressed  at the
same time (fig. 98).
                                  Fig.  98.
  3d. The double inclined plane is especially useful  in  many compound  frac-
tures of the thigh, often admitting of greater facilities for dressing the wound,
and the °-eneral management of the case, than any other apparatus that can be
applied.
  4th. The starched bandage may be  employed in  most  cases.  In treating
fractures of the  shaft of the femur with  the starched bandage, the following
plan will be found convenient.   A dry roller should be applied to the whole of
the limb evenly and  neatly, which must then be  covered with a thick layer of
wadding; a long piece of  strong pasteboard, about four inches wide, soaked in
starch, must next be applied to the posterior  part of the limb, from the  nates
to the heel.  If the patient is very muscular, and the thigh large, this must be
strengthened, especially at its upper part, by having slips of bandage pasted
upon it.   Two  narrower strips of pasteboard are now placed along either side
of the limb, from  the hip to the ankle, and another shorter piece on the forepart
of the thio-h.  A double layer of starched bandage  should  now be applied over
the whole, with a strong and well-starched spica.   It should be cut up and
trimmed on the second or third day, and then reapplied in the usual way.   With
such an apparatus as this  I have treated many fractured  thighs, both in adults
and children, without confinement to bed  for more than three or four days, and
without the slightest shortening or deformity being left  (fig. 79).   The  points
to be especially attended to, are, that the  back pasteboard splint be very strong,
at the upper part especially, and that the spica be well  and firmly applied, so
that the hip and  whole of the pelvis be immovably  fixed.
   [In the treatment of fractures of the  thigh, the majority of American sur-
geons prefer dressing the limb in the extended position,  and for the most part
make  use of the apparatus of  Desault, as  modified  by  Dr. Physick.   This is
composed of two splints; an external  one  extending from near the axilla to
beyond the foot, and an internal one  reaching as high up as the perineum.
Both  splints  should be enveloped in a splint cloth.   The  perineal or counter-
extending band is made of  muslin stuffed with cotton, and should be provided
at its extremities with strong tapes, or,  better  still, with a strap and buckle.
These  should then be carried through mortices in  the upper extremity of the
lono- splint, and thus counter-extension  may be obtained in a line nearly parallel
with the long axis of the body.  To prevent excoriation of the perineum, it is
well to encase the counter-extending band in chamois leather.
   Extension  should be effected by the  buckskin  gaiter,  by a  handkerchief,
or by  means  of two  long stout strips  of adhesive plaster.   These  should 
230
SPECIAL  FRACTURES.
be applied  on either side of the limb in a longitudinal direction, and should
reach from above  the knee to beyond  the  sole of  the  foot;  two or three
                    circular  adhesive bands will  effectually  prevent them
       Fig. 99.       from  slipping.   The remaining portions of the apparatus
                    consist of compresses; of a short anterior splint, should
                    there be any tilting  upwards of  the  superior fragments;
                    and of two  junk-bags.   These  latter  should be placed
                    between the limb and the splints,  and lateral pressure
                    exerted by means of transverse tapes carried around the
                    whole apparatus.
                       For the purpose  of keeping up an accurate degree  of
                    extension, it may often be convenient for the surgeon to
                    avail himself of  some mechanical contrivance adjusted to
                    the inferior extremity  of the  long splint.   The  most
                    eligible  of the  many inventions for this  purpose, are,
                    we believe, the endless  screw  of Dr. Hamilton,  and the
                    extending screw of Dr. T. Hewson Bache.  By the me-
                    chanism of the latter, the extending power is so applied
                    as  always to act in the  line  of the  longitudinal axis
                    of the limb.
                       If the surgeon in the  treatment of  a fractured  thigh,
                    should desire to dress the limb on an inclined plane, the
                    apparatus  of Professor Nathan R. Smith,  of Baltimore,
                    will be found to answer the purpose admirably.  It is light,
                    portable,  and when  the limb is  suspended, permits of a
                    slight swinging motion.   In fractures also of the bones of
                    the leg, it frequently will fulfil every indication.]
                       Fractures in the vicinity of  the knee-joint. —
 The lower end of the  femur is  not  unfrequently broken  in  a transverse direc-
 tion, both condyles being detached.  This may occur in children  from the lower
 epiphyses  not  being as yet solidly united to the shaft of the bone.  In other
 cases again the fracture extends through  one of the condyles, detaching it from
 the shaft of the bone.   The readiness with which crepitus can be felt, and the
 line of fracture made out, determines at once the nature of this accident.  These
 cases are sometimes complicated with wound of the knee-joint, rendering ampu-
 tation necessary.  They are best treated  on the double inclined  plane.  I have
 lately had  a case of impacted fracture in this situation  under  my care, the upper
 fragment, which  was very oblique, being firmly driven into the cancellous struc-
 ture of the lower one (fig.  99).
   Fractures of the patella are  most frequently met with in men, not very
 commonly occurring in women, and  very rarely in children.   I have, however,
 seen the patella broken in a child under ten  years of age.   They may be  the
 result of direct violence, when  the  fracture is  often comminuted, or the bone
 may be  broken longitudinally, being  split, and the joint injured.   But most
 frequently they occur  as the consequence  of  muscular action; the bone being
 torn across by the violent  effort made by the extensor muscles of the thigh, in
 the attempt a person makes to save himself from falling when he suddenly slips
 backwards.  All fractures of the patella from  muscular action are transverse,
 the lower portion of the bone being fixed by the ligamentum  patellae; the upper
 segment is torn off by  the spasmodic action of the extensors at the moment that
 the knee is bent, whilst the person is in the act of falling backwards.   It  not
 unfrequently happens  when one patella has  been fractured,  that the  unsteadi-
 ness of gait causes the opposite one to  be broken by  muscular action in an effort
 to save a fall.   The same patella may be broken more  than once; in those cases
 that I have seen, the second fracture has always occurred in the upper fragment,
 a little above the line  of original fracture.
 
fractures of  the  patella.
231
  The signs of this fracture are very evident.  When transverse, the separation
between the fragments, which is much increased by bending the knee (fig. 100),
and  the inability to stand   or  to  raise  the injured  limb, indicate  what
has  happened;  when  longitudinal  or com-
minuted, the crepitus and mobility of the frag-
ments ; and there is usually considerable swell-
ing of the knee-joint in these cases, with perhaps
wound of it.
   When the bone is broken transversely, it very
rarely indeed unites  by osseous matter, in con-
sequence of the  wide  separation of  the  frag-
ments ; there are, however, two  or three cases
on record in which this  kind of union has taken
place in these  fractures.  In the longitudinal
and comminuted fractures, osseous union readily
occurs, the fragments remaining  in close appo-
sition.  In the majority of cases of transverse
fracture, the fragments remain separated by an interval varying from one-fourth
of an inch to an inch, but in some instances the gap is much greater, amounting
even to four or five inches.   When the separation does not exceed an inch and
a half, the gap is  usually filled up by fibrous or ligamentous tissue, uniting the
fragments  firmly.  In some of the cases, however, in which the separation be-
tween  the  fragments does not exceed  this distance, and  in  most of those in
which  it extends  beyond it, Mr.  W. Adams  has found that the fracture is not
united by any plastic matter that has been thrown out, but that the fragments
are bound  together simply by  the thickened  fascia which passes over the patella,
with which is incorporated  the bursa patellae.  Mr. Adams finds that the apo-
neurotic structure thus uniting the fragments may be arranged  in different ways.
Thus, it may pass between, and  be adherent to the anterior  periosteal surface
of both fragments; or, the connecting aponeurosis maybe reflected over, and be
adherent to, both the fractured surfaces; or,  lastly, and this is the most frequent
 form of arrangement, the connecting aponeurosis may pass from the periosteal
 surface of  the upper fragment to the fractured surface of the lower one, to which
 it becomes closely and firmly united.  In the majority of cases, when united by
 aponeurotic tissue, the fragments gape somewhat  towards the skin, coming into
 better contact posteriorly.  Thus, it would appear that a patella fractured trans-
 versely may unite in two ways;  most frequently, by the  intervention of thick-
 ened  aponeurotic structure,  and, next, by a ligamentous or fibrous band.  Of
 31 specimens in the London  museums, examined  by Mr. Adams, it was  found
 that in 15 aponeurotic union had taken place, in  12 ligamentous union, and in
 the remaining 4 the kind of union could not be determined.
    The aponeurotic  union always leaves a weakened  limb  and an unprotected
  joint, for  in consequence of the separation of the fragments, the folding in of
 the fascia, and its adhesion to the capsule of the joint, the  fingers can be thrust
 in between the articular surfaces of the knee.
    In the  treatment  of  a fractured patella, the principal  point  to be attended to
 is, to keep the fragments in  sufficiently close apposition  for ligamentous  union
 to take place between them. With this view, the upper fragment, which is
 movable, and has been retracted  by the extensor muscles of the thigh, must be
 drawn down, so as  to be approximated to the lower one, which is fixed by the
 ligamentum patellae.   This  approximation  of the fragments may be effected
 either by  position and  relaxation of the muscles, or by mechanical contrivance.
 By placing the patient in a semi-recumbent  position, and elevating the leg con-
 siderably,  so as to relax  the  muscles of the thigh completely, the upper frag-
 ment may be brought down to the lower one, and, if necessary, may be retained
 there, after any local inflammation  that results from the accident has been sub- 
232
SPECIAL  FRACTURES.
dued, by moulding a gutta percha cap  accurately to  and fixing it firmly upon
the knee, or by the application of pads of lint and broad straps of plaster.   This
position must  be maintained for at least six weeks, at the expiration of which
time the patient may be  allowed  to  walk about, wearing, however, an elastic
knee-cap, or, what is  better, a straight  leather splint in  the ham, so as to pre-
vent the knee being bent for at least three months.  If this precaution be not
taken, the union between the fragments, which at first appear to be in very close
contact, will gradually lengthen, until in the course of a few months an interval
of several inches may be found between them.  In these cases, however, even
though the separation between the fragments be  great, it is remarkable how
well the limb may be used, especially on level ground; and with the  aid of a
knee-cap but little inconvenience is experienced by the patient.
   Compound  and comminuted  fractures of the patella, especially if occasioned
by bullet-wounds, and injuring the knee-joint, are usually cases for immediate
amputation.
   In most cases of fractured patella the starched bandage will be found a very
useful mode  of treatment, the patient being with  it enabled to walk  about
during the whole of the treatment. The action of the bandage is much increased,
by drawing down and fixing the upper lragment by two broad strips of plaster
firmly applied above it.   A back splint of pasteboard is required to fix the knee,
and a good pad of lint, with a figure of  8 bandage, should be applied above and
below the fracture to  keep it in position.  In several cases I have  obtained very
close and firm union  between the fragments in this way, without  confining the
patient to bed after the third day.
   Fractures of the Leg.—The bones of the leg are frequently broken.   The
tibia,  though a stronger bone  than  the fibula,  is most frequently fractured,
owing to its being more exposed and less protected  by  muscles, and receiving
more directly all shocks communicated  to the  heel.   The fractures of the  upper
part of this bone are  usually transverse, and result from  direct violence;  those
of the lower  extremity, oblique, and proceed from  indirect  violence.  When
both bones are broken, the usual signs of fracture, such as shortening, increased
mobility at the seat of injury, and  crepitus, render the  diagnosis easy;  but
when  one bone  alone is  broken, it is not always a very simple  matter to  deter-
mine the existence of the fracture; the sound bone, acting as a splint,  prevent-
ing displacement, and keeping the limb of a proper length and steady.  If it
be the tibia alone that  has been broken, the  fracture may be detected by run-
ning the finger along the  subcutaneous edge, until it comes  to a point that is
somewhat  irregular, puffy, or tender, where by accurate examination some mo-
bility  and slight crepitus may be detected.  When the fibula alone is broken,
the thick layer of the peroneal  muscles, overlaying its upper two-thirds, renders
the detection  of the fracture difficult, but in the lower third it is easy, by  atten-
tion to the same signs that occur in fractured  tibia.
   In  the treatment of fractures of the leg,  M'Intyre's  splint will  usually be
found of great service during  the earlier periods, more especially if there  be
much ecchymosis or extravasation, as it keeps the limb in an easy position, and
admits of the ready application of evaporating lotions.   After the swelling has
subsided, the starch bandage should be applied, and the patient  be  allowed to
move  about on crutches.   In  some  cases  of  fracture of the bones of the leg,
however, M'Intyre's apparatus is not applicable.   This is more particularly the
case when the fracture is very  oblique, from above downwards, and from before
backwards; under these  circumstances, the fragments cannot be got into good
position so long as the limb is kept extended  and resting on  its  posterior sur-
face ;  the  bones riding  considerably, and one or other  of the fractured ends
pressing upon the skin in such a way as often to threaten ulceration.   In these
cases it is, that  division of the tendo Achillis has been  practised, with a view
 of removing the influence of muscular contraction.  This appears to me, however, 
fractures  near ankle-joint.
233
to be an unnecessarily severe procedure, and certainly was not a very successful
one in two cases  in which I practised  it; for although the tendon was ex-
ceedingly tense, but temporary benefit  resulted, the  displacement returning
under the influence of the other muscles inserted into the foot.   In these cases
the bones  may usually be got into excellent position by flexing the thigh well
upon the abdomen, and the leg upon the thigh, so that the heel nearly touches
the nates,  and then laying the limb  on its outer side on a wooden leg splint,
provided with a proper foot-piece, and keeping it  fixed in this  position.   In
some  cases the swing-box will be  found a useful and  very easy  apparatus.
In  some fractures of the  leg, the lower end of the upper fragment  projects
considerably, and cannot be got into  proper position so long as the knee is kept
bent; but  if it be extended, so as  to relax the extensors of the thigh, the bone
is readily brought  into good position.  In fractures  of the leg, however, as in
all injuries of a similar kind, no one plan of treatment should be adopted exclu-
sively,, but the means had recourse to should be varied, and suited according to
the peculiarities of each individual case.
   Compound fractures of the leg are  best treated  on M'Intyre's splint, which
admits of proper dressings being applied to the seat of injury more readily than
any other  apparatus.   The details of the treatment of these  injuries  must be
conducted in accordance with those general principles that were discussed in
speaking of compound fractures.
   In fractures of  the leg, the starch  bandage is especially applicable. It should
be  applied as follows.   A dry roller having been  put on to the  limb, well
covered with  wadding, a strong pasteboard splint, four inches broad, and long
enough to extend  from the  back of the knee to six or eight inches beyond the
heel, should be applied to the back of the leg.  The projecting terminal piece
is now to be turned up along the sole of the foot, and two lateral  strips adapted
to either side of  the  limb.  Over this the  starch bandage, single  or  double,
according  to  the  size of the limb, must be tightly applied.  After it is dry,
about the end of the second day,  it  must be  cut up as represented in Fig. 81,
and re-adjusted, and the patient may then walk on crutches with  perfect safety.
In  compound fractures of the leg, a trap may be  cut in the bandage, as repre-
sented in Fig. 82, through  which  the wound can be dressed.
   Fractures in  the vicinity  of( the ankle-joint are amongst the most
 common injuries of the bones of  the lower extremity.   They are usually occa-
 sioned by twists of the foot, by catching it in a hole whilst running, by jumping
 from a height to the ground, or off a carriage in rapid motion.  These fractures
 are usually associated with severe  strain, or  even  dislocation,  of  the ankle.
 The twist  of  the foot is almost invariably outwards, the sole remaining  slightly
 turned in  this direction, though not always to the extent that Dupuytren states,
 and the inner malleolus projecting under the skin;  most commonly the  toes are
 turned somewhat  out, and the heel in.
   Fractures  of the lower  ends of the Tibia and Fibula present four  distinct
 varieties.
   1st.  The fibula may be broken at from two to three inches above the mal-
 leolus externus, the deltoid ligament being either stretched or  torn.
   2d. The fibula  may be fractured about three inches above the ankle, the tip
 of the malleolus internus being splintered off as well.  This constitutes the form
 of  injury  called " Pott's fracture," and is perhaps the most common fracture in
 this situation.
   3d. The fibula  may be fractured at about three inches above  the ankle, and
the lower end of the tibia at the same time be splintered off in an oblique direc-
tion from without, downwards and inwards (Fig. 10J.).  And, lastly, the  internal
malleolus  may alone be broken off,-the fibula remaining  sound, but  one of the
divisions of the external lateral ligament being torn through.
   The  signs  of these fractures vary somewhat according to  the bone that is 
234
SPECIAL  fractures.
injured.
Fig. 101.
          When the fibula alone is broken, there is but slight displacement of
                     the foot, but great pain and much swelling, with perhaps
                     indistinct  crepitus and irregularity of outline at the seat
                     of fracture.  If the tip of the inner malleolus is broken
                     off as well, this may be ascertained by feeling the depres-
                     sion above the detached fragment. In those cases in which
                     the lower  end of the  tibia is obliquely splintered, as well
                     as the  fibula broken,  there  are  not only the  ordinary
                     signs of fracture, with eversion  of  the toes, and a cor-
                     responding turning inwards of the  heel,  and some rota-
                     tion of the foot outwards,  but the  malleoli are widely
                     separated,  giving  an  appearance of great  increase  of
                     breadth to the joint; crepitus is very readily felt, and a
                     depression  can be perceived corresponding to the line  of
                     fracture.
                       In these cases there is always a great deal of swelling
                     from ecchymosis and inflammatory action, which requires
                     to be subdued by the continuous application of  cold be-
fore  any apparatus  can be applied.  If there is not much displacement of  the
foot, the treatment may best be conducted by splints with  good  foot-pieces, and
the starch bandage.   If the foot be much twisted, Dupuytren's splint should be
applied on the opposite side  to that on which the twist of the foot has taken
place, the pad being thickly folded at its lower end, and not descending below
the ankle.  Much stiffness is always felt after union has taken place, the ankle
remaining weak and useless for a long  time.
   Compound Fractures of the ankle-joint are very serious injuries, commonly
requiring amputation, if associated with dislocation and extensive wound of the
                             soft parts.  If,  however, the wound be of but
                             moderate extent, clean  cut, and  the tibial arte-
                             ries uninjured, the fractures should be reduced,
                             a portion of bone being perhaps sawn off in order
                             to  accomplish this, and the limb  then  placed
                             upon a  leg-splint with the foot well supported.
                                Fractures of the  foot almost invariably
                             result from  direct violence, and  are usually ac-
                             companied by much  bruising, and injury of  the
                             soft parts; hence there  is  usually but little dis-
                             placement, and when the fracture is simple, rest
                             and position  alone are  necessary.   Compound
                             fractures of the foot, attended by much bruising,
                             often require partial removal of the part, or am-
                             putation of  the leg.
                                The only special fractures of the foot requiring
                             particular attention, are  those of the calcaneum
                             and the neck of the astragalus.
                                The calcaneum may be broken either by direct
                             violence, as when a person jumping from a height
                             alights  forcibly on  his  heel, and thus fractures
                             the bone; or else  by the powerful action of  the
                             muscles of the calf tearing off a portion of  the
                             bone.
                                When the os calcis is broken  through at  its
                             posterior part, beyond the insertion of the lateral
                             ligaments, the detached  fragment will be drawn
up by the action of the strong muscles of the  calf.   But when  the  fracture
occurs across the body of the bone, no displacement can  take  place, owing to
 
fractures  of  the  ribs.
235
the lateral and interosseous ligaments keeping the posterior fragment in posi-
tion, and preventing its being drawn away.
   In the  first form of  fracture, the pain, swelling, flattening of the heel, and
prominence of the malleoli, indicate the nature of the  injury, even though
crepitus be wanting.  In  the  second variety, the mobility of the fragment,
and  its projection posteriorly by the muscles of the calf, point to the existence
of the fracture, which  is confirmed by the occurrence of crepitus.
   In the treatment of these injuries, subduing  inflammatory action,  keeping
the part fixed, by means of bandage and gutta-percha splints, with due attention
to the relaxation of the muscles, is all that can be done.   Union probably occurs
by bone in some cases, though very commonly by fibrous tissue.   [In fig. 102,
the  simplest treatment of fracture of the  os calcis is represented, the leg being
flexed upon the thigh,  and  the foot extended upon the leg, by means of a slipper,
attached by a cord to a band encircling the lower part of the thigh.]
   Fracture of the ribs  and costal cartilages.—These injuries commonly
arise from  direct violence, the part that is struck being driven in  towards
the  thoracic cavity, and thus broken.  In other cases again the fracture  occurs
by indirect violence, the fore part of the chest being forcibly compressed, so
that the rib is bent outwards, and thus snaps.  When  the injury is the result
of direct violence, the pleura, lung, liver, or diaphragm,  may be wounded, thus
giving rise to the most serious  and fatal consequences, such as hemorrhage,
emphysema, and inflammation of the parts injured.  When it is occasioned by
indirect violence, the thoracic organs may be contused and thus injured, although,
as the fracture takes place in a direction  outwards, they  are not under the cir-
cumstances liable to be punctured by the fragments.   In  some rare cases, the
ribs have been known  to be broken by the violent contraction of the abdominal
muscles during parturient efforts.
   Any one of the  ribs may be  broken, and  frequently several are fractured at
the  same  time.  The middle true ribs  are those that most frequently give way,
being most exposed, and at the same time fixed.  The first and second ribs are
seldom broken, being  protected by the clavicle and shoulder;  when fractured,
the  injury is always a  very dangerous one, on account of the importance  of the
subjacent structures.  The lower ribs being less  firmly fixed than the others,
commonly escape, unless very great  and direct violence be inflicted upon them.
Any part of a rib may be  broken by direct violence; but when the fracture is
the  result of compression of the chest, it is usually the convexity, or the  neigh-
borhood of the angle of the rib that gives way.  These fractures most commonly
occur in elderly people, in  whom the elasticity of the thoracic parietes  has less-
ened as the result of age.
   Symptoms. — The  chief symptom complained  of is  a sharp pricking and
catching  pain at  the  seat  of injury, in breathing deeply, or in coughing.   In
order to avoid this, the  inspirations are  shallow, and the breathing principally
abdominal.  On  laying  the hand over the seat of injury, and desiring the pa-
tient to cough, a crepitus may often be felt; and in  most cases this is audible
on applying the ear to the chest.  Occasionally the  outline of the rib will be
found to be irregular,  and  in some instances, where several ribs are broken, the
whole side of the chest is flattened and depressed.
   In treating fractured  ribs, the  surgeon need not concern himself so much
about the union of the fracture, as about  the prevention  of pain to the patient
in breathing, and  the  subsequent occurrence of serious  inflammation  or other
mischief within the chest.
   Any displacement that may exist  usually remedies itself without  the  neces-
sity  of the  surgeon interfering.   If, however, a  portion  of the rib continues
depressed, it  had  I think  better  be left so; the suggestions  that  have been
made for elevating these fractures by means of sharp hooks and screw probes, 
236
injuries of  joints.
beino- more likely, than the continuance of the depression, to  occasion serioua
mischief to the contents of the thorax.  In order to prevent undue motion of
the broken  bone, and  consequent irritation  produced by its puncturing  the
pleura or lung, the movements of the injured part of the chest may be restrained
by  the application of a broad flannel roller, or of a laced  napkin round it.
Instead of these means, I have for some years past found it more useful to apply
a roll of adhesive plaster round the chest.   The plaster must be about a foot in
width, and should be sufficiently long to make one and a half turns round the
body.   It should be applied very tightly, and  may be left on for ten days or a
fortnight, when it may require  re-application.   It supports  the chest more
firmly° and  evenly than   an  ordinary bandage,  affording the  patient  great
comfort.
   The prevention of inflammatory action must  be attempted by the  employ-
ment of bleeding, if  necessary;  but  certainly by the  adoption of a  spare diet
and complete  rest.   Any complication  that  may occur, such as  emphysema,
inflammation  of  the  lungs  or pleura,  must  be  treated in  accordance  with
the principles that will  be laid down  in speaking  of  injuries of the chest
generally.
   It occasionally happens that one or more of the costal cartilages, especially
the fifth,  sixth, seventh, or eighth, is broken by direct violence.   This injury
requires the same treatment as a fractured rib; the broken cartilage most com-
monly uniting by a bony  callus which surrounds the fractured ends.
                         CHAPTER  XVI.

                       INJURIES  OF  JOINTS.

  Joints are often contused by kicks, falls, or blows, so as to be severely injured,
with much pain, and  consecutive inflammation  of the capsule, synovial mem-
brane, or other structures entering into their formation.  The treatment should
be actively antiphlogistic, with complete rest of the part.   In a later stage, an
elastic bandage, cold douches, and friction, are useful.
  In some cases the bursa, situated in  the neighborhood of a joint, is seriously
bruised, and becomes inflamed in consequence; often giving rise to troublesome
suppuration and some sloughing.  When this takes place, free incision into the
inflamed part, in addition  to the ordinary antiphlogistic treatment, will afford
speedy and effectual relief to the patient.
   Sprains.—When a joint is twisted violently, so that its ligaments are either
much stretched or partially torn, though there is no displacement of the osseous
surfaces, it is said  to be sprained.  These injuries are  exceedingly troublesome,
and  most frequently occur to the wrist and  ankle joints.   The  pain attending
them is very severe, and often of a sickening character, and the sprain is rapidly
followed by swelling and inflammation  of the joint and investing tissues, often
of a  very chronic and tedious character.  As the inflammation subsides, stiffness
and  pain in using the part  eontinue for a considerable  length of time, which, in
some cases, give way to a kind of rigidity and wasting of the limb.  In others,
again, a rheumatic tendency appears to be set up by injuries of this description,
and  occasionally it happens that in strumous subjects destructive disease of  the
joint is induced. 
WOUNDS  OF  JOINTS.
237
  If the sprain is slight, rubbing the part with a stimulating  embrocation, and
giving the support of a bandage, is all that need be done.  But if it be at all
severe, more active measures must be had recourse  to.  The best mode of
averting the inflammation, which is the thing to be dreaded in these cases, is to
keep the part for several hours in cold water, or well moistened with an evapo-
rating lotion, or wet by means of irrigation.  Should this not check the inflam-
mation, leeches should be freely applied, and when the swelling has somewhat
subsided, the joint should  be supported with an elastic  roller or stocking, a
starch bondage, or a leather splint, and be well douched with cold water twice
a day, and afterwards rubbed or kneaded with  soap  liniment, until its usual
strength and mobility are  restored.   This,  however, very commonly does  not
occur in sprains of the knee and ankle for many weeks;  a degree of stiffness,
combined with inflammation, being left until the  stretched and  lacerated liga-
ments have regained their normal condition.

                         WOUNDS  OF  JOINTS.

   A joint is known to be wounded when synovia escapes from the aperture, or
 when the interior of the articulation is exposed.  If  there is any doubt as to
 the wound penetrating the  synovial membrane, no means, by probing or other-
 wise, should be taken to ascertain this, as in  this way the very occurrence that
 is to be dreaded  may be induced by the surgeon.  The fact of the wound pene-
 trating the joint  will speedily be cleared up by the symptoms  that supervene.
   The severity of the wound of a joint depends chiefly on the size of the articu-
 lation, but partly on the nature of the wound.
   When a small joint, as one of the fingers, is opened, the injury may  often be
 recovered from, without destruction of the  articulation.  When a large joint is
 opened, even by  a small incised or punctured wound, there is great danger lest
 such extensive local mischief and  constitutional disturbance ensue as to lead to
 the destruction of the articulation, with loss of the patient's life.  When the
 wound is large, lacerated, or contused, with fracture of the articular ends of the
 bones, one or other of these consequences certainly results.   It is especially in
 grown-up persons that these unfavorable  consequences ensue; in  children, ex-
 tensive injuries of  large joints may heal favorably, though, if the child be of a
 strumous habit of body, destructive action is apt to be set up.
   The source of danger in  a wounded joint is the inflammation  set up in the
 articulation (traumatic arthritis).  A few hours after the infliction of the injury
 the joint swells,  becomes hot, painful, and throbs. The pain increases, becoming
 tensive and excessively severe.  If the aperture be large, synovia freely escapes,
 which soon  becomes  mixed with pus.   If  it be  small, but  little  more than a
 puncture, the joint swells and fills  with purulent fluid, which  will either escape
 through the original wound or find an outlet for itself through a new situation.
 There are startings in the limb, with excessive pain  in any attempt at moving
 it.   The constitutional disturbance becomes very severe, the patient being occa-
 sionally carried  off by  the violence  of  the irritative fever.  In  other cases
 symptoms of purulent absorption come on, and death  results from pyemia.
   If the patient survive this period of acute action, abscesses will form around
 and above the articulation,  the discharge from which,  as well as from the joint,
 induces irritative fever and hectic.  Should this danger be passed through, and
 the patient  survive, it will be with a partially anchylosed limb, the utility of
 which is greatly  impaired.
   The severity  of the symptoms  in  the wound  of a large joint is evidently
 dependent on the extent and depth of the synovial membrane which suppurates,
 and to the pus thus formed being pent up in the midst of tense and unyielding
 ti«sues, from which it has not a free exit.  It  is  the  admission of air  into the
 joint that occasions the  suppuration, for we  find that in the most extensive sub- 
238
INJURIES  OF  JOINTS.
cutaneous wounds and lacerations of joints, as occur in dislocations and fractures,
suppuration scarcely ever takes place.   The presence also of the air appears to
exercise an injurious influence upon the pus that is collected in the depths of
the joint, causing it to become putrescent and acrid, and  thus increasing  the
local irritation greatly.   It is also this retention of acrid and putrescent pus, in
contact with a large inflamed surface, that gives rise to ataxic fever and pyemia,
that so frequently prove fatal in these injuries.
   Traumatic arthritis differs from the destructive and disorganizing idiopathic
inflammations of joints in this: that when the inflammation occurs as the result
of a wound, the synovial membrane is the part primarily affected;  if the carti-
lages become involved,  they are so secondarily; the articular ends of the bones
not participating in the morbid action.   When a joint is the seat of disorganizing
inflammation of an  idiopathic character, the mischief usually commences in  the
osseous articular ends, or in the  cartilage, the synovial membrane  being often
the last affected. In the traumatic form, the disease may be said to  radiate from
the centre of the joint; in the idiopathic, from the circumference.
   In recent cases of traumatic arthritis we find the synovial membrane swollen,
infiltrated, gelatinous-looking, and of a crimson  color;  the contiguous or sub-
 jacent portions of  cartilage are softened  and  partially  eroded.   Under  the
microscope, a disruption of the cartilage cells may be observed, and the  inter-
vening substance is granular; these changes gradually cease in  deeper sections
of the cartilage, which will  be found to present a healthy appearance.  In  the
more advanced stages of the disease, when the joint has been suppurating per-
haps for months, it will be found that the synovial membrane is deeply vascular
in places, in other parts pulpy and  infiltrated with, or replaced by grayish or
yellowish plastic matter.  The  cartilages are  eroded in patches, exposing  the
rough and injected surface  of the articular extremity of the bone;  where  not
 eroded they are pulpy and disorganized.  Occasionally partial but  unsuccessful
 attempts at bony union will have been set up  between the opposed  exposed
 osseous surfaces.
   In the treatment of wounded joints, the first point to be determined must be
 whether amputation should be performed, or an attempt made to save the injured
 limb.  If the joint be  small, there can be no doubt that we may  attempt,  and
 shall usually succeed in saving it.  But if it be one of the larger articulations,
 the line of practice must be determined by the extent  of the injury to the  soft
 parts, and the constitution  of the patient.  If the wound be but small, and is
 clean cut, no surgeon would be justified in having recourse to immediate ampu-
 tation, even though it be the knee that is injured.  But if the joint is exten-
 sively laid open, with  much contusion and  laceration, perhaps dislocation, or
 fracture and splintering of  the bones, the case is different.  Under these unfa-
 vorable  circumstances,  however, in the upper  extremity, and even in the  ankle,
 the limb  may not  unfrequently be saved.  If the bones be  comminuted, the
 removal of splinters and partial resection  of the  articular ends, may advantage-
 ously be practised  in many  cases, more particularly if the patient's constitution
 be young and sound, and  the soft parts not too  extensively damaged.   But if
 these be largely lacerated and widely contused, and the patient aged or broken
 in health, amputation  is imperatively called  for.  This is more especially the
 case, when the knee is the articulation injured; extensive lacerations of  this
 joint, more particularly complicated  with  dislocation or comminution  of the
 bones, being cases for early amputation.
   If it be determined to make an attempt at saving the limb, the principal point
 is, if possible, to close  the wound by the first  intention, and thus to prevent the
 occurrence of suppuration.   If  it be  a puncture, or  clean cut wound,  this  may
 occasionally be done by bringing its edges together and placing a  piece of lint
 soaked in collodion upon it, or a strip of plaster washed over with resin varnish,
 the inflammatory action being subdued by continuous irrigation with cold water: 
DISLOCATIONS.
239
no poulticing or warm  fomentations  should ever be allowed during this stage.
Union may take place under this dressing, but in the majority of cases the in-
flammation that is set up in the joint, causes so abundant a secretion of synovia,
that it becomes loosened by the tension and outward pressure of the accumulated
fluid which escapes from under it.
   If suppuration have come  on, free incisions,  as recommended by Mr. Gay,
should be made into the joint so as to procure an early outlet for the pus;  the
part must  be well poulticed, and an  attempt made at procuring anchylosis by
the granulation  and cohesion, through fibrous tissue,  of the articular surfaces.
By making free  and early incisions  into  the joint after suppuration has  once
been sat up,  the dangers resulting from decomposition of the pus and its absorp-
tion into the system are in a great measure lessened, and the constitutional irri-
tation produced by the tension of the parts at once removed.  The joint itself
is not put into  a worse  condition by being  more freely opened, for when one
suppuration  has been set  up in it, even  to a  limited extent, destruction  of its
tissues must ensue; and the most favorable termination that can  be expected is
the  production  of anchylosis.  At the same time constitutional treatment must
be employed, with the view of lessening febrile  action and removing irritation;
the administration of antimonials, with calomel and opium, being especially ser-
viceable; but free purging and all other sources  of irritation should be avoided.
   If the case proceed favorably the discharge will gradually  lessen, and the
constitutional disturbance subside.   The joint  must  then be placed in such a
position, that when anchylosis results, the limb  may be most serviceable to the
patient.
   If,  however, as very frequently happens when the larger joints are wounded,
the  suppuration  within the articulation,  and  the abscesses that form outside it,
reduce the  patient to a  hectic state, secondary amputation speedily becomes
inevitable.
   When the wound in the joint is too extensive for union by the first intention
to be effected, and yet it  be thought proper to make an effort to  save  the limb,
the  continued application of  ice or of cold irrigation, and active antiphlogistic
treatment, must be had  recourse to, and free and early  incisions to relieve ten-
sion and let  out  matter, so as to lessen the intensity of the suppurative  inflam-
 mation that will  be  set  up.   In the great majority of these  cases, however,
 where the larger joints, of the lower extremity especially,  are implicated, ampu-
 tation will eventually be required; the instances of recovery under these circum-
 stances being altogether exceptional, the patient indeed not unfrequently sinking
 during the attempt at saving the limb.

                             DISLOCATIONS.

   By a dislocation is meant the more or less complete displacement of the bony
 structures of a  joint.  In the orbicular joints, as  the  hip and shoulder, the
 osseous structures may be  completely separated  from  one  another, the disloca-
 tion then being complete.   In  the hinge joints, as  the elbow and knee, the osseous
 surfaces commonly remain partially in contact, though displaced from their nor-
 mal relations to  one another;  here the dislocation is incomplete.  In most dislo-
 cations the  integuments  covering  the displaced bones  are  put  greatly on the
 stretch,  but  in some_ they are ruptured, and then the dislocation is compound.
 Besides these varieties,  surgeons recognise  spontaneous dislocations, in which
the displacement does not occur from external violence.   In other cases again,
the  dislocation arises from congenital malformation of  the joint, in  consequence
of which the bones cannot remain in proper apposition.
   Dislocations are predisposed  to by various conditions,  amongst which the
arrangement of  the joint appears  to exercise most influence;  orbicular joints
being more liable to dislocation than any of the other articulations, whilst in 
240
INJURIES  OF  JOINTS.
some of the synchondroses  they never occur.   Malgaigne finds, that  of 491
cases of dislocation, 321 occurred in the shoulder, 34 in the hip, 33 in the
clavicle, 26 in the  elbow, 20  in  the  foot, besides others in the  thumb, wrist,
and jaw.
   Dislocations are seldom met with in children, in whom fractures of the epi-
physes more readily occur.  Travers, however, has seen the hip dislocated in a
boy five years of age.  In old  people the bones are so brittle, and  the ligaments
so tough, that  violence  causes fracture rather  than dislocation.   Hence it is
principally in young and middle-aged subjects that dislocations  are met  with.
They are necessarily more common in men than in women, from the nature of
their respective occupations.
   It is  well known  that it is rather  owing to the  continuous tension of the
muscles, than to any arrangement of their osseous and ligamentous structures,
that the articular ends of the bones of the extremities are kept in their proper
positions, and that considerable  external violence  may be applied to  a  limb
without  dislocating it.   If, however,  the muscles be  taken by surprise,  or if
they  have  been weakened by previous injury  of any kind, the joint becomes
predisposed to  dislocation, and may be displaced under the influence of very
slight causes.   In this way the same joint may be repeatedly dislocated.   Thus
I have seen a man whose humerus had been dislocated between 40 and 50 times,
owing to a weakened state of  the deltoid.
   The direct causes of dislocation are external violence and  muscular  action.
The external violence may act either directly upon  a joint, forcing or twisting
the articular ends  asunder, as happens  when  the foot is displaced by  a  twist
of the ankle, or when the thumb is dislocated backwards by a blow.  But  more
commonly the force acts at a distance from the  joint that is displaced, and the
head  of the bone is thrown  out of its socket by " the  lever-like movement of
the shaft," as happens when the head  of the humerus is dislocated by a fall on
the hand.
   Muscular action  alone may cause the dislocation of a bone,  even though the
part be  previously in a sound  state.   Thus, the  lower jaw has been  dislocated
by excessive gaping, and the humerus, by making a violent muscular effort. If
the joint have^ already been weakened by previous injury or disease,  muscular
action is especially^ apt  to occasion its displacement.   The congenital disloca-
tions, in all probability, arise from irregulaf  muscular contractions in the foetus
by which the bones are displaced, and the normal  development of  the  joint
interfered with.  In dislocations  of the orbicular joints, after  the  head  of the
bone  has been thrown out of its articular cavity, it is often still further displaced
by the contraction of the muscles, which continues  until they have shortened
themselves to their full  extent, or until  the  dislocated bone comes in contact
with some osseous prominence that prevents its further retraction.
   The existence of a dislocation is rendered evident by the change in the shape
of the joint, and  in  the altered relation of the osseous prominences  to  one
another; by the articular end of the displaced  bone  being felt in a new  posi-
tion, and by an alteration in the length of the limb,  and in the direction of its
axis.  Besides this, there is after a time, if not immediately on the occurrence
of the  accident, impaired motion of, and pain  in  and around,  the injured
articulation.
   The effects of dislocation on the structure of a joint are always of a  serious
character.  The bones that enter into the formation  of the  articulation are not
unfrequently fractured as well as displaced, more  particularly  in hinge  joints;
the cartilages may be injured,  and the ligaments are always much stretched and
more or less torn, the capsule of the joint suffering  especially.  In many cases
the muscles and tendons in the immediate neighborhood are  lacerated  as well
as  displaced, and the vessels  and  nerves  compressed.  The skin  is commonly
stretched, and sometimes ruptured,  when the dislocation becomes compound. 
REDUCTION  OF  DISLOCATIONS.
241
If the dislocation be a simple one, and if reduction be speedily effected, these
injuries are soon  repaired; and although  a good deal of stiffness may continue
about the joint, its functions are not usually permanently interfered witk
   If the dislocation be left unreduced, important changes take place within and
around the joint.  Its cavity becomes filled up by a kind of fibrinous  material,
almost cartilaginous in structure.   The  ligaments  are  shortened and^wasted,
and a false joint  forms around the articular end of the bone in its new situation.
In some cases the bone upon which the dislocated head rests becomes depressed
into a shallow cup-shaped cavity, so as to receive it.   In others the depression
is formed by the elevation of a rim  of callus  upon  the  subjacent bone, and in
both  instances the cellular tissue in the neighborhood becomes consolidated into
a capsule of a fibroid character, surrounding and fixing the bone in its  new situ-
ation, and usually admitting of  but a  limited  degree of motion.   The  soft
structures that have been lacerated at the time of the dislocation become matted
together by plastic material, the muscles  shorten, atrophy, and at last undergo
fatty degeneration from disuse; the neighboring vessels and nerves may become
 attached to the new joint, or their sheaths become incorporated with the altered
 structures in contact with them.
    In the treatment  of dislocations, the first and principal indication consists in
 replacing the bone  in its normal situation as speedily as possible.   In doing
 this, the surgeon has two great difficulties to overcome: 1st, the contraction of
 the muscles of the  part; and, 2nd, the anatomical structure  of the joint.
    The great obstacle to reduction is, the tonic contraction of the muscles in-
 serted into or below the displaced bones; and in the reduction of the disloca-
 tion  the surgeon's efforts are chiefly directed to overcome this contraction.  The
 longer the dislocation is  left  unreduced  the  more powerful  does this become,
 being less at the moment of the  accident, and immediately afterwards, than at
 any subsequent  period.   Hence reduction should be attempted as soon as pos-
 sible after the  occurrence of the accident, and if the patient be seen at once,
 the bone may sometimes be replaced without much difficulty by the unaided
 efforts of the surgeon.  Thus Liston reduced  a dislocated hip by his own efforts
 immediately after the accident  occurred.  If a  few hours have  elapsed, the
 muscular tonicity becomes so great that special means must be adopted in order
 to diminish it; and if some weeks or months have been allowed to pass by, the
 dislocation may have become irreducible, partly owing to permanent contraction
 of the  muscles which  have  been  shortened by the  approximation of their
 attachments, and which it is impossible to overcome, but chiefly, by the cohesion
 of the surrounding tissues, and the formation of adhesions about the head of
 the bone.
    In the reduction of a recent dislocation, advantage may sometimes be taken
 of the occurrence of faintness, or of  the patient's  attention  being distracted to
  other matters, in order to effect the return, the muscles being  then  taken by
 surprise, and the bone readily slipping into its place.   Such measures as these,
 however, cannot be depended upon, and  muscular relaxation should be induced
 by the administration of chloroform or ether.  By  the employment of these
 valuable agents, the muscles of the strongest man may be  rendered perfectly
 flaccid and powerless in a few minutes, so as to oppose no action whatever to the
 reduction of the dislocation, which has thus been wonderfully simplified and
 facilitated.  In no  department indeed of practical  surgery has the administra-
 tion of anaesthetic agents been  attended by more advantageous results  than
 in this.
    Mechanical contrivances  are  much less frequently had recourse  to  for the
 reduction of dislocation now than formerly.   It is,  however, occasionally neces-
 sary to employ apparatus  calculated to fix the articular surface from which  the
 bone has escaped, and to draw down the displaced  bone to such an extent  that
 it may be replaced  on the surface on which it should  be lodged.  If the patient
        16 
242
INJURIES OF  JOINTS.
Fig. 103.
have not been  anaesthetized, it will be found that so soon as the bone is well
brought down  by the extending force so as to get opposite its articulation,
being disentangled from osseous points upon which it may have hitched, it will
be drawn at once into its proper position by the action of its own muscles, with
a sudden and distinct snap;  the  muscles of the part being the most  efficient
agents in the reduction, so soon as the bone is placed in a position for them  to
act upon it.  When, however, the patient has been placed under the influence
of chloroform, the muscular system being thoroughly relaxed, the bone  will not
slip into its place with a snap or'sudden jerk,  but is reduced more quietly, and
rather by the efforts of the surgeon than by any sudden contraction of its own
muscles.   It is important to  note these differences in the  mode of reduction,
lest the surgeon, expecting to hear the snap or feel the jerk when chloroform
has been fully administered,  and, not doing so, should imagine  the bone not  to
be reduced, and continue an  improper degree of extension.
   The purely mechanical means for the reduction of dislocation are sufficiently
simple: the patient's body,  and the articular  cavity into  which the  luxated
bone is to be replaced, are fixed  by a split sheet, a jack-towel, a padded belt,
or some such  contrivance, by which counter-extension  is practised.   In  some
cases the hands  of an  assistant, or of the surgeon himself, or the pressure of
his knee or heel constitute the best counter-extending means.
   Extension may now be  made  either by the surgeon  grasping the limb to be
reduced and drawing it downwards, or else by means of a bandage  or  jack-
                              towel fixed upon the part, with  the clove-hitch
                              knot  applied in the way represented in the an-
                              nexed cut (fig. 103).  If more force be required,
                              the multiplying pulleys (fig. 125), or the  dislo-
                              cation tourniquet invented by Mr. Bloxam (fig.
                              126), may be  used, by which  any amount of
                              extending force that may be required can readily
                              be set up and maintained.   The "adjuster" in-
                              vented by Dr. Jarvis  is a useful and powerful
                              instrument for the  same purpose.  These con-
                              trivances, however, are  much  less frequently
                              required now than formerly, owing  to surgeons
                              taking advantage of the  paralyzing effects of
                              chloroform upon the muscular system, and con-
                              sequently not  requiring so much force  to over-
                              come their contractions.  When any powerful
                              extending force is applied, the skin of the part
                              should always  be protected from being chafed,
                              by a few turns of a wet roller.  The extension
                              must be  made  slowly and  gradually,  without
                              any jerking, equality of motion as well  as force
                              being attended to.  In this way the contraction
                              of the muscles  is gradually overcome,  whereas
                              sudden  and  forcible extension might excite
them to react against it.  The traction is most advantageously made in the axis
that the limb has acquired in its new position,  without reference to its normal
direction or to  the situation of the joint.  In this way the head of the  bone  is
replaced by being made to pass along the same tract that it has torn for  itself
in being dislocated, and thus is replaced without the infliction of any additional
violence to the tissues around the joint.
   The question as to whether the extending force should be  applied to the bone
that is actually displaced,  or to  the  further  end of the  limb, has been much
discussed, and  appears  to  have received more  attention than it deserves.   It
is true that, by applying the extending  force to the displaced  bone itself, the
 
REDUCTION  OF  DISLOCATIONS.
243
surgeon has greater command over its movements, with less chance of injury
to the intervening bones; whilst, by applying the extending force to the lower
part of  the extremity, he has the advantage of a longer lever for the reduction
of the head  of the  bone.   This lever, however, it must be remembered, is  in
many cases  a broken one, and  cannot be made to act if the bone has to  be
replaced in the direction of the flexion of the joints that enter into its compo-
sition.  For  this  reason, we find  that some dislocations  are best  reduced  by
applying  traction  to the bone  itself that is  displaced, as  in  luxations of the
femur and of the bone  of the fore-arm; whilst, in other cases, as in the dislo-
cations  of the humerus,  most advantage is gained by  applying the extending
force to the end of the limb.
   But I look upon these points as of comparatively little  consequence, believ-
ing that when the patient is not anaesthetized, the muscles of the limb themselves
effect the reduction without the  necessity of the surgeon employing any very
powerful  lever-like action of the bone;  and that when the patient is paralyzed
by chloroform, the bone is in most cases readily replaced  by the simple move-
ments impressed  directly upon it,  or even upon its articular end, by the hands
of the surgeon.
   In reducing a dislocation, it is  of especial importance to attend  to the rela-
tion of the osseous points in the neighborhood of the joint, and to disentangle
the displaced  bone  from any of these upon  which it may be  lodged.   This is
especially the case in  such hinge-joints  as  the jaw and elbow, in which the
arrangement of the articulation is  somewhat complicated.
   After the  dislocation has been reduced, the bone must be retained in position'
by proper splints and bandages, if necessary;  the joint  being kept quiet for two
or three weeks, according to its size, so as  to allow of proper union taking place
in the capsule and neighboring structures.   Any consecutive inflammation may
often be prevented by the continuous  application of cold; and, if set up, must
be treated by local antiphlogistic means.
   In dislocations  of old  standing, reduction is opposed not only by the powerful
contraction of shortened muscles, and by a kind of rigid atrophy of the neigh-
boring structures, but also by the existence of adhesions between the displaced
bone and surrounding parts. If the dislocation have existed for several months,
these obstacles will  in  general be sufficiently powerful to render it impossible
 to effect the reduction  at  all, or without the employment of such force as to
 occasion  dangerous  laceration  of  the tissues about the  displaced bone, and
 serious inflammation of  them;  as happened in the cases related by Dr. Gibson,
 in which rupture of the axillary artery followed attempts at reducing old dislo-
 cations  of  the shoulder.  If it be determined to attempt the reduction, the
 pulleys must be used, the patient  being put  under chloroform; but every pre-
 caution must be taken not to allow the traction to be carried to  too great extent,
 lest sudden  laceration of the parts occur.
   The latest period at which reduction  should be attempted,  varies much  ac-
 cording to the nature of the dislocation.   It may be successfully practised at a
 much later period in luxations of the orbicular than of the hinge joints; and
 it is especially in the shoulder that these late  attempts may be advantageously
 undertaken.  According to Sir A. Cooper, however, the latest  period at which
 reduction even in this  articulation can  generally be successfully effected, does
 not exceed  three months and eight weeks for the hip; but within this time it
 may often  be safely accomplished,   Thus, Dupuytren reduced twenty-three
 cases of  dislocated  shoulder between the fifteenth and eighty-second day after
the accident; and Breschet reduced  the hip  on the seventy-eighth  day.   At a
considerably later period, however, than this, the luxated  bone has  been put
into place.   Thus Smith, of the United States, reduced one dislocation of the
shoulder  at the seventh  month, and another at ten  and  a half months.   In the
reduction of some of these old-standing dislocations, it has been proposed to 
244
INJURIES OF  JOINTS.
divide by  the subcutaneous section those muscles which appear to offer the
greatest  obstacle to the return of the bone.  In this way Dieffenbach has suc-
ceeded in reducing a dislocation of the humerus two years after its occurrence.
In some  cases, however, as I have more than once witnessed, this plan does not
succeed,  owing evidently  to the  existence  of  contractions  in, and  adhesions
between, other tissues than  the  muscular, and  to the changes that have taken
place in  the articular surfaces, preventing the head of the bone being replaced
or retained in its new position.
   Compound dislocations  are amongst the  most serious injuries to which the
limbs can be subjected.  For not only is there such extensive laceration of the
soft parts that cover and enter into the formation of  the joint, as to give rise to
the most severe forms of traumatic arthritis, but the bones are often  fractured,
and the  main vessels of the limb perhaps greatly stretched  or torn.
   The treatment  of  a compound dislocation must be conducted  on the same
principles that guide the  surgeon in the management of a wounded joint; —
obtaining union if possible by the first intention, subduing  inflammatory action,
and letting out matter as it forms.   Owing to the rupture of the ligaments and
of the muscular attachments, there is usually no difficulty in  the reduction, the
bones being readily replaced; but the danger consists in the destructive inflam-
matory action  that will be set  up  in  the joint and limb, from the extensive
injury inflicted upon them.  This  varies greatly,  according to the  size and
situation of the joint, and the state of the soft parts.  If it be small, as one of
the  phalangeal articulations, the  dislocation may  be reduced,  and  the  parts
.covered  with  cold lint.   If it be one of the larger joints, the line of practice
will vary according to other circumstances than the mere dislocation.   Thus, if
it be in  the upper extremity, the patient  being healthy, and the soft parts not
very extensively contused or torn, the bones may be replaced, cold  irrigation
assiduously applied, and antiphlogistic treatment pursued.   If there be fracture
conjoined with the  dislocation,  resection should be  attempted, as was success-
fully practised by Hey in  several cases  of injury of the elbow of this descrip-
tion ; but if the soft parts be greatly injured  as well, and especially if the blood-
vessels and nerves of the limb have  suffered, amputation must be performed.
   In the lower extremity, amputation is more frequently necessary; in the
knee, almost invariably so.  Sir A. Cooper states that  he  knows no accident that
more imperatively demands amputation than compound dislocation of this joint.
Yet there are exceptions to this rule; thus, Mr. White had a case of compound
dislocation of the knee-joint in a  boy, nine  years of age, at the Westminster
Hospital, in which he saved the limb by sawing off the condyles of the femur
and reducing  the bone.   In the compound dislocations of the ankle and the
astragalus, an  attempt should generally be made to  save the limb, in the way
that will be more specially pointed out when we come to treat of these injuries.
   After recovery from compound dislocations, the joint will remain permanently
anchylosed;   hence  attention to position  during the treatment is  essentially
required  In many cases,  however, very good motion  is  ultimately obtained,
though the stiffness may continue for some length of time.
   The complication of fracture of the shaft  of°one of the  long  bones with dis-
location  of its head  increases considerably the difficulty of reduction  Under
these circumstances, it has been  recommended to consolidate  the fracture first,
and then to attempt the reduction.  But to do this is only to defer and increase
the difficulties.  At least seven or eight weeks would elapse before the fracture
were sufficiently firmly united to bear the requisite traction to reduce so old  a
dislocation, and then there would be great chance of rupture of the callus, and
 certainly extreme difficulty in the reduction.   It therefore appears to me much
safer, under  all circumstances, to reduce the dislocation at  once, and afterwards
to treat  the fracture in the ordinary way.  In reducing a dislocation complicated
 with fracture of the shaft of the displaced  bone, the fracture must first be put 
SPONTANEOUS DISLOCATIONS.
245
up very firmly indeed, with wooden splints completely encasing the limb.   The
patient must then be put fully under the influence of chloroform, which is of
the most essential service  in  these cases, and when the muscles are completely
relaxed,  extension and  counter-extension being  made  in  the  usual  way, the
reduction may be  effected.   The extending  means should always be  applied
upon the splints, so that there may be no dragging upon the fracture.   In this
way I reduced last winter, without  any difficulty, a dislocation of the head of
the humerus into the axilla, complicated with comminuted fracture of the shaft
of the bone, in a remarkably muscular man to whom I was  called by Mr. Byam,
and about the same time I had a case of dislocated elbow,  with  fracture of the
shaft of the humerus, under my care at the Hospital, that was reduced  with
ease in the same way.   After the bone has been reduced the  fracture can be
treated without difficulty.
   When a  simple fracture  extends into the articular  end of the bone, as in
some dislocations  about the elbow and  ankle, there is no material increase in
the  danger of the case  or in the difficulty of its management.
   In compound  dislocation  with  fracture of the articular ends,  removal of
splinters, partial resection or amputation will be required, according to the seat
and extent of injury.
   Spontaneous dislocations may occur either suddenly or  gradually, according
to the nature  of the cause that gives rise to them.
   In many cases they result from the destruction of the  joint by old disease;
the ligaments and cartilages being destroyed by suppuration,  the  head of the
bone becomes carious and absorbed, and the articular surfaces are displaced by
ordinary muscular action.  This we commonly see in old cases of hip disease.
   There, is, however, another and more  rare form of spontaneous dislocation to
which the hip and  shoulder are liable, and which has been especially studied
by Mr. Stanley.  In  these  dislocations the head  of the bone slips out of the
articulation without any very marked  sign  of disease about  the joint, and
certainly without any previous destruction of it.  In these cases there is either
a paralytic condition of the capsular muscles, as has been observed several times
in the shoulder, the deltoid  having become paralyzed and thus allowed the
bone to slip out of place; or, as has been noticed in the hip, obscure rheumatic
or neuralgic pains have for some time been seated in the joint.   The dislocation
may not be confined to  one joint, but may affect several.   Thus some time ago
there was a case in University College  Hospital, in which both shoulders and
hips were dislocated spontaneously.  In many cases it occurs suddenly, and
often without any pain to  the patient,  the  deformity of the   limb attracting
attention to the  accident, though in others it has been preceded by rheumatic
affection of the joint.  The treatment  of these cases is not very satisfactory.
Reduction in  many cannot be accomplished, but in  others it may be  effected
readily enough; though the bone  cannot be  fixed in the joint,  out of  which it
slips again.   In a  case  of spontaneous dislocation  of the hip, without any
apparent disease of the  joint occurring, in a young woman who was placed under
my care by Mr. Ashton, I readily effected reduction by the pulleys, three weeks
after the occurrence of the displacement.   The  limb was then fixed with the
long splint, and maintained  at a proper  length for two or three weeks; when,
in consequence of a  severe  bronchitic  attack, it became necessary to  remove
the  apparatus, and the displacement speedily returned.   Whilst convalescent
from this attack she  fell and fractured  the displaced femur in  its upper third,
thus rendering it impossible to replace the bone again.   In another  case of
spontaneous dislocation  of the knee, occurring in the same painless  manner, the
joint could not be replaced, and permanent deformity was left.  After reduction
in similar cases, a splint or starched bandage should be worn for a considerable
length of time, so as to give a chance for the ligaments of the joint to recover
themselves.  If there  be a  rheumatic  tendency, that should  be removed by 
246
SPECIAL  DISLOCATIONS.
suitable treatment, and if there be  a paralytic condition of the muscles, elec-
tricity, the endermic application  of strychnine and cold douches with friction,
may be advantageously employed.
   Congenital dislocations are  occasionally met with in the hip, shoulder, wrist,
and jaw, and have of late years attracted the attention of surgeons through the
labors of Gu6rin, Smith, Chelius, Robert, and others.  These dislocations are
closely allied in cause and nature with other congenital deformities of the limbs,
such as club-foot, &c.  In them there  is usually found imperfect development
of some portions of the osseous articular apparatus.   Whether this is so origi-
nally, thus causing the displacement of the  bones, or consecutive upon disuse,
occasioned by spasmodic action of the  one set of muscles or paralysis  of an-
other, dependent on some irritation in the nervous centres, is scarcely worth in-
quiring here.  In  some cases it would appear as if faulty position of the foetus
in utero, or undue  violence during birth, may have occasioned the displacement.
These dislocations  are probably incurable, as  there is always  congenital defect
of structure in the articular ends of  the bones.
                         CHAPTER  XVII.

                      SPECIAL  DISLOCATIONS.

   Dislocations of the  lower jaw are of rare occurrence, and when met
with are frequently occasioned by spasmodic action of its depressor muscles, —
opening the mouth too widely, as in fits of laughing, of gaping, or in attempting
to take too large a bite.  Occasionally this accident has resulted from blows'or
kicks upon the chin, or from the violent strain upon the part in tooth-drawing.
The mechanism of the dislocation is simple; when the mouth is opened  the
inter-articular fibro-cartilage with the condyle glides  forwards on to the emi-
nentia articularis.  If this movement be  continued too far, and the external
pterygoid musclecontracts forcibly at the same time, the condyle slips forward
into the zygomatic fossa, the coronoid process  hitching against the malar bone,
the axis of the ramus being  directed obliquely backwards, and the dislocation
being thus complete.   In this way both condyles may be displaced, or only one.
   The signs^ of this  dislocation  are  evident from the nature  of the accident.
The mouth is widely opened and cannot be closed; deglutition and speech  are
impaired, the labial  consonants  not being pronounced; there is  dribbling of
saliva over the lower lip;  the chin  is  lengthened, and the lower line of Teeth
advanced before those  of the upper jaw;  the  cheeks are flattened, and there is
a depression in front of the meatus externus.   There  is also an oblong  promi-
nence in the temporal fossa between the eye and  the ear.   If the dislocation is
left unreduced, the patient slowly regains some  power of movement over  the
jaw; he gradually approximates the  lips, and, after a length  of time, may even
be enabled to bring the lines of  teeth into apposition.
   When one condyle only is dislocated, the axis of the  lower jaw is directed
towards the opposite  side to that on which the displacement exists, and  the
general signs are the same, but in a less marked degree, as those that are met
with when both sides  are  dislocated.   The hollow before the meatus  on  the
injured side is, however, well marked, and  serves to  point  out the seat and
°aiUr? °d w displacement, the diagnosis of which is not always readily  made;
indeed, R. W. Smith  states that he has seen  attempts at reduction applied to  the
uninjured side. 
dislocations  of  the  CLAVICLE.            247
  Sir A. Cooper has  described a subluxation of the jaw, which is most fre-
quently met with in young and delicate women, in which the head of the bone
appears to slip before the interarticular cartilage, so as to prevent the mouth
being closed.  Most commonly the natural efforts  of the  part are sufficient to
return the head  of the bone  into the glenoid  cavity with a loud snap, or a
cracking noise.
   The reduction of a dislocated jaw is easily effected, it  being only necessary
to push the angle of the bone downwards and backwards, so as to  disentangle
the coronoid process from under the zygomatic arch, at the  same  time that the
chin is raised by the surgeon's fingers, in order that the temporal and pterygoid
muscles may draw the head of the bone into its proper position.  The reduction
is best effected by the surgeon standing before the patient and  applying his
thumbs, well protected with a thick  napkin, to the molar teeth on either side,
and thus depressing the angle of the jaw forcibly, at  the same time  that  he
raises the chin by means  of his fingers spread out and  placed underneath it.
The bone is  then returned into its place with  so forcible  a snap,  that, unless
care be taken, or the thumbs be well covered up, they may be severely bitten.
When only one condyle is luxated, the efforts at reduction should be applied to
the injured side only.  In the cases of subluxation, Sir A. Cooper recommends
a tonic plan  of constitutional treatment,  such as iron, valerian,  and shower-
baths ;  to this I have found the application of a series  of  blisters over  the arti-
culation a useful addition.
   After the reduction the four-tailed bandage should be applied,  as in cases of
fracture of the jaw, and  for several days the patient  must not be  allowed to
talk, or to eat. any solid food, lest the displacement return, which it always has
a great tendency to do.  Very old dislocations of this  bone may in  this way
be reduced.   Thus Stromeyer replaced  one at the  end of twenty-five, and
Donovan one at the end of ninety days.
   The congenital dislocation  of the condyle of the lower jaw is a remarkable
and rare condition, for  an acquaintance with which we are chiefly indebted to
Mr. Smith.  In this condition there is a singular distortion of countenance.
The osseous and  muscular structures on the  dislocated side are atrophied, the
teeth of the upper jaw projected beyond  those  of the lower, contrary to what
occurs in the accidental dislocations; the mouth  can be closed, speech is perfect,
and there is no  dribbling of saliva.  Congenital  dislocation of both  condyles
has not yet been observed.
   Dislocations of the Clavicle are  rarely met with in comparison to the
 frequency of fractures of this  bone, owing doubtless to the  short  and firm liga-
 ments by which it is attached to the sternum and acromion, and  to its usually
 receiving any force that is applied to it in a line that corresponds to its axis,
 thus causing it to be rather bent and broken than luxated.
   Either the sternal or the acromial end of the clavicle may be dislocated, and
 the simultaneous displacement of both has even been observed.
   The sternal end  of the clavicle may be luxated in a direction forwards, back-
 wards,  or upwards, being thrown before, behind, or above the  sternum.
   In the dislocation forwards, the end of  the bone can be felt in  its new posi-
tion, the  point  of  the shoulder is approximated to  the mesial  line, and  the
depression above and below the clavicle are strongly defined.   It is occasioned
by blows upon the  shoulder, by bending this part forcibly backwards, or by vio-
lence applied to the elbow whilst the arm is raised from the side.
   This dislocation, which is amongst the  most frequent to which  the clavicle is
subject, may readily be reduced by pushing the shoulder outwards and bending
it backwards.  The principal difficulty in the treatment  consists in preventing
the return of the displacement, owing to the shallowness  of the articular  surface
upon which the clavicle lodges.  With this view a pad and  figure of 8 bandage
must be firmly applied upon the displaced end of the bone. 
248
SPECIAL  DISLOCATIONS.
  The dislocation upwards is of extremely rare occurrence.  The signs in the
two recorded cases were  so  evident  as not  to lead to any difficulty in  the
diagnosis of the accident, the projection of the sternal end of the clavicle in its
new situation being subcutaneous, and at once cognizable to the touch.   In the
treatment, a bandage and  pad, with elevation  of the elbow, brought the bone
into good position.
  The dislocation backioards is not of common occurrence, though, according
to Nelaton, there are  at least  ten or a  dozen  cases  on record.   This luxation
appears generally to have  resulted from  the point of the shoulder having been
driven upwards, or by the hand being violently drawn forwards.  It has also
been observed to result from  the direct pressure of the clavicle backwards, as
by the kick of a horse, and has resulted  as a secondary consequence of curvature
of the spine.
  The signs are those that usually attend a dislocated clavicle, shortening of
the shouider, and deformity about the upper part of the sternum;  but, besides
these, a special train of symptoms is occasioned, by the pressure of the displaced
bone upon  the trachea, oesophagus,  and  vessels of the neck; in consequence of
which, so much congestion of the head, giving rise even  to a semicomatose
state with  difficulty in breathing and swallowing, may result, as to require  the
removal of the end of the bone, as happened in a case related by Sir A. Cooper,
in which the surgeon was obliged to saw off the dislocated end.   In some cases
the end of the bone is thrown upwards  as well as backwards; in others it takes
rather a downward direction.    In the treatment of  this dislocation, it is easy to
effect the reduction of the bone by making a fulcrum of the  fist in the axilla,
and then bringing the  elbow  well to the side, at the same time that an assistant
puts his knee between  the patient's shoulders  and bends them back; but it is
difficult to  retain it in proper position.   With this view, the figure of 8 bandage
tightly applied to the points of the shoulders, and crossed over a large pad placed
in the middle of the back, will give the most  efficient support to  the  part, the
elbow being at the same time  well fixed to the side and drawn back.
   The dislocations of the outer end of the clavicle are more commonly met with
than those just described.  The most  frequent accident  of this description is
that in which the bone is thrown  upon the upper surface of. the acromion or
upon the anterior  part of the  spine of the scapula.  In several cases of this
accident which have of late  years  presented  themselves at University College
Hospital, there has been no difficulty whatever in the diagnosis;  the prominence
formed by the displaced bone,  the narrowing  of the  distance from the mesial
line to the point of the shoulder, the facility of the reduction of the dislocation,
and the tension  of the clavicular portion  of the trapezius muscle, indicate the
nature  of  the accident.   The treatment may in  general be successfully con-
ducted on the same principles as those on which a fractured clavicle is managed.
In  some cases, however, the dislocation has  a tendency to return.   Under these
circumstances, M. Laugier has found that Petit's tourniquet  strapped from the
shoulder to the  elbow, and properly tightened, keeps the bone in good position.
   The outer end of the clavicle has been dislocated under the acromion by the
application of direct violence to the end of the bone.  This form of displace-
ment is so rare that Nelaton states  that there are only three cases on record;
several instances have, however, of late been mentioned in the journals.  The
diagnosis must be easy, simple digital examination  pointing  out  the nature of
the accident, and the treatment must be conducted in the same way as that of
fractured clavicle.
   The acromial end of the clavicle has been known to be displaced underneath
the coracoid process.   Here also simple examination and the clavicular bandage
suffice for diagnosis and treatment.  The only instance of simultaneous disloca-
tion of both ends  of the clavicle that I am  acquainted with, has been reported
by Richerand. 
DISLOCATIONS  OF  THE SHOULDER.           249
  Dislocations of the shoulder occur far more frequently than those of any
other joint.   Their pathology and treatment have been so clearly elucidated by
Sir A.  Cooper, that there is little left for subsequent writers but to follow the
descriptions given  by that great-surgeon; though several  of the modern  French
surgeons, especially Velpeau, Malgaigne, and Goyrand, have thrown some new
light on  the subject.  The reason of the frequency of these dislocations is to
be found in the shallowness of the glenoid cavity, the large  size and rounded
shape  of the head of the humerus, and  the weakness of the  ligaments; but,
above  all, in the extent and force of the movements to which  the joint is sub-
 jected.   These displacements indeed would be much more  frequent than they
even are, were is not for the protection afforded to the joint by the osseous and
ligamentous arch formed by the coracoid process and acromion  with their liga-
ments, the great strength and close connection  of the capsular muscles with  the
 joint,  and the support given by the tension of  the long head of the biceps over
its weakest part;  but the principal obstacle to dislocation is  the mobility of  the
scapula enabling all movements communicated to the hand and arm  to react
 upon that bone.
    The shoulder joint is susceptible of four dislocations.  Of  these, according
 to Sir A. Cooper, three are complete, and the fourth partial.  I think, however,
 that on examination, it will be found that the  so-called partial dislocation is in
 reality a complete one. The directions in which the head of the bone is thrown
 are downwards and slightly inwards under the glenoid cavity (fig. 104); for-
Fig. 104.          Fig. 105.        Fig. 106.          Fig. 107.
wards and inwards beneath the clavicle (fig. 105); backwards and dowmcards
under the spine of the scapula (fig. 107); and inwards and slightly downwards
beneath the coracoid process (fig. 106).   Thus  three  dislocations are more  or
less inwards, only one being backwards or outwards.
  In  the dislocation downwards, or the subglenoid (fig. 104), the head of the
bone  lies in the axilla, resting against the inferior costa of the scapula below the
glenoid cavity, and lodged between the subscapular muscle and the long portion
of the triceps.   This dislocation is the most frequent of all, and is an accident
of extremely common occurrence.   In it the axillary artery and plexus of nerves
are  compressed and stretched by the dislocated head  of the  bone;  the tendon
of the subscapular muscle  is commonly torn near to its insertion to the lesser
tubercle of the  humerus, and the capsular ligament largely lacerated.   The
supra-spinatus muscle may also  be  torn through,  or a portion of the great
tubercle of the  humerus detached, and the rest of  the  capsular muscles put
greatly on the stretch.
  In  the dislocation forwards, or the subclavicular  (fig. 105), the  head of the
bone  is thrown  on  the  inner side of  the coracoid  process, lying upon the
second and third ribs under the pectoral muscles, and immediately  below the 
250
special  dislocations.
Fig. 108.
  clavicle  (fig.  108).  In  a case recorded  by Mr.  Curling,  the  infra-spinatus
  and subscapularis muscles  were torn away from the  tubercles of the hume-
                            rus,  and the  teres  minor partially lacerated, the
                            capsule being completely separated from the  neck
                            of  the bone,  which  pressed forcibly  upon  the
                            axillary vessels and  nerves.  In  two cases which I
                            have had an  opportunity of examining, the great
                            tubercle was torn  away from the head of the  bone
                            with much  laceration of the capsule and extensive
                            extravasation.
                              In the dislocation backwards or the subspinous
                            (fig.  107), the head of the humerus lies behind the
                            glenoid cavity, and below the spine of the scapula
                            between the infra-spinatus and teres  minor mus-
                            cles.  Mr. Key  has  found the tendon of the sub-
                            scapularis torn across, together  with  the  internal
                            portion of  the capsular ligament; the  supra-spi-
                            natus and long head of  the biceps being stretched,
                            but not ruptured.
    In  the case of incomplete dislocation reported by Sir A. Cooper, the head of
 the bone was found to be  thrown out of the glenoid cavity (fig. 106), lyin<*
 under the coracoid process upon the  anterior part of the neck of the scapula*-
 the capsular muscles were not torn, but the long head of the biceps had been
 ruptured.  The description  given by Sir A. Cooper of this case, and reference
 to the illustrative plate in his work  on " Dislocations," appear to point to a form
 of injury of the shoulder-joint which has of late years been specially described
 by the French surgeons as a variety of the  dislocation downwards; that form of
 displacement,  indeed, which by Boyer  has been described as the dislocation
 "inwards," by Malgaigne the "subcoracoid " luxation, and  by Velpeau as the
 "subpectoral" dislocation; in  which the head of the humerus is placed in front
 of the neck of the scapula,  and underneath the subscapular muscle.  Why Sir
 A. Cooper described this as a partial dislocation, I do not understand; for not
 only was there rupture of the capsule and of the long tendon of the biceps, but
 the woodcut at page 401 of the last edition of his work shows clearly that the
 head of the bone had formed a new  articular cavity for itself, in the subscapular
 fossa,  being apparently completely thrown out of the glenoid cavity.
   It appears to me that the only dislocation of  the humerus to which the term
 partial is strictly applicable, is that which has been described  by Mr. Soden, in
 which  the long tendon of the biceps is  displaced from its groove  or ruptured,
 and the head of the bone thrown upwards and forwards under  the coracoid pro-
 cess, but not out of the glenoid cavity.   It is to this form of displacement, also,
 that Air. Callaway seems disposed  to confine the term partial.
   Dislocations  of the shoulder-joint are almost invariably the  result of falls upon
 the  hand or elbow, the particular variety  of dislocation depending upon  the
 direction of the shock  communicated to the arm and the position of the limb at
 the  time  of  receiving it.  On this  account we almost invariably find the dis-
 placements in a direction  inwards and downwards.  When a person saves him-
  i'ni1"? Wlth J1S ,ams Widel? stretched' out, the head of the bone is driven
 with all the force of a long lever against the lower and inner portion of the cap-
 sule, which being ruptured in this its weakest part, allows the bone to be thrown
 UPm? 0rm    \DSlde -°f  the inferior costa  of the scapula, and  thus into the
 axilla   When  the patient falls upon his elbow, the  inner part of the  joint is
still acted on, but the leverage not being so great, the head of the bone is thrown
upwards or forwards under the clavicle.  This dislocation is also often the result
ot direct violence applied to the shoulder.
  The  dislocation  backwards can  only take place when  the arm  happens to 
          dislocations  of the shoulder-joint.       251

receive the shock at the time that it is stretched across the chest.  As this is an
unusual position for any injury to be received in, this dislocation is proportion
ately rare.   An obstacle  to this displacement may also be found in the great
strength of the outer portion of the capsule of the joint as  compared with the
inner.
   Amongst these various dislocations those into the axilla are by far the most
frequent, and that  under the  clavicle next.  The displacement of the head of
the bone under the spine of the scapula is so rare, that Sir A. Cooper only met
with two cases of it; two cases have occurred at the University College Hospital;
both were reduced without difficulty.
   The  signs of dislocation of the humerus are sufficiently obvious,  varying,
however, according to the nature of the injury.  In all cases there are six com-
mon signs,  viz., 1st, a flattening of the shoulder;  2d, a hollow.under the acro-
mion; 3d, an apparent projection of this process; 4th, the presence of the head
of the bone  in  the abnormal situation; 5th, rigidity;  and 6th, pain about the
shoulder.
   In the dislocation downwards — subglenoid (Fig. 104) the head of the bone
can usually readily be felt in the axilla, at its anterior and under part; the arm
is lengthened to the extent of about an inch, the forearm is usually somewhat
bent, and the fingers often numbed, in consequence of the pressure of the head
of the bone on the axillary plexus.  The elbow is separated from the trunk and
carried somewhat backwards, but can be approximated to the side.  If the head
of the  bone cannot be felt in the axilla, its presence then may be ascertained,
as Cooper directs, by raising the elbow from the  side, when it at once becomes
perceptible.
   In the  dislocation  forwards — subclavicular  (Fig.  105) the head of the
humerus can be felt and seen under the pectoral muscles beneath the  clavicle;
the arm is shortened, the axis of the limb being directed towards its head, and
the elbow is a good deal separated from the side and thrown back.
   In the dislocation inwards — subcoracoid (Fig. 106) there is less deformity
about the shoulder than in  the other  luxations,  the acromion  not  forming so
distinct a projection.   The limb is somewhat shortened, the elbow being carried
backwards and slightly away from the side;  the  head  of the bone is  placed
deeply  in the upper and inner part of the axilla,  and cannot be very distinctly
felt, owing to its being thickly covered with soft parts, by the coraco-brachialis
as well as by the pectoral; rotation of the arm and elevation of the elbow being
 usually required in order that it may be detected.
   When the head  of the bone is dislocated below  the spine of the scapula (Fig.
 107), it can be felt and seen there,  more especially when the arm is rotated;
 the axis of the limb is likewise altered, being directed backwards.
   In the partial dislocation the signs do  not appear to be very evident.  In
 Mr. Soden's case there was slight flattening of the outer and posterior parts of
 the joint, and the  head of the bone  appeared  to  be  drawn higher  up  in the
 glenoid cavity than usual.  There was great pain induced by any movement of
 the biceps muscle, and  on attempting any overhand motions the head  of the
 bone became locked by the acromion.
   Dislocations  of the humerus may readily be diagnosed from  fractures  of the
anatomical and surgical neck of the bone, by the existence of the signs which
are common to all luxations, and by the  absence  of crepitus.  In  fractures in
this situation, also, the glenoid cavity always continues to be occupied by the head
of the bone.  The existence of crepitus, of slight shortening but little alteration
in the axis of the  limb, and no correspondence between this and the position of
its head, are additional signs of value in establishing the diagnosis.   Paralysis
of the  deltoid from a blow may simulate  a  dislocation, the  shoulder being flat-
tened and  the acromion projecting; but here the mobility of the joint, and the 
252
SPECIAL  dislocations.
presence of the head of the bone in the glenoid cavity, establish the absence of
dislocation.
  The reduction of a dislocated humerus may be conducted on three different
plans; — by  the heel in the axilla — by the knee, or — by drawing the arm
upwards.  Whichever plan is adopted  the patient  should, if strong,  be put
under the  influence of chloroform; when  his muscles  are paralyzed by  this
agent, but little force is required to effect the  reduction, the surgeon's unaided
strength usually sufficing for this purpose.   If more  power, however, should be
required than he  can exercise, extension may be made by assistants drawing
upon  a towel properly fixed round the lower end of the humerus, or else by the
pullies attached to the same part of the  limb.
  1st. The reduction of the  dislocation by the heel in the axilla is certainly the
easiest procedure  in ordinary  cases.  In adopting this plan, the patient is laid
upon  his back upon a low bed or couch; the surgeon seating himself upon the
edge of this on the same side as the dislocated arm, takes the limb by the wrist,
and fixing  one foot  firmly upon the ground, places  the other, merely covered
with  the stocking, well up into the axilla,  so that the heel may press  against
the lower border of the scapula, and the ball of the  foot act upon the humerus
(Fig. 109).   He  then draws  the limb  steadily downwards, and when it is dis-
engaged to  a sufficient extent, brings the  hand across  the patient, using his
foot  as a fulcrum, by which  the head  of the bone  may be reduced by being

                                  Fig.  109.
pushed upwards and outwards.  This  mode of reduction is especially service-
able in  ordinary dislocations  into the  axilla, and in those under the clavicle.
In  the latter, however, it will  be  necessary to draw the arm  more obliquely
downwards and backwards, and to press the foot  somewhat forwards upon  the
head of the bone, after it has been disengaged  by being brought  below  the
coracoid process.
  2d. The reduction by the knee in the axilla is precisely the same in principle
as the  last, though not by any means so good a plan; the knee being too large
and not following the movements of the humerus so readily as the foot.  In
effecting the  reduction by this means, the patient should be seated on a chair,
and the surgeon standing by his side, and resting one foot upon the seat, place
his  knee in the axilla.  He then seizes the patient's  arm above the elbow with
his  right hand, and  steadying the  acromion with his left, draws the limb well
down;  then bringing it across the knee, the head of the bone is reduced. 
dislocations  of  the  elbow.
253
  3d. In some cases  reduction is easily effected by laying the patient  on his
back, when the surgeon sitting behind him  raises the arm perpendicularly by
the side of the head, at the same time that he fixes the acromion.  In this way
the head of  the bone  is brought directly upwards into the glenoid cavity.
   If the patient is very muscular, or the dislocation of old standing, it may be
necessary to have recourse to the  pullies  in  order  to  effect reduction.  In
applying these the scapula must be firmly fixed, the  counter-extension being
made by passing the patient's arm through a slit in the middle of a  jack towel,
which should be fixed firmly to a hook or staple  in the wall.   The  extending
force may then be  applied  immediately above  the  elbow; and  traction being
made slowly and  steadily in the direction of the axis of the limb, the head of
the bone should be  directed  to  the  glenoid  cavity by the  pressure  of the
surgeon's hands,  so soon  as it has come to a level with  it.  In this way dislo-
cations of the humerus of many weeks, or even months' standing, have been
successfully reduced; but in employing these powerful means, especially under
the influence of chloroform, the surgeon should always bear in  mind that unless
care be taken, serious mischief,  even laceration of the axillary artery, may
result.   After dislocation of the humerus has been reduced, the  limb should be
bandaged to the side  and supported  in a sling;  and if inflammation occur about
the joint, leeches and evaporating lotions may be had recourse to.  In compound
dislocations  of the humerus, the bone must be reduced as speedily as possible,
and the wound closed, the local inflammation being combated by irrigation  and
other appropriate means.
   After reduction, there is a tendency for  the head of the bone to be drawn
upwards and outwards under and against  the acromion, owing evidently to the
deltoid and coraco-brachialis muscles not being any longer counterbalanced in
their actions by  those that have been separated from the  head of the bone.
 Compound  dislocation of the head  of the humerus is a rare accident.  I have
known it occur in two directions, downwards and forwards.  In it, even  though
the injury be extensive, it is better not to amputate  if the brachial vessels and
nerves be uninjured.   The limb may then  be  saved by reducing the bone at
once; after this the wound should be closed and dressed lightly, and kept cool
by constant irrigation.  If  the axillary artery is ruptured, either completely or
through its inner and middle coats, obstruction  to the arterial circulation of the
arm will ensue, and amputation must be performed through the  articulation.
   When the dislocation is complicated with a fracture of the shaft of the bone,
it  should be reduced at once by putting the fracture up very firmly, and then
attempting  the reduction by one of the usual methods.  In the case to which I
have already referred, p. 244, I succeeded  without  difficulty by means of the
heel in the  axilla.  The fracture must then be  treated by lateral splints.
    Congenital dislocations of the shoulder-joint have only of late  years attracted
attention.   Mr. Smith has ascertained, by post-mortem examination, the exist-
ence of two varieties  of this condition — the sub-coracoid and the sub-acromial
luxations.   In these  there  is wasting  of the muscles of the shoulder and arm,
the motions of which are extremely  limited, whilst those of the scapula are  pre-
ternaturally  great.  The condition of the bones is also remarkable.   In a  case
of congenital subacromial luxation of both shoulders there was no trace of a gle-
noid cavity, but  a well-formed socket existed on the outer side  of the neck of
the scapula, receiving the head of the  humerus, which was small and distorted.
These dislocations,  though existing from birth,  usually become more marked as
age advances, but are  necessarily irremediable in  consequence of the malformation
of the osseous structures and the wasting of the muscles.
   Dislocations of the Elbow are by no  means unfrequent  accidents, and as
they are often occasioned by direct violence, in consequence of which much
swelling speedily sets in, their signs are frequently obscured, and the diagnosis
rendered proportionately difficult;  more especially when the dislocation happens 
254
special  dislocations.
to be complicated with fracture of the  articular ends  of the bones.   In these
cases  indeed, it is only by a  correct acquaintance with the normal relations of
the osseous  points, and by a comparison between those  of opposite sides, that
the surgeon can detect the true nature of the injury.
  The varieties of dislocation of the elbow-joint are very numerous, either both
bones of the forearm or only one being  implicated.  The most common disloca-
    \                                            tion  is that in which both
                   [Fig. 110.                    bones are thrown backward*
                                                (fig. 110),  with or without
                                                fracture of the coronoid pro-
                                                 cess.  This injury is readily
                                                recognized by the projection
                                                backwards of the olecranon,
                                                carrying with it the tendon
                                                of the triceps.  The articu-
                                                lar end of the humerus also
                                                 can  be felt projecting in
                                                front of the elbow.  When
the coronoid process is not broken  off, it  is fixed against the posterior surface
of the  humerus, the  forearm  being immoveably placed  in  its new  position.
When this process is fractured there is  great mobility about the joint, and crepi-
tation may be felt as the arm is drawn forwards.
   Dislocation  of both bones forwards can scarcely occur without fracture of the
olecranon.  There are, however, cases on record in which the bones have been
so displaced without this process being  broken.   In  this  injury the elongation
of the forearm, the projection of the condyles  of  the humerus, and the depres-
sion of the posterior surface  of this  bone, render the  diagnosis sufficiently easy.
When the olecranon is broken off, there is elongation  of the forearm and great
mobility, but the detached fragment can be felt behind the humerus.
   The lateral dislocation of the bones of the forearm is almost invariably incom-
plete; either the head of the radius hitching  against  the internal condyle, or
the ulna coming in contact with the  external one; complete lateral dislocation
of the bones of the forearm being excessively rare.  The only instance that I am
acquainted  with is a luxation  outwards, reported by Nelaton, and of which he
has given a woodcut.
   The ulna or radius alone may be displaced, and, in some cases, both bones are
dislocated, but in opposite directions, thus  complicating considerably the nature
of the accident.
   The  only dislocation to which the ulna  alone is subject is that in a direction
backwards.  This seldom happens without more or less dislocation of  the head
of the  radius.   When it occurs it may be recognized by the projection of the
olecranon backwards, and  by the head of the radius being  felt in its normal
situation during the movements of pronation and supination.  In  the  majority
of cases the coronoid process would be fractured, at the same time causing ready
disappearance and recurrence of the dislocation with crepitus.
  _ The  radius alone may be dislocated  forwards, backwards,  or outwards.  The
dislocation forwards is certainly the most common.   In the many instances of
it that I have seen, it has resulted from a fall on the palm of the hand, by which
the lower end of the radius being driven backwards, the upper end is tilted for-
wards with the whole force of the  leverage of the bone,  and in this way, rup-
turing the annular ligament, is thrown against the external condyle.  The signs
of this displacement are the following: — The forearm is slightly flexed and in
a mid state between pronation and supination ;  any attempt at the latter position
occasions great pain, as does also the effort at straightening the arm. The elbow
can only be bent at an obtuse angle, in  consequence of the head of the radius
resting against the lower end of the humerus (figs. Ill, 113).  On rotating the
 
dislocations of  the  elbow.
255
radius much pain is experienced, and the head of the bone can be felt to roll on
the fore part  of the humerus, the external condyles  of which project unnatu-
rally.  The hand and arm can be fully pronated, but cannot be supinated more
than half way.  The whole of the outer side of the arm is deformed, being car-
ried somewhat upwards (Fig. 112).   The rupture of the  annular ligament in
this dislocation makes  it very difficult to keep the head of the radius properly
fixed, so as to prevent a recurrence  of the displacement.  In some cases, and
indeed not unfrequently, there is incomplete dislocation of the radius forwards,
arising  either from falls upon the hand, or from violent twists of the forearm.
In these we have the preceding signs, though to  a less marked  degree.   The
most characteristic symptom, however, is the inability on the part of the patient

                                 Fig. 111.
Fig. 112.
to flex  the  forearm upon  the  arm.   This he can never do to a greater extent
than to  bring the elbow to a right angle (fig. 111).  On being told to touch the
tip of his shoulder with his forefinger, he  will find it impossible to do so.
   The dislocation of the radius backwards is of  extremely rare occurrence;  it
may always be recognized by the head of that  bone being felt subcutaneously
behind  the external condyle; the movements of  the elbow, and of the radius
especially, being at the same time very limited and painful.   The dislocation
of the radius  outwards is  of  more frequent occurrence than the last form of
injury, the head  of the bone  being thrown on the outer side  of the external
condyle, where it  is felt under  the  skin, rolling as the hand  is moved.   The
natural  motions of the  joint are of course greatly interfered with.
   The radius and ulna  are sometimes displaced  in opposite directions, the ulna
being thrown  backwards, and  the radius forwards.  This injury, of which I
have seen two instances at the Hospital,  usually results from  heavy falls upon
the hand, with  a wrench  of the limb at  the  same time, as when a person is
thrown out of a carriage, or lights upon his hands, in consequence of which the 
256
special  dislocations.
Fig. 114.
bones are twisted and displaced in opposite  directions.  The deformity is of
course great, but readily recognized by the combination of the characters of the
two forms of displacement, provided an examination  be made before the swell-
ing has  come on, which rapidly sets in.
  Dislocations of the elbow-joint are very frequently complicated with fracture
of one  or other  condyle  of the  humerus, of the olecranon, and, as we have
already  seen in  displacement  of the  ulna, of the coronoid process.  In these
complicated injuries, an  exact diagnosis is often  extremely difficult, owing to
the  looseness and mobility of  the parts,  and  to the great tumefaction  that
accompanies accidents of  this description.   It is in  these  cases that  a good
knowledge of the relative bearing of the different  osseous  points, aided by a
comparative examination of the opposite limb, will alone  enable the surgeon to
effect a proper diagnosis  of the nature of the injury.
  The mode of  reduction in dislocations of the elbow-joint varies  according as
the ulna is displaced or not. When the  ulna is dislocated, in whatever direction
it may be thrown, and whether the radius be displaced at  the same time or not,
we  shall find that  the great  obstacle to reduction is the hitching of the pro-
cesses of that bone against the  articular end  of the humerus.   If either the
olecranon or coronoid process be fractured, this entanglement cannot take place,
and the joint then  slips into its position without difficulty, though it is very
difficult to  maintain it  there.   The reduction of  the displaced  ulna,  when
uncomplicated by fracture, may always be effected, as Sir  A.  Cooper has recom-
mended, by bending  the arm over the knee.   The patient being seated on a
chair, the surgeon  rests one foot upon  the  seat,  and placing the knee in the
bend of the injured elbow, grasps the  forearm with both  hands;  fixing the
                                    arm, he  presses the knee firmly  against
                                    the inner aspect of the forearm, so as to
                                    disengage the  ulna from the lower end
                                    of the  humerus, and  at  the  same time
                                    he bends  or  pushes  the fore-arm into
                                    proper  position; into  which,  indeed, it
                                    has a  tendency to  return  by the  action
                                    of its  own  muscles, so soon  as the op-
                                    posing  osseous  surfaces are separated
                                    (fig. 114).
                                       In dislocations  of  the  radius,  this
                                    movement across the  knee is not  neces-
                                    sary.   All that is  required is to fix the
                                    upper  arm,  and  then  employing  exten-
                                    sion from the  wrist  to  straighten the
                                    arm  well, when, by bending the elbow
                                    at right angles,  the head of the  radius
                                    may be pressed into a proper position.
                                       After reduction has been effected, the
                                    limb should be firmly put up in  lateral
                                    angular  splints,  the  hand being kept
                                    semi-proned.   If  the radius has been
                                    displaced, a pad should be  firmly ap-
                                    plied over its  head, so as to prevent a
                                    return of the displacement, which is very
                                    apt to occur when the  orbicular ligament
                                    is torn.  The inflammation which usually
results must be  combated by the free application of leeches and of evaporating
lotions.   When  this has subsided, passive motion may be  commenced, and fric-
tions and douches had recourse to, so as to remove the stiffness that is apt to be
left about the joint.
 
dislocations of  the  wrist.
257
Fig. 115.
  In those cases in which the dislocation is complicated with fracture of some
part of the articular ends, and in which the diagnosis of the precise nature of
the injury, owing to the swelling  or  other causes, has  not been very clearly
made out, the  joint should be placed in as good a position as possible, by the
process of traction, flexion, and moulding, so as to bring the osseous points into
proper bearing with one another; the angular splints must then be  applied,
and local antiphlogistic treatment had  recourse to.  At the end of a month or
five weeks, passive motion may be commenced, lest permanent rigidity come on,
which is  very  apt to supervene.   Compound  dislocations of the  elbow-joint
require to be treated on the same principles  on which compound fractures of
this articulation  are managed.   Dislocations of both bones have been  reduced
some weeks after the occurrence of the accident, and of the radius alone at as
late a period as two years after the displacement.
   Dislocations of the Wrist are of rare occurrence,  so much so that their
existence has been denied by Dupuytren and other modern surgeons.  Although
there can be no doubt that fractures of the lower
end of the radius, more  especially of an  impacted
character, have  often been mistaken  for  these
displacements, yet there can be no question  that
they do  occasionally, though rarely, occur.   Any
doubt that may formerly  have existed  upon this
point, in  consequence of the want of  post-mortem
examinations, has been  recently cleared up by the
dissections of  cases that have been  made by Mar-
jolin and Voillermier.   The observations of these
surgeons, together with  those previously  made by
Sir A. Cooper, tend to  show  that  dislocation  of
the hand  from the  carpus may take  place either
backwards or forwards  (fig. 115).  In whichever
direction  the accident occurs, a prominent smooth
convex swelling, corresponding to the first row of
the carpal bones, is  felt  and  seen opposite   the
wrist.  There  is some shortening of the forearm,
and the styloid processes  of the  radius and  ulna
form a projection  on the opposite side to that in
which the carpal tumor is seen.   The facility with which the  deformity is
removed, and the displacement reduced, together with the general laxity of the
wrist-joint, enable the
surgeon  to   diagnose                        Fig. 116.
the  injury  from  im-
pacted fracture of the
radius.  The existence
of the convex swelling
points out, that it is not
a  mere sprain of the
wrist that has occurred.
   Besides these,  an-
other  form of disloca-
tion of the wrist may
occur,  in  which the
hand and the  carpus
are thrown forwards under the radius and  ulna.  This displacement, which has
not, I believe, been previously observed, is illustrated  in  the  accompanying
figure taken  from a cast  sent to  me  by  my friend Mr. Cadge  (fig. 116).  In
it  the projection of the styloid process of the ulna and  the lower end of the
 
25S
SPECIAL  DISLOCATIONS.
radius forming  a slightly  concave line, contrasts  strongly with' the convex
swellino' observed in the dislocation of the hand from the carpus (fig. 115).
   The treatment of  these cases is simple: reduction, which is readily effected,
must be maintained  by the application of antero-posterior splints.
   Congenital Dislocations of the Wrist may take place either forwards or back-
wards.   The limb is in either case greatly deformed. The bones are shortened,
and  altered in shape, more especially the lower end  of the radius.  The muscles
are  also shortened,  the  extensor tendons forming a sharp angle as they pass
over the carpus.
   Dislocations of single Bones of the Carpus  are by no means of frequent
occurrence.   The bone  that is most commonly displaced  is the os  magnum.
This accident usually happens from falls, in which the  hand is violently bent
forwards, in consequence of which this bone starts out from  its articulation,
projecting  as a  round hard tumor on  the  back of the wrist  opposite to the
metacarpal bone of the middle  finger.   It  may be readily reduced by  being
pressed  upon at the  same time that the hand  is extended, thus pushing it into
proper position.  There is, however, a great  tendency for this  bone to slip out
again, leaving considerable weakness  of  the joint, so much so that in two cases
recorded by  Sir A. Cooper, the patients found it  necessary to wear artificial
supports.
   The pisiform bone has been observed to be displaced by Evans and Fergusson,
but I am not aware  that dislocation of any other of the  carpal bones has been
 described.  A case, however, lately occurred to me at  the Hospital, in which
the  semi-lunar  bone  appeared to be dislocated.   The patient in whom this
 accident happened  had fallen from a height, injuring his spine, and doubling
 his  right hand under him.   On  examining the wrist, a small hard tumor was
 felt projecting on its dorsal aspect, which readily disappeared on extending the
 hand  and  employing  firm pressure, but started up  again so soon as  the wrist
 was forcibly flexed.   It was evident that this bone  belonged to the first row of
 the carpus, articulating with the radius, and  from  its size, its position towards
 the radial side  of  the  carpus, and its  shape, which  could be very distinctly
                       made out through the integuments, there could be little
                       doubt that it was the semi-lunar bone.
                         The only metacarpal bone that admits  of dislocation
                       is that  of the  thumb;  and  though  the articulation
                       between this  bone and  the  trapezium  appears at first
                       not to be of a character to resist much external violence,
                       yet displacement of it seldom takes place.  This is pro-
                       bably owing in a great measure to the powerful muscles
                       by which the bone is supported in all cases in which the
                       force is applied  upon its  palmar aspect, as it most fre-
                       quently is, as well as to the little leverage offered by so
                       short  a bone.   These  luxations, however, have  been
                       observed  in  two directions, backwards and  forwards.
                       The dislocations backwards, which are the most common,
 are  often compound,  arising from powder-flask  or gun-barrel  explosions  in
 the palm of the hand, by which the joint  is opened,  and the bone thrown
 backwards.   The reduction is in  general  easy, extension being made  from
 the thumb by means of a piece of tape  applied round the first phalanx.
   Dislocation of the  metacarpophalangeal articulations  are by  no  means of
 common occurrence, though occasionally met with (fig. 117).   Most frequently
 the proximal phalanx of the thumb is the bone that is dislocated, being thrown
 backwards on the metacarpal bone.  The signs of  this accident are sufficiently
 evident, the prominence formed by the articular surfaces being distinctly marked.
 This dislocation of  the  proximal phalanx of the thumb has, owing to the diffi-
 culty of its reduction, attracted  more attention  than it would at  first appear to
 
          DISLOCATIONS  OF  BONES  OF THE CARPUS.       259

deserve.   So great has this difficulty been in some cases as to render the dislo-
cation  irreducible, or  to  compel the  surgeon to have recourse  to operative
interference in order to replace  the  head of the bone.  The obstacle to the
ready reduction of this small bone has been attributed to different causes.  Thus,
Hey supposed that it was owing to the constriction of the  neck of the  bone
between the lateral ligaments of  the joint; and Dupuytren entertained a very
similar opinion, looking upon the position of these  ligaments as the  principal
source of  difficulty.  The folding in of the anterior  ligament of the joint and
the interposition  of a  sesamoid bone  between the articulating surfaces has also
been looked upon as giving rise to this peculiarity.
   The more probable explanation, however, appears to be that the neck of the
metacarpal bone  becomes locked between or constricted by the two  terminal
attachments of the short flexor of the thumb, which must be carried back over
its head,  together with the displaced phalanx.  The observations of Vidal,
Malgaigne, and Ballingall, point to this as the cause.
   In many cases this dislocation may be reduced readily enough by the surgeon
making extension with  his fingers simply, and  then  pushing  the  bone  into
place; or, better still, after making some traction, by forcibly bending  the pha-
lanx towards the palm of the hand.  If these means  do not suffice, the  hand
should be fixed, and steady traction then be made from the  phalanx, to which,
previously protected by a strip of  wet wash-leather, a piece of tape has  been
applied with a clove-hitch knot;  or if more force be required, the pulleys may
be used.  In  some cases the bone may be replaced by passing  the ring of a
door-key  over the thumb, fixing one  side against the projecting head of the
phalanx,  and then drawing and  pressing  this into  its proper position.  If all
these means fail, subcutaneous section of the opposing muscle may be practised.
If the dislocation be left unreduced, Sir A. Cooper says that the patient may
still have  a very useful thumb.   In compound dislocation of this joint the bone
may usually readily be replaced;  should there be any difficulty its head  must
be removed, the  dislocation being  then reduced with  great  readiness, and the
wound treated in a simple manner.
   [A novel and exceedingly successful method for the reduction of this trouble-
some dislocation (fig. 118), has been practised by Dr. Crosby, of New Hampshire.

                    Fig. 118.                           Fig.  119.
He directs that the surgeon, seated by the side of the patient, should press up-
wards and backwards the dislocated thumb, until the first phalanx assumes a posi-
tion perpendicular to the metacarpal bone (Fig. 119).   The base of the phalanx
should then be pressed forwards by the thumb  of the surgeon, when it will be
found that flexion can easily be accomplished, and the joint restored to its natu-
ral position.  Dr. Crosby states that in the great number of cases which  have 
260
SPECIAL  DISLOCATIONS.
occurred to him, he has  never failed  to  effect reduction  in a single instance.
Vide American Journal of the Med. Sciences, April, 1858.]
                         Dislocation of the phalanges rarely occurs; when met
       Fig. 120.       with, these displacements are readily recognized by the
                      deformity they entail  (fig. 120), and as easily reduced
                      by pressure and traction in proper directions.   In com-
                      pound dislocation of the phalanges, the bone should be
                      replaced, the finger supported by  a pasteboard splint,
                      and the wound  dressed lightly.  In some cases it is ne-
                      cessary to remove the projecting end of bone before this
                      can conveniently be done, anchylosis then results, a suffi-
                      ciently useful finger being left.
                         Dislocations of the Hip. — Notwithstanding the
                      great depth of  the  acetabulum, the complete manner in
                      which  the head of the thigh  bone  is received into its
                      cavity, the firmness of the  capsular ligament, and the
                      great  strength  of  the  capsular muscles that surround
                      and support the joint, dislocations of the hip are  more
frequently met with than  those of many other  joints that appear less perfectly
supported.  This is doubtless in a great measure  owing to the great length of
leverage of the femur acting upon its  head, when external violence is applied
to the knee, and of that of the whole  length of the lower extremity when it is
applied  to the foot.
   The different forms  of dislocation of the femur  have been  expressed with
great clearness and  precision by Sir A. Cooper,  who has shown that its head is
most commonly thrown upwards and somewhat backwards, so as to  lodge on
the slightly concave surface between the acetabulum and the crista ilii, resting
on the gluteus minimus, and  having the trochanter turned forwards (fig. 121);
or it may be thrown downwards into  the foramen ovale lying upon the obturator
externus muscle  (fig.  123); or, forwards and upwards upon  the horizontal
branch of the pubes under the psoas and iliac muscles to the outer side of the
femoral vessels (fig. 124).   The head of the bone may also be thrown backwards
into the sacro-sciatic notch, resting upon the pyriformis muscle (fig. 122). These
are the four forms  of dislocation of  the hip, admitted by Sir A. Cooper, as of
the more usual character; besides these, however, may be added, as not of very
unfrequent occurrence, that form in which the  bone is thrown backwards and
somewhat  downwards  behind the tuberosity of the ischium.   In  addition to
these, other less common forms of dislocation have been noticed; for instance,
one in which the head of  the bone lies between the anterior superior and the
anterior inferior spinous processes of the ilium, or that in which it  has  been
thrown upon the spine of  the ischium.   In all these various forms of dislocation
there is  rupture  of the capsular ligament and of the ligamentum teres, with
laceration of the muscles  about the joint, and  extravasation of blood into and
around them.
   The signs, causes, and treatment of the different dislocations of the hip differ
so greatly from one another that, practically, it becomes  necessary to describe
each of these displacements as a separate lesion.  In considering these, we may
reduce the more ordinary dislocations of the hip to four distinct varieties, besides
which, however, it  is necessary to bear in  mind, that other and less usual forms
of displacement may occur.
   The most common dislocation is that in which the  head of the bone is thrown
upwards and backwards  upon  the  dorsum  of the  ilium, or rather upon  that
portion of  the bone which extends between the acetabulum and the sacro-sciatic
notch (fig. 121).   This displacement  differs  so slightly in its  pathology and
treatment from the  dislocation into  the sciatic notch (fig. 122), described as a
distinct variety of the injury by Sir  A. Cooper, that 1 think  it is more consis-
 
dislocations of the hip.
261
tent with the true  nature of these accidents to look upon  them as essentially
the same, the displacement in both cases being upwards and backwards, but in
different instances  partaking more of one or other direction.  This dislocation
may therefore be described as the ilio-sciatic.
  The next  distinct dislocation is  that in which the head of the  bone is
thrown downwards upon the obturator foramen, hence termed the thyroid dis-
location (fig. 123).

    Fig. 121.                 Fig. 122.           Fig. 123.        Fig. 124.
   The third variety is the pubic, where the head of the bone is thrown upwards
 upon the pubes (fig. 124); and lastly,
   The sciatic dislocation, in which the bone is thrown downwards and back-
 wards behind the tuberosity of the ischium.
   Thus it will be seen that in whatever direction the displacement occurs, the
 head of the bone has a tendency to sink into  some cavity or depression, or to
 lie upon one of the osseous surfaces in the neighborhood of the acetabulum.
  In the dislocation upwards and backwards or the ilio-sciatic, if the head of
 the bone rest upon the dorsum of the ilium, the hip will be found to be a good
 deal distorted, the gluteal  region being somewhat prominent, and the  upper
 part of the thigh enlarged, in consequence of the approximation of the muscu-
 lar attachments.   The head of the bone can be felt in its new situation, more
especially on rotating the limb; the trochanter is less  prominent than natural,
usually lying close against the brim of the  acetabulum, and being  turned 
262
special  dislocations.
forwards; there is considerable shortening, varying from one and a half to three
inches, and the position of the limb is remarkable, being distinctly rotated in-
wards, with the thigh slightly bent upon  the  abdomen, and  the leg  upon the
thigh, so that the knee is semi-flexed, and raised from the surface on which the
patient is lying.  The foot is inverted, so  that the ball of the great toe rests on
the ankle of the sound limb, and the heel is somewhat raised.  The axis of the
thigh is directed towards the  sound knee  (fig. 121).  The movements of the
joint are greatly impaired; abduction and eversion  are not practicable, but in-
version, abduction, and some flexion upon the  abdomen, can be practised.
   When the head of the bone slips a little further back so as to become lodged
in the sciatic notch, we have the dislocation backwards of Sir A. Cooper.  In this
the same symptoms exist, though to a less  degree; hence the diagnosis  is propor-
tionately difficult (fig. 122).  There is much less deformity about the hip in this
variety of the  displacement,  owing to the head  of  the bone sinking into the
hollow  of the  notch, and  thus presenting the trochanter nearly in its usual
position at right angles with  the  ilium, though  somewhat behind and a little
above its normal  situation.   In consequence of the  head of the bone being
received in a depression, the  axis  of the  limb is  not altered  to the same extent
as when  it is  thrown upon  the  plane surface of the dorsum  ilii; hence the
inversion of  the knee and  foot, though existing, is not so strongly marked. As
the sciatic notch is but a little above the level of the acetabulum, the shortening
of the limb is  inconsiderable, not  exceeding  half an inch or an inch at most.
The  axis of  the limb also is directed across the  middle of the sound thigh in
consequence of the bone being thrown further backwards.  Thus the signs of
these two forms of dislocation are nearly  identical in character, though varying
in degree, the  principal difference being,  that when the head of the bone rests
upon the dorsum ilii, the axis of the femur is directed to the sound knee,
whereas, when the head of the bone  is lodged in the sciatic notch, the axis of
 the limb is directed across the middle of  the  sound  thigh.
   The dislocation upwards and backwards is that which is most frequently met
with in the hip.   It is occasioned  by violence  acting upon  the limb whilst
 abducted; with the body bent forwards upon the thigh, or the thigh upon the
 abdomen, as when a person  is struck on the back  with a heavy weight, or
 thrown forwards, or falls whilst carrying a heavy  load upon his shoulders,  when
 the upper and posterior part of the joint receives the whole of the strain. Under
 these circumstances, the capsular  ligament is ruptured, and the bone slips out
 of its articulation.
   The diagnosis of this form  of dislocation is easy in proportion as the head of
 the bone lies high on the dorsum  ilii.  The more it sinks towards and  into the
 sciatic notch, the more difficult does the detection of the displacement become,
 and  the  greater the risk of its being overlooked altogether, or mistaken for a
 sprain.   The only severe injury of the hip with  which the dislocation upwards
 and  backwards can be confounded, are those rare cases in which there is frac-
 ture of  the neck of  the femur, with inversion of the limb;  here, however, the
 increased mobility,  and the  existence  of crepitus,  will enable the surgeon td
 effect the diagnosis.   In ordinary cases of fracture of the neck,  the existence
 of eversion of the limb at once points out that the head of the bone is not dislo-
 cated on the ilium.
   The reduction of this form of dislocation is effected in the following manner.
 The patient having been  put under the  influence of  chloroform, is laid on his
 back upon a strong table  between two staples, one of which should be fixed to
 the floor, and  another at a point  above  the  level of the body, in a direct line
 with the axis of the limb,  and about  twelve feet  apart.  The counter-extending
 force, consisting  of  a jack towel or of  a padded  leather belt, must  then be
 passed between  the injured  thigh and perineum, and fixed  to the staple in the
 floor.  The  pulleys  must now be attached to proper straps or to a towel fixed 
dislocations of the  hip.
263
with a clove-hitch knot immediately above  the  knee,  by one end;  the  other
extremity being attached to the staple in the wall, which should be so situated
as to be continuous with  the axis of the lower part of the limb.  The knee
being then  slightly bent  and rotated inwards, traction is applied  slowly and
steadily until the head of the bone  has  approached the acetabulum, when the
surgeon  rotates the limb  inwards so that the head may slip into its  socket
(fig. 125).  If difficulty occur in raising the bone over  the  acetabulum, the

                                 Fig. 125.
plan recommended  by Sir. A. Cooper, of passing a towel under the thigh to
enable an assistant  to lift the head of the  bone over the brim of that cavity,
maybe had recourse to.  The fact of the reduction being accomplished, is ascer-
tained by comparing the bony points of the limb with those of the opposite side,
and seeing if they  correspond.   A  long splint and spica bandage should now
be applied to fix the  thigh, and the patient be kept in bed for a fortnight, so
that reunion of the ruptured tissues may take  place.  In reducing this dislo-
cation, there is some danger of the  head of the bone slipping  downwards into
the sciatic  notch, if the  limb be too much raised.   This accident, which has
happened to some very excellent surgeons, may be mistaken for  reduction of the
bone,  a serious mistake, that would, unless corrected, entail permanent lameness
on the patient.
  When the bone is thrown upon the sciatic notch, the  reduction is  difficult,
and a slight modification  of the treatment  is required; this  consists  in  laying
the patient on his sound side instead of on  his back, and  making extension
across the middle of the  sound thigh instead of immediately  above his knee, as
in the last case.   In the  reduction of this dislocation, also, Sir  A. Cooper gives
the very valuable advice, of lifting  the femur out of the notch and  over the
edge  of the acetabulum by means of a round-towel placed under the upper part
of the thigh and over the shoulders  of an assistant, who at the same time should
rest his limbs on the patient's pelvis, and then raising his head draw the bone
towards its socket.
   Reduction of dislocations on to the dorsum ilii or sciatic notch, may be effected
readily enough whilst  the patient is  under chloroform, by " manipulation" of the
limb,  as introduced  by Dr. Reid, of Rochester, TJ. S.  This  is  done by flexing
the leg on the thigh,  carrying the dislocated thigh over the sound one, upwards
across the pelvis, as high as the umbilicus, and  then by abducting and rotating
it outwards.
  In  the  dislocation  downwards into the obturator foramen  we find the hip
flattened, and  the prominence of the trochanter completely absent, or indeed
replaced  by a depression.  The  limb is lengthened by about  two inches, ad-
vanced before the other, and considerably abducted (fig. 123).  The knee is bent
and incapable  of extension;  the foot usually points forwards,  but is sometimes 
264
SPECIAL  DISLOCATIONS.
slightly everted,  and is  widely separated from its fellow.   The  body is bent
forwards in consequence of the tension of the  psoas  and iliac muscles, and in
thin persons the bone may be felt in its new situation.
  This  dislocation  appears  to  be occasioned by the limb being  suddenly and
violently abducted, as by falls, with the  legs widely separated; in consequence
of which the head of the bone is tilted against the inner side of the capsule;
and rupturing this, is thrown into the thyroid notch.
  In the reduction of this dislocation the patient  should be placed upon hia
back, the counter-extending girth, or towel, is then placed round the pelvis,
                                              and  fixed  firmly to a  staple
                                              next to the sound side of the
                                             patient.  A  padded  girth  is
                                             then  to be placed between the
                                             perineum and the upper part
                                              of  the  dislocated thigh.   From
                                             this,  extension   is  made by
                                             means  of the pulleys or the
                                             tourniquet, which  are fixed to a
                                             staple at a  little distance  from
                                             the injured  side of the patient.
                                             Extension  having  then  been
                                             made to  such a  degree  as  to
                                             elevate the head  of the  bone
                                             from  the depression in which it
                                             lies,  the surgeon  passes  his
                                             hand behind the sound leg, and
                                             seizing the ankle of the injured
                                             limb, draws  it  backwards and
                                             towards the  mesial line, taking
                                             care to  keep the knee straight,
                                             and thus throwing the head of
                                             the bone into  the acetabulum
                                             by  the action  of  a long lever
                                             (fig. 126).
                                               The dislocation  upwards (fig.
                                             124)  on the pubes presents very
                                             unequivocal  signs.  The  hip is
                                             flattened; the head of the bone
                                             can be distinctly  felt lying  in
                                             its  new situation  above  Pou-
                                             part's ligament,   to  the  outer
side of  the femoral vessels, where it may be  made  to roll by rotating the limb.
The thigh  and knee are  slightly flexed, rotated outwards,  and abducted; the
limb, which is separated from its  fellow,  is shortened  to the extent of an inch.
  I he cause of this dislocation is either direct violence applied to the back of
the thigh whilst the limb is abducted, or from  the  patient  making a false step
m walking, and suddenly throwing his body backwards in order to avoid a fall,
twisting and displacing the limb.
  With regard to  the  treatment, Sir Astley Cooper advises that the patient
should  he  upon  his back, with his legs widely separated; and  that counter-
extension  being then made  by a girth carried between the perineum and the
injured thigh, and fixed to a staple in front of  and  above the body, the pulleys
should be fixed upon the lower part of the thigh, and the extension made down-
wards and backwards.   After this has been continued for a sufficient time, an
assistant lifts the  head of the bone by means of a  towel over the brim of the
acetabulum (fig. 127).
 
DISLOCATIONS  OF  THE  PATELLA.
265
  The dislocation  behind the tuberosity of the ischium is of very rare occur-
rence.
                                 Fig. 127.
  Dislocations of the patella are not frequently met with.   They may,
however, occur  in four directions, viz. outwards, inwards, upwards, and edge-
ways or vertically.
  The dislocation outwards is the most  common variety of the accident, the
bone being thrown upon the outer side of the external condyle of the femur,
with its axis directed somewhat  backwards  and downwards.  The  knee  is
flattened in front, and  is broader than usual;  the patella can be felt in its new
situation, and the muscles that form the quadriceps extensor are rendered tense,
mere especially the vastus internus;  the leg  is sometimes extended, but more
frequently  the  knee is slightly  flexed.  This accident usually happens from
sudden  muscular contraction in persons who  are knock-kneed.  In some cases
it has  been occasioned by direct violence, driving the bone out of  its position.
Most frequently the dislocation is not quite  complete, the patella being only
partially displaced  outwards,  with some rotation  of the bone in  the same
direction.
  The dislocation inwards is of very rare occurrence;  Malgaigne, who  has
investigated this subject, being  of opinion  that  there is only one case of the
kind on record.
  In these lateral dislocations, reduction  may be effected by laying the patient
on his  back, bending the thigh  on the abdomen, and raising  the  leg so as  to
relax the extensor muscles.  The surgeon then, by pressing down that edge of
the patella which is furthest from the middle of the joint, raises the other edge,
which, being tilted over the condyles, is immediately drawn into position by the
action  of the extensors.
  A remarkable form of dislocation  of the patella  is that in which this bone
becomes twisted upon its axis in such a way that it is placed vertically, one of
its  edges being fixed  between the condyles, or upon the external one, and the
other projecting under the skin,  and pushing  this  forwards  into a distinct
tumor.   In some cases the bone  is turned almost completely round, the pos-
terior  surface  becoming partly  anterior.   The  signs of this  dislocation  are
evident, manual examination indicating the vertical displacement of the patella,
with a deep depression on either side. The limb is completely extended, flexion
being impossible.
  This peculiar dislocation has most  generally arisen from  sharp  blows  or
severe  falls upon  one edge of the patella, whilst the limb was semi-flexed,  in
consequence of which the bone appears to have been semi-rotated  and fixed
in its new position.  Violent muscular contraction, however, conjoined with
a twist of  the  leg, but without any  blow, has been known to occasion it  in
some cases. 
266
SPECIAL  DISLOCATIONS.
  The reduction of this displacement is  always  attended with great difficulty,
and indeed in some cases has been found  to be quite impracticable —surgeons
having ineffectually  attempted, by  means of elevators and  the section  of the
tendons,  to replace it, and  the patient having  eventually died from traumatic
suppuration of the joint, with the displacement unrelieved.   The cause of this
difficulty of reduction is not very  distinctly  made out: it  is certainly much
greater than can  be  explained  by simple muscular contraction, and may not
improbably  be owing to the  resistance offered  by  the aponeurotic  structures
which cover the bone becoming twisted or entangled under it, or, as Malgaigne
supposed, by the superior angle of  the bone  being wedged in the subcondyloid
space. If relaxation  of the muscles of the thigh,  and the employment of proper
pressure upon the  patella, do not succeed, reduction  may perhaps be effected by
directing the patient to make a sudden and violent muscular effort at extension
of the limb, or by attempting to  walk.  In other cases, again, it may be  readily
replaced by bending the leg, and rotating it on the axis of the tibia at the same
time that the patella is pressed into position, as Vincent recommends.  Should
these  plans not answer, I  do not think it would  be advisable to have recourse
to subcutaneous section of the tendon of the  quadriceps extensor and  of the
ligamentum patellae.  In one case,  in which both these structures were divided,
the  patella remained as firmly fixed as ever, and  the patient  eventually died of
suppurative  inflammation  of the knee-joint;  and  in no  case  in  which it has
been practised, does it appear to  have facilitated  the reduction of the bone.
   Dislocation  of  the patella  upwards can only  occur as a consequence  of the
rupture  of its ligament.   This accident, which  is  always accompanied  by
much inflammation  of the joint, requires the  same treatment  as  a fractured
patella.
   Dislocations  of the Knee. — This joint, owing to the  breadth of its arti-
 cular surfaces, and  the great strength of its  ligaments, is  seldom  dislocated.
When such  an  accident  happens,  it usually arises from  falls from a great
height, or by the  patient jumping from a carriage  in motion.   The tibia may
 be displaced in four directions: forwards, backwards, or to either  side.  Besides
 these displacements, the joint is subject to a partial luxation dependent upon
 displacement of the semi-lunar cartilages.
   The lateral dislocations  of the tibia are the most common.  They are always
 incomplete, and are usually accompanied  by a certain degree of rotation of the
 limb in an outward direction.   These displacements may either be external or
 internal.  In  the first, the  outer  condyle of the  femur rests upon the inner
 articular surface of  the tibia.  In  the other, the inner condyle is placed upon
 the outer articular  surface of the head of this  bone.  In either case the knee
 is slightly flexed; there is a marked sulcus in the situation of the ligamentum
 patellae; the  extensor muscles  of the  thigh are relaxed,  and  the deformity
 of  the joint indicates at  once the nature of the  displacement to which the
 bones are subject.   In these cases reduction  is always easy;  indeed, occa-
 sionally it is effected by the unaided efforts of  the patient, or by a bystander.
 It may be accomplished by flexing the thigh upon the abdomen, then extending
 the leg, and, at the same time, by  a movement of rotation replacing the bones
 in proper position.
   The dislocation backwards may be complete or incomplete.  When complete,
 the  posterior ligament of the joint is torn,  the muscles  of the ham are
 stretched, the limb  is  shortened to  the  extent  of an  inch  and  a  half or  two
 inches, and is semi-flexed; the head of the tibia can be felt in the ham, and
 there is a deep transverse depression in  front of the joint immediately below
 the patella.
   The dislocation of the tibia forwards is of more frequent occurrence than the
 last accident.   In it, the lower end of the femur is felt projecting into the ham,
 compressing the vessels to such  an extent occasionally as to arrest the circula- 
DISLOCATIONS  OF  THE  KNEE.
267
tion  through the lower extremity, lacerating  the ligaments and stretching the
muscles in this situation.  The tibia is felt to project forwards, its head forming
a considerable prominence on the anterior part of the knee, with a deep depres-
sion immediately above it and the patella, which  is rendered  more evident by
the extensors of the thigh being relaxed;  the leg  is usually rotated somewhat
inwards or outwards, and there is shortening to the extent of about two inches.
   These antero-posterior dislocations are very commonly incomplete.  When this
is the case, they present the same symptoms, but to a less marked degree, that
characterize the comple displacements.
   In the  treatment of these dislocations, extension should be made from the
ankle whilst  the thigh is fixed in a semiflexed position; when the leg has been
drawn down sufficiently, proper manipulation will bring the bones into accurate
position;  splints must then  be applied,  means taken  to subdue local inflamma-
tion, and  the joint kept perfectly at  rest for two or three weeks, at  the  end of
which time passive motion may be commenced.
   The subluxation of the knee, or "internal derangement of the knee joint,'' is
an accident of  more frequent occurrence than any of those that have just  been
described.  It  usually occurs by the patient, whilst walking, striking  his toe
against  or tripping  upon a  stone, when he is suddenly seized with acute and
sickening pain  in the knee, often so severe as to cause him to fall to the ground.
Before doing so, however, he is conscious of having  strained or otherwise injured
the joint.  On examination it will be found semiflexed, the patient being unable
to extend the limb properly, and every effort being  attended by Severe pain. In
the course of a very short time the joint becomes  swollen, being distended by
synovial secretion, and symptoms of subacute synovitis are speedily superadded
to the original  injury.
   This accident, originally described by Hey, and  since investigated by Sir A.
Cooper and others, is owing to the semilunar  fibro-cartilage slipping away  from
under the internal condyle,  either before or behind  it, so as to bring its  surface
and that  of  the tibia into direct apposition.   The severe pain that  is always
experienced  is owing, in all probability, to the nipping  of the loose folds of
synovial membrane  that  lie within the joint, and  that go by the name of the
mucous and alar ligaments, and also  to the great stretching of the ligaments by
the partial displacement of  the bones.  The reduction may be effected by flex-
ing the joint, and then, when the muscles are off their guard, the patient's atten-
tion being directed elsewhere,  rapidly extending  it at  the  same time that a
movement of rotation is communicated to the leg.   The  evidence of complete
reduction consists in  the power of extending the articulation being regained by
the patient.  The synovitis that usually follows upon this injury requires to be
treated by local antiphlogistics and rest.  After it has been subdued, the patient
should  wear  a laced knee-cap, as the joint will be weakened and liable  to a
recurrence of the  same injury.
   Dislocations of  the knee-joint  are more  liable to serious complications  than
those of any other articulation.   Not only are the ligaments torn, and the mus-
cles injured, but stretching  and perhaps laceration,  of the  popliteal vessels, fol-
lowed by gangrene of the limb, may occur; or the joint may fall into a state of
suppurative and destructive inflammation, as the result of the injury.
   Compound dislocation  of the knee-joint constitutes one of the most serious
injuries to which the limbs  are liable;  the external wound being usually large,
ragged, and accompanied by the protrusion of the condyles of the femur, with
much laceration of the soft  structures in the vicinity of the joint.   These are
cases that certainly, as a general rule, call imperatively for amputation; indeed,
Sir A. Cooper looks upon this injury as especially demanding removal of the
limb.  Cases, however,  have occurred in which the limb, even under these cir-
cumstances, has been saved.   Hence, if the patient is young, and if the vessels
of the ham do not appear to have been seriously injured, the wound in the soft 
268
SPECIAL  DISLOCATIONS.
parts at the same  time not  being very extensive, or  much bruised, an attempt
may, with propriety, be made to save the joint.   In  a case of compound dislo-
cation of the knee forwards, in a boy,  the late Mr. A. White sawed off the pro-
jecting end of the femur which protruded through  the ham, and bringing the
wound together, succeeded in saving the limb.
  The head of the  fibula  has occasionally, though very rarely, been  displaced
by the  application  of direct violence to  it.  Boyer and Sanson have  each
recorded a case of this kind.
  Dislocations of the  ankle occur in consequence of displacement of the
astragalus  from the  bones of the leg,  whilst it continues to preserve its normal
connection with the rest of the foot.  These dislocations  are almost invariably
connected with fracture of the lower end of the fibula, or of the inner malleolus.
In fact, in looking at the arched  cavity into which the astragalus is received, it
is evident that this bone can scarcely  be displaced laterally without fracture of
one side of this arch.  In considering  these dislocations we must, in accordance
with the general nomenclature of similar accidents, in which  the distal part is
always said to be displaced  from the proximal, look upon  the foot as being dis-
located from the leg, and  not consider the  tibia as  being displaced  upon the
foot.   The direction of the  dislocation must consequently be determined by the
position into which the articular surface of the astragalus happens to be thrown.
It is  necessary to explain  this, inasmuch as a good deal of ambiguity occurs in
surgical writings from the same accident being described  differently,  according
to the view taken of the part displaced.  Thus, Sir  A.  Cooper speaking of the
tibia as being dislocated at the  ankle, whilst  Boyer and others regarding the
foot as the part displaced,  have  described the same  injury in directly opposite
terms.
   Dislocations  of the foot may take place in four directions, viz., laterally,
on either side; backwards,  and forwards.  In all cases,  the injury appears to be
occasioned either by the foot being twisted under the patient in jumping  or
running:  or else by its being suddenly arrested  by coming in  contact with the
ground whilst the body is  carried forwards.
   The dislocation outwards is of most frequent occurrence.   In it the inner
malleolus  projects forcibly against  the  skin;  there is  a depression above  the
outer ankle corresponding to a fracture of the fibula, and the  sole of the foot is
turned upwards and outwards; the inner side touching the ground, whilst the
 outer edge is turned up.   (Fig. 128).
                                             In the dislocation inwards, which
                [Fig. 128.                   is a rare accident, and according to
                                           Sir A. Cooper, a  much more dan-
                                           gerous one than that just described,
                                           the fibula is  not fractured, but the
                                           lower end of the  tibia is splintered
                                           off,  in  an  oblique  manner, from
                                           within outwards.   The outer edge
                                           of the sole  rests against the ground,
                                           and the inner side is turned  up-
                                           ward.
                                             The reduction of these lateral dis-
                                           placements is readily effected  by
                                           simple traction into proper position;
                                           leg-splints with lateral  foot-pieces
                                           must then be put on, or Dupuy-
                                           tren's splint may be applied on the
  same  side as the dislocation, opposite to that on which the eversion of the  foot
  takes place.
   In the dislocation of the foot backwards, the deltoid ligament is ruptured, the
 
dislocations  of  the astragalus.          269
fibula broken in the usual situation, and the tibia thrown forwards on the navi-
cular and internal cuneiform bones; the foot is consequently shortened, and
the heel rendered more projecting.  The dislocation forwards, in which the
foot is lengthened, and the tibia thrown upon the upper and posterior surface
of the os calcis, behind the astragalus, is an accident of such rare occurrence as
seldom to have been witnessed, although described.  In the treatment of these
antero-posterior displacements  of the ankle, traction of the foot in a  proper
direction, the leg being fixed and flexed upon the thigh, will readily be attended
by replacement of the bones, the application of lateral splints being afterwards
sufficient to keep the parts in proper position.
    Compound dislocations of the ankle-joint are serious, but by no means unfre-
quent accidents, the displacement occurring in the same direction and from the
same causes as the simple forms of injury.
   The treatment of these cases must depend to a considerable extent upon the
amount of laceration of  the  soft parts,  and the condition of the bones forming
the arch of the joint.   If the wound in the soft parts  be not considerable in
extent, clean cut, and with little injury  to the bones, the  limb should be placed
on a M'Intyre's splint; and the lips of  the wound, being well cleaned, brought
together  by  strapping,  or covered  by  lint soaked in collodion; evaporating
lotions may then be applied, the constitutional condition of the patient carefully
attended to, and the case treated much in the same way as a compound fracture.
In many instances this  plan will suffice, and the  patient will recover with a
useful limb, the joint being only partially anchylosed.
   If, however, the bones be  projecting  and comminuted, and the wound more
extensively lacerated, the question  of  amputation will  necessarily  arise.  In
many cases the operation may be dispensed with by adopting the  treatment
recommended  by  Mr. Hey,  of sawing  off the malleoli,  removing splinters of
bone, cleaning the wound, bringing together its  edges by simple dressing, and
supporting the limb at the same time upon a M'Intyre's splint.   If the joint be
still more seriously injured,  the  posterior tibial artery torn, or the foot greatly
contused, or if the patient's constitution be shattered and irritable, primary ampu-
tation should be had recourse to.  I believe, however, that the disinclination on
the part of surgeons to amputate in  these cases, owing to the strong expression
of  opinion by Sir A.  Cooper  in favor of the  attempt  to save the limb, has in
many cases been carried  to such an extent as seriously to endanger the patient's
life.   Secondary amputation may be rendered necessary, in consequence of gan-
grene, erysipelas, or extensive suppuration.
   Dislocations of the Astragalus. — The astragalus is occasionally dis-
placed from its connection with the bones of the leg above, and with those of the
tarsus below, being thrown either forwards or backwards, the displacement for-
wards happening far more frequently than that in the opposite direction.  In the
dislocation forwards, the head  of the bone may be thrown either outwards or
inwards, but I do not think there is any evidence to show that complete lateral
dislocation of  this  bone can occur irrespective  of displacement forwards; the
so-called  lateral  dislocations being  displacements of the bone  forwards, with
twists to one or other side.   In the  luxation backwards there is no rotation of
the bone, which is thrown directly behind the tibia, in the space between it and
the tendo Achillis.
   These dislocations invariably happen  from falls upon,  or twists  of the foot;
more particularly when  it is in a state  of extension upon the leg.  When the
foot is in this  position, the lower end of the tibia either breaks off on  the appli-
cation of sufficient violence,  or the head of the astragalus is forced out  of the
cavity of the  scaphoid, and its  bed on the os calcis, the particular kind of dis-
placement that occurs depending upon the direction in which the force is acting
and in which the foot is twisted.
  The dislocation of the astragalus forwards with twist of the bone inwards, is 
270
special  dislocations.
said to be of most common occurrence, although  I  have more frequently wit-
nessed that form of accident  in which the bone is  thrown somewhat outwards
as well  as forwards.  In either case the displaced bone forms  a distinct tumor
upon  the instep, in the outline of which the form of the astragalus can be dis-
tinctly made out.  Over this, the  skin is so tightly drawn as often to appear to
be on the point of bursting.   When the bone is thrown  somewhat inwards the
foot is  turned outwards, and  the internal malleolus projects distinctly.   When
the astragalus is thrown outwards, displacement of the foot in  an inward direc-
tion, with great projection  of the lower end of the fibula,  takes place..  In some
cases, fracture of the neck  of  the astragalus is conjoined with these dislocations,
and not uncommonly the  luxation is compound from the very first, or speedily
becomes so if left unreduced,  in consequence of the sloughing of the skin which
covers  the anterior  surface of the bones, the exposed portion of which under-
goes necrosis, and perhaps, eventually, exfoliation.
   The  dislocation backwards into the hollow, under the tendo Achillis, is of
rare occurrence, there being but seven recorded instances of this accident.  In
the majority of these there was displacement  of  the  bone inwards, as well as
backwards.   In these cases the diagnosis is easy, as the  bone forms a distinct
prominence, which can be  felt under the tendo Achillis.
   In many cases the dislocation of the astragalus is not altogether complete, the
under surface of the tibia not coming into direct contact with the upper surface
of the  os  calcis; a portion  of the astragalus  still intervening between these
articulations.
   The  reduction  of the dislocation forwards, whether attended by  lateral dis-
placement or not, varies greatly in the facility of its execution ; in some instances
being effected with the greatest possible ease, in others being attended by almost
insurmountable difficulties. This  difference in the facility of reduction depends,
I think, on whether the dislocation is complete  or not.  When the astragalus is
not completely thrown from under the arch formed by  the bones  of  the  legs, a
portion of it being still entangled between their articular surfaces and that of
the calcaneum, it may usually be readily reduced by relaxing the muscles of the
calf, and pushing the bone back into  its proper position.   But when the astra-
galus is completely dislocated, the upper surface of the calcaneum is drawn up
under the arch of the malleoli by  all the strength of the muscles that pass from
the leg to be inserted into the foot.   Under these circumstances, in order that
reduction take place, it is  necessary first of all to  separate the articular surfaces
to such an extent as to admit  of the astragalus being pushed back into its socket;
this  is almost impossible, owing  to the  great perpendicular thickness of this
bone, to the extent to which it is consequently necessary to draw down the foot,
and to  the little purchase that can be obtained on it.   In such cases as these,
the reduction has been greatly facilitated by the division of the tendo Achillis,
by which  simple operation  the whole  strain  of the  muscles  of  the calf is
taken off.                                     4
   If reduction is still impracticable, the bone must be left in its new situation.
If this  be in the direction  forwards, the skin will usually slough, and then a por-
tion of the exposed osseous surface, which will probably necrose, may be excised,
or the  whole of the astragalus dissected out by freely  exposing it and severing
its ligamentous attachments; the patient recovering with a somewhat stiffened,
but still useful, joint.   This  plan appears to be safer than excising the bone in
the first instance so  soon as the dislocation has been found to be irreducible.
   In luxation backwards,  the bone has not hitherto been reduced, except in one
case  which occurred in University College Hospital, and  in which the tibia and
fibula were fractured.  It  is by no means improbable that subcutaneous division
 of the  tendo Achillis may in  future enable  the surgeon to do this.   The result
is, however, satisfactory,  even though  the bone be not noticed,  the patient
 recovering with a useful foot.  If left unnoticed, the soft parts covering the 
dislocations  of  the  foot.
271
bone may slough, as happened  in a case  recorded  by Dr. Williams, of Dublin,
in which the bone was consequently extracted.
   In compound dislocation of the astragalus (fig. 129), the rule of practice must
depend upon the extent of injury.  If the integuments have merely been rent
in  consequence  of  the
tension  to  which  they                      Fig. 129.
have  been  subjected  by
the outward pressure of
the  displaced  bone,  an
attempt must be made to
reduce  the dislocation,
and if this be effected,
to close the wound by the
first intention.   If  the
bone  be  comminuted as
well  as  dislocated,  the
proper practice will be to
remove the loosened frag-
ments, and  to dress the
wound in the simplest manner, allowing it to heal by granulation.   If the bone
be irreducible, it is a question  whether it should be left or dissected out.  If it
be left, the wound in the integuments will certainly extend by a sloughing pro-
cess, the bone will inflame and become carious or necrosed, exfoliating in frag-
ments, and the patient will only recover after a prolonged, tedious, and dan-
gerous course  of treatment.   Under these circumstances, therefore, it appears
to me  that the simpler and safer plan both to limb and life consists in enlarging
the wound  in  proper directions, so as to dissect out  the  irreducible  astragalus,
and then bringing the articulating surfaces in contact, dressing the parts lightly,
and trusting to the formation of a new joint between the tibia and the os calcis.
So, also, if a simple  dislocation of the astragalus  become  compound in conse-
quence of the sloughing of the superjacent tense integuments, the exposed and
necrosing bone should be  removed in part or in whole, according to the circum-
stances of the case.   If, together with the dislocation of  the astragalus, the foot
be extensively crushed, amputation may be required either at the ankle-joint or
at some convenient part of the leg.
   Dislocation of the other tarsal bones is of extremely rare occurrence.   Most
of them, however, have been found to have been luxated at times.   Thus, for
instance, the calcaneum  has been dislocated laterally from its connections with,
the cuboid  in consequence of falls from a height, the sufferer alighting upon his
heel.   Chelius  mentions  a case in which this  bone was dislocated by the effort
of drawing off a  tight boot.   The reduction  seems  to  be readily effected by
relaxing the muscles, and pressing the bone back into its proper position.
   The scaphoid and cuboid bones have been found to be dislocated upwards in
consequence of a person jumping from a height and alighting upon  the ball of
the foot.  In these instances the limb is shortened and  curiously distorted,  the
toes pointing downwards,  the arch of the instep being increased so as to resem-
ble closely enough the deformity of  club-foot.   Reduction may be effected by
drawing and pressing the parts into position.
   The great cuneiform bone has occasionally been found to be dislocated.   Sir
A. Cooper mentions an instance of this  kind.   If reduction be not  effected by
pressing the bone into its position, no great evil appears to result to the patient,
the motions of the limb not being seriously interfered with.
   Dislocation of the metatarsal bones, though excessively rare, from the manner
in which they are locked  in between  the bones of the tarsus, and retained by
short  and strong  ligaments, yet occasionally occurs; instances being  recorded
by Dupuytren and Smith.  Liston also mentions a case of luxation of the meta-
 
272
injuries of  the  head.
tarsal bone of the great toe from direct violence.  Tufnell records  a case of
luxation  downwards and  backwards of  the  three internal metatarsal bones,
from a fall upon the leg by a horse rolling on its rider.  Luxations of the pha-
langes of  the toes but rarely happen, and present nothing special in nature or
treatment.
  Besides these instances of dislocations, properly so called, it occasionally hap-
pens that  accidents are met with that may in strictness be referred to  this head,
though differing somewhat from the usual characters of luxations.  Thus, for
instance, the sutures of the skull are occasionally separated, in consequence of
blows on the head.   So also the articulations between the vertebrae may suffer
displacement.   These injuries, however important, from the effects produced
upon  the contained organs, will be considered in the next chapters when treating
of injuries of the head and spine.
  It  occasionally happens, that in consequence of severe  blows  upon, or com-
pression of, the pelvis, the symphysis of the pubes, or the sacro-iliac articulation,
is displaced; here the nature  of the injury is indicated by the deformity that
results, and  the same treatment is required as in fractured pelvis.
  The lower angle and dorsal  border of the scapula is occasionally the seat of a
very remarkable kind of displacement, in consequence of which it projects at a
considerable angle  from the trunk, giving a winged  appearance  to  the back.
The cause of this  peculiar displacement is somewhat  obscure;  by  some it is
considered to be dependent upon the bone slipping away from under  the poste-
rior edge of the latissimus dorsi muscle; by others again,  and apparently with
more  reason, it is considered to be owing to paralysis of the  serratus magnus.
Whether this be dependent upon some morbid condition of the  muscle itself,
as Dr. Jacob supposes,  or be owing to a paralyzed state of the long thoracio
nerve, as Nelaton thinks, can  scarcely be determined.  In such cases as these,
I have seen  some benefit derived from the endermic application  of strychnine
on a blistered surface, and afterwards support by means of a properly constructed
apparatus.
INJURIES  OF   REGIONS.
                        CHAPTER  XVIII.

                      INJURIES OF THE HEAD.

  The consideration of injuries of the head is one of the most important studies
that can engage the surgeon's  attention.  The importance attached to it is not
so much due to the special considerations connected with the mere injury of the
scalp and  cranium; but rather to the effects that are produced as the result of
the implication of the brain and its  membranes, in many cases directly, and in
others indirectly, owing to the close connection that subsists between the actions
that take place in the external and internal structures  of  the head.  In conse-
quence of this tendency to cerebral  complication, it is of the first moment in
practice to study these  injuries  as  a whole, and with  special regard  to those
affections of the  encephalon produced by them; and  from which the injury of
the scalp and the fracture of the cranium derive the  greater part of their im-
portance.  It is therefore necessary in the first instance to  be acquainted with
the nature and treatment of the principal forms of cerebral affection that super- 
CEREBRAL DISTURBANCE.
273
vene upon these accidents, before we proceed to study the special  nature and
peculiar modifications of treatment required by the conditions that occasion them.

                     CEREBRAL  DISTURBANCE.

   There are two principal states of functional  disturbance  arising from injury
to which the brain is subject, viz., concussion and compression ; either of  these
may be followed by, or be complicated  with, inflammatory  actions of various
kinds, that derive much of their peculiar characteristics from the condition with
which they are  associated, and from  the injury by which they are occasioned.
   1st.  Concussion  or stunning  appears  to  be a shock  communicated to  the
nervous system  from the application  of such external violence as will produce
commotion  of the substance  of the brain, or interfere  with the  circulation
through it;  in consequence  of which its  functions become temporarily sus-
pended, usually in a slight and transitory degree, but occasionally to such  an
extent that the  patient does not rally for many hours from the  depressed state
into which he is thrown,  and perhaps  sinks without recovery.   In  those  cases
in which death  immediately results  from the  continuance and  severity of the
concussion, either no lesion at all may be found in the cerebral substance, or it
may have been  rendered  so soft and  semi-diffluent by the shock to which  it has
been subjected, as  to  be  evidently incompatible with life, even though no dis-
tinct rupture of  its substance appears to have taken place.  In  other  cases,
again, more  serious injury, such as rupture of  it, may have occurred.
   In the slighter cases  of concussion — that  degree  indeed which invariably
accompanies any severe injury of the head—the surface becomes  cold and pale;
the sufferer is  motionless  and insensible, or only answers when  spoken to in a
loud voice, relapsing again into speedy  insensibility, or  rather  semi-conscious-
ness;  the  pulse is feeble, the  pupils contracted, and the  sphincters usually
relaxed; the limbs are flaccid, and muscular power is lost.  After continuing in
this condition, which is the first stage of concussion, for a few minutes  or hours,
according to the severity of the shock, the second stage  comes  on, the circula-
tion gradually re-establishing itself, the pulse becoming fuller, and  the surface
warmer.  About  this  time the patient  very commonly  vomits; the  straining
 accompanying this effort appears to be  of service  in stimulating the heart's
 action, and driving the blood with more vigor to the paralyzed brain, thus tend-
 ing to restore  its functions; and we accordingly  find that, after vomiting has
 occurred, the sufferer quickly rallies.  In the more severe  cases, the symptoms
 that have  just been described are so  strongly marked that the patient appears
 to be moribund; there  is  complete prostration of all nervous and physical power;
 the surface being cold and  death-like, the eyes glassy, the pupils  either con-
 tracted or widely dilated, the  pulse  scarcely perceptible and intermittent.   In
 this state the patient may lie for hours, recovery being slow, and  the concussion
 merging  into some other,  and  perhaps  more serious affection of the nervous
 centres, or, indeed, in  some cases, speedily  terminating in death, apparently by
 failure of the heart's action.
   The terminations of concussion are various.   We have already seen that in
 some cases this affection  may speedily give way to complete recovery,  although
 slight headache, some  degree of giddiness, confusion of thought, and inaptitude
 for mental  occupation, may last for a few days before  the mental  powers are
 completely  re-established.   In  other cases  again, the concussion  may rapidly
 terminate in the patient's death, but between these conditions there are several
intermediate states.   Thus the recovery may be complete, but a permanently
irritable state of brain  may be left,  the patient, though capable of the ordinary
duties of life, becoming readily  excited by slight excesses  in diet or in the use
of stimulants, or  by mental  emotion,  though  not of  an  inordinate intensity.
These individuals, suffering from a preternaturally irritable brain  frequently die 
274
INJURIES OF  THE  HEAD.
suddenly in the course of a few months, or a year or two, after the receipt of the
injury.
  In other cases the recovery continues to be incomplete, although the patient
may be enabled to follow his usual  occupation, and to mix in  the ordinary
business of life; but yet his state is a precarious one, the brain being liable to
the occurrence of inflammatory disease on the slightest exciting cause.  In such
cases  as these, there is frequently a certain degree of impairment of mental
power, the  memory failing  either generally  or in certain important points, as
with reference to dates, persons, places, or language.  The speech is perhaps
indistinct and stuttering.  Amaurosis of one or both eyes, with perhaps squint-
ing or paralysis  of the  eyelid, may be left.   The hearing may be  impaired, or
noises of various kinds  set up in the ears.  There may be diminution or loss of
muscular and of virile power, especially, as Hennen  observes, in those cases in
which the  injury has been inflicted upon the back of the head; and Holberton
has noticed that when the medulla oblongata has been injured, the pulse may
continue preternaturally slow—an observation that I  have had several  opportu-
nities of confirming in injuries  both  of the  medulla, the pons, and the crura
cerebri.  For these symptoms  to occur,  it  is  by no means  necessary that the
original local injury should have been a severe one.   In some cases, in railway
accidents  more  especially, or in falls from a height, the whole nervous system
appears to be jarred  and  concussed without  any wound or apparent sign  of
internal injury  of the head.   At first the symptoms of  concussion  are but
slight,  perhaps even none are apparent, and  the  sufferer congratulates himself
on his escape, but gradually impairment of nervous power, manifesting itself in
one or  other of  the ways just mentioned, comes on, and the  health continues
broken through life.
   In other cases again, the symptoms of concussion may gradually terminate in
 those of compression, and not unfrequently  the reaction that comes on, passing
 beyond the bounds that are  necessary for the re-establishment of the healthy
 functions of the brain, terminates in an inflammatory condition of this organ.
   2nd.  Compression of the  brain is a common  condition in  injuries of the head,
 arising as  it does from a great variety of causes; — from the pressure of a por-
 tion of bone, of blood extravasated, or pus formed within the cranium, or from
 a foreign body lodged there.   In whatever way occasioned, however, the symp-
 toms, although presenting some differences, are tolerably constant.   The patient
 lies in a  state of coma, stupor or lethargy, being paralyzed  more or less com-
 pletely, heavy, insensible, and drowsy, not answering when spoken to, or only
 when addressed in a loud voice and shaken perhaps  at the same time.  The
 breathing is carried on slowly and deeply, with  a stertorous or snoring noise,
 and usually a peculiar blowing with the lips:  one or  both  pupils are dilated;
 the pulse  is full, often slow;  the faeces passing involuntarily, and the urine not
 uncommonly being retained; the skin may be cool, but in many cases, on the
 contrary, is rather hot  and perhaps perspiring;—not unfrequently this  state of
 stupor alternates with paroxysms of delirium, or of  local convulsive action.
   This state of coma may become complicated by the occurrence of symptoms of
 inflammation: and unless the cause that  produces the compression be removed,
 it usually  terminates speedily in death, the patient gradually sinking into more
 complete  unconsciousness,  and dying in an apoplectic condition.  In other, but
 much rarer cases, the coma may continue almost an indefinite  time, for many
 weeks or even months, until the compressing cause is removed, when the patient
 may recover consciousness, and the symptoms suddenly disappear.
   The diagnosis between concussion  and coma  has been  sufficiently indicated
 in the preceding description of these two conditions as not to  require special
 mention here.   But, in many  cases,  it must  be  remembered that one state
 merges into the other, so that the symptoms are not so distinctly marked as has 
TRAUMATIC  ENCEPHALITIS.
275
been  indicated,  and they are more especially obscured when associated with
inflammatory action.
  3rd. There is another condition of the brain, which, although differing com-
pletely from  concussion and compression,  not unfrequently complicates  these
states, or may  supervene independently of either,  upon severe injury of  the
head.  For want of a better term, this may be called irritation of the brain,
and appears often to be connected with laceration of the cerebral substance.  In
it the patient lies in a state  of semi-consciousness, unobservant of what is  going
on  around him, unless spoken to or roused.  He does not, however, lie  quietly,
but moans, tosses himself about, and not unfrequently twists and curls  himself
forwards, with his back  bent, and the knees drawn up towards the chest.  When
spoken  to, he answers in a peevish and irritable manner, if at  all: frequently
frowning and distorting his countenance, and being evidently pained at  any
attempt  at fixing his attention.   He is occasionally convulsed, and, at  other
times, is seized  with fits of violent delirium, shouting and screaming.   The
pulse is usually slow and  feeble, the skin  cool, and the face pale, with a total
absence of all signs of inflammation.   This condition most generally terminates
speedily  in convulsions, coma, and death.
  4th. Inflammation of the brain and its membranes  from injury (traumatic
encephalitis), is an affection of great frequency and corresponding importance.
It is a condition that is specially apt to supervene in all injuries of the  head;
though the liability to it necessarily increases with the severity of the accident.
This  form of inflammation  of the brain and its membranes may set  in with
great intensity in some cases, the symptoms of phrenitis being strongly marked;
in other instances,  again, it gradually creeps on in a slow and insidious  manner,
not attracting attention until it has given  rise to some  severe and  ulterior con-
sequences, as effusion or suppuration, when its symptoms  become  so mixed up
with  those of compression and of irritation, as to make  the exact  diagnosis of
the patient's condition far from easy.  The period at which inflammatory  symp-
toms  of  the brain may  manifest  themselves, after an injury of the head,  varies
greatly.   In some instances they set in almost immediately  on the patient reco-
vering from  the effects of the concussion ; the reaction from this state gradually
assuming an inflammatory character.  In  other  cases it is not  until after  the
lapse of several days that inflammation declares itself;  and, again, it sometimes
happens that the inflammatory affection does not supervene for weeks or months;
but then, occurring perhaps under the influence of comparatively trivial causes,
may  destroy the patient.
    After death, in cases of traumatic encephalitis, we usually find both the brain
 and  its  membranes affected.  The arachnoid is, however, the structure that
 appears  principally to suffer in  these cases, being thickened, so as to  become
 milky and semi-opaque.   Adherent lymph of a  greenish-yellow colour,  and
opaque  purulent appearance, is seen covering one or both  hemispheres of the
brain, being deposited  in largest quantity at  the seat of injury, and  not  unfre-
quently  extending across and into its  fissures, occupying especially the depres-
sions about its base.  The vascularity of the brain and its membranes is greatly
increased, the arachnoid being reddened in patches, and the vessels of the pia
mater becoming turgid and very numerous, forming a  vascular  net-work over
the surface of the  brain.   The sinuses also are distended with blood, the cere-
bral  substance exhibits an  increase in the  quantity of red points, so as  often to
present a somewhat rosy hue;  and the ventricles are filled with reddish semi-
turbid serum, a  large quantity of which is effused  about the base of  the  brain.
In  some of  the  more advanced cases, inflammatory softening of  the  cerebral
substance may occur.
   In considering the symptoms of traumatic  encephalitis it is useless to endea-
vor to make  a distinction between the inflammation of the brain and that of its
membranes;  the  two structures being always more or less implicated at the same 
276
INJURIES  OF  THE  HEAD.
time.   The most practical division of this disease following injury, is into the
acute and the chronic, or sub-acute encephalitis.
  The acute encephalitis  usually comes  on within  eight-and-forty hours of the
infliction of the injury.  The patient complains of severe, constant, and increas-
ing pain in his head; the scalp is hot, the carotids beat  forcibly, the pupils are
contracted, the eyes intolerant of light, and the ears of noise;  the pulse is full,
vibrating, and bounding; and wakefulness, with delirium, usually of a  violent
character, speedily comes on. All the symptoms of severe constitutional pyrexia
set in at the same time.
  By active and proper treatment this  condition may gradually subside until
the health is re-established, but  more commonly the symptoms of inflammation
merge into those of compression; the  delirium becoming  replaced partly or in
whole by a state of stupor, from which the patient is roused with difficulty, the
pupils gradually dilating, the  breathing  becoming heavy and  stertorous, the
pulse sometimes continuing with  its former rapidity,  at others becoming slow
and oppressed.   The  skin  is hot but clammy, the patient falls into a heavy,
dull, unconscious state, which alternates  with convulsive twitchings or jerkings,
and occasional delirious outbreaks. As death approaches, the sphincters become
relaxed, the pulse more feeble, the surface cooler, and the coma more intense
and continuous, until the patient sinks from exhaustion and  compression con-
 joined.   In cases such as these, pus may be found upon the surface, or within
the substance of the brain, in one case being diffused, in the other collected into
a more or less distinctly circumscribed  abscess.   In other cases again, the symp-
toms of compression appear to be induced by a thick layer of lymph lying upon
the surface of the  brain, or by a quantity of serous fluid being poured out into
the ventricles and about the base.
   The  chronic or sub-acute encephalitis  is the  most interesting  and important
variety of inflammation following injuries of the head.  It may come on a few
days after the infliction of  the  injury, or not  until months  have  elapsed.  It
 may arise from accidents that simply implicate the skull, as well as from those
 that extend their direct effects to the brain and its membranes.  The patient in
 many cases has apparently recovered entirely from  the   accident,  though in
 others  it will be found that some  one   symptom  indicative  of the brooding
 mischief still continues, such as headache, or impairment of sight or of hearing
 Occasionally,  the coming mischief  is foreshadowed  by an unusual degree of
 irritability of temper, by loss of mental  vigor,  or some other functional disturb-
 ance of the brain.   In cases such as these the  sub-acute  encephalitis may sud-
 denly come on, ushered in perhaps by an aggravation of the persistent symptom,
 or by the occurrence of an epileptic fit.   In other cases again, the symptoms set
 in suddenly without any warning, but usually with much intensity, and speedily
 prove fatal.
   The symptoms of the sub-acute encephalitis, when it has fairly set in, consist
 of those of inflammation, irritation, and  compression  of  the brain  conjoined;
 in some cases one, in other instances another, of the conditions  appearing to
 predominate.   The irritation and inflammation  proceed  from the  increased
 vascular action; the compression from the effusion of serous fluid,  of pus, or of
 lymph, exercising undue pressure upon  the brain.   The  symptoms consist of
 pain in the head with heat of the scalp, and either dilatation or contraction of
 the pupils, occasionally one being dilated and the other contracted.  Squinting,
 intolerance of  light,  delirium,  moaning, or screaming, unconsciousness, with
 convulsive twitchings of the limbs and  face, commonly occur with the ordinary
 symptomatic fever;  and lastly,  symptoms of  coma, rapidly terminating in  the
 patient's death.
   In the sub-acute encephalitis the same appearances are very generally found
 after death, as in the  more acute  form of the affection, but it commonly happens
 that it is the arachnoid membrane that is principally affected.  So constantly ia 
          TREATMENT  OF  CEREBRAL DISTURBANCE.       277

this  the  case, that some surgeons  have  proposed,  and not  altogether with
injustice, to apply the term arachnitis, to this form of traumatic  encephalitis,
looking upon the inflammation of the arachnoid as the principal lesion.
   5th. The formation of pus within the cranium is a point of much interest
in these  cases, and an endeavor has been made, especially by Pott, to lay down
rules by  which the occurrence of suppuration could be accurately determined.
Thus it has been said, that  if, during the continuance of encephalitis,  fits of
shivering come on, followed by the gradual supervention of  coma,  which slowly
becomes more and more complete whilst the constitutional symptoms of inflam-
mation do not subside; and if, at the same  time, a puffy swelling forms upon
the scalp, and the wound, if any, becomes  pale and ceases to secrete, the peri-
cranium separating from the bone, which is seen to be yellow and dry, an abscess
will have formed under the skull; and further, that  in  all  probability its seat
will correspond to these changes in the scalp and pericranium.
   In  many cases, doubtless, these signs have afforded proof of the existence
of pus within the cranium.   It but seldom happens, however, that the signs
attending the formation  of pus  within the cranium occur in the distinct order
and with the degree of precision above stated.  In the great majority of cases
the surgeon can only suspect the presence of pus by the symptoms of inflamma-
tion terminating in paralysis or  coma.  But  he  cannot say with certainty that
pus has formed, for the coma  may arise from the pressure of other inflammatory
effusions; but if  the puffy  swelling of the scalp or the separation of the peri-
cranium occur, then he  may feel himself justified in giving a more positive
opinion  as to its existence in some-situation within the cranial cavity, probably
beneath or in the neighborhood of the part thus affected.
   In  traumatic  encephalitis  secondary mischief often occurs  in some  of the
thoracic or abdominal viscera, the lungs and liver being especially  liable to be
thus implicated.  In the lungs, more particularly, it not unfrequently happens
that congestion runs into some  low form of pneumonia, and thus terminates the
 patient's existence.   In the liver it has long been  observed that  abscesses are
 apt to form as a consequence of injuries of the head   These usually occur as
 one of the  more remote  consequences of the injury, but yet there have been
 instances of an acute kind.  Thus,  Hennen  has seen an abscess form  in the
 liver of a temperate woman, thirty-six hours after the receipt of a blow upon
 the head.  This connection between abscess  of the liver and injury  of the head
 is doubtless the result of pyemia, consequent on the suppuration  of the diploe
 of the skull, the  hepatic abscess  being a metastatic deposit of pus  consequent
 upon inflammation of the veins of the diploe and of the cerebral  sinuses.
    The treatment of these various cerebral injuries, and their concomitant affec-
 tions, is one of the most important and difficult subjects  that can  arrest the
 surgeon's attention;  the difficulty depending in a great  measure on the  various
 conditions  that  have just  been described, not occurring in practice with that
 amount of distinctness and individuality by which  their characters can alone be
 conveyed in description, but being  associated together in such a way that the
 exact state of the patient cannot  so readily be made out.  There  are few cases,
 indeed, in  which practical tact  and  a nice discrimination and analysis of symp-
 toms are more required  than in those now under consideration.  It would, how-
 ever, be useless to attempt to describe the shades and modifications of treatment
 required in the management of the different  groupings  of  these various forms
 of traumatic cerebral disturbance.  We must therefore content ourselves with
 describing  the treatment of each state broadly and separately,  and leave the
 consideration of the varieties that so commonly present themselves  in practice
 to the individual  tact of the surgeon.
   In the treatment of concussion, the first great indication is to re-establish the
 depressed energies of the circulation and of the nervous system.  In effecting
 this, we must, however, be careful not to over-stimulate the patient.  The safest 
278
INJURIES  OF  THE HEAD.
practice is that which is applicable  to  the  treatment of shock generally; — to
wrap the patient up warmly in blankets, to put hot bottles around him, to em-
ploy frictions  to the  surface, and when  sufficiently recovered  to  allow him  to
swallow a small  quantity of warm tea.  Stimulants  of  all kinds should be
avoided, as  their after-effects may  be  injurious; unless the depression  of the
nervous energy is so great that reaction cannot be brought about without their
agency.
   When reaction has come on, steps should be taken to prevent the occurrence
of inflammatory mischief.  With this  view, if the  concussion have been slight,
it may be quite sufficient to purge the patient well, and to keep him quiet on a
regulated diet for a few days, directing him carefully to  avoid all alcoholic stimu-
lants and  mental  exertion for some time.   If the  concussion  have been more
severe  and  if the symptoms  of reaction have been accompanied by indications
of continuous cerebral disturbance, or been followed by giddiness, headache, or
confusion of thought, the safer plan will be to adopt  immediate steps for the
prevention  of mischief.   The patient should  be bled generally or locally by
leeches and cupping, freely purged, kept on a low diet, and, above all, remain
quiet in bed for some days.
   Should impairment of the mental faculties or senses be left, the more prudent
plan will  be to have recourse to mild antiphlogistic treatment.  Leeching, cup-
ping, blistering, the introduction of a seton in the nape of the neck, purging,
and more especially a mild mercurial course, with strict avoidance of all mental
and bodily stimulation, is the plan of  treatment  that requires to be pursued.
These cases must, however, be carefully watched, and kept under proper super-
vision for some length of time, as serious symptoms are apt suddenly to declare
themselves.
   When  acute inflammation of the brain or its membranes has come on, at what-
 ever period after the injury, active treatment should be at once adopted.  The
 head must  be shaved, and  an ice-bladder kept constantly applied.   Bleeding
 from the arm, repeated as often as the pulse  rises, as well as  by cupping or
 leeches, must  be  had recourse to; the bowels should be freely  opened, and
 rigid abstinence must be enjoined, the patient at the same time being confined
 to a darkened room, and removed from  all causes of excitement.   Calomel
 should then be administered, so as  speedily to affect the mouth.  As the disease
 assumes a chronic form, the same general  plan of treatment, modified according
 to the intensity of the inflammatory affection, must be persevered in, the patient
 being kept for a length of time after the subsidence of all the symptoms in a
 state of complete quietude.
   The subacute encephalitis which occasionally  follows injuries of the head,
 even at a  remote  period from their infliction, is a most dangerous and unman-
 ageable affection, being very apt to terminate in loss or impairment of sense, in
 diminution of intellectual power, or in local paralysis.   Much of the difficulty in
 the treatment of these cases appears to arise from the fact that the inflammation
 is often of  a  low or erysipeloid character,  consequently not admitting of active
 depletory measures.
   In these cases the best results are  obtained by the  proper administration of
 mercury  and the employment of counter-irritants.   The best mode of adminis-
 tering  the  mercury is to  give calomel in small and repeated doses, half a grain
 or a grain every four or six hours until the gums are affected, and to keep them
 so by diminishing, but not  leaving off  the  mineral.   The repeated application
 of blisters over the shaven scalp is perhaps the most useful form of counter-irri-
 tant, to which, in  more  chronic cases, a seton in the neck may be added.   So
 long as any symptoms  of inflammatory  action continue, this plan  of treatment
 must be steadily kept up.
   The irritation of the brain, that occasionally occurs  as the result of injury, is
 best treated by a moderate antiphlogistic plan, conjoined in some cases, and in 
          TREATMENT  OF CEREBRAL  DISTURBANCE.       279

others followed, by the administration of opiates.  This is the only consequence
of injury of  the  head in which opiates can advantageously be given.   They
should never be administered if there be any heat of head and fulness of pulse,
having a great tendency to excite  cerebral inflammation.  But in that peculiar
train of symptoms that occasionally follows injuries of the  head, and which I
have described as irritation of the brain, and in which there is a total absence
of all inflammatory action, I have  occasionally found a full dose of laudanum
quiet the delirium, and, by inducing sleep, restore the patient.  This, however,
requires great care.
   In all cases of coma from compression, the bowels should be freely opened by
placing a drop of croton oil, mixed with a little  mucilage, in the patient's meals,
or by the use of oleaginous or terebinthinate enemata.   The urine is  to be drawn
off twice in the twenty-four hours,  the  room darkened, and  kept quiet,  and ice
or an evaporating lotion applied to  the head.
   When symptoms of compression occur as the result of inflammation in the
cranium, the treatment  becomes surrounded by difficulties.   If, notwithstand-
ing antiphlogistic measures have been pushed to their full extent, rigors occur
and coma supervenes, conjoined with a certain amount of continuous inflamma-
tory action, the  question always arises as  to whether trephining should be had
recourse to, on the supposition of  matter having formed.   In these cases two
great difficulties  present themselves; the first has reference  to the existence of
pus within the cranium, and the second to its situation.
   The question  as to the actual existence of pus within the cranium, and the
 dependence  of the symptoms  of coma upon the  compression exercised  by the
 purulent deposit, is always a difficult  one to determine.  There  are,  as has
already been stated, no  absolute  and unequivocal  symptoms indicative  of the
formation of pus within the  cranium, the same  symptoms that accompany its
formation being  often  closely simulated by the effusion of serum, or of puriform
 lymph, on the brain or its membranes.   But although there  may not  be any
 symptom that is  absolutely and unequivocally indicative of the formation of pus
in this situation, it not unfrequently happens that the surgeon is enabled by the
 assemblage of general symptoms and local signs, to indicate its existence with
 considerable accuracy.  In these cases, however, it is usually impossible to deter-
 mine the exact seat of the purulent deposit with sufficient precision to admit of
 its evacuation by the trephine; — whether the  pus  be between  the cranium and
 the dura mater, between the layers of the arachnoid, underneath this membrane,
 between  the cerebral convolutions, or  deeply seated  in the  substance of the
 brain; whether  it be  situated under the seat  of injury, and be there  circum-
 scribed, or whether it be  so  extensively diffused as not to be  capable of com-
 plete evacuation. That these difficulties are real,  must be obvious to every prac-
 tical surgeon, and illustrative of them  I may mention the two following cases,
 out of many that I have witnessed.
   A«man was admitted into University College Hospital with an extensive lace-
 rated wound of  the scalp, denuding the pericranium.   He continued free from
 all cerebral disturbance  until the  tenth day after the accident, when he com-
 plained of headache, had quick pulse, and a  hot  skin.  At this  time it was
 observed that the denuded pericranium had separated  from  the skull.   He was
 treated  by active antiphlogistic  means, the symptoms subsiding, and went on
 favorably until the  thirty-fourth day, when he suddenly became delirious and
 unconscious, though easily roused when spoken  to loudly, and then answering
 rationally;  his  pulse  fell  to 48.   He died on the thirty-ninth day, comatose.
 On examination  after  death, the pericranium was found detached at the seat of
 injury; under this  the dura mater was thick, yellow, and  opaque, but no pus
 was observable.   On  separating the hemispheres, however, a large abscess was
 found situated  deeply in  the anterior lobe on  the  injured side, and protruding
 into the median  fissure.   It contained about one  ounce of pus.  In  such a case 
280
INJURIES OF  THE  HEAD.
as this, trephining would evidently have been useless; for although it was pro-
bable that there was pus within  the cranium, yet its seat could not have been
diagnosed, and the abscess could never have been reached.
  Another case that was admitted into the Hospital, was that of a man who
had received a large lacerated wound on the left side of the scalp in consequence
of a fall.  There was no injury to the  bone, and the patient went  on perfectly
well until the  seventy-seventh day, the wound cicatrizing.  He was then sud-
denly seized with hemiplegia of the right side, from which he recovered partially
by being bled ;  some twitching  of the  muscles, however, continuing.   On the
ninety-ninth day after the accident he became comatose, and was trephined by
Mr. S. Cooper, but without relief, dying with symptoms  of compression of the
brain on the third day after the operation.  On examination, thick yellow lymph
was found, covering the whole of the upper surface  of both hemispheres lying
between the arachnoid and pia mater, and  extending into the sulci  between the
convolutions.  There was an abscess in the substance of the brain on the surface
of the right hemisphere on the side opposite to the seat of injury.  Here, though
the  symptoms were  well marked,  and the diagnosis as to the existence of pus
correct, trephining was  also useless, as the pus could not be  evacuated.  These
cases serve to indicate the difficulties that surround any operation with the view
of evacuating matter from within the cranium.
   When, however, the  symptoms  of  inflammation have been interrupted by an
attack of rigors followed by  compression, with detachment of the pericranium,
or a  puffy swelling  of  the scalp, or by  the separation  of the pericranium, and
the exposure of yellow  and dry bone, there can be little doubt that the surgeon,
though bearing in mind the extreme uncertainty  of  the case, might be justified
in trephining at the seat of local change or of injury, in the hope of finding pus
deposited beneath the cranium, and thus  giving  the patient his only chance of
life.   And should it not be met with  there, and the  dura mater appear bulging,
and without pulsation, an incision  might even be  made through this membrane,
in the hope that the abscess being circumscribed  the escape of the pus might
be facilitated.  Should this attempt fail, there are few surgeons who would have
the hardihood to follow the example of Dupuytren, who plunged a bistoury into
the substance of the brain, and thus luckily relieved the patient of an abscess
in  this  situation.   But yet  even  though pus be found  under the  cranium,
between it and the dura mater, and is evacuated, the encephalitis will probably
lead on to the patient's  death.  Mr. P. Hewett states very justly that  the suc-
cessful termination  of  a case of trephining for  matter  between the skull and
dura mater, is all but unknown to  surgeons of the present day.

                     INJURIES  OF THE SCALP.

   Contusions of the scalp from blows  are of common occurrence, and present
some peculiarities that  deserve attention.   However severe  the contusion may
be, it seldom happens that the  scalp sloughs.   This is  evidently owing to the
great vascularity and consequent active vitality of the integuments  of the head.
In many cases a contusion in this  situation is followed by considerable  extrava-
sation of blood, raising up the scalp into a soft semi-fluctuating tumor.  It
occasionally  happens, especially in blows  on the heads  of children, that this
extravasation gives  rise to the supposition  that fracture exists, owing to the
edge of the contusion  feeling hard, whilst  the  centre is soft, apparently from
the  depression of the  subjacent bone.  In some cases, indeed, this deceptive
feeling will  occur without  any extravasation  of blood  under the scalp, the
depressed centre being due  to the compression of the scalp by the blow that
has been inflicted upon it.  This I have seen occasionally in children in whom
 the scalp is soft and somewhat spongy.
   The treatment of contusion of the scalp is very simple;  the continuous appli- 
INJURIES OF  THE  SCALP.
281
cation of evaporating lotions being usually sufficient for the removal of all effu-
sions.  Under no circumstances should a puncture be made or the blood let out
in any way.  Contusions of the scalp in girls  and  young  women have  been
known to be followed by severe neuralgic pains in the part struck.  This affec-
tion is extremely rebellious to treatment, but in two cases which I have  seen,
after lasting  for  a considerable  length of time, these symptoms  gradually
disappeared; in such cases as these, incisions down to the bone are said to have
sometimes been beneficial.
   It occasionally happens  that bloody tumors of the scalp form in newly-born
children, either from contusion of the head in  consequence of the pressure  to
which it is subjected in its passage; or else by the bruising of obstetric instru-
ments.  These tumors, which are often of large size  and fluctuating, are termed
cephaloematomata.   They may occur in two  situations, either between the
aponeurotic  structures of the  scalp and  the  pericranium, or between this
membrane and the skull itself.
   The sub-aponeurotie cephalcematoma is  by far the most common  variety  of
the affection.   It  usually forms a large soft fluctuating tumor, situated upon
 one of the parietal eminences, and having a somewhat indurated circumference.
 These tumors may usually be  made to subside in  a few days by the use  of
 discutient lotions.
   The sub-pericranial cephalcematoma is an injury of extremely rare occurrence.
 But Zeller, Valleiz, and others have determined its existence.  It appears as a
 fluctuating tumor, without discoloration of the  scalp, but with a hard  elevated
 circle around it, and a soft depressed centre, almost communicating the sensation
 of a hole in the cranium.  Pressure, however, gives rise to no cerebral  symptoms,
 and enables the surgeon to feel the osseous lamina at the bottom of the depres-
 sion.  These tumors are usually of small size, seldom larger than a walnut, and
 it not uncommenly happens that they are multiple.   It is worthy of note, how-
 ever, that each tumor  is always confined to a separate bone, never passing beyond
 the sutures, where the adhesions are  the strongest between  the pericranium and
 the subjacent osseous structure.   This affection is said to be most  frequently
 met with  in  children born in  first confinements, and is more common in boys
 than in girls; according to Bouchard in the proportion of thirty-four to nine.
    The pathology of this affection has been studied by Valleix.   This surgeon
 found that the  pericranium was  separated from the  bone by an extravasation
 of blood, and that both bone and pericranium were  covered with plastic matter,
 but otherwise  healthy.    He also found that the hard circle surrounding the
 depression was formed by a deposit of osseous and plastic matter which  bounded
 the extravasation.  This deposit was effected in such a way that on a transverse
 section  being made, the inner wall was found  nearly perpendicular, whilst the
 outer sloped down upon the cranium, thus giving a cratiform appearance to the
 margin of the tumor.  The treatment of this  affection must be conducted on
 precisely  the same principles as that of the other forms of scalp extravasated.
     Wounds of the scalp  are of very common  occurrence, and are more serious
 than corresponding injuries elsewhere, especially so when  occurring in persons
 about the middle period of life, and of unhealthy or broken constitutions.  It is
 not only  that these injuries are more likely to  be  followed by erysipelas than
 those of other parts of the body,  but it is also to the great tendency  to the pro-
 pagation of inflammatory mischief inwards to the encephalon, and to the com-
 plication of cerebral mischief so often accompanying  comparatively slight injuries
 of the scalp, that  these accidents owe much of their serious and often fatal cha-
 racter.  But though there be  this danger to life in  scalp injuries, there is com-
 paratively little risk to the scalp itself;  the abundant supply of blood it receives
 from closely subjacent arteries, and  its consequent great vitality, is  the reason
 why sloughing so seldom occurs, even though the part be  much bruised and
 seriously lacerated. 
282                  INJURIES OF  THE  HEAD.
  The treatment of wounds of the scalp necessarily varies somewhat according
to the nature of the injury.  If this be a simple  cut it will be sufficient, after
shaving the parts around and cleansing its interior, to  bring  it together with a
strip or two of adhesive plaster, and to dress it as  lightly as possible.  In these,
as in all other cases of injury of  the head, especial attention should be  paid to
the state of the brain, for however slight the external wound may be, serious
cerebral mischief may have  been occasioned; or, at all events, the same blow
that has caused the cut in the scalp may have given rise to such functional de-
rangement of the brain as may eventually lead to the worst forms of  traumatic
encephalitis.
  It more frequently happens that the scalp is bruised and lacerated  as well as
wounded, and very commonly that a large flap of integument is stripped oft' the
cranium, and  is thrown  down over the face or ear, so  as  to denude the bones.
In these cases, advantage is  taken of the great vitality of the scalp.  However
extensively contused  or  lacerated  this may be;  however much  it may be be-
grimed with dirt;  it is a golden rule  in  surgery not  to  cut  any portion of it
away, but  after shaving  the head and  ligaturing any bleeding vessels,  to wash
and clean it thoroughly, and replace it in  its proper position.   Here it must be
retained by the support  of  a few strips of  plaster, or by the application  of a
suture or two at the points of greatest traction.   If the edges do not  come pro-
perly together a piece of water-dressing must be applied, but the head must be
kept cool, and  as  little  bandaging and plastering had recourse  to as possible.
The patient should be freely purged and kept perfectly at rest on rather a low
diet, any cerebral symptoms that  occur being treated in  accordance with the
principles laid down in discussing traumatic affections of the brain.  In this way
union will very probably  take place through the  greater portion of the  injured
 surface; should it  not do so, however, or should any part slough, granulations
 spring  up and reparative action  goes  on with surprising rapidity.   If matter
 form beneath the aponeurosis of  the occipito-frontalis muscle, bagging  must be
 prevented by early counter-openings, and  by the  employment of compression in
 proper directions.  The pus has a special tendency to gravitate  into the upper
 eyelid  whenever  suppuration  takes place beneath  the frontal portion of the
 muscle, and here the counter-opening may be conveniently made.
   When the skull is extensively denuded in consequence of the scalp with the
 subjacent pericranium being stripped  off, we must not necessarily expect that
 necrosis and exfoliation of the exposed bone will occur.  In cases such as these,
 the flap must be laid down on the denuded osseous surface, to which it may pos-
 sibly contract adhesion.   Should it not do so, however, the exposed portions of
 the cranium may inflame, plastic matter be thrown out, and  thus granulations
 springing up, a covering be  formed to  the bone.

                     INJURIES  OF  THE  SKULL.

    Contusion of the cranial  bones occurring in injuries of the head, especially
 complicated with wound of the  scalp,  is often a  serious condition, if it be fol-
 lowed by suppuration in the diploe of the bone, and abscess  between it and the
 dura mater, or even under this membrane.
   Fracture and other  injuries of the bones of the skull  possess great interest,
 not so much from the lesion of the bone itself, as from its frequent complication
 with injury of the brain and its  membranes.   This cerebral complication may
 either be produced by direct injury occasioned by the fragments of the fractured
 bone compressing  or wounding  the brain, or  it  may be the result of the same
 violence that occasions the fracture concussing or lacerating the brain.
   Fractures of the skull are  invariably the result of external  violence.   This
 may act directly in breaking and splintering  the part struck, the fissures  often
 extending  to a considerable distance  and detaching large portions of the era- 
           FRACTURE  OF  THE  BASE  OF  THE SKULL.        283

nium; or, the violence may act in an indirect manner, producing the fracture
either without being applied immediately to the cranium, or else at an opposite
part of the skull to that which is struck.  Thus the base of  the skull may be
fractured by the shock communicated to it when a person, falling from a height,
strikes the ground heavily with his feet.   The other variety of indirect fracture,
that in which the solution of continuity occurs at a point of the cranium oppo-
site to that which has been struck, is the fracture by " contre-coup."
   This kind of fracture has been described  by some surgeons as of frequent
occurrence, whilst it has been denied  by others.   There can, however, be no
doubt that it does happen, though less commonly perhaps than is generally sup-
posed.   Every  hospital surgeon must  occasionally  have  seen  unequivocal
instances of it.   For its occurrence several conditions are necessary.   The skull
must be struck over a large surface, as when a person falls with his head  against
the ground.   If the blow alight on a thin  portion of it,  this will be directly
fractured; but if a dense and strong part of the bone be struck, as the parietal
eminence, or the lower part of the os frontis,  the shock transmitted through the
cranium generally will cause the thinnest and most brittle portions of the skull,
though distant, to give way in preference to the stronger part on which the blow
has immediately fallen.  These  fractures  by contre-coup are most common at
 the base of the  skull  and are  commonly much  radiated.   They are never
 depressed.
    An ordinary, simple, or undepressed fracture of the skull consists in a fissure,
 sometimes single, at other times starred, extending often to  a considerable dis-
 tance through the bones, radiating sometimes across  the  skull, and at others
 completely detaching the upper from the lower, or the anterior from the poste-
 rior segment of the  cranium.  In some cases the fracture extends  into one of
 the sutures, and  in  other instances, which, however, are very rare, the  sutures
 are separated without any fracture.
    These injuries usually occur from direct violence, but are also the  only forms
 of fracture that happen by contre-coup.  A  simple fracture,  such as this, gives
 rise to  no signs by which its diagnosis can  be effected.   If, however, the scalp
 covering the injured bone has been wounded, its existence may be ascertained
 by running  the finger-nail, or the end of a probe, over the exposed  surface of
 the bone, or by seeing a fissure into which the blood  sinks.   In these simple
 undepressed fractures no special treatment is required to the  fracture itself, the
 surgeon's whole attention being  directed  to the concomitant injury that may
 have been inflicted on the brain or scalp.  Active precautionary measures should
 be adopted without delay, with the view of guarding against the occurrence of
 inflammation of the brain and  its membrane,  even  though no symptoms  have as
 yet declared themselves.   So  soon as the patient has recovered from the con-
 cussion, his  head should be shaved, the  ice-bladder applied, and  blood freely
 taken away from the arm; the  bowels should  be well opened, and the room kept
 cool and quiet.   The employment of free and repeated bleeding is, however, of
 more service than any other means, and should never be omitted.
    The most serious, and indeed a very commonly fatal form  of simple fracture
 of  the skull, is that  which extends through  the base of the cranium.   These
 injuries usually occur by falls  from a height  or blows upon  the vertex or side
 of the head, producing a fracture which extends from the point struck across
 the base of the skull, often running through the petrous portion  of the temporal
 bone or into the foramen ovale.  They may also  take place as the result of
 contre-coup, or by a person falling from a height on his head, and having  the
 base of the skull broken in by the weight of the body projected against it. The
 great danger in these cases is the concomitant injury to the brain, either by its
 direct laceration or by the extravasation of blood upon it.  Though most usually
 fatal, these injuries are  not invariably so.  Not only does it occasionally happen
that patients with all those signs of fracture of the base of the  skull, which 
284
INJURIES  OF  THE  HEAD.
will immediately be described, are seen to make a complete recovery, but in the
different museums, specimens illustrative of recovery after this accident may be
met with.  Thus, in the College  of Surgeons' museum, there is the skull  of a
person who lived two years after a fracture at its base.
  The occurrence of fracture  of the base of the skull is very commonly sus-
pected when symptoms indicative of serious injury to the brain speedily follow
a severe blow upon  the head, owing to  the greater liability to injury of those
parts of the nervous centre that are most  important  to life,  in these than in
other fractures of  the skull;  the same violence  that occasions the fracture
injuring the  contiguous portions of brain, or lacerating some of the large venous
sinuses about the base of the  skull, giving rise  to  abundant  extravasation of
blood.  These  symptoms are  necessarily in the  highest  degree equivocal, and
much anxiety has been evinced by surgeons to discover  some special sign by
which the occurrence of this particular fracture may be determined.
   There  are two signs, the occurrence  of which leads to  strong presumptive
evidence in favor of the existence of this kind of fracture.  These are, 1st, the
escape  of blood, and 2ndly, of a serous fluid from the  ears, and  occasionally
from other parts in connection with the base of the skull.
   The  occurrence of bleeding from the ears  after an injury of the head cannot
by itself be  considered a sign of much importance, as it may arise from any
violence by which the tympanum is ruptured without the skull being necessarily
fractured.   If, however, the hemorrhage be  considerable and continuous, and
more especially if it be associated with other symptoms indicative  of serious
mischief within the  head, and if it have been occasioned by a degree of violence
sufficient to fracture the  skull, we may look  upon its  supervention as a strong
presumption that the petrous portion of the temporal bone  has been fractured,
and  perhaps one of  the venous sinuses in its neighborhood torn.
   Bleeding from the nose may of course arise  from any injury applied to this
organ without the skull being implicated;  but yet in some  cases of fracture of
the skull the hemorrhage proceeds from the interior of the cranium, the blood
escaping through a fissure in the roof of the nasal fossae.  In a patient of mine
who died five weeks after an injury of the head, accompanied by much bleeding
from the nose, a fracture by a contre-coup was found extending across one orbital
plate of the frontal  bone, and separating its articulation with the ethmoid.  In
this case the nature of the injury was suspected from the fact of the nose itself
having been uninjured by the blow, although the hemorrhage from it was very
considerable and continuous.
   The  discharge of a thin watery fluid from the interior of the cranium is of
rare occurrence, but when it happens may be considered  as pathognomonic of
fracture of the base of the  skull.   Indeed it is the most  certain sign of this
injury that we  possess.  This discharge usually takes place through the ear: but
it may  occur from the nose, of which I have seen one  instance,  and Robert
mentions another.   Still  more rarely it takes place from a wound in the scalp
communicating with the fracture, percolating  through this, and so being poured
out externally.  The only case of this kind with which I am acquainted is one
which was communicated to me by one of the pupils of  the  College, as occur-
ring at the Penrhyn Infirmary a few years ago.  In this case a boy received a
wound  on the back of the head, with depressed and comminuted fracture of the
skull.  On the nineteenth day after the receipt  of the injury a large quantity
of serous  fluid began to discharge  through the wound, and continued to do so
profusely until his death from coma four days later.
   There would consequently appear to be three situations: the ear, the nose,
and  a wound on the head, from which this discharge has been observed.   It is
an exceedingly valuable though most serious sign; and  Robert, who has investi-
gated this phenomenon with much closeness, states, that  the  cases  in which it
happens always terminate fatally.   This, however, is an error; for at least one 
           FRACTURE  OF  THE  BASE  OF  THE SKULL.        285

case  has occurred  at  the  University College Hospital, in  which the patient
recovered, although a large quantity of fluid was discharged from  the ear.  It
is usually associated with symptoms indicative of serious injury to the base of
the brain, but to this there are also exceptions, for I have  seen it take place in
cases of injury of the head, unaccompanied by any severe cerebral symptoms.
Most generally it occurs in young people.   Robert says that it does  so invari-
ably, but in one of the cases that I have witnessed the patient was  fifty-eight
years of age.
   The  quantity of fluid that is thus discharged is always very considerable, the
pillow usually becoming soaked by it, and  thus first attracting attention to it.
It is often necessary to keep a piece of sponge or a pledget of lint against the
ear, in order to prevent the fluid wetting the patient, as it trickles out, and if a
cup be  so placed  as  to collect  it,  an ounce or  two will  speedily accumulate.
Laugier states that he has seen a tumblerful discharged in a short time, and as
much as twenty ounces have been known to be poured  out in three days.  The
flow is usually continuous for several days, and  then  ceases.  It is remarkable
that the hearing does not always appear to be destroyed in the ear from which
the  discharge takes place.
   The nature and the source of this discharge have been particularly investigated
by Laugier, Chassaignac, Robert,  and Guthrie.  Its  physical and chemical
characters are  those  of a perfectly clear, limpid,  and watery fluid, containing a
considerable quantity of the chloride of sodium, with a little albumen in solu-
tion.   It is not coagulable by heat or nitric acid.
   The source  of this discharge has not as yet been  investigated with all  the
attention that its importance requires.   Laugier believed it  to be the serum of
the blood filtering  through a crack in the petrous portion of the temporal bone,
and so out through the ruptured tympanum.  This explanation, however, is evi-
dently not correct, for not only is blood extravasated in the living body incapable
 of this species of rapid and complete filtration, but the chemical composition of
 the fluid, which differs altogether from that of  the serum  of the blood, in con-
 taining a mere trace of albumen  and double the quantity of chloride of sodium,
 is incompatible with  this supposition.  By  others it has been supposed that  the
 fluid was furnished by the  internal ear, being  a continuous discharge  of  the
 liquor cotunnii, but its large quantity, and, above all, the fact of its occasionally
 escaping through the nose, establishes the  fallacy of this  explanation.  Again,
 it  has been supposed, but without  sufficient evidence, that the cavity of  the
 arachnoid furnished this secretion.  I think with Robert that there can be little
 doubt that this discharge consists of the cerebro-spinal  fluid, for not only does it
 resemble in appearance and chemical composition this liquid, but  there is no
 other source within the cranium that can yield with  equal rapidity  so large  a
 quantity of fluid; experiment having shown that the cerebro-spinal liquid is
 rapidly reproduced after its evacuation.  In order that this be discharged, it is
 necessary that the membranes of the  brain be ruptured opposite the outlet by
 which it  is poured forth.   This has actually been ascertained to be the case in
 carefully conducted dissections of injuries of the head in which this symptom
 has occurred.   When it is discharged through the ear it is not improbable, as
 Berard has remarked, that the laceration extends through the cul-de-sac of  the
 arachnoid, which is prolonged around the  auditory nerve in the internal audi-
 tory canal.  When it is poured out through the nose, it has probably been by
 the fracture extending through  the sphenoidal sinuses.
   The treatment of fractures of the base of  the skull must be conducted on those
 general principles that guide us in the  management  of simple fractures; no
 special means  can be had  recourse to, and in the great majority of cases a fatal
 termination speedily ensues.
   It occasionally though very rarely happens that in consequence of a  blow  a
 portion of the  cranium is depressed without being fractured, and even without 
286
INJURIES  OF  THE HEAD.
any serious symptoms  occurring.  Thus Green  mentions a case in which  the
bowl of a dessert-spoon might be laid in the hollow produced in the skull by a
blow, and no symptoms resulted.   These depressions without fracture can, how-
ever, only occur in children whose crania are soft and yielding.  In adults they
cannot happen without the  occurrence  of partial  or  incomplete  fracture.   It
must be borne  in mind, however, that the apparent depression produced by an
extravasation under the scalp may simulate this injury very closely, and a very
experienced surgeon may sometimes under  these circumstances be deceived, and
be induced to cut down on a suspected fracture when in reality none exists.
   Depressed fractures  of the skull may either be simple, without wound of  the
scalp, compound, or comminuted.  In the majority of cases, whether  the frac-
ture be simple  or compound, there is  comminution of the injured portion of
bone;  the fragments being perhaps driven into the brain.
   Depressed fractures  of the skull present many varieties; sometimes, though
very rarely, the external  table alone is depressed.  This is especially the  case
over the frontal sinuses, where it may be broken in, as  I  have seen happen from
the kick of a horse,  without the inner table being splintered,  or any bad conse-
quences ensuing.  Much  more commonly,  however, the  inner table is driven in
with  comparatively little  injury to the  outer one; it  has, indeed, been stated
that a portion of the inner table may be depressed without there being any frac-
ture of the external one; this, however, can scarcely occur, though it may happen
with but a very trifling fissure of the outer table.
   In all ordinary depressed fractures the internal table is splintered to  a greater
extent than the external one.  This is especially the  case when the fracture is
the result of gun-shot injury, or when it  has been occasioned by blows with a
pointed weapon, as the end  of a pick, or  a large nail, or the sharp angle  of a
brick.  In these fractures, which constitute the  dangerous variety termed punc-
tured, the outer table may be merely perforated  or fissured, whilst the inner one
is extensively splintered.  This splintering of the inner lamina of the skull to a
greater extent than  the outer one has attracted much attention, being of con-
siderable practical moment, and is usually said to be owing to its being more
brittle than the external table.  This, however, I do not consider to be the only
cause.  I should rather attribute it to the  direction of the fracturing force from
without inwards, causing  a certain loss of momentum  in passing through the
outer table; and that thus the inner table is splintered more widely than the
outer one, for the same reason that the  aperture of exit  made by a  bullet is
                                    larger than that of entry.   If this be the
               Fig. 130.              true   explanation,  the  reverse ought to
                                    hold good if  the force  be applied in the
                                    opposite direction.  It is very seldom that
                                    we have an opportunity of examining such
                                    a case; but a few years ago a  man  was
                                    brought to the hospital who had committed
                                    suicide  by discharging a pistol into his
                                    mouth and  upwards  through the brain.
                                    The  bullet had perforated the palate  and
                                    passed out at the upper part of the  cra-
                                    nium, near  the vertex (fig.  130).   On
                                    examining the  state of the bones, it was
found that the outer table of the skull was splintered  to a considerably greater
extent than the inner  one, showing clearly the influence of the direction of the
fracturing force.  I have since found  by experiment on the dead body, that this
is most generally the case when the blow is struck from the inside of  the skull
outwards.
   It occasionally happens as the result of sabre or hatchet  cuts on the head,
that a kind of longitudinal punctured fracture occurs, in which the outer table
 
            TREATMENT OF DEPRESSED  FRACTURE.         287

is  merely notched, whilst the inner one  is splintered  along the whole line of
blow.  In other cases, again, a  portion of the cranium is completely sliced off,
hanging  down in a flap of the scalp, and exposing the brain or its membranes.
   The symptoms of a depressed  fracture of the skull are of two kinds :  those that
are dependent upon the injury  to the bone, and those that result from the con-
comitant compression  or laceration of the brain.
   When the scalp is not wounded, the depression may sometimes be felt; but
very commonly it is masked by extravasation of blood about it, and the surgeon
is only led to suspect  its  existence by the continuance of  symptoms of compres-
sion from the time of the injury.  In all cases of doubt when these symptoms
exist, an incision should  be made through the scalp at the seat  of injury, and
the state of the skull examined. When there is a wound  in the scalp communi-
cating with the fracture,  the surgeon detects at once the existence of depression
and comminution  by examining the  bone with  his  finger through the wound.
Although symptoms of compression almost invariably exist from the first in cases
of depressed fracture, yet it occasionally happens that no cerebral disturbance
comes on for some days, even though the injury done be very extensive.  A
man, twenty-four years of age, was admitted  into University  College Hospital
under Mr. Morton.   He had been struck on the forehead with the sharp edge
of a quoit.  The frontal  bone was extensively*comminuted,  twelve fragments
being removed,  and the dura mater being exposed to a. considerable extent; yet
no bad symptoms occurred until the ninth day, when inflammation of the brain
and its membranes set in, and he speedily died.
   In other cases again, more especially in children and young  persons, in whom
the bones are  soft and  yielding, depression with  fracture may exist to  a con-
siderable extent, and no symptom whatever of compression  be produced at the
time or at any subsequent period,—the patient living with a  portion of his skull
permanently beaten in.
   The great danger in these cases of depressed and comminuted fracture  arises,
however, not only from the compression of the brain, but  from  the rapidity with
which inflammation is set up in consequence of the sharp fragments wounding
and irritating the membranes and brain.  Indeed, a wound  of the dura  mater,
however slight, is a  most dangerous complication, and  one that is not often
recovered from.   It is not, however,  necessarily fatal;  I  have  lately  had  a case
under my care,  in which, although  this occurrence had  taken place in  conse-
quence of depressed  fracture, the patient made a good recovery.  This is more
especially the case in  those injuries in which the inner table is extensively splin-
 tered, as in the  different  forms  of punctured fracture.  In these cases there may
 be no signs of compression, but inflammation  speedily sets  in,  and certainly
 proves fatal if the causes of irritation, the sharp spiculae, be allowed to remain
 in contact with  the dura mater.  This membrane becomes sloughy and  coated
 with a thick deposit of plastic matter, whilst the usual evidences of encephalitis
 are found in the other membranes and the brain.
   The treatment of a depressed  and comminuted fracture of the skull  varies
according to the nature and extent of the accident.
   If there be no wound  in the scalp, but the occurrence of symptoms of com-
pression and the existence of some irregularity of the cranium  at the seat of
injury lead the surgeon to suspect a depressed fracture, he should make a crucial
or T-shaped incision  down  upon the part in order to examine the bone,  and if
this be found depressed  to elevate or remove it.
   If the scalp be already wounded all that need be done to ascertain  the  nature
of the fracture, is to pass the finger into the wound and thus examine the bone.
If any fragments be  found  lying loose they should be picked  out, as their pre-
sence  can only excite injurious irritation; any bone that is  driven below  its
level must be raised, and, if completely detached, removed.
   In order to  raise  these depressed  portions of bone, it is  in many cases only 
288
INJURIES OF  THE  HEAD.
necessary to introduce  the point of an elevator underneath the fragment, and
using the instrument as a lever, elevate it into position.   If there  be not an
aperture sufficiently large for  the  introduction of the elevator, one  must be
made by sawing out an angle of bone at  a convenient spot by means  of a Hey's
saw or bone forceps. In this way sufficient spac* may usually be gained without
the necessity of applying the trephine.   If, however, the inner table be splin-
tered to a considerable extent, or, if there be no convenient angle that can be
removed, the trephine must be  applied in such  a way that at least half its circle
is situated upon the edge that overhangs the depressed bone;  the surgeon saw-
ing out by means of this  instrument a portion  of  the undepressed cranium, in
order that he may more conveniently get at the fragment.   After a  half circle
of bone has been removed in  this way, the depressed  splinters may be taken
out;  a  Hey's saw still  being occasionally required before the whole can be re-
moved ; the flaps  of scalp should then  be  laid down, a suture or two applied,
and water-dressing  put over the wound.  Rigorous antiphlogistic treatment must
then  be adopted with  the view of preventing or removing the  inflammatory
symptoms which set in.
   In all cases that  partake of the nature of a punctured fracture, those in which
there is but slight injury  of the external table, but considerable splintering and
depression of the inner one, the trephine must be applied on different principles
to those that guide us in  its use in ordinary depressed fractures.   In the punc-
tured fracture it is  applied, not to remove symptoms of compression which, in
all probability,  may not exist; but with the view of preventing inflammation,
which would to a  certainty be set up if the splinters of the inner  table were
allowed to continue irritating the membranes and  brain.  Hence it  is a rule in
surgery, in  all cases of  punctured  fracture, to apply the  trephine at  once, so as
to prevent those injurious after-consequences, which must otherwise  necessarily
result.   In  these  cases a trephine with a large crown should be used, and the
circle of injured bone  itself must be sawn out.
   Should, however, the use of  the  trephine have  been delayed  in  these cases
until inflammatory  action have been set up, the instrument may still be applied
with  advantage.  Some years ago, a boy was admitted into University College
Hospital, on the sixteenth day  after having been struck on the side of the head
by a  large nail,  which  projected from a door that fell upon him.  No symptoms
of any kind had occurred until the  eleventh  day after the  accident, when he
became dull and lost his  appetite;  on the sixteenth day, that of his admission,
he had suddenly  become drowsy and delirious, but answered rationally when
spoken to, and complained of pain  in  the head.   The pupils were dilated, the
skin  hot, and the pulse quick.   On examination  a small round  aperture from
which  some fetid  pus  exuded was discovered on the right parietal eminence.
On introducing a probe, which the hole just admitted, some rough  bone could
be felt.  Mr. S. Cooper immediately trephined the boy, removing  a  circle of
bone including  the small aperture   The inner table corresponding  to this was
found splintered to some extent, and the dura mater was seen to be thickened
and inflamed, but the patient recovered without a  bad symptom.
   In those  rare cases in which there is a depressed fracture, without symptoms
of compression, or even a wound of the scalp, the line of practice is somewhat
unsettled, as to whether  the depressed portion of bone should be left where it
is, or an attempt be made to  elevate it.  Sir A. Cooper, Abernethy, and Du-
puytren advise  that, if it give rise to no symptoms of compression, it is better
not to interfere with it; and there are several cases on record of patients who
have recovered in whom this course was  adopted, the depression  continuing
permanent.   I  am acquainted with a gentleman  upwards of fifty years of age
who  has a depression in the parietal bone as large as the bowl  of a table spoon,
the result of a fracture from a fall from  a horse when a lad, and from which no
 inconvenience has resulted.   I think,  however,  that this expectant  practice 
WOUNDS  OF  THE  BRAIN.
289
should not be followed too implicitly, but that we must be guided by the cir-
cumstances of  the  particular case.  If  the  depression be pretty uniform, of
inconsiderable  depth,  and occupy some extent  of cranium,  it may be  better
doubtless to follow  the practice of these great surgeons, and to wait for symp-
toms of  compression manifesting themselves before we interfere.  If, however,
the depression  be sharp, and  comparatively small in extent, we may reasonably
suspect the existence of considerable splintering of the inner table; and here
the safer plan would be, even in  the absence of  all symptoms of compression,
to trephine for the  same reason that we do so in punctured fracture — the pre-
vention of inflammatory irritation.
   The sooner this is done the better.  Danger does not arise from early opera-
tions,  but from delay.  The presence  of  depressed  and spiculated  fragments
pressing  into the dura mater must infallibly and speedily induce encephalitis.
I have several times trephined under such circumstances as these with success,
and have never had  occasion to regret doing so.  Even though several days
have elapsed and inflammation has set in, the proper treatment will be to remove
the  depressed and splintered bone, and thus give the patient his  only chance, a
slender  one, it is  true, of recovery.   Under such adverse  circumstances  the
patient may, however, be saved.
   A man was  admitted under  Mr. Liston for a long depressed fracture on the
side of the head, received by the blow of  a  brickbat;  though no sign of com-
pression  existed, yet  symptoms  of cerebral  inflammation were speedily set up,
and Mr. Liston trephined him on  the fourth  day after the accident; the man,
who was perfectly  conscious, walking into the operating theatre.  A consider-
able splintering of the inner table was found,  the  fragments of which were
 removed.   The dura  mater having been  punctured by one  of the spiculae  of
bone, diffuse suppuration of the membranes  of the brain set  in, and the  patient
 died in  a few days.   In this case, however, the necessity for early trephining
 was clearly indicated, notwithstanding the absence of any symptom of compression.
   When a depressed fracture  of the skull  is  complicated  with a  fracture or
 other injury of the spinal  column, it is sometimes difficult  to determine how
 much of the symptoms may be due to one accident, and what proportion to the
 other.   In such a case as this, however, we should, I think, treat the depressed
 fracture irrespective of the vertebral injury, thus giving the patient a chance of
 recovery, of prolongation of life, or, at least, of  return  of consciousness before
 death.  A man was admitted under my care into the hospital, with depressed
 fracture of the left  parietal bone, and injury of the cervical spine, the  precise
 nature  of which  could not be accurately determined.   He was in a state of
 complete coma and paralysis.  I trephined the skull and elevated the depressed
 portion  of bone; he  recovered his consciousness to a great degree, but  died in
 a few days, apparently from the injury to  the  spine.   On  examination after
 death we found a fracture of the fifth cervical vertebra.

         WOUNDS OF THE  BRAIN AND  ITS  MEMBRANES.

    Wounds of the brain and  its membranes are frequent in injuries of the head,
 and constitute one of the most important complications of these accidents. The
 extent of injury inflicted upon the cerebral substance has  wide  limits, from
 slight laceration without exposure, to denudation of the brain, disintegration,
 and escape of large portions of its pulp.
   Injury to the brain may be occasioned  in various ways.  The simplest form
 is that,  perhaps, which is not unfrequently met with in undepressed fracture of
 the skull, and sometimes happens without fracture, from  simple concussion or
 commotion of the head, laceration of the cerebral  substance occurring either
 under the seat of injury, or more frequently at a distant or opposite  point, by a
kind of contre-coup.   This laceration of the brain by contre-coup is by no means
        19 
290
INJURIES  OF  THE  HEAD.
of unfrequent occurrence.   I have seen many striking instances of it, and have
found it to be one of the commonest causes of death in simple fractures of the
skull.
   Laceration of the brain by contre-coup is attended by much extravasation of
blood;  and after death  the brain substance  is found  mixed up with coagula,
and forming a soft, pulpy, bloody mass.   This accident may occur without any
fracture of the skull, or external sign of serious injury, and usually results from
falls upon the back or side of the head, often from an inconsiderable height, as
in a person slipping suddenly up in frosty weather and  striking his head on the
pavement;  when the anterior or opposite portions  of the hemispheres  of the
brain to that struck  will be  found in the condition just described.
   The  brain and its membranes are often lacerated by the sharp spiculae of a
depressed fracture, which may penetrate to a considerable depth in its substance.
And, lastly, the injury may be occasioned by foreign bodies, such as bullets
traversing or lodging in the head, or by stabs and punctures through the thinner
portions of the  skull, especially the orbital plate  of the frontal bone.   In this
way pieces  of stick, tobacco-pipe, the point of a  knife, or a scissor-blade, may
puncture the anterior part of the brain.
   The  symptoms of wound  or laceration  of the brain vary greatly according to
the age of  the patient, the  seat of injury, and other conditions, which cannot
very readily be  determined.  If  the  injury implicate those portions of the
nervous centre at the base of the brain, the integrity of which is necessary for
the proper maintenance of the respiratory act, immediate death must necessarily
ensue.  If, however, portions  of this  organ  that  are less vital, as the anterior
lobes and upper part of the  hemispheres, are injured, but very slight symptoms
may occur; and in some cases, indeed, there is no positive indication  by which
this injury  of the cerebral substance can be determined, except by its exposure
and escape through  the external wound.  Hence it  is  that even the worst
injuries of the head are rarely immediately fatal, the patient being seldom killed
outright unless the medulla  oblongata be wounded.   Children, especially, have
been known to bear extensive injuries of the brain,  and even the loss of a con-
siderable  quantity  of cerebral  matter  without  any very serious  effects, either
immediate, or remote; and  it is by no means of uncommon occurrence to see
them live for several days with an extent of injury to the brain, that would
rapidly have proved fatal to  an  adult.   Twitchings of the muscles and epilepti-
form fits are commonly met with when  the brain is lacerated, and these compli-
cating  stertor, or alternating with it, indicate the nature of the mischief.
   Foreign bodies even  of large size and considerable weight have been lodged
for a_ considerable  time within the cranium, in contact with the brain, without
occasioning death.  Thus Hennen states that  he has seen five cases in which
bullets  were lodged within  the cranium, that did not  prove immediately fatal.
Dr. Cunningham relates the case of a boy who lived for twenty-four days with
the breech of a pistol, weighing  nine drachms,  lying on the tentorium, and
resting against the occipital bone. Dr. O'Callaghan has  recorded the remarkable
case of an officer who lived for about seven years  with  the breech of a fowling-
piece, weighing three ounces, lodged in the forehead; the  right hemisphere of
the brain  resting on  the flat part, from which it was  only separated by false
membrane.
   [Perhaps the  most remarkable  case on record  of severe injury of the head,
terminating in recovery, is the  one reported by Professor Bigelow, of Harvard
University (see  American  Journal of the Medical Sciences for July, 1850), in
which,  by the premature explosion of a blast, a tamping-iron, three feet seven
inches  in length, one and a quarter inches in diameter, and weighing thirteen
and a  quarter pounds, traversed the skull.   « The  wound thus received was
oblique, traversing the  cranium in a straight line  from  the angle  of the lower
 jaw on  one side to the centre of the frontal bone above, near the sagittal suture, 
         WOUNDS  OF  THE BRAIN. — HERNIA  CEREBRI.     291

where the missile emerged;  and the iron thus forcibly thrown into the air was
picked up at a distance of some rods from the patient, smeared with brains and
blood.   From this  extraordinary lesion, the patient has  quite  recovered in his
faculties of body and mind, with the loss only of the sight of the injured eye."]
   From the great  variety of effects produced  by these injuries,  it must be
evident that there  can be no one set of symptoms indicative of wound of the
brain, provided there be  no  external wound through which the condition of
the  cerebral substance can be ascertained.   In those  cases  in which this does
not  exist, we can at most only suspect laceration, if  we  find that the ordinary
symptoms of compression or concussion are associated with signs that do  not
usually occur in those conditions when uncomplicated; such as the contraction
of one  pupil, the dilatation  of the  other, and perhaps an alternation of  these
states with twitchings'of the limbs, hemiplegia of one side, or paralysis of an
arm, and of  the opposite leg, with perhaps involuntary spasmodic movements
of the other  members.  These  irregular symptoms, when accompanied by much
coldness of the surface, slowness of pulse, and depression  of vital power, may
generally be looked upon as indicative of  cerebral laceration.
   Wounds  of the  dura  mater  are always liable to be followed by symptoms of
the  most serious character, and  are seldom recovered from; diffuse meningitis,
the  formation  of pus within the cranium usually occurring  and speedily ter-
minating the patient's existence.  I have, however, seen recovery follow this
accident.
   Wounds  of  the  brain  may prove fatal, either at once by the injury of the
respiratory tract; in  the course  of a few hours, by the  continuance of shock,
and by the  extravasation of blood within the cranium; at a later period, by
the  occurrence of  encephalitis and its consequences;   or more remotely  still, by
the  supervention of paralysis and other ulterior effects of injury of the  nervous
system.
   In the treatment of injuries  of the brain, little  can be done after the system
has  rallied from the shock, beyond attention to strict antiphlogistic treatment,
though this need  not be of a very active kind.  In these  cases, indeed, as
much  should be left to nature  as possible, the surgeon merely removing all
sources of irritation and  excitement from his patient, and applying simple local
dressings.
   If any foreign body  be  lodged within the cranium, it must of course be
removed, if possible.   This may be done if it be situated near the external
wound, or  fixed in the  bones, but if it have penetrated deeply into the  sub-
stance  of the brain,  and have  got  beyond the limits of the  external wound,
it would be perhaps  more  dangerous to trephine  the  skull  on  the  chance
of reaching it, or in any other  way to  go in search of it, than  to  leave it
where it is.
   Fungus  or hernia cerebri.—In those cases in which a laceration of the
brain  and  dura mater communicates with a  fracture of the  skull, it  is occa-
sionally found, more particularly in children, that  a bloody, fungous-looking
mass of cerebral matter protrudes from the wound.  This tumor increases pretty
rapidly, pulsates synchronously with the brain, and may shortly attain the size
of a hen's egg, or  even become larger.  It is composed of softened and disinte-
grated  cerebral matter, infiltrated with lymph and blood.  This softening of the
brain, with red discoloration of its substance, extends for some little distance
under  the base of the tumor.   The mental condition of the  patient laboring
under  this  affection is in many cases not  much  disturbed  at first, there  being
merely some degree of cerebral irritation.   Speedily,  however, stupor comes on,
and death eventually occurs  from coma.
   The  treatment of  this complication  of fractures of the skull  is commonly
extremely unsatisfactory.  If the tumor be shaved  off, as usually recommended,
it generally sprouts again until the patient is destroyed  by irritation and coma 
292
INJURIES  OF  THE HEAD.
conjoined.   In some fortunate  cases, however, the  removal of the tumor is not
followed by its reproduction.   All that can be done is to  slice off  the growth
on a level with the brain ; to apply a pledget of wet lint, and a compress  and
bandage over the part, thus allowing it to granulate and the wound to cicatrize.

       EXTRAVASATION  OF  BLOOD WITHIN  THE  SKULL

  Commonly occurs in all injuries of the head accompanied by laceration of the
brain, and  in many of those in which the skull is fractured without that organ
being injured.   Indeed, when we  reflect on  the  great vascularity of the parts
within the cranium, the large  sinuses, the numerous arteries, that ramify both
within the bones and at the base of the brain, and the close vascular network
extended over the surface of this organ, we can easily understand that extrava-
sation of blood is one of the  most frequent complications  of these injuries and
a common  cause of death, when they terminate  fatally at an early period after
their occurrence.
  Extravasation of blood within the cranium may take place either from  the
fracture tearing across one of the meningeal arteries distributed on the inside of
the  skull,  or by a fragment of  bone wounding a sinus, or  the vascular network
on  the surface of the brain, or it may proceed  from laceration of this organ
breaking down  its capillary structure.  In  other  cases  again, as in gun-shot
wounds,  the hemorrhage may occur as a  consequence  of the  wound  of  the
vessels by  the bullet or other foreign body.
  The extravasation  may occur in four situations.  1st. Between the dura
mater  and the skull,  where  it is most commonly  met with; 2d. Within  the
cavity  of the  arachnoid;  3d. Upon the surface  of the brain; or, 4th, within
its  substance  and its ventricles.  It is usually most  considerable when poured
out upon the  dura mater, or within the cavity of the arachnoid at the base of
the brain.   It is in smallest quantity immediately on the  surface of  that organ,
or within its substance.  It is,  however, seldom found in  the  latter  situation as
the  result  of violence, without being also met with more superficially.   The
quantity effused in  any one case seldom  exceeds  four ounces; and when in
large quantity, such as this, it  usually proceeds  from rupture of the meningeal
artery.
  Extravasation of blood is one of the most frequent causes of death in injuries
of the head, by inducing pressure  on  the brain, and coma.   The blood  that is
extravasated usually  coagulates into a firm granular clot.   There  can be no
doubt, however, that  extravasation of blood into the membranes of the brain
frequently  occurs without being attended by fatal consequences.   The blood
that is so extravasated may undergo various changes. It  would appear that the
extravasated blood may 1st, be absorbed entirely;  2d, that the  serous portions
and  coloring matter may be removed, leaving a fibrinous buff-colored  clot, which
may eventually become organized;  and  3d, the exterior of the clot may become
consolidated, whilst the interior contains fluid and disintegrated blood.
  The symptoms of extravasation are often by no means very clear; being those
of compression associated in  the early stages of  the  case with symptoms indi-
cative of laceration of the brain, and, at a later period, with those of encephalitis.
Putting out of consideration,  however,  these complications,  the more special
symptoms of compression from extravasated blood  may occur in two ways.  In
the  first variety there are three distinct stages, viz. concussion, a  return  and
some continuance of consciousness, and then  coma gradually supervening.  The
patient is  concussed  or stunned, as usual after  the receipt of a blow on  the
head;  from this he quickly rallies, and then symptoms of compression  set in,
and  gradually increase in intensity.  He becomes drowsy and dull,  with a slow
and  laboring pulse, dilated and sluggish pupils, and a tendency to slow respira-
tion ; as  the compression increases, complete stupor at length  comes on, with 
EXTRAVASATION  OF  BLOOD.
293
stertor in breathing, and there is either general paralysis, or hemiplegia of the
side opposite to the seat of injury.
  When the symptoms run this regular course it is probable that the extrava-
sation  results from injury of one of the meningeal arteries, or large venous
sinuses;  that the extravasation is confined to the membranes of the brain, and
that there is no laceration of the substance of this organ.   This may be termed
the meningeal extravasation ; and most commonly occurs from rupture of the
middle meningeal artery, which, from its situation in a deep canal in the parietal
bone, is peculiarly apt to be torn in injuries of the side of the skull.
   More commonly, however, it happens that the  patient never recovers his con-
sciousness  after having been stunned,  the  symptoms  of concussion speedily
passing into those of compression.   In these cases the paralysis is commonly
incomplete and associated with twitchings of the limbs or convulsive movements
of  the body generally, and  much restlessness with incoherent muttering: there
is sometimes contraction, at others dilatation of the pupils, and  it occasionally
happens that squinting is observed.   It is especially when there are convulsions,
that the pupils are observed to be in different conditions;  and I have  most fre-
quently noticed the pupil dilated on the side that is most convulsed.   In these
cases  the extravasation is probably connected with, and dependent on, laceration
or disorganization  of a portion  of the  brain, and may consequently be termed
the cerebral extravasation.
   The diagnosis of these two forms of extravasation from one another  is im-
portant, as  it is only  in the meningeal that any operative procedure can be suc-
cessfully undertaken, and it may usually readily be effected by attention  to the
symptoms just detailed.
   The diagnosis of the compression  from extravasation, and that from depressed
bone or inflammatory effusions within the cranium, is easily made.  In the case
of the depressed fracture, we have symptoms of compression continuing uninter-
 ruptedly from the  very first, and proper examination of the cranium will always
 lead  to the detection of the injured bone.   When inflammatory effusions, whe-
 ther of pus, lymph, or serum, exercise  undue pressure upon the brain, we find
 that  the signs  of  compression  have been  preceded by  symptoms of cerebral
 inflammation, and  that they are accompanied by  a good deal of pyrexia,  by
 quick pulse and hot skin; the character of the scalp wound likewise, and the
 separation of the dura mater when pus is effused, enable us to distinguish this
 condition  from those  cases in which the pressure is the result  of extravasated
 blood.
   From apoplexy, the diagnosis  is not always easily made,  more particularly
 when there  is no evidence that the head has been injured.  A man was brought
 to University College Hospital in a state of profound coma, in which  condition
 he had been found lying in the street.   There was no evidence of injury about
 the head, beyond  a  bruise, which  had probably been  received  when he fell.
 The case, which was supposed to be one of apoplexy, and treated accordingly,
 proved fatal in a few hours.   On examination after death the skull was found
 fractured, but not  depressed.   On the  opposite side to  the bruise and fracture,
 a coagulum weighing nearly four ounces and compressing the brain, lay between
 the dura mater and bone.  In such a case as this, it is evident that the history
 can alone  afford  a clue  to its true nature.  Even when the  head  has been
 injured  it is not always  easy.  A man was  admitted under my care, comatose.
 A fortnight previously he  had  been struck on the left side of the head behind
 the ear.   He was  stunned, bled freely from  the left ear,  but then  got tolerably
 well,  and went about his avocations  as usual until the day before his admission,
 when he  became  suddenly comatose.   There was stertor,  quick pulse, some
 heat  of head, the right pupil natural, the left, contracted.  He was  treated
 antiphlogistically, but died  on the third day.   On examination, a fracture on the
 left side of  the skull was found extending into the left internal meatus;  on the 
294
INJURIES OF  THE  HEAD.
right side of the head immediately opposite the fracture and the seat of injury,
a large coagulum was found  in  the cavity of the arachnoid,  with some serous
exudation about it.   Here was a meningeal extravasation, the  result of contre-
coup, existing without symptoms for fourteen days, and then proving rather sud-
denly fatal by the supervention of inflammation.
   From the insensibility of drunkenness the coma resulting from injuries of the
head may usually be distinguished, by the  absence of local  mischief, by the
smell of  the breath, and by the  face of the drunkard being flushed and  turgid
instead  of pale, as  in a person who is suffering from  the effects of a  severe
injury.   When a drunken  person has  met with an  injury of the head and  is
insensible, he should always be  carefully watched,  however slight the  injury
may appear to be, until time has elapsed  sufficient for him to recover  from his
drunken  fit, as it is impossible to say whether the stupor be the result of intoxi-
cation, or of mischief within the cranium, and I have known  cases sent away
from hospitals as drunk, when in reality the stupor was occasioned by depressed
bone.
   The treatment of extravasation of blood may be conducted on two principles,
either by  means of general and  local antiphlogistic  measures, having  for their
object  the arrest of further hemorrhage,  the promotion of absorption, and the
subdual of inflammatory action;  or  else by the application of the trephine, with
the view of allowing the escape of the  effused blood.
   The line of treatment to be adopted should, I think, have  reference  to the
character of the symptoms.   When  these  indicate the cerebral form of extrava-
sation, trephining can be of little service, and we must content  ourselves with
general antiphlogistics;  but when the extravasation seems to be meningeal, then
an attempt might be successfully made to evacuate the extravasated blood.
   Although the operation of trephining in cases of extravasation was formerly
much in vogue, it is seldom had recourse to by modern surgeons, and is only
proper in the meningeal form of extravasation.   It is very true that if it could
be ascertained without doubt that the extravasation is not only of the meningeal
character, but that it is  so situated that the blood may be removed through the
trephine  aperture, and  that there were no other serious injury to the brain or
skull, the operation should at once be performed.  And doubtless the case occa-
sionally happens  in which,  from the  situation of the blow, and  perhaps of a
capillary fissure  over the course of  the middle  meningeal artery, the gradual
supervention of signs of compression, after an interval of consciousness, and the
occurrence of hemiplegia on the side  opposite to that which  has been struck,
the surgeon is warranted in making an  aperture in the skull at the seat of
injury, in order to remove the blood that has been poured out, and to  arrest its
further effusion. ^ But the instances in which this assemblage of symptoms could
exist, with sufficient precision to justify an operation, are excessively rare.  Out
of some hundred cases  of serious and  fatal injury of the head  that have been
admitted  into University College Hospital during the last  fifteen years, in one
case only, I believe, has it been  found  advisable to  have recourse to trephining
for the removal of extravasated blood.   The case to  which I refer was that of a
man admitted comatose  three days after an injury of the head occasioned  by the
fall from a cab.   There  were no serious symptoms for some hours after the acci-
dent, but then stupor gradually came  on, amounting at last to complete coma.
On examination^ a bruise of the  scalp was found on the left  temple: through
this I made an  incision, and finding a starred fracture  over  the sinus  of the
middle meningeal artery, trephined  the bone, when a large coagulum was found
lying upon the dura mater, and on removing  this fluid, arterial blood freely
welled up.  The coma was relieved by the operation, and the patient made a
good recovery.  The most serious objection to the  application of the trephine
in cases of extravasation does not, however, consist so much in determining the
existence of effused blood within the cranium, or that the extravasation is of 
OPERATION OF  TREPHINING.
295
the meningeal  form, but rather in  diagnosing that it is so seated between the
dura mater and the skull as to admit of removal;  not being effused at the base,
or so widely coagulated over the surface of the brain as to be unable  to escape
through the aperture that may be made.   The likelihood of the co-existence of
fracture of the base of the skull and of laceration of the brain, giving rise to
the cerebral form of extravasation, must also be taken into account.   For these
various reasons, surgeons now very properly content themselves, in the  great
majority of cases of extravasation, with the employment of antiphlogistic treat-
ment, on the principles  already stated.  With this  view, the head  should be
shaved, the ice-bladder applied, the patient bled, purged, and kept at perfect
rest.   If, however, the signs are urgent, and pretty clearly indicate  the menin-
geal form of extravasation, and more especially if there be  hemiplegia on the
side opposed to that on  which the blow has been received, with an  injury in
the course  of the middle meningeal artery, the trephine  may be applied at the
seat of injury and  the blood removed.  It must be borne in mind that, however
clear  the signs, the extravasation  may not be  met with where the surgeon
expects to  find it.  Under these circumstances it is  better not to prosecute the
search by making  fresh  trephine apertures.   In no case would a prudent sur-
geon  trephine over the course of the middle meningeal  artery, in the absence
of local symptoms, on the chance of finding the blood there, as has been recom-
mended by some of the older surgeons.
   Operation  of Trephining. — Before concluding the subject of injuries of
the head,  it is necessary to  say a  few words  on  the  operation of trephining,
which, though far less commonly employed in  the present day than heretofore,
is one  of sufficient frequency in practice, as well as  of great importance from
the serious nature of the cases  that usually require it.
   The trephine may be applied to the cranium  for  two purposes;  either with
the view of preventing inflammation and its consequences, or for the purpose of
removing some cause of  compression.  The only case in which preventive tre-
phining is  practised by modern surgeons is  that  for the punctured  or starred
fracture of the skull, without stupor; in all other instances in which it is called
for, the object of its application is the removal of a  cause of compression  or of
irritation of the brain, such as a depressed portion of bone, foreign bodies either
fixed in the skull, or lying close under it, and  pus or blood extravasated within
the cranium.
   The operation  of trephining is  by no means a favorable  one in its results.
Of 45 cases reported  by Dr. Lenter, as occurring at the New  York Hospital,
in which, however, there is no  distinction made between  the application of the
trephine proper and of various instruments, such as the elevator,  Hey's saw,
&c, belonging to  a trephining case, only 11, or about one-fourth, recovered. Of
13 cases in which the trephine proper was used at University College Hospital,
by Mr. Cooper, Mr. Liston, and myself, 4 patients recovered; 1  other died of
injury of the spine unconnected with the operation, and the remaining 8 died
of inflammation of the brain or its membranes.
   The Parisian surgeons have not been very successful.  Nelaton says, that all
the cases of injury of the head, in which the trephine has  been used in the
Parisian hospitals during the last fifteen years, and they are 16 in number, have
terminated fatally.
   The trephine should  have a well-tempered crown, serrated half-way up its
exterior, the teeth should be short and broad,  and not too fine; the centre pin
must not project more than about the eighth of an inch, and care must be taken
that the screw which fixes it is in good working order.   The other instruments
required are a  Hey's saw,  an elevator that will not  readily  snap, and a pair of
strong dissecting forceps.
   The operation itself should be conducted in the following way: — The head
having been shaved, and the portion of the skull to which the trephine is to be 
296
INJURIES  of  the  spine.
applied having been freely exposed by means of a crucial or T-shaped incision,
or by the  enlargement of any wound that may exist, the trephine with the
centre pin protruded and well screwed down, is to be  firmly applied  until its
teeth touch the skull; it is then worked with rather a sharp, light, and quick
movement, the pressure being exercised as the hand is carried from left to right.
The centre pin must be withdrawn so soon as a good groove  is formed by the
crown, lest it perforate the skull first and injure the dura mater.   In this way
the outer table of the skull  is quickly divided, and  the  diploe  cut  into; the
detritus which now rises by the crown of the trephine is soft and bloody, instead
of being dry,  as it is whilst the outer table is being sawn.   As the instrument
approaches the  dura mater, the sawing must be  conducted  more warily, and
must every now and then be interrupted, in order that the  surgeon may examine
with the flat end of a probe,  or with a quill, the depth that has been obtained,
care being taken that this is uniform throughout the circle.   The  surgeon now
makes each turn very lightly, and now and  then  tries with a slight to-and-fro
movement whether the  circle of bone is loose.  So soon  as it is, he withdraws
it in the crown of the trephine, or raises it out by means  of the elevator.   In
this operation  the dura mater must not be wounded; if it be  injured fatal  con-
sequences will probably ensue.   The objects for which the trephining has been
had recourse to must  now be carried  out,  depressed bone elevated or removed,
and pus or blood evacuated.   The scalp should then be laid down again, a few
sutures and a  piece of water-dressing being applied.
  There are certain parts  of the skull, over the venous sinuses, for instance, and
near the base, to which no prudent  surgeon would  apply the instrument.   So
also, if it  were ever  thought necessary to trephine  at  the  frontal sinuses, the
outer table must first  be removed with a large crown, and the inner table sawn
out with a smaller one.
  After the operation careful attention must be paid to antiphlogistic measures
of a preventive and curative  kind, the great  danger to be apprehended being
inflammation of the brain  and its membranes.  In some cases also there is reason
to believe that suppurative phlebitis of the sinuses and veins of the diploe have
been the cause of death.
                         CHAPTER XIX.

                     INJURIES OF THE  SPINE.

   Injuries  of the spine, like those of the head, derive their importance from
the degree to which the enclosed nervous centre is implicated.
   The spinal cord is  subject to concussion, compression, and inflammation, as
the result of external violence, and any of those conditions may occur without
injury to the osseous and ligamentous structures investing it, although, in the
majority of cases, they are directly occasioned by fracture or dislocation of the
vertebras.   It may also be partially or completely divided by cutting-instruments,
gun-shot wounds, or a broken vertebra.
   Concussion of the spine varies greatly in severity.  In many cases of falls from
a height, and' of blows  upon the back,  the patient complains of great pain at
some part  of the spine, inability to stand, and a certain degree of weakness  of
the lower extremities.  In these cases,  rest for a few days in  bed, and more
especially the application of  dry cupping, or the abstraction of a few ounces of
blood from over the seat of injury, will speedily remove the symptoms. 
WOUNDS  OF  THE SPINAL  OORD.
297
  In  other  instances, however, the symptoms, slight at first, quickly become
much increased in severity, or may, from the commencement, assume a serious
character.   In such cases, there is some pain at the seat of injury, below which
there is  more or less complete paralysis,  sometimes consisting in mere debility
or impaired mobility of the lower limbs, at others of loss of sensibility and motion.
The sphincters are always  affected, there being more  or less incontinence of
flatus and faeces, and some difficulty in emptying the bladder, amounting at last
to complete  retention of urine.  These symptoms may, after continuing for some
weeks or months, gradually lessen in intensity until mere debility is left, which,
however, is  apt to continue  for a considerable time.  In other cases again, they
continue permanently, or terminate  in speedy death.
  In the more chronic forms  of the affection, traumatic  myelitis, usually of a
fatal character, is apt to come  on.   In these cases there is paralysis of the parts
below the seat of injury, associated  with pain and twitching of the muscles, the
pain in the  back being much increased on pressure.
  After death in cases of concussion of the spinal cord,  every condition is found
between slight ecchymosis, with some redness of the membranes, through all the
gradations of softening up to complete disorganization of its structure.  In many
cases there is extravasation  of blood into the substance of the cord itself.   When
this occurs  the  clot is most  commonly found in the grey substance, or  if not
actually confined to this, at  all events, towards the centre of the  cord and oppo-
site the seat of injury.   Occasionally blood is effused largely into the  spinal
canal, compressing the cord,  and  thus occasioning gradually increasing para-
plegia.   Sir A. Cooper mentions a  case in which this happened as the result of
a strain,  the patient dying at about the end of a twelvemonth.   When myelitis
has  occurred, the membranes are  found  congested and sloughy, and the cord
itself in every degree of red softening up to complete liquefaction.
  In the treatment of concussion of the spine it is necessary to keep the patient
in the recumbent position until the  lower limbs have regained their power. The
most convenient attitude for this purpose is upon the prone couch, which will
be  described when we come to speak of diseases of  the  spine.  The patient
should be cupped over the seat  of  injury, have his water drawn off, his bowels
opened by enemata, and his strength supported by a nourishing  system of diet,
which must be  continued so long as the paralysis lasts.   After a  time, more
especially if the bladder continues weak, blisters should  be applied to the spine,
and when merely a degree of debility is left in the lower limbs, the raw surface
so  produced may advantageously be sprinkled with strychnine properly diluted
with starch.
    Wounds of the spinal cord may occur from stabs with pointed instruments, from
gun-shot violence, or more frequently from  the injury inflicted upon it by the
pressure of  fractured vertebrae.  In the latter form of injury there is an associa-
tion of wound and compression, giving rise essentially to the same symptoms as
if the cord  were divided.
   When  the spinal cord is completely divided a certain set of symptoms occur
that are  common to all cases, at  whatever  part  of the cord the injury has been
inflicted, provided it be not  so high up as  to cause instant death.
  In the first place there is complete paralysis of sense and motion in all parts
below the seat of injury, though the mental manifestations continue intact.  The
precise seat of injury  may Often be diagnosed by the  extent of the paralysis.
Thus in injury of the lower part of the spine there may be paralysis of all those
parts supplied by the nerves of the sacral  plexus, whilst those from the lumbar
are not affected, the sensibility being lost below the knees, whilst above it is
perfect — thus leading to the inference that the injury has been inflicted above
the ohe and  below the other  set of nerves.  The temperature of the part becomes
lowered; though in some cases when the paralysis  is  not quite  complete, the
reverse has been observed; and after a time, a visible diminution takes place in 
298
INJURIES  OF  THE SPINE.
its nutritive activity, the circulation becoming feeble, with a tendency to conges-
tion at depending points.  This lessening of nutritive vigor is not, however, con-
fined to the paralyzed parts, but  the  whole of the system participates in it, the
patient becoming  speedily anemic and  cachectic.  The  skin  assumes a  dirty
cadaverous hue.^nd the cuticle usually  exfoliates in branny flakes.
   These general symptoms of paralysis as the result of injury present important
modifications according to the point at which the cord is divided.
   When the injury has been inflicted in the lumbar or lower part of the dorsal
region, there will be found to be  complete paralysis of all the parts supplied by
the nerves  given  off from the sacral or lumbar plexuses, or both; hence there
will be paralysis of the  lower extremities, of the-genital organs, and of the trunk
as high as the seat of injury.  There is always in these cases  relaxation of the
sphincter ani, and hence incontinence of flatus, and, to a great extent, of faeces.
There is at first retention of urine in consequence of the paralyzed state of the
bladder, the body of which is  unable to expel its contents; after a time, how-
ever, the urine dribbles  away as fast as  it is poured into the over-distended
organ, the neck of which has lost its contractile  sphincter-like action.  After
the first few days the urine will be observed to be ammoniacal in odor, and alka-
line in reaction.  This  is probably owing to changes  that it undergoes after it
has passed into the bladder, the mucous membrane of which becomes chroni-
cally inflamed, secreting a viscid alkaline muco-pus, which mixes with the urine.
In the early stages of the accident the penis will  usually be observed to be in a
state of semi-erection.  Patients who have met with injuries of this portion of
the spinal cord may live for many months and even for a year  or two, but even-
tually die, usually with sloughing of the  nates, or from the supervention of some
intercurrent visceral inflammation of a low type.
   When the  cord is divided in the upper dorsal region, about the level of the
third  dorsal vertebra,  we have not only the train of symptoms that has just
been mentioned as characteristic of  this injury lower down, but another set of
symptoms is superadded to them, owing  to the respiration being interfered with
in consequence of the paralysis of the greater portion  of the expiratory muscles.
The intercostals, and  those constituting the abdominal wall,  no longer acting,
an imperfect  expiration  is solely effected by  the elasticity of the walls of the
chest, and those expiratory movements, such as sneezing  and coughing,  which
are of a muscular  character, cannot be accomplished.  In these cases it will be
noticed, that  during inspiration, which is effected almost  exclusively by the
diaphragm, the ribs are  depressed instead of being  expanded and raised, and
the abdominal wall, which is soft and flaccid, is protruded far beyond its normal
limits.  In consequence of  the impediment to' respiration  the blood  is not
properly arterialized, and a slow process of asphyxia  goes  on, usually running
into congestive pneumonia, and terminating fatally in  about a fortnight or three
weeks.
   When the injury is situated  in  the  lower cervical vertebrae, not only do all
the preceding symptoms occur, but there will be paralysis of the upper extremi-
ties as well, and the inspiration  being  entirely diaphragmatic, the  circulation
 speedily becomes  affected, the countenance assuming a suffused and purplish
 look.   If the  cord have been divided  immediately above  the brachial plexus,
 the whole of the upper  extremities will  be completely paralyzed;  but if the
 injury be opposite the sixth cervical vertebra, it may happen  that the upper
 extremities are only partially paralyzed.  This happened in two cases of fracture
 of the spine in this region  that have lately been  under my  care at the hospital.
 In both these instances the paralysis existed on the ulnar but not on the radial
 side  of the arms, owing to the  external cutaneous  and radial  nerves  arising
 higher from  the  plexus than the ulnar, and thus just escaping injury.   It  is
 remarkable that in both these cases there was acute cutaneous sensibility in the
 arms  along the whole line of junction between the  paralyzed and  the  sound 
FRACTURES  OF  THE SPINE.
299
parts.  In. cases of injury of the cord in this situation death usually occurs by
asphyxia in the course of a week.
  When  the  division of the  spinal cord takes place above the origin  of the
 phrenic  nerve, opposite  to or above the third cervical vertebra, instantaneous
 death results from the paralysis  of the diaphragm, as well as of the rest of the
 respiratory muscles, inducing sudden asphyxia.
   It occasionally happens in  partial division  of  the  cord, as in some cases of
 compression resulting from fracture, that the symptoms are not so clearly marked
 as in the instances that have just been recorded.   Thus, for instance, the para-
 lysis may not  extend  to all the parts below the seat of injury; it may be attended
 by severe pain in some of the semi-paralyzed parts; or, motion may be affected
 in  one  limb,  and  sensibility in  another.  These  deviations from what is usual
 may generally be explained  by some peculiarity in the seat of the injury to the
 cord, or by the extent of its division.
   Fractures of the spine commonly result either from direct blows upon  the
 back, or else  by falls upon the head, in such a way that the body is violently
 bent forwards.
   The  signs  of this  injury, though by no means  unequivocal in  many cases,
 are  yet  sufficiently obvious in the majority of instances to admit of an easy
 diagnosis.  They are of two kinds; those presented by the injury of the bone.
 and those dependent on injury by compression  or laceration, or both,  of  the
 spinal cord.
   The  local signs are usually pain at the seat of injury, greatly increased on
 pressure or on moving the part, inequality of  the line of the spinous processes,
 with depression of the upper portion of the spine, and corresponding prominence
 of  the  lower.   There is an inability to support the body in the erect position,
 and to move the spine in any way;  hence, when the upper portion of the column
 is injured, the patient holds his head in  a stiff and constrained attitude, fearing
 to turn it to either side.
   The more general  symptoms of fracture of  the spine are dependent upon  the
 injury  that the cord has received.  If the fracture have  not implicated  the
 spinal canal, as when only the tip of a  spinous process has been broken off, or
 if it be unattended by displacement, although it may traverse  the body and
 arches, no symptoms depending upon injury  of the cord need exist, and  indeed
 occasionally are absent.  But in  these  cases even there is usually  some  degree
 of paralysis, owing perhaps to  the concussion to which the cord has been sub-
 jected at the moment  of injury; and occasionally a sudden movement  by the
 patient will bring on displacement, by which the  cord is compressed and all the
 parts below the injured spot paralyzed.   A woman was admitted into University
 College Hospital with an injury of the neck,  the nature  of which could not be
 accurately  ascertained.  She  was  in no  way paralyzed, but  kept her head in a
 fixed position.  A few days after  admission, whilst making a movement in bed,
 by which she turned her head, she fell back dead.   On  examination  it was
 found  that the spinous process of the  fifth  cervical vertebra had  been broken
 off short, and was impacted in such a way between the arches  of  this and the
 fourth as to  compress the  cord.   This  impaction  and consequent compression
 probably occurred at the  time of the  incautious movement, thus producing
 immediate  death.
   When there is  only partial displacement of the fracture there  may be but
 incomplete, paralysis of the parts  below the  injury; of one arm,  one leg, &c.
 In these cases there is usually great pain experienced at the seat of fracture,
 and extending from it along the line of junction  between the paralyzed and
 sound parts round the body or along a limb.   This symptom, which is of great
 importance as exactly defining the seat of injury, is owing,  as I found in a case
 of  fracture of the sixth cervical vertebra under my care, to the fractured bone
 compressing  and  irritating the  nerve   that  issues from  the vertebral  notch
 opposite the seat of injury. 
300
INJURIES  OF  THE SPINE.
   In the majority of cases of fracture of the spine there is, however, such dis-
placement of  the bone as to compress the whole thickness of cord, and thus to
occasion complete paralysis.  In  these  cases  the  symptoms are such as have
been detailed  when speaking of injuries of the spinal cord on the compression,
laceration, or  divisions of which they are dependent.
   Fractures of the spine are inevitably fatal, death ensuing in the two different
ways, and at the different periods  that have already been mentioned.
   The  treatment of these injuries is sufficiently simple.   No attempt at reduc-
tion can of course be  made.  All our efforts must be directed to the prolonga-
tion of life.   With this view, if the fracture be in such a situation, at any point
below the upper dorsal vertebra, for instance, as will hold out a prospect of the
life  being prolonged for a few weeks or months, means must be taken to prevent
the  occurrence  of sloughing of the nates, an accident that is of common, and
usually of fatal termination in  these cases.  'The patient  should therefore be
laid at  once on a water-bed, cushion, or mattress; he must be kept scrupulously
clean, and  his urine should be drawn  off  twice in the  day at regular  hours.
If, as usually happens after a time, the bowels become confined, relief must be
afforded by castor  oil,  or  turpentine  enemata.  A nourishing  diet  must be
administered, and perfect  rest  in one position  enjoined.   In this way life may
be maintained for a considerable length of time; and it is probable that ossific
union of the  fracture may sometimes take place, though the patient may not
recover from the paralysis, and will die eventually from disease of the cord.
   In cases of fracture of the spine with depression of the  arches, it  has been
proposed to trephine the injured bone and  elevate the fragment that has been
driven in upon the cord.  This  operation, though performed by Cline, Cooper,
and  Bell, is, I believe, now generally abandoned by the  best  surgeons in this
country, owing to its invariable, and, indeed, intrinsically fatal character.
   Dislocations of  the spine. — On looking  at  the arrangement of the  articular
surfaces of the vertebrae, the very limited motion of which they are susceptible,
and  the way in which  they are  closely knit together by  strong  ligaments and
short and powerful muscles, it is obvious that dislocations of these bones must be
excessively  rare.  So seldom indeed do they occur that their existence has been
denied by many surgeons.   But yet there are  a sufficient  number of instances
on record to prove incontestably that these accidents may happen.  Those cases
that have been met with have usually been associated with partial fracture, but
this  complication is not necessary.  In all, the displacement was incomplete, and
indeed a complete dislocation cannot occur.
   The dislocation of the atlas from the  occipital bone has only been described
in two instances; —by Lassus and by Paletta.   In the case by Lassus, death
ensued in six  hours, and the right vertebral artery was found to be ruptured.
In the other case, the patient is  said to have lived for five days, but the  report
is so_ incomplete that little value can be attached to it.
   Dislocations of the axis from the atlas are of more frequent occurrence. They
may happen with or without fracture of the odontoid process.   In either case
the  axis is  carried backwards,  and the  spinal  cord  thus  compressed.   This
accident is said to have taken place  by persons in  play lifting a child off the
ground  by its  head;  the  combination of  rotation and traction in this movement
being especially  dangerous, and  liable to occasion the accident.   For the  same
reasons  it has  been met with in persons executed  by hanging.  Death  would
probably be instantaneous  under  these  circumstances.  It has, however, been
stated that  in dislocations of this kind, life has been saved  by the  surgeon
placing  his knees against the patient's shoulders, and drawing or  twisting the
head into  position.   This, however, I cannot believe possible, if the  displace-
ment have been complete, as death must be instantaneous; the cases of supposed
dislocation and reduction having probably been  instances  of concussion of the
cord with sprain of the neck. 
INJURIES  OF  THE  FACE.
301
  Dislocation of any one of the five lower cervical vertebrae may occur.  These
injuries are usually associated with fracture, but sometimes, though rarely, they
happen without this complication.   In these dislocations, as in those  that  have
already been described, the displaced bone carries with it the whole of that por-
tion  of the vertebral column which is above it, no single bone  being  dislocated
both from those above and those below it.
  These accidents most commonly happen by  forcible  flexion of the neck for-
wards, though traction and rotation conjoined  have occasioned them.  In a case
of luxation  of the sixth from the seventh cervical vertebra, recorded  by J.
Roux, the accident happened by a sailor plunging into the sea for  the purpose
of bathing, coming head foremost against a sail which had been spread out to
prevent the attack of sharks;  he died on the  fourth day.   In a patient of mine
who fell out of the window in such a way that the head was doubled forwards
upon the chest, and who was brought to the hospital with  supposed fracture of
the spine, we found after death, which occurred on the fifth  day, that the seventh
cervical vertebra had been dislocated forwards from the first dorsal, there being
a wide gap posteriorly between the lamina of  these bones, with horizontal  split-
ting  of the intervertebral substance, detaching with it an  extremely thin and
small layer of bone from the body of the seventh.  There was no fracture about
the  articular processes, which were completely separated from one another. The
symptoms of this accident are necessarily excessively obscure, being very liable
to be confounded  with  those  of fracture. Reduction has been  effected in a
sufficient number of cases of this kind to justify the proceeding being adopted
when the danger is imminent.
   Dislocation of the transverse processes of the  cervical vertebrae  occasionally
occurs.  In these cases  the patient, after a sudden movement, or a fall on the
head, feels much pain and stiffness in the neck, the  head being fixed immovably,
and  turned to the opposite side to that on which the displacement has occurred.
In these cases I have known reduction effected by the surgeon placing his knees
against the patient's shoulders, drawing  on the head, and  then turning it into
position, the return being effected with a distinct snap.

                      INJURIES OF THE FACE.

   Cuts about the cheeks and forehead are of common occurrence. These injuries
present nothing peculiar, except that the structures of the face partake of the
same tendency to ready repair,  as well as to the supervention  of erysipeloid in-
flammation, that  characterize the scalp when injured.  In the treatment of these
wounds it is of much consequence to leave as  little scarring as  possible. Hence
the  edges, after being well cleaned, should be brought neatly into apposition by
fine  hare-lip pins and the twisted suture, or by a few points of interrupted
suture; more particularly if they are in  a transverse direction, and implicate
the  lips or nose.   When in the neighborhood  of the eyelids, especial care  must
be taken to prevent any loss of substance, lest the contraction of the cicatrix
produce eversion of the lid.  In those cases in which a portion of  the  nose or
lip has been lost, much may be done to repair the deformity by properly-con-
ducted plastic operations, as will be described  when we come to treat of diseases
of these structures.   The bleeding, which is often  rather free in wounds of the
face, in consequence of some arterial branch having been divided, may often be
arrested by passing the hare-lip pin under the vessel, and applying the twisted
suture  above it, so  that it may  be compressed.  If the lip  is cut from within,
by being struck  against the teeth, the  coronary  artery may  be  divided, the
patient swallowing the blood that flows into the mouth. Some years ago, a man ,
was brought to the hospital, drunk, and much bruised about the face.   Shortly
after his admission he vomited up a large quantity  of blood, which was at first
supposed to proceed from some internal  injury, but on examining his mouth, it 
302
INJURIES  OF  THE  NOSE  AND EARS.
was found that the blood came from the  coronary artery of the lip, which was
divided, together with the mucous membrane.
  It occasionally happens as the result of wounds or abscesses of the cheek that
the  parotid duct is  cut across, in consequence  of which the wound does not
close, a trickling of  saliva taking place upon the outside of the cheek, so as to
establish a salivary fistula, a source of much  disfigurement and  inconvenience
to the patient; the surface surrounding it being puckered in a somewhat exco-
riated, and the fistula opening by a granulating aperture.
  If this condition is recent, a cure may sometimes be accomplished, by paring
the edges of the external wound, bringing them into close apposition, and apply-
ing pressure upon the part.   If it  be of old standing, the probability is that the
aperture  into  the mouth is closed, and that something more will be required
than bringing the lips of the wound together.   To get it to close, we may adopt
the plan  recommended by Desault, of passing a small  seton from the mouth into
the fistula, so  as to make an artificial opening into the mouth, and then, when
the course of  the saliva has thus been established, closing the  external wound.
In order to make the internal artificial opening permanently fistulous, some sur-
geons have advantageously employed a red-hot wire.
  Besides the fistula of the Stenonian duct, other fistulous apertures may take
place in  the cheek, as the result of injury or disease, allowing the escape of a
small quantity of saliva.  These openings are always difficult to heal: the edges
becoming callous, and  not readily  taking on reparative action.   Closure may be
effected in some cases by cauterization with the nitrate of silver, or with a red-
hot wire, due  attention being paid  to the general health.   In other cases, again,
the  electric cautery, as employed by my colleague, Mr. Marshall, may prove
successful.  If, however, the opening  be free, with much indurated  structure
about it,  the surgeon may find it necessary to excise a portion of the edges before
bringing them together.
  Feneign bodies in the  nostrils, such  as  pebbles,  beads, dried peas, &c, are
occasionally met with in children, having been stuffed up in play, and becoming
so firmly fixed  as to require  extraction by the  surgeon.   For this purpose a
pair of urethral or polypus forceps will usually be found  convenient.  In some
cases, however, a bent probe or an ear-scoop will remove  the  impacted body
          most easily.
            The Ears are not unfrequently wounded in injuries  of the head
          and scalp; a portion of the  external ear being sometimes torn down
          and hanging over the side  of the  face.   In  these cases, as in scalp
          injuries, the  part should  never be removed, but, however  lacerated
          and contused, should  be cleaned and replaced  by means  of a few
          points of  suture and strips of plaster.   When the cartilaginous por-
          tion of the  ear is  divided,  nice management is usually required  in
          effecting perfect union.
            Foreign bodies are often  pushed into the ears of children in play
          with one another.   When pointed or angular, such as pieces of stick,
          they may  readily be extracted with forceps;  but when round and
          small, such as pebbles or  beads, they are not so  easily removed.
          Here the use of this instrument is of little service, the bent ear-scoop
          •may occasionally be  got round the body and thus remove it.
            In some cases I have found an instrument, as here represented, fig.
          131, and made by Coxeter on  the model of Civale's urethral scoop,
          useful in getting a foreign body out of the ear.   It can be introduced
          straight and then passed beyond it, when,  by the action of a screw  in
  ^     the handle, the scoop is curved forwards,  and so enables extraction
          to be readily effected.   In  other cases it is best got out by forcibly
syringing the ear with tepid water, injected by means of a large  brass syringe
in a full  stream, the pinna being drawn up  so  as to straighten the external
Fig. 131. 
INJURIES OF  THE  EYES.
303
meatus.  In this way the bead or pebble is soon washed out by the reflux of
the water striking against the tympanum.  Should these means not suffice it is
better to leave matters alone, and to allow the foreign body to become loosened,
than to poke instruments into the ear with the view of forcibly extracting it.
These  attempts  are  ill-advised, and I have known death follow prolonged and
unsuccessful efforts at the extraction of a pebble from the ear.
   Injuries of  the orbit if deep are  always serious, on account of the prox-
imity of the brain; thus it may happen  that a pointed body, such as a pieceof
stick or a knife  thrust into the orbit, perforates its superior wall, thus producing
a fatal wound of the brain.   Occasionally inflammation is set up in the loose
cellulo-adipose tissue contained in this cavity, giving rise to abscess, which may
point in either  eyelid; or, to inflammation extending itself  to the  encephalon.
In other cases wounds of the orbit may be followed  by loss of vision, without
the eyeball being touched, either in consequence of injury of the  optic nerve,
or perhaps from the division of some of the other nerves of the orbit producing
sympathetic amaurosis, as occasionally happens even from ordinary wounds of
the face, implicating some of the terminal branches of the fifth pair.
    Injuries of the eye-ball are so commonly followed by impairment or total
loss of vision as to constitute a most important series of accidents;  the delicacy
 of the structure of  this organ being such, that slight wound of its more  trans-
 parent parts, or displacement of  the lens, is often followed by complete opacity
 and loss of sight.
    Injuries of this organ may be  divided into contusions and wounds.
    A contusion  of the eyeball, without  rupture or apparent injury of any of its
 structures, may give rise to such concussion  of the retina as to be  followed by
 temporary or permanent amaurosis.  More frequently contusions of the eye are
 accompanied by extravasation of blood under the conjunctiva, and much ecchy-
 mosis of the eyelids.  A " black-eye " is best treated by the continuous applica-
 tion of a weak  arnica and spirit lotion.
    Contusion of the eye with rupture of some of the structures of the ball is a
 most  serious accident.   The  cornea may be ruptured, the humors  lost, and
 vision permanently  destroyed.  Most  frequently the  rupture  is internal, the
 outer tunics escaping all injury.  In this case we may have an extravasation  of
 blood into the  eye, completely filling the  anterior chamber, hiding and compli-
 cating deeper mischief within the ball.   This condition, termed hamophthalmia,
 is frequently associated with separation of the ciliary margin  of the  iris.   In
 other cases again, there may be  displacement of the crystalline lens, which may
 be driven into  the vitreous humor, be  engaged in the pupillary aperture, or fall
  forwards  into the anterior chamber.  As a consequence of such injuries the eye
  usually becomes inflamed with intense frontal and circum-orbital pain : disorga-
  nization of the ball, and ultimately loss of vision ensuing.
    The treatment of  these injuries must  always be of an  active antiphlogistic
  character.  Blood  should be freely taken  from the arm  by venesection, and
  from the temple by cupping, the iris being dilated by the application  to the eye
  of a  solution of the sulphate of atropine, of the strength  of two  grains to the
  ounce of distilled water;  the patient must  be  kept in a darkened room, on a
  strictly antiphlogistic regimen, and should be put under the influence of calomel
  and opium, as  speedily as possible.  In this  way, the inflammation will be sub-
  dued, the effused blood absorbed, and  perhaps vision restored.  In some cases,
  however, opaque masses and  bands of  lymph will be deposited in  the anterior
  chamber and  the  pupillary  aperture,  preventing more or  less completely the
  entry of light.   If the lens be displaced into the  posterior chamber it must be
  left there; if in the anterior it may be extracted through the cornea.
    Wounds of the eyeball may be divided into those that are merely superficial,
  and do not penetrate into its chambers; and those that perforate its coats.
    The  non-penetrating wounds are usually inflicted by splinters of iron, or other 
304         WOUNDS  OF  THE  MOUTH  AND  TONGUE.

metallic bodies, which become fixed in the cornea, or between one of the eyelids
and the ball.  Very painful and troublesome injuries are sometimes inflicted by
scratches of the eyeball with the nails of children.  In the treatment of these
superficial injuries, the first point is necessarily to remove any foreign body that
is lodged.  If it be fixed on the cornea, as commonly happens, it may be picked
off with the point of a lancet or cataract needle; if it is  a splinter of iron that
has been so lodged, it is well to bear in  mind that a small brown stain will be
left after the metallic spicula has been taken off;  this, however, will disappear
in the course  of a few days. In order to remove foreign bodies lodged between
the ball and the eyelids, these  must be everted  so  that the  angle between the
palpebral and ocular conjunctiva may be properly examined. ^ For this purpose
the lower eyelid need only be drawn down, whilst the  patient is directed to look
up ; but the eversion of the upper eyelid requires some skill. It is best effected by
laying a probe horizontally across it, immediately above the tarsal cartilage; the
surgeon then taking the eyelashes and ciliary margin lightly between his finger and
thumb, draws down the eyelid  at the same time that he everts it by pressing the
 probe firmly backwards and downwards against the eyeball;  the patient should
 then look down in order that the whole  of the  upper part  of the conjunctiva,
 where the foreign body will probably be found, may be carefully examined.
    Penetrating wounds of  the eyeball present great variety;  they are commonly
 inflicted by bits of stick, steel pens, children's toys, and not unfrequently during
 the shooting season by the explosion  of faulty percussion caps, or the lodgment
 of a stray shot in the eye.  In all cases  these accidents are highly dangerous to
 vision,  and when the foreign body lodges, it is usually permanently  lost.
    The danger that ensues  usually arises either from  the eye  being opened to
 such an extent that the humors escape,  or else, that the iris becoming engaged
 in a wound in the cornea, a hernial prolapse of it occurs.  The remoter  conse-
 quences usually arise from inflammation taking place  within the globe, so as to
 produce an opaque cicatrix of the cornea or of the capsule of the lens; or else
 there is danger that adhesions may form, stretching across between the iris and
 the lens, or between  these parts and the posterior surface of the cornea; or that
 inflammation may take place in all the structure of the  ball, giving rise to dis-
 organization of it.
    The treatment of these penetrating wounds is strictly antiphlogistic. Bleeding
 in the  arm, cupping on the temples,  low diet,  a darkened room, and the admin-
 istration of calomel  and opium, are the principal points to be attended to.  If
 the iris have protruded through a wound in the cornea, it should be carefully
 pushed back, and  a drop or two of the solution  of atropine  put upon the eye.
 If it cannot be returned, it may be removed with  a pair of  fine curved scissors,
 and at a later period any staphylomatous tumor that may form, should be touched
 repeatedly with a  pointed piece of nitrate of  silver.  If there is a tendency to
 the formation of  adhesions, or to the deposit of lymph within  the  pupil or the
 anterior chamber, our principal reliance should be upon small doses of calomel,
 in conjunction with  opium.  If the  lens or its capsule have become  opaque
 traumatic cataract thus forming, extraction may be required at a later period of
 the case.
    Wounds  of the mouth  are seldom met with, except as the result of gun-
 shot violence.  In these cases the amount of injury done to the soft structures,
 however great, is usually only secondary to  the mischief  that  results to  the
 brain, spinal cord, jaws and skull, and must of course be treated on the ordinary
 principles of gun-shot and lacerated wounds.
    Wounds of the  tongue usually occur from its  tip  or  sides being  caught
 between the teeth during an epileptic fit.  They have  been known to be inflicted
  purposely  by insane patients, in  attempts to excise this  organ.  Should the
  hemorrhage be free, the application of  a ligature, or  even of the actual cautery,
  may be needed to arrest it.  These wounds generally assume a sloughy appear- 
INJURIES OF  THE  THROAT.
305
ance for a few days;  then clean up, and granulate healthily.  It is  useless to
bring the  edges  together by sutures, which readily cut out.  If a large portion
of the tip be nearly detached, it must, however, be supported in this way; but
the threads should be thick, and passed deeply.
   The palate and the pharynx are sometimes lacerated by gun-shot injuries
of the mouth; or the wound may result by something that the patient happened
to have between his lips being driven forcibly backwards into his mouth.  Thus,
a tobacco-pipe may, by a blow on  the face, be driven deeply into the substance
of the tongue, or perhaps into the pharynx, wounding and  lodging behind the
arches of the palate, breaking off short; the fragment that is left in giving rise to
abscess, to ulceration of the vessels, and  perhaps fatal secondary hemorrhage.
In a case that was under my care a short time back, the soft palate was  nearly
completely detached from the palatal bones by a deep transverse wound, caused
by the end of a spoon being forcibly driven into the mouth.

                     INJURIES  OF  THE THROAT.

   The cartilages of the larynx may be  displaced, dislocated as it were by violent
 blows; or they may be fractured, though but very rarely, the  rupture in some
 cases taking place transversely,  in others  longitudinally.  Digital examination
 of the part would at once detect the nature of the injury.  In all these injuries
 there is danger of asphyxia, which  indeed may be induced by simple concus-
 sion of the larynx.  Should these symptoms be  very urgent, tracheotomy might
 be required.  If not, attention to position and support of the head will suffice.
   Wounds of the throat are of great frequency and importance, implicating as
 they do some of the  most important organs in the body.  They may be divided
 into three categories : —
   1st. Those that do not extend into the air or  food passages.
   2nd. Those that implicate the air-passages,  with or without  injury  of the
 oesophagus.
   3rd. Those that are accompanied by injury of the spinal cord.
   All these injuries are  most commonly suicidal, and may be  inflicted with
 every variety of cutting instrument.  Hence, though  incised,  they are often
 jagged, and partake somewhat of the character  of lacerated wounds, with great
 gaping of the edges.
   In  wounds of the first category there is very commonly free  and even fatal
 hemorrhage, and  this sometimes  though none  of the larger arterial or venous
 trunks are divided; the blood flowing abundantly from the venous plexuses and
 from the thyroid body.  If the larger  arteries  are  touched, as the carotid and
 its primary branches, the hemorrhage  may be so  abundant as" to give rise  to
 almost instantaneous death.   Another source of danger in these cases proceeds
 from the admission of air into the veins of the so-called "dangerous region" of
 the neck. For this a free wound" is by no means necessary, as is instanced by a
 remarkable case that occurred a few years ago near London, in which the intro-
 duction of a seton into the fore part of the neck was followed  by death, from
 this cause.
   The large nerves, such as the vagus and phrenic, cannot, in  a suicidal wound,
 be divided without injury to the neighboring vessels.  The division, however,
 of the respiratory nerves on one side only, or even of one of them, would in all
 probability be fatal in  man, by interfering with the proper performance  of  the
 respiratory act.   In  a  case with which I am acquainted, in which the  phrenic
 nerve was divided during the operation  of placing a ligature on  the subclavian
 artery, death resulted in a few days from inflammatory congestion of the lungs.
   In the treatment of wounds of the neck of this category, the principal points to
 be attended to are, in the first place, the arrest of hemorrhage by the  ligature of
 all bleeding vessels, whether arterial or venous;  and, secondly, bringing together
        20 
306
INJURIES OF  THE  THROAT.
the lips of the wound.   If the cut be longitudinal, this may be done by strips
of plaster.   If transverse, by a few points of suture and by position, the head
being fixed, with the chin  almost touching the  sternum, and  retained in  this
posture by tapes passing from the nightcap to a piece of bandage fixed round the
chest.   I have had under my care one  case, in which, owing to the  projection
and mobility of the larynx, the wound did not unite, a large  and deep gap being
left, which required a series of plastic operations in order to effect its closure.
   The air-passages are  commonly wounded  in suicidal attempts.   They maybe
known to be opened by the air being heard and seen to bubble in and  out of the
wound during respiration.  These wounds vary much in extent, from a small
puncture with the point of a penknife to  a cut extending completely  across the
throat, and even notching the vertebrae.   They are frequently complicated with
injuries of the larger vessels and nerves, and sometimes with wound of the oeso-
phagus.  Most commonly the cut is made high up in the neck, for the suicide
thinking that  it is the opening into the air-passages that destroys life, draws the
razor  across that part of the  throat where these are most prominent  and easily
reached; and  thus, by not wounding the  larger vessels, which are saved by the
projection of the larynx, frequently fails in  accomplishing his object.
   There are four situations in which these wounds occur: 1st.  Above the hyoid
bone;  the cut extending into  the mouth and wounding the root of the tongue.
When the wound is in this situation  it is  usually attended with a  good deal of
hemorrhage; and there is much trouble in feeding the patient, as the power of
swallowing is  completely lost.
   2d.  The wound may be inflicted in the thyro-hyoid space, laying the pharynx
open, but being altogether above the larynx.  This is the most common situa-
tion for suicidal attempts.  In  many cases  the incision is  carried so low as to
shave off or partly to detach the epiglottis and the folds of  mucous membrane
around it.   In other cases again, the  edges  of the glottis or the arytenoid  car-
tilages are injured, the  cut extending back  to the bodies of the vertebrae.   In
these  cases also, there  is  great difficulty in swallowing, and great risk of the
sudden supervention of oedema glottidis, and consequent suffocation.
   3d. When  the larynx  is wounded the incision is  usually transverse; but I
have seen a longitudinal cut made through the larynx, so as to split the thyroid
and cricoid cartilages perpendicularly.   In these cases of wounded larynx there
is much danger of the blood from the superficial parts trickling into the air-pas-
sages and asphyxiating the patient, and of inflammation of the bronchi and lungs
supervening at a later period.
   4th. Wounds of the  trachea are not so common as those of the larynx, from
which they differ but little in  the attendant  dangers.  The oesophagus is seldom
wounded, as it can only be reached  through the trachea by a  deep cut, which
will probably implicate the large vessels on one side or the other.  The spinal cord
can only be injured by gun-shot wounds of the neck, which are necessarily fatal.
   There are various sources  of danger in wounds  of the neck implicating the
air-passages.    The hemorrhage, whether it proceed from  any  of  the larger
trunks, or consist  of general  oozing  from a vascular surface, may either prove
directly fatal by the loss of blood, or indirectly so in consequence of the blood
trickling into  the  air  tube, and by accumulating in  its smaller divisions  pro-
ducing suffocation.  Another source of danger in some of these cases arises from
the supervention of asphyxia, either in  the way that  has  already been men-
tioned, or, in those cases in which the wound has been inflicted above the larynx,
from  the occurrence of oedema of the glottis.    This  condition  may likewise
occur in those cases in which the external  opening is very small, and occasionally
happens  suddenly when the wound has nearly closed.
   Another source of danger is the loss of the natural sensibility of the glottis,
in consequence of which it no longer contracts on  the application of a stimulus.
Hence food taken  in by the  mouth  may pass  into  the larynx and  make its 
WOUNDS  OF  THE  THROAT.
307
appearance in the external wound, even though neither the pharynx nor the
oesophagus have been wounded.   This I have observed  in many cases of cut-
throat ;  hence the presence of food in the wound cannot in all cases be con-
sidered  an evidence  of injury to  the food-passages.   This occurrence is always
a bad sign, and is never met with  in the earlier periods  of the  injury;  never,
indeed,  until a semi-asphyxial condition has come on, by which the nervous sen-
sibilities are blunted, or until inflammation  has been set up about the rima glot-
tidis, giving  rise to  so  much swelling as to interfere with the natural actions,
and to deaden the perception of the part to the contact of a  foreign body.  In
these cases also it will be found that the sensibility of the air-passages generally
is much lowered, so that mucus accumulates in the bronchi often to a dangerous
extent,  the patient not feeling the necessity for expectoration, and often, indeed,
having  much difficulty in  emptying his chest.
   The  occurrence of bronchitis  and pneumonia, either  from the inflammation
extending downwards from the wound, or in consequence of  the cold air enter-
ing the  lungs directly; without being warmed by passing through the nasal cavi-
ties, is perhaps the most serious complication that can happen in these injuries,
and constitutes  a frequent source of death in those patients who  survive the
immediate effects of the wound.
   The  depressed mental condition of  the patient also is usually unfavorable to
recovery in all  those instances in  which the wound  is suicidal, disposing him to
the occurrence of low forms of inflammatory mischief.
   Treatment.—We have  already  considered the management of these wounds
of the throat that do not interest the mucous canals in this region.  When these
are opened the same general  principles are required as in  the  former case.
Hemorrhage must be arrested by the ligature of  all   the  bleeding vessels,
whether arteries  or veins, so that no  oozing or  trickling into the wound may
take place.
   In some cases the hemorrhage  consists principally of  general venous oozing
which cannot be stopped by ligature,  the  patient drawing a large  quantity of
blood into the air-passages through the wound in them.   Under these circum-
stances, I have found it useful to introduce a large silver tube into the aperture
in the windpipe, and to plug the wound around it.  So soon as the bleeding has
fairly ceased, the plugs and the tube must be removed.
   The  edges must next be brought together by a few stitches introduced at the
sides, and by attention  to position, the head  being fixed by tapes  as already
described in the former section.   I think with Liston that in these  cases the
wound  should never be closely  sewed up, or stitches introduced into the centre
of the  cut.   If the edges of the integument be closely drawn  together, coagula
may accumulate behind them, in the deeper parts of the wound, so as to occasion
a risk of suffocation, and  as this must eventually close by granulation, no mate-
rial advantage can possibly be gained by this practice.
   There is an exception, however, to this rule of not using stitches in  the cen-
tral part of the wound in cut-throats;  viz., in those cases in which the trachea
has been  completely cut across.  Here a stitch or two on  either side of the tube
is necessary, in order to  prevent  the wide separation of the two portions that
would otherwise take place, owing to the great mobility of the  larynx and
upper end of the windpipe.
   In order to  lessen the liability to  inflammation of the  lungs,  the patient
should be put into a room, the temperature of which is raised to  about 80°
Fah., with a piece of lightly folded muslin acting as a respirator laid over the
wound.    So soon as  the cut surfaces begin to granulate,  water-dressing may be
applied, and the edge of the wound brought into apposition by strips of plaster,
and a compress if necessary.  During the treatment the  principal danger pro-
ceeds from  inflammatory  affections of the chest;  these  must accordingly  be
counteracted by the temperature in which the patient is placed, and by as active 
308
INJURIES OF THE  THROAT.
antiphlogistic  remedies as his  condition will  admit of.   It must, however, be
remembered that the mental depression and the bodily exhaustion from loss of
blood, that are commonly met  with  in  these  cases, do not allow a very active
course of treatment to be pursued.
  The administration of food in these cases is always a matter requiring much
attention.  As a general rule, the patient should be kept on a nourishing diet,
with a moderate allowance of stimulants.  If, as not uncommonly happens, the
food passages are opened, in  consequence of the wound extending  into the
mouth, the pharynx, or the oesophagus, it is of course  impossible for the patient
to swallow, and the administration of nourishment becomes a source of consider-
able difficulty.   This is best accomplished by means of an elastic gum  catheter
passed through  the  mouth into  the gullet or  stomach.   This is  easier than
passing the instrument through the  nose, and much better than introducing it
through the wound.  In this  way a pint  or  more of the strongest beef tea,
ox-tail soup, or  Liebig's " Liquor Carnis," which I have  used on  one or two
occasions with advantage, mixed with two or three eggs,..and having an ounce
or two of brandy added to it, should be injected regularly night and morning,
until the patient is able to swallow.  In  those  cases in which the wound is
above  the larynx, there is occasional danger of  the supervention of oedema of
the glottis; should this  occur, tracheotomy may become  necessary in  order to
prolong the patient's life.
  As after-consequences of wounds of the throat, we occasionally find  stricture
of the trachea or aerial fistula occurring.  If the cordas vocales happen to have
been injured,  loss of voice may result.
  Aerial fistula may sometimes form, owing to skin being adherent to the edges
of the wound  or air tube, and chiefly occurs when the cut is in the  thyro-hyoid
space; adhesion  taking place  between the integuments, which are doubled in as
is seen in the  os hyoides above, and  the  surface of the thyroid cartilage below.
When this takes place, there  is a  tendency to the  fistula continuing patent.
Under these circumstances I have found the following operation successful in
closing it:
  The  edges  of the fistulous opening being freely pared, and the knife passed
under them for  some distance, so as to detach them from subjacent parts, a
vertical incision is made through the lower lip of opening — so as to split it
downwards.  Two points of suture are then inserted into each side  of  the hori-
zontal incisions, bringing their edges in contact, but the vertical cut is left free
for discharges and saliva to drain through.   Unless this outlet be afforded, these
fluids will burst through the sutures and cause them to cut out.

                              ASPHYXIA.

  The  surgical treatment of asphyxia includes the management of those cases
in which respiration has been suspended by drowning, suffejcation, hanging, or
the inhalation of irrespirable gases.   The  general subject of suspended anima-
tion from these various causes cannot be discussed here, but we must briefly
consider some points of practical importance in its treatment.
  In cases of drowning, life is often  recoverable, although the sufferer  has been
immersed in the water for a considerable  time, for it must be borne  in mind
that though immersed, he may very probably not have been submersed.  The
period after which life ceases to be recoverable  in  cases of submersion, cannot
be very accurately estimated.   The  officers of the Humane Society, who have
great  experience in these matters, state  that most generally cases  are not
recoverable that  have been more than four or five minutes under  water.  In
these cases, however, although  submersion may not continue for a longer period
than this, the process of asphyxia does;  this condition not ceasing on the with-
drawal  of the body from the water, but  continuing until the blood  in the 
ASPHYXIA. — DROWNING.
309
pulmonary vessels is aerated, either by the  spontaneous or artificial inflation of
the lungs.   As several minutes are most commonly consumed in withdrawing
the body from the water and conveying it to land, during which time no means
can be taken to introduce  air into the lungs, we must regard the asphyxia as
continuing during the whole of this period; occupying, indeed, the time that
intervenes between the last inspiration before  complete  submersion to the first
inspiration,  whether artificial  or  spontaneous, after the removal of the body
from the water.  The latest time  at which life can be recalled, during this
period, is the measure of the duration of life in asphyxia.  If, however, during
this period, the action of the heart should cease  entirely, I agree with Sir B.
Brodie, that the circulation can never be restored.  But although we may put
out of consideration those marvellous  cases of  restoration of  life  that  are
recorded by the older writers, and which are evidently  unworthy of belief, are
we to reject as exaggerated and apochryphal cases such as that by Mr. Smethurst,
in  which recovery  took  place after ten  minutes' submersion; that by  Dr.
Douglas of Havre, in which the patient  was not only submersed, but had actu-
ally sunk into, and was fixed  in  the  mud at the bottom for  from twelve to
fourteen minutes;  or that by Mr. Weeks, in which the submersion,  on the
testimony of the most credible witnesses, exceeded half  an hour ?  I think that
it would be unphilosophical in  the  extreme to deny the facts clearly stated by
these gentlemen.   The more  so  that  in these,  as  in many other instances of
apparent death from drowning,  life appears  to be prolonged by  the  patient
falling into a state  of syncope at  the moment of immersion.  We should there-
fore employ means of resuscitation, even though the body has been under water
a considerable time.
   The means recommended by the Humane Society for the recovery of persons
 from drowning, and employed  at their Institution in Hyde Park, appear to be
 well adapted for the treatment of the  less severe  forms of asphyxia, or rather
 for cases of syncope from fright  and immersions in cold water.   They consist,
 after the nose and mouth have been cleared of any mucosities, in the application
 of heat by  means of a bath at about  the temperature of 100° Fahr. until the
 natural warmth is restored; in the employment of brisk friction, and in passing
 ammonia to and fro under the nostrils.   It  is evident that these measures can
 have no direct influence upon the heart and lungs, but can only act as general
 stimuli to the system, equalizing the circulation if it be still going on; and, by
 determining to the surface, tending to  remove those congestions that are not
 so much the consequences of the asphyxia, as of the  sojourn of the body for
 several minutes  in cold  water;  they would, therefore, be of especial service
 during the colder seasons of  the year.   A hot bath may also, by the shock it
 gives, excite the reflex respiratory movements.   With the view of doing this
 with  a greater degree of certainty, cold water should be  sprinkled or dashed
 upon the face at the time that the body is immersed in the hot bath, as in this
 way a most powerful exciting influence can be communicated to the respiratory
 muscles; and the first object  of treatment in all cases of asphyxia — the re-
 establishment of respiration — would more rapidly and effectually  be accom-
 plished ; deep gaspings ensuing, by which the air would be sucked into the
 remotest ramifications of the air-cells, arterializing the  blood that had accumu
 lated in the pulmonary vessels, enabling it to find its way to the left cavities of
 the heart,  and thus to excite that organ to increased  activity.  These means,
 then, are useful in those  cases of asphyxia in which the sufferer has been but a
 short time submersed, and in which the heart  is  still acting, and the respira-
 tory movements  have either begun of their own  accord  on the patient being
 removed from the  water, or in which they are capable of being  excited  by the
 shock of a hot bath, aided by the  dashing of cold water in the face.  At the
 same  time, the lungs may be filled  with pure air, by  compressing the chest
 and abdomen, so as to  expel  the vitiated  air, and then allowing them  to 
310
ASPHYXIA.
recover their  usual  dimensions  by the  natural  resiliency of their parietes.
A small quantity of air will, in this way, be sucked in each time the chest is
allowed to expand, and thus the re-establishment of the  natural process of
respiration may be  much hastened.   This simple mode of restoring the vital
actions should never be omitted, as it is not attended with the least danger,
and does not in any way interfere with the other  measures employed.   Dr. M.
Hall has recommended  that the patient be turned prone, so that the tongue may
hang forwards, the larynx thus be  opened, and that respiration be then set up
by gentle pressure  along the back, and  by turning  the  patient on his side at
regular intervals.   If,  by  these  means,  we  succeed in  restoring  the  proper
action of  the respiratory movements, it  will  merely be  necessary to  pay
attention to some points of the after-treatment that will presently be adverted
to.   Should we, however, fail in restoring respiration, we  should have recourse
to other and more active measures.
  In the more severe cases of asphyxia, warmth should be applied by means of
a hot-air bath, by which not only the natural temperature of the body may be
re-established, but the  blood  in the capillaries  of the surface be decarbonized.
The most  direct and efficient means, however, that we possess for the re-esta-
blishment of the circulation of these cases, is certainly artificial respiration.  In
this way the pulmonary artery and  the  capillaries of the lungs  can alone be
unloaded  of the blood  that has stagnated  in them, and the left side and sub-
stance of the  heart will be directly and  rapidly  supplied by red blood.  The
whole value of artificial respiration  depends, however, upon the way in which
it is employed.  Inflation from  the  mouth of an  assistant into the  nostrils or
mouth of the sufferer,  though objectionable, as air  once  respired is not well
fitted for the resuscitation of the few sparks of life that may be  left in the cases
in which  it is desirable to employ this  means, yet  in many instances is  the
readiest and indeed the only mode by which respiration can  be set up;  and
should  therefore always be had recourse to in  the first instance, or until other
and more efficient means can be got ready.

                                  Fig. 132.
  The  bellows, if properly constructed  for  artificial  inflation, so  that  the
quantity of air injected  may be  measured, are no doubt  very useful;  and if
furnished with Leroy's trachea-pipes, or, what is better, with nostril-tubes, may
be safely employed.   About 15 cubic inches of air may be introduced at each 
ASPHYXIA. — OVERLAYING.
311
stroke of the bellows, and these should be worked ten or a dozen times in the
minute.  The lungs should  be emptied by  compression of the chest  before
beginning  to inflate, and after each inflation by compressing  the chest and
abdomen; but care must also be taken not to employ much force, lest the air-cells
be ruptured.  But the safest, and at the same time the most efficient, mode of
introducing pure air into the lungs, is either by means of the split sheet, as
recommended by Leroy  and Dalrymple (fig.  132), or else by alternately com-
pressing the chest and abdomen with the hand, and then removing the pressure
so as to allow the thorax to expand by the  natural resiliency of  its parietes,
and  thus, each  time it expands, to allow a  certain quantity of air to be sucked
into the bronchi. The quantity, introduced need not be large, for by the laws of
the  diffusion of gases, if fresh air be only  introduced into the  larger divisions
of the bronchi, it will rapidly and with certainty find its way into the ultimate
ramifications of these  tubes.  This  last means of inflation has the additional
advantage of resembling closely the natural process of respiration, which is one
of expansion from without inwards, and not,  as when the mouth or bellows are
used, of pressure from within outwards.  In  one case the lungs are, as  it were,
drawn outwards, the air merely rushing in  to fill up the vacuum that would
otherwise  be produced within the thorax by the expansion of its  parietes;  in
the  other they are forcibly pressed upon from within, and hence there is danger
of rupture of the air-cells.
   The inflation of  the lungs with oxygen  gas is likely to be of  great service in
extreme cases of asphyxia.  I have  found by experiment that the contractions
of the  heart can be  excited by inflating the lungs with  this gas,  when the
introduction of atmospheric air fails in doing so, and there are  cases on record
in which  resuscitation  was  effected by inflating the lungs with  oxygen gas,
when  in  all probability it could not have  been effected with any other means.
In my Essay on Asphyxia will be found a case of resuscitation, in which oxygen
was successfully employed by  Mr. AVeekes after  the asphyxia had  continued
three quarters of an hour.  Whatever means of resuscitation are adopted they
should  be  continued for at least three  or  four hours, even  though no signs of
life  show themselves; and after resuscitation the patient should be kept quiet
in bed for some hours.
   The  danger of the supervention of secondary asphyxia after  recovery has
apparently taken place, is much increased, and indeed is usually brought about
by some effort on the  part of the patient  that tends to embarrass the partially
restored action  of  the heart and lungs.   The patient being to all appearances
 resuscitated is allowed to get up and walk home, when the symptoms of asphyxia
 speedily return.  Should  symptoms of secondary  asphyxia, such as stupor,
 laborious  respiration, dilatation of  the  pupils, and convulsions, manifest them-
 selves, artificial respiration should  be immediately set up,  and be maintained
 until the action of the  heart has been fully restored.  In these cases I should,
 from the  very great efficacy of electricity, in the somewhat  similar condition
 resulting from the  administration of  the narcotic poisons, be disposed to recom-
 mend slight shocks to be passed through the base of the brain and upper portion
of  the  spinal cord, so  as to stimulate the respiratory tracts.
   Asphyxia from  the respiration  of noxious gases,  such as carbonic acid, is
best treated by exposing the surface of the  body to cold air, by dashing cold
water  upon the  face,  and by setting up artificial respiration without delay, if
the  impression  of  cold  upon the surface does not excite these actions.   There
is a peculiar variety of this  kind  of asphyxia,  that is occasionally met with
among infants, the true  nature of which was pointed  out to  me by Mr. Wakley,
who, as coroner, has had abundant opportunities of witnessing it, as it is not
an uncommon cause of accidental death amongst the children  of the poor.   It
is that condition in which a child is said to have  been  overlaid;  the child
tieeping with its mother or nurse being found in the morning suffocated in the 
312
INJURIES  OF  THE THROAT.
bed.  On examination no marks of pressure will be found, but the right cavities
of the heart and  lungs are gorged with blood, and the surface livid,  clearly
indicating death by asphyxia. That this accident is not the result of the  mother
overlaying her child, is not only evident from the  post mortem appearances, but
was clearly proved by a melancholy case to which I was called a few years ago,
in which a mother, on waking in  the morning, found her  twin infants lying
dead on either side of her.  Here it was evident from the position of the bodies
that she could not have  overlaid  both.  The true cause of death in these cases
is the inhalation of, and slow suffocation by, the vitiated air which accumulates
under the bed-clothes  that have been drawn, for the sake of warmth, over the
child's head.  In such  cases as these, resuscitation by artificial respiration should
always be attempted if any signs of life be left.
   In cases of hanging,  death seldom results from pure asphyxia, but is  usually
the consequence,  to a certain degree at least, of apoplexy, and commonly of
simultaneous  injury of the spinal cord.   In these cases,  bleeding  from  the
 jugular vein may be conjoined with artificial respiration.
   If there should be a difficulty in setting up artificial respiration, through the
mouth or nose, as is more especially likely to happen when the patient has been
suffocated  by breathing noxious  gases, or in cases  of hanging,  tracheotomy or
laryngotomy should at once be performed,  and the lungs inflated through the
opening thus  made in  the neck.

            FOREIGN BODIES  IN  THE AIR-PASSAGES.

   Though  the introduction of foreign bodies  into the  air-passages is not a
very common  accident, yet  a great variety  of substances that admit of being
 swallowed has been found there : such as nut-shells, beans, cherry-stones, teeth,
 meat, money, buttons, pins, fish-bones, bullets, pills, pebbles, and  pieces of stick.
 These foreign bodies  are  not introduced into the air-passages by any effort of
 deglutition, for no  substance can  be  swallowed  through  the glottis; but  if a
 person, whilst swallowing or holding any substance in his mouth makes a sudden
 inspiration, the current of air may draw it between the dilated lips of the glottis
 into the larynx.
    The symptoms vary, according to the situation in which  the  foreign body is
 lodged, its nature and  the  period that has elapsed since the occurrence of the
 accident.  The foreign body may  lodge in one of the ventricles of the larynx,
 or, if light, it may float in  the trachea, carried up  and down by the movement
 of the air in  expiration and inspiration.   If too  heavy for this, it will  fall into
 one or other of  the primary divisions of the trachea, and, as Aston Key has
 observed, will most  commonly be found in the right bronchus, this being larger,
 and in a more direct line with the trachea than the left.   If the substance be
 small, it may pass into one of the  secondary divisions of the bronchi, and  if it
 continue to be lodged here for a sufficient length of time, may make a  kind of
 cavity for itself in  the substance  of the lung, where it may either lie in an
 abscess, or become encysted.
    The symptoms may be divided into three stages.  1st. Those that immediately
 follow the introduction of the substance.  2d. Those produced by the irritation
 of its presence; and 3d. Symptoms of an inflammatory character coming on at
 a later period.
    1st.  The  immediate symptoms  vary somewhat, according to  the size and
 nature of the body, and the part  of the air-tube that it reaches.  In  all cases
 thece is a feeling of  intense suffocation, with great difficulty of breathing, and
 violent fits of spasmodic coughing, often attended by vomiting; during which
 the foreign  body may be  expelled.  Indeed, its partial  entry  and  immediate
 extrusion, by coughing, is not uncommon.  In some cases immediate death may
 ensue at this period.   If it have entered the air-passages fully,  there is usually 
           FOREIGN  BODIES  IN  THE  AIR-PASSAGES.       313

violent coughing with feeling of suffocation for an hour or two, accompanied by
lividity of the face, great anxiety, and sense of impending death.  There is also
usually pain  felt  about  the episternal notch.  These symptoms then gradually
subside, but any movement on  the  part of the  patient brings  them on again
with renewed violence.  All these symptoms are most severe if the foreign  body
remains in the larynx; the voice being then  croupy, irregular in  tone, or lost.
If it be lodged elsewhere, so often as it  is coughed up, and strikes against the
interior of the larynx, an  intense feeling of suffocation is produced; and if it
happen to become impacted there,  sudden death may result,  even  though it be
not of  sufficient size to block  up the air-passage, but apparently by the spasm
that is induced.  Some years ago a boy died at the Westminster Hospital before
tracheotomy  could be performed, in consequence of a flat piece of walnut-shell
that had  got  into  the trachea being  suddenly coughed up, and becoming
impacted  in  one  of the ventricles  of the  larynx.  The symptoms, during this
period, are much less severe when the foreign  body is in the trachea or bronchi.
   2nd. When the foreign body has passed into the air-passages, and the imme-
diate effects produced by its  introduction  have  been got over, another set of
symptoms, dependent on the  irritation  produced by it, is met with;  and it is
during the occurrence of these  that the  patient is most generally brought under
the surgeon's observation.  These  symptoms are of two  kinds;  general and
auscultatory.
   The general symptoms consist of occasional fits of spasmodic cough, accom-
panied  by much difficulty of breathing, a feeling of suffocation, and an appear-
ance of urgent distress  in the countenance.  These attacks do not occur  when
the.patient is tranquil, but come on whenever the foreign body is  coughed up
so as to strike the larynx, and the upper and more sensitive parts  of the air-
 E>assages.   As a general rule  the distress is  less, the lower the  substance is
 odged; the  sensibility  of the inferior portion of the trachea  and bronchi being
much less acute than that of the larynx and the upper part of the trachea.  In
consequence  of the irritation, there is usually abundant expectoration of frothy
mucus.
   The  auscultatory signs depend necessarily  upon the situation of the foreign
body.   If this be loose and floating, it may be heard on applying the ear to the
chest, moving up and down, and occasionally striking against the side of the
trachea.  If it be fixed, it will necessarily give  rise to a certain degree of ob-
struction to the admission of the air beyond it, perhaps occasioning bruits during
its passage.   If it be  impacted in  the larynx, the voice will be hoarse and
 croupy, and there will be a loud rough sound in respiration, with much spasmodic
 cough and distress in breathing. If it be impacted in one bronchus, the  respi-
 ratory  murmur will be much diminished, or even absent,  in  the corresponding
 lung, and probably puerile in the other; whilst  percussion will yield an equally
 clear and sonorous sound on both sides  of  the chest, air being contained in the
 lung of the  obstructed  side, but not readily passing in and out.  If  one of the
 subdivisions of either bronchus be  occupied by the  foreign body,  the  entrance
 of air will be prevented in the corresponding lobe of that lung, though it enter
 freely every other part  of the chest.  If the foreign body be angular, or perfo-
rated, peculiar sibilant  and whistling noises may be heard as the air passes over
and through it.
   3rd. After a foreign body has been  lodged for a day  or  two, symptoms of
inflammation of the bronchi, or lungs, are apt to be set up; in some  cases, how-
ever, these only oocur after a considerable  time has elapsed, or, perhaps, not at
all, much depending, of course, on  the shape  and character of the irritant.  If
it continue to lodge, it generally forms for itself a cavity in the substance of the
lung, whence purulent and bloody matters are  continually expectorated, until
the patient dies in the course of a few months, or a year or two, of phthisis.  It
has occasionally happened, however, that the substance  has  been coughed up 
314
INJURIES  OF  THE  THROAT.
after a very long lodgment, the patient recovering.  Thus, Tulpius relates a case
in which a nut-shell was coughed up  after being lodged for  seven years, and
Heckster one in which a ducat was thus brought up after a lapse of two years
and a half, the patient, in both instances recovering. In other cases again death
may ensue, although the foreign body is coughed up;  thus, Sue  relates  an in-
stance in which a pigeon-bone was spat up seventeen years after its introduction,
the patient, however, dying in little more than a year from marasmus.
   The prognosis depends more upon the nature of the foreign body and its size
than on any other circumstances.  If it be rough, angular, and  hard, there is
necessarily much more risk than if it be soluble in, or capable of disintegration
by, the mucus of the air-passages.  So long as the foreign  body is allowed to
remain in, the patient is in imminent danger, either from immediate and sudden
suffocation, or from inflammation at a more remote period.
   The danger depends  greatly upon  the  length of time that it is allowed to
lodge.  Of 58 cases (4  of which have fallen under  my own observation,  the
remaining 54  being collected from various sources, and  constituting all those
that I have been able to find recorded) I find the time that the foreign body was
allowed to remain in, and the result of the case stated in 45 instances, which I
have tabulated as follows:
PERIOD THAT IT REMAINED IN.	NUMBEROF CASES.	RECO-VERED.	DIED.
	7 4 12 8 3 4 7	5 3 5 4 3 2 4	2 1 7 4 0 2 3
			
			
Between 1 month and 3 mouths.....			
			
Total........................	45	26	19
			
  From this it would appear that if the patient escaped the danger of the im-
mediate introduction, the greatest risk occurred between the second day and the
end of the first month, no  less than 11 patients  out of 20 dying during this
period, and then that the mortality diminished until the third month, from which
time it increased again.
  The cause of death also varies according to the period at which the fatal
result takes place.   During the first  twenty-four, and indeed,  forty-eight hours,
it happens from convulsions and sudden asphyxia.   During the first few weeks
it is apt to occur from inflammatory mischief within the chest,  and after some
months have elapsed the patient will be carried off  by marasmus or phthisis.
  Spontaneous expulsion of the foreign body, usually in a violent fit of coughing,
occasionally occurs.  Dr. Cross finds that there are 49 cases on record, in which
the body was spontaneously expelled, the  patient recovering.   Of these, in 37
it was expelled during a fit of coughing.   The  period during which a foreign
substance may remain in the air-passages before it is spontaneously expelled,
varies from a few minutes to many months or years; in one  case, a piece of bone
introduced at the age of three, was not ejected until sixty years had elapsed.
In 8 cases death followed the spontaneous expulsion.
   Treatment. — This accident is always a very serious one, and hence requires
prompt and energetic means to be used  in order  to save the  patient; and for-
tunately the means at our disposal, consisting of the simple  operation of opening
the trachea, and thus facilitating the expulsion of the foreign body, are usually
highly successful.  I find that of 56 cases in which the result was noted, 33 lived, 
FOREIGN BODIES  IN  THE AIR-PASSAGES.        315
and 23 died; but on  analyzing these cases more  closely, it appears that in 36
no operation was performed; the expulsion of the foreign body being trusted
to the efforts of nature.  Of these 20 died, and 16 lived.   In the remaining 20
cases, tabulated below, tracheotomy was performed;  of these 17 lived, and only
3 died, showing a remarkable success attendant on this operation.
PERIOD THAT IT REMAINED IN.	NUMBER OF CASES.	CURED.	DIED.
	3 2 8 5 2	2 2 7 4 2	1 0 1 1 0
			
			
			
	20	17	3
  Dr. Gross has since extended these statistics very materially, and has found
that out of 68 recorded cases in which tracheotomy has been performed, the
operation was successful in 60, and in 8 the patient died.
  Laryngo-tracheotomy was  done in 13 cases; of these, 10 successes, and 3
deaths.
  No means short of operation have been found of any use.   Emetics, sternu-
tations,  inversion, and succussion  of the body, are  all  either useless  or  dan-
gerous,  unless the air-passages have previously been opened.
  If, therefore, a patient is  seen  a few hours, days, or weeks, after a foreign
body has been introduced into the air-passages, or indeed at  any period  after
the accident, tracheotomy ought to be performed. But it may be asked, for what
purpose is the trachea opened ?  Why should not the foreign body be expelled
through the  same  aperture  by which it has  entered ?  The opening in the
trachea  performs a double  purpose; it not only serves as a ready and passive
outlet for the expulsion of the foreign body, but also as a second breathing aper-
ture in  the event of its  escaping  through the glottis.   The advantage of the
opening in the  trachea as a ready aperture  of expulsion is evident, from the
fact that of 14 of the operated cases in which it is stated how the foreign  body
was expelled,  I find that in 12 it was ejected  through the artificial  opening,
whilst in 2 only did it pass out through the glottis.
   The reason  why the foreign body usually passes out of the artificial  opening
in preference to escaping  by the  glottis, is, that the sides of one  aperture are
passive, whereas those of the other are highly sensitive and contractile.   Before
the operation is performed, it will be found that the great obstacle to expulsion
is not only the sensitiveness  of the larynx, great irritation being induced when
it is touched from within,  but also  the contraction of the glottis, by the closure
of which not only is the expulsion of the foreign body prevented, but respiration
impeded.   Every time the foreign  body is coughed up  so as to touch the inte-
rior of  the  larynx, intense dyspnoea will be produced, owing to sudden  and
involuntary closure  of the glottis, by which respiration is  entirely prevented
and suffocation threatened; the expulsion of the body is consequently arrested,
unless it were by chance to take the glottis by surprise, and pass through it at
once in the same way that it has entered  it,  without  touching its sides.  If
there is a second breathing aperture, though the larynx is equally irritated by
the foreign body, yet this  dyspnoea  cannot  occur, respiration being carried on
uninterruptedly by one opening whilst the foreign  body escapes  through the
other;  and  thus, under  these circumstances, it may pass through the glottis
with but little inconvenience to the patient.
   In some cases the foreign body is expelled at once after the trachea has been 
316
INJURIES  OF  THE  THROAT.
opened;  in  others, not  until some hours, days, or even  weeks, have elapsed
Thus, in Houston's case, a piece of stick was not coughed up until ninety-seven
days after the operation; and in Brodie's case, sixteen days elapsed  before the
half-sovereign came away.
  In some cases laryngotomy has been performed  instead  of tracheotomy, and
the foreign body has been equally well expelled.  Dr. Gross gives 13 instances
of this  successful  in their results, and 4 in which  death followed the operation.
  The expulsion has in some instances been facilitated by inverting the patient,
shaking him, or striking him on the back.   In cases in which the foreign body
is not readily expelled, it has been proposed to introduce forceps and extract it.
But although in some instances it has succeeded, the uncertainty and danger of
such a proceeding is so  great that few surgeons would be disposed to attempt it.
The introduction  of the forceps producing  violent irritating cough, during
which their points might readily be driven through  the bronchi, and thus
wound the lung or contiguous important structures.   Besides this, there would
be the danger of seizing the projecting angle at the bifurcation of the bronchi
instead of the foreign  body, and  thus  injuring  the  parts  seriously.  If the
foreign body is fixed, the safer plan would certainly be to leave the aperture in
the trachea unclosed, and wait for the  loosening of the body, and its ultimate
expulsion, which have hitherto occurred in  all  cases that have been  operated
on, or its escape might be facilitated by the  gentle  introduction of  a probe, so
as to dislodge it if seated in either bronchus, though this should be done with
great caution, or the patient may be inverted and succussed when the expulsion
may take place.   Should it not then escape the wound  should  be kept open by
means of blunt hooks, when, perhaps, it may be ejected.
   x\ntiphlogistic treatment  must be continued during the whole progress of the
case.  After the escape of the foreign body the opening in the trachea must
be closed.
   Dr. Gross' statistics are as follows: — of 159 cases spontaneous expulsion took
place in 57; of these 49 recovered and 8 died.
   Inversion of the body alone was successful in 5 cases.
   Laryngotomy was practised in 17; of these 13  lived and 4 died.
   Tracheotomy in 68;  of these 60 lived and 8  died.
   Laryngo-tracheotomy in 13; of these 10 lived  and 3 died.
   Scalds of the mouth, the pharynx, and the glottis, occasionally occur
from attempts to swallow boiling water; or these parts are scorched by the inha-
lation of flame.   The scalding of these parts chiefly happens to the children
of the poor, who being in the habit of drinking cold water from the spout of a
kettle, inadvertently attempt to take a draught from the same  source when the
water is  boiling.   The  hot liquid is  not  swallowed, but though immediately
ejected, has scalded the inside of the mouth and pharynx, giving rise to a con-
siderable degree of inflammation, which, extending to the glottis, may produce
oedema of it, and  thus speedily destroy life by suffocation.  In 3 cases which I
have had an opportunity of examining after  death, there was no  sign of in-
flammation below the  glottis,  though  the  lips of this aperture were greatly
swollen;  and this I believe to be invariably the case, the inflammation not ex-
tending into the interior of the larynx, as has been pointed out by Dr. M. Hall.
   The accident always  reveals itself by very evident signs;  the interior of the
mouth looks white and  scalded, the child complains of great pain, and difficulty
of breathing  soon sets  in;  which, unless efficiently relieved, may terminate in
speedy suffocation.
   In those cases   in which these  parts have been similarly injured by the flame
produced by the explosion of gas or of  fire-damp  being sucked into the mouth,
the same conditions present themselves.
   In the treatment of  this injury the  main point to attend  to is to subdue the
inflammation, before it  involves  the glottis  to a dangerous extent.   With this 
INJURIES OF  THE  "(ESOPHAGUS,
317
view, leeches should be freely applied to the neck, and calomel with antimony
administered.   If  symptoms  of urgent dyspnoea have set in, tracheotomy must
be performed without delay, and if the child be not too young, a tube introduced
into  the  aperture  so made, and kept there until the  swelling about the glottis
has been subdued  by a  continuance of the antiphlogistic  treatment.  In  the
majority  of the cases, however, that have fallen under my observation, in which
this  operation has  been performed, the  issue has been a  fatal one,  from  the
speedy supervention of broncho-pneumonia;  but as it  affords the only chance
of life when the dyspnoea is urgent, it must be done, though its performance in
very young children is often  attended by much difficulty, from the shortness of
the neck and the small size of the trachea.

                  INJURIES OF THE  OESOPHAGUS.

   Wounds of the oesophagus are chiefly met  with in  cases of cut throat, in
which, as has been already stated  in treating of these injuries,  they occasion
much difficulty by interfering with deglutition.
   Foreign bodies  not uncommonly become impacted  in the pharynx and oeso-
phagus,  and may produce great inconvenience by their size or shape.   If large,
as a  piece of money or a  lump of meat,  it may become fixed in the lower part
of the pharynx or the commencement of the oesophagus, which is narrowed by
the projection of the larynx backwards,  and, compressing or occluding the ori-
fice of the glottis,  may asphyxiate the patient at once.   If the foreign body get
beyond this point, it usually becomes arrested near the termination of the oeso-
phagus.   When it is small, or pointed, like a fish-bone, pin, or bristle, it usually
becomes entangled in the folds of mucous membrane that stretch  from the root
of the tongue to the epiglottis, or that lie along the sides of the pharynx.   In
some cases it may even perforate these, penetrating the substance of the larynx,
and  thus producing intense local irritation.
   The symptoms occasioned by the  impaction of a foreign body in the food-pas-
sages are sufficiently evident.  The sensations of the patient, who usually com-
plains of uneasiness about the top of the sternum; the difficulty that he has in
swallowing solids,  and perhaps the occurrence of an urgent sense of suffocation,
lead  to  the detection of  the  accident.  Should any doubt exist, the surgeon
may, by introducing his finger, explore nearly the whole  of the  pharynx,  and
 should  examine the oesophagus  by the cautious introduction  of a well-oiled
probang.
   If the impaction is  allowed to  continue  unrelieved, not only may deglutition
 and respiration be seriously interfered with, but ulceration of the oesophagus will
 take place, and abscess form either behind or between  it and the trachea, or fatal
 hemorrhage may ensue.
   It may happen  that the foreign body, by transfixing the coats of the oesopha-
 gus, has seriously injured some neighboring parts of importance.  Thus, in a
 curious case admitted into the University College Hospital, a juggler, in attempt-
 ing  to  swallow a blunted sword, perforated the oesophagus and  wounded the
 pericardium, death consequently resulting in the course of a few days.
   The treatment must depend upon the nature of the foreign body and its situa-
 tion.  Should it be of large size, blocking up the pharynx so as to render respi-
 ration impracticable, it may be hooked out with the surgeon's fingers.  Should
 asphyxia have  been induced, it  may be necessary to perform tracheotomy at
 once, and to keep up artificial respiration until the foreign body can be extracted.
 If it be small,  or pointed, as a fish-bone or  pin for  instance, though it  have
 lodged  high up,  the surgeon will usually  experience great  difficulty  in its
 removal, as it gets entangled between and is covered in  by the folds of the
 mucous  membrane, where from its small size it may escape detection;  and after
 it has been removed, the patient will experience for  some time a pricking sen- 
318
INJURIES OF  THE  CHEST.
sation, as if it were still fixed.  If the impacted body have got low down into
the oesophagus, the  surgeon must deal with it according to its nature.  If smooth
and soft, as a piece  of meat for instance, it may be pushed down into the throat
by the gentle pressure of the probang.  If, however, it be rough, hard, or sharp
pointed, as a piece  of earthenware or bone, such a procedure would certainly
cause perforation of the  oesophagus,  and serious mischief to  the parts around •
under these circumstances, therefore, an attempt  at  extraction should be made
by means of long slightly curved forceps, constructed for the purpose.
  It occasionally happens that the foreign body has  become so firmly impacted
in the pharynx or oesophagus that  it cannot  be  extracted with any degree of
force  that it is prudent to use;  under these circumstances it may become neces-
sary to open the tube  and thus  remove it.   The  operation of Pharyngotomy or
(Esophagotomy is, however, seldom called for, but if required may be performed
by making an incision about four inches in length along  the anterior border of
the sterno-mastoid muscle on the left side of the neck, the oesophagus naturally
curving somewhat towards this  side.   The dissection must then be carried with
great caution between the carotid sheath and the larynx and trachea in a direc-
tion backwards,  the omo-hyoid muscle  having been  divided  in order to afford
room.   Care  must  be taken in prosecuting  this deep dissection not to wound
either of the thyroid arteries,  more  especially the inferior one, which will be
endangered by carrying the incisions too low.  When the pharynx or oesophagus
has been reached, a sound or catheter should  be passed through the mouth into
this cavity, and pushed forwards so that its  point may cause the walls to project,
and thus serve as a  guide to the surgeon.   This must then be cut open, and the
aperture thus made  in the gullet enlarged by  means of a probe-pointed bistoury,
to a sufficient size, for the extraneous substance to be extracted.
                          CHAPTER  XX.

                     INJURIES  OF THE CHEST.

  Wounds of the chest derive their principal interest and importance from the
concomitant injury of the lungs, heart, or larger blood-vessels. When the parietes
alone are wounded, the injury differs  in nothing from  similar lesions in other
parts of the body.  In these cases if the surgeon be in doubt whether the cavity
of the chest has been penetrated or not, it is better for him to wait and to be
guided in his opinion  by the symptoms that manifest themselves, rather than by
probing the wound, running  the risk  of converting  it  into what he  dreads, a
penetrating wound of the chest.
  Wound of the  lung is the most common and one of the most serious compli-
cations  of injuries of the chest.  It  may occur without any external wound,
from the ends  of a broken rib  being driven inwards upon  this organ: most
frequently, however, it happens from a penetrating wound of the chest, by stab
or bullet
  The symptoms of this injury are sufficiently well marked. There is in the
first place the  immediate shock to the system that usually accompanies the
infliction of a severe injury, the patient at  the same time  being  seized with
considerable difficulty of breathing, followed by much  tickling and  irritating
cough, and the expectoration of frothy bloody mucus, or perhaps of large quan-
tities of pure blood.   If there be an external opening, the air may  pass in and 
EMPHYSEMA.                         319
out during the act  of breathing, and emphysema, pneumo-thorax,  or  pneu-
monia will speedily supervene.  On  auscultating the chest immediately  after
the infliction of the injury, and before there is time for the supervention of any
after-consequences, a loud  rough crepitation will be distinctly audible at and
around the seat of injury.
   The principal dangers attending a wound of the lung arise from the  bleeding,
both external and  internal, the  occurrence of emphysema,  pneumo-thorax,
pneumonia, and empyema.
   1st. The hemorrhage is usually abundant and often fatal, the patient spitting
up a large quantity of florid, frothy blood.  If it do not prove fatal in  the early
period of the injury,  this  bloody expectoration generally ceases  in a  great
measure in the course of forty-eight hours, giving way to sputa of a more  rusty
character.   If the  external wound be very free,  there  may also  be copious
bleeding from it,  but not unfrequently the  blood finds its way into the pleural
sac, rather than  through the external aperture, and accumulating in it, may
induce death, either by this  internal  and concealed hemorrhage, or by  occa-
sioning suffocation.   The symptoms of this internal hemorrhage, Hemothorax,
are those that generally characterize loss of blood, such as coldness and pallor
of the surface, small weak  pulse, and  a tendency  to collapse  with increasing
dyspnoea.  The more special signs  consist in an inability to lie on the uninjured
side, with, in extreme  cases,  some bulging  of the  intercostal spaces, and  an
ecchymosed  condition of the  posterior part  of the wounded side of the chest.
The  most important signs, however, are  those that are furnished by ausculta-
tion.  As the  blood gravitates towards the back  of the chest, between the
posterior  wall and  the diaphragm, there will be gradually increasing dulness
on percussion in  this situation, with  absence of respiratory murmur;  the other
portions of the lung, however, admitting air freely.
    2d. Emphysema,  or the infiltration of air into the cellular tissue of the  body,
 and pneumo-thorax, or the accumulation of air in the cavity of the pleura, are
 not unfrequent complications of wounded  lung, although  not  by any  means
 invariably met with.   These accidents more commonly occur when the external
 wound is small  and oblique, than when it is large and  direct, and not  unfre-
 quently happen  in  those  cases in which the lung is punctured by a fractured
 rib, without there being any external wound. In the majority of cases, emphy-
 sema and pneumo-thorax occur together, but either may be met with separately.
 The mechanism of traumatic emphysema  is most commonly as follows: The
 pleura costalis being  wounded and the  lung injured, at every inspiration a
 quantity of air  is  sucked into the pleural sac,  either through the external
 wound, or, if none exist, from the hole in the lung, thus  giving rise to pneumo-
 thorax.  At every expiration, the air that thus  accumulates in the pleural sac
 being compressed by the descent of the walls of the chest, is pumped into the
 cellular  tissue around the edges of the wound; and if this  be oblique and
 valvular, being unable to escape wholly through it, finds its way at  each suc-
 ceeding  respiration further into the large cellular planes, first about  the  trunk
 and neck, and eventually, perhaps, into those of the  body generally.   Though
 this is the way in which emphysema usually occurs, it may be occasioned other-
 wise.   Thus, for instance, I had lately under my care a woman who had  exten-
 sive emphysema of the  cellular  tissue of the trunk from fractured ribs, but
 without  any pneumo-thorax, the  lung having been wounded at a spot where
 it was attached to the walls of the chest by old adhesions, and the air having
 passed through them into the cellular  tissue  of the body, without first entering
 the cavity of the pleura.   Mr. Hilton  has described a form of traumatic eni-
 physema that arises by  the  rupture  of an air-cell or  bronchus without any
 external wound.   The air, getting into the posterior mediastinum, and, finding
 its way along the nerves and vessels  in this situation, passes  out through the
 cervical fascia, which  closes the upper part of the thorax, and  thus reaching 
320
INJURIES OF  THE  CHEST.
the neck, diffuses itself along the sheaths of the arteries  and nerves,  along
which it finds its way into the limbs; its  appearance  in which is first indicated
by its extending along the course of the vessels.
  The symptoms of emphysema are very distinctly marked.   There is a puffy
swelling, pale, and crackling when pressed upon, at first confined to the neigh-
borhood of the wound, if there be one externally; if not, making its appearance
opposite  the fractured  ribs, and  gradually  extending over the upper  part of
the trunk  and neck, to which it is  usually limited; in  some  cases, however,
which are happily rare, the swelling becomes  more general, the  body  being
blown up to an enormous size, the features effaced, the movement of the limbs
interfered with, respiration arrested, and suffocation consequently induced; after
death air has been found in all the tissues, even under the serous coverings of
the abdominal organs.  In traumatic pneumo-thorax there is a diminution or
complete absence of the  respiratory murmur on the  affected side, with a loud
tympanitic resonance on percussion,  puerile respiration in the  sound lung, and
considerable distress in breathing.
   3d. Pneumonia is an invariable sequence of a wounded lung, and constitutes
one of the great secondary dangers of these injuries; the inflammation that is
necessary for the repair  of  the wound in  this organ having frequently a
tendency to extend beyond the part injured, and not uncommonly  to terminate
in abscess.  Traumatic pneumonia resembles in  all  its symptoms,  auscultatory
as  well  as general,  the idiopathic form of the disease.   There  is the same
crepitation, dulness  on percussion, and absence of respiratory murmur  as hepa-
tization advances; with rusty sputa, much tinged with blood  in the  early stages.
It differs, however, from the idiopathic form of the  disease, in having  a less
tendency to diffuse itself throughout the lung, in being  limited to the injured
side  alone, and in more  frequently terminating in  abscess, which, however, is
 often dependent on  the  lodgment  of  some foreign body, such as a  piece of
 wadding or clothing, in the substance of the organ.
   4th.  Empyema  comes on  at a later period, being usually occasioned by the
 irritation of effused blood, or of  some extraneous substance  that has lodged in
 the pleura.   Its existence may  be  recognized  by dulness on  percussion, and
 absence of respiratory murmur  at  the  lower and posterior  parts  of the chest
 up to a level that has a gradual tendency to ascend,  and that varies according
 as the patient is upright or recumbent, until at last the whole side  of the chest
 being filled with pus, there is increase of its size on measurement, with bulging
 of the intercostal spaces, and compression of the lung against the spine.
   The prognosis in  wounds of the lungs is of course extremely unfavorable, but
 less so  than that of similar  injuries of most of the other viscera.   Gun-shot
 wounds of  the chest are more dangerous than stabs,  owing partly to the lacera-
 tion  attendant on a bullet-wound, but chiefly perhaps on the lodgment of foreign
 bodies  that so  commonly occurs in  these  injuries.   Guthrie states, that more
 than half of those who are shot through  the chest, die.  After the battle of
 Toulouse, of  106 such cases, nearly half died;  and of 40 cases at the  Hotel
 Dieu, 20 died.   Messrs. Mouat and Wyatt state that  of 200 cases of penetrating
 rounds of  the chest occurring in the Bussian army at the siege of Sebastopol,
 and  treated at Simpheropol, only 3 recovered.  The Russian surgeons, however,
 do not  bleed in these cases, but use digitalis instead.   The great danger and
 principal cause of death in these injuries is unquestionably the hemorrhage  that
 ensues.   This may prove immediately fatal if one of the larger pulmonary ves-
 sels  is  divided.  As the bleeding is  most abundant at, and  shortly after the
 receipt of the wound,  Hennen states that if the patient  survive the third day,
 great hopes may be entertained of his recovery.  After this  period the chief
 source of danger is  the occurrence of inflammation of the lungs and pleura, the
 extent and severity of which are greatly increased in gun-shot injuries  by the
 frequent lodgment of  foreign bodies within the chest.   Emphysema is seldom 
TREATMENT OF  WOUNDS OF  THE  CHEST.        321
a dangerous  complication, though  it  may become so if very extensive, and
allowed to increase unchecked.
  If both lungs are wounded at  the same time, the result is almost inevitably
fatal, either by the abundant hemorrhage  suffocating or exhausting the patient;
or else by the induction of  asphyxia  in  consequence of air being drawn into
both the pleural sacs, and thus  by compressing the lungs, arresting respiration.
This, however, does not  necessarily result, and there are  a sufficient number of
cases on record of recoveries after  stab or bullet wounds traversing both sides
of the  chest,  to show that collapse  of  the lungs and consequent asphyxia does
not necessarily result from this  double  injury, which indeed has also been deter-
mined experimentally on animals by Cruveilhier.
   The treatment of wounds of the chest,  implicating  the  lungs, must  have
reference to  the various  sources of danger that have just been indicated.
   The local  treatment is of a very  simple character.   If the wound have been
made by a bullet, all foreign bodies that  are within reach should be extracted.
If there is any difficulty in doing this, it  may be necessary to enlarge the aper-
ture and then to remove them; but the surgeon must  not go too deeply or per-
severingly in search of them, lest he excite more irritation than the foreign body
 would.  Light water-dressing  should  then  be applied, no  attempt being  made
 to close the  aperture, so  that the escape  of any extraneous substance that may
 have been left, or of extravasated blood, may not be interfered with.
   If the wound be a clean  puncture, the edges may be brought together and
 closed by means of stitches,  plasters, and  collodion, so  that the bleeding may be
 arrested, and the patient enabled to breathe with more ease.  It is seldom that
 there  is any troublesome hemorrhage from wounds of the intercostal arteries;
 should there  be so, the surgeon must  enlarge  the orifice of the wound, and
 secure the bleeding vessel in the best way he can.
   Wounds of the internal mammary artery are of rare occurrence, considering
 its exposed  situation.   They may however occur if the chest is penetrated in
 front through  the intercostal spaces, or costal  cartilages.  The danger in these
 cases  is from the hemorrhage taking place slowly into the anterior mediastinum,
 or one of the pleurae, without any external bleeding revealing the mischief that
 is going on within.   If the wound  of  the vessel be ascertained, an  attempt
 should be made, by enlarging the external aperture, to seize  and ligature the
 bleeding ends, cutting directly down upon them through the injured intercostal
 space, or the vessel might even be  followed beneath one of the costal cartilages,
 if necessary, by cutting  through this.  Should much blood have already been
 extravasated, this must  be removed through the  external wound, by the intro-
 duction of a female catheter,  or by the  application of  a cupping-glass over it,
 and the case then treated like one  of effusion into the chest.
   In  the  constitutional treatment  of  these injuries, the  first indication consists
 in diminishing the quantity of  blood circulating through the lungs, and thus
 endeavoring to arrest  the hemorrhage from these organs.   With this view, a
 free venesection, to the extent of from at least twenty to thirty ounces, or even
 more, must  be practised.  In this way the  bleeding may be stopped at once;
 should it recur, and the pulse  rise, blood  must be taken from the arm again and
 again.  The most experienced surgeons are unanimous in their opinion, that at
 this  stage of  the injury, the patient's safety lies  in free and repeated  venesec-
 tion.   The patient must then be kept lying on the injured side, and have nothing
 but ice or barley-water allowed.
   If  the patient survive the third day, the danger to be apprehended is from
 inflammation within the chest.  Here also bleeding must be practised, though
 it need not  be done  to the  same extent  as in the earlier stages of the injury.
 The inflammation must also be combated  by a rigid diet, and by the administra-
 tion of antimonials.  In fracture of the ribs with wounded lung, the same line 
322
INJURIES  OF  THE CHEST.
of treatment requires to be  adopted, but when the accident occurs in elderly
people, we may advantageously substitute calomel and opium for the antimonials
  If extravasation of blood into the pleura is going on, its farther effusion must,
if possible, be arrested by the same means that are adopted for the stoppage of
external hemorrhage.  When the bleeding has been checked in this way, the
blood must early be let out from the pleural sac;  for, if it be allowed to remain
there, it will speedily putrefy, giving rise to extensive formations of pus in this
cavity.   In order to prevent these occurrences, the wound.should be  opened
freely with a probe-pointed bistoury, on the fifth  or sixth day after the injury,
so that  the blood  may be discharged.  If it do not readily come away, a cup-
ping glass may be applied over the aperture, and thus  it may be withdrawn.
Should,  however, the hemorrhage continue notwithstanding the employment of
the means  indicated, Guthrie advises that the wound should be closed, so that
the blood that flows into the pleural sac may, by accumulating in this, compress
the lungs, and thus  arrest the further escape of  blood from  the wounded ves-
sels; the patient at the same time should be  made to lie on the injured side, in
order to increase the pressure exercised upon  the  wounded and bleeding organ.
On the sixth or eighth day the  chest  should  be  tapped, or the  wound  opened
again, in order to  evacuate the extravasation, and  prevent its acting as an irri-
tant to the pleura; or  by permanently compressing and  condensing the lung,
rendering this useless.
   In all cases of purulent effusion into the chest, Guthrie advises, with good
reason,  that tapping should be early performed, in order that the lung may not
be bound down by false membranes, and consequently being  unable to expand,
lead to permanent flattening of the side, and impairment of respiration.
   If any extraneous body, such as a bullet, a piece of wadding,  or of clothing,
have penetrated too deeply into the chest to be readily extracted through the
external wound, it would not be safe to  make incisions or exploratory researches,
with a view of extracting it; for, though its presence would increase the patient's
danger, yet, attempts at extraction would not only add to this, but in all proba-
bility be fatal.   In many cases, bodies so lodged form  an abscess around them,
are loosened, and  eventually are  spit up, or appear at the external wound.  In
others,  again, they remain permanently fixed in the chest, becoming enveloped
in a cyst, and so remaining for years, without producing irritation.  In this way
Hennen states that a bullet has been lodged in the chest for upwards of twenty
years; and Vidal  mentions a man who  lived  for  fifteen years with  the  broken
end of  a foil in his chest, which, after death,  was found sticking in the verte-
brae, and stretching across to one of the ribs.
   The treatment of emphysema  consists  of little  in addition to what is called
for by  the wounded lung.   In  many  cases, indeed, the air becomes  rapidly
absorbed, without the necessity of any local interference.   In others, again, the
pressure of a bandage may be  required.  If, however, the emphysema be so
extensive as to interfere with respiration, the external wound must  be freely
opened, and  scarification  made into  the  cellular  tissue, so as to give  exit to
the air.

           HERNIA  OF  THE  LUNG,  OR PNEUMOCELE.

   Hernia of the lung is an affection of extremely rare  occurrence.  It consists
in the protrusion of a portion of this organ  at some part of the thoracic walls
■so as to form a tumor under  the  skin.  It has most frequently  been  met with
after an  external wound, under the cicatrix  of which the  hernial swelling has
appeared;  but it  has been  known to  occur from fractured ribs without  any
wound, and even from violent straining during labor.   In these cases it is pro-
bable that the intercostal muscles and costal pleura having been divided or rup-
tured by the efforts of the patient, and  not having united afterwards, the lung 
           WOUNDS OF  HEART AND  LARGE VESSELS.       323

has, during expiration, gradually insinuated itself into the  aperture so formed,
until at last the hernial tumor appeared.
  This protrusion may take place at any part of the  thoracic parietes:  thus
Velpeau has observed it in the supra-clavicular region of a girl; but most  com-
monly it occurs on one  or  other side of the  chest.  The  tumor may attain a
large  size; I have heard Velpeau state that he has seen one, half as  large as
the head.  It does not appear to shorten life.
  The only case that has fallen under my observation is one that I saw in 1839,
in Velpeau's wards at La Charite: and, as the  signs of the affection were well
marked in this case I may briefly relate it, from notes taken  at the  time.  A
man  twenty-nine years of  age, left-handed, received in a duel, a sword wound
at the inner  side  of, and a little below the left nipple; he lost a considerable
quantity of blood, but did  not spit up  any,  the wound healed  in about a fort-
night, shortly after which he found the tumor, for which he was admitted three
months and a half after the receipt  of the injury.   On examination, an  indu-
rated cicatrix about half an inch in length was found a little  below, and to the
inner side  of the left nipple.  On aspiring or coughing, a soft tumor about the
size of an  egg appears immediately underneath the cicatrix, which it raises up;
it subsides under pressure, or when  the patient ceases  to inspire or to cough;
and its protrusion may be prevented  by pressing  the finger firmly on the part
where it appears, when a depression is felt in the  intercostal  muscles.  If the
fingers are slid obliquely over the tumor, it yields a fine and distinct crepitation,
exactly resembling that produced by compressing a healthy lung, and the spongy
tissue of the organ can be  distinguished.   On applying the ear a fine crackling
and rubbing sound is distinctly perceived; it is resonant on  percussion.   The
portion of protruded lung does not appear to re-enter the chest on inspiration,
but is firmly fixed in its new situation.   No treatment was adopted in the  case,
nor does any appear admissible in similar ones.
   The only affection with which a hernia of the  lung  can  be  confounded is a
circumscribed empyema which is making its way through the walls of the chest.
Here, however, the  dulness on percussion, the absence of respiratory murmur,
and of crackling under the fingers, will readily enable the surgeon to make the
diagnosis.
   It  occasionally happens in extensive wounds of the chest that a portion of the
lung  protrudes during efforts at expiration.   If the wound be free, the protruded
lung  may return on  pressure, or during inspiration.   If  left unreturned,  it
soon  becomes livid and  gangrenous; under  these circumstances it may be re-
moved by the knife or ligature;  but Guthrie  advises that  the protruded part
 should never be separated  from the pleura costalis by which it is surrounded at
 its base, so that the cavity of the thorax may not be opened;  the wound  must
 then be closed in the usual way.


         WOUNDS  OF THE  HEART  AND LARGE VESSELS.

   These injuries are generally immediately fatal from the sudden loss  of  blood
and  the nervous shock that the patient sustains.   There are many cases on
record, however, of persons that have walked or run some considerable distance
after receiving a wound  in  the heart, before  falling down  dead.   Olivier and
Sanson have collected 29 cases of penetrating wounds of the heart that did not
prove fatal in the first forty-eight hours after the receipt of the injury.   On
analyzing these, it would appear that the rapidity of death  depends greatly on
the direction of the wound  and the part of the organ injured.   When the
wound is parallel to the axis of the heart it is  not so speedily fatal as  when in
a transverse direction, and wounds of the  auricle are more immediately followed
by death than those of the  ventricle; the irregular contraction of the different
planes of muscular fibre that  enter into the  formation of the wall of the ven- 
324                INJURIES  OF THE  CHEST.
tricle tending to obstruct the free passage of the blood through the wound, and
perhaps to close it entirely.   The  size of the wound, however, will necessarily
influence the result more materially than its direction.   Without referring to
numerous cases recorded by the older surgeons, there are a sufficient number
of instances reported by modern writers to  prove that an  individual may live
for many days, and  even recover altogether from the  effects of a  wound by
which the cavities of the heart have been  penetrated, although with a foreign
body lodged in them.   Thus Ferrus relates the case of a man who lived for
twenty days with  a  skewer traversing  the  heart from  side  to side.   Messrs.
Davis and Steward found a piece  of wood,  three inches long, in the right ven-
tricle of a boy, who  lived  five weeks  after the accident had happened; and
Latour records the case of a soldier, who lived for six years after being wounded
with a musket-ball in the side, and in  the right ventricle of whose heart the
bullet was found lodged, lying against the septum.
   From the inquiries of Olivier it would appear that the right ventricle is more
frequently wounded than the left; next, the apex  or base of the heart, then,
the  right auricle, and least  frequently, the left auricle.
   The signs of an injury of the heart that is not immediately fatal, are not very
positive.  The  hemorrhage, the direction of the wound, the dyspnoea, the ex-
treme anxiety, syncope, and irregularity with smallness of the pulse, indicate
the  probable nature  of the mischief.  The most important information, however,
is to  be  derived  from auscultation; the occurrence  of friction, or some  other
abnormal sound, with absence of impulses, and increased dulness  on  percussion
over the region of the heart, may point to the seat of the injury.
   The pericardium may be injured without the heart being wounded; by stabs,
by gun-shot violence, or severe contusions  of the  chest.   In injuries  such as
these, inflammation  is set up, and the ordinary auscultatory signs of pericarditis,
such  as friction or creaking sounds, with dulness  on percussion, are distinctly
perceptible.  When blood is effused into the pericardial sac, these morbid sounds
may be absent, but the heart's impulse is weak,  and  the circulatory sounds dis-
tant, the layer of  blood preventing, as Mr. Guthrie has pointed out, the contact
 of the cardial and pericardial surfaces.
   Ruptures of the heart  from external violence, without penetrating wound of
 the chest, are not of frequent occurrence.  Mr. Gamgee has, however, collected
 27 published cases of this  accident.  On analyzing  these he finds  that, in at
 least one half of  the cases  the pericardium was intact;  12 of the ruptures were
 on the right, 10 on the left side.  The right ventricle was  ruptured in 8, and
 the left in 3 cases; whereas the left auricle was  torn in  7, and the right in only
 4 instances.   Death is usually nearly instantaneous,  though there are instances
 on record in which the patient has made some  exertion  after the rupture had
 taken place, and has even lived for several hours.   In a case of rupture of the
 right auricle recorded by Rust, the  patient  survived  fourteen hours.   The only
 case that has occurred in my practice was that of a man brought into the hospital
 dead, having fallen  from the top of a cart.  The right shoulder was bruised and
 the clavicle broken — showing clearly that  he had pitched on that  side; there
 was no other bruise about the body, or  evidence  that the wheels had  passed over
 him.   On examination, the liver was found  extensively torn, in fact smashed,
 and the pericardium was distended  with blood—there being  a triangular ragged
 aperture at the anterior part  of the  auricular appendage  of the  left auricle,
 through which it had escaped.
   Wounds of the aorta and vena-cava are as fatal as those of the heart itself.
 Dr. Heil has, however, recorded a case in which a patient recovered, and  lived
 for  a twelvemonth, after receiving a stab that penetrated the ascending aorta. 
INJURIES OF THE  ABDOMEN  AND PELVIS.       325
                          CHAPTER  XXI.

           INJURIES OF THE ABDOMEN AND PELVIS.

  Injuries of the abdomen are  of frequent  occurrence.  They may be divided
into  contusions  of  the abdomen,  with or without rupture of internal organs;
into  non-penetrating  wounds, and into penetrating toounds; either  uncompli-
cated, or conjoined with injury  or protrusion of some of the organs contained
in this cavity.
   Contusions of the  abdominal  walls from blows or kicks, usually terminate
without serious inconvenience, but in some cases are followed by peritonitis of a
very acute  character,  which may prove fatal.
   In other cases again, the abdominal muscles may be ruptured, although the
skin may remain unbroken.  A man was  admitted under  my care into the hos-
pital, who had  received a blow from  the  buffer of a railway carriage upon his
abdomen, he complained  of great pain at one spot, and  on  examination after
death, we found the  rectus muscle  torn  across without injury either to the in-
teguments  or the peritoneum.  If the patient live, an injury of this kind is apt
to be followed by atrophy of the muscular substance, and perhaps by the occur-
rence  of a ventral  hernia at  a later period.  Occasionally  the contusion  is
followed by  abscess  in the  abdominal wall, which has a tendency to extend
widely between the muscular planes.   These abscesses should be opened early,
lest  they burst into the peritoneal cavity and occasion fatal inflammation.
   A contusion  of  the abdomen is often associated with rupture of some  of the
viscera.  In military practice these internal injuries are met with in the so-called
"wind-contusions;" in civil  practice they commonly result from blows, kicks,
the  passage of  a cart-wheel over the abdomen, or the squeeze  of the  body be-
tween the  buffers  of  two  railway carriages.   These " Buffer-accidents" are now
of common occurrence in hospital practice, resulting usually from the careless-
ness of  railway guards and  porters, who, trying to pass  between carriages  in
motion,  are caught and squeezed between the buffers.   In these  cases the  most
fearful internal injuries occur, often without an external wound.  A man was
admitted under my  care  into University College Hospital, in whom  the  liver,
stomach, spleen, and kidneys, were  crushed and torn; the heart was bruised,
being ecchymosed on its surface, and one of the lungs lacerated, without there
 being any  rupture or bruise of  the skin, or fracture of the ribs.  In this way
 any of the abdominal organs may be torn  or contused, the  particular one injured
 depending on the situation of  the blow.   The  organ  that is  most frequently
 crushed in this way is the liver, owing to  its large size  and the ready lacerability
 of its structure;  the other solid organs,  such as  the  spleen  and kidneys, not
 suffering so frequently: the pancreas I have never seen injured.   Amongst the
 hollow organs  the stomach most commonly suffers, and it is especially likely to
 do so if distended by a meal at the  time  that it is struck.  Any  portion of *he
 intestinal  canal may  be lacerated.  I have seen the duodenum, the ileum, the
 jejunum,  and  the large  intestine ruptured in  different  cases:  the mesentery
 likewise may be torn and the spermatic cord snapped across.
   The sufferer usually dies in the course  of a few hours, or at the utmost at the
end of two or  three days after the  receipt of these injuries, from hemorrhage
into the abdominal cavity, conjoined with shock to the system.  It is  seldom
that life is prolonged sufficiently for peritonitis to be set up, though  this is the
chief danger to be apprehended in those  cases that survive the more immediate
effects of the accident. When the solid organs  are ruptured, death most  com-
monly ensues from hemorrhage.   The shock in itself may prove fatal, though 
326      INJURIES  OF  THE ABDOMEN  AND PELVIS.

there be but little internal mischief done; thus, I have seen a man die collapsed
eight hours after a buffer accident, in whom no injury was found except a small
rupture of the mesentery, attended with but very slight extravasation of blood. It
does not follow, however, that these injuries are necessarily fatal.  Patients have
lived after all the signs of rupture of the liver or the  kidneys, passing bloody
urine, and having circumscribed peritonitis, and when death has occurred, at a
later period cicatrices have been detected in these organs; this indeed is  nothing
more than has been met with in ordinary  penetrating wounds of the  abdomen.
A patient was admitted into the University College Hospital for a severe blow
upon the back, accompanied  by symptoms of renal injury; on his death from
other causes, nine weeks after the accident, an extravasation of blood, with the
marks  of recent cicatrisation, was found in the left kidney.
   Rupture of the  liver is by no means invariably speedily fatal.   It  may be
so from great extravasation of blood, but when  this  is not  largely poured out
the  patient may live for  some considerable time.   A man  was admitted last
year under my care into University College Hospital, who  had been  crushed
between  the buffers of two railway carriages.   He  was  collapsed, and appa-
rently moribund, but rallied in  a few hours.   Two  days after the accident,
great pain and tenderness in  the  right  hypochondrium  were  complained of,
and dulness  on percussion was found to extend as low as  the umbilicus.  He
became jaundiced, and there were symptoms of low peritonitis; these were fol-
lowed  by great swelling of the abdomen, which became tympanitic; the perito-
nitis continued, and symptoms of intestinal obstruction came on, the  dulness
increasing, with fluctuation in  the flanks.  He died on the sixteenth day after
the  accident, and, on examination, no less than  240  oz. of bilious fluid, mixed
with flakes of lymph, were found in the abdominal cavity; the obstruction being
dependent on the pressure of this effusion, and on the matting  together of the
intestines by lymph.  There was a large rent found in the thick border of the
liver, which was beginning to cicatrise.
   The symptoms of an internal abdominal injury are often extremely equivocal.
If the liver or spleen have been lacerated, there will be all the effects of severe
shock  to the system, accompanied by those of internal hemorrhage; coldness,
and pallor of the surface,  a small  and feeble pulse, anxiety of countenance,
and great depression of the vital powers, with pain at the  seat of injury, and
perhaps  dulness on  percussion, from extravasated blood;  symptoms  that
speedily terminate in  the death of the patient.   If the  kidneys are  injured,
the patient will commonly experience a frequent desire to pass water, and this
will be tinged with blood, often to a considerable extent.   The absence  of blood
in the urine must not, however,  be  taken as an indication  that the kidney is
not injured; it may be  so disorganized as to be totally incapable of secreting,
and consequently no bloody urine finds  its way into the bladder.  A man was
admitted into the hospital under my care for a buffer-injury of the back; he
passed water untinged with  blood, but after death his right kidney was found
completely smashed  by the blow, with an  extensive extravasation of blood  in
the cellulo-adipose tissue around  it; here  it was evident that the disorganization
was so sudden and  complete, that no bloody urine had found its way  into  the
bladder.
   When the stomach is ruptured, it  commonly happens that the nature of the
accident is revealed by bloody vomiting; and when  the intestines have been
torn, by the  admixture of blood with the stools, if the patient lives long enough
to pass any.   These signs, however, do not occur in  all cases.   A man was ad-
mitted into the hospital  under my care, whose abdomen had been squeezed be-
tween a cart-wheel  and a lamp-post; during  the five hours that he lived after
the accident, he vomited several times, bringing up a meal that he  had taken
 immediately before.   In the vomited matters there was no  blood to be seen, but 
            TREATMENT  OF ABDOMINAL  INJURIES.        327

on examination after death it was found that the liver and spleen were not only
ruptured, but the stomach torn almost completely across near the pylorus.
   Emphysema of the abdominal wall,  and subsequently of the trunk generally,
may result from the  escape of flatus from a wounded intestine into the sub-
peritoneal cellular tissue, and  thence into the more superficial cellular planes.
When this  takes place, the same doughy, puffy, inelastic, crepitating swelling
of the subcutaneous  cellular tissue, that  is  met with in the thoracic form  of
the affection is observed.  The emphysema  usually commences in one or other
flank, and may then creep on up towards  the axilla, or in front of the abdomi-
nal wall.
   As a diagnostic sign, this form of emphysema is valuable in  those cases in
which the  intestines have been injured, either without any wound of  the ab-
dominal parietes, or if there be  wound, without protrusion of the injured por-
tion of gut.  In two cases in  which I have  observed it, this  condition was the
only positive sign of intestinal injury.   In  one case, the transverse duodenum
had been ruptured  where uncovered by peritoneum, by a buffer-accident; and
in the other, the rectum and meso-rectum had  been traversed by a  pistol-ball.
In both these cases  the  emphysema was extensive, the flatus having directly
passed into the subperitoneal  cellular  tissue.   In other cases  it  may do so
more  indirectly by having, in the first instance, passed  into the cavity of the
abdomen, and rendered that tympanitic; and so, as  in thoracic emphysema from
pneumothorax, escaped from this  into the  cellular tissue at the  edges of the
wound.
   The diagnosis of abdominal emphysema  requires to  be made from thoracic
emphysema, and from putrefactive infiltration  of air in the cellular  tissue.  In
the first case it may readily be effected by observing an absence  of the signs of
thoracic injury, and by the situation of the emphysema in the posterior or lateral
abdominal wall, or  around the lips of a wound.   From putrefactive emphysema
the cause, and the absence of low inflammation of the cellular tissue, renders the
diagnosis easy.
   The treatment of the various injuries of  the abdomen that  have just been
described is of a very simple  character.  If the symptoms indicate laceration
of one of the viscera, little can be done during the state of collapse supervening
on the accident, beyond keeping the  patient quiet, and employing  the means
that have been recommended for lessening the effects of shock upon the system.
 If the patient survive this period, we must guard against the supervention of
 peritonitis,  and limit, if possible, the extravasation of  blood into the abdomen,
should there be indications of its occurrence, by the employment of treatment
that will presently  be described.
    Wounds  of the abdominal wall that do not  penetrate the peritoneal cavity,
if uncomplicated with internal injury,  usually do well, and require to be treated
on ordinary principles.   If incised, and so  extensive as to require sutures, the
stitches should only be introduced through the skin, never through muscular or
tendinous structures, the union  of which could not be effected in this way; the
parts injured must also be relaxed by  careful attention to position.
    Wounds that penetrate the  cavity of the abdomen are  of especial interest, on
 account of  the frequency with which they are complicated with  peritonitis, and
 with injury of some of the viscera.  They may, for practical purposes, be divided
 into those that penetrate the peritoneal  sac, without wounding or causing the
protrusion  of any of the  contained organs,  and those that are complicated with
protrusion,  or wound of some of the viscera.
   1st.  Penetrating wounds of the abdomen without visceral protrusion or injury,
are somewhat difficult to  distinguish from simple wounds of the abdominal wall,
though the escape  of a small  quantity of reddish serum may reveal the nature
of the accident.  In these cases the  surgeon should be careful  not to push his
examination too far, by probing, or otherwise exploring the injury.  In the ab- 
328
INJURIES  OF  THE  ABDOMEN.
Bence of peritonitis or other signs of mischief, he must treat it as a simple wound
of the abdominal wall, and  should any complication occur, must meet that in
the way that will immediately be described.
  2d.  In a penetrating wound with protrusion or injury of the viscera, the risk
is necessarily greatly increased; here the chief  danger is from peritonitis, in-
duced either by the wound, — by the extravasation of the intestinal contents
into the peritoneal cavity, or by the accumulation of blood in it.  It but seldom
happens  that death results from hemorrhage in these cases, though this may, of
course, occur if any of the larger vessels be injured.
  3d.  Protrusion of uninjured intestine, mesentery, or omentum, may take place
through  the wound in the abdominal wall.   This protruded mass is always  of
very large size in comparison with the aperture from which it escapes, the sides
of which being overlaid by it, constrict it pretty  tightly, so as to form a distinct
neck to  the protrusion.   If left unreduced, the mass  speedily loses its polish
and bright color, becoming dull and livid from congestion ; it then inflames, and
soon becomes gangrenous from  the  pressure  exercised upon it by the sides  of
the aperture through which it has passed.
  4th. In many cases the protruded  intestine is wounded.  The existence  of
this further injury will readily be ascertained, by the escape of flatus, or of the
more fluid contents of the gut.   The characters of the wound vary, as Travers
has pointed out, according to its size.   If it be a mere puncture in the gut, or
even an incision two or  three lines in length, an eversion or prolapsus  of the
mucous membrane will take place, so as to close it to an extent sufficient to pre-
vent the escape of its contents.  If the aperture be above four lines in length,
this plugging of it by everted  mucous membrane cannot take place, and then
the  contents  of the  bowel  are more freely  discharged;  but, even under these
circumstances, there  will be  a tendency to  the protrusion  of the membrane,
which forms a kind of lip over the edge of the cut.
   5th. A wounded intestine which  does  not protrude, but remains within the
peritoneal sac, presents the same conditions.   In these cases, however, there is
the additional danger of the extravasation of the intestinal contents into the peri-
toneal cavity.' This extravasation of feculent matter, unquestionably one of the
greatest  dangers that can occur in wounds of the abdomen, inasmuch as by its
irritating qualities it gives  rise  to and keeps up the  most intense peritonitis,
takes place  less frequently than might be expected.  For this there are several
reasons.   In the first place, we have already  seen, that, if the wound in the gut
be below a certain size, there  is a natural tendency to its occlusion by eversion
of the mucous membrane  into  it.   Besides this, it must  be borne in mind
that, though in ordinary  language we  speak of  the "cavity"  of the abdomen,
there is in reality no such thing; there being no empty space within the perito-
neal sac into which extravasated matters could  fall,  but  the whole of the visceral
contents of the abdomen being so closely and equably brought into contact by
the  pressure of the abdominal muscles and of  the diaphragm, that it requires
some degree of force for the intestinal contents to overcome this  uniform sup-
port, and to insinuate themselves between the  coils of contiguous portions of
intestine.  The influence exercised by the continuous pressure of the abdominal
walls  upon  the intestinal contents, is  well shown by  the greater facility with
which these escape from a portion of wounded  intestine that has been protruded,
than from one that is still lying within  the abdomen.  In the former case, faeces
will escape  from a much smaller aperture than  in the  latter instance, in conse-
quence of the gut not being supported on all sides by the uniform pressure to
which it is subjected within the abdomen.   It is seldom, indeed, that faeces are
extravasated from gut that  is not protruding, unless it be very full at the time
of  the injury, or the wound in it  be very extensive.  The  influence of the
equable  pressure of  faeces was well illustrated in a case in University College
 Hospital, of a man who was shot through the abdomen.  The intestines, which 
WOUNDS  OF  THE  INTESTINES.
329
contained much  feculent matter, were traversed  by the bullet  in  four places.
He lived twenty-four hours, and yet no feculent extravasation took place.
   Blood is extravasated, more readily than the intestinal contents in wounds of
the abdomen. This is in a great measure owing to the vis-a-tergo influence exist-
ing in an artery of moderate size, such as one of the branches of the mesenteric,
being sufficient to overcome the equable pressure and support of the abdominal
walls.
   These extravasations, whether of faeces or of blood, when  once formed have
little tendency to diffuse themselves, but become localized in the neighborhood
of that part from  which  they were  originally poured out, owing, in the first
instance, to the surrounding pressure, and, at  a  later  period, to the deposit of
plastic matter between the  folds of intestine and neighboring viscera.  In this
way the diffusion of irritating matters through the abdominal cavity being pre-
vented, the likelihood of the occurrence of wide-spread and fatal inflammation
is much diminished.
   The existence of these extravasations may, in many cases, be recognized by
dulness  on percussion around the wound, by the localized swelling to which they
give rise, and, sometimes by their escape through the external aperture.
   In the treatment of penetrating wounds of the abdomen, we must first consider
 the management of the injured parts;  and, afterwards, the prevention or cure
 of the consecutive  peritonitis.
   If the wound have not implicated any of the  abdominal viscera, it must be
 closed by relaxing  the abdominal muscles by position, by introducing a few
points of suture through the integuments, if it be extensive, and by applying a
compress and plaster, supported  by a bandage.   The patient should then have
a full dose of opium given  him;  about 2 grains of solid opium or 40 minims of
the liquor sedativus, which must be repeated in  from  four to six hours, so that
the effects may be  kept up.   He should  then be kept perfectly quiet in bed,
and no  nourishment given for a few days, except barley-water and ice.   The
bowels should not be opened by aperient medicine,  lest abdominal  irritation be
set up, but  oleaginous  enemata may  be  administered at the end of a week or  >
ten  days.                                                                 ^v.
   If the intestine be wounded but not protruding, we must endeavor to limit the
 peritonitis that will ensue,  and also  to prevent feculent extravasation.   With
this view the patient should be laid on the injured side with the wound depend-
 ent, so as to allow the faeces to escape through it if disposed to do so.   If the
 injury be about the umbilicus he must lie upon his  back with the knees drawn
 up and bent over a pillow.   Opium must then be administered in the full doses
 already indicated, and repeated in grain doses at least every fourth or sixth hour,
 so that  the system be kept well under its influence.   The value  of opium in
 these cases is very  great; it not only seems to moderate the inflammation that
 takes place in the peritoneum, but is of the greatest  utility in preventing ex-
 travasation  of faeces. This it does by arresting the peristaltic movements of the
 intestine, and thus, by keeping it from change of position, lessening the chance
of the escape of its contents.  This arrest of the intestinal movements also tends
greatly to the closure of the wound.   Travers has  shown experimentally, and
his investigations have been confirmed by subsequent observations on the human
subject,  that wounds of the  intestines are closed by lymph that is thrown out,
not only from the contiguous peritoneal surfaces of the  part actually injured, but
from that of neighboring coils; so that the aperture in the gut becomes perma-
nently glued and attached  to  the structures in its vicinity.   In order that this
process should take place, it is necessarily of the first importance that the move-
ments of the bowel be paralyzed; and it is a beautiful provision of nature that
the very inflammation which closes  the  wound, arrests that peristaltic action,
the continuance of which would interfere with its agglutination to, and closure 
330
INJURIES  OF  THE  ABDOMEN.
by, the neighboring parts.  Until the necessary degree of inflammation to effect
this is set up, the intestinal movements must therefore be arrested by opium.
   If  extravasation of feculent matter have taken place into the cavity of the
abdomen, an attempt might be made to facilitate its  escape  by removing the
stitches  and plasters from  the external wound, and  placing the patient on the
injured  side, so that this  may be in the most dependent position; should the
lips of the  wound have already become adherent to one another,  they might
even  be  gently and carefully separated by  the introduction of a probe, and in
this way an outlet afforded the effused matters.
   When a  portion  of intestine or of omentum has protruded, it should  be
replaced as speedily as possible, before strangulation has occured  to occasion
gangrene of the  protruded mass.   In  order to effect reduction, the abdominal
muscles  should be relaxed by bending the  thigh  upon the abdomen, when the
surgeon  may gradually push back  the  protrusion  by steady pressure upon it;
no force  must, however, be had recourse to, or any rough handling of the exposed
and  delicate  parts; but  if  it be  found  that their return cannot readily  be
effected, owing to the constriction  of  the neck  of the tumor, the aperture
through which they  have escaped must be carefully enlarged, in a direction
upwards, by means of a probe-pointed  bistoury, or a hernia-knife, guided by a
flat director.   The  incision necessary  to   enlarge the  opening sufficiently to
admit of reduction, need not exceed half-an-inch in length.   In replacing the
protruded parts, whether by the aid of incision, or not, care must be taken that
they are fairly put back into the cavity of the  abdomen, and not pushed  up
into  the sheath  of the rectus, or into the subserous  cellular tissue lying before
the peritoneum; an accident that would be  fatal by allowing the constriction of
the neck of the protrusion to continue unrelieved.   In effecting the return the
surgeon  should not  push his finger  into the cavity of the abdomen, but must
 content  himself with simply replacing the protruded gut, or  omentum, and
allowing it to remain  in  the immediate neighborhood  of  the wound in the
 abdominal  wall,  to  which it  will contract  adhesions;  and through which  its
 contents may escape, in the event of any  sloughing action  being  set up in it.
 If the  protrusion be inflamed, it must equally be replaced without delay; but
 should  the intestine have  become gangrenous from continued constriction and
 exposure, no attempt at reduction  should be made, but an incision must be
 carried  through it, so as to allow of the escape of faeces, and the formation of an
 artificial anus.   If  the protruded  omentum be gangrenous, it must be excised
 on a level  with  the peritoneum, to  the aperture  in which  that portion  lying
 within the  abdomen  will have contracted adhesions.
    If the intestine that protrudes be wounded, the treatment of the aperture in
 the gut  will call for special attention; and surgeons have been somewhat divided
 as to the line of practice that should be pursued in such a case.  The question
 that has been left open is, as  to the propriety of stitching up the wound of the
 intestine.   Scarpa and  S. Cooper were opposed to this practice on the ground
 that it does not prevent extravasation, and that the stitches produce irritation
 by acting as foreign bodies.   They proposed to return the wounded gut, taking
 care, however, to leave the aperture in it to  correspond with  that  in the abdo-
 minal wall, so that  an artificial anus might  be  established  by the cohesion of
 the edges of either opening to one another, these adhesions preventing extrava-
 sation.   To this  practice the  great objection  exists  that extravasation will
 probably occur before  there  has been  time for the effusion of lymph, and the
 agglutination of the contiguous surfaces; besides which, it is impossible to secure
 the  necessary correspondence between the  two  apertures,  the wounded gut
 being very  liable to  alter its position  after it has been replaced.   It  has also
 been found by experience that one  of the  objections urged against the  employ-
 ment of a  suture, that it cannot prevent the escape of feculent matter, is  not
 valid.   If  it  be  properly applied, it may effectually do so, as was  shown by a 
         TREATMENT OF  WOUNDS OF  THE  ABDOMEN.     331

successful case under my care, the details of which have been published in the
"Lancet," for 1851. That the stitches act as sources of irritation to any serious
extent is  also doubtful.   Travers found by experiment that when a wounded
gut was sewn up, and  returned into the abdomen, the  sutures quickly became
bridged or coated over with a thick layer of lymph, and gradually ulcerating
their way inwards, at last dropped into the cavity of the intestine, being dis-
charged per  anum, and leaving a firm  cicatrix at the point to which they had
been applied.  For these various reasons, Guthrie, Travers, and other surgeons
of experience, advocate the practice of stitching up a wounded and  protruding
intestine,  with which opinion I entirely agree.  Much,  however, depends upon
the  way in which the  sutures are applied.   They  should  be introduced by
means of a fine  round needle, armed with
sewing silk,  in such a way that the perito-               Fio. 133.
neal surfaces on either  side of the wound
alone  are brought into contact as adhesion
takes place solely between them, the wound
in the other  structures of the gut filling up
by plastic deposit. It has been recommended
that the  needle  should  only penetrate the
peritoneal and  cellular  coats,  no muscular
tissue being taken  up in it, lest  retraction
of the included  fibres,  by dragging  upon
the  stitches, might  re-open  the  wound.
This,  however,  it is extremely difficult  to
do.  The  safer plan is doubtless to carry the
suture through  the  whole  thickness of the
gut, bringing the stitches out  at  about the
one-sixth of an inch from the  edge of the
cut, from each other, in such  a  way that the serous surfaces are drawn into
apposition (fig. 133).  The kind  of suture that should be used is the " glover's
stitch."   When the lips of the wound  have been nearly brought into apposition
in this way, it has been proposed  to leave the  end of the thread hanging out of
the  aperture  of the abdominal wall, and to withdraw it  when it becomes loose;
but  I think  it better not to leave it, as it might induce great irritation, acting
like a seton  in the peritoneal cavity.   It is better, therefore, to cut the ends
short  close to the knot, when the suture will eventually become covered with
lymph, and find  its way into the  inside  of the gut  by ulcerating through the
muscular  and mucous coats.
   After the  aperture in it has been thus closed,  the protruded portion  of the
intestine  must be reduced,  having previously been  properly cleansed with a
little lukewarm water.   The reduction must  be effected in the way  that has
already been described, the  surgeon being especially careful not to push the
wounded  coil of intestine far  into the abdomen, but to leave it close  to the
external orifice,  so that in the event of extravasation occurring, or the stitches
giving way,  a ready outlet  may be afforded.  Should the wound  in the abdo-
minal  wall be extensive, it  must be closed by means of sutures  and  plasters,
supported by a bandage, the inferior  angle  being left open to allow of the
escape of extravasation.   The wound in the peritoneum had better be left; but
should it be very extensive, the  practice that was successfully adopted under
such circumstances by Mr. Wood, of stitching up the aperture in it, might be
had  recourse to.   The after-treatment must be conducted in all respects on the
same principles  that guide us in the management  of an intestine that has been
wounded without protruding.   Care must be taken, by attention to the position
of the patient, and by the free  administration of opium, to  keep the bowel  as
quiet as possible  near the  external opening;  the urine should  be  drawn off
twice in the twenty-four hours,  and no  purgative whatever administered, lest by
 
332
INJURIES OF  THE  PELVIC  VISCERA.
the excitation of peristaltic action, adhesion be disturbed and extravasation take
place.   After the lapse of six or eight days, an enema may be thrown up, and
repeated from time to time.   No food should be allowed for the three first days,
during which time  tea and barley-water should be freely taken; after this, beef-
tea and light food that leaves no residue may be administered.
   Traumatic peritonitis is the great danger  to  be apprehended in  all these
injuries of the abdomen, and it is by inducing this  that extravasation of faeces
or of blood so  frequently proves fatal.  It is true that a certain degree of
inflammation  of the peritoneum  is  necessary for the healing  of  all abdominal
wounds, but it  must be limited in  extent and plastic in character.  It is the
more diffuse  form  of  peritonitis, attended  by the exudation of turbid serum,
and shreddy, ill-conditioned lymph, that is  so  speedily fatal.   In these cases,
we meet with the ordinary symptoms  of the idiopathic form of this affection;
— uniform tenderness about the abdomen, with much  tympanitis,  more par-
ticularly in  the neighborhood of the injury,  with  occasional stabbing pains,
followed by tympanitic  distension,  vomiting, and hiccup, a small, quick, hard
pulse, often assuming a wiry incompressible character, with considerable pyrexia,
and great anxiety of  countenance.   The traumatic  peritonitis will set in  and
run its  course with great rapidity; in  a case in University College Hospital,
already alluded to, of  bullet  wound of the abdomen, the patient lived 24 hours.
Two or three pints of serous effusion with much puro-plastic matter, and great
reddening of the whole of the visceral and much of the parietal peritoneum had
ensued.   As  the inflammatory extravasation  increases, dulness  on percussion
will manifest itself—usually first on  the flanks, and then gradually extending
forward until it may occupy  a great  extent of surface in the abdomen.  In the
treatment of  this disease we must be  guided by the character of the inflamma-
tion.  If it be of a sthenic  form, and the patient young and robust, he should
be bled freely in the arm, and  have  leeches abundantly applied over the surface
of the  abdomen; a pill  composed of two grains  of  calomel and one grain  of
opium may then be administered every sixth hour, or oftener, if  the patient be
 not influenced by the  narcotic; and rigid abstinence from all except  ice and
 barley-water should be enforced.  If the peritonitis be the result of a wounded
intestine, it is safer to omit  the calomel, using mercurials  instead to the inside
of the  thighs, but giving opium freely.   When the  peritonitis occurs in an old
 or feeble subject, our principal  trust must be in the administration of opium
and free leeching of the abdomen, followed perhaps by a blister, which may
 be  dressed with  mercurial  ointment.   In these cases, however, early support
 will be required, with perhaps the administration of wine or stimulants.   The
 inflammatory extravasation will gradually be absorbed under  the influence of
 the calomel, aided by  blisters.

               INJURIES OF  THE  PELVIC  VISCERA.

   Rupture of the bladder, from  blows upon the abdomen, or  penetration of it
 by bullet wounds,  is not of very unfrequent occurrence, and is especially liable
 to happen if this organ be distended at the time it  is struck, when very slight
 degrees of accidental  violence, as running against a  post, falling off a bed, may
 occasion its rupture.   The effects of these injuries vary considerably,  according
 to the part that has  given  way or  been wounded.  If the laceration have oc-
 curred in those portions of the  viscera that  are invested by peritoneum, the
 urine will at once  escape into  the pelvic and  abdominal cavities, and speedily
 occasion death  by  the intense  irritation and inflammation set up by it.  I have,
 however,  seen  a case in which, even  under  these circumstances, the patient
 survived ten days.  If, on the other hand, that portion of the organ  have been
 ruptured which is uncovered  by peritoneum, the urine will infiltrate  into the
 cellular tissue  between  this membrane  and the abdominal wall, and  diffusing 
         INJURIES  OF THE  URETHRA  AND PERINEUM.     333

itself widely, produce  destructive sloughing of the  tissues  amongst  which it
spreads.   In these cases life may be prolonged for some days, when the patient
commonly sinks from the  combined irritative and inflammatory action.  Still,
however, it must be borne in mind,  that  numerous cases  of  injury of  the
bladder,  more  especially from  gun-shot wounds,  have recovered,  and that,
although we must look upon  this accident as of the gravest  character, yet that
it cannot be considered as being necessarily  fatal.
  The symptoms of a ruptured bladder are sufficiently evident; the  injury in
the  hypogastric region, followed by collapse, by intense  burning  pain in  the
abdomen  and pelvis, with  inability to pass  the urine, or,  if any have escaped
from the urethra, its being  tinged  with blood, are usually  sufficient  to point
to the nature  of the accident.  If in addition, it is found, on introducing a
catheter,  that  the  bladder is  empty, or that  but a small quantity of bloody
urine escapes, the surgeon may be sure that this organ has been  burst.  In the
case of gun-shot injury, the escape of urine,  which generally takes place through
the  track of the bullet, will afford incontestable evidence of the mischief that
has  been produced.
   In the treatment of these  cases, the most important indication is the preven-
tion of further extravasation by the introduction of a full-sized elastic catheter
into the bladder, which must be  left there,  so that  the' urine  may dribble away
through it as  fast  as it accumulates.  If any sign of  extravasation makes  its
appearance, free and deep incisions should be made into the part, so as to facili-
tate the early escape of the effused fluid and the putrid sloughs.  I cannot but
consider all active  antiphlogistic treatment as out of place in  these  injuries,
never having  seen  the  slightest benefit from their employment.  The  only
chance that the patient has,  if once  extensive extravasation have occurred, is
that there may be sufficient power left in the constitution to throw out a barrier
of lymph that will limit the diffuse  and sloughing inflammatory action set up,
and the prospect of this would certainly not be increased by the employment of
depletory measures.  There  will also be so  great a call  upon the powers of the
system at a later period, after sloughing has fairly set in, that a supporting or
even stimulating plan of treatment would rather be required.
   Foreign  bodies,  such  as pieces  of catheters, tobacco-pipes, pencils, &c, are
occasionally met with  in  the urinary organs, having been introduced through
the  urethra.   In some  cases  they are soon spontaneously expelled, but more
usually they require extraction;  sometimes  they may be fortunately seized with
a small  lithotrite or urethral  forceps in the direction of their  long  axis, and
thus extracted;  but more frequently they  require to be removed through  an
incision  made  into  the bladder.  This is more safely done by the mesial, rather
 than by the lateral operation of lithotomy.
   It occasionally happens that musket-balls, pieces of clothing, &c, have been
 lodged in  the bladder  in gun-shot  wounds of  that  organ.   These  speedily
 become  incrusted  with  urinary  deposits, and giving rise  to the symptoms  of
stone in the bladder, require to be removed by lithotomy, an operation that has
 proved very successful in these cases, evidently in consequence of the healthy
 condition of the urinary organs.   Mr. Dixon  has collected from various  works
the  details of 15 cases, in which balls that had either primarily entered the
 bladder  or found their way into this  organ  by abscess or ulceration after  being
lodged in the neighborhood, had been extracted by operation.   In 10 of these
cases the result was successful;  in  the  remaining 5 no record is made of the
termination.
   Mr. Stanley has  related a  remarkable case in which the ureter was  ruptured
by external violence, and in which the patient recovered; a very large accumu-
lation of fluid  forming on the injured side of the abdomen, with considerable
circumscribed tumefaction and fluctuation, and which required repeated tapping,
In another case in which the pelvis of the  kidney was ruptured, a similar col- 
334          INJURIES  OF  THE  PELVIC  VISCERA.
lection of urine took place within the abdomen, requiring tapping; as much
as six pints being removed at one sitting.  On examination after death, which
occurred on the tenth week from  the accident, a large cyst was found behind
the peritoneum, communicating with the pelvis of the kidney.
   Laceration of the urethra not uncommonly happens from kicks on the peri-
neum, or in consequence of falls from a height, the patient coming astride upon
a girder or a plank of wood, and rupturing the urethra at the triangular liga-
ment.   In these  cases there is great bruising, and sometimes wound of the
perineum, and if an attempt have been made to pass water, the patient will find
himself unable to do so, the effort being also accompanied by deep and burning
pain, followed perhaps by the  discharge of blood or a few drops of bloody urine
from the urethra.   The consequences of this  injury are often most disastrous.
The immediate result is usually extravasation  of urine  into the perineum,
which, if not checked by proper treatment, rapidly passes  forward through the
scrotum  up upon  the abdomen, giving rise to extensive  sloughing of every
portion of cellular tissue with which it comes  in contact, and leading perhaps
to the rapid destruction of the integuments of these  parts, and the consequent
formation of extensive and deep abscess and ulceration.  If the patient recover
from this mischief, he will very likely do so  with a fistulous  opening  in the
perineum, and  ultimately  suffer from a very intractable form of  stricture, which
in some cases may be completely impassable, in consequence of a portion of the
urethra having been torn  across and sloughing away.
   The treatment of this  injury consists  in  the early  introduction of a catheter
into the bladder.  If this can be done  before  the patient has made an  attempt
at passing his urine, much of the immediate danger of the  case  may be averted,
by the  prevention of urinary infiltration.  The catheter, which should be an
elastic  one,  must  be left in  the bladder for a few days.   If any hardness,
throbbing, or other sign of irritation occur in the perineum, free incision should
be made into the part, so  as to afford a ready outlet for any urine that may have
been effused.  If  the surgeon find it impossible to get a catheter into the blad-
der, the urethra being torn completely across, he should pass it as far as it will
go, and then putting the  patient in the position for lithotomy, make a free inci-
sion in the mesial line, upon  the point of the instrument, so  as  to make an
opening in the perineum  communicating with the deeper portion of the urethra,
or he might puncture through the rectum if the bladder be distended; but it is
best to get a free  outlet for the urine through the perineum, if possible.   As
the urine becomes extravasated,  the  surgeon must follow its course with free
and deep incisions, supporting the strength of the patient at the same time by
a due allowance of stimulus and  nourishment.  If, when  the  urethra  is com-
pletely torn  across, the urine  finds a difficulty  in escaping,  and relief is  not
afforded by the perineal incision, the bladder becoming  distended, it should be
tapped through the rectum, in the way that will be described when we come to
Bpeak of diseases of the urinary organs.
   Foreign, bodies  are occasionally impacted in the vagina or rectum.  A variety
of things, such as pieces of stick, glass bottles, gallipots, &c, have been intro-
duced into these canals.   Their extraction is often attended with great difficulty,
in consequence of the swelling of the mucous membrane over and around them,
and the depth to  which  they have  been pushed.  In order  to remove them,
lithotomy or necrosis forceps  may  be required.  In some  cases, the  foreign
body has been found to transfix the wall of the canal in which  it is lodged, and
 by penetrating the peritoneum, has  speedily occasioned the patient's death.  A
remarkable case of this kind  has  recently occurred in my practice, in which a
 cedar pencil, five  inches  long, and  cut to a point, had been forced up through
 the posterior wall of  the  vagina of a young woman into the  abdominal cavity.
 Here it transfixed two coils' of the small intestine, and after a sojourn  of eight
 months was  extracted by  an incision through the anterior abdominal wall, mid- 
                        BURNS  AND  SCALDS.                    335

way between the umbilicus and Poupart's ligament, where its point was engaged
in the fascia transversalis.   It had occasioned repeated attacks of peritonitis,
and after its extraction death resulted from that cause.
   Laceration of the Perineum.—The perineum is occasionally ruptured
during parturition.   When the laceration is of limited extent and recent, union
may usually be effected by bringing and  keeping  the  thighs together immedi-
ately after its occurrence.  Should the lacerations have existed for some weeks,
but  not extend into  the sphincter ani, it may usually readily be repaired by
paring the edges freely, and passing two deep  quilled sutures so as to bring the
opposite sides together.
   When the laceration is very extensive, extending  through the posterior wall
of the vagina, the perineum, the sphincter ani, and  the  rectum, in fact tearing
through the recto-vaginal septum, more energetic and careful treatment will be
required.   The bowels having  been  well cleared out, and  the patient being
placed in the position for lithotomy, the edges and  sides of the rent  must be
freely and deeply pared.  The sphincter ani should  then be
freely divided on either  side of the coccyx, as recommended     Fig. 134.
by Mr. Brown, in order that its action may be paralyzed and
all tension of the  parts  removed.  Three  points  of quilled
suture should then be deeply  passed through  the freshened
sides of the laceration, and the  edges brought together by  a
few  points of interrupted suture (fig. 134).  The success of
the  operation will entirely depend on the attention bestowed
on the after treatment of the case; the mode of conducting
this has been laid down  with  much precision by Mr. Brown.
The principal  points to be attended to are as follows: — Im-
mediately after the operation, a full dose of opium should be
 given, and a grain administered every sixth  hour with the
 view of arresting all intestinal action.  The patient should be  laid on  her side,
 and a catheter retained  so as to prevent  any dribbling of urine over the raw
 edges, which would be fatal to their union.  The deep sutures  should be left in
 for four or  five days, the superficial ones for about a week; during this period 1
 have found it advantageous to keep the part covered with collodion. When the
 sutures  are removed, a pad  of  dry lint,  supported  by a T bandage, should  be
 applied.  The bowels should not be allowed to act  for at least  ten or twelve
 days, lest  the freshly united surfaces be torn through.   During the  whole of
 this period the patient's strength must be supported by good diet, and scrupu-
 lous attention  paid to the cleanliness of the  parts.   Plastic operations of this
 kind should not be performed unless the  patient is in a good state of health.
                        CHAPTER  XXII.

                  effects  of  heat and  cold.

                        BURNS  AND  SCALDS.

  A burn is  the  result of the application of so great a degree of heat to the
body as to produce 'either inflammation  of the  part  to which it is applied, or
charring and  complete disorganization of its  tissue.   A scald is occasioned  by
the application of  some  hot fluid to the  body, giving rise to the same destruc-
tive  effects  that are met with in burns, though differing from  them in  the
appearances produced.
 
336
BURNS  AND SCALDS.
  Local effects.—Burns and scalds vary greatly in the degree of disorganization
of tissue to which they give rise; this  variation depending partly  upon the
intensity of the heat that is applied, and partly upon its duration.  The sudden
and  brief application  of flame  to the  surface produces but very slight disor-
ganization of the cuticle, with some inflammation of the skin.   If the part be
exposed for a longer time to the action of the flame, as when a woman's clothes
take fire, the  cutis itself may be disorganized, and, if the  heat be still  more
intense, as  when  molten metal  falls upon the  body, the  soft parts may be
deeply charred, or the  whole thickness of a limb  destroyed.   So,  also, the
effects of scalds  vary greatly, not only according  to the temperature of the
liquid, but  according  to its character; the more oleaginous and thicker the
fluid, the more severe  usually will the scald be.
   These various  results of the application of heat  to the  surface have  been
arranged by Dupuytren into  six different degrees of burn. In the  1st,  there
is merely a scorch of the skin, slight redness  with efflorescence of the cuticle,
but no permanent injury.  In the 2d degree there  is  not only general  redness
of the part to  which the heat has been applied, but vesicles form, either at once
or in the course of a few hours, and  sometimes attain a very considerable mag-
nitude.   In the  3d  degree, the  cutis itself is destroyed, yellowish-grey or
brownish eschars forming, which involve  the whole  thickness of the skin, the
surrounding integument being  more  or  less reddened and vesicated, and the
part extremely painful.  If this amount  of injury is the result of a  scald, the
eschars will be found to be soft, pulpy, and of an ashy-grey character.  In the
4th  decree, the whole thickness of the skin and part of the subcutaneous cel-
lular tissue are destroyed, dry, yellowish-black, insensible eschars being formed,
with considerable inflammation  around them, leaving, on their separation, deep
and luxuriantly granulating ulcerated surfaces.   In the 5th degree, the eschars
extend  more deeply, implicating the muscles, fasciae, and soft structures.  And,
in the 6th degree, the whole thickness of the  limb  is completely destroyed and
charred.   This is the celebrated classification  introduced  by Dupuytren, and
adopted by most writers on the subject, as a practical  exposition of the local
effects  of  burns.   These  various  degrees are  usually  found  associated, to a
greater or  less extent; indeed,  in the more severe forms, the three or four first
degrees are almost invariably met with.
   The  primary local  effect, then, of  a burn, if superficial, is to  excite inflam-
mation of  the skin; if more extensive,  to destroy the vitality of more or less
 of the  soft structures, and even the bones.  When  the cuticle is unbroken, the
inflammation  speedily subsides, with some desquamation.  When the soft parts
 are  charred, they  are detached by a process of ulceration, analogous to what
 happens in the separation of  sloughs, and an ulcerated and  suppurating surface
 is left, remarkable for the large size, the florid color, the great vascularity, and
 the rapid growth of its granulations.   The cicatrization of such an ulcer as this,
 though generally proceeding with great rapidity, has a constant tendency to be
 arrested by the exuberance of  the granulations.  The cicatrix that results is
 usually thin,  and of a bluish-red color, and is especially characterized by a great
 disposition to  contract, becoming, after a time, puckered up, and much indu-
 rated.   This process of contraction and  hardening, which begins immediately
 on the completion of cicatrization, continues for many months, giving rise fre-
 quently to the most serious deformities, and to the  complete loss of motion and
 use  in parts.   These cicatrices are  of a fibro-plastic and  fatty character, and
 often extend deeply  between, and mat together the muscles, vessels, and soft
 structures  of a limb, of the face, or  neck.
   The constitutional effects resulting  from burn are of the most serious and
 important character;  they are  dependent not so much upon  the depth  of the
 injury as upon its situation, the extent of surface implicated, and the age of the
 patient.   Thus, a person may have his foot completely charred and burnt off by 
STAGES  OF  BURNS.
337
a stream of melted iron running over it, with far less constitutional disturbance
and danger than if the surface of the trunk and face be extensively scorched to
the first and second degrees.   Burns about  the trunk, the head, and the face,
being far more  likely to  be  attended  by serious constitutional mischief than
similar injuries  of the  extremities.  In  children the  system generally suffers
more severely from  burns than  in adults.  The constitutional disturbance
induced by burns, in whatever degree, may be  divided  into three stages: 1st,
that of  depression and congestion; 2d, of reaction and  inflammation; and, 3d,
of exhaustion and suppuration.
   1st. The period of depression and  congestion  occupies  the first forty-eight
hours, during which death may occur before inflammatory action can come on.
Immediately on the receipt of a severe burn, the patient becomes cold, collapsed,
and is seized with fits of shivering, which continue for a considerable time ;  he
is evidently suffering from the shock of the injury; the severity of the shiver-
ing is usually indicative of the extent of the constitutional disturbance induced
by the burn, and is more  prolonged in  those injuries that occupy a great  extent
of surface, than in those which, being  of more limited superficial extent, affect
the tissues deeply.   On the subsidence of the symptoms of depression, there is
usually a period of quiescence before reaction comes on, and during this  period
the patient, especially if a child, not unfrequently dies  comatose;  death  result-
ing from congestion  of the brain and its membranes, with, perhaps, serous effu-
sion  into the ventricles or the arachnoid.   Besides these lesions, the mucous
membrane of the stomach and intestines, as well as the  substance of the  lungs,
are usually found congested.
   The  pathological  phenomena of  this  period are altogether of a congestive
character.
   2nd.  The next period, that of reaction and inflammation, extends from the
second day to the second week.  In it irritative fever sets in early, with a degree
of severity proportionate to the  previous depression, and as this stage advances
special  symptoms commonly occur dependent upon inflammatory affections, more
especially of the abdominal and thoracic viscera.  Death, which is more frequent
during  this stage than in the  preceding  one, is usually connected with some
inflammatory  condition of the  gastro-intestinal mucous membrane, or  of the
peritoneum.   The lungs  also are frequently affected, showing marked evidence
of pneumonia or bronchitis; but the cerebral lesions are not  so common as  in
 the first stage; though when they occur they present more unequivocal evidence
 of inflammatory action.
   It is  in  this stage of burn,  that that very remarkable  and serious sequela,
 perforating ulcer of the duodenum, is especially apt to occur.  Mr. Curling, who
 first attracted attention to it, explained its occurrence  by  the supposition that
 Briinner's glands endeavor by an increased action to compensate  for the sup-
 pression of the exhalation of the skin, consequent upon the burn; and that the
 irritation thus induced, tends to their inflammation and ulceration.  This ulcera-
 tion may, as Mr. Curling  remarks, by rapidly proceeding to perforation,  expose
 the pancreas, open the branches of the hepatic artery, or, by  making a commu-
 nication with the serous  cavity of the abdomen, produce  peritonitis, and thus
 cause death.  It usually comes on about the tenth day after the occurrence of
 the injury; seldom earlier than this.  The only exception that I am acquainted
 with was in the case of a child  nine years of age, who  died on the fourth day
 after the burn, in University College Hospital, and in whom an ulcer, about the
 size of  a shilling, with sharp  cut margins, was  found in the duodenum, the  in-
 testinal mucous membrane generally being inflamed.  That these ulcers are not
invariably fatal  is evident from a case  mentioned by Mr. Curling, in which, on
death occurring eight weeks after the injury from other causes, a recent cicatrix
 was found in  the duodenum.  These affections seldom occasion any very marked
 symptoms to indicate the nature of  the mischief, the patient  suddenly sinking. 
338
BURNS  AND  SCALDS.
In some instances there is  hemorrhage, though this is not an unequivocal sign,
as I have several times seen it happen from simple inflammatory congestion of
the intestinal mucous membrane;  pain in the right hypochondriac  region and
perhaps vomiting may also occur.
   3rd. The period  of exhaustion  and  suppuration, continues from the second
week  to the close of the case.  In it we frequently have symptoms of hectic,
with much constitutional irritation from the long  continuance  of exhausting
discharges.   If  death occur, it is  most frequently induced by inflammation of
the lungs or pleura; affections of  the  abdominal organs  and brain being rare
during this stage of the injury.
   The influence of extent, degree, and situation, on the prognosis of burns has
already been stated.   The  most fatal  element indeed of these injuries is super-
 ficial extent.  The cutaneous secretion being arrested over a large surface of the
skin,  congestion of the  internal  organs  and of the  mucous membrane must
ensue; and hence death may happen directly from this cause, or from the super-
vention of inflammation in the already congested parts; more particularly in the
early periods of life, when the balance of the circulation is readily disturbed.
The degree  of burn rather influences the prognosis unfavorably so far as the
part itself is concerned, than as the general system is affected.  The most fatal
period in cases of  burn is the first week  after the accident.   I find that in 50
cases of death from these accidents, 33 proved fatal before the eighth day; 27
of these dying before the fourth day.  Of the remaining 17 cases, 8 died in the
second week, 2 in  the third, 2 in the fourth, 4 in the fifth, and 1 in the sixth.
   The treatment of burns  must have reference  to  the constitutional condition,
as well as to the local injury.   A vast variety of local  applications  have  been
recommended by different surgeons, such as flour, starch, cotton wadding, treacle,
white paint,  gum,  solution of India rubber, &c.; the  principle is, however, the
 same, viz., the protection of the burnt surface from the air.  I shall here, how-
 ever, content myself with  describing the method  that is usually followed with
 much success at the University College Hospital.
   The constitutional treatment is  of  the  utmost  consequence.  We  have seen
 how  death arises at various periods after these accidents from different causes,
 and we must modify our treatment accordingly.  The first thing to be done after
 the infliction of a severe burn is to bring about reaction ; the patient is trembling
 in a  state of extreme depression,  suffering  great pain, and  may sink from the
 shock unless properly supported.   A full dose (about thirty minims  for an adult)
 of the liquor opii  should be given at once in some  warm brandy and water, and
 repeated, if  necessary, in  the  course of an hour  or  two; to a child the dose
 must be proportioned according  to  the age.   The burnt clothes  having been
 removed, the patient should be laid upon  a blanket,  and, whatever the degree
 of the burn, be well covered with the finest wheaten flour by means of  an ordi-
 nary dredger. The flour should be laid on thickly, but uniformly and gradually,
 forming a soft and soothing application to the surface.  If the cuticle have been
 abraded or vesicated, the  flour will  form a thick  crust by admixture with the
 serum discharged from the broken surface. If the skin be charred, the discharge,
 which will be speedily set up around the eschar, will  take the flour on to the
 part, forming as it were a coating  impervious to the air.  The crusts thus formed
 should not be disturbed until they become  loosened by the influence of the dis-
 charges of the  part, when  they should be removed; and the  ulcerated surface
 that is exposed, dressed with water-dressing, red wash or lead ointment, accord-
 ing  to the  amount of irritation  existing,  the suppurating  sore indeed being
 managed on ordinary principles.   In  some cases lint dipped in the " Carron oil,"
 composed of equal parts of linseed oil and lime water, to which a small quantity
 of spirits of  turpentine might be  added, has appeared to agree better than any-
 thing else, and in others cotton  wadding answers  admirably.  Whatever local
 application be adopted, I  hold it  to be of the utmost importance in the early
 stages of the burn to change the dressing  as seldom  as possible; not until it 
TREATMENT  OF  BURNS.
339
has been loosened, or rendered  offensive by  imbibition of  the discharges.
Every fresh dressing causes the patient very severe  pain, and  certainly retards
materially the progress of the case.
   When the stage of reaction has fairly set in, the  patient's  secretions should
be kept free by the administration of an occasional mild purgative and salines.
Should any inflammatory symptoms about the head, chest, or abdomen  manifest
themselves, it  will  be necessary to have recourse  to antiphlogistic treatment
proportionate  to  their severity.   I have certainly  seen  patients saved  under
these circumstances by the employment  of blood-letting and  the proper appli-
cation of leeches.  At a later period in the case, when the strength has been
exhausted by the  continuance and the  amount  of the discharges,  good diet,
quinine, and a general tonic plan  of treatment will be required, and any symp-
toms of hectic that supervene  must be met in the ordinary way.
   As cicatrization advances, much attention should be paid  to repressing the
exuberant granulations by the  free use of the nitrate of silver, and the position
of the part must be carefully  attended to, so  as  to counteract, if possible, the
 after-contraction that  ensues.  With this view, the part must be properly fixed
by means  of bandages,  splints, and mechanical contrivances, specially adapted
 to counteract the tendency to  contraction  of  the cicatrix.   This is especially
 necessary in burns about the neck, when there is a tendency for the chin to be
 drawn down on to  the sternum, and great deformity to be thus occasioned; and
 in burns at the inside of limbs or the  flexures of joints, when after-contraction
 is very apt to ensue.  In such cases I  have advantageously employed the elastic
 traction of India-rubber bands to counteract the tendency to contraction of the scar.
   Operations for the removal of the effects  of  contraction,  consequent upon
 burns,  are occasionally required, and  if judiciously planned and executed, may
 do much to remedy the  patient's condition.   The great obstacle to the success
 of these operations, however, consists in the fact that the  granulations which
 spring from the contracted cicatrix are in their turn liable to  take on the same
 contractile action as the original  cicatrix.  After the division of the  cicatrix,
 also, it is often found that  the subjacent structures have been so rigidly fixed
 in their abnormal position as not to admit of extension.   It may then be neces-
 sary to  divide some of  these, as  fasciae  and tendons, before  that part can be
 restored to its normal shape.
   These operations are  most likely to be successful when  they are practised for
 contractions at the flexures of the joints, as at the bend  of the elbow, for  in-
 stance.  There, all that need to be done, is to divide the  cicatrix down  to the
 subjacent healthy structures, and  then, by the  proper application of splints or
 screw apparatus, gradually to extend the limb; if any muscles or tendons are
 found  to  offer  resistance  they may be  divided,  if this  can  be done without
 inflicting  too serious a  wound upon  the part, and impairing its after-utility.
 Much caution, however, will here be necessary; for if the contraction be of old
 standing,  the  arteries and  nerves  will likewise  have become  shortened, and
 will be incapable of stretching under any force that it may be safe to employ.
 Operations that are undertaken for the removal of the disfigurements that occur
 about the  face  and neck  as the  result of burns, require much management.
 Instead of simple  division of the cicatrix, it has been  proposed to dissect it
 away entirely in some  cases, in others, to transplant portions of healthy skin
 upon the surface thus denuded, or that results  from the  gaping of  the wound
during extension of the limb.   In other instances, again, to divide it gradually
 by the  pressure of a silver wire, passed through and twisted over it.   In addi-
tion to the division of the cicatrix, Mr. James,  of Exeter, and Mr. Quain, have
in these cases very successfully employed a screw-collar, by which the  chin can
be loosed from the sternum, and gradual extension of the cicatrix effected.
   Amputation may be required if the  burn  has  destroyed the whole thickness
of a limb;  the part charred should  then be removed at once, at the most con-
venient point above the  seat of injury; so also amputation may be required at 
310
EFFECTS  OF COLD.
a later period, if, on the separation of the  eschars, it is found that a large joint
has been opened, and is suppurating, or if the disorganization of the  limb  is
so great as to exhaust the powers of  the patient in the efforts at repair.   Great
caution, however, should be employed in  determining on  the  propriety of am-
putating when the burn has extended, though in a minor degree, to other parts
of the body, lest the  powers  of the  patient  be  insufficient for the double call
that will thus be made upon them.

                              FROST-BITE.

   When the body has  been exposed to severe or long-continued cold we find,
as in the case  of burns, that local and constitutional effects are produced.  The
local influence of cold  is  chiefly manifested on the extremities of the body, as
the nose, ears, chin, hands, and feet,  where the circulation is less active  than at
the more central parts.  It chiefly  occurs  to  an injurious degree in very young
or aged persons,  or in those whose constitutions have  been depressed by want
of the necessaries of life.
   In the first degree  of frost-bite  that calls  for the attention  of the surgeon,
there is a feeling  of stiffness,  with  complete numbness  of the  part that has
been exposed to cold; it looks pale, has a  bluish tint, and is somewhat shrunk.
In  this state the vitality of the part is not destroyed, but is merely suspended.
On the return of circulation and the  vital  actions in the affected part,  a burning
tingling pain is felt, it becomes red, and shows signs of a tendency to  inflamma-
tory action.  Indeed, this  appearance of inflammation, often accompanied by a
burning sensation, is probably the immediate consequence of extreme degrees of
cold, as is experienced on touching solidified carbonic acid or frozen mercury.
   In the next degree of cold, the  vitality of the  part is completely destroyed;
all sensibility and motion  in  it are  lost, it becomes  shrunken and  livid; but
though its vitality may have been annihilated by the immediate application
of the cold, it is not until  the part has become thawed that gangrene  usually
manifests itself; it  then  appears to  do so by the violence of the reaction  in-
duced, the part  rapidly assuming a  black color, becoming  dry, and separating
eventually, as all other mortified parts do,  by  the formation  of a line  of ulcera-
tion around it.
   The constitutional effects of a low temperature need not detain us.   It is well
known that after exposure to  severe or long-continued cold, a feeling of heavi-
ness and stupor comes on,  which gradually creeps on to an irresistible tendency
to sleep, which,  if yielded to, terminates  in  coma, and a speedy, though pro-
bably painless, death.
   The treatment of frost-bite consists in  endeavoring to restore the vitality of
the frozen parts.  In doing this the  great danger is, that reaction may run on
to so great a degree as to induce sloughing of the structures whose vitality has
already been seriously impaired.   In  order to prevent this  accident occurring,
the most gradual elevation of  temperature  must be had recourse to for restoring
the part.   The patient should be placed in a cold  room, without a fire,  any ap-
  roach to which  would certainly lead  to the destruction of the frost-bitten mem-
  ers.  These  must  then  be gently rubbed with snow, or cold water, and held
between the hands of the  person manipulating; as reaction comes on, they may
be enveloped  in  flannel or woollens,  and a small quantity of some warm liquid
or spirit and  water  administered to  the  patient.   In this way sensibility and
motion will gradually return, often with much burning and stinging  pain, red-
ness, and vesication of the part.   If gangrene have come on, or if the reaction
run  into sloughing, the sphacelated  part, if  of small  size, may be allowed  to
detach itself by the natural process of separation ;  if of greater magnitude, am-
putation of the  injured limb may be required.   This should be done at the
most convenient  situation for  the operation so soon as the line of separation has
fully formed. 
DIVISION    THIRD.

     SURGICAL  DISEASES.
                       CHAPTER XXIII.

                               abscess.

  An abscess signifies a collection of pus occurring in any of the tissues or in-
ternal cavities of the body.  In structure, an abscess consists of an accumulation
of pus situated in the midst of, and surrounded on all sides by a layer of fibrine
deposited  in and consolidating the neighboring tissues.   This lymph, which
constitutes the wall of the abscess, varies greatly in thickness  and consistence,
in some cases being scarcely perceptible, in others, some lines in thickness and
of corresponding firmness, constituting, perhaps, the principal part of the mass.
This wall  of "limiting fibrine" is always very vascular, in consequence of the
inflammation  and  congestion of the tissues  that enter into  its  composition.
Outside it there  is an infiltration of sero-plastic matter, and beyond this again
we reach the healthy tissue.
  Surgeons divide abscesses into various kinds, according to the symptoms
attending them, their duration  and  cause.   Thus  they speak habitually of
acute and chronic, hot and cold, lymphatic, diffuse, metastatic, and puerperal
abscesses.
  The acute or phlegmonous abscess may be taken as the type of the disease.
When it is about to form, the part which has been  previously inflamed  swells
considerably, with a throbbing pulsatile pain; the skin becomes shining, glazed,
and of a somewhat purplish-red.   If the  abscess be very deeply seated, the
superimposed  tissues  become  brawny  and  cedematous, without,  perhaps, any
other sign indicating the existence of pus.   As the  swelling approaches the
surface it softens at one  part, where  fluctuation becomes perceptible,  and  a
bulging of the  skin  covering its summit  takes place;  this pointing of the
abscess indicates that it is about to burst, and discharge its contents, which it
speedily will through a circular aperture formed in the skin.  The pointing
is an  interesting pathological phenomenon,  and takes place in the following
way: — An abscess, originally formed perhaps deeply in the substance of  a
limb,  enlarges  by the  extension  of the periphery of its wall,  and by the
innermost layers of  this  structure  at  the same time degenerating into pus.
As  the wall extends, it has  a  special tendency to  approach towards a free
surface, whether that  be external or internal, skin or mucous membrane; all
the tissues between it and the surface towards which it is progressing being
gradually absorbed or melting into the abscess.  It is in this  that  the pointing
essentially consists, and  the mode in  which it  is finally accomplished  would
appear to be  as  follows: — the pressure that the tumor exercises from within
outwards  causes  compression of those  vessels, that,  passing from the deeper
parts, ramify between the summit of  the  abscess and  the superjacent  skin for
its  supply.  In  consequence of this  pressure upon, and interference with, the
                                                             (341) 
342
ABSCESS.
circulation through these vessels, the nutrition of the parts supplied by them
is  arrested, and  they become  softened, disintegrated  in  structure, and less
resistant to the progress of the tumor  than those tissues which surround it on
other sides, and which have  not had  their vascular supply interfered with, or
lost their normal cohesion.   The abscess then naturally makes  its way at this,
the point of its circumference, where  it meets with least resistance to its pro-
gress.  As it approaches the surface, the skin at first becomes more or less livid,
tense, and cedematous, conditions indicating the interference with  its circula-
tion ; as the summit of the abscess presses  upwards, the overlying skin loses its
tension, and  becomes  relaxed;  it then sloughs at the most central point, from
which the cuticle has previously peeled off, and the outward pressure of the pus
speedily detaching  the slough,  the abscess discharges itself.   Though  acute
abscesses, if left to themselves,  usually run  this course and burst through the
skin, the mucous or serous surfaces, or  even into the interior of joints, yet some
collections of pus, if  very deeply seated, cannot find their way to  the surface,
but  extend through the cellular planes of  the limb in a lateral  direction, bur-
rowing and undermining parts to a great  extent;  or if situated  in dense and
unyielding structures, as in bone, are  imprisoned within a case through which
they may be unable to penetrate; in other rare instances, the abscess disappears
by the pus becoming absorbed.   After an  abscess has burst, the cavity usually
closes by granulations springing up from within, and by the collapse of its walls;
in some cases, however, it does not completely close, but contracts into a narrow
canal, forming a sinus or fistula.
   Chronic abscesses are of very common occurrence, a piece of dead bone having
given rise to irritation in its vicinity, or a gland, or some portion  of the subcu-
taneous cellular tissue having become indurated, tender, or subacutely inflamed,
at last slowly  and without any constitutional symptoms, or much appearance of
local disturbance except the swelling, softens and breaks down into a somewhat
thin, flaky, curdy, puriform fluid, though in other instances the pus is perfectly
healthy.  These  abscesses do not readily point, but often extend laterally, bur-
rowing for a considerable distance from their original seat.   In other cases they
become circumscribed by a thick and dense wall of fibrine, through which it may
be extremely difficult, and perhaps impossible, to detect fluctuation, the disease
then simulating a solid tumor.   The duration of these chronic  abscesses with-
out opening, is often very remarkable, even when situated in soft parts. I have
seen large chronic abscesses in the iliac fossa and groin, perfectly stationary for
nearly two years.  When situated in denser structures,  as in the substance of
the breast for instance, the  wall may become so dense as to resemble a cyst, and
the disease will continue in the  same state  for a great length of time.  In the
bones, abscesses may exist for an indefinite period.
   The cold, lymphatic or congestive abscess  occurs not  unfrequently with but
very slight precursory local symptoms,  and indeed not uncommonly without any
at all.   The patient, who has usually been  cachectic, and suffering some time
from general debility, after feeling slight uneasiness in the groin, iliac fossa, or
axilla, finds suddenly a large fluctuating tumor in one or other  of these situa-
tions ;  there is perhaps no pain in the part, and no discoloration of the skin, but
the fluctuation is always very distinct,  the limiting fibrine being in small quan-
tity.  On  opening  such an abscess as this, there will  usually be a copious dis-
charge  of thin unhealthy  pus, which  when examined  under the  microscope
will  be found to contain  ill-developed, withered cells;  in some cases the con-
tents appear to be a clear semi-transparent or oily-looking matter, probably sero-
plastic effusion.
  Diffuse abscess^ forms rapidly  in  the  cellular tissue,  as  the result  of diffuse
inflammation  of it.   In  these cases there is no limiting fibrine, and hence the
pus often spreads widely, producing extensive destruction of parts beforejt  is
discovered.  A particular variety of this form of abscess is the puerperal, occur- 
ABSCESS,  VARIETIES OF.
343
Fig. 185.
ring in women after parturition, in various parts of the body, especially in the
iliac fossa, the cellular planes of the thigh or in the joints, and in the adipose
tissue of the orbit, often destroying the globe of the  eye.  To these forms  of
the disease the metastatic abscesses are closely allied.  They commonly occur in
connection with phlebitis and  pyemia, are very numerous, and are met with in
the substance of organs as well as the cellular tissue and joints.   The three last
species of abscess are varieties  of the acute form.
   The tympanitic or emphysematous abscess, which  contains gas as well as pus,
is occasionally met with in the neighborhood
of the  mucous  canals, chiefly  at the  ante-
rior and lateral parts of the abdominal walls
and about the sacrum.  Sometimes the com-
munication with the intestine  is very free,
in other cases it is  not so evident.  These
collections are often perfectly resonant  on
percussion,  the air  being above, the  fluid
below, and sometimes gurgling, is very dis-
tinct in them.
   Abscesses are met with in all regions  of
the body, but more  especially in the cellu-
lar tissue; partic J&py in those parts where
this tissue is aburmant, and the absorbent
glands are  numerous.   They may occur at
any period of life, from  the earliest infancy
to old age.   I have  opened a very large  ab-
scess in the axilla of a. child about a fort-
night old.   Their size varies from that of a
pin's point  to  a tumor containing a pint or
more  of pus.   In  some cases when very
large  they  are multilocular, the  different
cysts being  connected by narrow channels
of communication; in this way I have seen
a large  abscess extending from the lumbar
vertebrae through the iliac fossa down the
thigh, the ham, and the leg, until  at last it
was opened by the side of the tendo Achil-
 lis, forming five or  six  distinct cysts, com-
 municating with one another by contracted
 channels (fig. 135).
   The pressure-effects of abscess are often
 important.   By compressing the nerves  of
 a part it may give  rise to very severe pain
 and spasm at a distance from its seat, and in  this way in some  apparently neu-
 ralgic affections it has turned out that the pain has been occasioned by the pres-
 sure of an abscess  on the trunk of a neighboring nerve.   When blood-vessels
 come into relation with an abscess, they usually become coated by a thick layer
 of lymph, which guards them from injury.  In some cases, however, they become
obliterated  by the conjoined effects of  the pressure and the inflammation, in
which they partake  as well as  the adjacent tissues.  In other  cases, more par-
ticularly in  strumous and  cachectic individuals, the blood-vessels  not having
been guarded by the protecting lymph, have  ulcerated and burst into  the  cyst
of the abscess,  occasioning sudden, dangerous, or even fatal hemorrhage.  It is
seldom, however,  that a large  artery or veins  pours  its contents into an abscess
that  had not  been  opened.   The various  mucous canals, more especially the
trachea  and the urethra, may  be  injuriously compressed  by neighboring  ab-
 
344
ABSCESS.
scesses ;  so also bones may become necrosed, and joints inflamed and destroyed,
from the same cause.
  The  diagnosis  of  abscess, though usually easily  made, at times requires
attention.  The surgeon believes that an acute  abscess is about to form when,
after rigors and some modification of the inflammatory fever, he finds  the local
signs characteristic of  the formation  of pus; more especially a throbbing pain
in the part, with softening of any induration  that may  have existed, and oedema
of the cellular  tissue covering it.  His suspicion is turned to certainty, and he
knows that an abscess has'formed, when, after the occurrence of these symptoms,
fluctuation can be felt, and the other signs manifest themselves.   This fluctua-
tion may, however, readily be confounded with the undulatory sensation that is
communicated  by  some tissues from  the  mere infiltration of sero-plastic fluid
into them, or even without this, from their natural laxity, as  is sometimes the
case in  the cellular tissues  of the nates and thigh  in persons of lymphatic
temperament.   This, indeed, is a difference  of degree rather than of kind, as
pus would make its appearance in the course of a few  hours, if the tumor were
left to itself.   The mere occurrence of fluctuation is  not  of itself sufficient to
determine more than that a fluid exists in the part.   The question  necessarily
arises, is this fluid pus?  In the majority of instances the history of  the case,
the character of the pain, the previous existence and the continuance  of symp-
toms of  inflammation,  enable the surgeon to  answer in thefaffirmative.  But if
there be but obscure evidence of inflammation having existea^and if the swelling
be of long standing, the fluctuation being perhaps deeply seated and indistinct,
the safer plan will be for the surgeon to introduce an  exploring  needle, and to
see what the true  nature of the fluid is;  by this simple means many embarrass-
ing mistakes in diagnosis  may be avoided.   The tumors with which  abscesses
may be confounded, are those soft solid growths in which there is a high degree
of elasticity, giving rise to a species of undulation, as in some kinds of encepha-
loid tumor; so also fluid tumors of various  kinds, such as cysts  and enlarged
bursae, may be  confounded with abscess.  In these cases the previous symptoms,
the situation, and the  general appearance and  feel of the tumor, will usually
enable the surgeon to effect a ready diagnosis; but should any doubt exist, the
exploring needle or trochar must be introduced,  when* the escape or  not, of a
drop or two of pus will determine  the question.   Coxeter's " suction trochar"

                                 Fig. 136.
(fig. 136), is of especial service in cases in which it is  desirable to withdraw
some of the  contained fluid for closer examination.  The diagnosis of an abscess
having pulsation communicated to it by a subjacent  artery, from an aneurism,
will be discussed when we  come to speak of that  disease.  It may be well to
mention that the pains  occasioned by  the pressure  of some forms of  chronic
abscess upon neighboring nerves have been mistaken for rheumatism.
  Abscesses  vary greatly in danger, according to their  nature, size, situation,
&c.  The chronic form is usually attended by more risk than the acute and the
diffuse.   The puerperal and pyemic are especially hazardous to life, being gene-
rally associated with a bad  state of the blood.  The large size of some abscesses
is an element of great risk, occasioning not only a very abundant discharge  of
pus, but  likewise  great  constitutional  irritation when opened.  Abscesses that
are situated  in the neighborhood of important organs, as  about the neck of the 
ABSCESS,  VARIETIES OF.
345
bladder, or in the  anterior mediastinum, are  necessarily much more  hazardous
from  the  peculiarity of their situation  than those which are met with  in  less
important regions.  The cause of the abscess also influences the result; if it be
a piece of dead bone that can be removed, the discharge will  speedily cease on
its being taken away, but if it be so situated that it cannot be got rid  of, it will,
by acting as a continuous source of irritation,  keep up  a discharge  that may
eventually prove fatal.  The constitution of the patient influences our  prognosis.
Such  an  amount  of discharge  as would inevitably prove fatal in a  cachectic
system, may influence a sound one but very little; so also, the wasting effect of
the abscess  is better borne  about the  middle  than at either of the  extreme
periods of life.
   The treatment of abscess presents three points requiring attention.   The  first
object should be to prevent the  formation of matter; the next, to take steps for
its  evacuation when formed; and, lastly, to endeavor  to  close the cavity that
results.
   In order  to prevent the formation of matter, it is necessary to get rid of any
local  irritant that may exist;  thus dead bone  should be removed, or extravasated
urine  let out of the cellular tissue.  After this has been done, the preventive
treatment must consist in the active employment of local antiphlogistic means,
such  as leeches  andf^ld evaporating lotions: any slight tenderness  that con-
tinues after the innjmarnation has subsided must be removed, and  that swelling
from  exudation maror, which  is especially the precursor of chronic abscess,
must be got rid of by the continuous application of some discutient lotion.  One
composed of iodide of potass, 3 i., spirits of wine, 3 i-, water,  § vij., is extremely
useful; in some cases absorption may advantageously be promoted by mercurial
ointments or plasters.   When once pus  has  formed, it is a question whether it
can be absorbed again;  in general, it certainly  cannot, more  especially if once
a distinct cyst has formed around it;  but in some cases it may undergo absorp-
tion ; thus,  in hypopium, we  occasionally observe that the  pus deposited in the
anterior chamber of the eye  is removed, and I think it probable that the same
may happen when it is infiltrated into the  tissues  of a part, without a very dis
tinct  wall surrounding it.  The more fluid parts of chronic abscesses occasionally
become absorbed, leaving a cheesy residue behind, which may degenerate into
cutaceous matter.
   When, notwithstanding the employment of antiphlogistic means, it is evident
that pus is about to form, the treatment  should  be completely changed, and by
the aid of warmth and poultices, an endeavor should be made to hasten suppu-
ration. When this is fully established, the abscess having become " ripe," steps
must be taken for the evacuation of  the  matter.   The  treatment of acute  and
of chronic abscesses differs essentially in this respect.
   In the acute abscess the matter should be let out as soon as it is fully formed,
especially in those varieties of the disease connected with  a morbid state of the
system, as in the metastatic and puerperal forms.   When this is done, the con-
stitution at  once experiences great relief, the fever and  general irritation sub-
siding materially; the  free  incision  by which  this is accomplished  not  only
letting out the pus and  lymph, but removing tension, and by encouraging local
bleeding, lessening the  inflammatory  action.  The rule of opening  an acute
abscess early is especially imperative when the  pus is formed in the sheaths of
the tendons and under fibrous expansions, as in the palm of the hand;  so, also,
when it is situated deeply in the cellular planes of a limb, under the larger
muscles, where it has a tendency to diffuse itself extensively.  In those cases
likewise in which it is lodged in close proximity to a joint, or under  the peri-
osteum, it must be let out early;  so also  when it presses upon mucous  canals or
important organs,  as on the urethra or trachea, or when it is dependent  on  the
infiltration of an irritant fluid into a part, as by urinary extravasation, it must be
evacuated without delay.  The pus should  always be let out early before  the 
346
ABSCESS.
skin covering it is  thinned,  when  the abscess  is situated in the neck or in
any other part where it is desirable  that  there  should be  as  little scarring as
possible.
  In the case of chronic abscesses, the rule of surgery is not so explicit.  Here
the collection is often large, coming  on without any very evident symptoms, and
giving rise  to no material inconvenience; but if it be opened, putrefaction of
the pus, consequent upon the entry  of air into the extensive cyst, will give rise
to the most serious  constitutional disturbance, setting up  irritative  fever that
may rapidly prove  fatal  in a debilitated  frame, and  should the patient escape
this danger, the drain  of an abundant  suppuration may  speedily waste him.
Hence, it not uncommonly happens  that  a patient may carry a chronic  abscess
unopened, without any very serious disturbance, for many months or even years,
but when once opened, that he will die in a few days.  If, however, the chronic
abscess be so small that  no danger is to be apprehended from  the inflammation
of its cyst,  or if it be situated in parts where its presence may give rise to dan-
gerous pressure, the matter should be let out without delay.
   There are  three  modes by which abscesses  may  be opened, each of which
possesses  advantages in  particular cases: — these are by incision, by tapping
with a trochar, and by making an aperture into the cyst with caustic.
   Incision is the only plan that should be practised i-a^mxite abscesses.   For
this purpose a lancet, an abscess-bistoury (fig. 137), or a^^Hpe-shaped knife may
be used.  The incision  should be made either at the pornt where fluctuation is
most  distinct, or at  the most dependent part  of the tumor, so  as  to prevent
after-bagging of the matter.  It  should be made by holding the bistoury or

                                   Fig. 137.
lancet short, and introducing it perpendicularly into the softened part.  If the
depth to be  reached is  considerable, a bistoury should be used, the blade of
which  should be half turned  round after its introduction, when the pus wells
up by its side, the point  being felt to move freely in the cavity of the abscess.
The incision must then be continued for a moderate extent in the direction of
the natural folds of the skin of the part, or in the course of  the vessels.  The
pus should be let out freely, so as to allow the walls of the abscess to collapse,
but it should not be forced out by squeezing the sac.   It may happen, after the
escape of the pus, that the cavity of the abscess fills with blood by the rupture
of some small vessel situated in its wall;  this, however, is of  little moment, the
hemorrhage speedily ceasing on the application  of pressure, of a bandage, or of
cold.   After the opening has been made, a poultice or water-dressing must be
applied; the cavity left, eventually fills up either by the coalescence of its sides,
or by granulating from below; if it fill  again with pus, a fresh incision, termed
a "counter-opening," must be made in the most dependent part.
  In the treatment of chronic and cold abscess, all three plans may be employed
for opening the sac. If  it be of small size, an incision should be made into it
at once.  If the collection be considerable, we must wait  until an opening has
been rendered necessary  by the tendency to implication of the skin, or by inju-
rious pressure being exercised on important  parts; the pus should then be let
out by the  valvular aperture recommended by Abernethy, the object being to
limit the entry of air into the interior of the abscess, to  lessen  the chance of
putrefaction of any pus that is left, and  of consecutive inflammation of the cyst.
The valvular opening is made by drawing the skin covering  the abscess well to
one side, then passing  the bistoury directly into the sac, and  allowing as much 
OPENING OF  ABSCESSES.
347
of the pus to escape as will flow out by the collapse of the walls of the abscess;
before the matter has quite ceased to flow, and before any air can consequently
have got into the sac, the skin should be allowed to recover its natural position,
bo that the aperture in it and in the cyst may no longer directly communicate.
A piece  of plaster, or of lint soaked in collodion, should  be placed upon  the
external  wound, which will probably heal under this covering in the course of
a short time.   When the  cyst of the abscess has  again  filled  somewhat, this
process may be repeated; and less and less pus being allowed to accumulate in
it before each succeeding evacuation, it may  gradually contract and close.
   Instead  of making the valvular opening in this way, a chronic abscess may
sometimes be advantageously opened by tapping with a trochar and  canula  of
moderate size, the instrument being introduced obliquely between the skin and
the abscess, and then made to dip down into the sac.  After the withdrawal of
the canula, the aperture may be closed as in the former  case.  There is, how-
ever, one disadvantage in this plan of opening abscesses;  that if the discharge
be curdy or shreddy, it is very apt to block up the canula, and thus  to interfere
with  the proper evacuation of the matter.
   The potassafusa, though  a painful application, may be advantageously used
for opening  those  chronic abscesses, the skin covering which is much  under-
mined, congested, aj^ discolored.   In  these cases I commonly employ  it with
great  advantage.  ^Hfs also useful in  the  after-treatment, when much solid
plastic matter is ler^Dy  dissolving this away, and thus preventing the formation
of sinuses.
   In  some forms  of abscess it will be  found that those processes which  are
necessary for  the  contraction and  closure of the cyst, after  its  contents have
been  evacuated, do not  readily take place;  and  it becomes necessary to have
recourse to other  measures,  in order to excite sufficient  healthy inflammatory
action, to occasion the deposition of that plastic  matter by which the cavity is
filled.  With  this view,  a  seton of two  or three threads  may very  usefully be
passed across the cyst by means of a naevus needle, or by a long straight needle
pushed up through the canula used for tapping (fig. 138).  It should be  left
in for a few days, by which time healthy inflammation will be set up.  In other
cases  again, after the cyst has  been tapped, the red wash or some  tincture of

                                  Fig. 138.
iodine should be injected and left in.  These methods of exciting inflammation
are especially useful  when  the  cyst  is thin, and  of a very chronic  character.
When the walls are very thick and  dense, as sometimes happens in abscesses
of very old standing situated in the neck, an  elliptical piece  of the anterior
portion of the cyst should be dissected out, and the remainder  of the cavity,
lightly dressed  with  lint, be allowed  to  fill by granulation.   This plan of
treatment  is often very successful, and I have in  this way cured abscesses in
the neck of seven  or eight years' standing, which have resisted every other plan
employed.
  The constitutional  treatment  of abscess  must be  conducted on the  general
principles laid down in discussing the management of suppurative inflammation 
348
ABSCESS.
(p. 97); but it must be borne in mind, that as abscess is always  a disease of
debility, a tonic and stimulant plan will early be required.

                        SINUS AND  FISTULA.

  After an abscess has been opened, its  cavity may not fill  up completely, but
contracting into a  narrow  suppurating track, forms a canal  without disposition
to close, and  from which a small quantity of pus constantly exudes, thus consti-
tuting a sinus or fistula.
  The  cause  of this non-closure of the  cyst of an  abscess may be referred to
the following heads: — 1st.  The presence  of a foreign body, as of a piece of
dead bone at the bottom, may keep the track open; 2d. The passage of irrita-
ting secretions, as of urine, faeces, saliva, &c, through the abscess, will prevent
its  complete  closure;  and 3d.  The  contraction  of neighboring  muscles  will
occasionally prevent the due coalescence of the sides of the abscess; as when it
is in the neighborhood of the sphincter ani, and as may occasionally happen in
abscesses about the limbs.
  A  sinus or fistula  consists  of a narrow channel, often  long and winding
having an external orifice  that is usually somewhat protuberant, being situated
under or in the midst of loose  florid granulations.   Th^wfells of this  channel,
which are always  indurated, are lined by a structure reBBbling mucous mem-
brane ;  this, however,  it is not, but simply consists  of {Wayer of imperfectly-
formed granulations, exuding ichorous pus.   If the orifice be occluded, this pus
will collect within  the  sinus,  and distending its walls, reconvert it into an
abscess.   In  structure, therefore, a sinus or fistula may be  said to  be a Ion"-
narrow, chronic abscess, with a permanent external aperture.
  The  treatment  of a sinus or  fistula has reference  to its  cause in  the  first
instance ;  for until the foreign body that keeps it open  and maintains  the
discharge is  removed, it  will  be  useless  to  attempt its  closure.  After its
removal, we  may endeavor to procure obliteration of the sinus by one of three
methods.
  1st.  The  employment of pressure, by  means of  a roller  and graduated
compresses, so as  to cause an agglutination of its  opposite sides.   This plan is
useful in those  cases in which  the  sinus  is recent, without  much surrounding
induration,  and so  situated, as  upon the trunk,  that pressure can easily be
applied.
  2d. A more healthy inflammation may often usefully be excited in the sinus,
by  injecting it from time  to time with red wash, or with tincture  of iodine, by
passing the threads of a seton through  it, or  stimulating it by the occasional
contact of a  red-hot  iron.   My colleague, Mr. Marshall,  has invented a very
ingenious and useful apparatus, by means of which a platinum wire, introduced
cold, is heated red-hot by the galvanic current.  This plan of treatment, which is
fully detailed in a paper published in the " Medico-Chirurgical Transactions"
for 1851, has frequently been  employed  with  much success in the University
College Hospital in the treatment of fistulae and sinuses to which other methods
were not very applicable.
  3d. The last method consists in  laying open the sinus from end to  end, and
then dressing the wound so that  it  may heal from the  bottom;  in  this  way
neighboring  muscles,  that have kept it  open by their contractions, may  also
be set at rest.   The division of the sinus should be done with a probe-pointed
bistoury,  introduced through  the external  opening  either  by the aid of  a
director or without such assistance.   The operation should be done effectually,
the  sinuses  being usually  followed  as  far  as  it is  prudent  to  go,  and  laid
completely open. 
VARIETIES OF  ULCERS.
349
                        CHAPTER  XXIV.

                                ULCERS.

  Various forms of ulcer, affecting the cutaneous surface or mucous mem-
branes, are familiar to  the  practical surgeon.   When  occurring in the skin, as
the result of non-specific  disease, they  may be  arranged under the  following
heads : the Healthy—the Weak—the Indolent—the Irritable—the Inflamed—
the Phagedenic or Sloughing—the  Varicose—and the Hemorrhagic.   Besides
these varieties, each of which is  marked by distinct  characteristics,  various
other forms of ulceration depending on specific causes, as the syphilitic, scrofu-
lous, lupoid, cancerous, &c, are met with, all  of which will be treated under
their respective chapters.
   The varieties presented by ulcers are by no means dependent on local condi-
tions merely, though these influence them greatly, but are in  a great measure
owing to constitutional causes.   Indeed, the aspect of an ulcer, the character of
its granulations and of its  discharge, are excellent indications  of the state of
health and of the general condition  of the patient, as well as of the local disease
that exists.        yf
   Ulcers may be situated upon any part of the cutaneous surface as the result
of  violence;  most commonly when occurring from disease of a non-specific
character, they are seated on  the  leg,  but when arising from some  specific
affection they occur in particular situations, as on the penis, lips, &c.
   The  healthy or purulent ulcer may be considered  the type of the disease,
presenting a  circular  or oval  surface, slightly depressed, thickly studded with
small granulations exuding laudable pus,  and having a natural  tendency to
contract and heal.  It is the object of all our treatment to bring the other forms
of  ulcer  into this  condition.   In the  management of this healthy ulcer, the
treatment should be as simple  as possible, water-dressing and the pressure of a
bandage usually enabling it readily  to cicatrise.
   The weak ulcer not uncommonly occurs from emollient applications having
been continued for too long a time to the last variety of the disease, the  granu-
lations  then  becoming  high and  flabby, with a  semi-transparent  appearance
about them,  and sometimes rising in  large, exuberant,  gelatinous, reddish-
looking masses above the surface of the sore.   These high granulations have a
feeble vitality, and readily slough.   The treatment  of this form of ulcer consists
in  keeping the part elevated and carefully bandaged, with an astringent dressing
to  the sore;  such as a weak solution of the sulphate of zinc or of copper, or the
" red wash," according to the following formula: — Sulphate of zinc, grs. xvj.;
comp. tinct.  of lavender and  spirits of rosemary, of each  jtij.; water  §viij.,
will be found a most useful application, in addition to touching the granulations
from time to time with the nitrate of silver.
   The indolent ulcer is always  of a very chronic character; it is situated upon
the outer side of the lower  extremities, between  the ankle and calf, and most
frequently occurs in men about the  middle period in life.   It is deep  and exca-
vated, with a  flat surface,  covered  by irregular and badly-formed granulations,
exuding  a thin and  sanious pus, having hard, elevated, and callous edges, and
presenting generally an irregular and rugged look.  The surrounding integument
is congested  and  matted to the subjacent parts;  there is usually very little
subcutaneous cellular tissue about it, the skin being firmly fixed to the  subjacent
fascia;  and it would appear as if it were in consequence of this want of a vascular
substratum from which to spring, that granulations do not readily arise.   There
is no pain attending this ulcer, and its surface, which often attains a very large
size, may usually be touched without the  patient feeling it.  The principle of 
350
ULCERS.
the treatment here is two-fold, to depress the edge, and to elevate the base of
the sore.  This is effected by pressure and  stimulation conjoined.  The treat-
ment should be commenced by rubbing the surface  of the  ulcer and the sur-
rounding congested integument with nitrate  of silver;  a linseed-meal poultice
should then be applied for twenty-four hours, after which  the sore should be
properly strapped  on the plan recommended by Baynton.  The best plaster for
this purpose is the emplastrum saponis, to which some  of the empl, resinee is
added to make  it sufficiently adhesive; this, spread upon calico, should be cut
into strips sixteen or eighteen  inches in length  and about an inch and a-half
in width; the centre of the strip  should then be laid smoothly on the side of
the limb opposite  to the sore, and its ends being brought forward, are to be
crossed obliquely over  it.  Strip after  strip must be applied in this way until
the limb is covered for a distance of a couple of inches above and below the
ulcer.  If  the sore*  be  near the ankle, this joint should be included  in  the
strapping.   Each strip of plaster  should be applied with an equal degree of
pressure, which may often  be  considerable, and should cover at least one-third
of the preceding strap; the limb must then be carefully bandaged  from the toes
to the knee.  Under this plan of treatment,  the edges will subside, the surface
of the sore become florid, and granulation, yielding abundant discharge, speedily
spring up.   Much of its  success will  depend upon the dpse attention that is
paid to  the case;  if the skin be irritable, no resin-plast^rshould be used, but
merely the soap or lead, and the plasters should be changed at least every forty-
eight hours.  If the discharge be very abundant, small holes should be cut in
the strips to allow it  to escape.   When by this plan of treatment  the edges of
the sore have been brought down, and the granulations sufficiently stimulated,
an  astringent lotion  with bandaging  may advantageously be  substituted  for
the plasters.  In some  of  these cases I have found  benefit from the internal
administration of liquor arsenicalis.
   The irritable ulcer is mostly met with in women about the middle period of
life, more especially in those  of  a nervous and  bilious temperament.  It is
usually of  small size, and  situated about the  ankles, or upon the shin.   Its
edges are irregular,  but  not elevated, the  surface greyish, covered with a thin
slough, and secreting unhealthy sanious pus.   Its  principal  characteristic is
the excessive pain  accompanying it, which often, by preventing sleep, disturbs
seriously the general health.  In the treatment of this ulcer we must attend to
the constitutional as well as the local  condition.  The patient should be put
upon an alterative course of medicine, with aloetic purgatives and some sedative
at bed-time to procure rest.  The mode of topical medication that  I have found
to  succeed  best is to brush the  surface of the sore and the surrounding parts
from time to time with a strong  solution of  the  nitrate of silver, and  then to
keep emollient and  sedative applications to it, such as lead and opium lotions.
The occasional  application of  the nitrate  of silver  deadens materially  the
sensibility of the sore and assists its granulation.
   The inflamed ulcer is characterized by much redness, heat, and swelling of
the surrounding parts, with a thick and offensive discharge, often streaked  with
blood; it may come on from the  over-stimulation  of one of the other varieties.
The  treatment must be locally and  generally  antiphlogistic.   The  elevated
position, the application of leeches around the sore,  and of cold evaporating
lotions to the surface of the limb, will speedily subdue the inflammatory action,
after which, the healing process takes place  with  great rapidity.
   The sloughing ulcer, when not specific, is an increased degree of the inflamed
variety, usually occurring in a feeble  or cachectic constitution, and generally
accompanied  by a  good  deal of fever of  the irritative  type.  An angry
dusky red  blush forms about the sore, which becomes  hot and  painful; the
surface  assumes a  greyish sloughy look, the edges  are sharp  cut, and the
ulcerative action extends rapidly.  The treatment in these cases should consist 
VARIETIES  OF ULCERS.
351
in improving the general health by lessening irritation, and keeping up tone.
The administration of opiates with  nourishing but unstimulating diet, should
be  trusted to at the  same  time that  the local action is subdued by rest and
warm opiate lotions.   When the inflammatory condition has  subsided, tonics
should be given internally, and a grain or two  of the  sulphate of copper or of
zinc may be added to the lotion with which the sore is dressed.   The specific
varieties  of sloughing ulcer will be  considered in the  chapter on  Hospital
gangrene, &c.
   The  varicose ulcer derives its chief  characteristic from  being complicated
with, or dependent upon, a varicose  condition  of the  veins  of the leg.   In
this affection of the  venous trunks the skin gradually undergoes degeneration,
becoming  brawny, of  a purplish brown  color, and being  traversed in  all
directions by enlarged and tortuous cutaneous veins.  The  ulcer forms at one
of these  congested spots, by the breaking down  of the already disorganized
and softened tissue, forming a  small  irregular chasm of an unhealthy appear-
 ance, and varying much  in  character,  being  sometimes inflamed, at others
 irritable or  sloughy, and then  becoming indolent.   One of  the most serious
 effects  of this  ulcer is,  that by  penetrating  into one of the dilated veins it
 occasionally gives rise to very abundant hemorrhage, the patient, in the course
 of a few seconds, losing a pint or two of blood.   This hemorrhage may be
 readily arrested by  laying the patient  on  his back, elevating  the limb, and
 compressing the bleeding point with a pledget  of lint and a roller.  The
 treatment of a varicose ulcer must  have special reference to the condition of
 the veins that occasions  it; no local applications having  much effect unless
 the pressure of the column of blood in the dilated vessels be taken off the part.
 This may be done by means of a well-applied bandage, made of elastic material,
 or a laced or elastic  stocking applied  to the leg, so as to keep  up a uniform
 pressure upon the distended vessels.  In some cases, the length of the column
 of blood may be broken  by the  application of a vulcanized india-rubber band
 below the knee. In many cases the cicatrizations of the ulcer cannot be brought
 about in this way, or, if it heal, it will  constantly break open again;  or hemor-
 rhage may  have occurred from  a ruptured vein upon its surface: means  must
 then be  taken for the  permanent  occlusion of the  varicose vessels by  their
 ligature,  as will be described in the chapter on those affections.  As this pro-
 cedure, however, is attended by some  danger from the occasional induction of
 phlebitis or erysipelas, it should not be had recourse to unless the existence of
 one or other of' the conditions just  mentioned urgently calls for  it.
    The hemorrhagic  ulcer is a dark, purplish-looking  sore, occurring  in women
 suffering from amenorrhcea, and having a special tendency, whence  its name,
 to ooze blood about the menstrual periods; it usually partakes of the character
 of the  irritable ulcer, and requires to be  treated by constitutional means, having
 for their object the improvement of the patient's general health; with this view
 the preparations of iron and aloes are especially useful.
    Various forms of ulcer occur upon the mucous membrane of the throat, rectum,
 and genital organs.   As these, however, are commonly of a specific character,
 they will be hereafter described.  When ulcers of the  mucous  membrane  are
 not of  a specific character, they present  the general appearances characteristic
 of the cutaneous, healthy, inflamed, or weak varieties, and  require the topical
 applications suited  to these conditions; though generally  they will bear and
 require the free employment of caustics, especially of the nitrate of silver. 
352
MORTIFICATION,  OR GANGRENE.
                          CHAPTER  XXV.

                MORTIFICATION,  OR GANGRENE.

  The local death of a part of the body, in surgical language, is termed Morti-
fication  or  Gangrene: when  the morbid  action is  confined to the osseous
structures or to tne cartilages, it is termed Necrosis;  when limited  to the soft
tissues of a  limb, Sphacelus; and when accompanied  by ulceration, it is called
Slough.   Many other varieties of gangrene  are  recognized by surgeons; like
all  other  diseases,  it may be  acute or chronic  in its duration;  as the parts
affected are moist  and swollen or dry and shrivelled, it  may be divided into
the moist and  the dry or mummified gangrene; so, again, according to its cause,
it is spoken of as idiopathic or traumatic, and very frequently  and most
correctly, perhaps, arranged  under  the denominations of constitutional and
local, without reference to the comparatively accidental  circumstances of its
dryness or moisture.  Besides  these, various  specific  forms of the  disease  are
met with, which will require special consideration.
   Whatever form  the gangrene may assume, there are certain local phenomena
that are common to all the varieties of it.  There is complete loss of sensibility
and of motion in the part affected, the temperature of which falls considerably
below  that  of  the body generally,  giving  rise to a sensation of  damp and
clammy  coldness,  and after a time there is an odor  of  putrescence evolved,
with very commonly an  emphysematous crackling from effusion of gas into
the tissues  of the part.  The color  of the  part affected is usually of a dark
purplish or greenish-black, more or less  mottled with red.   This, which is
unlike anything else in  the system,  shows  that changes  of  importance have
taken place in the solids  and fluids of the diseased tissues, and is usually con-
nected with the moist and  swollen form of the disease.  In the dry variety of
gangrene, the color  is often  at  first  of  a pale  tallowy-white, with a mottled
appearance  upon  the surface.   The  skin soon  shrivels, becomes dry,  horny,
and semi-transparent, and eventually  assumes a brown, wrinkled appearance;
in other cases, again, the gangrened part is brown, dry, and shrivelled from the
very  first.  These  differences in the color  of the  mortified  part indicate
corresponding differences in the  cause of the affection.   In  general terms, it
may be stated that the dark varieties  of gangrene are the  result of destructive
changes taking place in the  very part itself, or are of constitutional  origin,
whilst the pale form  of the affection occurs as a consequence  of some obstruc-
tion in the  supply of blood to the part, and is a local disease only, influencing
the constitution secondarily.
   The processes adopted by nature for the arrest of gangrene, by the formation
of a line of demarcation, and  for the  detachment of  the  parts that have  lost
their vitality, by the extension of ulceration along the line of separation, have
already been fully described (pp.  103,104).
   The  constitutional symptoms vary greatly: when the disease is strictly local,
affecting a part of but limited extent, and of no great importance, perhaps, to
the economy, they are not very strongly marked.  If, however, the gangrene,
although limited, implicate organs  of importance to  the  system, as a knuckle
of intestine, for example, marked symptoms declare themselves.  Whatever the
precursory  condition may  be, the  full invasion of the gangrene, if it be of
rapid  occurrence,  is always accompanied by constitutional disturbance of an
asthenic type, attended  by great depression  of the powers of the system, with
a dull  and anxious  countenance, and a feeble, quick, and easily compressible
pulse;  the  tongue is brown, and soon  becomes loaded with sordes.  When the 
VARIETIES OF  GANGRENE.
353
gangrene is internal, a sudden  cessation of pain, with  hiccup,  vomiting,  and
tympanitic distension  of the  abdomen, may be superadded to the symptoms,
and  indicate the mischief that has occurred.  Death usually supervenes with
low  delirium, twitchings, and coma.  When the invasion of the gangrene  is
more gradual, as we see in some of the constitutional  forms affecting the lower
extremities, the symptoms are usually those of irritative fever, eventually  sub-
siding into the asthenic form.
   The diagnosis of gangrene is  easily effected when this condition  has fully
developed itself; but in the early stages, before it is positively declared,  it is
not  always an easy matter to  determine its existence.   The  ecchymosis and
discoloration  of a  bruise, the  collapse and  lividity  that result from cold,  or
the  dark purple hue occasioned  by long-continued congestion, may readily be
 confounded with impending gangrene.   In these  cases  of doubt, the surgeon
 should not be in too great  a hurry to pronounce  an unfavorable opinion, and
 still less to  act upon it, for it not uncommonly happens that parts of the body
 that had to all appearance lost their vitality, may by proper treatment regain it.
   The prognosis of gangrene is  always bad, so  far  as  the  part  itself is  con-
 cerned, though it  occasionally happens that when it is not fully established,
 partial recovery may unexpectedly take place.  So far as the life of the patient
 is at stake, much will depend  on the cause of the affection, and the age and
 strength of the individual in whom it occurs.   At advanced periods of life, and
 in a feeble state of system, the result is always unfavorable; so also whilst the
 gangrene  is  spreading, the  prognosis is  bad, as it is  impossible to say where
 the morbid action  may stop; but when once the line of demarcation has formed,
 indicating as this  does the  possession  of  a certain vigor of  constitution, the
 principal danger is over, and then  the  result will depend on the  power of the
 patient, and the support that can be  given during the  processes of separation
 and of repair.
   The causes of gangrene are very various.  They may be arranged under four
 principal heads:
   1st. The intensity or specific nature of the inflammation of a part may give
 rise to its death by the stagnation of the blood within its vessels, or by inducing
 such changes in it as are incompatible with life.
   2d. The arrest  of  the circulation through a part is a common cause of gan-
 grene, and may be occasioned in  one  of  three ways;  either by strangulation of
 the part generally; by the obstruction of the  flow of blood through the  main
 arteries  leading to it;  or, by the return of blood through the principal veins
 coming from it being interfered with.
    3d. Traumatic  causes  of various  kinds give  rise to different forms of gan-
 grene, most of which we have already considered.  Thus the severe  contusion,
 compression, or laceration of a  part may occasion gangrene of it (page 116); the
 infiltration of an irritating fluid into  a part; and, lastly, its exposure to intense
 heat or cold  will destroy the vitality of the tissues implicated.
    4th. Specific poisons of various kinds occasion special diseases, of which gan-
 grene is the  principal characteristic.   Thus  hospital gangrene, malignant pus-
 tule, noma, carbuncle, and ergotism,  are instances of specific affections, accom-
 panied by gangrenous action.
   Amongst the causes, some are constitutional, others, local, in  their action : —
 those forms of gangrene  are  said to  be constitutional which arise from intense
 or specific inflammation of the part—from obstruction of the circulation in con-
 sequence of  a diseased state of  the  heart  and vessels,  or from the  action  of
 various specific poisons.  On  the  other hand, those varieties  of gangrene  are
 local which arise from injuries of all kinds, whether applied to the part itself,
 or to the main artery leading to it, by its ligature  or wound.
   Some of the varieties of gangrene that have just been indicated, such as those
 arising  from the  intensity of  the inflammation,  and  from various  traumatic
        23 
354
MORTIFICATION,  OR GANGRENE.
causes, have  already been discussed (p.  116); whilst those that arise from ob-
structed  circulation, or that take the form of specific diseases, are left for our
consideration here.
   Gangrene from Arrest of Circulation.—Arrest of circulation may act
in three  ways in inducing gangrene : — 1st, by the arrest of all the blood, arte-
rial, venous, and capillary, in the part, as in strangulation by a tight ligature;
2d, by obstruction of the arteries, and  consequent deprivation  of blood; and
3d,  by venous obstructions, and by  consequent  over-accumulation  of blood.
1st. A part is often purposely strangled by a surgeon in many operative pro-
cedures, or its circulation may in  this way be arrested, as the result of certain
diseased conditions.   In either case, the strangulation acts by stopping more or
less completely the  whole circulation  of the part.  If it  be sufficiently severe,
it may kill the tissues  outright; as, for instance, when a naevus or pile is tied,
all flow  of blood to or  from the part is suddenly arrested, and  its vitality
destroyed, the tissues that have been  strangled  shrivelling, and separating by
ulceration along the line of ligature.    When the strangulation is not so severe
as this, great congestion in the part ensues, consequent on the interference with
the return of the venous blood; the part strangled becoming dark and congested,
phlyctenas or vesicles  arising  on its surface, and effusion taking place  into its
tissue.   Inflammation becoming at last  superadded to the effects of the strangu-
lation, and still more embarrassing the circulation of the part, sloughing takes
place by the  conjoined  action of the strangulation and the inflammation; all this
we see occurring in a constricted gut.
   2d. Arterial obstructions.—When a part of the body is deprived of its proper
supply of blood,  mortification  may ensue.   This we see occasionally happen
 when the circulation is arrested through the main artery of a limb by its liga-
 ture or wound.  Most commonly, when the principal trunk of an artery is ob-
 structed, the collateral circulation is  sufficient  to maintain the vitality of the
 part; but should this be interfered with in any way, gangrene ensues from the
 simple deprivation of that blood which is necessary to the maintenance of its
 life.  Indeed, the sudden loss of a large quantity of blood from the  system
 generally may occasion the death of some of the extreme parts of the body, in
 which the circulation  is  naturally most  languid.  Thus Sir B. Brodie relates
 the case of a drunken man, who, being bled to an inordinate extent,  was seized
 with gangrene of both feet.
    The want of a due supply of arterial blood to the limb may be occasioned in
 three ways :—1st, by the ligature or wound of the main trunk; 2d, by obstruct-
 ive arteritis; 3d, by calcification, and consequent occlusion of the vessel.   This
 form of  gangrene varies  materially, according as it arises from  one or other of
 these causes.
    When a limb becomes gangrenous  in  consequence of the  ligature or wound
 of its main  artery, without any other  injury to the vascular system, it will be
 found to become cold, to  feel heavy, and to  lose its sensibility; at the same
 time  it assumes a dull tallowy-white  color, mottled with greyish or brownish
 streaks.   This state of things is  chiefly met with in the lower extremity; the
 integuments  of the foot die, become  semi-transparent and horny-looking where
 they are stretched over the tendons of the intsep, and the part thus presents a
 shrivelled appearance.   In the course of a short time, the pallid color will be
 lost, the part becoming brown or blackish.   This form of gangrene may  invade
 the whole of the lower limb, but most commonly is limited to the foot, stopping
 either just above the ankle, or if not,  then immediately below the knee, as
 Guthrie has observed; the arrest taking place in one or other of these two spota
 on  account of the  greater  freedom of the collateral circulation  here than in
 other parts of the limb.   If any of the large venous trunks become obstructed
 or otherwise  implicated, so that the return of blood through them is interfered
 with, at the same  time  that  the supply by the arteries is arrested, the  limb 
SPONTANEOUS  AND SENILE  GANGRENE.         355
Fig. 139.
generally assumes a greenish-blue color, and rapidly runs into putrefaction.   In
some of these cases it happens that sloughs of the integument and subcutaneous
cellular tissue  form,  although the limb  generally preserves  its vitality.  The
treatment of these forms of gangrene, which are  strictly local, is described in
the chapter (p. 174) on wounded arteries.
   Gangrene may occur from the circulation being arrested  by disease taking
place in the coats of the  arteries.  This  is the variety of the affection, that  is
commonly called  spontaneous.   It may be the  result  either of obstructive
arteritis, or of  plugging up an artery that has undergone calcification  or senile
degeneration.
   Spontaneous gangrene  from acute obstructive arteritis  may occur at  all ages;
in young  people as well as in old.  It happens as frequently, indeed I believe
more frequently, in the  upper than the lower extremities, and is of the humid
                   variety.  Its pathology  and treatment  will be  fully con-
                   sidered  when we come to speak of arteritis.
                     Spontaneous gangrene is termed "senile" when  it occurs
                   in consequence of the coats  of the arteries becoming rigid
                   and  calcified (fig.  139),  and unable to maintain the circula-
                   tion of  the limb.   It is  met with in the lower extremities
                   of people past the middle period of life, and increases  as
                   age advances : a sensation of weight in the limb occurs, with
                   coldness, itching, and tingling  in the feet, and with cramps
                   in the calves, and  the circulation of  the  part  is habitually
                   defective.   This  condition  commonly exists for a conside-
                   rable length of time'before gangrene comes on.   In many
                   instances this  sets in without any exciting ciuse; but  in
                   other cases the mortification is immediately set up as the
                   result of some  slight  inflammation accidentally induced; by
                   the excoriation produced, perhaps, by a tight  boot, or by a
                   trivial wound in cutting a corn  ; the inflammation occasioned
                   by this  slight injury  being sufficient  to disturb the balance
                   of the circulation  in  the already weakened part to so great
                   an extent, that gangrene ensues.   This generally makes  its
                   appearance in  the form  of a  cold,  purple or blackish-red
                   spot on the side of one  of the toes; this spot may be sur-
                   rounded by an inflamed  areola, and accompanied by much
                   smarting and burning pain;  it spreads by gradually involv-
                   ing  the inflamed areola, which continues  to  extend  in
                   proportion  as  the gangrene  progresses.   In such  cases
                   the  toes  and  feet
                   simply shrivel, with-
                   out any sign of local
                   inflammation or con-
                   stitutional  disturb-
                   ance.   In  one or
                   other of these ways
                   the *  affection  gra-
                   dually creeps up the
                   limb, invading per-
                   haps  one toe  after _-
                   the other, involving lis
                   the instep and the
                   sole of the foot, and,
unless it  terminate by  the  formation  of  the  line of demarcation, or death put
an end to  the  patient's  sufferings, it may extend up the ankle  or leg.  The
part that  is affected is always black, dry,  and shrivelled, resembling  closely the
Fig. 140.
  Femoral and tibial
arteries  obstructed
in senile gangrene.
 
356
MORTIFICATION,  OR GANGRENE.
appearance presented by a dried mummy; hence it is often  termed mummifi-
cation  (fig. 140).   There  is usually considerable constitutional disturbance
sometimes  pyrexial  at first, but  secondarily sinking  into an  irritative  or as-
thenic form, in these  cases, and the disease is generally fatal in from a month
to six weeks.  I  have known  the disease  continue, however, with very little
constitutional  disturbance for more than  twelve months.  In  other instances,
again, the gangrene  being limited to a small extent, the patient may recover.
   Gangrene may also occur from inflammation affecting the principal artery of
a limb, and perhaps occluding  it completely, without any previous disease in
the vessel.  In these cases there are the  usual signs of arteritis, such as ten-
derness along  the course of the vessel, cessation  of  pulsation in its terminal
branches, intense  superficial  pain  in the  limb,  followed by the rapid superven-
tion of dark, dry  gangrene  in  the whole  of the extremity up  to the point at
which the vessel is inflamed.   This affection, of extremely rare occurrence, has
been described as spontaneous gangrene.   In some cases it partakes of the cha-
racters of  the  humid  form, owing  to the implication of the  veins.   It is,  I
believe, most frequently  met with  in  the upper  extremities,  at least all the
instances that I have seen of it have been situated there, and I have observed
it most commonly in women, occurring even at an early period of life.   It is
of the dry variety, in consequence of the  arrest of the flow of  blood into the
limb, and usually  occurs in a broken constitution, being frequently  fatal by the
supervention of typhoid symptoms before  any attempt can be made by nature
to separate the mortified part;  after death, in these cases, the inflamed  vessel
will be found firmly plugged up by a dense coagulum, which completely arrests
the circulation through it.  The pathology of the arterial system in reference
to these  two forms  of gangrene, will  be  more  fully discussed  in a subsequent
chapter.
   3d.  Venous obstruction.—Gangrene may arise from obstruction to the return
of blood through  the veins of a part, the disease occurring from the circulation
being  arrested  by the  overloading  of the  capillaries with venous blood.   Gan-
grene  is especially apt to take place, if the arterial supply is  diminished,  at the
same time that the return of venous blood is interfered with; as when an  artery
and vein are compressed, or when the femoral vein is wounded accidentally at
the time that the artery is ligatured.  Gangrene from this cause is always of
the moist kind, attended by great swelling from oedema, with discoloration and
rapid putrefaction of the part.
   This gangrene, from venous obstruction, is  also especially  apt  to occur in
those cases in which the heart's action is weakened, or the flow of blood  in the
aorta lessened,  at  the same time that the  force of the impulse  in  the arterial
system is so lowered that the heart is  unable to push the  blood through the
loaded vessels.   Those cases of gangrene of the extremities that are occasion-
ally met with from pure debility,  as after fevers, often appear to originate in
this way.
   The various  forms of traumatic gangrene, whether arising from  the severity
of the injury, from  the inflammation following it, from the  depraved condition
of the blood, from the irritation of extravasated fluids, or from  the effects of
burns, or of frost-bite, have already been considered when treating of these
respective injuries;  and the more specific  forms of the affection we shall shortly
describe.
   Treatment. — As  gangrene  proceeds from such a great variety of causes,  it
must be very evident that no one plan  of treatment can be  applicable to this
condition, and  it becomes necessary, not  only to modify our therapeutic  means
according  to the  cause  of  the disease, but also with  special reference  to the
constitution of the  patient, and with  regard to  the  stage  in which we meet
with the gangrene;  and,  indeed, it often requires great tact  and experience  to
accommodate the  treatment in  this way to the varying phases of the case.  I 
    TREATMENT OF SPONTANEOUS AND  SENILE GANGRENE.   357

have already considered the treatment of the inflammatory (p. 104) and the
traumatic and local (p. 175) forms  of gangrene, and  shall, therefore, consider
merely in this place the general principles that guide us in the management of
those varieties that have been considered as the result of constitutional causes
— the  spontaneous forms; and in these cases the constitutional management of
the patient is of greater moment than the local treatment of the disease.
   In the constitutional treatment of these forms of gangrene, there are  three
principal indications: lstly. To remove the cause, if possible, and thus to  arrest
the gangrene.  2ndly. To support the powers of the system during the process
of the separation of the sloughs; and 3rdly.  To lessen the irritability of the
nervous system.
   In the removal of the constitutional cause, we  must look wholly to the con-
dition  of the patient's system; if this be in an  inflammatory or. febrile  state,
we must have recourse to the modified  antiphlogistic  plan  described at  p. 86.
But the opposite condition, that of debility, may equally occasion or complicate
the gangrene, which may recognize an enfeebled state of the circulation of the
part, or of the system generally, as its cause, and there may be every possible
combination between  this and the inflammatory condition.  Under these circum-
stances, it will be necessary to conjoin an antiphlogistic plan of treatment with
remedies of a tonic, or even stimulating  character.  It is this plan  of treatment
that is commonly found to  succeed best in  the spontaneous gangrenes; here
moderate antiphlogistics are perhaps  required in the earlier stages, with a light
nutritious diet and mild tonics  as the disease advances, and in the later periods,
when  the  constitutional symptoms  assume  an  asthenic character, stimulants
should be given.  The best stimulants to administer in these cases  are wine or
porter, according to the patient's habits  of life, and these should  be  given in
combination with nourishment, so as not  merely to  raise the  pulse, but to pro-
duce  a more permanent tonic  influence on  the  system generally.  If  much
 depression occur, the medicinal stimulants, more especially ether, ammonia, and
 camphor, are of material service.   The  only tonics that are of much  value in
 these  cases, are the preparations of bark and some of the vegetable bitters, as
 gentian  and  cascarilla; and though the specific virtues  that were formerly
 attributed to them can no longer be accorded, yet, when they do not irritate the
 stomach, they are  of unquestionable service in combating the asthenic symptoms
 and improving the digestive powers.  In  these cases I look upon  bark or gentian,
 in combination with the chlorate of potass and ammonia, as of undoubted value.
    After the proper employment of means calculated to remove the constitutional
 cause of the gangrene, the system must be  supported against  the debilitating
 effects that accompany the  process of ulceration and  of suppuration necessary
 for the separation of the mortified parts.  During this period, there is less irri-
 tation and more debility, and stronger tonics and  stimulants can be borne, but
 we should be careful not to overstimulate the patient.  On this point it is ex-
 tremely difficult to lay down any rule;  every possible variety as to the  quantity
 and quality of food and stimulus being  required by different individuals.   The
 safest guides are the state of the pulse and tongue; if they improve, the means
 employed agree.   At the  same time hygienic measures  should be  carefully
 attended to; cleanliness and  free  ventilation, with  the  abundant use  of the
 chlorides, are of the  first moment, so that the patient be  not poisoned by his own
 exhalations.
    The third indication, that  of lessening the  irritability of the  system that
 always supervenes, and which  is partly owing to  the  severity of the  pain, and
 partly to the shaken and depressed  state of  the  nervous system, is best carried
 out by the administration of opium; and although this drug may not act as a
 specific, as Pott supposed, yet  in many cases, but especially in  the  gangrene of
 the toes and feet of old people, it  is undoubtedly a remedy of the greatest value.
 A grain of the solid  opium may be administered advantageously every  6th, 8th, 
358
MORTIFICATION,  OR  GANGRENE.
or 12th hour, according to the effect it is found to produce, care being taken at
the same time that the bowels do not become confined.   The hiccup, which is
often distressing in these cases, is best remedied by the administration of chloric
ether and camphor.
   The local treatment of the gangrenous part should be conducted on the prin-
ciples described (p. 104), leaving the separation of the sloughs as much as pos-
sible to nature, diminishing the feetor which occurs, by the use of the chlorides,
preventing the  absorption  of  morbid matters by the line  of separation, and
dressing this with wet lint or calamine cerate, and lastly, endeavoring to heal
the ulcer that results on the detachment of the sloughs.
   The treatment of " senile gangrene," presenting, as it does, some peculiarities,
requires a few words to be specially devoted to it.  By some  surgeons this dis-
ease has been treated on a strictly antiphlogistic  plan, on the supposition that
the obstruction of the arteries was caused by the inflammation of their coats;
this, however, is certainly an erroneous doctrine in a great number of cases; and
though inflammation may occasionally affect the  calcified coats of an  artery, it
is always a low form of the disease that does not bear depletion.  Sir B. Brodie
very justly observes, that in these cases  the local precursory inflammation termi-
nates in mortification, because the inflamed part cannot obtain the  additional
supply of blood that it requires; hence if blood is abstracted from  the system,
and the action  of the  heart weakened, the cause of the disease will only be
aggravated.  But though depletory measures are  not admissible, we must guard
against running into the opposite  extreme, and  over-stimulating patients labor-
ing  under  this  disease.    Senile  gangrene  commonly  occurs  in individuals
belonging to the wealthier classes of society, who  have lived high, taken insuffi-
cient exercise, and consequently got the system into an irritated, plethoric, but
enfeebled state.   In this condition stimulants and the more powerful tonics  are
not well  borne, they heat the system, accelerate the pulse, and interfere with
digestion; and, as Sir B. Brodie observes, it is  of great  importance in this dis-
ease to attend to the state of the digestive organs, in order that  nutrition may
go on, and that blood of a proper quality may be  made.  In order to accomplish
this, a light, nourishing diet, partly animal and partly vegetable, should be given,
and a moderate quantity of wine, beer, or brandy allowed.  The bowels must be
relieved from time to time by a rhubarb draught  or  simple aperient pill.  It is
better  to avoid mercury in any form in this disease, as it depresses  the system,
and hence it should not be used,  even as an aperient, unless the state of the
liver imperatively required it.   If the digestion  become impaired, a stomachic,
as the infusion of cascarilla, or the compound infusion of gentian with a little
ammonia, may be administered.  The administration of opium in  these cases, as
recommended by Mr. Pott, has received the sanction of almost every practical
surgeon.   Sir B. Brodie's opinion  on this point is peculiarly  valuable; he says,
" If I am not  greatly mistaken, the  result of a particular case will very much
depend on this, — whether opium does or  does  not agree with the patient.
From  2 to 4 grains of opium may be administered in divided  doses in  the course
of the twenty-four hours, the quantity being increased  as the system becomes
accustomed to its effects.  If it disturb the stomach and occasion headache not-
withstanding the use of aperients, it must, however, be  discontinued, as it will
increase the irritation of the system.   With respect to  the  comparative advan-
tages of the depletory and  stimulating plans  of treatment in senile gangrene,  I
think it may fairly be stated that neither method should be employed exclusively;
that in those cases in which there is much action going on, in which the spread
of the gangrene is preceded  by a red  angry blush, with much pain and heat,
low diet  and moderate depletory measures will  be most useful, whilst  on the
other hand when it is  simply a shrivelling  of the toes  and  feet, without  any
sign of being preceded by local increased action, or by constitutional disturbance
of a febrile type, a tonic <»r stimulating plan will succeed best. 
TREATMENT OF  SENILE GANGRENE.          359
  The local means to be employed in senile gangrene are of a simple character.
It is of great importance to keep up the temperature of the limb, and to equalize
its  circulation as much as possible;  this is best done by the application of cot-
ton-wadding or of  carded  wool, in thick layers around the foot and leg, so as to
envelop the limb completely in this material,  over which a large worsted  stock-
ing may be drawn, or a silk handkerchief  stitched.   This dressing need not be
removed more than once or twice a week unless there is much discharge from
the line of separation, then it must be  changed more frequently; the gangrened
part itself should be covered with a piece  of lint, soaked in chlorinated lotions.
When the soft parts have been separated,  and the bones of the foot exposed,
these should be cut across by means of cutting-pliers or a  small  saw, and  the
sore that results dressed in the  ordinary way with  some astringent  lotion or
slightly stimulating ointment.   The Balsam of Peru, either pure or diluted with
an  equal part of yelk of egg, is a very excellent application in these cases.   In
the event of the patient recovering, he  must be careful to avoid exposure to cold,
and to keep the legs warmly clad at all seasons of the year.
   The question of amputation  in cases of  gangrene of the limbs is of great im-
portance  to the practical surgeon,  and is  one, on certain points of which  the
opinions of the best practitioners are still  at variance.  At first sight it appears
rational to cut off a limb  that is dead, disorganized, and offensive, and this may
be done when the gangrene is,  strictly speaking, a local condition; as,  for in-
stance, the result  of a severe injury; any affection of the constitution in  such a
case as this being secondary to the local mischief, and dependent on the irrita-
tion set up by it, and on the effort made by nature to  rid the system of a spoiled
member.    But when the constitutional disease is  the primary affection,  and
when  the gangrene is consecutive to and dependent upon this, it would clearly
be useless to cut  off the mortified part, as the same morbid action might,  and
would, be set up in the stump or elsewhere. Hence the broad question of ampu-
tation in  cases of gangrene turns upon the fact of the mortification being local
or  constitutional in its origin.
   When  the gangrene is  local, therefore, we usually  amputate at once.   This is
 especially the  case when  the mortification  results from severe injuries, or is the
result of the wound or ligature of an artery.   Here, I think, for the reasons that
have been given (p. 176), that amputation should be performed as soon as the gan-
 grene has unequivocally manifested itself, without waiting for the line of demarc-
 ation.  The result of amputation for  traumatic gangrene is, on the whole, very
 unfavorable, the patient very commonly sinking from a recurrence of the disease
 in the stump, or from the constitutional disturbance that had previously set in;
 those cases being  especially unfavorable in which the cellular tissue of the limb
 is  much infiltrated and disorganized, the affection indeed partaking more  of the
 characters of constitutional disease, with some forms of which it is closely asso-
 ciated.
    There are two  exceptions to the rule of amputating in  traumatic  and local
 gangrene before the occurrence of the line of demarcation, viz., in the case of
 gangrene from frost-bite, and in  that from severe burns; in these injuries it is
 better to wait for the line of separation to form, and then to fashion the stump
 through it as the  circumstances of the case require.
    In  gangrene from constitutional causes, it is a golden rule in surgery never to
 amputate until the line of separation has formed; for as it is impossible in these
 cases  to  say where the mortification  will  stop, the  amputation might  be done
 either too high, or not high enough; and, under any circumstances, the morbid
 action would to a  certainty be  set up in the stump.   It is not even sufficient in
 such cases as  these to wait until  the line of demarcation has formed  before
 removing the limb; these spontaneous or  constitutional gangrenes having often
a tendency to remain stationary for some days, and then creeping on, may readily
overstep the line  by which they had at first appeared to be arrested.  Besides 
360
GANGRENOUS DISEASES.
this, the local disturbance and inflammation set up by the amputation might be
too great for the lessened vitality of the system or part, and might of itself occa-
sion a recurrence of the gangrene.  Hence in these cases it is always well to
wait until the line of separation has ulcerated so deeply that there is no chance
of the gangrene overleaping this barrier, at the same time that means are taken,
by the  administration of tonics, nourishing food, &c, to improve the patient's
strength and fitness for the operation.  So soon as this  has been done  in a satis-
factory  manner, and all the soft parts, except the ligaments,  have been ulcerated
through, the mortified part should  be separated, by cutting through the remain-
in "■ osseous, ligamentous, or tendinous  structures, and then means should be
taken to fashion the stump that has been so formed by nature.  In some cases
this will be  sufficiently regular to  serve every useful purpose after it has cica-
trized ;  in most instances, however,  it will be found that the bones protrude to
such an extent, or that the ulceration has affected the soft  parts so irregularly,
that it will be necessary, in order to give the patient a useful limb, to amputate
through the face of the stump, or  higher up; all this, however, must be left to
the discretion of the surgeon,  but  no procedures  of  this kind should be under-
taken until  the  patient's  strength has  been restored sufficiently to  bear the
operation.
   In senile  gangrene it has recently been proposed to amputate the thigh high
up.  This practice has been successfully adopted by  Mr. Garlike, Mr. James of
Exeter, and others, and certainly deserves a trial in all cases  in which the health
is otherwise good and the constitution tolerably sound.   It  has not as yet been
adopted in a sufficient  number of cases  to warrant a positive opinion on its
merits; but it would appear that  for it to succeed, the amputation  should be
done high up in the thigh, so that there may be a better chance of meeting
with a  healthy condition of the vessels and good vitality in the limb;  the opera-
tion being performed on the principle, that this form of gangrene is dependent
on local disease obstructing the vessels  of the part, and not always on constitu-
tional causes.
                        CHAPTER XXVI.

                      GANGRENOUS  DISEASES.

                              BED  SORES.

  When a part of the body is compressed too severely, or for too long a time,
even in a healthy constitution, it  loses its vitality, and a  local limited slough
results; this separates, and an ulcer is left, which cicatrizes in the usual way.
But in certain deranged states of the health, more especially when the blood is
vitiated and  the constitutional powers lowered, as  during fever, or when  the
patient is old, debilitated, or  paralyzed, the skin covering  those points of  the
body that are pressed upon in the recumbent position, such as the sacrum, the
trochanter, the elbows, shoulders, and heels, becomes  congested and  inflamed,
assuming a dull reddish-brown color, and speedily becomes excoriated without
any pain being felt by the patient.   If means  be not taken to relieve the part
from the injurious compression to which it is subjected, and more  especially if
it be irritated by the contact of faeces or urine, the subcutaneous cellular tissue
corresponding to  the  inflamed patch will be  found  to  have become widely
softened and doughy, being converted, with the skin covering it, into a tough 
SLOUGHING  PHAGEDENA.
361
greyish slough, from under which a  thin ichorous pus  exudes.  This slough
may extend by a process of undermining of the integuments covering it, and
on its  separation extensive mischief will be disclosed, the fascia and tendons
being  exposed, or  the bones  laid bare, and  soon  becoming roughened and
carious.   In some cases, even, the inferior aperture of the spinal canal may be
laid open, or death result from a low form of arachnitis, in consequence of the
irritation spreading to the membranes  of the cord.   In other cases, again, the
patient dies worn out by discharge and irritation.
   The treatment of these cases is in a great measure  of  a preventive character.
When a patient is likely to be confined to bed for many weeks, especially by
an exhausting disease, steps should  be taken, by proper arrangement of the
pillows, and by the use  of the  water-bed  and cushions,  to  prevent  pressure
being  injuriously  exercised upon any one part.   At the same time cleanliness
and dryness should be carefully attended to, by proper nursing,  by the use of a
draw-sheet, and by furnishing the bedstead with the  necessary arrangements
of bed-pan, etc.  The  skin on the exposed parts may be protected by the appli-
cation  of  collodion or soap-plaster spread   upon wash-leather  or  amadou, or,
what is better, may be strengthened  by being washed with spirits  of wine,
either  pure, or having two grains  of the  bichloride of mercury dissolved in
each ounce.
   If the skin have become chafed, the removal of pressure is  imperative, and
the abrasion  may be washed over with collodion; if a sore has formed, it may
be dressed with the balsam of Peru, either pure or diluted with the yelk of
egg, spread upon  lint.   In these cases, also,  the use of the  prone couch may
occasionally be advantageously substituted  for that  of the ordinary bed pre-
viously  employed.  When sloughs  have  formed,  their  separation  must  be
facilitated by the use  of  charcoal or chlorinated  poultices, and the ulcers that
are  left should be dressed with  astringent  and  aromatic  applications, such as
catechu, tincture of myrrh, etc.;  but no dressing that the surgeon can  apply
will cause these ulcers to heal, unless the patient's general health improve, and
then they will speedily get well under simple treatment.

                      SLOUGHING  PHAGEDENA.

   This affection, which is also commonly known by the  names of hospital, con-
tagious, or pulpy gangrene, is  a  disease characterized  by a rapidly destructive
and spreading  ulcer,  covering itself  as it extends by an  adherent slough,
and attacking open sores and wounds.  It is rarely met with in its fullest
extent, except in military practice;  the accumulation of the wounded, and the
want of the necessary cleanliness and attention during  an  active campaign,
appearing to dispose to it.  It used formerly to desolate  the civil hospitals, but,
thanks to the sanitary measures  that  are  now so generally  adopted in these
institutions, it has almost disappeared from them, though still an outbreak of
it occasionally takes place.  During the last few years, it has been met with in
most of the London hospitals,  and has  twice made its appearance in that of the
University College.
   When  sloughing phagedaena  invades a  wound that  is previously  perfectly
healthy, the  surface  of the sore becomes  covered with  grey, soft  points  of
slough, which  rapidly extend, until the whole of the ulcer is affected.  At the
Bame time  it  increases  rapidly in superficial extent, and  commonly in depth;
the  surrounding integument  becomes  cedematous, swollen, and of a livid red
color; the  edges  of the  ulcer are everted, sharp cut,  and assume  a  circular
outline, and its surface is covered with a thick, pulpy, greyish-green tenacious
mass, which is so firmly adherent  to  the sore  that it cannot be wiped off from
it, being merely  moved  or swayed  to  and fro when  an  attempt is made  to
clean it.  There is usually some  dirty yellowish-green  or brownish discharge, 
362
GANGRENOUS DISEASES.
and  occasionally  some bleeding;  the pain  is of a  severe  burning,  stinging,
and  lancinating character,  and the  fcetor from the surface is considerable.
The ravages of this  disease, when fully developed, are  very extensive.  The
soft parts, such as the muscles, cellular tissue, and vessels, are transformed into
a grey pulpy mass, and the bones are  denuded and necrosed.  The larger blood-
vessels resist the  progress  of the disease longer than any other parts, but may
at last be exposed, pulsating at the bottom of the deep and foul chasm.  There
is little  risk of hemorrhage taking  place, however, in  the  early stages;  but
when the  sloughs are separating, an artery may give way, and bleeding to a
dangerous  or fatal extent ensue.   Hennen  states that there is most danger of
this happening about the eleventh day.   When the sloughs are thrown off, in
the  form of reddish-brown  or greyish-green viscid  and pulpy masses, a very
sensitive granulating surface is left, having a great  tendency to bleed, and to
be again invaded by the  sloughing action.
   Blackadder has described  an  ulcerated form of this  affection, in which a
vesicle containing a bloody  ichor forms, with  a hot, stinging pain; this  breaks,
leaving a circular  ulceration about the size of a split  pea.   The ulceration once
formed, rapidly extends by  sharp-cut  edges into the surrounding integument.
   On  the  two occasions that I have  had the  opportunity of witnessing out-
breaks of this  disease, in the University College Hospital, the  surface of the
wound affected became rapidly covered with  a yellowish-grey pultaceous  slough.
In  some cases  there was hemorrhage, but most  commonly a small quantity of
fetid discharge  only was poured  out, the edges of the sore became  sharp-cut
and defined, and the ulceration extended  further in the skin by an eighth or a
quarter of  an inch than  in the subjacent cellular tissue.   In the majority of
instances, the disease was confined to the skin and cellular tissue, exposing, but
not usually invading, the muscles and bones, though in  some cases these were
affected.   The ulcers, which had  a somewhat circular shape, were surrounded
by a dusky inflamed areola  of some width.   When once the morbid action was
stopped, they cleaned rapidly, throwing out large vascular granulations.
   The constitutional symptoms are inflammatory in  the first instance,  with a
tendency to asthenic and  irritative  fever  as the disease  advances.   In  the
majority of cases  they follow the local invasion of the sore; Blackadder, Rollo,
Delpech, and Wellbank, have all found this to be the case, and in the instances
at  University College Hospital it certainly  was so.   Hennen  and Thompson,
on the other hand, state that the constitutional symptoms precede  the  local
ones.  This discrepancy  of observation may be  explained by the difference in
the cause of the disease;  if it occur from contagion, the constitutional symptoms
will be  secondary;  if  from causes  acting  on  the general  system, they may
probably be primary, to the local affection.
   All wounds and sores  are liable to  be  attacked in this way, but the disease
most frequently affects  those that are of  recent  origin;  the more  chronic
affections, and those that are specific, very usually escape.
   The  causes  are of various kinds;  primarily it commonly originates  from
overcrowding in hospitals,  from  want of cleanliness, ventilation, and  change
of dressings; from that accumulation, indeed,  of animal  exhalations arising
from the sick  and wounded, which is a source of various forms of low fever
and of allied diseases; and when so  occurring, this disease may be taken as an
evidence of the infringement of the sanitary  laws in  accordance with which the
arrangements of the institutions should be regulated.  But though it commonly
has its origin in this way, especially in the crowding  of military hospitals after
a hard-fought action, it is met with out of hospitals.  Well-marked cases of this
affection, some of a very severe character, have at times occurred amongst  the
out-patients at the  University College Hospital.  In these cases, as in many
others, it  was  probable  that  the disease was  occasioned by the neglect of
hygienic conditions in the  close  and  ill-ventilated  houses of the poor aided 
SLOUGHING  PHAGEDENA.
363
possibly by some atmospheric or  epidemic influence; influenza, erysipelas, and
phlebitis being also very prevalent.  This had been observed at the time of the
first occurrence of the disease at our hospital, in 1841, and I think it is difficult
not to recognize a similarity of cause in these different affections.   When once
it has occurred it may rapidly spread by contagion, though there is no evidence
to show that it is of an infectious character.  Hence the necessity of preventing
its being spread by nurses or attendants, by the incautious use of  sponges, and
of destroying the dressings used  by the patients.
   In the treatment of this affection the first  point to attend to is to prevent the
extension of the  disease to  patients that are not  as yet affected by it.  This
may be done by separating those that have been seized with it, from the healthy,
by ventilating the wards, washing the floors with a solution of the chlorides,
whitening the walls, and fumigating the apartment with chlorine gas.
   The extension of the sore  must be stopped by the free application of fuming
nitric acid, or of the actual cautery to its edges and surface.  I have used both
these agents, but give the preference to the nitric acid if strong and freely
applied, the sides and edges  being well sponged with it.  The actual cautery is,
however, very useful in those cases in which the surface to be destroyed is very
 extensive, or if there  is a tendency to hemorrhage.   Should it not reach the
 deeper portions of the  sore, nitric acid may be freely sponged into them.  After
 the cauterization a strip of lint soaked in a strong solution of the watery extract
 of opium, should be laid around the  margin of  the ulcer, so as to cover the
 surrounding areola; and the separation  of the sloughs must be encouraged by
 the  continued  application of charcoal, yeast, or chlorinated  poultices.   When
 they have separated, and the surface of the sore has cleaned, it may be dressed
 with a lotion composed of one grain of the sulphate of copper,  and five of the
 watery extract of opium to  the  ounce of water.   The granulations, which are
 very luxuriant and vascular, will be found to skin  over  with great rapidity, and
 the cicatrix like that of an ordinary burn will contract very firmly.
   Should arterial hemorrhage occur, it must be arrested by the application of
 a ligature to the bleeding point, but if this does not hold, as will probably be
 the case from the softened state of the tissues, the actual  cautery must be applied,
 or, the limb at  last removed in the event of all other means failing.
   In some cases it happens that though the sloughing  action is checked at one
 part of the surface, it has a tendency to spread at another.   When this is the
 case it may be necessary to apply the  caustic or cautery repeatedly.  In others
 again, the  sloughing action cannot be stopped,  but opens large arteries, and
 destroys  the greater part of the soft  tissues  of a limb, and then it may be a
 question whether amputation should be performed during the  spread  of the
 disease, or the patient left to die of hemorrhage or exhaustion.  Such a contin-
 gency is not  of common occurrence,  but yet it may happen, and the operation
 be successful, as appears by the  following case, though  there would necessarily
 be great danger from a recurrence of the disease in the stump.   The wife of a
 butcher applied at the hospital, with a slight wound of  the forearm, inflicted by
 a hook.  It was dressed in  the ordinary way,  but in  the course of a few days
 she  returned with  extensive sloughing  phagedaena  of the  part,  she was
 immediately admitted, and the disease was arrested by the energetic employment
 of the local  treatment above described; not, however, until after considerable
 destruction of  the  tissues on the inside of the forearm had taken place.  She
 left the hospital before the wound was completely cicatrized, and  returned in a
 few days with a fresh attack of the disease more extensive and severe than the
 first, and which could  not be permanently stopped, either by the actual cautery
 or nitric acid.   The radial  artery was opened and required ligature, and the
 whole of the soft parts, from the wrist to the elbow, were totally disorganized,
and  the bones  exposed.  There was  now very severe  constitutional irritition,
and  the case was evidently fast hastening to a fatal termination.  Under these 
364
GANGRENOUS DISEASES.
circumstances I amputated the arm  midway between the  shoulder  and elbow;
and, notwithstanding that the local  disease was progressing at the  time of the
operation, and the  great constitutional disturbance that existed,  the  patient
having a pulse of 160 to 170, at which it continued for more than  a fortnight,
she made a  good  recovery; to  which the  free  administration of stimulants
greatly contributed.
  The  constitutional treatment  of  this  disease  must have  for its object the
removal  of the combined  state of debility and irritation in  which  we find the
patient.   The  bowels  should be  kept freely  opened by warm aperients;  as
nourishing a diet as the patient will take, with a liberal  supply of stimulants,
should be ordered, and these may be  increased by the addition  of  the brandy-
and-egg  mixture, or of ammonia in  proportion as  depression comes on.   At the
same time I have found great advantage from the administration of a  mixture
of carbonate of ammonia, gr. v.;  chlorate of potass, Bj ;  compound tincture of
bark, 3 j ; decoction of bark, % jss, every four or six hours; or if the patient
will bear it, quinine in full doses, from five to seven grains of the sulphate every
six hours, with an opiate at bed-time,  or more frequently  if there be much pain
and irritation.

         GANGRENOUS  STOMATITIS, OR  CANCRUM ORIS.

   A peculiar phagedsenic ulceration, closely resembling the last-described affec-
tion, is occasionally met with in the  mouths of ill-fed children living in low and
damp  situations, most commonly occurring  between the  second and sixth or
 eighth years, but more especially about the period of the second dentition.
   The mildest form of this  affection presents itself as  small, deep, and foul
greyish ulcers, situated  on  the  inside of the lips  or cheeks, and attended with
a red spongy condition  of the gums and  much fcetor of  the  breath.  In these
cases, good food and air, with nourishing diet, the administration of bark, with
the chlorate of potass, and the  use of chlorinated lotions, with the  honey of
borax, will soon bring about a cure.   The  Spanish snuff (Sabilla) applied to the
sore mouth, or placed  in a small cambric bag on the tongue,  has  a very good
effect in cleansing these sores,  and especially in soothing irritation.
   In the more severe  form of the affection, the true cancrum oris, we find,
 commonly during  convalescence from some of the eruptive diseases of child-
hood, or, if mercury have  been  incautiously administered  during a weak  state
 of the  system, that one of the  cheeks  becomes swollen, brawny, tense,  and
 shining, being excessively hard, and  presenting a red  patch  in its  centre.   In
 consequence of this swelling, it is -often difficult to open the mouth; but if the
 surgeon can gain a view of its inside, he will see a deep and  excavated foul
 ulcer  opposite to the centre of the external  swelling, covered with a brown
 pulpy slough.   The gums are  turgid, dark,  and ulcerated, the  saliva is mixed
 with putrescent matters, and as the  ulceration in  the mouth  extends, the swell-
 ing sloughs, and a large, dark, circular gangrenous  cavity forms in the cheek,
 opening through into the mouth; during all this time the child suffers little,
 but, as the  disease advances,  it  commonly becomes drowsy, and  at last  dies
 comatose.  When  fully developed, this affection is most  fatal.   Rilliet and
 Barthez state that not more than  1  in 20 cases recovers.
   The treatment of cancrum oris is that of hospital  gangrene; the sloughing
 mass should be deeply  cauterized with nitric acid, but not with the actual cau-
 tery, lest the cheek  be  destroyed, the  mouth syringed with the  dilute chlorides,
 and the  system supported with beef-tea, wine, and  ammonia,  in doses propor-
 tioned to the age  of the child.   After the cure of the disease,  the cheek may
 be deeply cicatrized, contracted, and rigid, much in  the same way as after  a
 burn, requiring possibly some  plastic operation in order to enable  the  child to
 open its mouth properly. 
BOILS — CARBUNCLE.
365
                                 BOILS.

  A boil is a hard circumscribed tumor of a violet or purplish-red color, flat-
tened, though somewhat conical, suppurating slowly and imperfectly, and always
attended by a small conical central  slough of cellular tissue  called a core.   It
consists of an inflammation of the subcutaneous cellular tissue, and of the under
surface of the true skin.  The tension and hardness accompanying this affection
render it extremely painful and annoying to the patient.   It is most commonly
seated in the thick skin of the back, the neck, or the nates.
  Boils most frequently make  their appearance in young people, but are com-
mon enough at all ages, and are usually seen either in very plethoric or in very
enfeebled constitutions, often  following some of the  more severe  febrile  dis-
eases, and attending convalescence from them.   In other cases, the system ap-
pears to have fallen into a  cachectic state, often without any evident cause,  and
this terminates by a critical eruption of boils.  A sudden change in the habits
of life,  as from  sedentary to active  pursuits, a course of sea  bathing, &c,  will
also occasion them.  They are  commonly met with in the spring of the year,
but  may occur at all  seasons, and are occasionally epidemic, as has been  the
case during  the  last  few years in London.    When once they take place, they
are often extremely tedious, crop after crop continuing to be evolved.
  In the treatment of boils,  the  constitutional  condition of the  patient, on
which  the disease is dependent, requires to be carefully attended to.  As  they
most commonly occur in a cachectic and broken  state of the system, the  pre-
parations of iron will be  found to act beneficially.   This  mineral may very
advantageously be administered in combination with  ammonia and  chlorate of
potass, after which the patient may  be put upon a course of sarsaparilla  or bark
with the mineral acids.  Should this fail, and the boils appear to be dependent
on  a low state of health, quinine in large doses, in combination with sulphuric
acid, may be advantageously used.   In other instances again, and  especially if
the disease be associated with pompholyx, arsenic will be found of  service.   In
many cases, however, the  surgeon will be baffled whatever be the treatment he
adopts, the tendency to the disease appearing rather to terminate of itself, than
brought to a close by remedial measures.  During this  plan  of treatment,  it is
 necessary to keep the  bowels free by the occasional administration of an aloetic
 purgative.  If the boils  occur in  young people who are otherwise  tolerably
 healthy, or in  plethoric  individuals, this tonic  plan of  treatment will not  suc-
 ceed ; but saline aperients and  the liquor potassae, in doses  of from twenty to
 thirty minims twice a day, will usually speedily remove the affection.   In some
 cases yeast may be advantageously administered.
    The local treatment of this disease is of a simple  character; when they are
 forming, the most useful  dressing is a warm spirit lotion kept.applied with lint
 and oiled  silk; as suppuration comes on, a  linseed meal  poultice, either simple
 or made with  port wine, may be advantageously applied. Most commonly the
 boils may be allowed to break, when  they discharge a thick pus, together with
 the central  core, thus leaving a  small  cavity in and  under the  skin, which,
 however, soon fills up.   The  surgeon may in some cases find it  necessary to
 open them with a crucial  incision if they are large, and do not appear disposed
 to  break of themselves.  When the boils commence as a small irritable pustule,
 they may  occasionally be kept back by touching the point of this with nitrate
 of silver,  or a saturated solution of the bichloride of mercury.


                               CARBUNCLE.

   A carbuncle consists essentially of a circumscribed and limited  inflammation
 of the  subcutaneous cellular tissue, rapidly running into suppuration and slough.
 Indeed, the formation of pulpy greyish or ash-colored sloughs,  whether re- 
366
ERYSIPELAS.
suiting from the specific nature of the inflammation, or from the strangulation
of the parts by the accumulation  of serum and  blood, is characteristic of the
disease.
  A carbuncle begins  as a  flat, painful, hard, but somewhat doughy, circum-
scribed swelling of the integuments  and subjacent cellular tissue.  It is of a
dusky  red hue, slightly elevated, but never losing its  flattened  circular shape •
ss it increases in size, the skin  covering it assumes a purple or brownish-red
tint, becomes undermined, and gives way at several  points, forming openings
through  which ash-grey or  straw-colored sloughs  appear, and  from which  an
unhealthy  purulent discharge  scantily  issues.  The size of  these swellings
varies  from one to six inches in diameter; most commonly they are  about a
couple of inches across.  Carbuncles are generally met with on the posterior part
of the trunk or  neck,  being rarely seen anteriorly, or on the  extremities.   I
have, however, had  to treat a very large carbuncle situated on the abdomen, and
have met with them on  the shin, forearm, forehead, and often on the face.  The
constitutional disturbance attending this disease is always of the asthenic type
the complexion  is  peculiarly sallow  or yellow,  the  pulse  feeble, and  tomnie
loaded; and if  the  tumor be large,  or is seated on the head,  a fatal termination
may take place, the patient sinking into a typhoid state.
  This affection,  with  many points of resemblance, yet differs from boils in its
greater size, the dusky red of the inflamed integument, its broad flat character,
and the large quantity of contained slough in proportion to the small amount
of purulent discharge.   Unlike boils, carbuncle is very rare in young people,
and never occurs in robust individuals.   Indeed, it is always  occasioned by, and
is by itself indicative of a broken  state of the constitution, being usually met
with in individuals  of a debilitated  and irritable habit of body who have passed
the middle period of life.
  The treatment  of carbuncle  consists in  supporting the constitutional powers
by the use  of the preparations  of bark in  combination with ammonia, dietetic
stimulants, and such nourishment as the patient will take,  care being had  at
the same time to clear out the bowels well, as the intestinal canal in these cases
will often be found  to  be offensively loaded.   The local  treatment  consists  in
making an early  and free crucial  incision  through  the whole thickness and
extent of the swelling.   If the sloughs that are now exposed be loosened, they
must be  removed, and  if not  completely detached, the  part must be  covered
with linseed and port wine poultices, and when the sloughs have cleaned off,
the sore that is left should be dressed with Balsam  of  Peru,  creasote, or the
unguent Elemi.
  There  are two other gangrenous  diseases, the malignant pustule, and a pecu-
liar dry gangrene of the extremities, induced by eating spurred rye, and hence
called\ ergotism.   These affections, however, are so rarely met with in this coun-
try, that  their consideration need not  detain us.
CHAPTER  XXVII,

   .  ERYSIPELAS.
  Erysipelas is an affection that so  frequently and  seriously complicates most
other surgical diseases and injuries, that its study is- of the utmost importance
to the practical surgeon.   It usually manifests itself as a peculiar and  distinct
form of inflammation; as much so as any of the other varieties, the adhesive, 
ERYSIPELAS.
367
the suppurative, the ulcerative or the gangrenous.  Erysipelas, or, as  it may
be termed, the erysipeloid infiammation, including all those varieties  of this
condition that are  usually spoken of as " diffuse," has a remarkable  tendency
to spread or diffuse itself with great rapidity by continuity of surface, to change
its seat, and not to be  limited  by any adhesive action.  It may extend itself
over any continuous surface;  the skin,  the cellular  tissue,  the  mucous and
serous membranes,  and  the lining membrane of arteries, veins, and lymphatics,
are all liable to be affected by it.   Hence, to describe it as a cutaneous  disease,
as has often been done, is in the highest  degree incorrect  and unphilosophical,
and evinces a very  limited acquaintance with its true nature.  Indeed, not only
must we look upon erysipelas as a disease that  may affect any surface, external
or internal, but we  must consider  the constitutional disturbance that takes place
in erysipelas  as the essential disease.  This, it is true, is usually complicated
with diffuse inflammation of the  integument, and then constitutes one of the
ordinary forms of erysipelas.   But a constitutional fever may occur of precisely
the same type as that which we observe to precede and to accompany the local
inflammation without any such complication.  This I had  especial occasion to
observe  in a very fatal outbreak  of erysipelas that took  place in one of my
wards a  few years ago.   On that  occasion, all the cases in which the cutaneous
form of  erysipelas  appeared were marked by severe  constitutional  disturbance,
attended by much  gastro-intestinal irritation.  But precisely the same  type  of
general febrile symptoms, and  the same  irritation of the  stomach  and bowels,
occurred in patients in the same ward, in whom no local or surface evolution
of the disease took place, as in those  affected  by the  ordinary  cutaneous form
 of it.  The true pathology of the diffuse, low, or erysipelatous inflammations
 has yet to be made out.  They are all closely connected with one another, and
 are evidently blood or constitutional  diseases, under  whatever name they go.
 The similarity of causes, of effects, and  of constitutional disturbance, makes it
 probable that they are all essentially dependent on one common condition of the
 blood, and that the particular local manifestation that occurs, whether it be
 erysipelas, phlebitis, low cellulitis, or diffuse abscess, is secondary  to this, and
 perhaps in some degree accidental.
   A chief characteristic of this erysipeloid fever is its incompatibility with the
 localization  of any inflammation  that  may exist  at or occur after its invasion;
 and hence, when it attacks the system, it causes already existing inflammations
 to assume a diffuse or spreading  character, extending themselves over any sur-
 face on  which they happen to  be  situated.   It  is especially apt, in this way, to
 cause those inflammations to spread which  have not already been localized, by
 the deposit of adhesive matter.  Hence, recent wounds  are more  liable  to be
 affected by it than granulating  ones, in which  the inflammation has already
 taken on  a plastic  character, which requires to be overcome  before the diffuse
 form can  set in.
    The constitutional fever in erysipelas almost invariably at first  assumes the
 sthenic form, but very speedily  runs into an asthenic or irritative type, with
 a quick feeble pulse, brown tongue, pungent hot skin, and muttering delirium.
 The disease is truly an affection of debility; it is in consequence  of the want
 of  a sufficient degree of power in the part, or in  the system, for the deposit of
 plastic matter, and the limitation of the inflammation by this, that the local
 affection spreads itself unchecked along  the surface it  invades.  The tendency
 that invariably exists in erysipelas to the occurrence  of sloughing and suppu-
 ration of the affected  tissues, is a further indication  of the  asthenic and low
 character of the  disease.   This  view of the  nature  of the constitutional dis-
 turbance in erysipelas  is of great importance  in  reference to the treatment of
 the disease,  as it  demonstrates  the  necessity of not lowering  the patient's
 powers too much during the early period of the affection, when it often tempo-
 rarily assumes a truly sthenic  character. 
368
ERYSIPELAS.
  Erysipelas is especially apt to become complicated with low visceral inflam-
mation ;  the membranes  of the  brain, the  bronchi and  lungs, or the gastro-
intestinal mucous surface, are commonly implicated in this way; and it is often
through  these complications that death results.
   Causes.—Erysipelas may arise from causes existing in the patient himself, or
from  the conditions by which he  is  surrounded or to which  he  is subjected.
It commonly originates primarily in want of attention  to the hygienic condi-
tions  that  should surround a patient; and is one of the penalties inflicted by
Nature on  those who neglect or  are  incapable  of attaining those  prime requi-
sites of health—good food, temperance, cleanliness,  and pure  air.   Were these
attended to  as they should be, erysipelas and  the  allied diffuse inflammations
would scarcely  be met with.   Some persons appear  to be naturally predisposed
to erysipelas to so great a degree, that the application of cold  or slight stomach
derangement, or a trivial  superficial injury may excite it.  This  predisposition
to erysipelas most commonly takes  place in individuals of a plethoric  and gross
habit of  body; those especially  who have a tendency to gout appearing to be
liable to  the ready occurrence of the  disease.   But this  predisposition is most
generally acquired by habitual derangement of health, and is especially induced
by  any  of the depressing causes  of disease, such as over-fatigue, anxiety of
mind, night watching, and  habitual  disregard of hygienic  rules as  to diet,
exercise, air, &c.  The habit of body, however, in which erysipelas  is most
frequently met with as a consequence of very trivial  exciting causes, is that
which is induced by the habitual use of stimulants to excess.   It  is more espe-
cially in  that state of  the system characterized by an admixture, as it were, of
irritability and of debility, in which no plastic  lymph is deposited as the result
of inflammation, but in which this condition is  followed by  a rapid tendency
to the formation of pus  and slough, and to extension of disease in a diffuse
form, that erysipelas is so very readily induced.   This condition of body is met
with amongst the laboring poor as  the result of the privation of the necessaries
of life, conjoined with the habitual over-use of stimulants and exposure to the
various  depressing causes of diseases, arising  from bad food, impure  air, &c.
Amongst the wealthier classes it occurs as a consequence of  high living, want
of exercise, and general indulgence in luxurious and enervating habits.
   Some  diseased states of the blood appear to predispose, in the highest degree,
to the supervention of erysipelas.  This is especially the case in diabetes and in
granular disease of the kidneys attended by albuminuria.  As a consequence
of renal  disease, erysipelas will  occur idiopathically, or from the most trivial
causes;  a  scratch, the sting of an  insect, or any of  the   minor operations
in surgery, more especially about  the  lower part of the body, will occasion it.
And  not  only is  it  readily induced in this  way, but it will  extend  in an
uncontrollable  manner in  these  states of  the system, there being apparently in
them an  utter want of limiting or reparative power in an inflammation however
set up.
   Amongst  the  circumstances  that surround the patient, and that tend to the
production of this  disease, season  of  the year  and atmospheric changes exer-
cise a marked influence.   Not  only is erysipelas much  more frequent  in  the
spring and autumn than at other  seasons of the  year, but we not unfrequently
find it coming  on suddenly on  the setting-in of  cold easterly winds, or on the
occurrence of sudden atmospheric vicissitudes.   So also erysipelas often assumes
an epidemic character, as the result of those peculiar,  but, at present, inexpli-
cable conditions of the atmosphere, in which  disease generally assumes a low
type,  and  in which  epidemic catarrhs,  influenza,  phlebitis,  and  other  allied
affections prevail.  Epidemic erysipelas is almost invariably of a low  form, and
is very commonly associated with some peculiar  train of visceral complication
that distinguishes the  particular outbreak of the  disease.
   But not only is erysipelas epidemic, it is also contagious.   The contagion of 
           CAUSES  AND  SYMPTOMS  OF  ERYSIPELAS.        369

erysipelas, after having been  repeatedly denied, can I think  no longer be con-
tested.  Travers, Copland, Bright, Nunneley,  and others have adduced cases
in proof of its contagious character, and instances have repeatedly fallen under
my own observation, in  which erysipelas, often unfortunately of a  fatal  form,
has been communicated to the servants, nurses, or relatives of  patients affected
by it.   A remarkable  proof of the contagious  nature of erysipelas occurred in
the spring of 1851, in one of my wards  at the University College  Hospital.
The hospital had been free from any cases of the kind for a considerable time,
when  on  the 15th of  January, at about  noon, a man was admitted under my
care  with gangrenous erysipelas  of the  legs,  and placed in Brundrett Ward.
On my visit, two  hours  after his admission, I ordered him  to be removed to a
separate room, and directed the  chlorides to  be freely used in  the ward from
which he  had been taken.   Notwithstanding these precautions, however, two
days  after this, a patient, from  whom a  necrosed portion  of ilium had been
removed, a few weeks previously, and who was lying in the  adjoining bed to
that in which the patient with the  erysipelas  had  been temporarily placed, was
seized with erysipelas, of which he  speedily died.   The disease then  spread to
 almost every case in  the  ward, and proved fatal  to several patients who had
 recently been operated upon.  In several instances patients were affected with
 the constitutional symptoms without any  appearance of  local inflammatory
 action, but characterized by the same gastro-intestinal irritation that marked the
 other cases.
   Erysipelas may not only spread in this  way  from patient to patient, but any
 diffuse inflammation,  as phlebitis, inflammation of the absorbents, low or puer-
 peral peritonitis and pyemia may give rise to external erysipelas,-and in its turn
 be occasioned by it—a strong argument in favor of the allied nature of all these
 affections.   Then again the  contact of dead or putrescent animal matters with
 recent wounds may occasion  it.   In  this way the disease is  not unfrequently
 originated in hospitals by  dressers going direct from the dead house, and espe-
 cially from  the examination  of the bodies  of those who have died  of diffuse
 inflammation, to the bedside  of patients without taking  sufficient  care to wash
 their hands or change their  clothes.  For this reason  also it  is  of great conse-
 quence that the same instruments be not  used for practising operations on the
 dead, and performing them on the living body.
    The principal  exciting  cause  of erysipelas is certainly the presence of a
 wound.  It is  chiefly recent wounds, however, that  are affected  by it;  when
 once  the adhesive or suppurative inflammation is set up, the wound is  not so
 liable to take it on unless it  be  in  bad constitutions, the formation of limiting
 fibrine appearing to lessen the liability to the  occurrence of the disease.   When
 erysipelas  is epidemic,  it is well for the  surgeon  not to perform any operation
 that can conveniently be postponed until it is  less  rife; and in no case should a
 patient on whom an  operation has  recently been  performed be  put in a neigh-
 boring bed, or  even in the same ward, as  a case of erysipelas.   The size of  the
 wound has  little  influence on the occurrence of erysipelas, which takes place as
 readily from a small as  from  a large one.  The more severe forms of erysipelas
 however, chiefly occur in those cases  in which  the  fasciae  of the  limbs  are
 opened up, when the disease  may spread  through the  deeper intermuscular
 planes of cellular tissue.  Injuries  about the head and hands  are those that are
 most liable  to be followed by this disease.
    But though we must constantly bear  in  mind  the  constitutional  nature of
 erysipelas, it will be  more convenient and practical to describe  it as it affects
 different tissues and  organs.   With this view, we may divide it primarily into
 external and internal erysipelas.
    By external erysipelas is meant that variety of the disease which affects
 the skin and subcutaneous cellular tissue.  This form  of the  affection has been
 described with an absurd degree of minuteness  so far as the transitory and
        24 
370
ERYSIPELAS.
accidental characters  of its duration, shape, and appearance are concerned, by
many of the writers on the Diseases of the Skin, who, in their anxiety to record
minute  and accidental  shades of difference in appearance, have  entirely  lost
si«ht of the true nature of the disease.  The division adopted by Lawrence into
the simple, the  (Edematous, and the phlegmonous forms, is a practical arrange-
ment that is commonly adopted by surgeons. I prefer, however, and shall adopt
the division made by Nunneley in his very excellent  work on  erysipelas, as
founded on the true pathology of the affection.  He arranges external erysipelas
under the cutaneous,  the ccllulo-cutaneous, and the cellular varieties.
   1st. The cutaneous erysipelas is the slightest form of the disease, implicating
merely  the skin;  it  comprises  many  of the species of erythema of different
writers, and corresponds to the simple erysipelas of  Lawrence.
   The  symptoms  of  this  affection  are as  follows: — A patient is seized with
rio-ors, alternate chills and flushes, followed by headache, nausea, a quick pulse,
a coated tongue, and  hot skin; in from twenty-four to forty-eight hours the rash
appears, though sometimes it comes out simultaneously  with the  constitutional
disturbance.   If there be a  wound,  the secretions of this dry  up, and  the
margins become slightly swollen, and affected by the red blush.  If the disease
occur idiopathically without a wound, it most commonly appears upon the face,
next upon the legs, and lastly upon the trunk.  The rash is of a uniform  but
vivid rosy red hue,  sometimes  becoming dusky, and always disappearing on
pressure;  it usually fuses  away  into the color of the healthy skin, but is some-
times distinctly margined.  It is accompanied by some slight cedematous swell-
ing which is often  considerable where the cellular tissue  is  loose,  as in the
eyelids and scrotum,  and there is usually a stiff burning sensation in the  part.
Vesicles or blebs often form, containing a clear but  hot serum, which speedily
becomes turbid, and dries  into brawny desquamation.  The redness may spread
rapidly along the limb  or trunk, or  if the face is affected, travel quickly from
one side to the other, causing such  swelling of the eyelids as to close them, and
giving  rise to much tensive pain in  the ears.  Sometimes the disease disappears
in one  part of the body, reappearing in another.   This, which is the erratic
erysipelas, is  often a dangerous form  of the  affection, occurring in advanced
stages  of  pyemia, and indicating  approaching death.   In these varieties of
idiopathic erysipelas, Arnott states that the  fauces  are  always  involved.   This
affection usually disappears without inducing any serious mischief in the  part
affected, but in some cases abscesses form, more especially in the loose cellular
tissue of the  neck and of  the eyelids.  In other cases again, oedema of the part
continues with some irritability and  redness  of  the skin and  peeling of the
cuticle; and in some rare  cases  the simple erysipelas seems to take on a gan-
 grenous or sloughing character,  especially about the umbilicus  and genitals of
young  children.
   The  constitutional symptoms  of  the cutaneous or simple erysipelas, present
 every variety between  the sthenic  and asthenic  forms  of inflammatory fever.
 When  the disease occurs in London, it certainly most frequently assumes a low
 type.   There is also  in most cases a good deal of derangement of the digestive
 organs, the tongue being much  coated, with tenderness about the epigastrium,
 dark offensive evacuations, and  not unfrequently diarrhoea.   When the scalp is
 affected, severe headache, with symptoms of cerebral inflammation, are commonly
 met with.  Most frequently recovery takes place by the gradual  subsidence of
 the symptoms;  this form of the disease seldom proving fatal unless the scalp is
 affected, and  the brain consequently implicated.
   2nd. The cellulo-cutaneous or phlegmonous erysipelas differs from the variety
 just described, in the degree of inflammation, and the depth to which the tissues
 are affected.  The intensity of  this form of inflammation is such as invariably
 to terminate, if left to  itself,   in  diffused suppuration and sloughing of  the
 tissues.  In depth it invariably  extends to the subcutaneous cellular tissue, and 
         VARIETIES  AND  SYMPTOMS  OF  ERYSIPELAS.     371

though generally bounded by the  fasciae lying beneath this, not unfrequently
implicates these if they have been opened up, extending to the inter-muscular
cellular planes, the sheaths of the tendons, and other deep structures of the
limb or part.
   The cellulo-cutaneous or phlegmonous erysipelas is ushered in by the ordinary
symptoms of inflammatory fever, accompanied or followed by the signs of severe
inflammation in the  part affected.  The redness is uniform, of a deep scarlet
hue, and pretty distinctly bounded; the pain is from the  first pungent and
burning, though it may soon assume a throbbing  character; the swelling,  at
first soft, diffused, and admitting of distinct pitting, soon increases, and becomes
tense and brawny, the skin being evidently stretched to its full extent, and the
limb appearing perhaps to be double its natural size. Large vesications or blebs,
containing sero-purulent fluid, sometimes of a sanious tinge, make their appear-
ance in many cases.  This is the condition that usually continues up to the sixth
or eighth day after the invasion of the disease, during the whole of which time
the constitutional symptoms have presented the ordinary type of sthenic inflam-
matory fever;  about this time,  however, a change commonly takes place, either
for better or  worse.  If, under the  influence of  proper treatment, and  in a
tolerably healthy constitution, the inflammation subsides, resolution takes place,
with a gradual abatement of all the symptoms.  If, however, as  usually happens,
the disease runs on  to more or less sloughing or suppuration  of the part, no in-
crease of the swelling, pain,  or redness takes place, but, on the contrary, some
diminution in these signs may  occur, giving rise to an apparent, though decep-
tive amendment in the patient's condition.  The skin becomes darkly congested,
and the part, instead of being tense and brawny, has a somewhat loose, soft, and
boggy feel, communicating a semi-fluctuating, doughy sensation to the fingers.
This change from a tense brawny state to a semi-pulpy condition is  indicative
of the formation of pus and  slough beneath the integument, and should always
be anxiously watched for by  the surgeon.  It must be remembered that it occurs
without any material change in the  size, the color, or the  general appearance
of the part, but  can  only be  detected by careful palpation of it; hence the
necessity of the surgeon daily examining with his own fingers the state of parts
inflamed, and neither trusting to the reports of others, nor to the general ap-
pearance of the diseased structures, for the probable condition of the subjacent
 tissues.  If an incision be now made into the affected part, the cellular membrane
 will be found loaded with an opalescent fluid distending its cells, but not flowing
 from the wound;  the retention of this fluid in the cellular tissue giving a gela-
 tinous  appearance to  the sides of the incision, which rapidly degenerate into
 slough and pus.  If the alteration in structure have advanced to a stage beyond
 this, the cellular tissue will be  found to have been  converted into  dense masses
 of slough, lying in  the midst of thin and unhealthy ichorous pus; these have
 not inaptly been compared in appearance  to masses of decomposed tow, of wet
 chamois leather, or  to the membranes of a foetus a few months old.  Whilst these
 changes are going  on below the  surface, the skin, at first  congested, becomes
 somewhat paler, and  assumes  a white or  marbled appearance, rapidly running
into black sloughs, and being undermined to an immense extent by large quanti-
 ties of broken-up cellular tissue and  of ill-conditioned pus, without any appear-
ance of pointing, however extensive  the subcutaneous  mischief may be.  These
destructive changes expose  muscles, fasciae, and blood-vessels, and may induce
necrosis of the bones or destroy the joints.  They occur most  readily in those
parts of the body that possess the lowest degree of vitality,  and hence are more
common in erysipelas of the  legs than in the same affection of the scalp.  If the
patient recover, there will be tedious  cicatrization of the  deep cavities that are
left, or considerable oedema, often of a solid character, a kind of false hypertrophy
of the part, which may continue for some  considerable  time.   In other cases
again there may be such extensive local destruction  or  gangrene of the soft 
372
ERYSIPELAS.
tissues, with exposure and death of the bones or suppuration of the joints, that
amputation of the limb may be required as a means of saving the patient's life.
No operation of this  kind, however, should ever be practised for the after-con-
sequences of erysipelas, unless these be  strictly localized with no tendency to
spread, all specific constitutional fever having been completely removed, except
such as is of a hectic character, and dependent  on the exhausting influences of
the suppuration and disorganization  of the tissues.
   During the progress of these local changes, the constitutional symptoms have
assumed corresponding modifications.  At first of an acute inflammatory charac-
ter,  when  suppuration and  sloughing have set in, the fever often  suddenly
assumes  an asthenic form, although  in some cases there is no diminution in the
severity  of the symptoms,  until after an attempt  for a few days to bear up
against the exhausting influence of  the disease, the constitution gradually gives
way, and death speedily supervenes.   If the patient survive the stage of slough-
ing, and if the discharge continue abundant, hectic with diarrhoea, gastro-intes-
tinal irritation, metastatic abscesses  or pyemia may carry him  off.   If  recovery
eventually take place, it may be at the expense of a  constitution impaired and
shattered for years.   This disease is most dangerous in the old and infirm, or in
young children.  The immediate  danger is always greatest when  the head is
affected, from the extension  of the  disease to the membranes of the brain,  and
the supervention of erysipelatous  arachnitis.   The  remote danger  from the
effects of suppuration, necrosis, and inflammation of the joints, is greatest when
the lower extremities are the seat of erysipelas.
   A variety of the cellulo-cutaneous erysipelas has been described as cedematous
erysipelas.  By this is meant not merely that  effusion into the  cellular tissue
which occurs in all the varieties of the  disease, but  a peculiar form, specially
marked  by oedema of the cellular tissue, with less inflammation of the  skin than
usual. There is much swelling, which pits deeply, with but little pain or tension,
and but moderate redness  of the skin;  the constitutional symptoms are  less
 marked  than in the other varieties  of the disease; it is principally met with in
 old people, or in persons of a dropsical  tendency, in whom it occurs  especially
 about the legs, scrotum, or labia, sometimes giving rise, by the effusion  of a sero-
 plastic fluid, to permanent and solid enlargement of these parts.
   3d. The cellular erysipelas, or as it is  often termed, diffuse inflammation of
 the cellular tissue, or cellulitis, is a  disease that has been particularly described
 by Duncan, Arnott, Lawrence, and  Nunneley.  It always  arises from a wound
 or injury, often, however, of an apparently trivial character, and most commonly
 affects the sub-cutaneous cellular membrane, though occasionally it extends to
 the sub-aponeurotic tissue, and then is a more severe and dangerous affection.
 Though commonly arising as a consequence of  ordinary injuries, it  is  especially
 apt to follow those in which there has been any inoculation of animal poisons,
 as in dissection wounds, the  stings of insects, and the bites of venomous reptiles.
 In whatever way arising, it  is characterized  by the rapidity and extent of the
 sloughing of the affected tissue, and by great depression of the powers of the
 constitution.   That the diffuse inflammation of the cellular tissue, whether it is
 limited  to a finger, or implicates the cellular membrane of half the body, is a
 variety of erysipelas affecting this membrane primarily, and the skin secondarily,
 there can be no doubt.   The  points of  resemblance between cellulitis and ery-
 sipelas have been well shown by Nunneley.  Not only are the local effects pre-
 cisely the same in the two diseases ;  the same swelling, tension, infiltration of pus,
 and formation of gangrenous shreds and sloughs, but the constitutional symp-
 toms, though  differing perhaps  in  degree, present no variety as to  character.
 The results also are identical, there being the same impairment  of structure
 locally,  the same tendency to involve parts  at  a distance, and to the  formation
 of secondary abscesses.  So  also these two diseases occur in the same constitu-
 tions, in the same states of the atmosphere, and in the same situation ; one form 
        DIAGNOSIS  AND  PROGNOSIS OF  ERYSIPELAS.     373

of disorder may produce the other, and, lastly, the same treatment is required
for both affections.
   The symptoms  of cellular erysipelas are great swelling, tension, and pain in
the limb, which feels brawny in some parts, cedematous in  others.   The skin,
which is slightly reddened in patches, has a mottled appearance, and speedily
runs into blackish sloughs.   The extent to which the disease may spread varies
greatly; when once it has set in, it commonly runs rapidly up the whole of a
limb, extending also to  the sides  of  the  trunk;  in other cases, again, its vio-
lence appears to be principally expended at a distance from the seat  of injury;
thus, in a case of a punctured wound of the finger, the  diffuse inflammation may
principally take place in the extended planes of cellular tissue about the axilla
and sides of the chest.  It is important to bear in mind that this form of ery-
sipelas sometimes affects the internal planes of cellular tissue. This may happen,
for instance, in  the fasciae of the pelvis after lithotomy, or in the anterior medi-
astinum after operations at the root of the neck.   The sloughing often occurs
with remarkable rapidity in the course of thirty-six or forty-eight hours, the cel-
 lular membrane being broken down into ill-conditioned pus and shreddy sloughs,
 more especially when the disease has resulted from the inoculation of an animal
 poison.  Death  may in such cases occur in two or three days; in other instances,
 again, several weeks elapse before a fatal result declares itself.
   The constitutional  symptoms are those of asthenic fever in  the most marked
 degree; a quick and feeble pulse, brown tongue, and muttering delirium, being
 early concomitants of this affection.
   The diagnosis of the various forms of erysipelas is generally  easily  made.
 From the exanthemata,  it is distinguished  by the character of  the eruption, its
 limited extent,  and usual complication with injury.  From inflammation of the
 veins, or of the absorbents, the diagnosis is not always so easy, more especially
 as the two conditions frequently co-exist.  If it be a  vein that is inflamed, the
 general absence of cutaneous redness, the existence of a hard round cord, and
 the tenderness  along the course of the  vessel, are sufficient  to establish the
 diagnosis.    In  inflammation of the  absorbents, the redness will  be  found not
 to be uniform, but to consist of a number of small and separate red streaks,
 running in  the direction of the lymphatics, and affecting the glands towards
 which they course; these two affections, however, erysipelas  of the skin and
 inflammation of the absorbents, are almost invariably conjoined; hence a definite
 diagnosis is not of much importance.
   The prognosis in any case of erysipelas  depends on a variety of circumstances.
 The form  of the  disease influences  greatly the result, the cutaneous  variety
 being attended with  least  danger, the cellular with the most.   The traumatic
 is more dangerous than  the idiopathic form.  Much, however, depends on  other
 circumstances, such, for instance,  as the  seat of the  affection; that attacking
 the head and lower limbs being the most dangerous; when the  head  is affected,
 encephalitis being  apt  to ensue.  When the legs are extensively implicated,
 sloughing of the skin and cellular  tissue, with denudation of the  bones and
 destruction  of the joints, may occur.  The  disease,  in all its forms, is most
 dangerous at either of the extremes of life.  The previous state of health of the
 patient also influences  greatly the result.   If the  constitution be sound, very
 extensive mischief may be recovered from; if, on the other hand, it is depressed
 or broken  by want of the necessaries of life, by fatigue, over exertion, or in-
 dulgence in  stimulants, a very slight amount of disease may probably prove
 fatal.  The most dangerous complication of erysipelas, and one which when it
 exists almost precludes the hope of recovery, is a granular state of the kidneys
 with albuminuria.   I have  never  seen any patient laboring under this disease,
 and attacked with erysipelas, escape with  life;  the  sloughing and suppuration
running on unchecked by any treatment that could  be adopted.  The particular 
374
ERYSIPELAS.
type the erysipelas may assume, and  the occurrence of gastro-intestinal or pul-
monary complications, will also seriously affect the result.
   Treatment  of erysipelas. — The occurrence of  erysipelas is  best  guarded
against by attention to hygienic measures, more  particularly to proper ventila-
tion with pure air, and the avoidance of over-crowding of patients.   In hospitals,
erysipelas may be produced at will by  want of attention in these respects,
and it will usually be found that the  persistence of erysipelas in certain wards,
or  even  its repeated appearance in  certain beds, is owing to some local cause,
such  as  the  emanations from a drain, on the removal of which the disease will
cease.   Scrupulous  attention to cleanliness, also,  on  the part of nurses and
dressers  should be enforced, and the latter should not be allowed to go straight
from  the dead-house  to  the ward without  previously washing their hands in
some chlorinated solution.  When  erysipelas has already occurred, its further
spread may be prevented by isolating the patients  affected, and at once taking
active measures to purify the ward from which they have been removed.
   The curative treatment of erysipelas must always  be conducted with reference
to the low character of the local inflammation, its  tendency to run into suppu-
ration and  gangrene, the asthenic type that the  constitutional fever readily
assumes, and the frequent complication of visceral inflammations of a congestive
form.   The  apparent intensity of the  local  inflammation  must  not  lead the
surgeon  into  the fatal error  of employing an over-active antiphlogistic treat-
ment, more particularly if the  disease be  epidemic, when it always assumes a
low type.  In  the treatment of this affection, it is  especially important to look
to the future, and to remember that, if active depletory measures are employed
 early, with  a view  of lessening the present disease, it will  be at the risk of
inducing more extensive sloughing, and  perhaps  to lower the  patient's powers
to such a degree, as to prevent his bearing up under the  depressing influence
of the after-consequences.
   In the treatment of the cutaneous or simple form of erysipelas, we must in the
first instance clear out the stomach and bowels by an ipecacuan emetic followed
by a calomel  and colocynth pill, and  some  saline aperient.   If the patient be
young, robust, and the disease  be of a somewhat sthenic character, he should
be kept  on  a mild  diet, and  have  salines, with small  doses  of antimony,
administered every fourth or sixth hour.  If the patient be advanced  in years,
and the  disease  assume  a lower form, no  antimony should be given, but effer-
vescing  salines, or the acetate of ammonia  in  camphor mixture, may  be admi-
nistered.  If the disease from the first assume a low type, or if it subside into
this, the carbonate  of ammonia in five or  ten grain doses should be added  to
the preceding  mixture, in which the decoction of bark may then  be substituted
for the camphor julep.  In many of the low forms  of  erysipelas,  medicines are
not well borne by the patient, the stomach rejecting them, and then I have seen
 the best possible results follow the free administration of the brandy-and-egg
mixture, to which I am in the habit of trusting in the majority of these cases.
During the progress of the disease, simple purgatives must be given from time
to  time.  When this form of erysipelas occurs in persons of a gouty habit, it
may  often be advantageously  treated by  the administration of  colchicum  in
salines.
   The local treatment of this, as of every variety of erysipelas, is of equal im-
 portance with  the constitutional management.  Warm applications assiduously
 continued, especially poppy and chamomile fomentations applied by means  of
 flannels or spongio-piline, afford the greatest possible relief.  Cold lotions should
 never under any circumstances be  employed : they not only act injuriously  by
 lessening the  vitality of  the  part,  and thus favor local sloughing,  but they
 may chance to cause a retrocession of the disease, and the consequent affection
 of some internal organ.   The local abstraction of blood and of serum  from  the
 inflamed part, by the plan introduced  by Sir B,. Dobson, of rapidly making 
TREATMENT OF ERYSIPELAS.
375
with the point of the lancet a large number of small punctures, from a quarter
to half an inch deep, is of much value, by lessening the tension  and swelling,
and  consequently diminishing the inflammatory action; a warm fomentation
cloth or poultice should be laid over the punctures, so as to encourage bleeding
and the escape of serum.   Astringent applications to the inflamed surface, such
as a strong solution of the nitrate of silver, are recommended by some surgeons.
I have seen them pretty extensively employed by the late Dr. A. T. Thomson,
but not with any very marked success.  A boundary line of nitrate of silver is
occasionally drawn  around the  inflamed  part, with the view of checking  the
extension of the disease.   I  have often done  this, and seen it done by others,
but never apparently with any benefit;  and have now discontinued the practice
as a useless source of irritation.  The application of a bandage is occasionally
necessary  after the disappearance of the erysipelas, in  order to remove  the
oedema that results.
   In the treatment of the cellulo-cutaneous erysipelas, more energetic constitu-
tional and  local means  are  required than those just described.   In the early
stage of the disease, our object is to prevent the inflammation running into gan-
grene of the  affected tissues.  The fever being at this period commonly of a
sthenic character, the more active administration of purgatives, antimonials, or
 effervescent salines is required.  I have never seen a case  in which blood-letting
is required, and strong antiphlogistics, such as salines,  should  be  given with
great caution.   The best plan is, perhaps, to give an emetic and  purge, to  clear
out the stomach  and bowels, and then to give effervescing salines  with carbonate
of ammonia, in full  doses, gr. x. to gr. xv.  As the disease advances, and symp-
toms of more or less depression come on,  it may be necessary to  effect that gra-
dual change from a depletory to a stimulating plan of treatment that has already
been described in speaking of the management of inflammatory fever; in doing
this, the pulse and the  tongue must be our guides; as the one becomes feebler
and the other browner, so must ammonia, bark, and  especially  port-wine, and
the  brandy-and-egg mixture, be administered.   In the more advanced stages of
the  disease, when sloughing and suppuration are fully established, our sole object
must be by nourishing diet, and the use of stimulants and tonics, to bear the
patient through the depression and subsequent hectic that ensue.
   The local treatment of the cellulo-cutaneous or phlegmonous erysipelas, must
be conducted  on essentially the same plan as that  of the  cutaneous variety,
though with the employment of more active means.  The part affected must be
 kept at rest, must be elevated if it be a limb, and have hot chamomile and poppy
 fomentations assiduously applied, cold being more prejudicial here even than in
 the last form of the disease; in this way,  the  swelling and tension may perhaps
 be removed, and the sloughing of the cellular tissue prevented.  In the majority
 of cases, however, other  means will be required to effect this,  and  with this
 view none are more efficacious than incisions  made into  the part;  by these an
outlet is afforded for the blood and effused serum, which, by distending the ves-
sels and cells of the part, produce  strangulation of its tissues and consequent
sloughing.   This mode of practice, originally introduced by Mr. C. Hutchinson,
is generally allowed to  be the most  effectual means we possess for the  preven-
tion of sloughing; hence the incisions should  be made early, before there has
been time for the tissues to  lose their vitality.   So soon, indeed, as  they have
become  brawny, indurated and tense, incisions properly made and placed will
afford the greatest possible relief to the part and the patient, taking down the
tension by their gaping, and the swelling  by the exit  they afford to  blood and
serum.   Much difference  of opinion  has existed  among surgeons,  as to  the
extent to  which incisions should be practised in  these  cases.  Some recom-
mending that one long  cut  should  be  made  through the inflamed structures;
others contending, on the contrary, that a number of  small incisions better
answer the proposed end.  The objections to the long incision are, that so con- 
376
ERYSIPELAS.
sidierable a wound not only inflicts a serious shock upon  the system, but that
the loss of blood from it is  often so great as to be of serious, and even of fatal
consequence  to the patient, cases having occurred in which life has been lost
from  this cause, or the hemorrhage  only arrested by the ligature of the main
artery of the limb,—and also that a single long incision does not relieve tension
so effectually as a number of smaller ones.   The  incisions consequently should
be of limited extent,  from two to three  inches in  length: at most they should
not extend deeper than into the gelatinous looking subcutaneous cellular tissue,
unless it happen that  the disease have extended beneath  the fascia,  when they
may also be carried  through  it.  Mr.  South  recommends  that the incisions
should be so arranged in fours, as to enclose a diamond-shaped space,
and states that in this way the greatest relief is given to the tension |         I
of the part: after the incisions  have been made, the part should be
well poulticed and fomented so as to facilitate the escape of serum.  As it is
not the object of the surgeon  to draw blood  in these cases, any undue  amount
of hemorrhage should be arrested by plugging the wound.   After suppuration
and sloughing  have taken place, as indicated by a boggy  feel of the parts, free
incision  should  be made  in order to let out pus and sloughs.   After this the
skin will often be found  to be greatly undermined, blue,  and thin, with matter
bagging in the more dependent parts; if so, egress must be made for it by free
counter-openings.   During  the after-treatment frequent dressing is necessary so
as to  prevent an accumulation of pus, and the sloughs must be removed as they
form.   Care  should be taken not to destroy any of the vascular connections of
the skin with subjacent parts, but in  order to get proper cicatrization  it will
often be found necessary to Jay open sinuses, or to divide bridges of unhealthy
and  blue integument  stretching across chasms left by the removal of the gan-
grenous cellular tissue.   If  the loss of substance be great, the cicatrix that forms
may be weak, imperfect, or so contracted as to occasion great deformity of the
limb.  In  other cases, again, the diseased state of the bones and joints may be
such  as  to call  for ultimate  amputation, either in  consequence of the local
deformity and annoyance, or in order to  free the  constitution from a source of
hectic and  of irritation.   Under  all circumstances, the patient's health will
usually continue in a feeble and  shattered state for a considerable time aftei
recovery from this form of  erysipelas, requiring change of air and great atten-
tion to habits of life,  a nourishing diet, &c.
   In the treatment of the cellular variety of erysipelas, it is usually necessary to
administer stimulants early;  ammonia,  wine,  or  brandy may be  required from
the very first.   The surgeon must judge of this by the constitutional condition
of the patient, and more particularly by the state of his pulse and tongue.  The
local  treatment is precisely of the same  kind as  that adopted in phlegmonous
erysipelas, except that the incisions require  to be made earlier and perhaps more
freely; in all other respects, there  is no difference between the general manage-
ment of the two forms of the disease.
         SPECIAL  FORMS  OF  EXTERNAL  ERYSIPELAS.

  Erysipelas of newly-born infants is occasionally met with, more  particularly
in lying-in hospitals,  or in situations where the  mother and child are exposed
to depressing causes  of disease.  It usually  makes its appearance a few days
after the birth, at first about the abdomen and genitals, but spreads rapidly over
the whole of the body, being characterized by a dusky redness, which  rapidly
runs into  gangrene of the affected tissues.  It has been supposed to arise from
inflammation of the umbilical vein, or of the umbilicus itself.  It is an extremely
fatal affection,  owing  to the feeble vitality of the  child, and  presents but few
points for treatment;  change of air and of nursing, with the administration of 
SPECIAL  FORMS OF ERYSIPELAS.
377
a few drops of Sp. ammonia  or brandy from time to time, being all that can
be done.
   Phlegmonous erysipelas of the head is of very frequent occurrence from slight
injuries or operations about the scalp and  face, more  particularly in elderly
people and those of unhealthy constitution.   In this  form of erysipelas  there
are two special sources of danger; one is from sloughing of the occipito-frontalis
muscle, the other  from inflammation  of the  membranes of  the  brain.   The
occipito-frontalis sloughs, in consequence of the pressure to which it is subjected
by the swelling of the planes  of cellular tissue between which it lies;  and the
encephalitis occurs apparently by the extension  of the inflammation inwards.
In the treatment of this affection more active antiphlogistic means, such as vene-
section, with salines  and antimony, are required than in the management  of
other forms of erysipelas.   With the view of preventing sloughing of the muscle,
a free crucial incision should  be made through the scalp down to the bone, the
head, of course, having been shaved at the onset of the disease.
   Bagging of matter must be prevented by free counter-openings, and the appli-
cation of pads and bandage wherever it is likely to occur.  However much the
scalp may be undermined, or the bones of the cranium exposed, adhesion usually
takes place, and the vitality of the parts is preserved.
   Erysipelas  of the scrotum, the  "inflammatory oedema,"  so well described
by Liston, is of frequent occurrence, as the result of wounds, ulcers, and other
sources of irritation in this neighborhood.  In this affection the scrotum swells
 to a large size, being uniformly red,  but with a semi-transparent glossy appear-
ance, pitting readily on pressure, and feeling somewhat soft and doughy between
 the fingers;  the integuments of the  penis are also greatly swollen and cedema-
 tous, and sometimes the inflammation extends to the cellular tissue of the cord.
 The chief characteristic of this form of erysipelas is its tendency to  run into
 slough  without any previous brawny or tense condition of the parts, the  dartos
 becoming so distended with sero-plastic fluid that the  circulation through it is
 arrested and its tissue loses its vitality.   When an incision  is made into  it in
 this condition it scarcely bleeds, and the sides of the wound present a yellowish-
 white gelatinous appearance.  The  treatment of erysipelas of the scrotum is
 simple; it consists in making a free incision about four inches in  length  from
 behind forwards on either side of the septum, taking  care, of course, not to go
 so deep as to wound the testes; the  part must then be  supported on a pillow,
 and well poulticed and fomented.   If this incision be not made at  once, a great
 part, or even the whole of the scrotum may slough away, leaving the testes and
 cord bare; under these unpleasant circumstances, however, the parts will  often
 with great rapidity cover themselves with a new integument.   The oedema of
 the penis usually subsides of itself, or by making a few punctures in it; should
 its integuments, however, threaten to slough, a free incision must be made into
 it, or the prepuce be slit up.
    Erysipelas of the pudenda is  occasionally met with  in  ill-fed unhealthy
 children in whom  cleanliness  is  neglected.   The parts become of a dusky or
 livid red, swell considerably,  and quickly run into gangrene, which spreads  up
 the abdomen or down the nates.   It may prove fatal  by inducing  peritonitis
 or exhaustion.  In the  treatment, ammonia, bark, and  the  chlorate of potass,
 with good nourishment, and  a little wine, are the principal means to be em-
 ployed, at the same time that yeast or chlorinated poultices are applied locally.
    Erysipelas of the fingers, or as it is commonly called " whitlow,"  is a frequent
 affection  in old and in young people, either occurring spontaneously in cachec-
 tic constitutions, or  arising from  the irritation produced by scratches, punc-
 tures, or the inoculation of the part  with poisonous or  putrescent matters.  It
 is most common in the spring of the year, when, indeed, at times  it appears to
 be epidemic, large numbers of persons suffering  from  it without any very appa-
 rent local cause. 
378
ER YSIPELA S.
  That whitlow is truly an erysipelatous affection of the fingers appears to be
the case for the  following  reasons: — lstly. Because  the  causes, whether of
season, infection,  or local irritation, appear to be the  same in both affections.
2dly.  The  constitutional disturbance is  always very severe for so  slight a dis-
ease, and assumes the same  character of speedy depression  that we observe in
erysipelas.   3dly. The inflammation of the affected finger is invariably diffuse,
never being bounded by adhesion, but always tending  to terminate in suppura-
tion and sloughing.  And, lastly, so soon as the  disease  spreads beyond the
affected finger, or to the back of  the hand, it assumes a distinctly erysipelatous
appearance and character.
   The inflammation of whitlow is in  many cases  confined  to the  pulp of the
finger, commencing in the  dense cellulo-fibrous  tissue  forming this, and often
arising from a very slight  injury, as  the prick of a pin or splinter, but not
unfrequently without any traumatic cause.  The  part  becomes extremely pain-
ful, hard, red, and swollen;  it then suppurates to a limited extent, with  some
sloughing  of the cellular  tissue.  In many cases  the ungual phalanx, which
is imbedded in  the  cellulo-fibrous  digital pulp, necroses when this  sloughs;
there is usually some inflammation of  the lymphatics of the arm accompanying
this affection, and not unfrequently  a  good deal of constitutional fever and
irritation.
   In the more severe cases  of whitlow, the inflammation, which is  of an exces-
sively painful character, owing probably  to the tension  of the parts, extends to
the sheaths of the tendons, and.  then constitutes an affection that is fraught
with  danger to the utility  of the finger or  hand.  In these  cases the whole
finger swells considerably, becomes  red and tense, with much throbbing and
shooting pain;  the inflammation rapidly extends to the dorsum  of the hand,
which becomes puffy, red, and swollen, presenting the ordinary characters of
erysipelas.  Although the  palm be  greatly swollen,  it  usually  preserves its
natural color, or becomes of a dull white, owing to  the  greater thickness of the
cuticle in this situation.   Pus rapidly  forms, both in the finger and hand, and
finding its way into  the  sheaths of the tendons,  will spread up  the forearm
under the annular ligament.  There is usually no  fluctuation to  be felt in the
finger, even though pus may have formed, but in other parts of the hand  it
may readily be detected in the usual way.   In these cases there is always much
sloughing conjoined with the suppuration, the cellular tissue of the finger and
hand, the tendons or their  sheaths, and  the palmar fascia, being all more or
less implicated.   In many cases the joints of the fingers are destroyed, and the
phalanges necrose, or if this do not happen, the tissues of  the part may be so
matted together as the result of sloughing and suppuration, that  rigid and con-
tracted fingers, or a stiff and comparatively useless condition of the hand, may
be permanently left.
   In the treatment of this affection, the patient  should  be well purged, and
kept  upon a strictly antiphlogistic plan  during the early stages.   At  the same
time  the  inflamed finger should be  freely leeched, and then  alternately poul-
ticed and  soaked in very hot water for twenty-four or forty-eight  hours, being
kept  during the whole of this  time  in an elevated position.  In  this way the
inflammation may be sometimes cut short at its  onset;  should it, however, con-
tinue to progress, the finger becoming hard, with much throbbing, a free longi-
tudinal incision must at once be made  along  either side of it, so as  to relieve
tension and prevent sloughing; this, though a painful  procedure, should  never
be omitted, on account of the importance of the preservation of  the full utility
of the part.   The incision  is best made from the proximal towards  the distal
end of the finger, so that if the patient make an attempt to withdraw the hand
during the operation, he will rather facilitate the cut  being made than other-
wise.   In making these incisions, however, the sheaths of  the tendons should,
if  possible, be avoided;  if  these be opened, the tendons will  probably slough, 
INTERNAL ERYSIPELAS.
379
and the finger be left in a permanently extended and rigid state.   The finger
must then be well soaked in hot water, and poulticed.  In this way the inflam-
mation  may be  arrested, and sloughing happily prevented; should, however,
matter have formed, this must be let out as it accumulates, and all hardened
and sodden cuticle peeled from the part.  After the  opening has been made,
and any sloughs that have formed come away, it not unfrequently happens that
a large  and fungoid granulating mass  sprouts up;  this will, however, gradually
subside, as the swelling of  the finger goes down and  the  inflammation  abates.
If the nail become loosened,  it had better be removed, as it may otherwise keep
up irritation;  it must not, however, be torn off if adherent, but then  merely
scraped and cut away so far as loose.  When the whole of a finger is affected,
the hand should be placed  on a pasteboard splint so soon as the inflammation
has been somewhat subdued,  lest contraction of the affected finger ensue, which
may eventually extend to the neighboring ones.
   When the joints are implicated, destruction of the cartilages commonly ensues,
but yet, by position, and rest on  a splint, a tolerably useful, though stiffened
finger may be left.   When the bones are implicated, some operative procedure
usually becomes eventually necessary.  If the ungual phalanx alone be necrosed,
it may be excised through  an incision on the palmar side of the finger, the pulp
and nail being left;  in this way I have often preserved a finger that must other-
wise have been removed.   Amputation of the  finger of the  metacarpo-phalan-
geal articulation will usually  be required when the second or proximal phalanges
are involved,  though here, partial operations by cutting and scraping away the
diseased bone, may  sometimes  be usefully done.  During the later stages  of
these affections, tonics, good diet, and stimulants will be required for the re-es-
tablishment of the health.

                      INTERNAL ERYSIPELAS.

   By internal erysipelas is  meant those forms of diffuse inflammation which
affect the mucous or serous surfaces, or the lining membrane  of arteries, veins,
lymphatics.
   The  mucous surface that is chiefly affected by this disease is that covering the
fauces, the pharynx, or the larynx.
   Erysipelas of the fauces may occur in consequence of the disease spreading
 from the head and face to  these parts, or it may commence as a  primary affec-
 tion, occurring perhaps at the same time that the rash appears on the cutaneous
 surface on some distant part of the body.  When the fauces are erysipelatous,
 they present  a bright crimson or scarlet color, with some swelling and thicken-
 ing of the soft palate and uvula;  there is also most commonly some huskiness
 or complete loss of voice, and occasionally some croupy symptoms.  At the same
 time there is a good deal  of low constitutional fever, with a pungent, hot skin,
 and quick pulse.  This form  of erysipelas is of a peculiarly contagious character,
 and occurs not unfrequently in the attendants  of those who are laboring under
some of the  other varieties  of  the disease; of this  I have seen numerous  in-
stances.  In  many  cases, also, it is epidemic, spreading through a house, and
 affecting almost every inmate.   In the treatment of this  affection, the best
 results are  obtained by sponging the inflamed parts freely with a  strong  solu-
 tion  of the  nitrate  of silver;  and, if there be much constitutional depression,
administering full doses of  ammonia, with camphor or bark.  Should the dis-
ease go on to sloughing, constituting some of the forms of" putrid sore throat,"
which not unfrequently happens, the mineral acids and bark, with chlorinated
port-wine gargles, and the brandy-and-egg mixture  for support, will be found
most useful.   In many cases, tlris disease continues limited to the palate and
fauces; but in others it extends either upwards or  downwards.  It  may extend
upwards through the nares, out  of the  nostrils, and  thus spread over the face 
380
ERYSIPELAS.
and head.  It may extend downwards, affecting the gastro-intestinal membrane,
or more frequently implicating the larynx.
   Erysipelatous Laryngitis, as described  by Byland, Budd, and others, is an
extremely dangerous affection.  The inflammation in these cases commencing in
the fauces, rapidly spreads  to  the  mucous membrane and loose submucous cel-
lular tissue, external to, and within the larynx, giving rise to extensive cedema-
tous infiltration of these parts  with sero-plastic fluid, which, by obstructing the
rima o-lottidis, may readily suffocate the patient.   In consequence of this spe-
cial tendency to oedema, the disease has by many writers been termed "cedema-
tous lartnujitis."   After death, in these cases, the submucous cellular tissue of
the fauces, that about the base and fraena  of the epiglottis, and especially that
which covers the posterior part of the larynx, will be found to be distended with
serum or a sero-puriform fluid. This infiltration  occupies the rima of the glot-
tis, and  extending into the interior of the  larynx, gives rise to such swelling
that its cavity is nearly obliterated.   Great as the swelling may be, however, in
all these parts, it  never spreads below the true vocal chords.  This fact, which
is of considerable importance, is owing to the mucous membrane coming closely
in contact with, and being  adherent to, the fibrous tissue of which  these are
composed, without the intervention of any submucous cellular tissue.  The pro-
gress of this oedematous  inflammation of the mucous membrane, and  loose sub-
mucous tissue in these situations, is often  of an amazingly rapid character, the
swelling being sufficient to  induce suffocation at the end of thirty-six or forty-
ei^ht hours, or even sooner.   If the patient  be not carried off in this way, there
will be a great  tendency to suppuration and sloughing of the affected tissues,
leading  perhaps  eventually to death from absorption of pus, and low constitu-
tional fever.
   The symptoms of this affection are strongly marked: the patient, after being
 attacked with erysipelas  of the fauces, attended by some difficulty and pain in
 deglutition,  with  huskiness of the voice, is seized with more or less difficulty in
 breathing, coughs hoarsely and with a croupy sound, and complains of tender-
 ness under the angles of the jaw and about the larynx.   The difficulty in breath-
 ing increases, and may speedily threaten the life of the  patient, giving rise to
 intense  fits  of dyspnoea, in one of which he will probably be suddenly carried
 off.  On examining the throat from the interior of the mouth, the fauces will
 not only be  observed to  be much and duskily reddened, but by depressing the
 tongue the epiglottis  can be felt,  and perhaps seen, to be rigid and erect.
   In the treatment of this affection local means are of the first importance.  The
 tongue having been well depressed, the posterior part of the larynx, the epiglottis
 and its fraena must be well scarified by means of a hernia knife, with which this
 operation may be most readily and safely done.   The  patient should then be
 directed to inhale the steam of hot water, and a large number of leeches may be
 applied under either angle  of  the jaw, to be  followed by large and hot poultices;
 at the same time, the bowels must be kept well opened, and the patient treated
 antiphlogistically or otherwise, according to the  condition of the constitutional
 fever.   Most frequently, in these cases, I have found antimonials of great ser-
 vice in the  early stages, followed at a later period by support and stimulants.  A
 few hours after the engorged tissues  have  been unloaded by scarification, the
 fauces, pharynx, and upper part of the larynx should be well sponged out with
 a strong solution of  the nitrate  of silver (^i.  to §i.) which  must be applied
 freely, coagulating  the  mucus, and taking down  the increased vascular action.
 If, understanding the employment  of these means, the dyspnoea increase, the
 face becoming pale,  livid, and bedewed with a  clammy perspiration, it will  be
 necessary, in order  to save the patient from impending suffocation, to open the
 windpipe.   In doing  this I prefer the operation of laryngotomy, for reasons that
 will be mentioned when I come to speak  of the diseases and operations of the
 air-passages.  In order that this  operation should  be  successful, it must not, 
               PURULENT  INFECTION, OR PYEMIA.          381

however, be too long delayed, and should not be looked upon as a last resource;
if done in time, and time in these cases is most precious owing to the rapid pro-
gress of the disease, the  patient's life may probably be saved; but if deferred
too long, congestion  of the lungs will have come on, the blood will cease  to be
properly arterialized, and the patient will  sink from a slow asphyxia, even though
air be at last freely admitted.   If the patient survive to the stage of sloughing,
chlorinated gargles and support must be  our chief reliance.
   Erysipelas  of the  serous membranes  is of common  occurrence in surgical
practice, being frequently met with in the arachnoid  and peritoneum.  These,
like all  other  serous membranes, are  liable to two distinct forms of  inflamma-
tion, one, which is of a sthenic character, having a tendency to  the  formation
of plastic  lymph; the other, which  is of a diffuse or erysipeloid form,  being
always accompanied by the  exudation of a plastic unorganizable fibrine.
   Erysipelatous or  " diffuse" arachnitis commonly occurs as a consequence of
injuries of the head and erysipelas  of the scalp.  In these cases there is usually
a flushed  countenance, bright  staring eyes, low muttering delirium, alternating
with a comatose condition, and rapidly terminating in death; the constitutional
symptoms are those of  low irritative fever.  On examination after  death, the
arachnoid and pia mater will be found  greatly injected with blood,  forming  a
close red  net-work  of vessels  over the  surface of the  brain,  the substance of
which is usually somewhat  injected, the ventricles being distended with  a red-
dish-colored serum.  If examined at a later period in the disease than this, the
inflamed arachnoid will be found to be covered with a layer of opaque puriform
lymph of a greenish-yellow color and slimy consistence.
   Erysipelatous or  "diffuse" peritonitis is not unfrequently met with in aged
and cachectic subjects after  the operation  for hernia, or as a consequence of
various diseases and  injuries of the pelvic or abdominal organs.   In  this form
of peritonitis, the symptoms are often of a latent character, the disease  being
 chiefly indicated by obscure pain diffused over the abdomen, with tenderness on
pressure, and an anxious depressed  countenance, a hot skin,  and a  small  and
rather hard pulse.  On examination after death, the subperitoneal cellular tissue
 will be  found injected, the peritoneum opaque in parts,  covered  with filmy
 patches of greyish lymph,  and usually containing a largish quantity  of opaque
 dirty-looking turbid fluid, mixed  with shreds and  flocculi of  lymph.  This,
 though  closely resembling pus in appearance, is serum with lymph intermixed,
 and is of  a peculiarly acid, acrid, and irritating character.   It is this form of
 peritonitis that is so dangerous to  dissectors; inoculations  of  the fingers with
 any of  this fluid being often productive of the most serious and  even fatal
 consequences.
    The erysipelatous inflammation of the lining membranes of  the vascular sys-
 tem, will  be fully discussed when we come to consider diseases of these parts.
                      CHAPTER  XXVIII.

               PURULENT INFECTION,  OR PYEMIA.

  By pyemia is meant a dangerous and often fatal affection, supposed to depend
upon  the  admixture of pus with the blood.   This disease is closely allied to
some of the lowest and worst forms of erysipelas, with which indeed it is com-
monly associated, and to which  it presents  great  similarity in its causes, symp-
toms,  and  effects. 
382           PURULENT INFECTION,  OR  PYEMIA.
  Like erysipelas,  pyemia commonly occurs at those  seasons  of the year, and
under those atmospheric  conditions in which  diseases of a low type are preva-
lent, frequently as the result of overcrowding in hospitals, and it is in unhealthy
and  cachectic constitutions that it usually manifests itself.   Though it is least
frequently met with during the earlier periods of life, yet it may make its ap-
pearance at any age, and  I have seen very young children carried off by it.
  Pyemia is never, I  believe, an idiopathic  or  primary affection, but either
occurs subsequently to an injury or wound of some kind by which inflammation
is excited, which has in most cases reached the stage of suppuration before the
pyemic symptoms come on; or in connection with some low form of suppurative
inflammation.  Thus we often see boils, carbuncles, diffused  abscess, erysipelas
of the  skin,  or erysipeloid inflammation of the veins or absorbents  precede its
occurrence.   Wounds of  veins, of bones, and of joints, are the injuries that are
especially apt to be followed by this  disease;  and in  the puerperal state  it is
often met with, probably  as the result of uterine phlebitis.
  Pyemia is characterized specially by two series of phenomena.  The first is
a state  of great depression of the powers of the system;  the second, the forma-
tion of abscesses in various parts of the body.   The symptoms are as follow: —
The patient is seized with  rigors,  usually of a  very severe and continuous
character, but occasionally short and  transient, sometimes occurring irregularly,
at others  being repeated  almost periodically twice or thrice in the twenty-four
hours, for some days in succession; in some cases  these rigors are not attended
by  any sensation of cold,  but in  others  they are, and  then alternating  with
much  febrile disturbance resemble very closely an ague fit; any open wound
that may  exist at this  time usually becomes foul, sloughy, and ceases to secrete
pus, though  I have seen it continue  healthily  granulating throughout  the dis-
ease.   The skin  is  hot, and has a burning pungent feel.   The breath has that
peculiar sweetish, saccharine or fermentative smell that is commonly noticed in
all  febrile diseases  of a  low type; this odor of the breath, and indeed of the
body generally, often  occurs  early in the disease, and  must then be taken as a
very unfavorable sign.   The  secretions  are  arrested, the pulse is  quick and
feeble, the face is usually pale, with a very anxious drawn look, but sometimes
flushed and the eyes bright;  there is hebetude and dulness of mind, with slight
nocturnal delirium, but perfect consciousness  on  being spoken  to;  about this
period, patches of  erratic erysipelas  frequently make their  appearance on the
surface, and  the skin  assumes a dull, sallow, and earthy, or a bright yellow,
icteric tint, which  may extend even to the conjunctivae.   The  symptoms now
indicate an  extreme depression of the vital powers, the pulse becoming  small
and fluttering, the tongue brown, with sordes about the teeth, and low delirium;
usually from the sixth to the tenth day, but sometimes earlier, diffuse  suppura-
 tion  begins  to take place in different tissues, joints, and  organs.  This may
 occur in  the viscera without occasioning any.material pain; if seated in the
 cellular tissue, or in the  substance of muscles, there is much doughy  swelling,
 with some redness; if in the joints,  the swelling is often considerable, the pain
 usually intense and of a very superficial and  cutaneous  character, the patient
 screaming loud  with  the  agony he suffers.   These  pains, which  are chiefly
 seated in the knees, ankles, hips, and shoulders, often simulate rheumatism very
 closely.
   The progress of the disease is usually from  bad to worse, sometimes  rapidly,
 but at other times  not uninterruptedly so, there being remissions and apparent,
 though not real, improvement.  The patient rapidly wastes, the body becoming
 shrunken, the muscles soft, and the  skin  loose and pendulous; great debility
 also  sets in.  The abdomen  becomes tympanitic, diarrhoea or profuse sweats
 come  on; pneumonia or  pleuritic effusions declare themselves ; delirium, from
 which the patient  is easily roused, alternates  with sopor, and at last  he  sinks
 from  exhaustion.  Death usually takes place  about the  tenth or twelfth day, 
SYMPTOMS  OF  PYEMIA.
383
though it may occur as early as the fourth, or the patient may linger on for six
or seven  weeks.
   In other cases pyemia occurs in a very insidious  manner, without rigors, but
merely with prostration, and some low fever of an intermittent kind; after a
time the skin assumes a yellow tint, as do the conjunctivae.  The urine is very
high-colored,  and perhaps  the peculiar odor in the  breath or body  may  be
noticed; but the patient continues in  a quiet state, his wound clean, and sup-
purating healthily.  He  gets, however, symptoms of low pneumonia or pleurisy,
with, perhaps, pain and fulness in one joint, where abscess forms, and then the
disease fully declares itself.
   The  formation of  numerous  purulent  deposits, "secondary or  metastatic
abscesses,"  as they are  often termed, is one of the most marked features  of
pyemia.   These  abscesses  usually contain a somewhat thin and oily-looking
pus; at  other times, however, it is thick and laudable.   The more oily-looking
fluid, though  opaque and yellow, and closely resembling true  pus, will, on micro-
scopic examination, be found to  differ  from this  in  the absence of  the true
nucleated pus-corpuscle, though it contains an immense number of granular cells
 (figs.  49 and 50.)   After  removal it often forms a  firm fibrinous  coagulum.
 These purulent collections vary greatly in  size and in situation, they are found
 in the viscera, in the cellular and  muscular structures, in the serous membranes,
 and in the joints.
    Pyemic abscesses differ  from ordinary purulent collections, not only in the
 peculiar character  of the  pus that they contain, but more particularly in the
 rapidity with which they form, a few days commonly sufficing for them  to attain
 a  large  size.  So,  also, their very widely-spread  character, and the  insidious
 manner  in  which they occur, — the tissues, as it were, breaking down without
 any inflammation, — constitute the distinguishing features of these collections.
    The visceral  abscesses vary in  size from a pin's  head to a walnut;  in many
 cases the organs affected are studded with them.   These collections are most
 frequently met with in the lungs, being seated on the surface of  the organs, or
 in the interlobular fissures,  next, in the  liver, and then, in the.spleen;  they  are
 usually  surrounded  by a darkly-inflamed and condensed layer of tissue, which
 forms an imperfect wall to the  collection. They may occur in  other organs;
 thus, my friend, and late house-surgeon, Mr. Gamgee, has on several occasions
 observed them in the prostate.
    When the pus is infiltrated into the cellular tissue and  muscles of the limbs
 and trunk,  it will form immense diffuse collections of a thin and serous matter,
 commonly mixed with shreds of the cellular membrane of the part.   These col-
 lections are most frequently met with, perhaps, in the axilla,  down the flank and
 about the back, in the iliac fossa, thigh or calf, and may either be confined to
 the subcutaneous, or extend to the deep intermuscular cellular  planes  in these
 regions; or  may even  form in the muscular substance  itself, being diffused
 between the fasciculi which are softened and disintegrated.  Most commonly
 the presence  of these collections is indicated by patches of cutaneous or erratic
 erysipelas,  and by  a doughy,  cedematous,  and boggy  state of the  superjacent
 integuments.
    Accumulations of pus in the serous and  synovial membranes  are  common in
 this disease;  the arachnoid, the pleura,  or  the peritoneum may all be affected
 in this way.  More frequently, however, some of the joints, especially the knees
 and shoulders, become filled with a thin, yellow, purulent liquid.   These arthritic
 abscesses are usually indicated by the  occurrence of intense pain, often of a
 cutaneous or  superficial  character, with fluctuation and swelling in the articula-
 tion affected.  It often happens, however, that large accumulations of  pus form
 suddenly in joints, without having been preceded  by pain or any other sign of
 mischief;  in these  cases the interior of the joint, though  filled with  pus, will
 be found to be tolerably healthy, there being no erosion of cartilage  or destruc- 
384          PURULENT INFECTION,  OR  PYEMIA.
tion  of ligament, but  merely  some  inflammatory injection  of the  synovial
membrane.
  Not only are the appearances just mentioned commonly met with in cases of
death  from  pyemia, but we  find the viscera, more  particularly  the  brain  and
lungs inflamed, and, not unfrequently, a diffused erysipelatous  redness of some
membranous surface, as of the arachnoid or gastro-intestinal mucous membrane.
  The diagnosis of pyemia  is  not always  easy in the earlier stages, when the
rigors, depression, and other signs of constitutional  disturbance  may be looked
upon as common to other intercurrent diseases.  As  the affection declares itself,
however, the continuance and severity of the rigors,  the extreme  want of power,
the icteric tinge of the skin, the peculiar faint and sickly odor  of the breath,
and  the occurrence of metastatic and visceral abscesses, indicate the true nature
of the attack.
  The question necessarily arises, to what are the symptoms and  destructive
effects of  pyemia due ?   There  can be little doubt that they are owing to  the
alterations that take place in the blood itself.   It is only in this way that  the
remarkable diffusion of the disease, the variety of tissues affected, and the wide-
spread tendency to suppuration that characterizes it  can be explained.  That the
blood undergoes important changes in  this disease is unquestionable; it is thin,
dark-colored, and, after  having been drawn from the body, forms  a loose, spongy
coagulum, from which  a moderate  quantity of rather turbid or milky-looking
serum separates.   On examination under the microscope it will be found that,
besides the ordinary red corpuscles, the blood contains, often in large  quantities,
corpuscles, that in some cases closely resemble the  ordinary white ones of the
healthy blood, and at others present such exact similitude to the pus-cell, that
the most practised eye fails in detecting a difference.  These corpuscles may be
few  in number, and at other times so abundant that they occupy  the field of the
microscope to the  exclusion of  the red.  The existence of these corpuscles in
the blood, which I believe will invariably be found on careful examination, more
especially in that taken from the larger veins, constitutes apparently  one, if not
the  essential element  of the disease.   That they  are true pus-corpuscles, in
many cases, would seem to be probable from their microscopic appearances; in
others again, they do not present the characters of the true pus-cell, differing
from it in the shape, or in the absence of a nucleus, and in their more irregular
outline;  resembling indeed  more closely the white corpuscles, or some of the
ill-developed granulation or exudation-cells that are met with in cold or lymphatic
abscesses  occurring in  cachetic constitutions.  Whatever differences  of appear-
ance these corpuscles may present, they can best be compared to those pus-cells
that are found in many unhealthy abscesses, and more especially in the diffuse
purulent collections  occurring in the cellular tissue or the  joints in this very
disease;  and like  these I think we must look upon  them as products of inflam-
mation, though perhaps of a low and aplastic form.
   The question that next presents itself is, how do these corpuscles find their
way into  the  blood ? and how do the  other changes that occur  in the physical
characters of this fluid take place ?   By some  surgeons it has  been supposed
that the pus is actually and bodily absorbed from the surface of the suppurating
wound, and  so admixed with   the blood.   This explanation, however,  is not
tenable, as there is not  only no proof, but no reason to believe in the possibility
of the absorption of a pus-corpuscle in its state of integrity from the surface of
a wound.   Then, again, it has  been supposed that the pus having trickled, or
in some other way found an  entrance into the open  mouth of a divided vein, as
upon the  surface of a stump or in a sawn bone,  has  gained access to the general
circulation.   But  it is difficult to understand  how pus  can possibly become
admixed with the general current of  the  blood in this way; for if the vein be
sufficiently open  to  allow of the entry of one fluid, it would certainly be so to
admit of  the escape of the other.  The theory that has the most advocates at 
CHANGES  IN  THE  BLOOD IN PYEMIA.          385
the present day, is, that the pus  enters the circulation as a consequence of
phlebitis, being formed directly by the lining membrane  of an  inflamed vein,
and thus poured at the moment of its evolution into the current of blood passing
along the vessel.   This dependence of pyemia on suppurative phlebitis, more
especially of a diffuse  character, has been strongly advocated by Hunter, Arnott,
Berard, and others,  and  affords  an easy solution  to the  difficulty, and has
acquired considerable weight from the fact that in many cases these affections
are found co-existing.  I am by no means prepared  to deny that the pus does
in all probability in very many cases become directly admixed with the blood
in this  way, and  that suppurative  phlebitis is consequently in  these instances
the cause of the pyemic symptoms.  This explanation would indeed be conclusive,
if it could  be  shown that phlebitis was the only, or even the most frequent form
of diffuse inflammation occurring in connection with  pyemia, and that it always
took place  as a precursor and concomitant  of the blood  affection.  But this I
believe  not to be the  case.   I have had opportunities of examining the bodies
of a considerable  number  of patients who have died of pyemia, and I have
certainly often found evidence  of other diffuse  inflammations as well  as of
phlebitis;  and in some cases no  inflammation of the  veins could be detected on
the most careful investigation  specially directed  to this point; and hence I
cannot  but come  to  the conclusion that pyemia, though frequently co-existing
with, may  occur independently of suppurative phlebitis, and cannot in all cases
be necessarily considered a consequence of that disease.
   Tessier  maintains  that pyemia  is always independent of phlebitis, being a
primary blood disease.   The  doctrine, however, is  irreconcilable with the
established fact, as pointed  out  by Sedillot, that the injection  of pus  into the
blood produces a disease identical with pyemia; that this affection is always
preceded by local  inflammation,  and usually by suppuration, and that a distinct
connection has been pointed out by Hunter, Arnott, and  Berard between  sup-
purative phlebitis and pyemia.   Besides this, the presence of cells in the blood
resembling the pus-corpuscle admits of proof.
   In the  very excellent essay  published by Mr. Henry Lee on this subject,
that surgeon expresses his opinion that the introduction of pus into the system
from an inflamed or injured vein is rarely the first step  in  purulent infection,
but must have been preceded by some change that has taken place in the blood,
by which  its  coagulating  power  has  been impaired.   Mr. Lee's views are
 supported  by a number of ingenious experiments.
   How are we to account for the changes that the blood undergoes, and which
 whether resulting from suppurative phlebitis or not, are the essential causes of
 the pyemic symptoms ?
   The  explanation that I would suggest as to the cause of the presence  of the
 true or imperfectly formed  pus-cell in the blood  in these cases is the following.
 For pyemia to occur, I believe  it to be invariably and absolutely necessary that
a local inflammation previously exist in  some  part of the  body.  This  may
either be  external or internal;  it  may be limited in size to that of a boil, or
it may be  as extensive as  the  surface of a sloughy stump.  In all cases this
inflammation  is of, or tends to assume, a suppurative character; and in all, the
constitution is broken, and of that kind in which the corpuscular or aplastic
lymph  commonly forms.  It is not difficult to suppose that the blood in circu-
lating through the  part  so diseased, instead  of undergoing  those  peculiar
changes that are impressed upon it in its passage through tissues that are
sthenically inflamed,  and of which the  most remarkable is the formation in it
of a large  quantity of plastic filamentous  fibrine, — as evidenced by the hard
firm coagulum, by the  formation  of the buffy coat, and by the tendency to
the deposition of coagulable lymph, as well as by the occurrence of constitu-
tional fever of the sthenic  type, — may undergo alterations in  composition, of
equal extent, though  of a far different kind.   It appears not improbable that 
386           PURULENT INFECTION,  OR  PYEMIA.
the fibrine formed in the blood in these  low inflammations, occurring in broken
constitutions and at unhealthy seasons, may assume that corpuscular or aplastic
character which we have already seen to be the invariable result of these con-
ditions, and that the corpuscles, which  are met with intermixed in greater or
lesser  quantity  with  the blood  in  pyemia, and  that bear a sufficiently close
resemblance to  granulation or exudation-cells, to  all the various forms of the
unhealthy, and  occasionally to the  typical variety of the  pus-corpuscle, are in
reality the conditions under which superfibrination  of the blood with corpuscular
lymph  would necessarily  show  itself.  That, consequently, instead  of being
formed from without, and absorbed or poured into the blood, they are actually
generated in that fluid itself during its passage through  the unhealthy-inflamed
tissue, not however by any conversion of the blood-globule into  a lymph or pus-
cell, but as a consequence  of  those changes which we know, by their  effects, to
be impressed upon the blood  by  circulation through inflamed tissues, but with
the precise nature of which we are still unacquainted. It is also by these blood-
changes  in  pyemia  that we may account for the remarkable constitutional
depression that  exists;  for if, as  there is every reason to believe, the admixture
of plastic fibrine with the blood will occasion sthenic inflammatory  fever, the
formation of aplastic exudation-matter in that fluid may occasion a correspondingly
low type of constitutional disturbance.
   As  the  blood circulates through an inflamed vein, not only would those
 changes take place in it that occur in its  passage through other tissues, but it
would  thus become  mechanically mixed  with the pus and exudation-matters
 poured out in large quantity by the lining membrane of the  vessel; and hence
 we may  explain the greater  liability  to the  occurrence of pyemia after or in
 combination with  suppurative phlebitis,  than in connection  with  any other
 inflammatory affection  elsewhere situated.
   When once these corpuscles are admixed with the blood, it  is probable  that
 abscess is a necessary result from their  mechanically occluding the capillaries,
 as Cruveilhier long ago showed experimentally to be the case.  The pus-cells,
 being  larger than the blood-corpuscles, become  arrested in the capillaries of
 organs, and thus constitute  points of irritation, around which inflammation is
 set up, and in which suppurative action takes place; these changes  being first
 induced  in those organs, the  capillaries  of which are of a very small  calibre, as
 in the lungs.
    The tendency to suppuration of joints, and to the formation of diffused col-
 lections in the  muscles and cellular tissue, can scarcely, however; be  accounted
 for in this way, and are probably dependent on other causes, amongst  which the
 low crasis of the blood is  the most powerful.
    The treatment of pyemia  is of the most unsatisfactory character.   It doubt-
 less happens that patients occasionally recover  from this disease, but such a
 result must be looked  upon as a happy exception to its  commonly fatal termi-
 nation.  The  only plan of treatment  that holds out any reasonable  hope of
 success,  appears to me to  be the stimulating and tonic  one.   I have certainly
 6een service done, in some cases, and indeed recovery effected, by the  adminis-
 tration of large doses of quinine, as much as  five  grains being given every third
 or fourth  hour, with the best effect.  A very serious case of pyemia, lately
 under my care at the  hospital, occurring after  amputation of the arm, and
 accompanied not  only by all  the  symptoms  of that disease in a very marked
 manner, but by pleuritic effusion, swelling  and  tenderness over one hip, and
 secondary hemorrhage from  the stump, got well by perseverance  in the  tonic
 and  stimulating plan  of  treatment.  If  the  depression  is very great, the car-
 bonate of ammonia in ten or fifteen grain  doses may  be given from time to time;
 such  nourishment as the patient will  take,  with a liberal allowance  of dietetio
 stimulants, being  also administered.
    In the case of a superficial vein being inflamed, it has been  recommended by 
TUMORS.                             387
some of the French surgeons, as Bonnet, Berard, and Laugier, that the  actual
cautery should be freely applied  along the course of the vessel, and they state
that the best results have followed this practice.  As abscesses form, they must
be  freely opened;  and  the  diffuse and  purulent  collections  forming  in the
cellular tissue  must be  evacuated.
                        CHAPTER  XXIX.

                               TUMORS.1

  The frequency with which tumors fall under the observation of the surgeon,
the great variety in their characters, and their important relations, local as
well as constitutional, render their consideration one of great moment. Accord-
ing to Hunter, a tumor is "a circumscribed substance produced by disease,
and different in its nature and  consistence from the surrounding parts."   This
definition, though not perhaps accurately correct in some forms of tumor, which
do not differ in their nature from neighboring parts, is yet substantially a good
and convenient one.  By a tumor may also be said to be meant a circumscribed
mass, growing in some tissue or organ of the  body, and dependent on a morbid
excess or deviation of the nutrition  of the part.   The tumor thus formed in-
creases in size by an  inherent force  of its own, irrespective of the  growth of
the rest  of  the system, and differs essentially from  the normal structure and
appearance of the part of the  body in which it grows.  In order to constitute
a tumor, it  is necessary that the normal form  of the  part be widely departed
from — a mere increase in its size, so long as it  preserves its usual shape, being
scarcely considered in  this light.   Thus, if the tibia be uniformly enlarged to
double its natural size, it would be  said to constitute a hypertrophy,  not a
tumor; but, if a  comparatively small rounded mass  of bone project directly
forwards from its tuberosity, it would be said  to be a tumor, and not a mere
hypertrophy.
   Surgeons divide tumors into two great classes, the non-malignant and the
malignant.   This division, though practically  convenient, is  not  scientifically
exact.   Recent researches have shown that,  although some tumors,  as the
cancers,  are always and essentially malignant, and others as uniformly benign,
as  lipomas  and some  cysts,  yet that many others that  are  usually innocent
may, under certain conditions, at present unknown, take on a truly malignant
action : this has led to the establishment of an intermediate group, that may be
termed the  semi-malignant.
   The non-malignant, innocent, or  benign  tumors are strictly local.   They
resemble more or less  completely the  normal textures of a part, and  hence are
very  commonly, though not  perhaps with strict  propriety, termed  homomor-
phous.  They usually grow slowly, are  more or less distinctly circumscribed,
being often enclosed in a cyst, and have no tendency to  involve neighboring
structures in  their  own  growth; any change that they induce in  contiguous
parts being not  by the degeneration or conversion of these into  their own
structures, but simply by the  effects  produced  by their size and pressure dis-
placing or atrophying  them.   They are  sometimes single, but not unfrequently
multiple, developing either simultaneously or successively; but if in the latter

  1 In Paget's Lectures on Surgical Pathology, vol. ii.  will be found the most philosophical
account of tumors in this or any other language. 
3S8
TUMORS.
mode, without any connection with preceding  growths.   If removed  by ope-
ration, they do not return ;  but if left to the natural processes  of nature, they
may slowly attain a great size, remain stationary, and at last atrophy, decay, or
necrose.
  The essentially Malignant tumors  differ  widely from  those last described.
They cannot be considered as strictly local diseases, as in many cases they result
primarily from a constitutional vice, or if local in the first instance, have a ten-
dency rapidly to affect the  constitution.   They are  essentially characterized by
an  extreme vegetative  luxuriance and  an  exuberant vitality.   They  proceed
from a germ which,  in a manner  at present unknown to us, is  formed  in some
organ "or tissue, where it develops by an inherent force  of its own, irrespective
of neighboring parts, producing a mass which  differs entirely in structure and
appearance  from anything  observed in the normal  condition of the body; and
hence, not unfrequently called heteromorphous.   This term, however, cannot be
considered strictly accurate, inasmuch as the microscopic elements of which this
mass are composed have their several analogues in the normal structures of the
body.   This mass, which may either be infiltrated in the tissues, or localized by
being confined to a cyst, increases quickly in size; not uncommonly indeed the
rapidity of the growth  may be taken  as a measure of  the malignancy of the
tumor.   As it increases in size, it tends  to implicate the neighboring structures
in its own growth, and  to affect distant organs through the medium of the lym-
phatics or the blood; if removed  by operation  it has a great tendency, under
certain conditions, local and constitutional, to return in  its original site or else-
where, though it does not necessarily do so.  If left to its own development, a
malignant tumor will inevitably soften, necrose,  and ulcerate, often with much
pain, profuse hemorrhage,  and the induction of a peculiar  state of constitutional
cachexy, which speedily and necessarily terminates in death.
   Interposed between  these two classes, we find a third group  that  partakes
more or less of the characters of both; these  may be termed  semi-malignant
tumors.
   The  malignant tumors are usually of a cancerous nature, but " malignant"
and "cancerous" are not synonymous.   Every malignant tumor is not a cancer,
though  every cancer is a  malignant growth.   Some tumors are malignant in
their course, though they present neither to the naked eye nor to the microscope
any cancer structure or any heteromorphous constituent, but are strictly homo-
morphous, being fibrous, fibro-plastic, or cartilaginous.   In most instances such
tumors are benign  in  their  course as well  as  in  their structure, but in other
cases, and without any evident cause, they affect a truly malignant action; thus
the term malignant would  have reference rather to the  course adopted  by the
tumor than to the structure of the growth itself, for  a tumor maybe anatomically
benign,  but functionally malignant.  Paget has very fully described  varieties
of the fibro-plastic as well as of the fibrous and cartilaginous tumor, which though
preserving throughout  a uniform character, microscopical  and otherwise, that is
 not considered malignant, have nevertheless destroyed  the  patient by repeated
 recurrence after removal, and  by ultimate ulceration, sloughing, and contamina-
 tion of neighboring tissues, or even of  distant organs through the medium of
 the circulation.  He makes the important observation  that in different persons
 and under different conditions the same disease may pursue very opposite courses,
 appearing in some to be of an innocent, in  others of a  malignant type; and he
 makes the very interesting practical remark, which agrees entirely with the result
 of my own observation, that the children of cancerous parents may be the sub-
 ject of tumors apparently  innocent in structure, but certainly resembling malig-
 nant growths in  the rapidity of  their progress, their liability to ulcerate and to
 bleed, and their great disposition to return after removal.
    Innocent and malignant tumors are occasionally met with in  the same  person,
 four or five different kinds of growth even occurring in  one individual.  I have 
INNOCENT  TUMORS.
389
seen in one patient a scirrhous  breast, an  enchondromatous tumor of the leg,
and atheromatous cyst on the back, with scrofulous glands in the neck.  Ma-
lignant and benign  formations may even be found in the same mass; thus ence-
phaloid and enchondroma are not unfrequently met with together in the testis.
This, however, must not be taken as any evidence of the possibility of the con-
version of one into  the other, and indeed there is no proof that a non-malignant
can be converted under any circumstances into a malignant  tumor of a different
type;  a fibrous growth  may degenerate and assume all the character of malig-
nancy, at last destroying the patient, but  there is no evidence that it can ever
be changed into a cancerous mass.  A malignant tumor may, however, be depo-
sited on the site of a non-malignant growth that has been removed : thus I have
seen a scirrhous nodule deposited in  the  cicatrix left after the removal of a
cystic sarcoma of the breast.
  Beside these various forms of tumors, others are met with of a constitutional
and specific character, such as those that occur in scrofula and syphilis.

           NON-MALIGNANT,  OR INNOCENT TUMORS.

  The innocent tumors may, I think, be  most conveniently arranged  in three
great classes.
  1st. Encysted tumors of all kinds.
  2d.  Tumors  dependent on  the simple  increase of size  of  already  existing
structures, in the tissues or organs in which  they occur; as, for instance, fatty
tumor in adipose tissues, exostosis in connection with bone,  &c.
  3d.  Tumors  dependent on  the new growth of already  existing structures,
in situations  where they  are not  normally  found; as,  for instance,  a carti-
laginous tumor in the midst of cellular tissue, or a fibrous tumor under a serous
membrane.
                         I.—E NCT8TED  TUMORS

  Encysted tumors  arrange themselves  into two great classes.   1st. Those
that are dependent  upon the gradual accumulation of  a secretion in a naturally
existing duct or cyst, with dilatation and  hypertrophy of its walls: 2d. Those
that result from the new formation of a closed cyst in  the cellular tissue of the
part, and the distension of it by  the secretion from its  lining membrane.
  1st. The encysted tumors arising from simple distension  and gradual hyper-
trophy of the walls of  a  duct or cyst are  met with in three forms,  (a) As
encysted  tumors of the skin and subjacent cellular tissue occurring in various
parts of the body, and dependent on the closure of the excretory ducts of the
sebaceous  glands:  (p) As formed by  the  accumulation  of secretions  in, and
the  closure and dilatation of, the ducts of other secreting glands and organs,
as in the sublingual  or mammary gland: (y) Those  formed by the retention
and  modification of the secretions in cysts without excretory ducts, as in the
bursae.
  (a) Encysted tumors occurring from the obstruction of the excretory duct of
the sebaceous  glands, include the various forms of atheromatous  tumors that
are met with on the surface of the body.  These are usually situated upon the
scalp, face, neck, or back; sometimes, however, they occur  elsewhere ;—thus I
have  removed a very large one  from  the  forepart of a girl's  arm, and others
from  the labia and  groin.  In size these tumors vary from that of a pin's head
to an orange; the  smallest occur on the eyelids, the  largest  on the shoulders
and scalp.   They are often very numerous, especially about the head, where  as
many as thirty  or forty may be met with at the same time; and most frequently
they form in women about the middle period of life:  they are smooth, round,
or oval, movable under the integument, either  semi-fluctuating or elastic, though
sometimes solid to the touch.   In some parts where the sebaceous follicles are 
390
INNOCENT TUMORS,
Fio. 141.
large, as on the back, a small black point can often be detected on the surface
of the tumor, through which an aperture may be found leading into its interior,
and admitting the expulsion of its contents.   In structure they are  composed
of a cyst which varies greatly in  thickness, being sometimes  thin, filamentous
and soft; at others so thick, hard, laminated, and elastic, that it is almost impos-
sible not to believe it to be a new formation; these cysts attain their greatest
density on  the scalp, and  are here  often very firm, elastic, and resisting, even
though of but small size.   In structure they are  composed of cellulo-fibrous
tissue, with an epithelial lining, and generally appear to be a dilated and hyper-
trophied state of the sebaceous follicles, though not improbably, as Paget sup-
                               poses, they  may  at times be new formations.
                               They  are usually  attached  by loose and lax
                               cellular  tissue to the  subjacent parts;  but, if
                               thin, are often  pretty  closely incorporated with
                               the  super-imposed skin;  if inflammation is set
                               up  around  them   they  become more  solidly
                               fixed.  The contents  of  these  cysts are very
                               various,   most  usually consisting  of  a  soft,
                               creamy,  pultaceous, or  cheesy-looking mass, of
                               a  yellowish-white color,  which  has  sometimes
                               in old cysts become dry and  laminated,  looking
                               not  unlike parmesan.  In  others, again, of old
                               standing and large size, the  contents may be
                               found to  be  semi-fluid,  the  more liquid parts
                               being of a brown, green,  or  blackish  tint.
These  various contents are essentially composed of modified sebaceous secretion,
such as epithelial scales, fat  granules, cholesterine, granular  matter,  and rudi-
mentary hairs in various proportions (fig. 141).
   The  growth of these tumors is often very slow, but not  unfrequently after
                     remaining stationary  for years, they  take  on a rather
                      rapid  increase.  The tumor itself, though painless, may
                      give rise to uneasy sensations by compressing nerves in
                     its vicinity; it usually continues to grow slowly until the
                     patient being annoyed  by its presence, gets it removed
                     by operation.   If  left untouched, it occasionally,  though
                      rarely happens, that the sebaceons matter exuding through
                     an aperture on its  surface forms a  kind of scab or crust,
                     which by a process of sub-deposition  becomes conical;
                     and being gradually pushed up from below, at the same
                     time that it  assumes by exposure a dark brown color,
                     forms an excrescence that looks like a horn, and is  usually
                     considered  to be  of that  character (fig.  142).   These
                     " horns" have been met with on  the head, on the buttock,
and occasionally in  other situations, and  have been well described by  Mr. Eras-
mus Wilson; some time ago a woman applied to me with  one about an inch and
a half  long growing from the upper lip.
   In other cases again, these tumors inflame and suppurate;  the skin covering
them becomes adherent and reddened, ulceration takes place, and if the  cyst be
small and dense, it may be thrown off by the suppurative action in the surround-
ing tissues.  If of  larger size, ulceration of the integuments covering  it takes
place,  and  the sebaceous  matter is  exposed; this may  then putrefy,  become
offensive, and  break away in  unhealthy suppuration.  In other cases again,
peculiar changes take place in this tissue, large granulations  are  thrown out in
it, and the atheromatous mass appears to vascularize, becoming irregular and
nodulated,  rising up in tuberous  growths with everted edges, exuding  a fetid,
foul discharge,  becoming adherent to subjacent parts, and  assuming a senii-ma-
Fig. 142.
 
CYSTIC  TUMORS.
391
lignant appearance, forming at last a sore perhaps as large as a saucer, as in the
annexed  figure of a case  sent to me by Dr.
Bryant  (fig.  143).   Sebaceous cysts which
have  undergone  this change may  however
readily be distinguished from such malignant
growths  by a microscopical examination of
their exudation or debris, these consisting of
pus  and healthy epithelium, mixed up with
fatty matters more or less disintegrated.
   The only diseases with which these tumors
can  be  confounded  are abscesses and fatty
growths.  From an abscess an encysted seba-
ceous tumor  may  be distinguished by its
history, slow growth, situation, elasticity, and
mobility, and the existence of the dilated
orifice of the sebaceous duct, through which
some of the  contents  can be squeezed, the
microscopical examination  of  which will
serve to confirm the  diagnosis.  From a fatty
tumor these growths  may be diagnosed by their firmer and more regular feel,
and in case of doubt by the evacuation and examination of their contents.
   The treatment of a tumor of this kind  simply consists in its removal, after
which it is never reproduced.   This may most readily be  done by transfixing
and cutting it across with the scalpel or bistoury, and then  seizing the side of
its cut edge with a pair of forceps,  pulling the cyst out of its loose cellular bed.
This plan may commonly be adopted with  those seated about the head, face, or
neck.  When about the  back, trunk, or limbs, they usually require to be dis-
sected out, being more closely incorporated with the skin, and often adherent by
former inflammation to the subjacent parts. In doing this, care should be taken
that the whole of the  cyst is extirpated;  the wound that is left should then be
dressed  lightly, and speedily heals.  If, however, any portion of the cyst be left
behind, a troublesome fistula may remain.  When occurring upon the scalp, a
large number of these tumors may be removed at one sitting; as,  however,
there is always some danger  of erysipelas following operations in this situation,
it is only prudent to select a favorable season  of the year, and not to operate if
the  tumor be in any way irritated at the time, or the health  out  of order.
Erysipelas is especially apt to occur after these operations in elderly people of a
stout make and florid complexion.
   The  horns and semi-malignant  ulcers that result from  these growths may
require excision.  If, however, the ulceration  be connected with the cranium by
its base, or be very extensive, as  in the case depicted  above (fig. 143), it will
be safer to treat it by the application of a weak solution of the chloride of zinc,
or by occasionally touching it with fused potass.
   (0) Various forms of encysted tumor may arise  from the closure and  dila-
tation of the  ducts  of other excretory organs;  as, for  instance ranula  by the
occlusion of the  salivary ducts, encysted hydrocele by the closure of the tubuli
testis, or cystic  tumors of the breast by the  obstruction of the lacteal ducts.
These affections, however, constitute special diseases, the consideration of which
must be deferred to subsequent chapters.  The general principle of treatment
in these kinds of affection, consists either in restoring the freedom of the outlet
by the excision of a portion of the wall, or obliterating the  cyst by making an
incision into it, and allowing it to granulate from the bottom.
   (y) Cysts may arise by the distension of cavities which are unprovided  with
any excretory duct;  as  for instance the  bursae which often attain a very con-
siderable size under these circumstances.  The structure of  these cysts becomes
greatly altered;  sometimes the walls are thin and  expanded; at others  they
 
392
INNOCENT TUMORS.
acquire a thick  cellulo-fibrous, almost ligamentous, appearance.  Inside they
are often  warty-looking, from  the deposition  of imperfectly-organized  fibrine,
often arranged in a laminated form.  Not unfrequently attached to the walls,
and floating in the interior, are a number  of  granular, melon-seed-like  bodies,
greyish or yellow in color,  semi-transparent, elongated or irregular in shape,
usually rather  hard,  but sometimes  soft and  flocculent.   These appear to be
composed of masses  of  imperfectly-organized  fibrine, somewhat resembling in
structure  granulation-cells, and often form in large quantities, so as to block
up the interi6r  of  the cyst, converting  it into   a  solid tumor.   The  fluid
contents of these cysts  are usually thin and serous, of a yellowish or brownish
color.   In their progress these cysts are found to increase up to a certain size,
when  they usually thicken  and harden, in  consequence of the fibrinous trans-
formation just described;  or else  inflame  and  suppurate  in an  unhealthy
manner.  They may  occur in  any of the  situations in  which bursae naturally
exist or are accidentally formed, and  which will be mentioned hereafter, but are
most commonly met with upon the knee cap, the nates, or the first joint of the
great toe.
   The treatment of these cysts consists in  attempting their absorption by the
use of stimulating plasters;  or, if this fail, in  the  removal  of their contents by
tapping.  Their  cavities are then  closed by exciting inflammation and suppu-
ration  within them,  by  the  introduction of a seton, by injection with stimu-
lating  solutions, or by the subcutaneous section.   If these means fail, excision
will be required,  more especially if the tumor have assumed a dense and fibrous
character.
   2d.   Cysts occasionally are met with as new formations, filling by their own
secretion.   They occur  in the general cellular tissue, and in connection with
the  sheaths of tendons, but  most frequently about the generative organs, more
especially in the ovary, in the broad ligament of  the uterus, or in the breast.
These  cysts vary most widely in size, from  that of a millet-seed  to  tumors
weighing many pounds,  and  filling up the greater part of the abdominal cavity.
When small, they are usually thin-walled, and are  often imbedded in a matrix
composed of imperfect  hypertrophy  of the  organ  in which  they are situated,
as in  the breast  and testes; when large, as in the ovary, the walls  are thick,
firm, satiny, and often  very tough.   Projecting  into their  interior are solid
masses, consisting of cauliflower-like growths, occasionally filling up the whole
inside  of  the cyst with compact solid  white layers.   These " intracystic" growths
cause by their increase in size the gradual absorption of the more fluid contents,
until,  at last, their development is arrested by the  cyst wall.
   These cysts may be divided  into the simple and  the compound.  The simple,
or, as  they are commonly called, serous cysts, are met with in almost every
situation, being composed of a thin expanded  wall, containing a slightly viscid,
6erous fluid.
   The compound, or, as they are often called, proliferous or  multilocular cysts,
are especially met with  in the ovary, and  have been studied with  great  care
by Hodgkin.   Of these there are two varieties, the first consisting of an aggre-
gation of  simple cysts closely packed  and pressed together; the second composed
of cysts having others growing from  their walls.   The cavities of these multi-
locular cysts present  the greatest possible variety in their contents;  fluid, from
a limpid serum to a semi-solid jelly-like matter, and of every shade, from light-
yellow to  greenish-black, or  dark-brown, is met with in them; solid  intracystic
growths, cancerous masses, or the debris of epithelial and cutaneous structures
are also found in them.
   Encysted tumors  containing hair  and fatty matters (pilocystic tumors), are
occasionally met  with.  These would, in   many instances, appear  to  be  the
remains of a blighted ovum inclosed in the body, as  they are congenital, and
usually contain some foetal  debris,  such as portions of  bone, teeth, &c.   The 
WARTS. — SARCOMA. — POLYPI.
393
hairs  in  these tumors are connected with, and grow from, cuticular structures
in which sebaceous  follicles are  commonly distinctly  observable.  The fatty
master which they contain in large quantity, and which may either be solid or
perfectly fluid, is in  all probability the result of fatty degeneration of the soft
tissues of which they are composed.  These tumors are most  frequently met
with  in  the  abdomen, especially about the ovaries, mesentery, and  omentum ;
they have  also been observed  in connection with  the  testes, having probably
descended into the  scrotum with this gland.  A very remarkable case of this
kind  lately occurred at  the University  College Hospital under Mr. Marshall.
They have also been found about the face, but never,  I believe, in connection
with the thoracic cavity or extremities.
   The sanguineous cyst,  or hsematoma, is a peculiar variety of the simple form,
and has  been described  by Paget as especially occurring  about the neck, the
parotid,  the anterior part of the thigh, the leg, the shoulder, and  the  pubes.
It  is especially characterized by containing fluid blood, more or less altered in
appearance.   He describes these cysts as being formed in three different ways:
either by hemorrhage into a previously existing  serous cyst, by transformation
from a naevus, or by a vein becoming occluded and dilating into a cyst.  These
sanguineous  cysts may sometimes resemble in general  appearance encephaloid
disease.   A case of this kind was sent to me by my friend, Dr. Henry Bennet
—a tumor about the size of an orange, of nodulated appearance, existing in the
leg of a woman below the knee,  where it had been gradually increasing in size
for about a couple of years.  So  close was  the resemblance to malignant  disease
presented by the tumor, that the limb had been condemned for amputation by
some surgeons who  had  previously seen  the case;  as, however, the growth, on
 examination, turned out to be  a sanguineous cyst, as  its walls were  thin  and
 adherent, and as it extended too  deeply into the ham to admit of ready removal,
 I reduced it by successive tappings, and then laying it open,  allowed  it to
 granulate from the bottom.  When practicable, however, the cyst should always
 be dissected  out.

    II. — TUMORS ARISING  FROM SIMPLE  INCREASE OF SIZE OF ALREADY EXISTING
                                   TISSUES.

   These tumors differ from simple hypertrophy of the part " in this,  that to
 whatever extent the hypertrophy may proceed, the  overgrown part always main-
 tains itself in normal type of shape and structure, while a tumor is essentially a
 deviation from the normal type of the body in which it grows." (Paget).
   This  section comprises, 1st, tumors connected with  the integumental struc-
 tures, as warts, polypi, &c.; 2d,  lobular hypertrophies, with more  or less modi-
 fication  of glandular structure, as in the breast; 3d, fatty tumors; 4th, vascular
 tumors; 5th, tumors of nerves;  and 6th, tumors of bones.
    1st.  Simple tumors of this kind that develop on the  integumental structures,
 whether cutaneous  or mucous, are warts and condylomata.  These essentially
 consist in an increased deposit of laminated cuticle, usually with some augmented
 vascularity of the cutis.   They exist with especial  frequency  in the mucous,
 the muco-cutaneous, and the more perspirable surfaces; thus the prepuce, the
 vagina,  the axilla, and the cleft  of the nates are their chosen seats.   When oc-
 curring on the skin, they are usually hard and horny where the cuticle is natu-
 rally dry, and then constitute true warts; but where the skin is  perspirable, and
 the cuticle moist, they  are flattened, expanded, soft, and white,  and are then
 termed  condylomata or mucous tubercles.   When situated on the  mucous mem-
 branes,  they are  usually pointed, somewhat pendulous, or  nodulated  on the
 surface, very vascular, and bleed readily when touched.
   Closely allied to  some of these warty structures is a peculiar  pinkish-white
 fibro-vascular tissue, which is  occasionally met with in old cicatrices as  an out- 
394                     INNOCENT TUMORS.
growth  of these,  and not unfrequently recurs after  removal; this  disease is
termed cheloid.
  The general principles of treatment of these affections consist in  their removal
by excision, ligature, or caustics, according to their size, situation, and attach-
ments.  Excision  is usually preferable when they are seated on mucous sur-
faces ;  the ligatures should be used if they are large and pendulous, and caustics
should be employed when they are seated on the skin or a muco-cutaneous
surface.
  Pendulous sarcomatous growths, forming large tumors commonly called "wens,"
may occur on any part of the surface.  They are smooth, pedunculated, firm,
somewhat doughy, but non-elastic, pendulous, and  movable, slowly  increasing
without pain, often  to a very great size.   It is in warm climates, and  in  the
Hindoo and Negro  races, that  they attain their greatest development, having
been met with fifty,  seventy, and even a hundred  pounds in  weight.   They are
chiefly seated about  the genital organs, enveloping the scrotum, penis, and testes
in  the  male, or depending from  the  labia of the  female.   That remarkable
enlargement of the leg occurring in the Mauritius, and some parts of the West
Indies, and hence termed Barbadoes leg, is an affection of this kind.   In  struc-
ture these growths appear to be a simple hypertrophy of the fibro-cellular element
of the part affected, being composed of a loose reddish stroma, moist with a serous
fluid.   In the treatment of these affections, pressure and  iodine applications
may be tried in the earlier stages, with the view,  if possible, of checking their
growth;  at a later period they must, if large, be removed by operation, though
this procedure is at times an extremely severe one, owing to the great  magnitude
they attain.
   Polypi are pendulous masses  growing from any mucous surface, but more espe-
cially  from  the nose, ear,  throat, uterus,  and rectum.  The term  polypus is
applied very indiscriminately to various pendulous tumors growing from mucous
membranes.  The true mucous  or gelatinous polyp is composed of the elements
of this membrane expanded and spread out, and consists of a loose fibrous stroma
covered by epithelium more or less distinctly ciliated, the cilia being often beau-
tifully seen when recent specimens are examined under the microscope.  The
 so-called fibrous or medullary polyp consists of other forms of tumor growing
from,  and  covered  by, mucous  membrane.   The true  mucous polyp  grows
 rapidly, being a soft and vascular reddish-purple or brown-looking  mass, and
 may expand greatly, giving rise  to serious symptoms of obstruction in the passage
in which it is situate, bleeding freely when  touched, destroying the bones by its
 pressure, and producing great mischief and disfigurement.  It is especially in the
 nose and uterus that it  attains  to a large  and dangerous size.  The treatment
 consists in removing it according to its situation, its degree of vascularity, and
 the nature of its attachment, by avulsion, ligature, or excision.
   2d. Hypertrophy of glandular structures. — This forms an important series
 of special affections, chiefly occurring in the lymphatic  glands, the  breast, and
 the testes.  The parts becomes chronically enlarged and indurated,  often with-
 out any signs of inflammatory action,  though in other cases  as the result  of this
 condition.   On examination, the structure of the gland will either be found to
 have undergone an  imperfect  and ill-developed  hypertrophy in some  of its
 lobules, or to be expanded and infiltrated with plastic matter, the consequence
 of chronic inflammation; or else to have undergone tuberculous deposition when
 occurring in strumous subjects.  The principle of treatment in these tumors
 consists  in an endeavor to remove the mass by frictions with the preparations
 of iodine, or by the application  of stimulating and absorbent plasters.  If these
 means fail, methodical  pressure may sometimes  advantageously be  employed,
 and, as a last resource, extirpation by the knife.
    3d.  Fatty tume>rs constitute  an important class of surgical diseases, as they
 occur very extensively in almost every part of the body, and at all ages, though 
FATTY AND FIBRO-CELLULAR TUMORS.        395
they are most commonly met with about the earlier periods of middle life.  In
the majority of cases they appear to  originate without  any evident cause; in
other instances again they can be distinctly traced to pressure or to some local
irritation, as to that of braces or  shoulder-straps  over the back and shoulders.
In  one case I have  known the disease to be hereditarily transmitted to the
members of three generations of a family.
   Fatty accumulations take place  under two  forms, one  diffused, the other cir-
cumscribed ; it is only the latter variety that is termed the  adipose tumor.  The
diffused form of fatty deposition occurs in masses  about the chin or nates with-
out constituting a disease,  though  it may occasion  much disfigurement.
   Fatty or adipose tumors may form in  all parts  of the  body as  soft, indolent,
inelastic, and doughy swellings, growing but very slowly; being either oval or
round,  but not unfrequently lobulated,  and occurring most frequently in the
subcutaneous fat about  the neck and shoulders; but  occasionally met with
between the muscles, in  the neighborhood of joints, of serous membranes, as of
the  pleura, and of mucous canals.  A  very  curious  circumstance  connected
with these tumors is that they occasionally shift  their seat, slowly gliding for
some distance from the original spot on which they grew; thus, Paget relates
cases in which fatty tumors shifted their position from the  groin  to the  peri-
neum  or the thigh.   I have known  one descend from the shoulder on  to the
breast.
   They may attain a large size, but only occasion  inconvenience by their pres-
sure or bulk; they rarely ulcerate or inflame,  nor  do they  undergo any ulterior
changes of structure.
   These fatty growths have  been divided into  three varieties,  according  to
their structural differences.  The most common form of fatty tumor, that called
lipetma, is  a mass of  yellow, oily, fatty matter and cellular tissue, inclosed in  a
fine thin capsule, having small vessels  ramifying over its surface.  This tumor
is usually  more or less lobulated, often  remarkably dentated, and  sending out
irregular prolongations that extend to some little distance  into the surrounding
cellulo-adipose tissue.  Another variety, the cholesteatoma of  Muller, is of much
less  frequent occurrence;  it  is a smooth, laminated, white and dry fatty mass,
contained  in a cyst,  and apparently composed of crystalline fat inclosed in
meshes of cellular tissue.   The third  variety  of fatty tumor consists of masses
occurring in the ovary, or in multilocular cysts in other situations.
   In the treatment of fatty tumors little can be done except  by extirpation with
the knife, by which the patient is speedily and effectually ridded of the  disease.
The tumor being encapsuled and but loosely adherent  to adjacent parts, readily
turns out  and the wound often heals by the first intention.  It is true  that we
have the sanction of Sir B. Brodie's high authority for the administration of the
liquor  potassae in some  of these  cases,  under which treatment this eminent
surgeon states that fatty tumors have occasionally  disappeared.
   Fibro-cellular tumor. — This growth,  described  cursorily by many writers as
the cellular tumor, has been more fully examined by Paget.  It is not of  com-
mon occurrence, and  when met with it is most frequently found in the scrotum,
the  labium, the deep muscular interspaces of the thigh,  and on the scalp, in
which situations it may form tolerable  large  masses, attaining sometimes to  a
weight  of many pounds.   When occurring about the scrotum and labium, these
tumors  must not be  confounded with  elephantiasis of these parts, from which
they may be distinguished by being limited and circumscribed masses, and not
mere outgrowths.  They  happen  only  in adults  who otherwise are in  good
health,  and grow quickly,  forming soft,  elastic, rounded, and smooth tumors;
they are not attended by any pain.   After removal they are found to possess  a
thin  capsule, to be of a yellowish color, and to  contain  a  large  quantity of
infiltrated serous fluid, which may be  squeezed  out abundantly.   As  these 
396
INNOCENT TUMORS.
tumors are of a perfectly innocent character, no hesitation need be entertained
about their removal.
  4th. Tumors dependent on an increase of the vascular tissue, as aneurism by
anastomosis, — of the nervous tissue,  as some kinds of neuromata, — and of
osseous tissue as exostoses, and never extending beyond  the structure primarily
implicated, constitute such special affections,  that it will  be more convenient to
reserve their consideration until we come to speak of the particular diseases of
the structures to which they belong;  and it will be sufficient for the present to
indicate  their existence as pertaining  to this group.

III. — TUMORS  DEPENDING ON THE NEW  GROWTH  OF  STRUCTURES IDENTICAL WITH, OR
   VERY CLOSELY RESEMBLING,  NORMAL TISSUES IN SITUATIONS WHERE TUEY ARE NOT
  NORMALLY FOUND.
   This class  is an important one, inasmuch as  it contains  not  only  innocent
growths, but some that are  of  a semi-malignant character.   The fibrous, the
fibro-plastic, and the enchondromatous tumors  are  those that are chiefly met
with in it.
   1st. Fibrous tumors. — These growths are by no means so common as many
of the affections that have already been described;  they are met with in various
situations, as in the testes and mamma, uterus and antrum, about joints, in the
periosteum, in the subcutaneous cellular tissue, and  in  connection with nerves.
The situations in which they are most frequent, and where their structure is
                                          and this  is the condition in which
they are often presented to the surgeon.   Eventually, however, they are apt to
undergo disintegration, becoming  infiltrated, cedematous, and  softening in the
centre, or at various points of the  circumference;  they then break down into a
semi-fluid mass, the integuments covering them inflame, slough, and an unhealthy
suppuration mixed with  disorganized  portions of the tumor is poured out,
leaving a large and unhealthy slough  chasm  from  which fungous sprouts may
shoot up: readily bleeding on the  slightest touch and giving  the part a malig-
nant appearance; the patient eventually falling into a cachectic condition, and
becoming exhausted by the hemorrhage and  discharges.  In other cases again,
these tumors may degenerate into a spongy calcareous mass  of a brownish color
and hard consistence;  but they never undergo proper ossification.   More rarely 
SEMI-MALIGNANT TUMORS.                397
the interior of these growths softens and undergoes absorption, so as occasionally
to form cysts of large size, containing fluids of various shades of color.   Paget
relates the case  of a very large cyst of this kind formed by the hollowing out
of a fibrous tumor of the uterus being twice  tapped by mistake  for  ovarian
dropsy.  The treatment of these  tumors is in a great measure palliative, but
when so situated as to admit of removal, as in the neck, under the angle of the
 jaw, or in the antrum, they should always be extirpated.
   2d.  The next class of tumors, though closely resembling the fibroid in struc-
 ture, have a great tendency to recur after removal, to disintegrate and contami-
 nate neighboring parts and even the system at large.  They are in their appear-
 ance innocent, but in  their course malignant.  This class comprises the so-called
 semi-malignant tumors, viz., the  malignant fibrous,  the recurring fibroid, the
 fibro-plastic, and the enchondromatous  tumors.
   The malignant fibrous tumor closely  resembles in  its general  appearance and
 microscopic elements the ordinary fibrous growths, but its great characteristic is
 its recurrence after removal, with much tendency to ulceration, sloughing, and
 hemorrhage, forming not only in  its original  locality, but  in internal parts of
 the body at a distance from it.
   The fibroplastic or  myeloid tumor  was first  described by Lebert, and has
 been  investigated by Paget, who  finds it to stand intermediate in structure
 between the  fibrous and fibro-cellular, resembling pretty closely that of granu-
 lation-cells  in  the  process of development  into  fibro-cellular tissue,  having
 parallel fibres with wide fibro-plastic cells, and occasional  oat-shaped nuclei.   It
 is found about the jaws, in the bones, in the cellular tissue of the neck, and in
 the mammary gland.
   These tumors, the albuminous sarcoma of Abernethy, present marked cha-
 racters.   On  making a section  of them  they  cut  in a uniform, smooth, and
 somewhat elastic manner; are semi-transparent, shiny,  and juicy-looking, of
 a greenish-grey, bluish or pinkish color, often spotted  or stained with dis-
 colored  marks,  varying  in  tint from a blood to a  pinkish, brownish,  or livid
 red hue, which, if extensive, gives them a fleshy look; their structure is usually
 brittle.   They most commonly occur in young people, without pain  and without
 any known cause.  In the majority of  cases they may be safely removed with-
 out the  prospect of recurrence, but  occasionally,  and  without any apparent
 reason, they return after removal.  Lebert relates six cases of this disease in
 which recurrence took place after operation, with secondary deposits in  internal
 organs.
    The recurring fibroid tumor has been described  by Paget as closely resem-
 bling in general aspect the common  fibrous tumor, whilst  in  its  microscopic
 structure it is very like the fibro-plastic tumor, its most marked character being
 its tendency to recur after removal.  Of this peculiar and hitherto undescribed
 disease, he relates two cases, one a tumor of the upper part of the  leg, which,
 between 1846 and the end of 1848; had been removed five times, re-appearing
 for the sixth time after the  last operation, when,  attaining a large size, and
 becoming ulcerated, amputation was  deemed advisable; this  operation, how-
 ever,  was followed by death.  The examination of this  tumor presented " very
 narrow, elongated, caudate, and oat-shaped nucleated cells, many of which had
 long  and subdivided terminal processes."  In the second case, a tumor of the
 shoulder had  been removed, and  returned four times between  May, 1848, and
 December, 1849, re-appearing in  the  following year for the  fifth time,  the
 patient, notwithstanding, appearing at  this period  to be a strong and healthy
 man.   He also relates a case by  Gluge, in which a similar tumor was five times
 removed from the scapula, its sixth re-appearance being followed by death.  The
 most  interesting of all,  perhaps, is a case by Dr. Maclagan, in which, after three
 removals, no further recurrence  of the disease  took place.  It is a remarkable
 circumstance that these recurrent tumors appear, according to Paget, to become 
398
INNOCENT TUMORS.
more malignant in their growth in the later than in the earlier recurrences, ac-
quiring more and more the characters of true malignant disease, becoming more
painful, rapidly  degenerating, and giving  rise to an ulcerating  fungus, which
eventually proves fatal by exhaustion and hemorrhage.
  3d.  Enchondroma, or  the cartilaginous tumor, carefully studied  by Miiller,
and investigated by Paget, is an exceedingly interesting affection, whether we
regard  the peculiarity of its structure, its comparatively frequent occurrence,
or the large size that  it occasionally assumes.   It takes place under two distinct
forms; most commonly as an innocent growth, but in  other cases assuming a
malignant tendency and appearance.   These two forms present different signs;
in the first case, the echondroma occurs as a hard, smooth, elastic, ovoid, round,
or flattened tumor, of small, or but of moderate size, seldom exceeding that of
an orange, and growing slowly without pain.   In the second  form, it approaches
in its characters to malignant disease, growing with extreme rapidity, attaining
an enormous size in a few months, and contaminating the system  by the deposit
of secondary echondromatous growths in internal organs; under these circum-
stances, it would appear to  have occasionally been mistaken for the rapidly
spreading forms of encephaloid disease.
   But although occasionally assuming the course  that is  usually adopted by
true malignant  growths only, it must  be borne in mind that enchondromata,
especially of the testes, are not unfrequently associated with encephaloid; and
when so,  the secondary deposits are usually of the latter character only, although
in some rare cases even these have been found of a mixed nature.
   When  these growths attain a tolerably large size, though  occasionally whilst
they are still of but moderate dimensions, ossification may occur  in some parts;
whilst a process of disintegration may take place in others, they soften, break
down, and  liquefy in their  interior, causing  the  skin  which covers them  to
become duskily inflamed, eventually to slough, and to  form fistulous openings,
through which a thin jelly-like matter is discharged.  In some  cases it would
appear that large  tumors of this description, softening in  the centre, and
becoming elastic and semi-fluctuating, have been  mistaken  for cysts, and have
been tapped on this supposition.  In small enchondromata the opposite condition
more   frequently  occurs,  the  tumor  becoming  indurated,  and  undergoing
ossification.
   The accompanying cut is a good illustration of the microscopical characters
                                          of  these tumors (fig.  145).   It
                                          shows a clear matrix, in places thinly
                                          granular, in others slightly fibrous,
                                          imbedded  in which  are  cells and
                                          nuclei of various forms  and sizes,
                                          some round or irregularly oval, from
                                          5«jo-th  to  gjjotii  of an  inch  in
                                          diameter.  Many are branched  or
                                          caudate; some  of  the  spheroidal
                                          cells   are  granular, others have
                                          nuclei  of  irregular  outline; inter-
                                          spersed among  them are  a few oil
                                          globules.  The general appearance
is that of foetal cartilage, from which it can with difficulty be distinguished.
   Most frequently enchondroma occurs in connection with some of  the short
bones, more particularly those  of the  metacarpus  and  the phalanges of the
fingers, presenting hard rounded knobs in these situations, where, however, it
seldom attains  a greater magnitude than a walnut or a pigeon's egg.  When
 large, it is commonly met with in or upon the head of the tibia, or the condyles
 of the femur, forming in these situations rapidly increasing growths of consi-
 derable magnitude.  It may also form in the parotid  region, in the muscular
 
ENCHONDROMA. — CANCER.
399
interspaces of the neck, thigh and  leg, and in  the testes.  When connected
with the  bones, enchondroma  may either
spring from  the periosteum, gradually en
veloping, absorbing, and eventually  destroy-
ing, the osseous structures, though at first
not incorporated with them.  This  is  their
usual mode of origin when  occurring in the
femur or tibia:  when seated on the short
bones, especially on the metacarpus and pha-
langes  (figs. 146,  147),  they  commonly
spring from the interior of the osseous struc-
ture,  expanding, absorbing, and involving
its walls in the general mass of the' tumor.
When occurring in cellular regions uncon-
nected with bone, the enchondroma is softer,
and does not present such  distinct cartilage
cells as in the osseous enchondroma.  Most frequently these enchondromatous
masses occur in  childhood, or shortly after puberty, appearing as it were to be
an overgrowth of the cartilaginous element of  the osseous system at this period
of life.
  The treatment consists either in excision of  the tumor, or amputation  of the
affected part.  Excision may  be practised when the tumor is seated  in the
parotid region, or otherwise  uncon-
nected with bone.   When forming                 Fig. 147.
a part of the osseous  structures, it
cannot well be  got  rid  of  without
the removal of the bone that it  im-
plicates by amputation.   If, under
these circumstances, excision of the
tumor only be attempted, it will be
found that the whole mass  cannot
be  removed, and  that  it  rapidly
grows again, or that  the  wound
formed by the operation   remains
fistulous  and  open.   Most  com-
monly a permanent  cure is effected
by the ablation of the tumor in  one
or  other of these ways,  but cases have occurred of the more rapidly growing
 form of the  disease recurring, after its removal, in a softer  state than before,
 and with a close approximation to malignancy  in appearance  and action.   It is
 worthy of remark, as showing the connection  between enchondroma and malig-
 nant disease, that  cartilaginous masses have  been met with in the midst of
 encephaloid tumors of the  bones and testes.

                                 CANCER.1

   Having now considered  innocent tumors, that have no tendency to contami-
nate neighboring structures, or to return after  removal; and the semi-malignant,
which, though innocent in  structure, are malignant in their  course, and, under
  1 It is not my intention to enter largely into the general history of malignant  diseases,
as space will not admit of my  doing so;  I would therefore refer my  readers who wish for
further information on this interesting subject to the works of  Abernethy; the papers by
Lawrence;  the admirable  and magnificent " Illustrations of  the Elementary Forms of
Disease," by Sir R. Carswell;  to the excellent  and copious monograph by Dr. Walshe;
and to Mr. Paget's philosophic Lectures on this subject.  In these  different sources will
be found nearly all the information at present possessed by the profession on the import-
ant and interesting subject of  Cancer.
Fig.  146.
 
400                             CANCER.

certain obscure conditions, local  or constitutional, as yet undetermined, have a
disposition to recur after operation; we next proceed 'to the study of that form
of malignant growth which has, as it were, a natural and constant tendency to
affect the system, to  implicate neighboring structures, and to return in its  ori-
ginal site, or at a distance from it, after extirpation.
   Cancer differs  from all normal structures by being distinctly and essentially a
new product,  never, under any circumstances, existing in  a healthy system, and
possessing vital properties  and an organization that is peculiar to itself.  Cancer
presents itself in four  if not five varieties,  which  differ  so much from  one
another  in  appearance,  in rapidity of  growth, in  consistence, color, and struc-
ture, as at first sight  almost to appear to constitute essentially different diseases,
but yet having so close a family resemblance,  and  presenting so many points of
identity, that, physiologically and  pathologically speaking, they must be consi-
dered as mere varieties of the same  class  of  tumors.  The varieties of cancer
generally admitted are the scirrhus, or  the  hard cancer; encephaloid, or the soft
cancer;  colloid, or gelatinous cancer; melanosis, or the black cancer.
   We meet with cancer, in one or  other of these forms, usually the encephaloid,
associated with some of  the normal constituents of the body.  With cartilage,
as chondroid; with  bone, as osteoid;  with an erectile  vascular structure, as
aneurismal;  and with  epithelial  cells, as epithelial  cancer.   Other varieties
of cancer are met with,  deriving their  distinctive characters from some pecu-
liarity of structure.   Thus, when  cysts are largely developed in the substance
or in the surface of the  growth, we have cystic cancer;  and when the  surface
assumes a dendritic and papillated character,  the form of the disease is termed
villous.
   These  various  forms  of cancer differ from one another in  appearance and
consistence;  the scirrhus being hard, firm,  semi-transparent, of a bluish  or
greyish  color;  the  encephaloid  being  brain-like  in  appearance,  soft, and
hemorrhagic; the colloid resembling glue,  or honey in its comb; the melanosis
being black,  sometimes  solid, at others liquid; and  the  epithelial form occur-
ring  as  nodules  or  ulcers, presenting  peculiar characters.   They vary also in
the  rapidity  of their growth, in their vascularity,  and in the order  of their
malignancy, in all of which respects  they may be  arranged as follows:  1st.
Encephaloid; 2d. Scirrhus;  3d.  Melanosis; 4th.  Colloid;  5th. Epithelial
cancer.
   Great as the differences amongst them are, however, the points of resemblance
are still more striking; thus,  one form  of cancer may take the place of another,
or be associated with it; encephaloid occurring after the removal of scirrhus,
or being associated  with  melanosis; or colloid and scirrhus being met with
together in  the  same tumor.   This identity  of seat and of recurrence, which
tends more  than anything else to establish  a  common  origin amongst these
tumors, has been specially pointed out  by Carswell.  Then, again, these tumors
are all of a truly malignant  character, having a tendency to induce a peculiar
and similar condition of system that goes by the name of the cancerous cachexy.
In chemical  composition, also, they are all very nearly identical, being princi-
pally composed of albumen.
   The microscopic characters of the different forms of cancer have of late years
attracted considerable attention amongst pathologists.  They  consist, in all  the
varieties, essentially of the same elements, though these may differ somewhat
in appearance and  in  relative  preponderance, in the  different  forms of  the
affection.  In all there  is  a fibrous stroma or basis, firmer  and closer  in some,
as in  scirrhus, than in the  others.    This yields, by scraping or pressure, a
turbid'fluid  termed the cancer juice, in which granules, cells,  pigmentary  and
fatty matters, are found in varying proportion. The granules, which are minute,
sometimes amorphous, at  others presenting that  peculiar  vibratory condition
termed the molecular movement,  are  met with  in all the  varieties of cancer, 
VARIETIES OF  CANCER.                   401
though  they occur in  largest quantity in  scirrhus.  The cells to which great
importance has been attached by various observers, and which have often been
looked upon as characteristic, or pathognomonic, of the disease, though  erro-
neously so in the strict acceptation of the term, present, however, such peculiar
characters, that  it is  almost  impossible  to  mistake them.   They  are large,
spherical, fusiform  or spindle-shaped,  elliptic or caudate, having often two or
three terminations, are usually com-
pound,  granular,  have large nuclei,
and  prominent, well-marked nucleoli
(fig. 148).  These various appearances
are presented by them in all forms of
the  disease;  it  is,  however,  more
especially in the encephaloid variety
that they  assume  a  large  size, and
present their most marked fusiform
and caudate shapes (fig. 149).  The
pigmentary cells are  principally, if
not altogether, found in  melanosis.
   Much diversity of opinion  exists  Cells from Scirrhus of Breast (rapidly recurring).
amongst surgeons as to the value that
should  be attached to these microscopic  signs in determining the true nature
of many tumors; some being guided by these appearances alone, others looking
upon them as uncertain  and fallacious, and  trusting rather to the general cha-
racters  of the  growth.   The latter, however, appears to me to be too limited  a
view of the subject,  for
although the unaided eye
of an experienced surgeon
may in many cases recog-
nize  the true  character
of a tumor, and the mi-
croscope in  some few in-
stances fail  to  reveal it,
yet there can be no doubt
that, in many cases, it is
 only by the aid of  this
 instrument that the real
 nature of the growth can
 be determined.
   It is doubtless true that
 every one  of  these  mi-
 croscopic  elements  may
 separately  occur  in  the
 normal tissues  and secre-
 tions of the body, some
 in  those  of  the adult,
 others,  as  the  caudate
 and  fusiform corpuscles,
 in the embryo; but though
 this be the case,  it does
 not appear that they are
Fig. 149.
Cells from Encephaloid of Tongue (rapidly growing).
ever found in any tumors except those of a  cancerous nature; and in these it
is  rather by the  aggregation  of these  appearances, than by any single one in
particular, that the true character of the disease is determined.  In these exa-
minations,  however, the  experienced  surgeon will  find  that  the  appearances
presented  to the  naked  eye will assist him much  in pronouncing  upon  the
malignant or  cancerous character of the tumor.  It is certainly a remarkable
       26 
402
CANCER.
circumstance, that the "recurring," or semi-malignant diseases, as well as those
that are truly cancerous or positively malignant, present, under the microscope,
structures that closely resemble those  of  tissues  in process  of development,
either in form of imperfect exudative matter and fibro-cellular tissue,  as in the
fibro-plastic  tumors, or in the similarity presented by the corpuscles of encepha-
loid to some of those of the soft tissues in the embryo.
   The general characters  that  attend  the  progress of these several  forms of
cancer present  numerous   points  of resemblance.  When once formed,  the
tumor continues progressively to  increase  in  size with  a degree of rapidity,
and to an  extent, that varies  according to its kind;  the  scirrhous  tumors
growing  most slowly, and  attaining but moderate dimensions;  the  encepha-
loid and  colloid often with great rapidity, and  to an immense size.  When the
full growth of the tumor  is attained, the  process  of decay commences.  The
mass softens at some  point, the  skin covering which becomes duskily inflamed
and  ulcerated,  an irregular  sloughy  aperture  forming,  through  which  the
debris of the mass are eliminated in an ichorous or sanious fluid, having often
a  peculiar fetid  smell.  The ulcer then pretty rapidly increases, with everted
edges, a  hard and knobby  or soft  and  fungating surface,  and the discharge of
a  dark fluid, often attended by hemorrhage,  and occasionally with sloughing
of portions  of the mass.    Coincident with  the  implication and ulceration of
the skin, there is usually deposit in the lymphatic  glands, with great increase
of pain,  and most  commonly  with the  supervention of the constitutional
cachexy; though in  some  cases this condition  precedes  the cutaneous impli-
cation.  This cachexy appears to be the  result of the admixture of cancer germs
with the blood,  and  their circulation  through  the  body;  or to  some other
modification in the condition of the blood, induced by the action of this growth
on the economy.  The  exhaustion resulting  from  the ulceration, sloughing,
and  consecutive  hemorrhage, also commonly increases  this  cachectic state;
in many instances it  is not marked until after the skin has become affected, and
in others it does not supervene  until  ulceration  is actually set up.   In this
cachexy  the countenance  is  peculiarly pale,  drawn, and sallow, so that the
patient has  a very anxious and care-worn look.  The  general surface of the
body commonly  acquires  an  earthy  or yellowish  tint,  and  not unfrequently
large spots  of pityriasis or chloasma make their  appearance  on various  parts
of it;  the appetite  is impaired,  the voice enfeebled,  the muscular  strength
greatly diminished, and the pulse weak.   The  patient complains  of pains in
the limbs, of lassitude, and of inability for  exertion; he emaciates rapidly, and
frequently suffers by the occurrence  of cancerous  deposits in  internal organs;
and at last  dies  from exhaustion, induced by the  conjoined effects of weakening
discharges,  general debility, and pain.
    These general characters, however,  present certain varieties of  importance,
according to the form of cancer that is developed.
    The scirrhus, or hard  cancer,   is  most  commonly met with in the breast
and lymphatic glands.  It occurs in  two forms, either as a circumscribed mass,
or infiltrated in the tissue  of an organ.   In either  case it  forms a hard, craggy.
incompressible,  and  nodulated tumor, at first movable  and  unconnected  with
the skin, but soon  acquiring  deep-seated attachments,  and  implicating the
integument.  It grows slowly,  seldom  attaining a larger size than an orange.
It is painful, aching  generally, at  times with much radiating and shooting pain
through  it; these sensations vary according  to the part affected, and to the
sensibility of the individual; the  pains are especially severe  after the tumor
has been handled, and at  night are of a lancinating, neuralgic character.  It
may thus continue in a chronic state for a considerable length of time, slowly
increasing,  gradually extending its deeper prolongations and implicating the
more superficial parts.  In some  cases, more particularly in elderly people,
scirrhus  gives  rise  to atrophy of the organ in  which  it  is seated, causing 
SCIRRHUS.
403
wrinkling and puckering of the surrounding skin, which becomes adherent to
the tumor, which may thus continue in a very chronic state.
  The ulceration usually takes place  by the skin becoming adherent at one
point to the tumor either by dimpling in, being as it were drawn down towards
it, or else by being pushed forwards, stretched and implicated in one of its more
prominent  masses;  it then becomes of a dusky and livid red, somewhat glazed,
and covered by a fine vascular net-work.   Softening occurs at one point, where
a crack or fissure  forms; a clear, gummy drop of fluid exudes  from this, and
dries in a small scab upon the surface; this is  followed by a somewhat bloody
discharge of a thick and glutinous character; and the small patch of  skin from
which it issues becoming undermined, speedily sloughs away, leaving a circular
ulcer.   This gradually enlarges,  becoming ragged and  sloughy, with craggy
everted edges, having irregular masses arising from its surface, and discharging
a fetid sanious pus.   The pain increases greatly,  and the  lymphatic  glands  be-
coming involved the cachexy is fully developed, and the patient is destroyed by
it,  or by the secondary visceral deposits.   In old people, ulceration of scirrhous
masses often assumes an extremely chronic  character, the growth in  them  not
being endued  with the same vitality as in the young.  The ulcer in these cases
is flat, sloughy, of a greyish-green color, hard and rugged, with puckered edges,
much  wrinkling  of the surrounding skin, and exhaling  the  usual fetid odor.
In younger persons, and especially in stout women with florid complexions, this
disease usually makes rapid progress.   So also, if inflammation  be accidentally
set up in the neighboring tissues, cancerous infiltration takes place in them, in
consequence probably of the products of  inflammation effused around  the tumor
undergoing cancerous transformation  almost as soon as deposited.   I  had  lately
under my care an old man with a cancerous tumor of the leg, which, after re-
maining stationary for seven years, became  accidentally inflamed, and has since
then increased with very great rapidity.  Occasionally, but very rarely, scirrhous
masses slough out, leaving a large ragged cavity,  which may even cicatrize, and
thus a spontaneous cure has  been known  to  have occurred.   The  cancerous
infiltration will extend to a considerable distance  around the tumor into integu-
ment that to the naked eye appears quite healthy, but which with  the  micro-
scope will afford unequivocal evidence of the existence of cancer germs diffused
through it.  The  cancer infiltration  extends  like  a  halo around the original
tumor, and very probably shades  off into the  surrounding  textures.   It is of
 great importance in determining the question of operation to bear this in mind,
 and not to act on  the supposition of the tumor  being distinctly and abruptly
 defined.
    The secondary deposits from scirrhous tumors may take place in the viscera,
 or the lymphatic glands; in  the former situation, they are usually of an  en-
 cephaloid character, in the latter they assume the scirrhous form.
    After a scirrhous  tumor has been removed, though still  feeling firm under
 the fingers, it is not so hard as when it was in  the body, owing, as Dr. Walshe
 observes, to the escape of its  fluids and  consequent loss of turgescence.   On
 cutting it with a scalpel it usually creaks somewhat as it is divided, and pre-
sents a whitish or  bluish-white glistening surface, intersected by white  bands,
which  apparently  consist  partly  of new structure, partly of included cellular
tissue.  This section has not inaptly been compared to the appearance presented
by a cut through a turnip or an unripe pear, hence  termed  napiform and api-
noid by Walshe; and from its reticulated  character, carcinoma reticulare, by
Muller.  On examining the fibrous stroma,  or net-work,  which forms the basis
of  the tumor, it will  be found to be composed of fibrous or fibro-cellular tissue.
The soft greyish-blue granular material seated in the meshes of this, may be
squeezed or scraped off in a liquid state as cancer-juice.   This is composed of a
multitude  of nucleated corpuscles, granules, granular cells, and  globular, cau-
date, or spindle-shaped bodies. 
404
CANCER.
  The encephaloid or soft  cancer, or, as it is often termed, medullary sarcoma,
is the most malignant and  rapidly-growing form of this disease.  It is met with
in the globe of the eye, in the nares or other cavities of the  face, in  the arti-
cular ends of bones, the testes, and the  breast, and often attains  an enormous
size, equal to that of an  adult  head, or of half the body.   It occurs in two
stages, either as a tumor, encysted or infiltrated, or as a fungus after protrusion
through the skin.
   It commences as a tumor, which, though  occasionally somewhat hard, is usu-
ally from  the first, or at all events soon becomes, soft and elastic, being more or
less lobulated, growing rapidly, and having a  semi-fluctuating feel.   The skin
covering it is at first pale and loose, with a large net-work of blue dilated veins
spreading over it.   As  the tumor enlarges, the skin becomes adherent, disco-
lored, of a purple-brown tint, and at  last  ulcerates  at one point; from this a
large fungous  mass, rugged,  irregular, dark-colored,  and bleeding profusely,
rapidly sprouts  forth, constituting the affection  to which Mr. Hey gave the
appropriate  term  of fungus hsematodes;  when once  this condition has been
reached death rapidly ensues from exhaustion and hemorrhage.  Pulsation has
been  met with in  particular forms of  very  vascular encephaloid;  in these
cases also a loud bruit has been detected that may be heard on the application
of a stethoscope, synchronous with the pulsation and the heart's action.  These
symptoms have been most  frequently met with in encephaloid  tumors connected
with  bones, and may, unless  care be taken, cause  the  disease to be confounded
with aneurism.
   The constitutional cachexy in  encephaloid occurs  early, and is well marked,
and secondary affections of the lymphatic glands and viscera  often  take place,
occasionally of a scirrhous character.
   After removal the tumor is found to be very vascular, displaying on injection
a close net-work of vessels.   On a section  being made, it commonly presents a
soft pulpy  white  mass, closely  resembling  cerebral substance, stained  and
blotched with bloody patches, varying  in color  from a bright red to a maroon-
brown, and  dependent on blood that has been  infiltrated  into its substance.  In
other  cases again, its  section  has been compared to  that of a raw potato or a
piece of boiled  udder.   On closer examination  its tissue will be  found to con-
sist of a  stroma of delicate fibres supporting the soft medullary or brain-like
structure; this may be seen to be composed in a great measure of  large quan-
tities  of  corpuscles, nucleated,  compound, and  granular, fusiform, angular,
clubbed, or caudate, often  with two terminations.
   The colloid, gelatinous, or alveolar cancer, may occur in distinct masses, often
of  very large size, or be infiltrated in the tissue  of organs; as it  is most com-
monly met with in the viscera, it does  not so often  fall  under the  observation
of  the surgeon as the other varieties of cancer.  Yet  it may  form superficially,
as is shown  by a preparation in the University College Museum of  a  scirrhous
breast containing colloid.
   In structure it consists  of cells  filled with a clear semi-transparent yellowish
gelatinous or honey-like material, resembling indeed exactly the structure  of  a
honey-comb.  The septa forming these cells are distinctly fibrous,  and regular
in their arrangement.   The gelatinous matter contains  caudate  and nucleated
cells in considerable quantity, presenting the  same characters as  those  of the
other varieties of  cancer.
   Melanosis or black cancer, has been specially studied by Sir Robert Carswell,
who arranged it under  the heads of punctiform  melanosis, in which the dark
pigmentary matter occurs in the  shape  of minute points or dots scattered over  a
considerable extent of surface.   The tuberiform melanosis, occurring in  tumors
which vary in bulk from a millet-seed  to an egg or an orange, always  assuming
a  globular,  ovoid, or lobulated shape,  and being principally met with  in  the
cellulo-adipose tissue, or on the surface  of serous  membranes.  The stratiform 
ENCEPHALOID.
405
and liquiform melanosis, which take place principally upon serous membranes,
or in accidental cavities where  the black pigmentary matter looks not unlike
Indian ink.   Melanosis most frequently presents itself to  the surgeon in con-
nection with the eye, occasionally in the skin and subcutaneous cellular tissues,
and rarely in the bones.  It resembles somewhat  in  its general progress and
characters the  encephaloid form  of cancer, ulcerating and  throwing out dark
fungous masses; occasionally indeed, as Carswell has pointed out, it is distinctly
associated with the other varieties of this disease.  In microscopic structure it
somewhat resembles encephaloid, consisting of a stroma, with caudate, granular,
and compound  cells, but containing a large quantity of pigmentary matter in
granules, molecules, and masses.
   The  diagnosis of the different forms  of cancer is not always easily made.
Scirrhus when in tumor may very readily be confounded with  fibrous tumors
and various  chronic glandular masses, or with the indurated atrophy of a part;
in many of  which cases indeed the diagnosis cannot be correctly effected until
after removal.  In other cases, however, the rugged feel, the lancinating pains,
the tendency to the implication of the lymphatics, or to affection of the general
health, will  commonly  serve to establish the diagnosis.   When ulcerated,  the
previous condition of the tumor, the  general character  of the  sore,  and  the
microscopic  examination of the debris, may serve to establish its true character.
   Encephaloid in tumor, may be confounded with abscess, cysts, fatty, erectile,
and sanguineous tumors; and when pulsating, with aneurism.   In  these cases
careful palpation, the existence of elasticity, without fluctuation, and the presence
of the large and tortuous veins  ramifying over the surface of the mass, may
establish its true character. When it is fungating, it might be confounded with
the sprouting intra-cystic growths, that sometimes spring from the interior of a
cystic  tumor.  Here however a microscopic  examination of the debris, as well
as the existence or not  of contamination of neighboring lymphatics, will estab-
lish the true nature of  the affection.
   The  causes of cancer are often exceedingly obscure.   In many cases it  un-
doubtedly is of an hereditary character, Velpeau says, in  more  than one-third
of the patients he has met with, not that the disease itself is  existent at birth,
but that the tendency to it is connate; that tendency manifesting itself at those
periods of life and in those organs in which cancer usually develops itself.  It
may, however, actually be a congenital affection; thus it has been met with in
the eye at birth, and in the Museum  of University College, is a preparation of
a small melanotic tumor existing  in the  cerebellum  of  a  child that only lived
three days after birth.   It  may occur  at all periods  of life from the  earliest
ages;  and  will evince  itself in  persons from eighty to  ninety years of age.
According to Dr. Walshe,  the mortality from cancer goes  on steadily increasing
till the eightieth year; hence the popular belief that the middle  period of  life
is most obnoxious to it, would appear  to  be an erroneous one.   All forms of
cancer are not however met with in equal frequency at all ages; the encephaloid
being  the most common  in  the  young, and  scirrhus in the  middle-aged and
elderly.  Colloid rarely occurs before  the age of thirty.   Cancer often appears
without any exciting cause, when it is evidently, as in hereditary and connate
cases,  the result of some peculiar constitutional condition,  the nature of which
is altogether unknown  to  us, but under the influence  of which the  peculiar
growth characterizing  it springs up.   In many cases, however, it can  be dis-
tinctly  traced to some exciting cause, being immediately occasioned by a blow,
injury, or other violence, or by  a  long-continued irritation of the part, that
eventually becomes affected; thus in  women a blow on  the breast  often  gives
rise to cancer, and the irritation of a broken tooth may occasion it in the tongue.
It is a  question whether external causes of this kind can give rise to  the pro-
duction of cancer without the previous existence of constitutional predisposition
to the disease.  That cancer even  when apparently excited by local causes, may 
406
CANCER.
in reality be of constitutional origin, cannot admit of a doubt; more especially
in those  cases in which it is  hereditary, or in which  it makes its  appearance
almost simultaneously in different  parts of the  body with a  strongly marked
cachexy.   But in many other instances it certainly appears to  be strictly local
in its origin,  as when it slowly occurs after the infliction of some violence, and
without  any  evidence of constitutional  disturbance or contamination.  Velpeau
truly observes, that those organs which are most exposed  to  external irritation
and  violence, are most liable to  cancer.   It is impossible to look  upon those
cancers as  ab initio constitutional, which arise from external causes in an other-
wise healthy individual,  slowly increasing in size without  any tendency to mul-
tiplication  or sign of constitutional cachexy, until  by the implication of the
neighboring lymphatics or glands the cancer  germs have entered  the system.
It is true that it may be argued  that the cancer could not be excited locally  in
these cases, unless a tendency to it already existed in the system.  But this
appears  to  me to be a begging of the whole question; there is no proof of the
existence of  any constitutional  infection at the time of the  occurrence of the
disease,  or until it has existed for a sufficient length of time for the lymphatics
to be affected and the blood to be poisoned; and it certainly appears to  be more
reasonable to look upon the  local disease as the primary affection, occurring
originally in  a healthy constitution, but  after a time infecting  the system gene-
rally, than to regard the mere local  manifestation  as in itself a  proof of the con-
stitutional nature of  the  disease. It is true that we are ignorant of the manner
how a cancer-germ can be produced by the local action of the part in which it
is generated, but we  are as little acquainted with  the essential mode of produc-
tion of an exudation-cell or of a pus-corpuscle, which we know to be the result
of strictly local actions; and it seems to  me  that  the difficulty is in no way
solved, but simply pushed back  a step by the  attempt to  prove that in  all cases
of cancer-formation,  a constitutional cause or predisposition  exists, which im-
presses the cancerous character upon local actions taking place  in such a system.
The cases  in which cancer appears to be primarily and strictly a  local affection,
influencing the constitution secondarily, are by no means  of unfrequent occur-
rence—we commonly see for instance, a woman in perfect  health receive a blow
 upon the breast, which  gives rise to some  passing inconvenience at the time;
after a lapse of some weeks, though still with an unimpaired state of health,
she  notices a small lump of a scirrhous character.   This may continue station-
 ary, or but slowly increase for months or years, and it is not until the lymphatics
 become enlarged, and the glands in the axilla indurated, that the  constitution
 begins to  suffer, and a tendency to secondary deposits to manifest itself.   In
 such cases as these it is in vain to argue that  the cancer could not have sprung
 up unless  there were a constitutional tendency to it.  There  is  in  these cases
 no  evidence  whatever of any affection of the constitution, or of any general
 predisposition to cancerous disease,  until after  sufficient time has  elapsed for the
 germs to be  absorbed, and  the blood to  be poisoned  by them (p.  410).

                      TREATMENT   OP CANCER.

   The treatment of  cancer may be considered to be of a constitutional and of
 a local  character.  All  curative constitutional treatment is,  I believe, utterly
 useless  in cases of cancer, no  constitutional  remedies appearing  to  have  any
 influence on the progress of this disease.  I  am not  acquainted with  any case
 of cancer, either from my own observation, from conversation with other sur-
 geons,  or  from  published statements, that affords satisfactory evidence of any
 internal remedy having cured this disease.  It is true that many so-called cases
 of cancer  have, at various  times, been  stated  to have been cured  by different
 medicines, but it must be borne in  mind, that in  a less advanced state of patho-
 logical  knowledge than exists  at  the  present  day,  almost  all hard  chronic 
TREATMENT  OP  CANCER.
407
tumors were  called scirrhous, and many  intractable  ulcers, cancers; mistakes
which  are not  unfrequently  committed, and  sometimes unavoidably so, even
with the improved means of diagnosis that we at present possess.   Not one of
the many remedies that have been vaunted as  being specific in this disease, and
by which cures have been  stated to have been effected, has obtained the con-
fidence of the profession, or has, on further trial, corresponded in  its effects  to
the statements of those who introduced it.  I therefore  think  it  but waste of
time to discuss the supposed advantage to be derived from hemlock, sangui-
naria, iron, arsenic, and iodine, in  the  treatment of cancer.  But though cura-
tive treatment can effect nothing in these cases, much may be  effected in cases
that do not admit of operation  towards  the alleviation of  the  patient's  suffer-
ings, and perhaps even towards retarding the progress of the disease, by proper
palliative treatment.   With this view, the diet should be mild, nutritious, easy
of digestion, unstimulating, and sufficient to  support the strength under the
wearing influence  of pain  and discharge; and the preparations  of opium, of
conium,  and  hyosciamus, must  be  freely administered in  order to  relieve the
patient's sufferings, and to procure rest.
   The local means are those upon which the surgeon places the greatest reliance
in these affections.  In order to prevent the rapid extension of  the  tumor, it is
of great importance to subdue  all local excitement going on within  and around
it; in  proportion to the amount of action existing in  the part the  disease will
usually extend with rapidity;  any inflammatory condition of the neighboring
tissues being especially prejudicial in this respect.  Hence, under  these circum-
stances,  the occasional application  of a few leeches  will often be of considerable
service.  No counter-irritation, however, ought to  be employed in the vicinity
of the cancerous part, as it only excites action in and  around it, and hastens the
process of ulceration; the skin especially is  apt to  become rapidly infiltrated
by the cancerous disease under it,  if irritated  by the  application of iodine and
other stimulants.  If the tumor be painful, and the  skin  covering it still un-
broken, great relief may be obtained by the application  of belladonna plasters.
In some cases I have found powdered conium spread  on  cotton wadding, useful
in the same way.  As it is of  importance to  prevent, as long as  possible, any
breach of surface, the application  of these sedative plasters and powders should
be persevered in with the view of supporting the integument.   The local appli-
cation of ice, so as to freeze the tumor more or less completely, has been recom-
mended of late years by Dr. J. Arnott; it may, possibly, in some cases retard
the growth or lessen the pain, but there is no  evidence to  show that it can be
considered as a curative agent.
   When the tumor is  ulcerated, the foetor must be diminished by the applica-
tion of weak solutions of the chlorides, to which opiates  may be advantageously
added with a view of lessening the pain.
   Caustics.—The employment of caustics for the  destruction of  cancers is of
old date, and their use has, in all ages and  countries, been resorted to by em-
pirics, who profess to remove, by secret remedies less painful and more  effica-
cious than the  knife,  tumors of a malignant  nature.  As their application, to
use Velpeau's  expression, requires neither a knowledge  of anatomy or of ope-
rative surgery, they have always been  popular with  many who would  hesitate
to use the knife.  In this country, however, they have  never enjoyed any very
extended reputation, and in fact have, perhaps, not been legitimately employed
to the extent that they deserve, especially in  ulcerated and recurrent  cancers,
or in those so situated on the skin and muco-cutaneous surfaces as not to admit
of being very readily or safely extirpated by operation.
   The great objection to the use of caustics has been the  severity and the con-
tinuance of the pain induced by them, lasting not only for hours, but for days
— more intense and prolonged than any occasioned by the knife; and as it is
usually necessary, in  order to  destroy effectually the morbid growth, to repeat 
408
CANCER.
the application of the caustic several times, the suffering is often greater than
the most resolute patient can submit to.
   The chief  argument in  favor  of caustics  is  that when cancers are thus
destroyed they are less liable to  relapse than when  extirpated by  the  knife.
There is, however, no positive evidence in proof of this before the profession;
but it is not improbable that the  chemical action of the  caustics may extend
so widely into neighboring tissues  as  to destroy  or  render unproductive the
cancer cells by which they are infiltrated, and on the development of which the
local  recurrence of the disease depends.  Another advantage urged in favor of
caustics, in the correctness of which Velpeau acquiesces, is, that enlarged lym-
phatic glands are more likely to go down under their use than when the primary
cancer is extirpated by the knife.    Some of the  advocates of the use of caus-
tics in the treatment of cancer  pretend that  the  agent employed  exercises a
specific action on the morbid structure, which is confined to it, and does not
extend to the neighboring healthy tissues.   But this assertion  is entirely des-
titute of foundation.
   The caustics that have been and that are employed in the treatment of cancers
are very various.  They cannot be used indiscriminately,  and consequently  we
must briefly consider them separately.
   1.  The concentrated mineral acids, especially the anhydrous nitric and sul-
phuric, are often advantageously employed.  The concentrated nitric acid may
be usefully applied to small superficial cancerous ulcers; it rapidly destroys the
tissues, and  does not spread too  widely, but it is not potent enough for the
destruction  of tumors.   The glacial sulphuric acid,  rubbed into a black  paste
with  powdered saffron, is the caustic which Velpeau extols as the most efficient
in cancerous tumors, more particularly if of a fungating or bleeding kind.  It
converts the part to which  it is applied  into a  thick, hard, carbonized eschar,
with  but little surrounding inflammation, and as its action is rapid, the pain is
not prolonged.  On the separation of the hard slough, a  healthily granulating
cavity will be left, which cicatrizes rapidly with much contraction.   It also acts
as a hemostatic, rapidly shrivelling and drying up large bleeding and discharging
fungi.
   2.  The caustic alkalies, especially potass and lime, either alone or in combi-
nation,  in the shape of the Vienna paste, or fused into sticks, are very energetic
in their action, but they have the  disadvantage of spreading widely if applied to
a large surface, and by softening or dissolving the parts, giving rise to  a ten-
dency to hemorrhage.   They may, however, be advantageously used to  small
cancers of the face.
   3.  Various mineral salts, more particularly the chlorides  of antimony, zinc,
and bromium, the acid  nitrate of  mercury,  and  the arsenious  acid, are often
employed with much success in the treatment of cancers, ulcers, and growths.
   Of the various chlorides, that of  zinc is the most useful.  This  is applied by
being made into a paste with from one to four parts of flour, moistened with  a
little water.   It must, in  order to act, be  applied to a raw surface.  M. Can-
quoin states that a paste, made of equal parts of the  chloride and  of flour, four
lines in thickness, and applied  for  forty-eight hours, destroys the parts  to  the
depth of one-and-a-half inch.  Where  of less strength and substance, its  action
is proportionately limited.   It may sometimes be used in the form of small sticks,
which are pushed deeply in several directions into the substance of the  part to
be destroyed.   In other cases the tumor may be deeply and rapidly attacked by
applying a layer of the chloride of zinc paste over the whole of its surface.  The
slough produced by this application  is then incised in several directions, until
the parts beneath, to which the caustic has not penetrated, are  reached  by the
incisions so made; pieces  of lint covered with the paste are put into them,  and
afterwards fresh incisions made, until the cauterizing influence  is  extended to
 the bottom  of the tumor, which finally sloughs out in a mass. Of the utility of 
TREATMENT OP  CANCER.
409
 his caustic there can be no doubt, but the chief objection to its use is the inten-
 ity and continuance of the pain occasioned by it.   Mr. L. Parker has suggested
that this may be prevented or lessened by freezing the part.  Landolfi has recom-
mended the use of the chloride of bromium in combination with those of gold
and zinc, but this caustic does not appear to possess any decided advantage over
the simple chloride of zinc, and is objectionable on account of the fumes evolved
during its use.
   Arsenic exercises  a powerful action  upon cancerous growths, and constitutes
the chief ingredient  in many of the secret preparations used by empirics;  it is,
however, a dangerous agent, and excites  great inflammation and pain.  If too
freely used, it may induce poisoning, and not a few deaths have resulted in this
way; it should, accordingly, not be applied to a surface exceeding a shilling in
size at  one time.    The most convenient mode of  applying  it appears to  be
Manec's paste,  composed of  one part of arsenious acid to eight of cinnebar, and
four of burnt sponge, rubbed down to a proper consistence with a little water.
   The sulphate  of zinc, dried, finely levigated, and made into a paste with gly-
cerine, or  an ointment with axunge, has been very strongly recommended by Dr.
Simpson, as one of the most efficient and convenient of all caustics in rodent and
cancerous ulcers.  In action it somewhat resembles the chloride of zinc, but is
less painful.
   The treatment by compression  is a plan that has been alternately greatly ex-
tolled and much depreciated.   It was fully tried at the Middlesex Hospital, by
 Mr. Young, forty years  ago, and  unfavorably reported upon by Sir Charles Bell
 at that  time; it consequently fell into disuse  in this country, but was revived by
 Recamier in France, and  employed largely by him.   Although he published a
 favorable account of this practice, it  made but little progress amongst French
 surgeons, the only one who seems to have used it to any extent being M. Tan-
 chou, who employs  a peculiar topical  medication conjoined with it.   In this
 country the  practice fell  into complete oblivion,  until Dr. Arnott, some  years
 ago, invented a mode of employing pressure by means of an elastic air-cushion;
 since which time it has been pretty extensively employed with varying degrees of
 success.
   In employing pressure, Young principally had recourse to  plasters  and ban-
 dages.  Becamier used amadou  applied  with an  elastic roller;  and Tanchou
 recommends spring pads, under  which small bags or pieces of cotton wadding
 impregnated with various medicinal substances are placed, so as to protect the
 skin and act upon the tumor.   Dr. Arnott's plan consists of pressure exercised
 by a Mackintosh air bag, held in  its  place  by straps, and pressed upon by a
 truss-spring, the pressure exercised by which may be made to vary from two-
 and-a-half to twelve or even sixteen pounds.  These different plans should not
 be employed indiscriminately, but may all be of service in particular cases.   I
 have employed  all  these methods, but have never found any permanent advan-
 tage from any of them.
   The first question that necessarily arises in reference to  the employment  of
 pressure in these cases, is whether it can effect a cure.  This it could only be
 expected  to  do by  producing atrophy and the subsequent absorption of the
 strictly  local forms of cancer.   The only case on record, with any pretension to
 a conclusive character in this respect, is one related by Dr. Walshe, in his excel-
 lent " Treatise on Cancer," of the cure of a tumor of the breast, believed  to be
 cancerous, by compression.   But even this instance I  cannot look upon as by any
 means conclusive; for although no one can entertain a  higher opinion than I do
 of the very remarkable diagnostic  tact possessed  by Dr. Walshe, yet I think
there can  be no doubt in the mind  of any surgeon that it  is absolutely impos-
sible to determine in many cases, by any amount  of diagnostic skill, the true
nature of a chronic tumor of the breast, and that  in fact we constantly see the
most experienced practitioners find after the removal of the tumor that it was 
410
CANCER.
of a different character to what they had previously anticipated.  This difficulty
attaches  to  Dr. Walshe's case, and  I  think that we possess no proof that the
tumor of the breast, which underwent absorption  under the pressure of Dr. Ar-
nott's apparatus, was of a truly cancerous character, and that  it might not have
been a  chronic mammary tumor  or some  similar growth, that we  know will
disappear under this kind of treatment.
  But if compression cannot be shown ever to have cured a cancer,—can it not
retard  the progress or relieve the  sufferings  attendant upon this disease ?  I
believe that in some cases it  may certainly do both, though  in others it  is as
unquestionably injurious.  It appears occasionally to retard the growth of the
tumor, when applied in the early stage, simply by preventing its expansion, and
perhaps by diminishing the supply of blood sent to it by compressing its nutrient
vessels, and by causing absorption  of  surrounding inflammatory infiltration; in
these cases likewise it relieves for a time the pain by lessening the turgescence
of the  part.   In  other  cases, however, I have known  it to act injuriously by
pressing out and diffusing the tumor more widely, appearing to increase the ten-
dency to implication  of neighboring parts, and  occasioning great  suffering.
When the tumor is ulcerated, or if the skin covering it is  inflamed, pressure
cannot be employed with any advantage;  and most commonly irritable, sensitive
patients cannot support the constriction of the chest that it induces.
   Excision.—With regard to the question of removing cancers  by the  knife,
much  difference  of opinion  exists amongst surgeons, for though all  deprecate
indiscriminate recourse to this means in this affection, some go so far as to dis-
pute the propriety of ever operating for this  disease, whilst others restrict the
operation to  certain cases of a favorable character.  These questions are  neces-
sarily of considerable importance,  and  require  attentive consideration.
   The great objection that has been urged against  operating in these cases is,
that cancer being  assumed to be from  the first  a constitutional  affection, it is
useless to remove the local tumor, leaving the  constitutional vice (p. 406).  For
such an argument as this to have  any  value, it must first be shown that cancer
is ab origine a constitutional  affection, and that it is not a local disease in the
first instance, which being allowed to remain unchecked will at last contaminate
and poison the system.   The evidence we possess would, however, rather lead
us to the opposite conclusion, namely, that cancer is originally local, and only
becomes secondarily constitutional.  This opinion, which Velpeau strongly sup-
ports, is founded on the following reasons: —
   1st. We  constantly see cancerous tumors spring up in individuals who have
always enjoyed perfect health, and who are to all appearances  perfectly well at
the time of the occurrence of the disease.
   2d. These tumors are not  unfrequently the result of some local injury or
irritation.
   3d. The constitutional  health  does not in the majority of cases appear to
suffer  until  some  weeks or months have elapsed, when as  the lymphatics or
glands  become implicated, or neighboring tissues invaded, signs of cachexy
set in.
   4th.  If the disease be removed  in the  early stage and before neighboring
parts have become contaminated, the health often improves materially.
   5th.  In the great majority of cases the patient remains free from any recur-
rence of the disease for some considerable period.
   6th. In some instances no recurrence whatever takes place, the  disease being
eradicated from  the system, which could  not be the case if it were constitu-
tional.
   7th.  We  observe the same tendency to  recurrence  after  removal, and to
secondary deposit  in distinct  organs  in  other tumors which are  incontestably
primarily local, such as the fibro-plastic and the enchondromatous, and only be-
come constitutional in their more advanced stages, and in a secondary manner. 
OPERATION  FOR  CANCER.
411
  The objections that have been urged against the general propriety of opera-
ting in cases of cancer, do not apply so much to the operation itself, the risk
attending which is not greater than that of other operations of similar magni-
tude,  as to  the  liability of the patient  speedily suffering  from a return of the
disease, so  that  an operation that is at least unnecessary will have  been per-
formed.  That this  objection is in a great  measure a valid one, is undoubted;
the experience of all surgeons tending to establish the fact that the majority
of  patients operated upon for cancer die eventually,  and  usually within a
limited time,  from a recurrence of the disease.   Thus,  Sir A. Cooper states,
that in only nine or ten cases out of a hundred, did the  disease not return in
three years; and Brodie has  found that it generally proves fatal in two or three
years after the operation.  After removal of the tumor, the disease may return
in the cicatrix, even before this is healed :  in the neighboring lymphatic glands
with or without the cicatrix having been involved, or in internal organs.  When
it returns in the cicatrix, it usually makes  its  appearance in  the form of small
hard  nodules of a purplish-red color, and covered with a very thin integument,
which speedily runs into ulceration, presenting  the  ordinary characters of the
cancerous sore.   The disease is especially apt to recur if  the  skin have become
involved, if the  lymphatic glands are enlarged, or if there  be  constitutional
cachexy before the  operation; so also if  the  tumor is growing rapidly at the
time  of removal,  and especially if the patient be robust and strong with a florid
complexion.
   In determining the question of operating in  cases of cancer, several points
of great importance present themselves for the consideration of the surgeon.
He has first to consider whether the operation is likely to free his  patient com-
pletely from the  affection; or, in the event of its not doing so, whether at least
life may not be prolonged by the  removal of the cancerous tumor; and, lastly,
even  though  the patient  be  eventually carried off as speedily as he otherwise
would have  been, whether  his  sufferings  may not be much lessened by the
removal of the local affection.
   That in some cases a cancerous tumor may be removed With every expectation
of the patient being  completely freed from  the  disease,  cannot, I think, be
doubted;  although  it may  be true that  such  instances are not of frequent
occurrence.  Yet they not unfrequently fall under the observation of surgeons,
 and would certainly tend to prove that the affection is not in all cases of a con-
 stitutional character, and that if we can happily succeed  in removing it during
 its local condition, there  is  a good prospect  that  the  patient may be rescued
 from a  return of the affection.   Velpeau states  that he  has perfectly cured
 patients by the removal of cancerous tumors, at least that no return  has taken
 place for 12, 15, or 20 years after extirpation.  The evidence of Sir B. Brodie
 on this point is extremely  valuable;  writing in  1846,  that  eminent surgeon
 states, that " So long ago as  1832, I removed a breast affected with a scirrhous
 tumor, and the lady is still in good health—at least, she was so last year.  Since
 the operation she has married, and had children.   Last year I was called to see
 a  lady on account of another complaint, on  whom I performed  the  operation
 thirteen years ago, and found that she  continued free from the old disease; and,
 very lately, I have heard of another lady, whose scirrhous breast I removed six
 years ago, and  who continues well."   The evidence of  Mr. Fergusson is also
 very positive on this  point, and he  speaks in a manner with which I perfectly
 agree. ^  He  says, "Nevertheless, as excision  gives the only chance of security
 —a point  on which most parties seem to agree—an operation should always be
 resorted to, provided the knife can be carried beyond the supposed limits of the
disease; and, moreover, I deem it one  of the duties of the practitioner to urge
the patient to submit to such a proceeding."   The opinions of these eminent
surgeons, supported as it is by the general practice of the profession, tends to
show that  in some cases, at least, the disease may apparently be extirpated from 
412
CANCER.
 the system by excising the tumor before the constitution has become implicated.
 But even  though, in many cases, we may not  expect to accomplish so desirable
 a result as this, and to cure the patient completely by operative procedure, may
 we  not reasonably hope to improve his health, to prolong his life, or to relieve
 the sufferings to which he  is subjected, by this means.   I am  decidedly of
 opinion that we may do so, and though a patient may at last be carried off by
 some  of the recurrent  forms of cancerous disease, his health may  have been
 improved, his life may have been prolonged, and much suffering may have been
 spared him by a timely operation.  This is more particularly the case  in en-
 cephaloid  cancer, in which early removal of the  disease is unquestionably suc-
cessful, in many cases, in prolonging life.  The observations  of Mr. Paget, on
 this point, are peculiarly valuable.  He  states  the average duration of  life of
 those patients laboring under this form of disease, in whom  the primary affec-
 tion is  removed, to be about  34 months;  whilst the average life of those in
 whom the disease is allowed to run its course, is scarcely more than one year.
    But I think that the introduction of anaesthetic agents into operative surgery
 has very materially altered the bearings of this important question.  So long as
 an  operation was a source of great pain, and of much consequent anxiety and
 dread, a surgeon might very properly hesitate in subjecting his patient to severe
 suffering with so doubtful a result; but now that a patient  can be  freed by a
 painless procedure from a source of much and  constant annoyance, discomfort,
 and suffering, the surgeon may feel  himself justified  in  thus affording him a
 few months or years  of comparative  ease,  though he  may be fully  aware that
 at the expiration of that time the affection may return, and will certainly prove
 fatal.  Even then, his  condition may be much  improved, for  the recurrent is
 often less distressing to the patient than the  primary disease, for, as it often
 takes place in internal organs,  it is not attended with the same amount of local
 pain and distress.
    In discussing the propriety of operating in a case of cancer, the surgeon can,
 however,  have little to do with general or  abstract considerations.   He has to
 determine what had best be done in the particular case that he is actually con-
 sidering, and it will serve  him little in coming to a conclusion as to the line of
 practice that he should adopt, to refer to the statistics of the gross results of
 operations, or to general comparisons between the results of cases that are not
 operated upon and those  that are.   The whole question narrows itself to the
 point as to what should best be done  in order to prolong the life, or relieve the
 suffering,  of the particular individual whose case is being considered.   In order
 to come to some definite conclusion on this, it is necessary to classify the different
 cases of cancer, and to arrange  them  under the  heads of those  in which no
 operation  is justifiable; those in which the result of any such procedure would
 be very doubtful; and, lastly, those in which an operation is attended  with a
 fair prospect of success.
     Cases not admitting of operation. — 1st.  The operation  ought never to be
 performed in those cases in which there are several cancerous tumors, existing
 in different parts of the body at the same time.  Here the  disease is evidently
 constitutional, and could  not be  eradicated by any series  of operations.  2d.
 Then, again, if the cancerous cachexy is strongly developed, or if the  disease
 be hereditary, it is useless to remove a local affection, as the malignant action
 will certainly manifest itself elsewhere, or,  perhaps,  even speedily return in
 the cicatrix.  3d.  So also if the tumor be of very rapid growth, and be still
 increasing, there would appear to be  so vigorous a local tendency to cancerous
 deposit, that it will speedily develop itself  again in the cicatrix.   4th.  If the
 tumor be  so situated  that it cannot  be completely and entirely  extirpated by
 cutting widely into the surrounding  parts, it ought not to be meddled with;
 otherwise  the affection will to a  certainty return in  the cicatrix before it has
 closed.   It is  not  alone  necessary to remove the tumor, but the surrounding 
OPERATION  FOR  CANCER.
413
tissues to some extent, even if apparently healthy.  5th. If the whole of the
affected organ, as a bone, cannot be  removed, or, if the skin and  glands be
involved, it is  useless to attempt the extirpation  of the growth, as a speedy
relapse may be confidently looked for.   6th.  In the very  chronic and indurated
cancers of old people, it  is often well  not to interfere, as in these cases the
affection makes  such slow progress, that it does not  appear in any way to
shorten life, and the mere operation might be attended with  serious risk at an
advanced age.
   Doubtful cases. — Those cases in which the result of an operation is of an
extremely doubtful character, but in which no other means offer  the  slightest
prospect of relief to the patient, have  next to be considered.   1st.  Cancers of
the  eye, tongue, and  of  the testes belong to this category, for though more
liable to return than  similar affections of any other part of the body, yet they
may be considered fit cases for  operation, inasmuch as in no other way has the
patient the slightest chance of being relieved from  his disease.   2d.  In those
cancers that are already ulcerated, the  surgeon may sometimes  operate in order
to give the patient ease  from  present suffering, or, perhaps, as in some cases
recorded by Brodie, with  the view of prolonging the duration of life; but he
can  have little expectation of effecting a permanent cure.   3d. If the tumor
be of so large  a size, or be so situated that its removal cannot be undertaken
without so serious an  operation as to occasion in itself considerable risk, the
propriety of operating is always very doubtful.
   Cases for operation. — Those cases of  cancer in which an operation is, in my
opinion, not only perfectly justifiable, but should be urged upon the patient as
affording the best prospect of preserving  his life, are those in which  the  disease
 has  appeared  to originate from a strictly local cause  in persons otherwise  in
 good health, in whom  there is  no  cachexy or hereditary taint.  If the tumor
 be of a scirrhous character, slow in its progress, single, distinctly circumscribed,
 without adhesions to, or implication of, the skin or glands, and more especially
 if it be attended with much pain, or with immediate  risk to life from any cause,
 and if the whole of the  growth,  together  with a sufficient  quantity  of the
 neighboring healthy tissues in which it is imbedded can  be removed with care,
 the case may be looked upon as a fit one  for operation.
   In all encephaloid cancers also, early operation should be practised with the
 view of prolonging life.
   An important question in connection with operations for cancer, is at what
 period of the growth they may be  done with the best prospect  of success.
 Most surgeons, taking a  common-sense view of this question, are in favor of
 removing the  affection as  early as  possible, feeling that as it is difficult to say
 when the local form of the disease becomes constitutional, it is safer to remove
 it as soon as its true nature has been  ascertained; and I confess that I can see
 no  advantage  that can be gained by delay.   The necessity for early operation
 in medullary cancer is  admitted  by all, but with regard  to  scirrhous  cancer,
 the opinion is entertained by some, that in many cases  there is a better pros-
 pect of success if the operation be  delayed: and  it is stated  by  Hervez de
 Chagoin and Leroy d'Etiolles, that the result of those  cases  operated on after
 the cancer has lasted  for some  time, is  more favorable  than that of those  in
 which an early operation has  been done;  the cancer often appearing to be
 arrested in  its development and to localize itself as it  becomes more chronic,
 and having consequently a less tendency to speedy return after removal.   That
 the result of operations in such selected cases is favorable, is probable enough,
 as it may be reasonably supposed that the more active varieties of cancer, those
 that possess the greatest amount of vegetative  activity and  of reproductive
 power, may have got into a condition unfavorable  to  operation, or even may
 have  carried  off the patient before any period of arrest in their  growth has
 occurred, during which their extirpation could be practised with a fair prospect 
414
CANCER.
of success.  In delaying operation there is, however, much danger lest valuable
time be  lost in the employment of means which, ineffective in arresting the
disease, may become positively injurious by allowing time to the morbid growth
to contaminate the glandular system, or to extend widely through neighboring
tissues.  If we  look  upon a  cancer as a morbid  growth that must necessarily
destroy life, either by changes  taking place  in its own substance or by the
contamination of the system,  and that is intractable to all medication, whether
topical or constitutional, we must look upon its extirpation as the only resource
that Surgery offers; and we  may assuredly infer, that  the liability to  constitu-
tional  infection, and wide-spread local contamination, will be less in proportion
to the early removal of the morbid mass.

             EPITHELIAL CANCER. — EPITHELIOMA,

  Epithelial cancer differs from the other varieties of the disease in its anatomical
structure, in being seated  on  the cutaneous, or more frequently, the mucous or
muco-cutaneous surfaces; and  in  its  being  but very seldom the cause  of
secondary visceral deposits.   It resembles the other forms of cancer, however,
in  its  tendency to local  infiltration and ulceration,  in its extension to the
lymphatic system, and in the  induction of death by cachexy.
   This affection is  chiefly met with in the neighborhood of the outlets of the
body, upon the muco-cutaneous surfaces, being commonly seated  upon the lips,
the tongue, the cheek, the scrotum, the anus,  and  the uterus; but it may  occur
upon the skin of the extremities and trunk, chiefly in the hands, feet, and  back.
It  commences either  as a small tubercle, which  rapidly ulcerates,  or  appears
from the first as  an intractable ulcer of limited size, with hard and everted
edges, and a foul surface;  it slowly spreads, and appears at first to be local, but
after a time contaminating the glands in the neighborhood, it induces cachexy,
and destroys  the patient  by  exhaustion.   It  seldom occurs secondarily in the
viscera, though, the liver, lungs, and heart have  been  observed to be affected;
but extensive deposits in the lymphatic glands in the vicinity of the  parts
affected, even deep in the iliac and pelvic regions, invariably take place after
the disease has lasted for some time.   It may form in the submucous cellular
tissue as a distinct rounded pendulous or fibrous-looking tumor.  I removed lately
such a growth from the inside of the cheek of an  old woman; it looked fibrous
on section, but was an epithelial cancer, about  the  size of a cherry, round and
pedunculated.   On examination an epithelial cancer will be found to be com-
posed of a fibrous basis, with a large quantity of condensed and morbid epithelial
scales, closely packed upon it.   These scales  so closely resemble those of the

                                                       Fig.  151.
Cells from epithelial cancer                           Is<i^
      of lower lip.                  Cells from chimney-sweep's cancer.
epidermis and  epithelium, that they cannot be  distinguished from them,  but
their  arrangement is different; they are packed together in masses or balls,
assuming  a concentric arrangement, hence termed  " Concentric globes" (figs.
150, 152), and in these present a somewhat fibrous  appearance.   According to 
TREATMENT OF  EPITHELIAL  CANCER.          415
Fig. 153.
Mr. Simon, however,  this fibrous  structure is  deceptive, depending upon  the
scales being much attenuated  and woven together.   In many cases  they  are
intermixed with globular bodies,  and in others with cells of various shapes,
resembling those found  in  the more truly cancerous diseases (figs. 150, 151);
and indeed so close is the resemblance
between the compound nucleated cells                 FlG- 152-
commonly met with in epithelial can-
cers with those of the other  cancerous
affections, that  I know of no way of
distinguishing them from one another,
and must look on these growths as of
a hybrid character.
   The treatment of epithelial  cancer
is more  satisfactory than that  of  the
other varieties of carcinomatous  dis-
ease which we  have  just  been con-
sidering, inasmuch  as this partakes
more of the characters of a local  and
less of a constitutional affection than
any other  form  of cancer.   Hence
free  semoval  by excision or  liga-
 ture,  or  complete  destruction  by
 caustics, will not uncommonly permanently rid  the  patient of this affection.
   Excision should  always  be  preferred  whenever  practicable, and should be
 done as soon as the nature of the disease is recognized, the part being thoroughly
 extirpated, together with a good wide margin of healthy
 tissue on either side  of and beneath it, so that no cancer-
 germs  may be left  from which new growths  can spring.
 When  the neighboring lymphatic glands are  but slightly
 enlarged,  the  operation may be  done  equally, the glan-
 dular enlargement, which may be dependent on irritation,
 gradually  subsiding.  If, however, it be more considerable,
 the affected gland  must be extirpated, but if there be a
  chain of  enlarged  glands, more  especially  in the  deeper
  cavities, no operation should be undertaken, as the  disease
  will then have become constitutional  and cannot be fully
  removed.   If the disease  be  situated on one of the ex-
  tremities, as the hand or foot, partial  or complete amputa-
  tion even may be the safest procedure, and such cases are
  less liable to relapse than others  in which such free extir-
  pation is  not admissible.
    The ligature may be advantageously employed when the
  cancer is  so situated that  incision is impracticable, either
  on account of dangerous hemorrhage  or from the impos-
  sibility of effectually extirpating the disease.   The part
  having been well insulated,  and effectually strangled  by
  stout whipcord ligatures, sloughs and separates  in a few
  days.   Of late  a more rapid process  of  strangulation has
  been invented by M. Chassaignac, who, by means  of the
  " ecraseur" (fig.  153),  removes  with  little or no  hemor-
  rhage, in  the course  of a few minutes, cancroid and other
  growths of considerable size, by a process of rapid strangu-
  lation  and crushing in  a  linear direction.   The ecraseur
  consists of a  loop  of fine steel  chain, which  having been
  passed over the tumor or through the  tissues  to be removed, is gradually tight-
  ened by a mechanism in  the  stem to which  it is attached.   In  applying this
 
416     OPERATIONS FOR THE  REMOVAL OP  TUMORS.

instrument it is often necessary, first of all, to insulate  and raise the tumor to
be removed by passing a thread through or under it (fig. 154), and then having
applied the chain's loop round its base, to tighten this  by working the handle
every ten or fifteen  seconds, until  the  mass is detached.   The resulting wound
is small and puckered in, and often heals with but little trouble.   If the mass
to be removed is  large,  two or more  ecraseurs  may be  used at the same time,
the chains having been passed through the tissues by means of a needle.  This

                                   Fig. 154.
instrument  appears to me to be chiefly  applicable to cases in which, as in
cancroid ulcer of the tongue, excision is hazardous on account of the hemorrhage
attending it, while the ligature  is  objectionable on account of the fetor and
discharge resulting from the slow separation of the sloughs.
   Caustics.—In some instances the  disease being so situated, as  in  some parts
of the face, or in the deeper cavities of the body, that it  cannot be dissected
out, the application of  caustics will be useful in procuring its removal;  but if
these agents are employed, care  should be taken that they be freely  applied, so
as thoroughly to destroy the whole  of the morbid textures.  The best prepara-
tions for this purpose are concentrated sulphuric acid, arsenic, the chloride of
zinc paste, fused potassa cum calce, the potassa fusa, the Vienna paste, and the
acid nitrate of mercury.  All of these may be applied successfully, though they
should not be used indiscriminately.   The chloride of zinc and the Vienna paste
are most useful when the ulcerated  surface is large, and indurated at its base or
edge.   The acid nitrate of mercury should only be employed when the sore is
small, superficial, irregular, and without much induration.  In such  cases, also,
the arsenical pastes and powders already described are very useful.  In epithe-
lial cancer, constitutional treatment is, I believe, as  ineffectual as in the other
varieties of the affection.
   When  a recurrence  takes place  after operation for epithelial cancer, it is
either  by a fresh deposit of cancerous matter in the cicatrix, or else  by the
neighboring lymphatic  glands which had  been contaminated before the opera-
tion, continuing to enlarge, and at last  ulcerating, and  thus destroying the
patient.

          OPERATIONS FOR THE REMOVAL OF  TUMORS.

   In describing the different forms of encysted tumor, the operative procedures
necessary for their removal have been adverted to.   We may now conveniently
consider the  steps that are generally necessary for the extirpation with the
knife of solid tumors from  the soft parts.   In the removal of tumors, the first
point to be attended to is the arrangement, shape, and direction of the neces-
sary incisions.   These should not only have reference to the  size of the growth,
extending well  beyond it at either end, but  must  also be  planned with duo 
        OPERATIONS POR THE REMOVAL  OF  TUMORS.     417

regard to  subjacent parts of importance.  As a general rule, they should be
carried in the direction  of  the axis of the limb  or  part, and parallel to the
course of its principal vessels; they must not only extend over the whole length
of the tumor, but also a little beyond it at either end; no cross-cuts should be
made, if they can possibly be  avoided, and  this  may usually be  done by the
proper position, and extension of the linear incision.   In  most cases, no skin
should be removed, a simple cut being made; but if the integumental tissues
be either very abundant  and loose, or else are adherent, an elliptical portion of
them may be  excised together with  the tumor.  In other instances, again, a
semilunar flap of integument may with advantage be turned up from the tumor,
the surface of which is then fairly exposed; this, however, can only be done in
some simple tumors,  such as fatty growths.   The  flaps covering it should then
be freely but cautiously  dissected back,  so as to expose  the sides and base of
the growth; as these  are approached, and the  surgeon gets in the neighborhood
of its more important and deeper  connections, increased care will be necessary,
as it not unfrequently happens that the tumor is in more important  relations
with deep-seated blood-vessels and  nerves of a large size than would at first
appear.  When practicable, the deep dissection had best be  commenced and
carried out from that part of  the base of the  tumor into which the  principal
blood-vessels appear to enter; they are thus early  cut, and being once  ligatured
 give  no further trouble,  as they would do were they divided from the  direction
 of their branches towards the trunk, when at each  successive stroke of  the knife
 a fresh portion of the vessel would be touched.  In  carrying on this  deep dis-
 section, the operator should proceed methodically from one side of the tumor
 to the other, the assistants  holding aside the skin so as to give as much room
 as  possible, whilst the  surgeon himself, seizing the mass with his left hand, or
 with a large double hook or vulsellum, and  dragging  it well forwards, uses  the
 knife by successive strokes, but in a leisurely and careful manner, avoiding  all
 undue haste, until he completely detaches  it from its connections.   The safety
 of  contiguous important structures will  be best secured by keeping  the edge
 of the knife constantly directed towards the  tumor, if this be of a non-malig-
 nant character; by attention to this rule, I have seen  Mr. Liston remove tumors
 with remarkable  facility and ease from the  neighborhood of most important
 parts.  If, however,  the growth be of a malignant character, the incisions must
 be made wide of the disease into  the healthy structures around; if this be not
 done, slices of the tumor may be  left from which  fresh growths rapidly sprout,
 or cancer-cells may impregnate the neighboring tissues through which they are
 scattered, and may eventually become so many fresh centres of malignant action.
 After the tumor has been removed, it  must be  carefully examined, with  the
 view of ascertaining whether  it is  entire, and if any portions have  been  left
 behind, these must be properly dissected out.   In some situations, as the axilla,
 or side of the neck  or groin, where the relations are of great importance, the
 less  the edge of the knife is used the better,  and  the growth  should be enucle-
 ated with the surgeon's fingers,  or with the  handle of the scalpel.  If it be
 found that the tumor extends more deeply than had been anticipated, and comes
 into such close relation  with important vessels, as  at the summit of the  axilla
 or in the perineum,  as to  prevent the surgeon dissecting it out without  immi-
 nent risk of  destroying the patient, the only alternative left is one that I have
 seen Mr. Liston adopt, and have had occasion myself to practice in  these situa-
 tions, viz., to throw  a strong whipcord ligature above the apex of the growth as
 high up as practicable, and then to cut off every thing below this.   On the
 separation of the ligature, any portion of the tumor that has been included will
 be brought away as effectually as  if it had been done with the knife.
   In some cases it will  be  found, after dividing the  fascia covering the tumor,
 that the attachments of the  growth are  not so  firm or deep as had  been pre-
 viously expected; this is  especially  the case in  some large  tumors  springing 
418
SCROFULA, OR  STRUMA.
from the side of the neck and the  parotid region, or in the groin;  then it may
often be removed  in a great measure  by separating the cellular tissue with the
handle of the knife, merely dividing  those  portions of the deeper  attachments
that are of a peculiarly dense character.   The surgeon should  never undertake
the removal of tumors  that cannot be wholly and entirely extirpated, as the part
left behind will always grow with  greatly increased rapidjty, often assuming a
fungous character; this is especially the case with malignant tumors, the rapidity
of increase of which is greatly augmented by partial operations.  Should, how-
ever, the  surgeon have  been deceived as to  the depth and connections of the
mass, and  should  he  find after commencing his operation that it is so situated
as not  to  admit of entire removal, he must, under the  circumstances, do his
best, and cut off  or remove  by the ligature as  much of the growth  as he can
expose with safety.
   The wound that is left after the removal of a tumor, usually unites partly by
adhesive inflammation, and partly by  the second intention;  it should be lightly
dressed, the edges being brought  together  with strips  of plaster and water-
dressing, and if large, supported by a compress and bandage.
                         CHAPTER  XXX.

                      SCROFULA,  OR STRUMA.

  By scrofula is meant a peculiar constitutional condition, either hereditary or
acquired, that leads to the formation of, and in  its full development is charac-
terized by the presence of, tubercle.   It is, however, only when fully developed
that scrofula gives rise to the local deposit of tuberculous matter.   The consti-
tutional condition that tends to this is  sufficiently characteristic; but although
we may recognize its existence, and speak of the  individual possessing such a
constitution as  having a scrofulous tendency or diathesis, he  can scarcely be
considered to labor under the fully formed disease unless tubercle  be deposited
in some of his tissues or  organs.
  The scrofulous diathesis is a peculiar constitutional state that is often  erro-
neously confounded with general  debility.   It  may, and  often does, co-exist
with this, but is  by no means synonymous with  weakness of constitution.   De-
bility often exists without any scrofulous tendency or taint, more particularly in
individuals of the nervous  temperament;  many delicate people,  though weak,
being perfectly healthy, and  showing no  disposition to this peculiar affection;
on the contrary, the scrofulous constitution is often conjoined with much mus-
cular power and mental activity.  But though no weakness may be  manifested
in either of these respects, scrofula is invariably conjoined with debility or per-
version  of the nutritive activity of the body.  This is  especially manifested in
certain tissues, such as the mucous and the cutaneous; and in those organs, the
vitality of which is low,  as the lymphatic glands, the bones, and the joints.  In
these, scrofula  is especially apt to influence the  products of nutrition and of
inflammation, more  particularly during the  earlier periods of life when  these
actions  are most energetic, in such a way as to  render its  existence evident  to
the surgeon.  It is this tendency to the  occurrence of particular diseases, and
to the engrafting of special characters  on  affections of certain tissues, that may
be considered as  specially indicative of the existence of the scrofulous diathesis;
of that condition which, in its extreme of  development, gives rise to the deposit
of tubercle in organs and tissues.   The existence of this diathesis is marked by 
SCROFULA OF TISSUES  AND  ORGANS.
419
the presence of a peculiar temperament, by special modifications  of the  seat,
form, and products of inflammation, and, lastly, by the development of tubercle.
  The scrofulous  temperament assumes two  distinct  forms, and each of these
presents two varieties.  The most common is that which occurs in  persons with
fair, soft, and  transparent  skin, having clear blue eyes with large  pupils,  light
hair, tapering  fingers, and fine white teeth; indeed, whose beauty is often great,
especially in early life, being dependent rather on roundness of outline than on
grace of form; and whose growth is rapid and precocious.  In these individuals
the affections  are strong, and the procreative powers considerable; the  mental
activity is also great, and is usually characterized by much delicacy and softness
of feeling, and vivacity of intellect.   Indeed, it would appear in  such persons
as these that the nutritive, procreative, and mental powers are rapidly and  ener-
getically developed  in early life,  but become proportionately early exhausted.
In another variety of the  fair  scrofulous  temperament, we find a coarse  skin,
short and rounded features, light grey eyes, crisp and curling sandy hair, a  short
and somewhat ungainly stature, and clubbed fingers, but not uncommonly,  as in
the former variety, great and early mental activity, and occasionally much mus-
cular strength.
   In the dark form of the scrofulous temperament  we usually find a somewhat
heavy,  sullen, and  forbidding  appearance; a dark, coarse, sallow,  or  greasy-
looking skin; short, thick, and harsh curly hair; a small stature, but often a
powerful and  strong-limbed frame, with a certain degree of torpor  or langor of
the mental  faculties, though the powers of the intellect are sometimes remark-
ably  developed.   The other dark strumous  temperament is  characterized by
clear dark eyes, fine hair, a sallow skin, and by mental  and physical organization
that  pretty closely  resembles  the first described variety  of the fair strumous
diathesis.
   In all these varieties of  temperament the digestive organs will be found  to be
weak and irritable.   This condition, which I  believe is invariably associated
with struma, and the importance of  which  has been pointed out by Sir James
Clark, must be regarded as one of the most essential conditions connected with
scrofula, and  as  tending  greatly to that impairment  of nutrition  which  is so
frequent in this state.  This  gastric irritability is  especially characterized by
the tongue, even in young children, being habitually coated towards the  root
with a  thick  white  fur, through which elongated papillae  project, constituting
the " pipped" or " strawberry" tongue; the edges and tip, as  well as the lips,
being usually  of a bright red color.   This state of the tongue is aggravated by
stimulants, high living, and the habitual use of purgatives.  In  the  fair varieties
the bowels are usually somewhat loose, but in the dark forms of struma there is
a torpid condition of the intestinal canal.    In all cases the action  of the heart
is feeble, the blood is thin  and watery, and there is a tendency to coldness, and
often to clamminess  of the extremities.
   One of the  most marked  characteristics of struma  is  certainly  the peculiar
modification that inflammation undergoes, whether we regard the course that it
takes, the form that it assumes, its products, or its seat.   The course of  inflam-
mation in strumous subjects  is always slow, feeble, and  ill-developed, the  more
active and sthenic conditions being  rarely met with.  In  its form it is  usually
congestive, ulcerative, or suppurative, and in  its products it is  characterized by
little tendency  to adhesion, by the  production  of  thin,  blue, weak, and  ill-
developed  cicatrices, and  by the formation  of thin,  curdy pus, with  much
shreddy, corpuscular lymph.
   The seat of strumous inflammation varies greatly, and  peculiar  modifications
of course, form, and products are assumed, according to the part that it affects.
The tissues  implicated by it  are chiefly the skin and mucous  membranes, the
joints, and the bones, occasioning a great variety of special diseases, according
as one or other of these structures are affected.   It is as the  result of, or in 
420
SCROFULA,  OR  STRUMA.
connection with these local affections that the general symptoms  of struma be-
come most marked.  Whatever  the variety of  temperament may be, the  indi-
vidual usually emaciates,  becomes  sallow,  cachectic, and  debilitated, and at
length falls into a state of  hectic or marasmus.
   When affecting the skin, scrofula  declares itself under a variety of cutaneous
eruptions,  especially the different forms of eczema  of the  scalp, and various
ulcers on the  surface,  usually weak, and largely granulating, with considerable
                                  swelling of  the  surrounding parts, and a
              Fig 155.              tendency to the formation of thin  blue and
                                   glazed  cicatrices  (fig.  155).   The integu-
                                   ments of the whole of the limb may become
                                   so much diseased in this way, cedematous,
                                   infiltrated and covered  by flabby ulcers and
                                   fistulae, the member being perhaps double
                                   its natural size, that amputation is the sole
                                   resource. This condition is met with in the
                                   arm and foot, and removal  of these  parts
                                   may then be necessary.
                                     The  mucous  membranes  are  commonly
                                   extensively affected,  and often present the
                                   earlier forms of scrofulous  disease in child-
                                   hood ; this  is more especially the  case with
                                   those of the eyelids and nose.    The con-
                                   junctiva becomes chronically inflamed, with
 perhaps ulceration of  the cornea.   The mucous membrane  of the eyelids may
 be  permanently congested and  irritated, with  loss  of lashes, constituting  the
 different form of psorophthalmia.   The mucous membrane lining the nostrils
 becomes chronically congested, red, and swollen, giving rise to habitual sniffing
 of the nose, and to a sensation as of a constant cold.  Occasionally that lining
 the antrum becomes irritated, and  may then occasion  an  enlargement of this
 cavity, or the discharge of unhealthy pus  into the  nostrils.  The  tonsils  are
 often found  chronically enlarged and indurated, with  occasional tendency to
 fresh inflammation; and the larynx may become the seat of various  forms of
 aphonia, dependent on congestion  of its lining membrane.  The state of the
 gastro-intestinal mucous membrane has already been described when speaking
 of the state of the tongue, and that of the  genito-urinary organs is also marked
                            by a tendency to debility and irritation, indicated by
           Fig. 156.          the  occurrence of discharges from the urethra under
                            the  influence of very slight exciting causes, and that
                            are  often very  permanent in their character.  The
                            occurrence of  calculus of the  bladder, especially in
                            children, may  also occasionally be attributed to the
                            scrofulous diathesis.
                              Perhaps the most important local diseases arising
                            under  the influence of this agency are those  of the
                            bones and joints.   The bones are liable to  the occur-
                            rence of various forms of caries and necrosis  (fig.
                            156) ;  more especially those that are spongy in their
                            texture, as the short bones of the foot, and the
                            articular ends  of long bones.   The joints are liable
                            to that large class  of affections  that are  commonly
                            included under the term  of white swelling, and
                            which consists of thickening, disorganization, ulcera-
                            tion, and  suppuration of the  synovial membranes
                            and cartilages.
    Lastly, some of the glandular organs  are  peculiarly prone to scrofulous dis-
 
CAUSES  OF  SCROFULA.                    421
ease.   Enlargement of the lymphatic glands, more particularly by the side of
the neck and under the angles of the jaw, is of such frequent occurrence, and
is usually so early a sign, that the surgeon, in determining whether an individual
is scrofulous or not, commonly passes his hand over the glands in this situation
in order to ascertain their condition and size;  these glandular enlargements are
especially apt to run into unhealthy and chronic suppuration.  The testes and
the mammae are occasionally affected, and  other glandular  structures, though
sometimes implicated, are by no means  so  commonly found diseased as those
that have just been mentioned.
   The occurrence of tubercle must be looked upon as  the great characteristic of
scrofula, and when it  happens it may be considered a sure sign of this affection,
which has then reached its ultimate development.   In those cases in  which the
scrofulous diathesis exist without having given rise to this product, it must be
considered as not having been called into full and  active operation, having
merely manifested itself in the minor  forms of disease, such as ulceration of
the skin and of the mucous surfaces.
   Tubercle, though sufficiently well marked  by its appearances and progress,
cannot be looked upon  as  a specific affection, but must be considered to be a
perverted or unhealthy development of the nutritive materials destined for the
repair of the body and the restoration of the blood.  According to Mr. Simon,
it consists of a disease of the lymph, or nascent blood.  It is a " dead concre-
tion," a  "fibriniform  product, insusceptible of development."  " The scrofulous
diathesis," says Mr.  Simon, "consists  in a peculiarity of blood-development,
under which the  nascent  blood tends to  molecular death by superoxydation."
According to Dr. Williams, " tubercle is a  degraded condition of the nutritive
material from which  the old  textures are renewed, and the new ones formed,
 and it differs from  fibrine or coagulable lymph  not in kind,  but  in degree
 of vitality and capacity of organization."
   Tubercle essentially occurs in  two forms, as semi-transparent  grey granu-
 lations,  smooth,  and  cartilaginous in look, somewhat hard, closely  adherent,
 and accumulated in  groups, often with a good deal  of inflammatory action in
 the surrounding  tissues.  These grey  granulations, usually about the  size of
 a small pin's head, appear to consist of modified exudation-matter.   They have
 a tendency to run into masses, and to  form the true yellow tubercle, which  is
 met with in opaque,  firm, but friable concretions of a dull whitish or yellowish
 color, homogeneous in structure, and without any appearance of  vascularity.
   The microscopic  characters  of tubercle present no very specific appearances
 (fig. 157).  We find that this product presents, under the lens, a homogeneous
 stroma,  which chiefly occurs in the grey granulations; a granular matter, which
 is principally met with in yellow tubercles; drops of molecular oil; and, lastly,

                  Fig. 157.                         Fig. 158.
Tubercle.                            pua.
considerable quantities  of imperfectly developed  small exudation-cells,  often
angular,  or broken at one  side, more or  less  disintegrated,  stationary, or
degraded.  Indeed, we  must often recognize tubercle  by its  negative rather 
422
SCROFULA, OR  STRUMA.
than its positive  characters,— by ascertaining what it is not; and so, by a pro-
cess of exclusion, arriving at its true nature.   It is most easily confounded with
pus (fig. 158), from which, however, the appearances differ sufficiently to  avoid
error, if a little care be taken.
   The progress of tubercle is most commonly to disintegration and liquefaction,
at the same time that it gives rise, by its irritation, to inflammation and suppu-
ration in  the surrounding tissues; hence  it  commonly leads to abscesses, the
pus of which is always curdy and shreddy.  In some cases, tubercle may become
indurated, and undergo a species of calcification.
   The causes of  scrofula, unless this be of a hereditary character, though very
various in their nature, are usually such conditions as influence injuriously the
nutrition  of the body.
   The  hereditary nature of scrofula is well  known both to the public and to
the profession;  for although the disease  is not commonly  connate, yet the
tendency  to it is, and  the characteristic nature  of the affection often manifests
itself at an  early period, notwithstanding  every effort  to prevent its develop-
ment.  That a parent may develop a tendency to mal-nutrition, to mis-develop-
ment of the blood, just as  he  may a  peculiar  feature or mental condition, is
undoubted.  It is by the hereditary transmission of peculiar combinations and
modifications of action  in  the   organization,  that  hereditary diseases  develop
themselves  at  certain periods in the  life  of the offspring, when the injurious
results  of the  morbid actions that have been transmitted have had time to be
produced.  There  are certain conditions which,  though not scrofulous, are sup-
posed to have a tendency to develop this disease in the offspring to which they
are transmitted;  thus, very dyspeptic parents commonly have strumous children;
so, also, the offspring of very old or very  young people  often exhibit a prone-
ness  to scrofulous affections.   The  influence of intermarriage is still a matter
of doubt, but I believe that it exercises little influence in this respect;  and it
is commonly stated that  the inhabitants of  small communities who intermarry
closely, such as those of  the Isles of Portland and of Man, are not more liable
 to scrofula than  other individuals.
    The most powerful occasioning cause  of scrofula, and  that which  in most
 civilized  countries is likewise the most frequent, is mal-nutrition, arising  either
 from want of food, or the administration of improper food in the poorer classes;
 or, from  over-feeding and over-stimulation  of the digestive organs amongst the
 children  of the wealthier orders of society, thus inducing  chronic irritation of
 the mucous membrane of the stomach, interference with the digestive powers,
 and consequently with nutrition.  The influence of food that is innutritious in
 quality or insufficient in  quantity, has  been shown by Mr. Phillips, in his excel-
 lent Treatise on Scrofula, to be  the  most immediate cause of this disease;  and
 when conjoined with the injurious effects of the confined atmosphere of  towns,
 of close  and over-crowded  rooms, and of want of light and exercise, may be
 considered as sufficient  to  occasion the disease in those  cases in which no pre-
 disposition to  it exists, and  greatly to  develop  any hereditary tendency to it in
 the system.  It is to the conjoined influence of agencies such as these that we
 must attribute the prevalence of scrofula amongst the lower orders of town and
 rural populations.
    Scrofula  is often called  into immediate action by the debility induced by
 previous diseases, such  as  measles, scarlatina, hooping-cough, etc.  It usually
 develops itself  at an early age, though seldom before the  child has reached
 its second year.  It is most commonly about the period of the second  dentition
 that the affection declares itself, and it is rare to meet  with it for the first
 time after the  ages of 25  or  35.  According  to Phillips, when it is  fatal it
 usually proves  so before the fifteenth year; 60 to 70 per cent, of the deaths
 occurring before  this age.  Sex does not  appear materially  to influence  the
 disease,  though, according to  the  same  authority, the  deaths of males from 
TREATMENT OF  SCROFULA.                 423
scrofula exceed those of females, in this country, by 24 per cent.   If, however,
we  are to regard  phthisis as an allied affection, people who are scrofulous in
early  life often becoming  phthisical at a later period,  these  numbers may
require correction.
  The treatment  of scrofula  should  rather consist  in  endeavoring to  prevent
the occurrence or  full manifestation of the disease, than in removing it when it
is actually existing.   Indeed, the preventive treatment  is perhaps of  most
consequence, and  by proper attention to it I have no hesitation in saying that
the development of the affection, even when  hereditary,  may be  stopped; and
the child of strumous parents, presenting perhaps the features  indicative of the
diathesis, may pass through life without the  disease having an opportunity of
declaring itself.   In order to accomplish  this, however, the preventive plan of
treatment must be commenced early, and continued uninterruptedly for a con-
siderable time, even for years.
   The preventive  treatment of scrofula may be said in general terms to consist
in close  and  continuous attention to hygienic rules.  The diet  must be  espe-
cially attended to, nourishing food, but of the lightest quality, being given.  A
great error is  often committed in overloading the stomach with more or heavier
food than it can digest, under the impression that  strong food is necessary to
give the patient strength.   In consequence of this error, the irritability of  the
mucous  membrane is kept up, nutrition is imperfectly and badly  performed,  the
 surplus food  is thrown off in the shape of lithates or other  products of mal-
 assimilation, and health and strength, which are  the results of perfect nutrition,
 become  impaired  rather than improved.   The use of stimulants, whether wine
 or  beer, should be very  sparing, and the milder and weaker should  be pre-
 ferred to the  heavier and  stronger kinds of malt liquor; the bowels  must be
 kept regular  with the simplest aperients; the  clothing  should be warm, and
 must cover the whole of the surface, and the patient should if possible  be kept
 in  well-ventilated rooms.   He should be  allowed  sufficient exercise in the open
 air, not  carried to the point of fatigue, and should, if  his circumstances will
 permit, have  change of air from time to time, alternating a sea  with an inland
 climate.  Bathing, also, whether  in  sea or river, with the habitual  use of  the
 tepid or cold  sponge-bath, and friction of the  surface with horse-hair gloves or
 a rough towel, so as to keep the skin in healthy action and its cutaneous  circu-
 lation free, should be regularly  practised.
   The curative treatment  should be specially directed, like the  preventive, to
 the general improvement of the nutrition, and through it to the augmentation
 of the constitutional vigor of the patient; all  those hygienic  means that have
  just been alluded to being continuously carried out.
    The more strictly medical treatment of scrofula consists in the administration
 of tonics and alteratives with the view of improving the patient's constitutional
 powers.  Before  they are administered, however, it is always necessary to  see
 that the digestive organs are in a healthy condition.   Scrofula is a consequence
 of mal-nutrition,  and unless we see that digestion, the first stage  of the  nutri-
 tive process,  is properly accomplished, all other means will be useless.   When
 the tongue is covered with a white, thick, creamy fur, having elongated papillae
 and red edges, the mucous membrane being in a state partly of  irritability and
 partly of debility, neither purgatives nor tonics  can be  largely administered;
 the one irritating, the other over-stimulating  the morbidly  sensitive  mucous
 membrane.   Under these  circumstances the patient should  be confined to  the
 mildest  possible diet, which must principally consist of milk, boiled fish,  white
 meats, and light  pudding, no stimulant  of any kind  being allowed except  a
 small quantity of weak bitter beer;  and unless  the patient have  been accus-
 tomed to the  use  of stimulants, this even had better be dispensed with.   Small
 doses of mercury with chalk, of soda and rhubarb, should be occasionally ad-
 ministered at bed-time, with some of the compound decoction of aloes on  the 
424
SCROFULA,  OR  STRUMA.
following morning, and a  few grains of the  carbonate of  soda  or  potass may
then be given twice or thrice a day in some light bitter infusion, as of casca-
rilla or  calumba.   In many cases of strumous  disease, more especially those
affecting the joints and bones, the liver will be found to be enlarged and slug-
gish in its action, the patient every now and then  becoming bilious, sallow and
jaundiced;  under these circumstances, small doses of bluepill, carried off with
the compound decoction of aloes or  a rhubarb draught, will be found necessary
from time to time.   When all gastric irritation has  been removed in this way,
or if it have not existed in the usual marked degree  from  the first, the patient
being pale and flabby, with a weakened condition of  the pulse, of the skin', and
of the mucous surface, then tonics may be administered, and the more specific
treatment adopted.
   The great remedies  which are employed with  the  view of removing scrofula
and curing the affections it induces, are iron, iodine,  the preparations of potass
and cod-liver oil.   These are all extremely useful, either singly or conjoined, as
they serve to carry out distinct indications in the management of this affection.
   Iron is most useful  in  pale  flabby anemic  subjects, increasing markedly the
quantity and quality of blood in the system.   The  best preparations for chil-
dren are, I think, the  vinum ferri and the iodide.  In older persons the tinc-
ture of the  sesquichloride, and some of the forms of the citrate of iron, appear
to be most serviceable; in other cases, again, the natural chalybeate waters will
be found to agree best.
   Iodine is  especially  valuable in promoting the absorption  of effused plastic
matters, and in lessening the  morbid hypertrophies which so commonly take
place in  scrofula.   The preparation  usually  employed is the  iodide of potass.
In order that this should produce its full effects, it  should be given as freely
as the patient will bear  it, continued  for a considerable  length of time, and
especially administered  in  combination with   other  preparations  of potass.
With the view of preventing its irritating the stomach, it should be given in a
considerable quantity of  some bland  fluid.   Its  combination with  the other
alkalies  renders  it  more efficacious in removing  strumous enlargements and
deposits  of  aplastic and tuberculous  matter.   For this purpose I have found  the
following form extremely  useful for adults, the  dose being proportionately
diminished  in the case of children:—

                       R Potassii iodidi
                          Potassae chloratae aa gj
                          Potassae  bicarbonatis  stiij.

Divide into  twelve powders, of which one is to be taken night and morning in
half a pint  of warm milk.
   In other  cases again, the liquor potassae, Brandish's alkaline solution, or lime
water given freely  in milk, are serviceable, but I prefer the above prescription.
Cod-liver oil is of essential utility in improving the nutrition of the body in
cachectic and  emaciated states  of  the system, more particularly  in growing
children, or in individuals who are  suffering from the wasting effects of stru-
mous suppuration; it  not only fattens  but strengthens the system, increasing
decidedly the  muscular power and the quantity  of red corpuscles in the blood.
It  may  often  very advantageously be administered in combination with  the
iodides of potass or of iron.  Of the  other  tonic  remedies which may be  em-
ployed in this  affection,  such as the preparations  of bark and  of  sarsaparilla,
I need say nothing beyond that they may often be usefully administered in ful-
filling ordinary therapeutic indications.
   The local treatment of scrofula consists in a great measure in the ordinary
local management of chronic  inflammation, modified according to the seat and
particular nature of the affection.   Much of the local treatment, however, espe- 
TREATMENT OP  SCROFULA.
425
cially in the more advanced stages, consists in removing the effects of the disease
in the shape of aplastic deposits, false hypertrophies, and  general  enlargement
and  thickening  of parts.  This  may usually be done by the application of
lotions containing the iodide or the  carbonate  of potass,  applied by means of
lint covered with oil silk; 3j. of each of the salts, with an ounce  of spirits of
wine to eleven ounces of water makes an  excellent application, that appears to
dissolve away the fibrinous and plastic deposits so common in this  disease.   In
many cases frictions with the iodide of lead  ointment, or pressure by means of
strapping and bandages,  will be found the most serviceable means that the
surgeon can adopt.   When matter forms, it should be let out in accordance with
the rules laid down in treating of the more chronic forms of abscess.  In these
cases the injection of the sac of the  abscess with a solution of iodine will be
found very useful.
   In cases of scrofulous disease  of the soft parts, the bones, or the  joints, the
question of the  propriety of operating, whether this be  for the excision  of a
tumor, the resection of  a  joint or bone, or the amputation of a limb, has often
to be discussed.   In these cases  operations should not, I  think, be undertaken
too hastily, too early in the disease, or especially in very young subjects.   The
affection being a constitutional one, it will often be found as the general health
of the patient improves by proper treatment, that local mischief, which at first
appeared of a very intractable character, gradually assumes  a more circumscribed
and  healthy form, and,  in fact, to a great  extent undergoes spontaneous cure by
the restoration of  the healthy action in the parts.  This we especially find to
be the case in young  children, in whom very  extensive  disease of the bones
and  joints may  often be  recovered from, without the necessity of any serious
surgical interference.   Should any operation  be undertaken it is desirable not
to have recourse to it whilst the disease is actively spreading.  Under these
circumstances,  it  is not  only probable that suppurative inflammation  of an
unhealthy  kind  may be set up in the wound  itself, but that disease of the soft
parts or bones may very likely recur  in the cicatrix of the original wound, or
that the corresponding parts on the opposite side of the body may become simi-
larly affected in  very chronic cases of scrofulous disease  of bones and joints.
I  have several  times observed after  excision  of the elbow, the knee, or the
bones of the foot and wrist, that the morbid  action has  returned  in the conti-
guous soft parts to such  an extent as to render a second  operation  necessary,
although the bones were not implicated, the  tissues in the neighborhood of the
cicatrix becoming swollen, spongy, and infiltrated with a quantity of gelatinous
semi-transparent plastic matter, running into unhealthy suppuration, with fistu-
lous tracts leading through it that could not be brought to heal.  In some cases
even of simple  strumous disease of the  integuments of  the arm, leg, or foot,
attended with great and irregular deposition of  plastic matter, and chronic and
intractable  ulceration,  amputation of the limb is the only course left to the
surgeon; when  strumous suppuration leads  to hectic, the  patient will  speedily
sink unless the  diseased structures be removed. 
426
SYPHILIS.
                        CHAPTER  XXXI.

                               SYPHILIS.

  By the  "venereal disease"  is meant any affection that arises from  sexual
intercourse.  It is usually considered to include two distinct specific diseases—
Syphilis and Gonorrhea, which were  supposed  by Hunter and his followers to
originate from  one and  the  same poison.  But this doctrine is erroneous, for
not only are the local  appearances and  constitutional conditions  induced by
these affections widely different, but Ricord has shown  in the most conclusive
manner, that the gonorrheal discharge, when inoculated on the skin or mucous
membrane, never under any circumstances produces a chancre; and that on
the other hand, chancrous pus can never be made to give rise to a gonorrhea;
but that in fact each disease  propagates itself, and no other.  The two diseases
may, however,  co-exist,  and  those cases  in which, after connection with the
same woman, different men have  contracted different forms  of the disease, or
even  both affections, are in all  probability to  be explained by the fact  that
Ricord has pointed out, that a woman may be affected by gonorrhea and deep-
seated chancres on the  uterus, so that although only supposed to be laboring
under one, she  might easily communicate both  or either of  these diseases; the
true nature of her ailments being only ascertainable by the speculum.
  Syphilis1 is  a specific disease, arising from sexual intercourse, and trans-
missible by the contact of its own specific pus with a tender surface; by inocu-
lation into the system through the medium  of the  secretions; or by hereditary
taint under certain  special  conditions.   It presents two distinct orders of symp-
toms, the local  and the  constitutional.  The local or primary symptoms, occur-
ring only on the part to which  the virus  is immediately applied,  and being
transmissible solely by  direct contact or  inoculation;  the  constitutional or
secondary  symptoms, dependent upon the absorption  of the poison into the
economy, affecting  consequently most of the tissues and many of the  organs,
and  being capable  of hereditary propagation, and occasionally of transmission
through the secretions.
  It would be altogether foreign to  the scope of this work  were I to enter into
the general question as to the origin of syphilis, a subject that admits of much
dispute, and that has been  keenly argued.   After an attentive  examination of
it, I think we cannot fail to  come to  the  conclusion that  syphilis  was  either
introduced into Europe, or originated there, towards the end of the fifteenth
century; or if it be  allowed  that it previously existed in the old world, in a
mild or modified form, that about this time it suddenly assumed great intensity,
all  its symptoms being  aggravated  in a remarkable and fearful manner, pre-
senting characters  that  have  certainly not  accompanied  it in modern times, if
we  except the  forms that were  observed in  the British armies during the
Peninsular war,  and, according  to  Larrey, among the French troops  during
Napoleon's German campaigns.

                         PRIMARY  SYPHILIS.

  Primary or  local syphilis is characterized by the presence of specific sores
of special  forms and appearance, characteristic  of the  nature of  the disease.
These may occur on the cutaneous,  the muco-cutaneous,  and mucous  surfaces,
most  commonly on the  latter, on account  partly of their  greater  exposure to

   1 Gonorrhea will be treated of in the chapters on Diseases of the  Urinary Organs. 
INOCULATION.
427
 contagion, but chiefly from their being less perfectly  protected by epidermis.
 These local specific  ulcers or chancres present  much variety as to their appear-
 ance and the course they pursue; so great indeed are these varieties, that they
 have been looked upon by some surgeons as  affording evidence of their  being
 distinct diseases, proceeding  from different poisons.   This  doctrine, however,
 has been  shown by Hunter, and more  recently by Ricord, to be entirely erro-
 neous,  the variety in their appearance  depending  on seat, constitution, and
 other  accidental circumstances.   A  chancre then  is a  specific venereal sore or
 ulcer, originating invariably  from  contagion, and  capable  of propagation to
 other parts of the same or different individuals by inoculation.  Like all other
 ulcers, a chancre presents two  distinct  periods; the first, in which it  is  either
 spreading or stationary, in which alone it is specific, and which may be of almost
 indefinite duration;  and the second, in which it has commenced to granulate,
 and a  process of repair to be set up  in it.
   Ricord has made  the important observation, that if the pus  from a  chancre,
 during its first period, be inoculated into any part of the surface of the  body,
 it will invariably produce another specific syphilitic  sore  or  chancre,  and that
 no pus that is not chancrous can, under any circumstances, occasion the specific
 venereal ulcer.  In this way it is always easy to test whether a suspected sore is
 syphilitic or not.  Ricord has further shown that syphilis is  always in  the first
 instance a local disease, being confined to the specific sore;  and that  the  con-
 stitutional symptoms are only produced by the  absorption of the poison from
 the chancre, which  is indeed a truly  poisonous ulcer, from which the virus may
 be absorbed into and disseminated through the whole system.
   Chancres almost  invariably result from  connection  with a  person  laboring
 under  primary  syphilitic disease, and hence  are  commonly met  with on the
 genital organs;  in the male, on the  glans, the inside of the prepuce,  or even
 the body or root of  the penis; in the female, on the  external organs of genera-
 tion or the uterus.   They may of course  occur in other  situations, as, for in-
 stance, the fingers of a medical man may be accidentally inoculated by contact
 with chancrous  pus, and they may form on other parts where  they have been
 accidentally or purposely inoculated.   Thus I saw some years ago, in  Ricord's
 wards,  a man  laboring under eczema  of the legs, in whom the cutaneous disease
 had been converted  into a series of immense chancres by accidental inoculation
 from a sore on the penis.
   When chancres are caught in connection, they usually commence with a small
 excoriation, which appears to have  been directly inoculated with the specific
 poison.   In other cases, again, though  more rarely, they may be seen at first in
 the shape of a small pointed  pustule, which speedily breaks, leaving an  ulcer
 of a specific character in  its site.  Very generally, however, this pustule escapes
 observation, and the disease is presented in the first instance as an ulcer.   The
■ chancrous ulcer, whatever form it assumes, seldom makes its appearance until a
 few days, five or six, after connection.  In some cases, however, I have observed
 it, evidently from the infection of a fissure or crack, on the day following im-
 pure intercourse, and occasionally, in rare instances, it does  not occur until a
 mueh" later period than that which has been  mentioned.
   Whatever be the  appearances presented by a chancre, there can  no longer be
 any doubt that the disease arises from one kind of  virus only, the modifications
 in  the sore depending on its situation, the constitution  of the patient, and occa-
 sionally on that of the individual who communicates the infection.  That this
 is so, is evident from the fact  that  every chancre, when inoculated, reverts to
 one typical form, and that however  much chancres may ultimately differ, they
 all present  the  same characters during  their early stages.   The progress  of a
 chancre that has been artificially inoculated on any part  of the cutaneous surface
 is as follows, and its study will serve  to  elucidate what takes  place under other
 circumstances.   During the first twenty-four hours  after the introduction  of the 
428
SYPHILIS.
specific pus into the skin on the point of a lancet, we find that some inflamma-
tion is set up around the puncture, which becomes hot, red, and itchy.   About
the third or fourth day, a pointed pustule is produced, which is at first deep-set,
but becomes on the following day more superficial, with some depression in the
centre, resembling pretty closely  a small-pox pustule; on close  examination,
this will be found not to be a true pustule, but rather a mass of epithelial scales
and pus not included in a distinct wall.  On the fifth day, it has become hard
at the base, apparently from the infiltration of plastic matter, and on the sixth
it has  usually dried, forming a  small  round scab, and  leaving an  ulcer which
presents the typical characters  of a true chancre, being circular and depressed,
with a foul greyish surface which  cannot be cleansed, sharp cut edges, a hard
base,  and an angry-looking red  areola around it.   This is  the  typical chancre,
and these are the appearances that every true  syphilitic sore on the skin will
present about the fifth or sixth day after  inoculation; from this time it may
diverge more or less completely from these characters, but will yet, if inoculated
at any time during the poisonous stage, produce an ulcer that will run the specific
course up to the same period, after which it may in its turn again  deviate into
one or other of the special forms that chancres occasionally assume. When inocu-
lated on a mucous surface, chancres do not so early assume an indurated character
around their base.
   The varieties presented by chancres have been described under various de-
nominations by the  numerous writers on syphilis.  The following classification
will, I think, include them all: — 1st, the simple chancre or chancrous excoria-
tion ; 2nd, the indurated or Hunterian;  3rd, the phagedenic;  and 4th, the
sloughing chancre.
   1st. The simple chancre, or chancrous excoriation, is  certainly that form of
the disease which is most commonly met with in London at present. It consists
of one or  more small  sores, of a very shallow character, resembling rather an
abrasion, with sharp cut edges, somewhat circular in shape, and having a tawny
greyish or  yellowish surface, with a narrow red areola around the edge : in many
cases attended with much heat and itching.   These sores are usually seated on
the cleft under the  corona glandis, or about the glans, the  wliole of which may
be studded by them.   In other cases, they invade the  frasnum, which may be
perforated, or they occupy the mucous surface of  the prepuce; in  no cases are
they indurated in their early stages.
   These  excoriated chancres   not  unfrequently present somewhat  varying
appearances.   In some cases their surface,  becomes covered with  large fungous
granulations, hence termed j"ungating sores.  In other instances, again, they are
truly irritable, becoming exceedingly sensitive, with a tendency to  spread, and
having an areola of a dusky red hue around them.  It  very frequently happens
that these  chancres are attended by much general  inflammation of the penis,
the organ being swollen, red, and  semi-transparent, from subcutaneous oedema;
usually in a state of phymosis, with a good deal of purulent secretion between
the prepuce and glans.
   2d. The indurated  or  true Hunterian chancre, as it is termed, is not by any
means so frequently met with as the last described variety; it may, however, be
looked upon as the typical form of chancre, resembling  in  every respect the
inoculated  form of the  disease.   The great characteristic of this form of chancre
is the induration of its edges and  base, and this character is met with from the
very first.  Any chancre, but more especially the chancrous excoriation, may
during^ its progress  become  indurated from  undue  stimulation, or from being
otherwise improperly inflamed, but the Hunterian chancre is indurated from the
very first, and continues so throughout.  This induration of the base is the
result of a peculiar plastic effusion, which, though it resemble microscopically,
and chemically, ordinary healthy lymph, yet very distinctly differs from it in its
vital characters, just as the pus of a chancre may differ in this respect from that 
VARIETIES  OP CHANCRE.
429
which is secreted by a healthy ulcer.   The great peculiarity of the plastic base
of the Hunterian chancre is certainly that it in some way serves as a source for
the continued production of the virus and the consequent impregnation of the
system with it.  Besides the presence of this induration, the Hunterian chancre
is characterized by its circular shape, its elevation above  the surrounding parts,
and the very adherent grey slough that covers its surface.  It is usually seated
on the glans, but not unfrequently on the skin of the prepuce or of the root of
the penis.
  3d. The phctgedsenic chancre  is characterized by a tendency to  erosion, with
much destruction of the  parts that it invades.   It may assume  the phagedaenic
character from the very first, or this  may be set up in one of the other varieties
of chancre  at some period of their  course.  The progress of this phagedaenic
or eroding chancre  is usually somewhat slow, but continuous;  it commonly
affects the glans, more especially in the neighborhood of the frsenum or urethra,
destroying a  considerable portion of the organ  in  this situation.   Mr. Wallace
has divided this form of chancre into  three varieties, that without slough, that
with white slough, and  that with the  black slough.   Each  of these varieties,
again, may be of a  simple, an  inflamed, or an irritable character.   This clas-
sification appears to me  to be  a useful and practical one, and I accordingly
adopt it.
  The phagedenic chancre, without slough, is a truly eroding  ulcer,  spreading
with sharp-cut edges, attended  by some  slight inflammatory action  and with
much activity of progress; it is commonly observed about the frsenum and under
part of the glans, and very frequently hollows out and destroys the  organ in this
situation to a considerable extent.
  In the phagedenic chancre, with white slough, we find an irregular eroding
ulcer, with a thin  margin of white slough situated at the junction of the dead
and living structures; that which covers the surface of the sore having usually
become darkened by exposure to air, to dressings, and to secretions.
  The phagedenic chancre, with black slough, differs but little from the last,
except in the color of the slough, which may be in a great measure accidental,
its  tendency to  induration, and  to somewhat rapid extension; it  must not be
confounded with the next form of chancre, which  presents many points of dif-
ference.  All these  varieties  of phagedaenic  chancre may be  inflamed, being
attended by much heat, redness, and swelling, increase of discharge and rapidity
of action ; or they may be irritable, occurring in cachectic individuals, when they
are accompanied by much pain, and usually a good deal  of constitutional  dis-
turbance of a nervous and irritative type.
  4th.  The  sloughing chancre, or gangrenous phagedena, is a combination of
rapidly spreading and destructive gangrene with the syphilitic poison.  It may
be looked upon as a gangrenous inflammation of a syphilitic character, and usually
affects the prepuce and glans; the parts becoming immensely swollen, red, and
somewhat brawny, and the prepuce being in a state of complete and permanent
phymosis;  a dusky black-looking spot soon makes its appearance on one side of
the organ ; this rapidly extends, giving rise to thick,  black, soft, and pultaceous
sloughs destroying perhaps the whole of the prepuce, and exposing and impli-
cating the  glans to a great extent, accompanied sometimes by copious hemor-
rhage from the dorsal artery of  the penis on the separation of the  sloughs, and
by denudation of the  corpora  cavernosa.  In other  cases again,  the prepuce
sloughs on one  side only, a round aperture forming in it, through which the
glans projects, giving the organ a very remarkable, and at first sight, somewhat
puzzling appearance.
  Chancres may be met with on any part of the male genital organs, their cha-
racters varying somewhat,  however,  according to the  situation  in which  they
occur.   Ihey are by far most commonly seated in the angle formed  between the
glans and the prepuce; they then appear most frequently at the  orifice  or on 
430
SYPHILIS.
the inner surface  of the prepuce, next on the fraenum, then on the glans, and
lastly at the orifice of the urethra, or on  the skin of the body of the  penis.
Occasionally chancres are met with on the ends of the fingers, or inside the lips.
The situations that specially modify the character of chancres,  are the fraenum
and the orifice of  the urethra.   Those about the fraenum are often sloughy and
irritable, have a great tendency to perforate or  destroy this fold  of mucous mem-
brane, and are more frequently followed by hemorrhage or bubo than any of the
other varieties of the disease.
   Urethral chancres are usually situated just within the orifice of the canal, and
may be seen on  pressing open its lips, in the form of a small sloughy sore, which
occasionally creeps out upon  the glans.  Sometimes they are more deeply seated,
so as to be out  of sight; when this is the case a thick, tenacious, sloughy, and
bloody discharge  appears  in small quantities from  the urethra; at a little dis-
tance  up the canal there will usually be felt, on grasping the organ between the
fingers, a circumscribed indurated  spot, which is somewhat painful on pressure
and after micturition.   These-chancres have been  found by Ricord to extend
along the whole of the urethra even to the  bladder, and it is  their presence in
this canal that  formerly led  to the supposition of the identity of syphilis and
gonorrhea,  an error the  nature  of which  has been cleared up by  the test of
• inoculation; the discharge from urethral chancres  producing the typical sore,
 that from gonorrhea giving no result when introduced  under the skin.
   In  women, chancres are usually situated on the external organs of generation,
 most  usually just inside the  fourchette  or labia minora, very  rarely indeed  on
 the lining  membrane of the vagina, but  sometimes on the cervix or os uteri;
 hence it is impossible  ever to pronounce a woman free from  syphilis without
 examining these  parts by means  of the speculum.  When situated upon the
 external organs, they are not unfrequently concealed  between the  rugae, or in
 nooks and corners of the mucous membrane.  In these cases their  presence may
 sometimes  be detected by the labia being swollen and  cedematous  from the irri-
 tation of the chancres.
    The diagnosis  of chancres is usually sufficiently  easy, the peculiar characters
 of the sore enabling  the surgeon to recognise it in all  its forms.  In other
 instances, however, it is by  no means easy to say positively whether an ulcer on
 the penis is or is not of a chancrous character.  It is  especially difficult to dis-
 tinguish some  forms of excoriated chancre  from herpes or  aphthae  on the pre-
 puce  or glans, or  from those slight excoriations that many men habitually con-
 tract  after a somewhat impure connection; so also the wound resulting from a
 ruptured fraenum often presents a suspicious appearance.   In  these cases, how-
 ever, the absence of any specific character  about the  sore,  its  immediate occur-
 rence after connection, the general  known tendency of  the  patient to these
 affections,  and  the fact of the inguinal glands  not being indurated and enlarged,
 as they are in cases of true chancre, will enable the sturgeon to make the diag-
 nosis.  When  the prepuce  is in a state of  inflammatory phymosis, it  is always
 extremely difficult to determine by mere examination whether there are chancres
 under it or not, though their indurated bases  may sometimes be felt through it.
 In the case of the indurated, the phagedaenic, or the sloughy chancres, there
 can be little difficulty in establishing the true nature of the affection.  In those
 cases  in which a comparison of the characters of the  sore with one or other of
 the different recognized varieties of chancre failed  in enabling the surgeon to
 determine the true nature  of the affection, it was thought at  one time that the
 influence  exercised  by mercury upon  the sore would determine whether the
 disease was syphilitic or not; the true chancres being supposed to be curable in
 no other  way  than by  the internal  administration of mercury: but although
 there can  be no doubt  that the influence exercised by treatment assists  the sur-
 geon  considerably in  the diagnosis of obscure cases, yet it  cannot be relied
 upon as a test of the nature of the disease, many syphilitic affections being 
TREATMENT  OP  PRIMARY  SYPHILIS.           431
readily curable by very simple  means  without mercury.   The  only sure and
unerring test that we possess of the nature of a suspicious sore, is the result of
the inoculation of its pus into some part of the surface of the body.   If this be
done with the point of a lancet into the inside  of the thigh, the typical chancn.
will be produced, if  the suspected sore be syphilitic, and no effect will result if
it be not so.   It must be borne in mind,  however, that if the ulcer from which
the pus is taken has got into a granulating state, no effect  may be produced,
whatever its previous condition has been ; and that if the sore, though of vene-
real origin,  be not  a primary  syphilitic one,  its  pus will not  be  inoculable.
Though inoculation is a sure and valuable test of primary syphilis, it should not
be  too freely had recourse to, as it not uncommonly happens, as I have several
times seen, that the  sore produced by it is far more troublesome in healing than
the original chancre.

               TREATMENT OP  PRIMARY  SYPHILIS.

   The treatment of syphilis is a subject that has engaged the anxious attention
 of  the most eminent surgeons, and one on which so much difference of opinion
 and practice still prevails, that I shall not endeavor to discuss the subject gene-
rally, but rather confine my remarks upon it to the consideration  of that form of
 treatment which has met with the sanction  of the best surgeons in this country,
 and which a tolerably extensive experience in hospital and private practice has
 led me to consider as  the most safe and effectual.
   The treatment of chancre is of a local and a constitutional character, the local
 treatment having for its object either to destroy the poisonous character of the
 sore, or to modify it so as to bring it into the state of a healthy  ulcer; the con-
 stitutional treatment is not only intended to  facilitate this, but to  prevent, if
 possible,  constitutional infection.
   The local treatment, then, has for its object either the destruction or the modi-
 fication of the specific character of the sore.   The complete destruction  of the
 local virus should always, if possible, be effected ; and if this can be done, in the
 early stage of the disease, according to Ricord, before the fifth day after inocu-
 lation, there will not have  been time for any constitutional infection to  have
 taken place  from the absorption  of the poison into  the system.   But  even
 though this time have been considerably passed before a surgeon sees the sore,
 it is well to destroy the ulcerating and poisonous surface, from which continued
 absorption must necessarily be going on.   This should be effected by the appli-
 cation of caustics in a sufficiently concentrated form to  destroy radically and at
 once the specific character  of the sore,  so as not only to save the pain, but  to
 prevent the irritation attendant upon frequent applications.  The  nitrate of silver
 which is commonly used  for this purpose is too weak to secure  the  effect it is
 intended  to  accomplish, being apt  to  irritate  and inflame, and  not to destroy
 the chancrous surface, thus necessitating repeated and painful applications.   I
 consequently prefer to this  the strong nitric acid, one application of which will
 very commonly suffice to annihilate the specific character of the sore, and which,
 though more energetic in action, is not more painful than the nitrate of silver.
 It  should be applied by means of a  small dossil of lint  wrapped round the end
 of a silver probe; with this the sore may be freely mopped, and then a stream
 of cold water having been poured  over it to wash away any superfluous acid, a
 light poultice or a  piece of water-dressing  should be  laid on;  after the small
 slough produced by the caustic has separated, a healthy granulating surface will
 be  left.   The caustic may be applied at any time during the continuance of the
specific condition of the sore;  but when once this has been destroyed, it should
not be  re-applied.  The potassa fusa and the potassa cum calce, though occa-
sionally used, are far less manageable and not more efficacious applications than
the nitric acid. 
432
SYPHILIS.
  These are the means that are generally most useful in simple and indurated
chancres.  In some cases, however, caustic cannot be used at once; this is espe-
cially the case if the sore be inflamed, or if it be concealed by a phymosis.   If
there be much inflammation about the sore and prepuce, this must first be sub-
dued by the  application of cold poultices, or of lead and spirit lotion.  When
removed, if the sore has not lost its specific character, the caustic should be
applied as usual.   When there  is much phymosis present, the prepuce  should
be slit  up, and the surface  of the sore  immediately freely touched with nitric
acid, so as if possible to prevent inoculation of the freshly-cut surfaces;  should
this  take place, they must also  be freely sponged with the caustic.  After the
slough produced by the caustic  has separated, the surface may begin to granu-
late  healthily at once, requiring  but simple  dressings; but in the majority of
cases it will continue in a somewhat unhealthy condition, requiring special topi-
cal applications to get it to cicatrize soundly.   If it be weak and fungating, an
astringent lotion, such as the following, will be found most useful: —

   R Tannin 9j.j  Tinct. lavandulae comp. gij.; Vini rubri ^iv.  Ft. lotio.
Or a solution of sulphate of copper may be applied, and the sore touched from
time to time with the nitrate  of silver.   If there be induration at its base, the
black or yellow wash will perhaps be found the best applications that can be
used.
   In the phagedenic chancres a  different management is required; if there is
much irritability about the sore,  the nitric acid cannot be borne, and here the
best application is an  opiate  lotion conjoined perhaps with small quantities of
the  chloride of soda.   If the part require more stimulation, a few drops of the
dilute  nitric acid may advantageously be added instead of the chloride.   In
these cases, however, the application of the strong nitric  acid may often be
required at a later period of the affection, on the removal of the local irritation
by the topical employment of sedatives.
   In  sloughing chancres, emollient and antiseptic applications will generally
be found to agree best;  carrot, opiate, charcoal, or chlorinated poultices should
be employed, the  sloughs removed, and  any parts that are partially destroyed
by the gangrenous action, as portions of the  prepuce, slit up, so as to  remove
tension and lessen  inflammation.  In  cases  of inflammatory sloughing of the
 penis, the hemorrhage that occasionally  results, from some of the blood-vessels
 of the organ being opened by this action, may be  looked upon  as highly bene-
 ficial, inasmuch as it is often followed by  an arrest  of the morbid process.
 When once the chancre is healthily granulating it must be  dressed in the same
 way as any common ulcer.   In using lotions to any form of chancre, care should
 always be taken to keep a piece of lint soaked  in the fluid constantly applied
 between the prepuce and the glans, and, in women,between the opposite labia;
 for  unless this be done, the  contact of the diseased  and inflamed mucous sur-
 faces with one another will tend to keep  up irritation and morbid action.
   The constitutional  treatment of primary syphilis  is of the first importance,
 not so much with,a view of getting the local sore to cicatrize, as to prevent, if
 possible, constitutional  infection.  As  it is impossible to say when the absorp-
 tion of the poison into the system takes  place, though it is probable, as Ricord
 supposes, that it  does not occur before  the  fifth  day, constitutional treatment
 should be had recourse to from the very commencement of the  disease.
   The  constitutional  treatment  of primary  syphilis has  undergone  various
 changes according to the prevailing doctrine  of the day.  It had been decided
 by the  surgeons of the last and of the  early part of this century, that mercury
 acted as a specific against the  syphilitic poison.  This  doctrine was so firmly
 established, that Hunter, and many of the great surgeons of his school, looked
 upon the curability of a sore without mercury as a proof that it was not syphi-
 litic.   About  the commencement of this century,  however, it was found by 
       SIMPLE  AND  MERCURIAL  TREATMENT COMPARED.   433

the observations of the army surgeons, amongst whom Mr. Rose took a prin-
cipal share in  this inquiry, that the different  forms of primary syphilis were
curable without the necessity of administering  mercury, or indeed to  have re-
course to any specific treatment whatever.  These  observations, which appeai
to have  been founded  on what was witnessed  in  Spain and  Portugal during
the Peninsular War, led  to the introduction of an important modification in
the treatment  of  syphilis,  viz., the non-mercurial  or  simple plan,  as  it is
termed:  a mode of practice that obtained great favor, and has been extensively
tried.  Of late years, however, a reaction has again, I think, taken place in the
minds of most professional men, and mercury is again employed in  the treat-
ment of  this disease, but  more moderately and scientifically, and consequently
more successfully, than  before.
   The arguments in favor of the  non-mercurial plan  of treatment are briefly
these : that by this system of treatment the constitution of the patient  is saved,
the introduction of a mineral which in many cases acts injuriously, and which,
as the disease  can be  cured without it, may at all events be  looked  upon as
unnecessary; then, again, it  is stated by  the advocates  of the simple treat-
 ment, that secondary affections less frequently follow this plan than they do
 the administration of mercury; and, lastly, that those distressing cases of con-
 stitutional syphilis, which are common after mercurial courses, and which are
 said to depend upon a  peculiar combination of the syphilitic poison  and the
 mineral in the system, are never met with in persons who have undergone the
 simple treatment.  These  arguments, however,  on  closer examination  and
 further experience, have not been proved to be quite so conclusive as  the  sup-
 porters of the  simple treatment appear to believe.  That a great number, per-
 haps the majority, of cases  of chancre can be healed without the administra-
 tion of mercury is undoubtedly the fact; but  in  many instances  it is equally
 true  that the  primary  sore will not cicatrize  properly unless the mineral be
 administered, or if it do close, that it heals in  an imperfect manner, readily
 breaking out again.  But it is a most serious error to confound the healing of
 the sore with the  cure of the disease.   The cicatrization of the ulcer  and the
 prevention  or  neutralization  of  the  constitutional infection, are two distinct
 things;  and  the  test  of the  relative  value of  these two plans  of treatment
 must  depend  rather  on  the  relative  frequency with which they are  followed
 by constitutional symptoms, and on the character that these  assume under one
 or other of these methods, than on the  mere  skinning over of the  ulcer.   I
 cannot agree  with the statement that secondary symptoms are less  frequent
 after the simple than  after  the mercurial  treatment of syphilis.   I have seen
 the non-mercurial plan of treatment very extensively employed at the Univer-
 sity College Hospital;  indeed it was formerly almost invariably practised there,
 more particularly in the syphilitic cases occurring among the out-patients under
 the late Mr. Morton, who strongly advocated it;  and I have had repeated occa-
 sion to  observe the frequency with which  it was followed by secondary symp-
 toms.   In private practice also I  have had considerable opportunities of  com-
 paring the two methods, and I can  safely say  that  I  have seen the simple
 treatment more frequently followed by secondary symptoms than  the mercurial
 plan has been when properly and  judiciously employed.  The supporters of the
 non-mercurial treatment,  when  obliged  to admit the  great frequency  with
 which it is followed by secondary symptoms, argue, that if more frequent, they
 are less  severe after the simple than the  mercurial plan;  and they state some-
 what dogmatically, and it appears to me without much evidence to support this
 statement, that mercury and syphilis  together form a sort  of poisonous  com-
 pound in the system which produces the worst  and most destructive  forms of
 constitutional  syphilis.   I deny, however, entirely that we have  any  proof of
 the existence of such a combination as that which is  supposed to be  produced
 by syphilis and mercury; no evidence that  I am acquainted with has ever been 
434
SYPHILIS.
adduced in support of the  formation  of such a poison in the system.  It is
doubtless  true that  after  an ill-regulated  mercurial  course,  constitutional
syphilis of a very severe character may occasionally appear; but this  seems to
me to be  rather owing to mercury having been  improperly administered in
constitutions that will not bear it, and  in which, by the induction  of a cachectic
and depraved condition of the system, it favors the occurrence of some of  the
more severe forms of secondary syphilis, in the same way that any other lower-
ing plan of treatment, or simple  debility might occasion them, but without the
exercise of any specifically injurious  influence.   Some of the worst  forms  of
constitutional syphilis that I have  of late  seen, occurred in patients to whom
no mercury had been administered, but in whom  the syphilitic virus had been
allowed to exercise its influence unchecked save  by the so-called simple treat-
ment.  I have seen the body covered  by immense ecthymatous crusts and sores
in one  case, rupial ulcers with  destruction of the nose and palate in another,
and the worst kind of syphilitic cachexy with the tuberculo-pustular syphiloid
in  a third;  in  none  of which had any mercury been  administered.  But
though I cannot admit that the  supporters of the simple treatment of syphilis
have brought forward any proof  of its superiority over the mercurial  plan,  and
though my own experience has taught me that secondary symptoms occur after
it with equal severity and with far  greater frequency than they do when mer-
cury is carefully and  judiciously administered, yet  I am quite ready to allow
that there are certain  forms of primary sore, especially those  of  a phagedamic
or sloughing kind, in  which the  simple treatment alone is admissible, the state
of the  constitution or the disease being such that mercury cannot be given in
any form.  In these cases the patient must be kept in bed, his bowels properly
regulated, and such a treatment adopted, in  accordance with  ordinary medical
principles, as will  tend to  subdue  local action  and improve his general con-
dition.  It is, indeed, especially in individuals of an  unhealthy or strumous
habit of body, or in those who are  suffering from local visceral disease of some
kind, that this plan  of treatment  should be  adopted.  So also  in those who,
from the nature of their occupations, are subjected to much exposure to wet
and cold, a mercurial  course  cannot be properly or safely administered, and the
simple treatment is the only plan that should be adopted.   In all other cases I
am certainly  of opinion that  mercury ought to be  exhibited, and this opinion
 appears to be entertained by  the most experienced  surgeons of the day in this
country and in France.
   The first question in  connection with the employment of mercury in syphilis,
 has reference to the principle on which this remedy is administered.  Whether
 mercury exercises a specific  action over the venereal poison or not, has been
 much discussed, and is difficult of proof.  I am certainly of opinion that it  does
 act as a specific in cases of  primary syphilis, but that this specific  action is much
 influenced by the condition of the  system, the  habits  of  the patient, and  the
 mode of administration of  the remedy; these conditions under certain circum-
stances tending to counteract or otherwise  to  interfere with its  operation.   As
 has already been stated, I  do not for  a moment  doubt that most primary sores
 mav be readily got to cicatrize without administering a grain of mercury to the
 patient, but I believe that  in these  cases, and my belief is founded on tolerably
 extensive experience  at the  hospital  to which I am attached, secondary symp-
 toms will be almost certain to occur,  and indeed will  appear pretty soon  after
 the cicatrization of the local sore;  the disease in fact appearing  to contaminate
 the  system  unchecked.  That  mercury in many  cases is antagonistic to the
 syphilitic poison, appears evident from the fact that in some instances chancres
 will not heal unless it be given internally, — from its influence  on  infantile
 syphilis,—and that when properly administered in healthy constitutions it may
 almost to a certainty be looked upon  as a preventive to the occurrence of con-
 stitutional syphilis.  When it fails, as it doubtless does in many cases to prevent, 
MERCURY  IN  SYPHILIS.
435
or to eradicate the  constitutional infection, the  cause  of the  non-success may
usually be traced either to want of care in its administration, or to the existence
of an impaired state of the patient's health.
  In  connection  with the administration  of mercury in syphilis,  therefore,
various questions present themselves, the proper determination of which is of
the first importance; these have reference to the state of the constitution, the
condition of the sore, and the mode  of the administration of the remedy.
  The state of the patient's constitution  influences materially the propriety of
the administration of mercury.  In ordinarily healthy constitutions it may always
be safely employed; but if the powers of the  system be broken by excesses of
any kind, if the patient be of a strumous habit of body, if he be irritable,
feverish, or excited, it must be exhibited with great caution, or should be with-
held until these states of the system are modified or removed.   It is especially
by  administering mercury to strumous and cachectic patients, or to those whose
powers have been broken by habitual dissipation, that so much mischief results;
and that  it occasionally gives rise, by acting  as a depressing  agent, to local
sloughing, or to some of the low forms of secondary syphilis.
   The condition of the sore in which mercury should  be given, is equally im-
portant as that of the health.   It should not be administered  during the  early
stage of an inflamed or irritable ulcer.   So long, indeed, as such a condition
keeps up in the sore, mercury will often act injuriously, by exciting a sloughing
tendency in it, more especially in debilitated or broken constitutions; hence it
is well to subdue  the inflammation or local irritable condition before the mineral
is employed.
   The particular  preparation of mercury to be given, the length of time that it
should be continued, and  the  rules to be observed during the mercurial course,
are all matters that influence greatly the result of the treatment.
   Mercury may be administered by  the mouth, by inunction, or by fumigation.
When it  is to be  given  by  the mouth in primary syphilis,  and when it  is
desirable to produce but a moderate effect upon the system, I prefer the iodide
of  mercury, in doses of one grain three times a day; or the Plummer's pill, in
five-grain  doses twice  or three  times  a day, will be found  extremely useful when
the constitution is  somewhat  irritable.  If it  be  desirable to produce a rapid
effect upon the system, five grains of blue pill may be given night and morning.
The other preparations of mercury are not,  I  think, required in the primary
form of the disease.  When it  is required to produce a moderate effect, especially
in somewhat delicate persons,  without irritating the  system or inducing much
salivation, the iodide is certainly  to be preferred to all other preparations.
   In some cases the bowels are so irritable that  the  administration of mercury
by the mouth  invariably purges the  patient; under  these circumstances the
mercurial inunction may be conveniently practised. This is best done by rubbing
a drachm of the strong ointment into the inside of each thigh for ten minutes
every night and morning; or  by putting a similar quantity upon a piece of lint
and letting the patient wear it during the day and night  in either axilla.
   The duration of the mercurial course  must depend upon the effect produced
upon the  sore;_ it need not be continued until this has cicatrized,  but it should
be  persevered in until all specific action in it  has ceased, and it has got into a
healthy and healing state.   This  impression is seldom produced  upon the sore
without a slight  effect  upon  the mouth  having previously been  induced, the
gums becoming spongy, red, and  swollen, and an increased flow of saliva taking
place.  It is never necessary to continueUhe mercury so long, or to give it to so
great an extent, as to produce very profuse salivation.  It was in attempting to
do this, and by administering the remedy in too large a quantity and too rapidly,
that the older surgeons produced  such injurious  consequences.   The effect pro-
duced upon the sore, rather than that upon the gums, should be our guide as to
the proper time for discontinuing  the mercurial. 
436
SYPHILIS.
  The rules to be  observed during a course of mercury exercise considerable
influence upon the effects produced by it.  The system should always be prepared
for its administration by a free  purge.  Whilst  it is being given, the  patient
should, if possible,  be kept in bed, or at  all events be  confined  to the house,
taking as much rest as possible; the diet should be moderate and unstimulating,
and the dress be  as warm as the season will admit.   If the  mercury be given
by the mouth, and  gripe, it will be found  useful to combine it with capsicum.
If it  purge, small doses of  opium may advantageously be exhibited in conjunc-
tion with it.   After it has been carried to the full extent deemed advisable, it
should not be suddenly left off, but gradually discontinued  by diminishing the
quantity daily during a week or ten days.  If administered in accordance with
these rules, and in  proper constitutions, we shall  seldom find  any of those
injurious effects  produced that were formerly described as  resulting from the
exhibition of this mineral; those severe and  extensive forms of ulceration of
the mouth leading  to necrosis of the jaws, and the mercurial erythema, or ery-
thismus, described  by the  older  surgeons, are now happily almost matters  of
history, being but  seldom if ever met with.
   These are the  general  principles  upon which primary syphilis requires to be
treated : now for  a few words as to the special management of the different forms
of chancre.
   The simple or excoriated chancre should be cauterized with nitric acid, dressed
with  water-dressing for two or three days until  the slough  separates, and then
with  the black wash, or the sulphate of copper, or tannin and wine lotion if the
sore be weak and fungating; in which condition  also it will require the occa-
sional application of the nitrate of silver.   At Ahe same time the  patient should
be put upon a mild course of the iodide of mercury.
   In the indurated or Hunterian chancre, the nitric acid may be freely applied
in the early stages,  so as  to destroy  the surface of the sore, but no  attempt
should be made to  burn away the indurated  base with caustics, as they will
prove unsuccessful in this, the indurated condition always extending beyond the
influence of the caustic.   In  these cases the best local application is generally
the black wash.  It is in this form of sore that mercury is especially useful, and
is most imperatively required; a  full  and  continued course should be adminis-
tered, and the influence of the mineral  kept up until all  hardness has disap-
peared ; unless  this be  done, the patient will  almost to a certainty suffer early
and severely from  secondary symptoms.
   In the phagedenic ehaneres the line of practice is not so clear, as much must
depend upon the particular form  of the sore, and the state of the patient's con-
 stitution.   If there be  much inflammation or irritation about the chancre, this
must always be subdued  in the first instance, by the  employment of mild local
antiphlogistic means and the application of opiate lotions.   In many  cases,
however, the  local  inflammatory action is best removed  by the  application of
 the  concentrated nitric acid, this being followed by opiate lotions or emollient
 poultices, the caustic being reapplied so often as there is a tendency to  the
 extension  of the disease.  The constitutional treatment  in these phagedaenic
 chancres must  usually be  of the non-mercurial kind; indeed, it is the  indis-
 criminate  use  of mercury  in these cases that has, I believe, brought so much
 discredit upon this remedy in syphilis.   The constitutional  treatment of phage-
 daenic chancre must be  directed by general medical principles; rest in bed, a
 mild diet, the administration of salines and opiates, in those cases  in which there
is inflammation  and irritation  conjoined; whilst in those  in which there  is a
 debilitated or cachectic condition, tonics, such as bark or iron, with good food and
 stimulants, may  be required, together with opiates to allay  pain  and to procure
 rest.   The preparations  of iron, especially  the ammonio-citrate and potassio-
 tartrate, either alone or in  combination with sarsaparilla, are especially useful in
 these cases.   Although  mercury is not  generally admissible in these cases, yet 
CONSECUTIVE  SYMPTOMS.                 437
in that form of phagedasnic  chancre that is characterized by a white slough, it
has been  found useful by Mr. Wallace, and the  utility of this  practice I can
confirm, having found  it of service in some of the more rebellious varieties of
this  disease; the mineral must, however, be very cautiously administered, and
in but small doses.
   In the gangrenous or sloughing chancre, if there be much local inflammatory
action and general  constitutional disturbance, the patient should be treated on
an antiphlogistic plan; be well purged, have salines, and in  some cases, anti-
mony, kept on a low diet, and have  local antiphlogistic treatment;  Free inci-
sions should be  made through the  sloughing  textures, so as to take down all
tensions, and as the powers  of the  system give way,  or, from  the first, if there
be much debility, iron, the mineral  acids, with  quinine, good nourishment and
abundant stimulants will be  required;  at  the same time that chlorinated char-
coal or yeast poultices are applied locally until the sloughs have separated, when
the sore must be dressed on ordinary principles.   Hemorrhage not unfrequently
occurs  from the dorsal arteries of the penis,  and sometimes to  an  alarming
extent,  the patient being occasionally reduced  to  the lowest  ebb by it.   It is
best  arrested  and the morbid action  checked  by the free application  of the
actual cautery, and it will usually be found that the hemorrhage has been salu-
tary, the local inflammatory action being at once arrested by it.
   After a chancre  has  been healed  in  one or other of these ways, we must
endeavor  to prevent the manifestation  of constitutional syphilis, by the general
improvement of the  patient's health.   This is usually best done by putting him
on a course of sarsaparilla with the mineral acids, and by scrupulous attention
for some months to his habits of life.  The syphilitic poison may linger for a
great length of  time in the system, not declaring itself by any overt manifesta-
tions so long as the health continues  good, but  if the patient fall into a  debili-
tated state, even though some years have elapsed, the disease will show itself at
once by some  of its  local effects.
                    CONSECUTIVE SYMPTOMS.

  The primary symptoms of syphilis are not unfrequently followed by a series
of affections which  may be  termed consecutive, depending as they do upon the
primary disease, but yet  being local in their character, and presenting no evi-
dence of constitutional infection.   These consecutive symptoms are, an indura-
tion of the chancrous cicatrix, bubo, and warts.
  Indurated  cicatrices. — Most excoriated chancres are healed without any"
cicatrix or other trace of them being left, but in the indurated, the phagedaenic,
and the sloughing chancres, there is always loss of substance, often to a conside-
rable extent, and consequently a depressed scar.   In  some cases, however, of
excoriated and Hunterian chancre, but most frequently, I think, in the excori-
ated chancre, an imperfect cicatrization takes place over the surface of the sore,
the specific character of which has not been destroyed; the consequence of which
is that the tissue of the  cicatrix gradually increases in  size, becomes indurated,
and is capable  of infecting  the  system.   These indurated cicatrices are espe-
cially apt to follow slight syphilitic excoriations, which may skin over sponta-
neously, even without the patient having been aware of their existence, or which
have  cicatrized under simple treatment.  Under these circumstances a patient
laboring  under  constitutional syphilis will  apply to a  surgeon,  and on being
questioned, may deny having had  any primary disease; but on examination an
indurated cicatrix will be found, evidently the result of a  chancre, that has not
been properly attended to.
  These  indurations vary in size from a  pea to a chestnut; they are usually^
Bituated on the mucous surface of  the prepuce or glans, and sometimes on the 
438
CONSECUTIVE  SYPHILIS.
fraenum, and are commonly accompanied by  an  enlarged and indurated con-
dition of the inguinal glands.  This indurated cicatrix is a condition of impor-
tance, as it shows the  persistence of the syphilitis poison in the site of the
chancre, where it exists as a continued source of infection to the system, which
it  may  poison  as effectually and as  quickly  as  an open  chancre, a  kind of
zymotic action being continued in it,  generating and transmitting the syphilitic
ferment into the blood.  These  indurations must be looked upon as infallibly
leading to constitutional  syphilis unless speedily removed.   If  left to them-
selves, they readily break  into secondary ulcerations, forming excavated and
sloughy sores.   On examining  their structure,  it  is found  to  be composed
simply of  plastic  matter, consisting of  the  ordinary filaments  of this,  with
spindle-shaped and elongated cells undergoing transformation into  fibro-cellular
tissue.  It is  a remarkable fact, that the  indurated cicatrix not  only always
comes  on slowly after the sore has apparently healed, but very frequently does
not make its appearance until after a lapse of some weeks or months, without
inflammation, pain,  or local inconvenience of  any kind, the surgeon often dis-
covering it without its having attracted the patient's attention.
   The treatment of this induration must  be conducted in the same way as that
of a Hunterian chancre, by means of a full and steady course of mercury, until
it  has wholly disappeared.  Unless  this be  done, there  is no safety  for the
patient from constitutional syphilis.   Caustics  should never be applied  to these
indurations, as  they occasion troublesome ulcers, and the only local treatment
that is likely to  be of any service is the  application of a piece of lint soaked in
black wash, so as to prevent excoriation.
   Bubo.—Every enlargement of the inguinal glands that  occurs in a case of
syphilis must not be considered a bubo.   The glands may be irritated by con-
comitant inflammatory  action about the  penis, as when balanitis  or phymosis
are present;  or they may be enlarged from the simple excitement of the parts,
especially in strumous  and debilitated  subjects.   In these  cases  the  affection
must be considered as a simple irritation of the inguinal glands, which will
speedily subside under proper antiphlogistic treatment of a mild kind.   Indeed,
it  scarcely ever happens that a chancre has existed for  some  days without the
lymphatic  glands in  the  groin becoming enlarged  and  somewhat indurated,
especially those  that lie parallel to Poupart's ligament, their enlargement being
attended with a degree of stiffness and dragging pain.   Under these  circum-
stances, true specific bubo is very apt to  occur if the patient  continue to walk
about, or if the  poisonous matter from the chancre becomes absorbed.   When
once the  glands in the groin have become specifically irritated it is extremely
difficult to prevent suppuration  taking  place.  Most usually  only  one or two
glands suppurate, although several may be enlarged, and  very commonly the
disease is  confined to one  groin only, though both may be affected, more  particu-
larly if the chancre is situated upon the fraenum; the suppuration may be limited
to  the gland immediately affected, or it may extend into the surrounding cellular
tissue, or even be chiefly confined to this.
   The syphilitic bubo is  essentially produced by the absorption and deposit of
the venereal virus in the  substance of the gland, the tissue of which becomes
poisoned, so that we may consider with Ricord that a bubo  is, properly speaking,
a chancre of an  absorbent gland, differing only in seat from that which is  situ-
ated upon the surface of the body.  Ricord has observed, and  I have often had
an opportunity of testing  the correctness of this observation, that the pus of  a
syphilitic  bubo  is as readily inoculable  as that of an ordinary chancre.  The
ordinary syphilitic bubo,  then, may be  considered as a  specific abscess of the
absorbent glands and surrounding cellular tissue.   It runs  the ordinary course
of an acute abscess, often undermines the skin to a considerable extent, with
much red  or purple discoloration, and when it has burst or been opened, pre-
sents a ragged sloughy-looking cavity, having  an unhealthy appearance; it most 
bubo.                              439
usually occurs about the second or third week after the first appearance of the
chancre, but may happen at an earlier or later period.
  The French surgeons have described a form  of bubo that they call bubon
d'embUe, or primary bubo; this  is said  to occur from the direct absorption of
the  syphilitic  poison  without the  previous  formation  of a  chancre.   It  is
seldom  that  satisfactory proof can be given of the  existence  of such a bubo.
It doubtless  frequently happens that small excoriated  chancres heal in a few
days, before which time, however, the  inguinal  glands  have become  irritated
and enlarged, and as the enlargement of the glands goes on after the healing of
the  chancre, a bubo may be  formed when  all trace  of its primary source has
entirely disappeared.
   Bubon d'emblee or  primary  bubo, has only fallen under  my observation  in
one case, and, until that occurred, I doubted its existence.  In the case referred
to, a young man applied to  me with rather a large abscess  in  the groin, for
which I sent him into  the  hospital,   On  being questioned, he denied ever
having had any syphilitic disease, though he  admitted  having had  intercourse
with a woman of the town.  On examining the penis no chancre, abrasion, or
cicatrix could be discerned.  The abscess was opened, and two ounces of rather
bloody and very thick pus let out; no  enlarged glands  could be seen.  As the
pus looked suspicious, it was inoculated into the left thigh, when two  distinct
and well marked chancrous pustules were produced.
   In some cases the bubo, as has been  well shown by Mr. Solly, assumes a ten-
dency to creep or spread over  the  neighboring integument,  extending in this
way to a considerable  distance down the thigh, upon the abdomen,  or over the
ilium; this creeping bubo is characterized by the peculiar semi-circular or horse-
shoe shape that the sore assumes, and by its tendency to  cicatrize by  one margin
whilst it slowly extends by the other, the cicatrix always being thin, blue, and
weak, closely resembling that of a burn.
   After a  bubo has disappeared, a good deal of induration may be  left  in the
glands of the groin, together perhaps with matting of the surrounding cellular
tissue, and this induration may continue for years, or even  for the remainder
of life.
   The treatment of bubo consists in the first instance of an endeavor to prevent
the occurrence of suppuration, and should this take  place, to let out the matter
and close the wound which results.
   The preventive treatment  of bubo is  of considerable moment; for if suppura-
tion take  place, a  tedious result will often be entailed on the patient.  It con-
 sists essentially in perfect rest of the part, the application of leeches, and of cold
 lead poultices; at the same time the free internal administration of  mercury as
 for a chancre  should  be persevered in; for not only has this a  tendency to
 promote the resolution of the swelling, but also to prevent the infection of  the
 constitution  which readily takes  place  when once the  poison has  entered  the
 absorbent system.  The employment  of antimonials in nauseating doses  has
 been strongly recommended  by  Mr.  Milton, and deserves, I think, the attention
 of the  profession.
   If there be  not much  inflammatory action about the bubo, but if this  be
 indolent and chronic,  the application of blisters, of discutient plasters, or of the
 tincture of iodine,  is occasionally useful.  A plan of discutient treatment  re-
 commended by  a  French army surgeon, M. Malplaquet, I  have   found very
 serviceable in several  cases.   It consists in applying a blister about as larce
 as half-a-crown over the  surface of the inflamed gland, and  dressing the raw
surface produced by it with a piece of lint soaked  in  a saturated  solution  of
the bichloride of mercury for a couple  of hours, when a white eschar will have
formed; a cold poultice should  then be applied, and continued until all excited
action has gone down.
   If, notwithstanding our  endeavors  to  prevent  suppuration, matter forms 
440     CONSTITUTIONAL, OR  SECONDARY  SYPHILIS.

within or around the gland, as evinced by the swelling becoming soft, boggy,
and  inflamed, it should be  freely opened, either by a  horizontal  or vertical
incision, whichever will give the readiest  outlet to the pus.  If the integu-
ments be much thinned, undermined, and of a bluish  color, I prefer making
the  opening with potassa fusa,  as it destroys  those unhealthy tissues which
would otherwise interfere with  the  cicatrization of  the wound.   The cavity
that  is now exposed  presents  a chancrous  appearance, being irregular and
sloughy, with elevated and  angry red  edges.   This should be dressed  with
the  aromatic wine  and tannin lotion, at the  same time that the system is kept
under the influence of the  mercury.   If  we find  that the character of the
sore does not improve, the potassa fusa should be freely  applied to its  surface
and edges,  and, after  the sloughs  have separated,  the granulations may be
dusted with red precipitate powder; the cicatrization will in many cases be
much facilitated by the application of a compress,  with a spica bandage, and
by keeping the patient at rest.   Not unfrequently the  healing of  the sore is
interfered with by the  overlapping of the undermined edges;  these  may
occasionally be  made  to  retract by  being  freely rubbed with the  nitrate of
silver.   If  this  do not succeed, it may be necessary to  pare them  off with a
knife or scissors, or to destroy them with  potassa fusa; the sore should  then
be dressed  from the  bottom,  and treated  on general principles.   Sometimes *
sloughing action is set up in the open bubo,  and  then extensive destruction of
tissue may  ensue, and even fatal hemorrhage from the femoral artery has  been
known to occur.
   Venereal warts.—Various forms of warts occur as the result of primary
disease, independently of  any  constitutional affection, arising from simple
irritation of the muco-cutaneous surfaces;  but, besides these, warts or verrucas
of a truly specific  and contagious character are met with.   These commonly
occur on the prepuce or glans, and are especially apt to be situated in the  angle
between these parts;  they are of a bright red color, very vascular, and, if left
without interference,  may increase immensely in size and number, distending
the prepuce,  and giving a  clubbed  appearance to  the  penis; there is always
phymosis attending them, and the tension  of the  prepuce  may be such, that
ulceration  occasionally takes place  in it, giving rise to a protrusion of  these
growths through an aperture in its side.  These warts are occasionally met with
in the vagina, forming large, irregular, cauliflower-looking  masses.   The  treat-
 ment consists in snipping and  paring them off with scissors, and afterwards
 touching the part from  which  they spring  with nitrate of silver, to  prevent
 their recurrence.  In  order to  do this  effectually, it is necessary to  lay open
 the prepuce in all those cases in which the glans cannot be freely  exposed by
 drawing this  back.

          CONSTITUTIONAL,  OR  SECONDARY  SYPHILIS.

   By constitutional syphilis is meant the  general  infection of the system by
 the venereal poison absorbed from a chancre, by which  it is always preceded;
 in many cases,  but not necessarily, a bubo has also been  one  of the antecedent
 symptoms.   This  form of  syphilis  is  commonly called secondary, in contra-
 distinction to the primary or local disease.   It manifests itself not so much by
 the  occurrence of any special diseases, as by the tendency it occasions  to the
 development  of inflammation  in various tissues and  organs, and by the peculiar
 impress that it communicates to the form  and course of the inflammatory
 affections it induces.
    Constitutional syphilis is not  contagious.   This point, which I look upon as
 one of the fundamental  doctrines in  syphilis, has  in my opinion  been  incon-
 testably proved by the observations of Hunter, and more recently by Ricord,
 who has shown that the pus from secondary sores is never inoculable;  obscr- 
CAUSES  OF CONSTITUTIONAL  SYPHILIS.
441
vations that are fully carried out by what may often be observed in practice.
It is, however, hereditarily transmissible  from parent to offspring, and  con-
versely it is communicable to the mother from the foetus in utero.
  The period at which constitutional syphilis declares itself usually varies from
six weeks to six months after the occurrence of the local disease.   Occasionally
it shows  itself earlier, about the second or third week, when it may be coin-
cident with the existence of primary syphilis; in  other  cases, again,  it  does
not manifest  itself for years after  the  primary disease.   Most commonly its
symptoms are progressive, the milder, such as the affections of the skin and
mucous membrane,  occurring  first;  the more severe,  as  those of  the bones
and organs,  afterwards;  but in other cases this progression is not observed,
symptoms of great intensity setting in early, without being preceded by those
of a slighter kind.
   When  once syphilis has become constitutional, it is extremely difficult to say
when it can be eradicated from the  system; and indeed it is a question whether
it may not impress the constitution  in a peculiar way, modifying certain actions
during the rest of life, as we know is the case in other specific diseases, such as
cow-pox or scarlet fever.  Certain it is,  that if neglected or improperly  treated,
it will affect the  system for an indefinite time, declaring  its  existence by
exciting  and modifying various  local  inflammations  years  after the  original
absorption  of the poison.  Ricord  inclines to the belief that a person who has
once had secondary symptoms, and gets  well of the  constitutional affection,
cannot have them a second time, though he contract a fresh chancre; and Mr.
E. Wilson attributes  many of the  ordinary non-specific cutaneous  diseases to
the latent influence of constitutional syphilis.  Without perhaps  admitting to
their full extent the doctrines of these surgeons, I certainly think  that  daily
experience tends to show that in many constitutions syphilis cannot be  eradi-
cated, and that, in most others, when once it has occurred, it is apt, even when
apparently cured, to modify certain cutaneous and other affections in a  remark-
able manner, after the lapse of many years; showing clearly that if the poison
no longer exist in the system,  the constitution has  received  a peculiar  impress
from it,  which it is  long in  losing.   These remote effects of syphilis have by
 Ricord been called "Tertiary."  This term is convenient, as indicating a peculiar
 stage of the constitutional manifestations, in which the tissues are more deeply
 affected than in the secondary form of the disease.
   Although the disease may continue to modify the system for years, or even for
 life, yet it seldom proves fatal.  In some cases, however, death may occur,  either
 by the cachexy that is induced, by  the supervention of phthisis, or by caries of
 the skull, and consequent disease of the brain; fatal and specific syphilitic dis-
 eases of the lungs and brain have been spoken of, but I do not think we possess
 positive evidence of the existence of such affections.
    It is especially when the disease has got into the  tertiary stage that it runs so
 protracted and tedious a course.   When the syphilitic manifestations are con-
 fined to affections of the  cutaneous and mucous surfaces,  the disease may, and
 does occasionally, wear  itself out, the materies morbi being apparently carried
 off by the secretions of these tissues; and  it is only in this way, I believe, that
 the affection can be eradicated from the system.
    That constitutional syphilis is dependent on the absorption of the syphilitic
 poison into the blood, and its consequent general diffusion  through the system,
 there can be little doubt.  Not only is this  rendered evident by the great variety
 of tissues and organs in which it manifests itself locally, but also in the induc-
 tion  of  the peculiar syphilitic cachexy.   Constitutional syphilis may affect the
 following tissues and organs, and usually does so in  the order in which they are
 mentioned —viz.,  the  skin, mucous membranes, periosteum, and  bones; the
 throat, tonsils, palate, eyes, nose, larynx, tongue, and testes.
   The first occurrence of constitutional syphilis is  often ushered in by febrile 
442     CONSTITUTIONAL,  OR SECONDARY  SYPHILIS.

symptoms, resembling those of ordinary inflammatory fever, but of rather a low
type.  In proportion to the severity of these is usually the rapidity of the pro-
gress and the extent of the local manifestations.
   In other cases again the patient gradually falls into a feeble and  emaciated
condition, becoming sallow and earthy-looking, with loss of hair, and depression
of mental  and bodily vigor.  In this condition not only are the nutritive func-
tions impaired, as is evidenced by his becoming weak and thin, but the repara-
tive actions are lessened, wounds do not heal kindly, and fractures are slow in
uniting.
   The syphilitic affections occurring on the skin and  mucous membranes  are
usually  of a secondary character, though  some belong to  the tertiary group;
whilst those  of the bones and different organs, as the larynx and testes, are com-
monly tertiary.  Although the integumental structures are usually first affected,
yet  it sometimes happens that the disease  manifests itself upon the deeper and
more important tissues, without  having previously implicated any  others.
   Constitutional syphilis  is not  by any means a necessary consequence  of  the
primary disease;  many of those affected with  chancre escape all after-conse-
quences ; in this respect much will depend upon the duration and nature of  the
primary sore, its treatment, and  the state of the patient's health.
   That  the  duration  of the  local disease  influences materially the  occurrence
of constitutional syphilis,  cannot I think be doubted.   Ricord states  that there
is no instance of secondary syphilis occurring if the chancre be destroyed before
the fifth day after the inoculation of the poison.  This may be so, but the state-
ment appears to me to be  scarcely capable of proof, as it is certainly of very rare
 occurrence for a chancre to be detected and completely destroyed so as to be con-
 verted into a simple granulating sore by the fifth day after the infection.  It is
 seldom  that it is observed much  before this period, and  even if it be, no surgeon
 could be sure of its complete  destruction at so early a period after its occur-
 rence.   Ricord also appears to  incline  to  the  belief that  the quantity of  pus
 absorbed from these primary sores destroyed before the fifth day does not influ-
 ence the  nature  or severity of  the  secondary symptoms, and in fact that  the
 patient runs no greater risk from one than from a dozen of them.  In this doc-
 trine I  cannot agree, for I can see no reason for placing syphilis in  a different
 category to  any other animal or vegetable  poison, in all of which the constitu-
 tional effects are certainly proportioned to  the extent of the local infection; at
 the same time I fully admit that the treatment of the sore and the state of the
 patient's health influence the severity of the constitutional phenomena to a very
 considerable extent, and  probably, indeed, to a greater degree than any other
 cause.   That the treatment of the primary sore exercises considerable influence,
 cannot  be doubted.   The liability to constitutional syphilis  is, I  believe, mate-
 rially lessened by a mercurial course, and the severity of the secondary symp-
 toms is not in any way increased if that  course be properly conducted.   The
 state of the patient's health also greatly influences the probability of the occur-
 rence of constitutional syphilis.  If, after the cure of the primary disease, his
 health  continue  good, no infection of the system will manifest  itself; but if
 broken or cachectic, then secondary syphilis will  occur cotemporaneously with,
 or at a  very early period after the primary disease ;  and indeed I generally  look
 upon the chance of the speedy  supervention  of secondary syphilis as more im-
 mediately dependent on this, than on any other cause.  It is remarkable for how
 long a time the syphilitic poison will continue dormant in the constitution with-
 out producing any local manifestation of its existence, until this is developed
 under the influence of a broken state of health.   I have at present under my
 care an extremely severe case of constitutional syphilis, in which twelve yearn
 have elapsed since the occurrence of  the  primary disease, during the whole of
 which  time no secondary affection occurred until the patient's health gave way
 from other  causes.  And I have had lately an officer under  my care in whom 
TREATMENT  OF  CONSTITUTIONAL SYPHILIS.     443
constitutional  syphilis in a very severe form occurred, for the first time, after
salivation for  hepatic disease, five years after the primary sore had  been con-
tracted ;  no constitutional manifestation declaring itself in the meanwhile.  Not
only does a state of ill health hasten the occurrence of secondary syphilis, but
cachexy, neglect, or indifference to its  existence, may keep it up indefinitely.
   But not only are the constitutional symptoms influenced by the causes that
have just been discussed, they are likewise modified to a considerable extent by
the character  of the primary sore.   Secondary syphilis certainly occurs with far
greater frequency and severity after the Hunterian  and the phagedaenic chan-
cres, than after other forms of the disease.   The question as to there being any
connection between the nature of the sore, and that of the consecutive constitu-
tional  affection, has been  much discussed, and though I cannot agree with the
doctrine of the plurality of venereal poisons, yet I hold with Carmichael that the
different forms  of primary sore will, if left  to themselves, be followed each by
its own peculiar train of constitutional symptoms. In fact I am fully convinced,
as the result of much and  close  observation on this point, that there is a general
 correspondence between the kind  of ulcer and  the  constitutional syphilis  that
 follows it; both in fact being chiefly dependent upon the state of the patient's
 health.  The  same condition of system, for instance, that will give rise to a pha-
 gedaenic  or sloughing  chancre, will occasion rupia or ecthyma with necrosis  or
 caries of the bones, as  the constitutional manifestations;  whereas that which
 occasions the  indurated chancre will equally modify the  secondary disease, so
 that it assumes a squamous form, accompanied perhaps by iritis and osseous dis-
 ease ; and the excoriated chancre will generally  be followed by papular or rose-
 olar eruptions, with  mucous tubercles on  the  tongue  or  throat.  That these
 sequences are of very frequent occurrence, I cannot doubt, having so frequently
 observed them; and  that they are not of constant occurrence is, I  believe, owing
 to the character of the constitutional affection being often modified, by the state
 of the patient's health having undergone a change subsequent to the cure of the
 primary sore.   Thus a patient having Hunterian chancre, will usually get psori-
 asis as the secondary cutaneous  disease, but let him fall into a cachectic state of
 health between the healing of the chancre and the  supervention  of the consti-
 tutional affection, and rupia will manifest itself.
    In  the treatment  of constitutional  syphilis,  our  object is not so much  to
 relieve or to remove any local morbid condition, as to eradicate a poison from
 the system;  and, indeed,  the various local manifestations, more especially those
 that appear upon the cutaneous and mucous  surfaces, may rather be looked upon
 as efforts of nature  for the  elimination  of the  virus from the system through
 the medium of the great excretory and  emunctory organs;  and it is often
 apparently by aiding this  natural  action by the administration of those remedies
 that act upon these tissues, that the poison is most effectually eradicated.
    During the continuance of the pyrexia, which often  ushers in the secondary
 symptoms, little  can be done in  the way of specific means for the removal of
 the disease from the  system;  rest and mild antiphlogistic treatment being all
 that can be accomplished  during this, the stage of invasion and of constitutional
 reaction.  At  a  later period, when the  cachexy,  which  is attendant on  the
 disease, has declared itself, attention to the  hygienic  and  dietetic management
 of  the  patient is of  the utmost importance;  a  light nourishing diet, often
 accompanied by the moderate  use  of  wine or  beer, and in some of the lower
 forms of secondary syphilis occurring as the result of phagedenic chancres in
 broken  constitutions, a general  tonic plan  of treatment, such as the administra-
 tion of bark, quinine, or  iron,  and more especially of cod-liver oil, with  the
 mineral acids and sarsaparilla, is required, in combination with the more specific
 means  that  we possess, for the  eradication  of the  disease from the  system.
 These  remedies  must  be administered in accordance with  general medical 
444     CONSTITUTIONAL,  OR  SECONDARY SYPHILIS.

principles, and no special instructions need consequently be laid down for their
use here.
   The great remedies that we  possess for the eradication of the  poison from
the system are, mercury, and the iodide of potass.  Of the value of mercury in
constitutional syphilis every surgeon of  experience  must have had abundant
proof.  It may admit of doubt whether mercury can be  justly considered as
exercising a specific action in constitutional syphilis, as there are some cases of
the disease that it certainly does not appear to influence in a beneficial manner,
and  others, the severity of  which is certainly increased  by the administration
of this remedy; but it appears to me that in these cases it is rather the patient's
constitution  which does  not bear the  remedy well, than the  disease that is at
fault.  We  know that in many states of  the  system, and in many individuals
unaffected by syphilis, mercury acts  injuriously, more especially when anything
like  cachexy is present; and we cannot  but suppose that the same injurious
influence on a particular habit of body must continue, though it be contaminated
with the poison of syphilis.   The best proof that we possess of the influence of
mercury over constitutional syphilis, an influence, indeed, that almost approaches
to the  nature of a  specific  action,  is in  the  case of infantile syphilis;  here
mercury will not only cure the disease, but will  eradicate the virus from the
system in a way that no other remedy can  accomplish.
   In the treatment of constitutional syphilis with mercury, everything depends
 on the proper administration of the remedy at a suitable period of the case, and
 in a  fitting condition of  the  constitution.  The question as  to the propriety of
 the administration of mercury in constitutional syphilis, the particular prepara-
 tion  to be used, and the period of the disease in which it should be given, must
 be determined in a great measure by the previous  treatment of the  primary
 disease, by the condition of the patient's general health, and by the duration
 of the secondary symptoms.   If mercury have been freely  given, perhaps in
 repeated,  irregular,  and ill-conducted  courses, for  the  cure  of  the  primary
 affection; if the  patient have fallen into a cachectic state, having lost flesh,
 color, appetite, and spirits; if the constitutional affection  have  assumed the
 tertiary form, and have  deeply implicated the bones, mercury should  not be
 given at all; or, at all events, not without proper previous preparation.   Under
 these circumstances I think we should  endeavor,  if possible, to remove the
 constitutional affection  without mercury.  It is true that in many cases we
 shall not succeed in doing so, but at least we improve the health, check the
 disease, and  bring  the  patient into a proper  condition to support a mercurial
 course,  should  it be thought necessary eventually to put him upon one.   It is
 in these conditions of the system that the nitro-muriatic acid and sarsaparilla
 are of so much service.   From twenty to thirty minims of the dilute acids  with
 half an ounce of the fluid extract of sarsaparilla in four ounces of water, may
 be administered three times a day.  To this,  the  iodide of potass, in five-grain
 doses, may often be  advantageously added; or, this salt  may be given alone in
 some bitter infusion, as of cascarilla, quassia, or bark;  or, if the  patient be in
 a very  cachectic and emaciated state, in cod-liver  oil.   It is in these cases,
 likewise, that the preparations of iron may be given with so much advantage.
 When there is great emaciation, I have found the combination of the iodides of
 potass and of iron with cod-liver oil, to be especially beneficial.  But useful as
 these remedies, especially the iodide  of potass  and  the  dilute mineral acids,
 unquestionably  are, more  especially  when   administered  in the  compound
 decoction of sarsaparilla, I do  not believe  that  they exercise  any  specific
 influence on the disease, or that they  do more than relieve or  remove  local
 manifestations, often of a troublesome and disfiguring character, failing altogether
 to cure  the  constitutional affections and to eradicate the virus from the system,
 for the  removal of which  mercury will at last be required.   Their great utility
 appears  to  consist  in removing cachexy, and in restoring the vigor  of the 
         TREATMENT  OF CONSTITUTIONAL SYPHILIS.     445

nutritive and  reparative actions, which  are  in  abeyance; and, by  improving
the general tone of the system, in enabling it to resist more effectually the
advance of the disease,  and, in some cases, perhaps, to allow this to wear itself
out.   That great advantage results from maintaining the  tone  of the system in
syphilis is undoubted; we  always find  that the  intensity of the ravages of the
venereal poison are  in  direct proportion to  the debility and want of resisting
power in the constitution  of the patient.  Besides  being useful in this way,
these remedies are often of service in removing local affections, and in repairing
the injury inflicted upon tissues and  organs by the low and specific inflamma-
tion that is set up in them.  In this respect, indeed, nothing  can exceed the
value of these remedies in constitutional syphilis.  I do not, however, believe
that the disease can be  eradicated from the system by these means, or that any
of these remedies, even the iodide of potass, can  take the place of mercury in
the treatment  of constitutional syphilis; indeed I cannot call to mind a single
case in which  this form of the  affection has been radically and  permanently
cured  without the  administration of mercury.  Those  cases  in which they
exercise most beneficial influence, are certainly instances in which mercury has
been  injudiciously administered, either for the primary or the secondary disease,
and in which  the powers of the constitution  have in this way been  sapped.
Under these circumstances, a course of the iodide of potass, or the mineral acids,
in sarsaparilla, should always be administered, with the view of improving the
patient's general health.
   Looking, therefore, upon mercury as the only remedy we possess  that  influ-
ences directly and permanently the venereal poison, I think that it should always
be administered in a full course during some period of the treatment of consti-
tutional syphilis.   The time at which it  should  be given is of considerable
importance; thus, it must  not be administered until  the initiatory pyrexia has
subsided under the use of  ordinary antiphlogistic  treatment; nor  should  it be
given if there is a very marked cachexy.  After this  has been removed, how-
ever, by other means, the exhibition of mercury may be proceeded with.
   In administering this remedy for constitutional  syphilis, we must not give it
largely, so as to affect the system rapidly, but as a mild course for some weeks,
so as to act freely upon the secretory and  excretory organs, and thus to eliminate
the poison from the system.  The most useful preparations are  the  bichloride,
in doses from the  twelfth to the  eighth of a  grain; or the iodide, in one-grain
doses three times a day.  These should be given with sarsaparilla, which keeps
up the power of the system and acts freely upon the kidneys and the  skin.
The  mercury should be continued for at least  from three to six weeks, until  a
decided improvement has taken place in the constitutional  symptoms.  I do
not think it desirable  to  produce  salivation; all  the good effects of mercury
 can be obtained far short of  this; and indeed if the remedy be pushed to such
 a point as  to  affect  the mouth  or gums, it will commonly act injuriously, by
 depressing  the powers of  the system  too  much.  I  therefore  think it well to
suspend its  administration whenever an impression has  been  made upon the
disease, and  before  this effect  has been produced.   The cautions necessary
during the mercurial course, when  administered for constitutional syphilis, are
precisely similar to those that we have described as  necessary during the primary
treatment of the disease.
   In some cases of constitutional syphilis, affecting the  skin  and more super-
ficial structures, mercury  may  conveniently be administered by fumigation.
This  plan  of treatment,  which has  been  especially recommended by  Mr.
Langston Parker, consists of a combination of vapour bathing and of mercurial
fumigation;  and this gentleman speaks  in the highest terms of the value of
this remedy in syphilis, as shortening the duration of ordinary treatment, and
permanently curing the disease without the constitution of the patient being in
any way injured by its  employment.   The baths  may also be associated with 
446     CONSTITUTIONAL, OR  SECONDARY  SYPHILIS.

appropriate internal treatment.  During the use of the fumigations, the patient
should be  dieted, and be put on a full  course of sarsaparilla.  The bath may
be administered every second day, and  should consist of about £j of cinnabar
slowly volatilized by means of a spirit-lamp, at the same time that steam  is dis-
engaged  from boiling water.   In this way I have for some time past used them
at the hospital and in private, and with very great success, in cases of syphilitic
cachexy with extensive cutaneous disease of an ecthymatous or rupial character,
in constitutions in which mercury could not be borne in any more active form.
   AVhatever plan of treatment be adopted, it should be  carried out for a suffi-
cient length of time; great evil often resulting by intercepting it too suddenly,
and contenting oneself with the removal of the local mischief, whilst the disease
is left firmly seated in the constitution.
   Local Secondary Affections.—We shall next proceed to consider the charac-
ter and treatment of the different local forms in  which  constitutional  syphilis
manifests itself.   These may be  considered as they affect different tissues  and
organs, and require  separate  consideration, according to the part that is influ-
enced by them.   We shall  consider them as affecting  the skin, the mucous
membranes, the mouth, nose, tongue, palate, larynx, testes, and the bones.
   The syphilitic affections of the skin, syphilo-dermata, or syphilides, present
various modifications of appearance, corresponding pretty closely to the different
groups of idiopathic cutaneous diseases; thus we  find  exanthematous,  papular,
squamous, vesicular, pustular, and tubercular syphilitic affections of the skin,
with various ulcers and growths.   These differ from the corresponding simple
cutaneous diseases in their  redness being  more  dusky or  coppery, in leaving
stains of a  brownish or purplish hue, in their outline  being circular, and in
their crusts or scabs being dark, blackish, thick and rugged-looking.   Besides
this, syphilis modifies materially  the general character of the cuticle, causing it
to assume a yellow or earthy tint.   The  worst forms of these affections are com-
monly met with on the face and more exposed parts of the body.
   Syphilitic diseases  of  the skin  arrange themselves  under the following
groups:—
   The roseolar  consists of blotches of  a reddish-brown or coppery tint, which
become more distinct as the redness declines; they vary in size  from  small
circular spots to large  and diffused patches.  These are  usually first observed
about the abdomen, and commonly occur early in the disease, often before the
primary  sore is healed.   Syphilitic roseola usually follows the chancrous exco-
riation, and is very frequently accompanied  by an erythematous condition  of the
throat.
   The squamous syphilide  occurs in small  patches of an irregular shape, of a
red and somewhat coppery color, which are commonly covered with thin filmy
scales.  In many instances the patches are, however, quite smooth, so as to have
a glazed  and almost shining look.  They are usually situated on the inside  of the
arms and thighs, often on the scrotum and penis, even occurring on  the  glans.
They also frequently appear on the palms  and soles, where  deep fissures  and
cracks are met with.  About the lips, the squamous syphilide gives rise to deep
and  troublesome  fissures.   It is often  associated with a deep and excavated
ulcer of  the  tonsils, with inflammation  of the iris, and  not  uncommonly with
disease of the periosteum and bones, and almost invariably follows the indurated
chancre.   Associated with this  condition are large  brown patches or  macular,
which occur on various parts of the body.
   The vesicular syphilide is of very rare occurrence.  In one case which fell
under my observation, it appeared in the form of  clusters of small pointed vesi-
cles, which, on drying,  left grey or brownish crusts and coppery marks.
   Syphilitic pustules, on the contrary, commonly occur;  beginning  as small
hard papulae of a coppery hue, slowly softening in the centre into a small deep-
seated pustule, having a large brown  or coppery areola,  and  forming  speedily 
SYPHILITIC  DISEASES  OF  THE SKIN.          44 7
 large circular dark-brown, or even  black scabs; usually flat and  irregularly
 crusted, at other times, conical.  When flat, they constitute syphilitic ecthyma;
 when conical, the rupial form of the  disease.   After their separation, trouble-
 some ulcers of a circular shape, and with rather a foul surface, are commonly
 left.  This  disease  first appears upon the  face, but speedily shows itself on
 various  parts of the body,  more  especially on the extremities;  it commonly
 occurs as an  early sequence  of the  phagedenic chancre, and is always indica-
 tive of constitutional cachexy; when  following other forms of chancre, it is, I
 believe,  owing to the system having  in the meantime fallen  into a low and
 broken state.
   Syphilitic  tubercles commonly occur  as  an  advanced  or  tertiary symptom :
 they appear as  hard, smooth, flat,  and elevated bodies, of a reddish brown  or
 purplish color, seated on  the face, the  tongue, the limbs, the penis, and the
 uterus.   They may be resolved by proper treatment, but have a great tendency
 to ulcerate and to destroy the parts on which they are  situated, giving rise  to
 large, deep, foul, and serpiginous sores.
   Syphilitic boils of an indolent character,  but painful, and  discharging a thin
 ichorous pus, with a core of shreddy cellular tissue, and leaving deep, irregular
 and foul ulcers, are not  uncommonly met with.
   Syphilitic  ulcers may result from  pustules,  tubercles, or boils,  or commence
 as tertiary sores:  they frequently occur where the integuments are  thin, or
 where they are moistened by the  natural secretions of the  part; they are cir-
 cular with  elevated edges, tend to  spread  in  circles, with a foul, greyish sur-
 face; often creeping along slowly, and destroying  deeply the parts they affect;
 leaving  cicatrices of a bluish or brown color, thin and smooth, which are apt to
 break open again on the application of any  slight irritation.
   The hair and nails are commonly affected in advanced  constitutional syphi-
 lis; baldness, constituting syphilitic alopecia, occurring either  generally  or in
 patches, without any apparent disease  of the skin.   Disease  of the nails, syphi-
 litic onychia, occurs in two forms,  either as  a foul  ulceration between the toes,
 or else as a chronic inflammation,  with fetid discharges in  the matrix of the
 nail; which becomes black,  more or less bent, and scales off, with the formation
 of a dirty ulcer under its detached edge.
   The treatment of cutaneous syphilis must be conducted in accordance with
 the  general  principles  already laid  down, and with special reference to the
 characters  of the concomitant constitutional condition, or  of  the  other  local
 manifestations  accompanying it.  In the  early stages,  when ushered  in  by
 febrile  disturbance, a  mild antiphlogistic  treatment is required: when the
 pyrexia has been subdued, more specific measures must be had recourse to.  In
 the roseolar forms the treatment of the secondary affection should be guided  by
 the previous management of the  primary sore.  If mercury have been  given
 for this, we should content ourselves  with  the iodide of potass in infusion  of
^ quassia, or what is better, in full quantities of the decoct, sarse. comp.  Should
* mercury not have been given in the primary sore, it must be had  recourse to
 in  the  secondary affection.    In the squamous syphilide, mercury, I think, is
 always  necessary, and  here  I give the preference to the iodide over the  other
 preparations.  In the pustular forms, syphilitic rupia and ecthyma, the  consti-
 tution being commonly shattered,  a tonic plan of treatment  is required in the
 first instance, after which the bichloride of mercury in tincture of bark or de-
 coction of sarsaparilla should be  steadily  administered.  In these cases also
 much benefit will be derived by the  mercurial fume-bath.  In the tubercular
 syphilide much the same treatment is required as in the last variety;  in  these
 cases, however, I have often found Donovan's Solution  of the greatest possible
 value, the disease rapidly disappearing under its use; the same  plan is required
 in the management of syphilitic boils.  In the treatment of secondary syphi-
 litic ulcers we shall find it necessary to use  caustic freely, with the view of set- 
448     CONSTITUTIONAL, OR  SECONDARY  SYPHILIS.

ting up a new and more healthy action  in  the part.   For this purpose nitric
acid, or the acid nitrate of mercury, is especially serviceable; on  the separa-
tion of the slough thus produced, the sore may be dressed with red precipitate
powder, or ointment, or the black wash, to which, if there  be irritation, opium
may be added, the same constitutional treatment, especially Donovan's Solution,
being had recourse to.   In  syphilitic alopecia, the internal  administration  of
the bichloride of mercury with bark or iron, and the external  use  of  a strong
stimulant, such as  the nitrate  of mercury ointment, or the  tincture  of lytta,
will be found  most serviceable; and  in  syphilitic onychia, the free application
of nitrate of silver, followed by the black wash, and the  bichloride of Dono-
van's Solution internally, is the proper treatment.
   Warts, excrescences, and vegetations, are commonly met with in constitutional
syphilis, especially  in  the neighborhood of the mucous canals, being usually
situated in  the neighborhood of the anus, the perineum, or scrotum; and  in
the  female, upon and  within the labia.  They are  also very frequently met
with about the tongue,  on the tonsils, palate, and lips.   When occurring in the
neighborhood of the organs of generation, they are usually large, flat, soft, and
uniform in  structure and appearance, with a good  deal of mucous exudation,
and a sort of perspirable moisture of the  neighboring skin.   When seated  in
the  mouth or throat they are usually small, and not so distinctly  elevated  or
circumscribed, but look  rather like a thickened and opaque condition of the
mucous membrane in these situations.  These  secondary warts, condylomata  or
mucous tubercles, as they are often  termed, differ essentially  from  the  primary
vegetations, not only in their appearance and  general  uniform character, but
in being dependent on  the  constitutional condition  of the  disease,  and not  on
local causes solely,  such as  the irritation of discharges and the want of cleanli-
ness.  They are also certainly  contagious;  and I have  known  instances  in
which they have  been  distinctly transmitted in this way.   Their treatment
must be constitutional as well as local;  the constitutional means should consist
in the administration of the  bichloride of mercury with sarsaparilla;  and  the
best local treatment that I  am acquainted with is to rub them freely with the
nitrate of silver, dressing the parts between  whiles with chlorinated lotions.
Not being pendulous or  distinctly protuberant, they do  not, like  the  primary
excrescences,  require excision.
 «< The mucous membranes  of the  mouth, nose, pharynx,  and penis  are com-
monly affected with secondary syphilitic eruptions;  these assume the  form  of
mucous  tubercles, or of  the exanthematous, tubercular, and ulcerative syphi-
lides.   The exanthematous affection, corresponding to the roseolar form of cuta-
neous  syphilis, and arising from the same  cause and in  the  same constitution,
principally affects the palate and throat.   The tubercular variety corresponds
to the squamous cutaneous  eruptions, and is chiefly met with as flat, hard, and
elevated tubercles in the interior of the mouth, nose, and  throat.   The ulcera-
tive affection  of the mucous membranes assumes a variety  of forms, which will
immediately be described, and occurs principally in the  throat and nose.  The
exanthematous affection of the mucous membrane is usually an early sign of
constitutional syphilis, frequently showing itself a few weeks after the primary
occurrence of the disease.   The other varieties belong. to the more  advanced
secondary or tertiary periods.
   The syphilitic affections  of the mucous membranes so readily extend to, and
are  so commonly associated with, corresponding disease of the deeper structures,
that we shall  more conveniently consider their different forms according as they
affect  distinct organs or parts of the body.
   The lips are commonly affected in persons laboring under the squamous syphi-
lide, with fissures or cracks usually  somewhat indurated, and  very painful in  the
movements of these parts.  The application of a pointed piece of nitrate of silver
to the bottom of the crack will give  the most effectual relief.   The inside of the 
      SYPHILITIC DISEASES OF  THE TONGUE  AND THROAT.   449

cheeks are not unfrequently affected in a similar manner, or become the seat
of mucous tubercles, which must be treated as has already been stated.
  The tongue may be affected with syphilis in various forms; when severely, its
disease usually constitutes one of the tertiary varieties of the affection. ^ In many
cases the mucous membrane becomes thickened, but preserves a peculiar glossy,
semi-transparent, almost gelatinous appearance, and, being irregularly fissured,
gives the  organ  a thick and misshapen look   In other instances, again, the
epithelium is dry, white and opaque in patches; the surface of the tongue look-
ing  as if it  had been  dyed white here and  there.  Occasionally, ulcers form
upon its surface or sides; these are usually irregular in Shape, with a foul sur-
face and a good deal  of surrounding induration, and, unless care be taken, may
readily be confounded with  schirrus  or epithelial  cancer of the  organ.   The
diagnosis of  these affections we shall consider when speaking of diseases of the
tongue generally.  Occasionally a hard elevated circumscribed tumor of a dark-
red  or purplish color slowly forms towards the centre of this organ; it increases
without  pain and in a gradual manner, and principally occasions inconvenience
by its bulk  and the impediment it occasions in the movements of the  tongue.
These various diseases indicate a deeply-seated  constitutional  affection, and
require the administration of mercury either in the form of iodide or bichloride.
Donovan's Solution is extremely useful in many of these  cases.  The ulcers
should be touched from time to time with the nitrate of silver.
   The syphilitic diseases of the throat are amongst the most common manifes-
tations of constitutional syphilis, and  frequently occur  early.   They  present
several distinct forms, corresponding  to analogous primary and secondary cuta-
neous affections.  One  of the  earliest conditions  is a  deep-red exanthematous
efflorescence  of  the  soft palate and  the pillars of the  fauces, either  without
ulceration, or with but superficial abrasion, but with much cachexy and depres-
sion  of  power, and  perhaps with considerable pyrexia.   It often occurs  about
the  period of the invasion of the roseolar or rupial syphilide, and requires the
same treatment as is necessary in these affections, together with the local appli-
cation of a  strong solution of  the nitrate of silver.   A  deep excavated ulcer,
with a hard  base and foul greyish surface,  of circular or oval form, is not unfre-
quently met  with on one or other tonsil; it corresponds to that class of secondary
phenomena that follows the  indurated chancre, and requires mercury in some
form for its  cure; in this and many other cases the mineral may most conveni-
ently be  applied to the throat by means of fumigation.  A sloughing  ulcer is
occasionally  seen on the side of the throat or palate, with much swelling, a foul
grey surface, and rapid  destruction of parts,  giving rise very commonly to per-
foration of the soft palate, and thus, by partially destroying the curtain between
the  mouth and the nose, occasioning serious inconvenience to the natient during
deglutition and  in speech.  This form of ulcer is connected with the rupial or
ecthymatous syphilides, and requires the same constitutional treatment as these.
The best local  plan is free sponging with strong nitric acid, and gargling with
solutions of  the chlorides.  More rarely a form of the  serpiginous ulceration is
met with, producing considerable contraction and inconvenient consolidation of
tissues after its cure.   It  is,  I  think, best treated  by  the local application of
nitric acid, and  the internal administration of the bichloride.
   The mucous membrane of the larynx is not unfrequently affected in advanced
syphilis.   In these cases chronic inflammation, with thickening and ulceration,
takes place  about the  rima  glottidis,  with the  general and local symptoms of
chronic laryngitis;  such as huskiness of voice,  cough and  expectoration of
tenacious or   offensive  mucus;  a difficulty in deglutition, and a  tendency to
choking on swallowing liquids, with tenderness on  pressure about the throat, also
come on.   These cases are usually accompanied by much constitutional cachexy,
and  not  unfrequently eventually terminate  fatally by the  sudden supervention
of oedema glottidis.   The constitutional treatment must depend upon the con- 
450       CONSTITUTIONAL,  OR  SECONDARY SYPHILIS.

comitant symptoms and the general state of the patient;  most commonly tonics
will be required.  The local means consist in the free application of the solution
of the nitrate of silver to the rima glottidis, and the occasional employment of
counter-irritation.  In syphilitic ulceration occurring about  the  sides or base
of the epiglottis, care must be taken in the application of the stronger escharotics,
such  as nitric acid, or the acid nitrate of mercury, as a small  quantity of these
if inhaled into the larynx  might  produce  serious  difficulty in  breathing or
even  fatal asphyxia.   In many cases  it  may  become  necessary  to  open the
windpipe, in order to prevent the patient dying of asphyxia; this must be done
in accordance with the rules  that will be laid down when treating of chronic
laryngitis.
   The nose is commonly affected  in constitutional syphilis, and  often destruc-
 tively so,  especially  in  individuals much exposed to changes of temperature,
 and who are unable to pay  proper attention  to  their treatment.   The mucous
 membrane becomes  chronically thickened, with  discharge of blood  and  pus,
 coryza, and  habitual snuffling.   In  other cases ulceration  takes place,  with
 a very fetid  odor of the  breath, and the formation of thick ecthymatous crusts
 on the septum, or between this and the alae.   This ulceration is  of a very per-
 sistent and  troublesome character, and requires  usually a mercurial treatment
 with the local application of  strong nitric acid, or of the acid nitrate of mercury,
 to  arrest its  progress.  In many cases ulceration will rapidly proceed to destruc-
 tion  and perforation  of the septum, or necrosis of the spongy bones, the vomer
 and ethmoid; sometimes excavating the whole of the interior of the nose, scoop-
 ing and  cleaning  it out into one vast chasm.   When  this happens, the nasal
 bones are usually implicated, being flattened, broken down and destroyed; the
 ale  and columna ulcerating away, and producing vast disfigurement.  Occa-
 sionally the  disease  extends to the bones of the base of the skull, and in this
 way  may occasion  amaurosis, epilepsy, or death.   The treatment of these nasal
 affections must be conducted in  accordance with general principles.  In many
 cases mercurial fumigation is extremely useful;  in others, where  the disease is
 of an ulcerative character, the strong acid and caustic applications already men-
 tioned, with  chlorinated solutions  occasionally sniffed up, will do much to stop
 the progress of the disease.   As necrosis occurs, the dead bone must be removed.
    Diseases of the periosteum  and bones are amongst the more  remote and severe
 effects of constitutional syphilis, when it has  reached the tertiary stage.   They
 are especially apt to  occur in  cases in which mercury has been  improperly admin-
 istered, and after the patient has passed through the whole  course of the less
 severe syphilitic affections, such as those of  the skin, mucous membrane, and
 throat.   These affections, however, especially of the periosteum, are not neces-
 sarily preceded by  the minor constitutional effects, but may  in some  cases
 declare  themselves at the same time that the affections of the skin and mucous
 membranes  do.  They  more commonly occur amongst the poorer classes,  espe-
 cially those who are  exposed  to atmospheric vicissitudes, and chiefly in strumous
 constitutions.
    Venereal periostitis  or nodes may occur in almost any of the  bones, but is
 most commonly met with on the tibia, the clavicle, or the  bones of the forearm.
 Some joints are  also not unfrequently affected by it;  the sterno-clavicular
 articulation and knee-joint are especially often the seats of this disease.
    Nodes are indolent, elongated, uniform, and hard swellings, sometimes tender
 on pressure, and generally but little painful  during the  day, but at night the
 aggravation of pain is  peculiarly marked, and  constitutes  perhaps the most
 distressing symptom in these cases.  They consist  of a thickened  state of the
 periosteum, with some plastic effusion within and underneath it, and occasion-
 ally thickening of the subjacent bone;  they  may continue permanently or may
 terminate by resolution, it is seldom that  they  suppurate, unless there be
 disease of the subjacent bone.   The treatment consists, if  there is  much ten- 
               SYPHILITIC  PERIOSTITIS. — NODES.            451

derness, in  the application of  leeches;  if  there  be no great  sensibility on
pressure, but considerable  nocturnal  pain, blisters  should be applied.   When
in a chronic state, the tincture of iodine  is a useful  application.   They some-
times become soft and prominent, and  feel semi-fluctuating, especially when
seated on the  cranium, so as  almost to tempt the surgeon to make an opening
into them;  this,  however, should never be done, as the  swelling, however
great, will subside under proper  treatment.   For the ultimate removal  of the
tumor, and the relief of the nocturnal pains, we possess  an excellent and sure
remedy in the iodide of potass.
   The venereal affections  are principally met with in those bones that are flat
and compact, as the cranial, nasal,  and maxillary bones.   In  these, various
forms of disease occur.   One  of the most common is perhaps chronic osteitis,
with  hypertrophy and  condensation  of  the  osseous  tissues, often  to  a  very
marked extent.   This affection may occur in the bones of the skull, but is also
met with in some  of the long bones, as the tibia and the  ulna; it is  character-
ized by very severe pain, especially of a  noctural character, accompanying the
enlarged and thickened state of the bone.
   Syphilitic necrosis chiefly  occurs in the  bones of the skull  and jaws, the
alveolar processes of which may exfoliate; the palatine process  of the superior
maxillary bone, the  spongy and the nasal bones, are  also commonly destroyed
by this morbid action; but it is a remarkable fact that  the palate  bones are
rarely,  if ever, affected.   In  consequence of this destruction of bony  tissue,
the interior of the nose becomes chronically  diseased,  the organ  may fall in, or
a  communication  be established between the nose and the mouth through'the
hard palate.
   Syphilitic  caries,  or  ulceration of bone,  presents  different  forms,  which,
according to  Mr.  Stanley, correspond  to  analogous ulcers and eruptions of the
skin.   Thus,  there may be the simple ulcer of the  bone,  showing a  rough,
irregular, porous, and depressed surface; the worm-eaten caries  consisting of
small pits or excavations, studding the surface; and the serpiginous or creeping
ulcer, marked by imperfect attempts at repair, and  the deposition of new  bone
in  nodules or masses.   The cranial bones are those that are most commonly
affected in this way, and their disease may sometimes  prove  fatal by the irrita-
tion set up by it in the brain or its membranes.   The bones of the extremities,
however, are not unfrequently similarly affected.
   The treatment of these conditions varies somewhat, according to the form the
disease assumes, and the previous management of the patient.   In osteitis, the
principal reliance  should be placed upon the  conjoined influence of calomel and
opium, provided the patient have not previously been fully mercurialized.  If
so, our chief reliance must be upon the iodide of potass.   In syphilitic necrosis,
the constitutional cachexy demands the principal share of attention; the necrosed
bone should be separated as it becomes loose, the local irritation depending on
its presence then  subsiding.   When  the  bone has fallen into a  carious state,
the iodide of potass, in combination with  iron, cod-liver oil,  or sarsaparilla,  with
the mineral acids, will improve the  tone of the system,  and stay the progress
of the disease.  The ulcerated  and exposed  bone requires to  be dressed  with
strong stimulants; the red oxide of mercury, in  ointment  or powder, is perhaps
the best; in some cases, touching the part freely with the acid  nitrate of  mer-
cury will establish a more healthy action.
  _ Syphilitic  iritis commonly follows the indurated  chancre, being  associated
with some of the more advanced secondary sequele of that form of the disease.
It  usually occurs  after  exposure to cold, and often  in people  that  are other-
wise strong  and healthy.   The ordinary symptoms of iritis,  somewhat modified,
characterize the affection.  The patient complains of dimness of  sight, pain in
the eye, and often of  very severe circumorbital  or hemicranial pains.   On
examining the eye, the conjunctiva will be found slightly injected, and a  zone 
452     CONSTITUTIONAL,  OR SECONDARY  SYTHILIS.

of pink vessels  to  be seated on the sclerotic, close to the cornea; the aqueoua
humor has  lost its transparency,  giving a muddy  look to  the eye,  and the
color of the iris is altered.  The pupil is irregular in shape, usually angular
towards  the nasal  side, and small yellowish or brownish  nodules of  lymph
may be seen to be deposited on the surface of the iris.   If the case be  left to
itself, or be improperly treated, it will advance to disorganization or to per-
manent opacity of the  eye.   The treatment of these cases consists in local
depletion by means of cupping and  leeches to the temples, and the  adminis-
tration  of calomel  and  opium  internally, at the same  time that a drop of the
solution of atrophine is put into the eye.  Most  commonly, as  the  mouth
becomes affected by the mercurial,  the eye will''clear, the  lymph becoming
absorbed, and the  pupil regaining its normal shape and color.   In  some cases,
however, a chronic inflammation  continues; under these  circumstances, the
best effects  result from the administration of small doses of the bichloride, with
repeated blistering  to the temples,  and, in a later stage, soda and bark may be
advantageously given.
   Syphilitic disease of the testicle is one  of the more  advanced conditions of
the constitutional affection.   It commonly occurs as  the result of that train of
symptoms that follows the Hunterian chancre, viz. squamous affections  of the
skin, the excavated ulcer of the  throat, iritis, and nodes, but usually does not
appear until these different manifestations of constitutional syphilis have each in
their turn passed away; the patient, indeed, appearing  to have recovered from
all disease,  and being otherwise in good health.  Commonly, the disease may
be referred to a blow, a squeeze, the occurrence of gonorrheal  epididymitis, or
some other  local cause.   The testis will then be observed gradually to enlarge,
until it attains the size of a turkey's egg, or even larger, being ovoid in shape,
heavy, and  smooth, not painful except by its weight, which causes dragging and
uneasy sensations in the cord and  loins.  This disease is very commonly accom-
panied by a small hydrocele, constituting, indeed, a hydro-sarcocele.  Most fre-
quently only one testis is affected; it is but very rarely that both are diseased.
The affection continues to  increase, giving  rise to uneasiness from  its size and
weight, but is not followed by suppuration or other inconvenience.
   Mr. Hamilton of Dublin has described another form of syphilitic sarcocele,
under the term " tubercular syphilitic sarcocele."  In this the testis is enlarged
to three or four times  its  natural bulk, of an irregular shape, presenting an
uneven, hard, and  knotty mass; it is neither painful nor tender, but inconve-
nient  from  its weight, causing pains in  the loins and cord.   Both testes are
usually affected, but one is worse  than the other, and when the disorganization
is great, Mr. Hamilton  states  that all sexual desire is  lost, and that  neither
erections nor emissions  take place; both, however, returning as the treatment
effects the restoration of the organ to its normal condition.   In these cases sup-
puration not unfrequently takes place, followed by  the discharge of thin pus,
the formation of fistulous openings, and occasionally the protrusion of a fungus.
This form of sarcocele occurs in persons of a broken and cachectic constitution,
who are suffering severely from the more advanced and  inveterate forms of ter-
tiary syphilis, especially of the bones and throat.
   In the simple syphilitic sarcocele  the enlargement of the testes is principally
due to the  deposit of semi-transparent white or yellow lymph, in a uniform man-
ner throughout the substance of the organ external to the tubuli.  In the tuber-
cular syphilitic sarcocele, Mr. Hamilton states  that tubercles of a yellow color,
and varying in  size from a split pea to a chestnut, or even larger, are found in
 the substance  of the organ;  these, softening, give  rise to  suppuration  in and
 around  them,  and thus to  the  ultimate disorganization of the testis, which
 becomes C6nverted into a hard irregular fibro-cellular mass, in which cretaceous
 matter is occasionally deposited.
   In  the  treatment of the simple form of sarcocele, a full mercurial course is 
SYPHILIS IN INFANTS.                   453
generally necessary; the bichloride in doses of the twelfth or eighth of a grain
three times a day, is the best preparation.  This should be continued for at least six
or eight weeks, or until hardness disappears.   Any hydrocele that exists should
be tapped, and the fluid drawn off by means of a small trochar and canula before
the treatment is commenced.   After the  mercury has been discontinued, the
remaining swelling of the testis may be got rid of by the internal administra-
tion of the iodide of potass, in five-grain doses,  twice or thrice daily, with fric-
tions with the iodide of lead ointment.  In  these cases, care should be  taken
not  to irritate the  scrotum with very stimulating applications, as the skin  is
tender, and readily becomes excoriated; ordinary strapping is of very little  use,
but in some cases I have found  strapping with the emplastrum ammoniaci cum
hydrarg.,  diluted with equal parts of emplast. belladonne, of service.   If sup-
puration occur, and a fungus protrude, the same treatment must be adopted as
will be described when we come to speak of the strumous testicle.
   Besides these various constitutional manifestations of syphilis, tumors of the
muscles and tendons, depending on this disease, have  been described by Mons.
Bouisson.  These  appear to consist of a limited  hypertrophy of the tissue of
the muscle, with an effusion of plastic matter in  its interior.   When affecting
the tendons, these tumors are elongated, and  resemble nodes upon them.   Their
presence is attended with some  pain during the contraction of the muscle; they
are usually somewhat globular, and vary in  size from a nut to a pigeon's  egg,
being accompanied by nocturnal pains.  They are best treated by the iodide of
potass.
                        INFANTILE  SYPHILIS.

   The existence of a primary sore on the labia of the mother may possibly infect
the child  at birth with primary syphilis, just as  it might inoculate  the hand of
the accoucheur; but syphilis thus contracted by  the  infant is not the form of
the disease that  is described as " infantile syphilis."   This is a truly hereditary
infection, transmitted to the infant  at the time of its conception, or communi-
cated to  it through the medium of the mother during intra-uterine life, and
existing as a constitutional affection at the time of its birth.  Though we  may
believe that syphilis is not easily eradicated from a system into which it has
once been received, and that under certain  conditions it may readily be trans-
mitted to the offspring; yet, I  think we  are still ignorant of the amount  and
nature of the constitutional  affection of the parents that is necessary for the
development of syphilis in their children, and that we are certainly not  war-
ranted in concluding that a parent who has been, or even who is actually affected
by constitutional syphilis, must  necessarily have syphilitic, or even a feeble and
strumous family; although the probability undoubtedly is that such will be the
case.  I have at present under my observation a gentleman whom I had attended
for  secondary syphilis, and  who, contrary to my advice, married  a  few years
ago, and  though he has since then suffered from psoriasis of the hands, mucous
tubercles, fissures on the  lips and  tongue, and  venereal sarcocele, yet his  wife
has borne a perfectly healthy family, not only without any syphilitic taint, but
without any apparent constitutional  cachexy.
   Syphilis, when  transmitted by the  parents, appears to lessen  the vitality of
the ovum to such a degree, that it either cannot reach its development, or, if it
do so, that the child that is born is  not only tainted, but enfeebled in constitu-
tion.  When  the ovum is infected with  syphilis,  several morbid states  may
result, according to the intensity of the infection.  It may be so blighted  that
it never reaches the maturity^of intra-uterine life, but becomes early aborted;
in this way many consecutive miscarriages may happen in consequence of ofle
or both of the parents having constitutional syphilis,  but if they be put under
proper treatment by a mercurial course, and the disease be thus eradicated from
the system, the  ovum will at the next pregnancy probably reach its full deve- 
454     CONSTITUTIONAL,  OR  SECONDARY SYPHILIS.

lopment.   The embryo may go its full time, and the foetus be born with syphi-
litic cachexy and  local manifestations  of the disease  fully  developed upon it.
More frequently, however,  it happens  that the child, although  cachectic and
sickly-looking, is brought into the world without any syphilitic affection, but in
the course of a few weeks, usually from the third to the  eighth, these declare
themselves.  Constitutional syphilis of a congenital nature  may manifest itself
even at the adult age.   This, though rare, has lately  fallen under my observa-
tion in a young woman of seventeen who was covered with marked syphilitic
psoriasis, with which she had been affected for several  years.  The mother told
me that  shortly after birth evidences of infantile syphilis had  appeared; that
these had yielded to treatment, but that as the period of puberty approached,
the  psoriasis, which was truly  of a  syphilitic nature, had shown itself.  In
other  cases, again, it is not impossible  that  the syphilitic  taint may manifest
itself in a different way than in  that which has just  been  alluded to; that no
local manifestation may occur, but that  an impaired and depraved state of con-
stitution  and of nutritive activity may be  inherited, which, in after-life, gives
rise to some of  the various forms of scrofula, or of other constitutional  disease,
dependent upon an enfeebled state of system, or a  diminution, as it were, of the
general vitality.
   The mode of communication  of syphilis to the ovum, or to the intra-uterine
foetus, is an investigation that has much occupied the attention of surgeons, and
is of considerable practical interest.  It appears certain that the poison may be
communicated to the embryo in at least four ways.   Thus, the father may have
a constitutional taint of which he has been imperfectly cured, and without com-
municating any syphilitic disease to his wife, may  be the parent of an offspring
that exhibits indications of being infected; or, the mother having a similar con-
stitutional disease, may in like  manner taint  her own offspring; or, again, the
diseased child may be born of parents both of whom are constitutionally infected;
and, lastly, the  mother may become pregnant with a healthy embryo, but after-
wards contracting syphilis, may  transmit it to her  offspring.  These points
appear to be generally agreed upon by surgeons of experience.
   There are several other questions, however, in connection with the transmis-
sion of syphilis  to and from infants, which are of an intricate character, and have
not as yet been cleared up to the satisfaction of all surgeons.   Thus, for instance,
it has become  a  question whether a  mother  pregnant with a  syphilitic foetus,
the offspring of a father laboring under constitutional disease, can be infected
through  it without she herself having had  primary  syphilis ?  Ricord  states
that a woman may be so infected; and Mr. J. Hutchinson  has lately advanced
a considerable amount of evidence in support of this doctrine.  Then, again, the
question has arisen whether a wet-nurse laboring under constitutional syphilis
can infect the child that  she suckles, the infant being contaminated through the
medium  of the milk.  Ricord admits this, but Acton states decidedly that the
disease cannot be so transmitted.   My own opinion is that it can, though rarely,
be so transmitted; and, indeed, there are  a number of cases on record in proof
of  this,  in " Ranking's Retrospect," vol. iv.   The  converse of this is also  a
matter of dispute, whether a syphilitic child can infect a healthy nurse.  This
question  is one  of very great importance, inasmuch as  actions for damages have
been brought by women who have stated that they have  become diseased from
the child that they have  nursed.   Ricord and  Acton deny the possibility of this
mode  of the  transmission  of syphilis, but there are  cases  recorded that prove
the contrary, and on such a question as this, one positive fact nmst necessarily out-
weigh any amount of negative evidence.   Not only have Hunter and Lawrence
related cases in which  an infected child  communicated the disease  to  several
 nurses in succession;  in Hunter's case  three wet-nurses were  successively
infected, two of whom gave the disease again  to their  own children;  but a con-
siderable mass of evidence  upon this point is to be found in " Ranking's Retro- 
SYPHILIS  IN  INFANTS.
455
spect," (Loc. cit).  The  disease is  especially apt to be communicated in  this
way if the nurse have any crack or abrasion upon her nipple, and the infant,
sores  upon  the  mouth.   Dr. Colles, however, who had great experience in
syphilis, states that the  disease may be communicated to the nurse  from an
infected child, by mere contact, without excoriation.
   The  symptoms of infantile syphilis are sufficiently well marked: consisting
principally of cachexy, with disease  of the mucous and cutaneous surfaces.  The
first indication is usually the cachectic appearance of the child;  this invariably
shows itself at birth, syphilitic children  being always described as being small,
shrivelled, wan,  and wasted, when born;  the face especially has an aged look,
the features being pinched, and the flesh soft and flabby;  the complexion gene-
rally has a  yellowish or  earthy tinge,  and these  characters continue until the
disease is eradicated from the system  of the child.   The first local  sign  that
declares itself is usually a congested condition of the mucous membrane of the
nose,  giving rise  to the  secretion of offensive mucus, and causing the child to
make a peculiar snuffling noise in breathing, as if it had a  chronic  catarrh;
this snuffling may exist  from the  time  of birth, but  generally comes on very
shortly afterwards.
   The disease manifests  itself upon the  cutaneous and mucous surfaces, some-
times before or  at birth, in other  cases  not until several weeks  have elapsed.
The most common period for the occurrence of these signs is the third  or fourth
week.  The cutaneous eruption usually makes its appearance on the nates, the
scrotum, the soles  of the feet, and around the mouth; hence, on examining  a
syphilitic child, these parts should always be looked at first.   It presents itself
in three different forms:  most frequently as flat tubercles, varying in size from
a split pea to a four-penny piece, smooth, slightly elevated, and of a coppery or
reddish-brown color.  These tubercles are often accompanied by cracks and fis-
sures about the  mouth and anus.   Though commonly called squamous, they are
not in reality scaly, but are always smooth and flat.  Intermixed with these are
brownish  macule or spots, differing in size, and variously figured.
   The vesicular or bullous eruption is not so common as those just described, but
yet I have frequently seen it in syphilitic children.  It appears in the form of
vesicles, about the size of a split pea, with a dusky coppery areola and base; dry-
ing into brown scales or scabs, and  commonly conjoined with the tubercular
affection.   These bulle are most frequently seen on the soles of the feet.
   The treatment of infantile syphilis is  of a preventive and curative character.
Its occurrence in the infant may be prevented by putting the infected mother
on a  mercurial course so  soon as her pregnancy is ascertained;  this indeed may
be necessary in  order to  prevent miscarriage, but should be done cautiously, and
by inunction, rather than by mercury  administered  by the mouth.   Should
 repeated  miscarriages  have  occurred,  as  the  consequence  of constitutional
 syphilis, one or other, or both the parents, if at fault, should be put upon a mer-
 curial course, and thus the recurrence of this accident be prevented.
   The curative treatment as regards the child is extremely simple.   It should
 be brought up by hand, lest it infect the  nurse or continue to receive fresh acces-
 sion  of poison from the diseased milk of its mother.  It must then be put under
 the influence of mercury, which in these cases  acts almost as a specific; and
 indeed the ready manner in which all disease may be eradicated from the sys-
 tem of a  syphilitic child  by this mineral, is perhaps one of the strongest proofs
that can be adduced of the specific character of its action on the venereal poison.
The mercury may be given by the mouth in the form of small doses of hydrarg.
cum  creta; but as it often purges the child when administered in this way, Sir
B. Brodie has recommended its introduction into the system  by inunction, in
which way I invariably employ it, and have found  it a  most  successful mode
of treating the disease.   The most convenient plan is, as recommended by Sir
Benjamin, to spread 3L of mercurial ointment on the under part of  a  flannel 
456           SURGICAL  DISEASES OF THE  SKIN.

roller stitched round the thigh just above the knee, and to renew this every day.
The treatment should be  continued for two or three weeks until all rash and
snuffling have disappeared, when the mercury having  been discontinued, the
cure may be perfected  by the administration  of small doses of the iodide  of
potass in milk or cod-liver oil.  Occasionally  the cutaneous manifestations  of
infantile syphilis are complicated with, and obscured by some  of the common
diseases of the skin incident to early childhood; more particularly with  eczema
impetiginodes of the head, face,  and body.  Under these circumstances  the
diagnosis may not be easy, though the history of the case, the concomitant  ap-
pearance of two forms of the disease, and the existence of snuffling and cachexy,
tend to establish it.   The eczema also, under these circumstances, is browner
and more squamous than usual.  In cases such as these,  the best plan is to treat
the syphilitic affection first with  the mercurial inunction, and then to put the
child under a mild course of Donovan's Solution, two or  three minims for a dose,
and keeping it at the same time on a good nourishing diet.
DISEASES  OF  TISSUES.
                       CHAPTER  XXXII.

 SURGICAL  AFFECTIONS OF THE SKIN AND  ITS APPENDAGES.

  The various specific cutaneous affections, such as eczema, scabies, impetigo,
acne, lepra, psoriasis, &c, properly fall within the province of the surgeon, and
are  commonly treated by  him in practice; but as the consideration of these
diseases would necessarily lead  into  the  whole subject of  Dermatology, the
limits of this  work would not enable  me to discuss so  extensive and special a
branch of surgery, and I must therefore content myself with the consideration
of some of those affections of the skin, which, as requiring manual assistance,
may perhaps be more properly looked upon as within the scope of the present
Treatise.  These diseases may be considered under the several heads of diseases
of the  appendages of the skin, as of  the cuticle and nails; the non-malignant
ulcers of the skin, and the malignant  ulcers and tumors of this tissue.
   Warts and  corns are affections of  the  cuticle with which the surgeon may
often have to interfere.   Warts  consist of elongated  papille, with strata of
thickened and hardened cuticle, usually situated about the hands and face, and
chiefly affecting young people; they appear in  many cases to be simple over-
growths of the cutaneous structures,  coming and  going without any evident
cause.   In other cases again they are  of a more permanent character, becoming
hardened, and dark in color, and continuing perhaps through life.   The treat-
ment of these affections is usually sufficiently simple.  As tfceir vitality is low,
they may be readily destroyed by the application  of caustics  or astringents;
among  the most useful of these I have found the concentrated acetic acid and
the tincture of the sesqui-chloride of iron.  Brodie recommends the solution of
gi. of arsenious acid in half an ounce  of nitric acid.  In some cases they may
be ligatured or snipped off with advantage.
  Corns usually consist of small  thickened  masses of epidermis accumulated on
those points on which undue friction or pressure has been exercised, in order to
guard the subjacent cutis from  injury.  These epidermic masses are usually
\ 
DISEASES OF  THE  NAILS.                 457
hard, dry, and scaly; at  other times they are  soft and spongy, owing to their
being situated in places where the secretions of the skin accumulate, thus keep-
ing them moist.  Under old and very thickened corns, it is stated by Brodie
that a small bursa is occasionally found.  Corns are at all times sufficiently pain-
ful, but become especially so if inflammation  or suppuration take place under-
neath them, the accumulation of a small drop  of pus under the thickened cuti-
cle,  which prevents its escape, giving rise to  very intense agony.  There  is a
special  form of corn that I have only seen in the sole of the foot, and which
may become the source of the  greatest possible pain and inconvenience to the
patient, preventing his walking, and in fact  completely crippling him.  This
corn is usually of small size and  round in shape, the neighboring cuticle being
always greatly thickened and hardened.  It is extremely sensitive to the touch,
the patient shrinking when it is pressed upon, as if an exposed nerve had been
injured.   On slicing it down with a scalpel, it will be found to be composed of
soft, tough, and  white epidermis, arranged in tufts  or  small  columns, in the
centre of each of which a minute black dot is perceptible.   Each tuft appears
to be an elongated and thickened papilla, and  the black speck is a small point
of coagulated blood which has been effused into it.   Around the depression in
which each of these corns is seated, the hardened cuticle forms a kind of wall.
   The treatment of ordinary corns consists in  shaving or rasping them down so
as to prevent the deeper layers of cuticle retained by the indurated superficial
ones, giving rise to pain by pressure on the papille of the cutis.  Relief may
also  be afforded by  removing all pressure from bearing upon the corn, by atten-
tion  to the shape of the shoe, and by wearing a piece of soft leather or of amadou,
having a hole cut in the centre into which the corn projects.  It is well to avoid
the application  of caustics to ordinary corns, injurious consequences being often
produced by these agents, especially in elderly people, in whom fatal gangrenous
inflammation, as  I  have  seen in one case, may be  excited  by their action.  If
the corn suppurate, it must be poulticed and shaved down, and the drop of pus
let out by puncture with a lancet.  In the painful papillated corn of the sole of
the foot I have found the application of  potassa fusa, so as  to destroy it  tho-
roughly, to be the best and the speediest remedy; and as this corn always occurs
in young people, no danger attends its use; or a poultice followed by the appli-
cation of a blister may bring it away.

                     DISEASES  OF  THE NAILS.

   The nails may become  diseased,  either by undergoing structural changes, by
having their matrix inflamed, or by growing into the soft tissues of the toe.
   In some broken states of health, and especially in persons suffering from squa-
mous disease of  the skin, the nails occasionally become blackish  or dark-brown
in color, are rugged, dry, and cracked, scaling off, as it were, without any appa-
rent affection of the  matrix.  This condition, of which I have seen several
instances, is best cured by a course of alteratives and sarsaparilla, the disease
yielding, as the general health  becomes improved.
   Onychia is a disease of the  nails dependent on inflammation  of the matrix;
it occurs under two forms, the simple and the specific.  In simple onychia there
is redness, heat, and swelling set up, usually on one side of the nail, in  the angle
of the tissue in which it is implanted;  there is no discharge of pus, and the nail
gradually loosens, becomes  dark-colored,  somewhat shrivelled, and may even-
tually be thrown off, a new nail making its appearance below, which commonly
assumes a somewhat thickened and rugged shape.  This disease usually results
from slight degrees of violence, as the running of thorns and splinters into the
finger.  The treatment consists in subduing inflammation by local antiphlogis-
tics,  poulticing, &c, and watching the growth of the new nail, which  may be
sometimes usefully directed by the application  of a layer of wax. 
•58
SURGICAL  DISEASES  OF  THE SKIN.
  The specific or malignant onychia is a more  serious affection, and is often
lependent  on injuries inflicted on the finger in a syphilitic or cachectic condi-
tion of the system.   In it a dusky-red or livid  inflammation  takes place at the
sides or root of the nail, ulceration is set up, accompanied by the discharge of
sanious  and very fetid  pus, and large loose granulations spring up at its root
and sides, so that the end of the toe or finger that is affected, and this is most
                           commonly either the  great toe, the thumb, or the
         Fig. 159.          index finger, becomes greatly enlarged and bulbous
                           in shape.   The nail then shrivels, becomes brown
                           or black, and peels  off in strips (fig. 159); after its
                           separation, thick epidermic masses, forming aborted
                           attempts at the production of a new nail, are depo-
                           sited at the base and sides.   In the treatment of
                           this form of onychia, both local  and constitutional
                           means are required.  The first and most  essential
                           point is to remove the nail, either in whole or part,
                           as it acts as a foreign body, and  prevents the heal-
                           ing of the surface from  which it  springs; the ulcer
                            should  then be  well rubbed with the nitrate of
                            silver, and dressed  with  black wash.  Colles recom-
                            mends fumigating it  with a mercurial candle made
                           by melting  sji. of cinnabar and  §ij. of white wax
                           together.  The constitutional treatment consists of
                           means calculated to  improve  the  general health;
with this view Sir A. Cooper recommends calomel and opium. I have generally
found the bichloride, with sarsaparilla or bark,  the most useful remedy.
   The ingrowing of the nail is an extremely painful and troublesome affection,
principally occurring in the great  toe, and brought about by wearing pointed
shoes, by which  the sides  of the  soft  parts of the  toe  are  pressed upon, and
made to overlap the edge  of the  nail.  An ulcer  here forms, the liability to
which is greatly  increased by the nail being cut square, so that the flesh presses
against a sharp and projecting corner of it; this  ulcer secretes a fetid sanious
discharge, and large granulations  are thrown  up by it.   The consequence of
this condition is  lameness and inability to walk  or stand with comfort.  Various
plans of treatment  have been devised with a view of raising the  edge of the
nail, partially removing it, and pressing aside the  soft structures.  I have  never,
however, seen much permanent benefit result from any of these means, and the
only method that is, I think, really serviceable  to the patient, is the removal of
the whole nail.   As this operation  is  an excessively painful  one,  the matrix
should be rendered  insensible by congelation.   It is performed in the following
way: the surgeon holds the diseased toe in his  left hand, and then running one
blade of a strong sharp-pointed pair of scissors  under the  nail up to its very
root,  he cuts  through its whole length, and  removing the scissors, seizes first
one half and then the other with a pair of dissecting forceps, and twists them
away from their attachments.  The raw surface left is  covered with  water-
dressing, and speedily throws out granulations  which form the rudiments of a
new nail.
               TUMORS  AND ULCERS  OF  THE  SKIN.

   We have  already considered the ordinary non-malignant  ulcers of the skin
(Chap. 24), as well as some of the simple tumors that occur in connection with
this tissue; we shall now proceed  to  the consideration of the more malignant
diseases of this structure, such as the cheloid and fibro-vascular tumors, lupus,
and cancer.
   Cheloid and fibro-vascular tumors of the skin are semi-malignant growths
Bituated on the trunk and  extremities, usually flat  and  expanded, oval, round,
 
LUPUS.
459
or irregular in shape, slightly elevated above the  surface of the skin, and com-
monly occurring in otherwise healthy individuals.  They may remain stationary
for years, but not uncommonly have  a tendency eventually to ulcerate, to bleed,
and  to assume a sort of malignant action; at  other  times  they extend slowly,
without  ulceration, moving  forwards as  it were  upon the skin, the part  over
which they have passed assuming much the appearance of the cicatrix of a burn,
being  red, contracted,  drawn in towards  the centre, and  wrinkled.   Closely
allied to these are those fibro-plastic  growths that have a tendency to sprout up
in scars, constituting the " warty tumor of cicatrices,"  described by Mr. Haw-
kins.  This morbid condition appears to be simply an abnormal  increase in the
activity of the development  of the cicatricial tissue which springs up with great
luxuriance.   These various  forms of tumor should always be extirpated early
by the knife, as they do not appear to be amenable to any constitutional or  local
treatment,  and have certainly a disposition  to  malignant degeneration.   As
there is a great tendency to local recurrence of the disease  after removal, it
should be widely excised, but even then it is likely enough to  return, requiring
perhaps repeated operations before the patient can be freed from this affection.

                                 LUPUS.

  Under the term lupus, various semi-malignant and  malignant affections of
the skin, of very different kinds, are commonly included; indeed, the distinc-
tions between lupus  and  the different forms  of  epithelial cancer have not  as
yet been well made out.  There are  three forms, at  least, in which the diseases
included under the term lupus may  make their  appearance.   1st, As a superfi-
cial affection of the  skin, not attended by ulceration, but accompanied by im-
portant and destructive changes in its tissue; this is the lupus non-exedens of
some writers;  2d, as a slowly ulcerating form of the disease, giving rise to the
different varieties  of lupoid ulcer;  and, 3d, the lupus  exedens, a disease  of  a
rapidly destructive character, not only eroding superficially, but destroying the
tissues deeply.   These various forms of lupus are most commonly seated on the
face or neck, but are occasionally met with on other  parts of the body, as upou
the limbs or trunk.
  Lupus non-exedens appears in the shape of a red  patch on  the skin, covered
by fine, branny, epidermic desquamation; it may remain stationary for years, or
slowly spread over a great extent of  surface, producing  contraction of the skin,
with wrinkling  and drawing in  of the features, and much  stiffness in their
movements.  The integument affected  by it may be in one  of two  states; it
may either continue red, irritable, and branny, having the appearance of a thin
cicatricial tissue, and in this way the greater part or the whole of the face may
be affected; or it may leave a firm, white, smooth, and  depressed cicatrix, ex-
actly resembling that produced by a burn, along  the anterior  margin of which
the  disease slowly spreads,  in the form of an elevated  ridge  composed of soft
bluish-white or reddish tubercles.
   The lupoid ulcer usually  occurs about the face or neck, but  sometimes on the
extremities of elderly people, or  of those in broken health.   It may commence
as the last described variety, which after a time breaks into an ulcer; or a small
crack forms in the first instance, which  scabs over,  and as this  scab  separates,
the characteristic  sore appears.   It is in the first  case a  round  or oval flat ulcer,
without granulations on  its surface and without action in it,  with  somewhat
elevated edges, often  stationary, at  other  times  slowly extending; in this way
it may continue for months upon the cheeks or neck.  In other instances again
it spreads more rapidly, attaining a large size, and  presenting a somewhat fun-
gating surface, from which  some  purulent discharge is  thrown off.   This  form
of sore I have most  commonly seen  about the ears  and  occiput in elderly per-
sons.  In other cases again  it spreads with great  rapidity, giving rise to exten- 
460
SURGICAL  DISEASES  OF  THE  SKIN.
sive ravages; thus, I have seen it extend down the whole side of the neck, from
the ear to the  clavicle, cleanly dissecting away the  skin,  and  exposing the
structures immediately subjacent, as the acromial and clavicular branches of the
cervical plexus of nerves, and destroying the patient by exhaustion.
  The lupus  exedens, or the more deeply ulcerating form of the disease, may
begin in two ways, with or without the existence of a tubercle on the skin.
It is most commonly seated on the nose, beginning by ulceration of the mucous
or  muco-cutaneous  surface, without  any  precursory tubercle, surrounded by
redness of a violet or dusky hue, and attended by much inflammation, swelling,
pain, and coryza.  The ulcer is at first covered by a thick scab; as this sepa-
rates the sore extends, and often rapidly destroys one  or both  ale, the tip and
columna; after  this the destructive action usually ceases  for  a  time, the sore
crusting over with greyish,  hard, and  adherent scabs, but  if not, it may go on
eroding one  half the face, producing  a frightful,  rugged-looking cavity, and
exposing and  destroying the bones and large cavities  of the face.  I  believe,
however, that these three forms of disease, that which is limited to the nose,
and that which extends widely over and through the face, essentially differ from
one another;  the first being generally of a scrofulous character, in fact consisting
of  strumous ulceration is one of the extreme parts  of the  body, the vitality of
which is below its normal  standard, and usually occurring  in young persons,
especially in women from eighteen to twenty-five  years of  age.   Another form
of  this destructive ulceration is an extensive, deeply-eroding, and  fatal  disease,
affecting the whole of the soft tissues and bones of the face, being distinctly of
a cancerous character, and ought  not, consequently, to be described as one of
the varieties  of lupus.   The third variety  is of syphilitic  origin, being one of
the most serious forms of tertiary syphilis.
  The  strumous  form  of  lupus  exedens, that which destroys  merely the
extremity of the nose, is commonly rapid  in  its progress, the part appearing
to melt down  under the disease, so that in the course of a few weeks the whole
of  the  organ is destroyed.   In other cases again  it  is very slow, occupying
perhaps  many years, and partaking somewhat of the red  and  branny form
of  lupus  non-exedens.   Occasionally  it  is  evidently associated with  and
dependent upon the syphilitic  taint, and ought  then to  be considered rather
as a variety of local syphilis in a strumous constitution than as  a distinct affection.
  It is not often that we have an opportunity of examining microscopically the
structure  of  lupus.   Some  time ago, however, I  removed by excision  a patch
                                              of  lupus   non-exedens,  which
                  Fig- 160.                     had existed  for fourteen years
                                              under the chin of a woman  aged
                                              thirty,  who  was   otherwise  in
                                              good health.  On  examination
                                              it was  found to  be  composed
                                              of large cells having clear and
                                              very distinct cell-walls,  many
                                              times  larger  than  blood disks,
                                              and well-marked  refracting nu-
                                              clei.   There were some cells,
                                              clear and globular, without nu-
                                              clei; others  were  fusiform and
                                              elongated with nuclei, evidently
                                              undergoing fibro-plastic transfor-
                                              mation  (fig.  160).  Molecular
                                              movement  was  very distinct in
                                              one of these globular cells. The
mass of  skin  appeared  to  be converted  into granular matter, intermixed with
these cells.
 
TREATMENT  OF  THE  LUPOID  ULCER.           461
  The diagnosis of lupus is not always easy, the disease  being specially apt  to
be confounded with some forms of impetigo, with syphilitic tubercles and sores,
and with  cancer.  From impetigo, it  may be distinguished by the absence of
pustules, and of the thick gummy crusts characteristic of this affection, as well
as by the less extent  of surface implicated, and  the deeper and more eroding
form of the lupoid ulceration.  From syphilitic disease of the skin, the diagnosis
is not always practicable, inasmuch  as  true lupus  may occur  as the  result of
constitutional syphilis.  In other cases the history of the  affection, the  limitation
of the disease, and the absence of intervening secondary manifestations, make it
easy to distinguish one from the other.  From epithelial cancer, lupus cannot
in some cases be distinguished, the two affections  indeed being closely blended
together, and being scarcely recognizable as distinct diseases.
   The  treatment of lupus depends in a great measure upon the variety of the
disease with which we have to do, and the  constitutional condition attending  it,
and calls for the employment not only of local but of general remedies.
   In lupus non-exedens we may, if  the disease be  limited, excise the  patch and
heal the  sore that results, by granulation.  Not unfrequently, however, the
cicatrix is apt to undergo fibro-vascular degeneration.   If excision  be not had
recourse to, on account  of the extent and superficial character of the  disease,
it is useless to  attempt to destroy it by caustics.  In  every case  in which I
have  seen these  means tried, they have failed in effecting  a cure.  In  some
instances, however, the application  of a strong solution  of the nitrate of  silver
to the morbid surface will induce a  healthier  action; though in the majority  of
instances local applications  of a soothing  kind can alone be borne.  Lotions
containing glycerins are especially useful, as they prevent the surface becoming
dry and harsh.  If the disease be situated on the  face,  care should be taken to
avoid exposure to cold winds, dust, &c.   In  the  constitutional treatment, the
avoidance of stimulants of all kinds, the use of a bland diet, and the employment
of some of the  preparations of  arsenic, will be  found  to be the  most likely
means to effect a cure.   Indeed, arsenic may  be considered the great  remedy in
this disease;  the  liquor arsenicalis, or the iodide in combination with  small
doses of  the biniodide of mercury, will be  found extremely useful;  so also
Donovan's Solution is most beneficial in many instances.
   In the treatment of the lupoid ulcer, the  same constitutional remedies should
be employed as have just been described, and a healthy action induced in the
sore by the application of the chloride of zinc paste to the whole of its  surface.
The best  mode of applying this is to  keep the  chloride prepared for use by
being  mixed with  two  or  three   parts of flour.   When  wanted, a sufficient
quantity of this powder should be made into a stiff paste, by the addition of a
little water, and then spread over  the  surface to  be attacked by it,  in a layer
about  the thickness  of a wafer; this should be left on  for two or three hours,
and then removed, the sore being covered with a piece  of water-dressing until
the greyish slough that has been produced  has separated, when the  caustic may
be re-applied as often as necessary.   Besides  the chloride of zinc, various  other
caustics may be  had recourse to, each of which possesses some peculiar advan-
tages   The nitric acid is useful, if the action to be produced is not required to  be
very deep, for as it hardens and coagulates the tissues to which it is applied, it does
not consequently extend so  far as  the chloride.'  The acid nitrate  of mercury
presents the same advantage as the nitric acid and other  fluid caustics, — that it
can  be applied  into  the fissures and hollows of the part into which the more
solid  caustics do not  penetrate, and is  certainly useful in inducing  a  healthy
action  in the part, especially if there be a syphilitic taint.   The  potassa fusa
and Vienna paste are useful, so far as their destructive properties are concerned,
but  are somewhat  uncontrollable,  and apt to spread.   The most convenient
mode of applying them is to cut a hole  in a piece  of plaster the exact size and
shape of the ulcer, to apply this around its  borders, then to cover the sore  with 
462
SURGICAL DISEASES  OF THE  SKIN.
a layer of potassa  cum  calce, one line in thickness,  and over this to  lay on
another piece of plaster.  In this way a considerable amount of caustic action
may be induced, which will be limited to the exact surface to which it has been
applied.  Of all these caustic applications, however, I give the preference to
the  chloride of zinc;  its action  is  more  continuous, and appears  to  give a
healthier stimulus to the part than any of the other  agents.
   The  treatment of lupus exedens must have reference to the constitutional
condition in which it occurs; if  this be of a strumous character, the adminis-
tration of cod-liver oil and the iodide of potass, with a nourishing diet,  will be
most serviceable;  if in a  syphilitic constitution, the  remedies  that  are appli-
cable  to the cure  of tertiary syphilis, such as the  bichloride of mercury and
Donovan's Solution, are especially useful.   In many cases also  in which there
can be no suspicion of a syphilitic taint, these preparations of mercury,  as well
as the iodides  of the same metal, may be administered empirically with great
advantage.   The  combination of arsenic, iodine, and mercury that exists in
Donovan's Solution,  or that is contained  in a pill composed of \ gr. iodide of
arsenic and A-% gr.  of biniodide of mercury, as recommended by Dr. A. T. Thom-
son, has appeared to me to be extremely beneficial, and in many cases certainly
exercises a marked influence in arresting the disease.  Whilst the patient is
undergoing a course  of these remedies, much attention requires to be paid to
 diet, clothing, and his general hygienic conditions.
   In the local treatment the first thing that requires  to be done is  to  subdue
 inflammatory action and irritation, by leeches, emollient  lotions, and opiate or
 henbane poultices.   As this subsides, the progress  of the disease will  usually
 be arrested, for a time at  least, and then by the application of  the  chloride of
 zinc, or the acid nitrate of mercury to  the  surface,  a  more healthy action may
 be set up, and the sore be got to cicatrize.  Great mischief, however, will result
 if the caustics be applied too  early, as the destructive action of the  disease
 will then be augmented.  The inflammatory redness and branny desquamation,
 resembling  lupus  non-exedens, that  surround  the  ulcer, may usually most
 readily be made to disappear by  the repeated applications of a strong solution of
 the nitrate of silver, which should be  applied every second day by means of a
 camel-hair brush.   The cicatrix that forms in this  disease is thin, and breaks
 readily, giving way on exposure to cold, or on  the occurrence of constitutional
 derangement.   The patient should,  therefore, for  some  length  of  time  after
 recovery, be careful  not to expose himself to any such influences.   In the more
 rapidly spreading  and worst forms of  lupus exedens,  that horrible  disease
 termed by the older surgeons, " Noli-me-tangere," nothing can be done  beyond
 the relief that is afforded by the administration  of  opiates, and a general seda-
 tive plan of treatment.

                        CANCER OF THE SKIN.

    Cancer may occur in  the skin  as a true scirrhous or encephaloid deposit;
 most  commonly, however, those affections of the skin termed cancerous, consist
 of the  epithelial  form of the  disease, and are usually seated about the lips,
 face,  and  scrotum,  or  at the   orifices of  the mucous  canals; these we have
 already considered  generally, and shall have to  revert  to them more fully,
 when treating of the special affections of these parts.  Some forms of lupus, also,
 may be of a cancroid character, but they do not exhibit  the true evidence of
 malignancy by infecting  the system, and giving rise to  secondary deposits  in
 the different viscera.
    True cancer of the skin may occur in  three forms: as the indurated wart of
 a scirrhous character, specially described by Scarpa; as scirrhous  or encephaloid
 infiltration and fungus; or as ulcers which, primarily  originating from some
 local  irritation of  a  simple kind, may by the persistence of this, assume a truly
 cancerous  character; thus I have seen the  scrotum and  the neighborhood  of 
CANCER  OF THE SKIN.
463
the apertures  of fistule in perineo, in a case of old standing disease, become
converted into a truly cancerous mass.
  The scirrhous wart  is  usually of the  natural  color of the  skin, but  some-
times of a reddish or dark-greyish hue, hard, and somewhat irregular in shape;
it may  remain  for a  long time stationary,  but at last ulcerates and spreads
rapidly, giving rise to  vast destruction of parts; the ulcers formed  by it pre-
senting the characters of cancer,  with  a hard  base, everted edges and foul
surface.
   The infiltrated cancer of the skin occurs in the  form of a flat dark indura-
tion, which scabs over with dark,  rugged, greyish-brown incrustations, having
shooting  pains  in  and around it,  and after remaining stationary perhaps for
years, runs into ulceration and rapidly destroys the parts it affects;  after ulce-
ration has been set up, the patient's  life, according to Dr. Walshe, is  seldom
prolonged beyond two  years.   Encephaloid cancer of the skin is of  rare  occur-
rence, but occasionally forms large  fungating masses sprouting from,  and solely
connected with, this tissue.  The cancerous  ulcers of the  skin may arise from
the irritation  and  contact of secretions, as of the urine, or an  unhealthy and
specific action may be  set up  in an old ulcer, as of the leg, and  cause it  to
assume a cancerous character  (fig. 161).  These cancerous ulcers may indeed

                                  Fig.  161.
occur upon almost any part of the body: I have seen them on the back, breast,
fingers, hand, thigh, and sole of the foot.   They are flat, grey or sloughy look-
ing, often with warty granulations, a good  deal  of induration about them, and
but little discharge.
  The treatment of cutaneous cancer  consists in the excision or amputation of
the part affected.   Its removal by excision, whether in the form of wart, crust,
or ulcer,  should be effected  so soon as its true characters  have declared them-
selves; provided  it  be  of such a size, and so  situated, that it  can be freely
removed  with a sufficient stratum of subjacent healthy parts,  and a wide border
of surrounding skin.  Should it be so situated  that its  excision  through sur-
rounding healthy  tissue  is not practicable, amputation of the limb must be had
recourse to, as was done in the case above depicted.  Under such circumstances
as these,  the limb may be removed at  no great distance above the disease, it not
being necessary, as in other cases of cancer of the extremities where the bones
are affected, to allow a joint to intervene between the seat of operation and the
malignant growth. 
464       DISEASES  OF LYMPHATICS  AND GLANDS.
                       CHAPTER  XXXIII.

    DISEASES OF  THE  LYMPHATICS AND  THEIR  GLANDS.

  Inflammation of the lymphatics, lymphatitis, angeioleucitis, is a diffuse, or
erysipeloid inflammation of these vessels.  In it, according to Tessier, the lymph
coagulates, forming a rosy clot which  obstructs the interior  of the vessel,  the
walls of which, at the same time, become thickened, softened, opaque, and sur-
rounded by a quantity of  infiltrated cellular tissue.
  This disease may be idiopathic, when it is closely associated with erysipelas;
but more commonly it is set up from  the irritation induced by an  abrasion or
wound.   During the progress of an ordinary injury, the patient is  seized with
rigors, followed by febrile reaction, and attended, perhaps, by vomiting or diar-
rhea-  These symptoms often precede by twelve or fourteen hours the local signs
of the disease, but more commonly accompany them.  On examining the part
it will, if superficial, be seen to be  covered  by a multitude  of fine red streaks,
at first  scattered, but gradually approximating to one another,  so as to form a
distinct band,  about an inch in  breadth, running  from the part affected along
the inside of the limb to the neighboring lymphatic glands, which  may be felt
to be enlarged  and tender.  The band itself feels somewhat doughy and thickened.
There is usually more or less edema of the  limb  from the implication of  the
deeper layers of vessels and their obstruction by the inflammation.  Along  the
course of the inflamed absorbents, erysipelatous looking patches not unfrequently
make their appearance, which coalesce until they assume  a  considerable size,
and constitute a distinct variety as it were  of erysipelas.   In  some cases  the
glands are  affected before  any other local signs manifest themselves, owing pro-
bably to the deeper seated lymphatics having been first  implicated;  and  not
uncommonly throughout the disease the inflammation continues to be  confined
principally to  this set of vessels, giving rise to great and brawny swelling of the
limb, but without much, if any, superficial redness.  The constitutional disturb-
ance at first of the  active inflammatory type may gradually subside into  the
asthenic form.
  The disease usually terminates in resolution at the end  of  eight or ten days,
not uncommonly it runs on to erysipelas, and in other cases again, limited sup-
puration may  take place, or a chain of abscesses form  along the  course of the
inflamed absorbents and in the  glands to which they  lead.   In  some  instances
after the disappearance of the disease, a state of chronic and rather solid edema
of the part may be left, giving rise indeed to a species of false  hypertrophy of
it, and constituting a troublesome after-consequence; more  rarely, death results
either from erysipelas, by the supervention of pyemia, or by  the occurrence of
secondary abscesses.   This is  chiefly  in broken constitutions, in which the dis-
ease has made extensive ravages, and becomes associated with low cellulitis.
  The diagnosis of inflammation  of  the  absorbents  is easily made; the only
affections with which  it can be confounded being  erysipelas and  phlebitis. From
the first it may be distinguished by the streaked  character, and limited extent
of the redness;  though as  the two affections  so commonly occur together the
distinction is of little moment.  From phlebitis, the  disease we are  now con-
sidering may be recognized by its superficial redness,  the inflammation  of con-
tiguous glands, and the absence of the knotted, corded state, characteristic of an
inflamed vein.
  The causes  of inflammation of the absorbents  closely resemble those of  ery-
sipelas, the disease being  especially disposed to by atmospheric vicissitudes, by
particular  seasons of  the year, more  especially  the  early spring,  and by the 
INFLAMMATION  OF THE LYMPHATIC  GLANDS.
465
epidemic constitution at the time tending to disease of a low type.  So also the
broken health of the patient and  the neglect of hygienic precautions tend to
induce it.  Amongst the more direct causes are wounds  of all kinds, but espe-
cially such as are poisoned by the introduction of putrid animal matters or other
irritants, or that are of recent origin.  It is very rarely indeed, that inflamma-
tion of  the absorbents occurs without some such cause, but yet I think we are
warranted  in considering it as of idiopathic origin in some instances.  I have at
least seen  cases  in which careful examination has failed in detecting any breach
of  surface, or evidence of poisonous absorption.
   The  treatment consists in the employment of antiphlogistic remedies, such as
 the application of a series of leeches along the course of the inflamed absorbents,
 followed by assiduous poppy fomentations; the limb at the same time being kept
 elevated.  The  bowels should be freely opened, and if there be  much pyrexia
 present, salines  with antimony may be administered. If the fever assume rather
 a low form, the liquor ammonie  acetatis  may be given in camphor  mixture;
 support being administered, or withheld, in accordance with the  principles laid
 down when speaking of the treatment of inflammation  generally.   If chronic
 induration and  edema  occur, the application  of blisters will be found to be of
 use in  taking down the swelling and hardness; bandaging so as to compress the
 limb methodically,  may be of service in the later  stages.   If abscesses form,
 these should be opened early, and treated on ordinary principles.
    Infiammation of the lymphatic glands, or adenitis, may occur either by the
 extension of inflammation along the course of  the lymphatics, by the irritation
 induced by acrid or  poisonous  substances conveyed along these  vessels, and
 not inflaming them, but inducing diseased action in the glands through which
 they are  carried; or as a consequence of strains resulting from over-exertion,
 as is often seen in the glands of the groin from walking too much.  In what-
 ever way occurring, inflammation of  the  absorbent glands is always attended
 by a stasis of the lymph, by coagulation of it,  and, if the whole or greater part
 of the glands of a limb are affected, the  course  of the fluid through  the ab-
 sorbent vessels  may be so seriously interfered with, that edema, often of a solid
  character, occurs in the lower parts from which  the lymph ought  to have been
  conveyed.
    Adenitis may be acute, subacute, or chronic.  In the acute form of  the dis-
  ease, which almost invariably occurs as a consequence of angeioleucitis,  there is
  pain, swelling,  tenderness, and stiffness about  the affected  glands, with a dull
  heavy sensation in them, followed by all the signs of acute abscess, the glands
  gradually softening in the centre, and the suppurative  inflammation  extending
  to the contiguous cellular membrane, through which it  becomes  somewhat
  diffused.  In  the  subacute inflammation, which is of common occurrence  as
  the result of  injuries or strains,  the  glands become  swollen, enlarged, and
  tender, and are matted together by the inflammatory and plastic  consolidation
  of the neighboring tissues.  If abscess form, it  commonly commences in the
  first instance in the structures around the glands, and  these are perhaps even-
  tually exposed at the bottom of  the cavity that results.  This is especially apt
  to happen in cachectic and strumous persons, from slight sources of irritation.
  Very commonly, in such subjects as  these, the inflammation of the glands runs
  into a chronic state;  which, indeed, may at last  terminate in their permanent
  enlargement and induration, or tuberculous degeneration.   When  the glands
  become  chronically inflamed  from the first, they will be found to be enlarged
  and hardened, with tenderness  and pain about  them; after a time suppuration
  takes place within them, or perhaps  it may occur in the cellular tissue around
  them, which,  breaking down, leaves them in the form of  reddish-grey or fleshy
  masses, that protrude in the midst of the suppurating cavity; as the inflamma-
  tion subsides,  the skin becomes of a reddish-blue or purple hue, is thinned, and
  firmly incorporated with the subjacent tissues.
         30 
466       DISEASES  OF LYMPHATICS  AND GLANDS.

  But the glands  not uncommonly enlarge chronically without any inflamma-
tion, simply as the result  of strumous disease or of chronic irritation of some
kind.  They  may  remain permanently enlarged, or,  after  continuing so for
months or years, may slowly break down into  unhealthy suppuration, leaving
the skin thin, blue, and undermined, with weak and often  protuberant cicatrices.
The pus discharged from these strumous glands is of a curdy, ill-conditioned
character.    In all probability  the  peculiar enlargement  and  tendency  to
unhealthy suppuration arise from the deposit  of  tuberculous  matter within the
gland.  These changes principally occur  in  the neck, especially in the  sub-
maxillary glands, and  the glandule  concatenate,  sometimes in  the  axillary
or  inguinal  glands, forming large indurated and  nodulated tumors, matted
together, and suppurating in the interstices  of the cellular tissue,  or in the
substance of the glands themselves.   This strumous enlargement of the glands
occurs chiefly in children and in young people, in whom  indeed it is  commonly
looked upon as one of the  most  frequent  accompaniments of  the strumous
diathesis.
  The treatment of inflamed  absorbent glands varies of  course greatly, accord-
ing to the stage of the affection.  In the acute stages, leeches  and fomenta-
tions are  especially required.   In the  subacute condition,  spirit-lotions  con-
taining the iodide of potass will  subdue the inflammation and take  down the
swelling;  at the same time the health must be regulated by aperients, and a
moderate  antiphlogistic plan of  treatment.  If abscess forms, this must be
opened with a knife, and the part well poulticed  afterwards; the fistulous open-
ings which are often left require to be treated by stimulating applications, espe-
cially the nitrate of silver, but very commonly they will not heal unless they
are slit up and dressed from the bottom.
  The chronic  inflammation or enlargement of the lymphatic glands, or the
induration left  as  the result of the  acute disease,  requires to  be treated on
different principles.   If  there be any pain and tenderness about  them, the
application  of the iodide and spirit-lotion will be required.   If they have
already suppurated, and an aperture  exist leading  down to an indurated mass,
or if there be surrounding induration  of the soft tissues,  it is often a good plan
to rub the ulcerated part freely with caustic potass,  which will dissolve it away
by  exciting  inflammation  around the plastic deposit, and  thus causing its disso-
lution into  pus.  When  merely chronically enlarged,  without being irritated,
methodical  friction with  the iodine  or  iodide of  lead ointment  will produce
absorption of the inflammatory effusion  constituting the bulk of the enlarge-
ment, and this  in  many instances may remove the  tumor entirely.  In other
cases, again, painting the  part with the tincture of iodine, and improvement of
the general  health, will cause the removal  of the  diseased  structure.  After
abscess has  formed and been opened, fistulous openings will be left, into which
large masses  of hypertrophied gland may be  seen  to  project.   These  are best
reduced with the red oxide of mercury, or potassa fusa;  indeed, if the glands
be  much enlarged and indurated, projecting into the openings made over them,
the potassa fusa is the best application that can be made use of, breaking down
and dissolving  away the  indurated mass.  In applying  it, care must be taken
that the caustic does  not spread  too widely; this  may usually be avoided by
coating the  surrounding integuments  with collodion.  Extirpation of enlarged
lymphatic glands is  seldom  necessary,  and if undertaken  may lead to more
serious and  extensive  dissections than  might appear  at first requisite, a chain
of diseased glands often extending to a considerable distance—after one has been
removed others coming in sight.  As a general rule, these operations should not
be  undertaken; cases,  however, occasionally occur,  in which  such a procedure
may be deemed advisable, *the affected glands being large, indurated,  and tuber-
culous, and  their disease  of many years' standing; under such  circumstances,
their extirpation may  be  proper, and I have not  unfrequently  had occasion, 
PHLEBITIS.
467
under such circumstances, to remove them from the axilla, sub-maxillary region,
and the posterior triangles of the neck.                    _
  The lymphatic glands occasionally become much enlarged in the neck, axilla,
or groin, without any indications of struma, but attended  by much debility, and
usually great emaciation ;  under these circumstances, the best remedies  are the
liquor potasse in full doses, and cod-liver oil.
   Besides these inflammatory and strumous enlargements  of  the lymphatic
glands, various other alterations  are frequently observed in  them;  thus, they
may  undergo  cancerous  degeneration,  as  the result  of  absorption  from  a
scirrhous, melanotic, or encephaloid  tumor.  In  other cases, again, they  have
been found to have undergone calcification, as the result of  tuberculous dege-
neration ; and, lastly, a varicose  condition of the absorbent vessels  that pass
through them has been observed by Amussat and Breschet, but these are rather
matters of pathological than of practical interest.
                      CHAPTER  XXXIV.

                         DISEASES  OF VEINS.

                              PHLEBITIS.

   Inflammation of the veins, originally studied by Hunter, has of late years
attracted the attention of many distinguished Continental and British patholo-
gists, amongst whom  may be specially  mentioned Breschet, Velpeau, Cruveil-
heir,  Arnott,  Lee,  and  Tessier.  This disease is  commonly excited by the
wound of veins,  as in operations, venesection, and  injuries  of various kinds;
or it may result  from the application of ligatures to them, and is especially
predisposed to by a previously unhealthy condition  of the  vessel, and by epi-
demic constitution and season;  in  fact,  by  those influences that dispose  gene-
rally to the diffuse forms of inflammation.
   When a vein is inflamed, important changes occur both in the coats of the
vessel and in the contained  blood.  The coats of the vessel generally become
thickened, the outer  one especially being vascular  and  infiltrated; the inner
coat becomes softened, pulpy, and  usually more or less stained by the coloring
matter of the blood of a dark-red or purple hue.   The blood in  the  inflamed
vessels  undergoes coagulation,  and adheres to their sides; this tendency to
adhesion and coagulation being increased by the effusion of plastic matter from
the wall of the vessel.  As a consequence  of this, its interior becomes stuffed
with a solid  mass of coagulated blood  and lymph.   This  coagulatian of the
blood in the  interior of the inflamed vein is a very remarkable circumstance,
and  appears to be specially induced by the morbid  action going on in  the coats
of the vessel, though in many cases it is doubtless aided by the blood becoming
entangled  in  the plastic  matter with which the lining membrane of the vein
speedily becomes coated.   Suppuration often takes place  in  the interior of the
vein, the pus being produced not by the transformation of the contained blood,
but by effusion from the coats  of the vessel.   These changes may occur in any
vein,  external or internal, and we often  find  them associated; the same vessel
containing  a mixture of  coagulum, fibrine, and  pus.  The  extent of surface
which-the  inflammation  may occupy varies from that of a small vessel a few
inches in length, to the trunk and branches of one of the largest veins in the 
468
DISEASES  OF  VEINS.
body.  In accordance with  these  pathological  conditions,  three  varieties of
phlebitis may be described — the adhesive, the suppurative, and the diffuse.
  In the adhesive phlebitis, plastic matter is thrown  out by the wall of the
vein, and the blood coagulating upon  and in  this, a firm plug is formed, by
which the vessel  is more or less completely  obstructed.   This obstruction of
the vessel which is the common result of this  form of the disease, may continue
permanently, the  plug becoming incorporated with its  coats, and  gradually
undergoing fibro-cellular degeneration it is converted into an impervious cord.
In other cases again, a channel eventually forms through the axis of this coagu-
lum, allowing the circulation through the vein to be re-established.
  The suppurative phlebitis is  always preceded or accompanied by the adhesive
form of the disease, the adhesive action bounding and limiting the suppuration,
and preventing the pus from becoming mingled with the  current of the blood.
If the plastic plug is sufficient to occlude the vessel, or if it become  absorbed
or  metamorphosed with  pus,  then  this fluid  may get  access to the general
circulation, and produce that serious and fatal train of symptoms  constituting
pyemia, and  depending on the  admixture of pus with the blood.  In this form
of the disease, the pus is usually found between the coats of the vessel and the
plug, or  in a portion of  the vessel unoccupied  by coagulum, but confined at
either end by a mass  of plastic matter; when thus limited or encysted, it can
do no mischief to the system;  but  if the plug that bounds it becomes absorbed
or degenerates, it will mix with the general current of the blood.   Pus has
been described as forming in the  centre of the coagulum, but  Gulliver has
shown that in  many cases the fluid described as pus is merely disintegrated
fibrine.
  The diffuse phlebitis is an erysipeloid  form  of the disease, often running for
a considerable distance along the coat of the vein, which becomes thickened,
pulpy, and red, without  adhesions  forming, or the  blood  coagulating; indeed,
in these cases there appears to  be a great want of plasticity in this fluid.  This
form of  phlebitis  is commonly, though  not always, fatal; its vitality  was sup-
posed by Hunter to be owing to the extension of the inflammation to the heart,
and  by Hodgson to the extent  of surface affected; but Arnott has shown that
the inflammation  scarcely ever  reaches the heart, and that the extent of vein
inflamed  is  commonly  very limited; it not  unfrequently happening  that the
disease proves fatal when but a few inches are affected, as in the vessels of a
stump.   Hence it is probable that  death is owing  either to the admixture of
pus with the  blood that circulates through the inflamed portion of the vein, or
by such changes induced  in the blood  by the inflamed surface over  which it
passes, as are incompatible with life.
  The essential difference between  these forms of phlebitis would therefore
appear to depend on the formation and situation of the plastic matter.  So long
as the inflammation is purely adhesive, or, as  the pus  formed by it is bounded
by adhesive plugs, it does not differ  in its  effects from ordinary inflammation;
but if the pus get into the circulation by the  breaking down or disintegration
of these limiting  plugs, or if the blood  be  deeply and seriously altered in its
characters by changes induced  in its passage over the inflamed surface, then we
get those peculiar phenomena indicative  of general blood-poisoning;  which
have been described as pyemia. (Chap.  28.)
  The symptoms of phlebitis vary according to the form  it assumes.   In the
adhesive  phlebitis the action is usually localized  and  limited; very commonly
arising from  traumatic  causes, and  not  unfrequently  sub-acute.  When trau-
matic, it may occur in any vein that  is wounded, but when idiopathic, it com-
monly occurs in those situated in the calf or leg,  especially if they are  varicose.
The inflamed vein is  hard, swollen, knobbed,  and painful, the knobs  constitu-
ting distinct enlargements opposite to the valves; if superficial, it  is  of a red-
dish-purple color, and is attended with some degree of stiffness and inability to 
VARIX.
469
move the limb.   There may perhaps be no pain, but only deep tenderness over
the course of the vessel.   There is always some  edema around  the  inflamed
vein, and in the part that supplies  it with  blood.  This edematous condition
of the  limb is a most important diagnostic  sign in deep-seated phlebitis when
the vein cannot be felt, as in the pelvis, for instance, and  may perhaps be  the
first symptom observed, coming on  either suddenly or gradually.   The edema
may give rise to a hard, white, and tense condition of the  limb, which pits on
pressure, though in some cases the hardness is too great for this.  Occasion-
ally, in deep phlebitis, the limb may suddenly swell to a considerable size, with-
out there being any sub-cutaneous edema.   In a case of phlebitis of  the deep
veins of the leg and thigh, lately under my care, the calf  of  the  affected limb
suddenly enlarged with great pain and  much  distension of the  sub-cutaneous
vessels with fluid  blood, but without any  sub-cutaneous edema.   As the in-
flammation subsides, the swelling of the limb goes down, the circulation passing
through  its former channels, or the blood  being  carried off by  the  collateral
venous system.  If suppuration take place, no change takes place in the symp-
toms so long as the pus is localized or encysted, until it perforates the coats of
the vein, and passing into the external cellular tissue, forms a common abscess.
If it break through its  plastic barriers, then, however, a very different  result
occurs, and the symtoms of purulent infection come on.  The  constitutional  dis-
turbance in these forms of phlebitis is  often of a  very mild character; in other
cases,  however, symptoms  of well-marked  pyrexia manifest  themselves, often
accompanied by rather a depressed state of system.
   The treatment of adhesive phlebitis consists in the free application of leeches
along  the course of the inflamed vessel, with rest of the limb,  and  fomentations;
at the  same time salines  and purgatives must be administered, and the ordinary
antiphlogistic means be had recourse to.  If depression come on, carbonate of
ammonia  must  be  early given.   The  hardness which is often  left  after  the
removal of the inflammation, may usually be got  rid of by salt and nitre poul-
tices, as recommended by Dr. Basham.   If abscesses form, they must be opened
wherever they occur.  If edema of the limb continue, the application of blisters,
or the pressure of an elastic roller, will remove this troublesome symptom.
   The diffused phlebitis is ushered in by the ordinary symptoms  of pyrexia, at
the same time that pain  and tenderness, with  a certain  amount of  edema  and
hardness, may manifest  themselves along  the course  of  the inflamed vessel.
These  symptoms, however, speedily give  way to those that characterize  the
lowest forms of ataxic fever, such as a fluttering pulse, a  brown tongue, sordes
about  the mouth and  teeth, with  much  anxiety of  countenance,  diarrhea,
vomiting, extreme prostration,  delirium,  and  death.   These symptoms  are,
indeed, due to the  formation of pus in the vein, its admixture with the blood,
and consequent poisoning of the system.  The whole danger and peculiarity of
diffuse phlebitis depend, I believe, upon this circumstance, and I would,  there-
fore refer for the consequences and  treatment of this form of the affection to the
chapter on pyemia (p. 381).

                                 VARIX.

   By  varix or varicose veins is meant a dilated condition of  these vessels with
hypertrophy of their coats, giving rise  to  edema, tension, weight,  and pain in
the parts they  supply, often with a good deal of numbness, difficulty in motion,
or loss of power' in the affected limb.   In other cases, their pressure on  the
nerves of the  part, as when occurring  in  the spermatic cord, may give rise to
very severe suffering.
   In appearance, varicose veins are tortuous, dilated, and  sacculated; they are
serpentine in their course, and feel thick under the finger.   They may be super-
ficial or deep-seated; when superficial, the disease is often  limited to one of the
larger  venous trunks of a limb, the smaller branches not being engaged.  This 
470
DISEASES  OF  VEINS.
we  commonly see to be the  case  in  the internal saphena; in other cases, the
small cutaneous veins  alone  may be affected, appearing as a close network of a
purplish-blue color under the skin, with much discoloration of parts, and some
edema of the limb; or both sets of vessels may be implicated.   The deep-seated
varix is not by any means so common as the superficial, and when it occurs, is
generally the  result of the  pressure  of the tumor, or of some  similar cause.
Varicose veins, especially when superficial, are very apt to inflame, with coagu-
lation of  the blood within their sinuses.
   The veins of the skin and mucous membranes are those that are most liable
to this affection.  It is most  commonly met with in the legs, and  more particu-
larly in the trunk of  the internal  saphena; but any of the superficial veins, as
of the  arms, chest, head, neck, hypogastrium, or  thorax, may be  affected; the
veins about the anus  are  especially liable  to varix, constituting some forms of
pile; so also, the spermatic veins very often become enlarged, constituting vari-
cocele.  As a general rule, superficial varix is  infinitely more common in the
lower than  in the upper part of the  body, owing evidently  to the tendency to
the  gravitation of blood in the more dependent situations.  When occurring at
any point above the pelvis, it may be  looked upon as arising, in all probability,
from the pressure of a tumor of some  kind upon the large venous trunks.  The
deep-seated veins that are principally affected are, the 'internal  jugulars, the
vena azygos, and the veins of the  prostate.
   The causes of varix are generally such conditions as induce more or less per-
manent distension of the veins.   Thus, for instance, blows, strains, and habitual
over-exertion  of a part, by driving the blood into the  sub-cutaneous veins, may
give rise to their distension;  so  also,  certain occupations may favor gravitation
of blood to the lower  part of the body; then, again, the length of a vein, as of
the internal saphena,  may occasion its dilation by the weight  of the long column
of the contained blood.   Any obstacle to the return of the blood from a vein, as
the pressure of a  tight garter  below the knee, or of  a tumor upon one of the
large venous  trunks,  may give  rise to its permanent distension, as well as to
that of all its branches.   In other cases, again, the affection, or the disposition
to it, appears to be hereditary, and in  many instances, it is difficult to recognise
any cause except an enfeebled and relaxed state of the walls  of the vessel, such
 as is met  with in tall, debilitated, and phlegmatic  people.   Age influences
 materially the occurrence  of  the disease, which is rare in the earlier periods of
 life, but  gradually increases  as the individual advances  in  years.  In women,
 especially, the  affection is common, in consequence, partly, of natural debility,
 but more frequently from  the pressure of the enlarged  uterus during pregnancy.
   In structure varicose veins are sometimes simply dilated without any thicken-
 ing of their  coats, but in other instances  they are truly hypertrophied, their
 cavity being  dilated  and  walls thickened, the vessel  likewise being elongated,
 forming  curves, and bending back on itself.  Sometimes the  enlargements at
 particular points appear to be multilocular, the vein forming a series  of  curves
 and dilatations together.  The valves  are  always insufficient in varicose veins,
 being usually  bent backwards or ruptured, and the lining membrane is marked
 by longitudinal strie.   The  blood in  these vessels has a tendency to coagulate
 in large masses,  the  vein being at  times the seat of inflammation, by which
 this tendency is materially assisted.   The neighboring and subjacent parts are
 much  modified in  structure, and  there is usually chronic edema, with infiltra-
 tion of the skin and cellular tissue, which may at last run into ulceration, giving
 rise to the varicose ulcer, which  has already been  described (p. 351), and which,
 if communicating with a large  branch, may  yield  a copious  or  even fatal
 hemorrhage.
   The treatment of varicose veins is  of a palliative  and curative  kind.  The
 palliative treatment consists in moderate compression exercised upon the vessel,
 so as to support its weakened and dilated coats,  and thus prevent  its further 
treatment of varicose veins.
471
distension and the  pain  occasioned by this, as well as the other after-conse-
quences, such as edema, disorganization, and ulceration of the skin.   The pres-
sure must be applied very smoothly and evenly, lest it irritate and ulcerate the
skin, or produce  distension  of the vein  below the part  compressed.   For the
purposes of compression, bandages and elastic stockings are commonly employed.
I know of no better material for. this purpose  than Churton's elastic bandages,
and I have in many cases used Huxley's stockings, made of an elastic woven
material, with great advantage.  In some cases an elastic pressure by means of
a vulcanized  India rubber band or garter may be applied around the limb so as
to simulate the action of  the valves of the vein; by compressing this it cuts off
the weight of the column of blood from the terminal branches.  In other cases
again the  application of a truss to the upper part of the saphena vein, as recom-
mended by Colles, may be of service.
   If a varix bursts, violent  bleeding  may suddenly take place so as to induce
faintness and even death.  The treatment  consists in laying the patient flat on
the floor and raising his leg, when the hemorrhage will cease.  The copiousness
of the bleeding may be accounted for by its occurring from the cardiac side of
the varix, the insufficiency  of the valves not  presenting the  ordinary obstacle
to the  downward flow of blood.  It may be permanently arrested  by the pres-
sure of a compress and  bandage.   Under certain circumstances, it  becomes
necessary to change  the palliative for a curative plan.  This is especially requi-
site under the following three conditions : — 1st.  If the varix be of such  large
size as to produce  much inconvenience, or to give rise to severe pain by its
pressure on the nerves in its neighborhood; 2d. If a varicose vein has  burst, or
is on the  point of giving way: or,  3d. If an ulcer dependent on its existence
will not heal.  Under one or other of  these circumstances it may be necessary
to have recourse to curative treatment.   With this view various  plans have
been recommended, all of which, however, have for their object the production
of obliteration of the vein at one point by exciting adhesive inflammation there,
and thus  causing it eventually  to degenerate into a fibro-cellular cord.   In this
way the trunk of a varicose vein and the larger masses of varix  may be occluded.
But can the disease be cured  by the  local  obliteration of the vein ?   To this
question I have no hesitation in answering in the negative.  Though the trunk
be obliterated, a collateral venous circulation is set up,  which is very apt in the
course of a few months  to  take on a varicose condition, and thus to cause a
return of the disease some time after  the operation.  But though  the cure  is
not radical, much  benefit may often be effected, by removing  varicose  knots
that occasion pain or inconvenience, by enabling an ulcer to cicatrize, or  by
occluding a vein from which hemorrhage has  occurred.   The principle of all
curative treatment in varix  consists in  exciting adhesive and  localized inflam-
mation in the vein  so as to occlude it, and thus, by directing the blood into
other  channels, to relieve the distension of the diseased vessels and the  incon-
venient results that follow this.  As the treatment thus necessarily involves the
artificial excitation of phlebitis, there is always some little  risk of the inflam-
mation passing beyond the  adhesive  stage into that of suppuration, or diffuse
inflammation: but  out of upwards of 150 cases, in which I have performed
these operations, not one has died.
   Various plans for obliterating the veins have been recommended by surgeons.
They resolve themselves  into four principal heads of treatment.  1st.  The sub-
cutaneous section of the vein, or  the  excision of an inch  or so of the vessel.
This plan  of treatment is severe, and not unattended by danger, as we  learn
from Sir B. Brodie.   2d. It has been  recommended by Mayo, Seutin, Bonnet,
and others, to excite inflammation in the vein by producing  a  series  of deep
eschars or issues in the skin covering  it, by the application of a caustic, such
as the  chloride of zinc or potassa fusa.  Mr. Skey speaks  very favorably of this
mode of obliterating varicose veins, as being  devoid  of  danger.   He recom- 
472
DISEASES  OF  VEINS.
mends the eschars to be made by the application of a powder, composed of three
parts  of lime  and two  of potass, made into a paste with spirits of wine at the
time  of application.  The eschars should not be larger than  a split pea and
their  number must depend  on the  extent  of the disease.   3d. Others a^ain
recommend  the obliteration  of the vessel by introducing needles into it and
transmitting a galvanic  current along and across  them.  Of this plan of treat-
ment  I have not  had any experience, nor do I believe that it is ever employed
by surgeons in this country.
  4th. The most convenient and  safest way of  obliterating the  vein, in  my
opinion, and that which I always employ, consists in compressing  the vessel at
several points, by passing a  hare-lip pin underneath it, laying a piece of wax-
bougie over it, and then applying the twisted  suture  around the pin and over
the bougie (fig. 162 a).   In this way the vessel gradually ulcerates by the pres-

                                  Fia. 162.
                            sure that is  exercised upon it, and  the  presence
                            of the bougie prevents  the ligature injuring the
                            skin.   In performing  this operation there  are a
                            few points that require attention ; thus care must
be taken that the vein be not transfixed, but that the pin be pushed, or rather
dipped, underneath it; the ligature should not be too thin, and must be applied
tightly over the bougie; several pins, as many as  eight  or ten, if necessary,
should be introduced along the course of the same vessel, at distances  of  about
three-quarters of an inch from one another; those highest up should be put in
first, and  they should be left in for at least a week or ten days, by which time
the obliteration  of the vessel will  have taken place.   I  believe that all the
danger of the operation consists in  the transfixion of the vein by the pin; the
operator may always know when he has done this by the escape of a few  drops
of venous blood; when the pin is properly passed under the vein, the operation
is a perfectly bloodless one.   If the vein is transfixed, the pin  should  immedi-
ately be withdrawn and passed at another point; if it be allowed  to remain in
the vein,  it will act as a foreign body, and suppurative phlebitis will ensue.
When the vein is properly compressed between the pin below and the bougie
above, adhesive inflammation takes  place in it, and it becomes obliterated at the
point  of  pressure.   By  attention  to  these  circumstances  I  have  never met
with any ill consequences in any of the cases  in which I have  performed this
operation.
  In  addition to the application of the  pins in the  usual way, Mr. Lee has
recommended  the  subcutaneous division  of that portion of the vein which  is
included between them, after coagulation of the blood has taken place.   This,
I have  found to be a useful  addition  to the ordinary treatment, and to insure
the obliteration of  the vessel.
  The points of the pins may be prevented pressing injuriously upon the skin,
by putting small pieces of adhesive plaster under  them.  The powers of the 
ARTERITIS.
473
constitution should at the same time be improved, and the activity of the circu-
lation kept up by nourishing  diet, tonics, and wine.  Whilst the pins  are in,
the patient must not be allowed to move about, and after they have been taken
out, the limb should be bandaged for some time. In general no ulceration takes
place about the pinhole apertures, but  occasionally in debilitated constitutions,
a sore forms, which requires to be treated on ordinary principles.
                        CHAPTER  XXXV.

                      DISEASES OF ARTERIES.

                              ARTERITIS.

  The causes of inflammation of arteries or of arteritis are extremely obscure;
in many cases it arises from constitutional causes, with the nature of which we
are  as yet unacquainted;  in the majority of instances,
however, it  is distinctly of traumatic origin, occasioned
by the wound, rupture, or ligature of an artery.
  Arteritis  occurs under  two  distinct forms, as  the
adhesive or limited, or as  the  diffused or erysipeloid/.
Adhesive  arteritis  may either be of an  acute or chronic
character, and may be idiopathic  or traumatic  in its
origin.  Diffuse  arteritis invariably  arises from injury or
ligature of the vessel.
  In the adhesive  arteritis, both the coats of the vessel
and the contained blood undergo important alterations.
In the simplest form, arising for instance from the pres-
sure of a tumor  upon an artery, the coats are thickened
and fused together, as  it were, so  as to form an imper-
vious  cord;  in the more acute forms of the disease, the
sheath and the external coat become pulpy and vascular,
with effusion of plastic matter in and around them.  The
middle coat does  not undergo any primary change, but
after  a  time becomes contracted, thickened, and some-
what  softened.  The  internal coat becomes softened,
pulpy, and stained by imbibition of the coloring matter
of the blood.   In consequence of these changes  in  the
coats, the vessel loses its elasticity and becomes brittle.
After the inflammation has existed for a short time, a
plug is deposited in the diseased part of the artery; this       ° dep°sitS in aorta-
plug assumes two  distinct forms.   It may be deposited as a membranous layer
of decolorized fibrine, occluding the orifices of collateral  branches (fig. 163);
but most frequently it is deposited  in the form  of  a conical  plug, which com-
pletely blocks up the vessel at the part inflamed, below which the calibre of the
artery is somewhat contracted (fig.  164). These plugs are formed of two distinct
materials, the middle and lower part being a mass of a yellowish or reddish color,
composed of inflammatory exudation-matter, intermingled with fibrine deposited
upon it by the circulating blood, and adhering firmly to the contiguous walls of
the vessel.  The upper portion of  the plug is of a black color,  and consists  of
simple coagulum, deposited upon and tailing  on to  the decolorized  mass; it is
 
474
DISEASES  OF ARTERIES.
usally long, narrow, and stringy, and is not adherent to the sides  of the vessel.
These plugs may continue permanently to block up the artery, which gradually
contracts  upon  them so as to be eventually converted into a fibro-cellular cord,
                 or they may be partly absorbed  or  channelled  through  their
     Fig. 164.     centre, or lastly,  they may be entirely removed  by absorption,
                 and the calibre of the vessel freely restored.
                   In  diffuse arteritis,  the morbid  appearances extend  more
                 widely, spreading along the coats of the  artery to a consider-
                 able extent;  there is redness  of a deep claret color, injection,
                 and thickening of the coats, a loss of the physiological pro-
                 perties of the vessel, with an  absence of all plastic exudation.
                   The secondary  effects of arteritis are of considerable import-
                 ance.   The plug, which renders the vessel impervious by ob-
                 literating it, may in some cases  give rise to  gangrene of the
                 parts supplied.   This is especially apt to occur if  the arteritis
                 be acute,  if the patient be aged, or if the plug be so situated
                 as to occlude some of the principal anastomosing branches, so
                 that  there may not be time  or opportunity for the collateral
                 circulation to  establish itself.   In  other  cases, again, plastic
                 matter may not only be  deposited at  the part inflamed, but may
                 even be carried lower down than the original seat of disease,
                 and thus accumulate in the  terminal branches  of the artery.
                 The vessel will thus be obstructed at two points, between which
                 a pervious part will  be included.  This double occlusion of the
                 vessel, I believe, renders gangrene  of the limb inevitable, at
                 least in all those  cases in which I have seen mortification result
                 from arteritis, this condition has existed.  The plastic matter
                 poured out at the inflamed point, may in some cases be carried
                 on through the terminal branches of the vessel into the  capil-
                 laries, and thus  entering the  general  circulation form buff-
                 colored deposits in various organs, more especially in the spleen.
                 In other  cases, again, it  is carried  into the veins, giving rise
                 there to phlebitis and to other similar conditions.
                    Arctation  or even occlusion of the interior of the artery, not
                 unfrequently occurs as a consequence  of inflammation of the
                 vessel.   This  usually results  from  chronic  arteritis,  often
                 excited by the pressure of a tumor  or of some other local irri-
                 tant.   As it is usually a slow process, there is abundant time
                 for the anastomozing circulation to be set up, so that the vitality
   illary artery.    of the limb,  or  part supplied  by the diseased vessel, is pre-
                 served.   The artery, that has been so narrowed  and closed,
 ultimately becomes converted  into a cellulo-fibrous  cord, up to the  nearest col-
 lateral  branch, just as if it had been occluded  by the application of a ligature.
   The symptoms  of arteritis  depend not only on the  condition of the  vessel
 itself, but on that of the parts which it supplies.   There is pain, with some ten-
 sion and  stiffness  of the  affected limb, with a good  deal of  tenderness,  and  a
 cord-like feeling along the inflamed vessel, in  which also a jerking and forcible
 pulsation can be felt.   The pain  below  the part of the artery that  is inflamed,
 is always of a very severe  character,  and is distinctly of two kinds; superficial,
 and deep; the superficial is seated in the skin, which is excessively sensitive to
 the touch, so that  the  patient cannot bear the finger to be laid upon it, just as
 is the  case in  neuralgia;  it is of a smarting and pricking character, and is I
 believe always associated with more or less loss of  muscular power; the deep
 pain is of a burning and lancinating character, and  not only follows the course
 of the vessels, but strikes through  the limb in different directions.  If the
 inflamed  part of the vessel be not  completely occluded by the  plastic plug depo-
 
DISEASES  OP  ARTERIES.
475
sited in it, the pulsation in the  arteries of the limb, below the seat of the dis-
ease, may continue  much as usual;  but in the majority of cases the  pulsation
ceases  in all  the vessels on the distal side of the inflamed spot, the  limb, gra-
dually loses its  temperature, becoming of a dark  or livid color, and  cold; but
yet the inordinate  sensibility of the surface  continues.  As the  gangrene ad-
vances, however, this is lost; the parts, at  the time that they lose their sensi-
bility, assuming the ordinary characters of dry, shrivelled, or mummified gan-
grene, until all indications of vitality cease.  If, however, the veins be inflamed,
as well as the arteries, the dark  moist variety of mortification will result.   It is
in this way that some of the so-called "spontaneous gangrenes" are occasioned.
The constitutional symptoms, which in the local limited adhesive arteritis are
in the first instance of an inflammatory kind, speedily sink into the ataxic form
as gangrene comes on.  In  the diffuse arteritis, the asthenic  fever sets in early,
and speedily destroys life.
   The spontaneous gangrene resulting from arteritis may occur in the upper as
well as in the  lower extremities, and is  not unfrequently met with  in young
people; at least  in most of the cases in which I have seen it, it has occurred in
individuals under the  age  of thirty.  When the result of pure  arteritis, inde-
pendent of any other structural  affection of the coats of the vessel, the gangrene
I believe most  commonly occurs in the  upper extremity.   Arteritis, however,
is by no means  necessarily  followed  by mortification; the liability to  the loss  of
vitality depends on the seat of  inflammation, being greater when it takes place
in the neighborhood of the large collateral trunks of the limb, and when it is of
an acute character, so that the anastomosing circulation has not time to  esta-
blish itself.   It also occurs more frequently when the arteritis is idiopathic, than
when  it is traumatic, as then a larger extent of vessel is plugged,  and there is a
greater tendency  to the occlusion  of  those  important collateral  branches by
which the vitality  of the limb is ultimately to  be preserved.  The clogging of
the terminal branches by the plastic matter poured out at the seat of inflamma-
tion and washed down into the lower part of the limb, is a powerful cause  of
gangrene.   Those  arteries, the  inflammation of which most commonly termi-
nates  in this way, are the iliac  and  the axillary; and it is not uninteresting to
observe that the cause of danger in  this disease is the very condition that gives
safety in phlebitis, viz., the plugging of the vessels with plastic matter.
   The treatment of arteritis must be conducted on general principles.   Leeches
should be applied  to the part and perhaps blood taken from the arm; calomel
and opium may then be administered, but as a general rule I would prefer the
exhibition of those salines,  such as nitre and the acetate of potass in large doses,
which we  know by experience  to possess considerable influence  in the solution
of fibrinous deposits.  When gangrene  has  supervened, we must wait for the
 line of separation before amputation is had recourse to, as the disease must be
 looked upon as being of constitutional origin.

              structural  diseases  of  arteries.

   The arteries  are the seat of various structural lesions which play an important
part not only in giving rise to  ulterior diseases in the vessel itself, but in dis-
posing to various affections of the organs  which it supplies.   If we look  on  an
artery as a tube composed of tissues that  differ largely in their organization and
structure,  we must necessarily consider their diseases to be equally varied, and
we shall find that whilst the changes which take place in the external or cellular
coat, in which the whole of the vital or nutritive activity of the vessel -resides
are chiefly of a  conservative character, those that have their  seat in the internal
and middle  coats have a destructive tendency.   This important  difference  in
the  character of the diseases of the coats of'the vessel, is  dependent on their
relative degrees of vascularity and of vitality.   The diseases of the internal coat 
476
DISEASES  OP  ARTERIES.
are the most interesting  in a pathological point of view, those of the external
coat in a practical one.
   The  coats of  an artery are  liable to the following changes:—1st. Plastic
deposit on and under the  lining membrane;  2d.  Fatty and granular degenera-
tion ; and 3d. Calcification.
   1st. The plastic deposits on the free  surface are of a fibrino-albuminous cha-
racter, occurring  in the form of rounded, semi-transparent, and glistening masses,
usually met with in  the aorta or larger  arteries around  the  mouths of their
secondary vessels, or of aneurismal sacs; and not unfrequently agglomerated on
calcareous spicule, where  they attain great thickness.   They are almost struc-
tureless, gelatinous, sometimes  rosy-looking, and  cut with a hard cartilaginous
section.   The plastic deposits on the attached  surface of the  lining membrane
are opaque, semi-transparent, yellowish-white, elastic, but hard masses, composed
essentially of plastic matter with some oily globules intermixed.
   2d. The fatty and granular degenerations  of the  internal coats are of the
most interesting  character, and play an important  part in arterial diseases.  They
occur under the  different forms of atheroma and steatoma, and are met with
either in the arterial coats themselves, or in the plastic deposits which occur
upon or underneath them.  These atheromatous deposits occur in very different
forms, according to their age, &c.  Their first appearance is in the shape of fine
white opaque streaks, situated  in the substance of the lining membrane of the
artery.   As such, they are most commonly met with  in the upper part of the
arch of the aorta and in the neighborhood of the orifices of the large arterial
trunks; especially along that part of the vessel from which the intercostals arise.
Here they  may be seen at a very early  age.  I have met with them in children
of three, five, or seven years old.  As the disease advances these streaks aggre-
gate together so  as to form a large, white, and  opaque patch; in this condition
the middle coat is implicated.  This becomes thinned  by the pressure of the
patch, and, from  being yellow and elastic, is altered into a grey, semi-transparent,
and inelastic membrane, which often becomes stained  by imbibition with blood,
and corresponds  to the steatomatous deposits of  Scarpa and Hodgson.   In the
third stage the patch softens, becoming converted into a pultaceous, or cheesy
mass, and even sometimes undergoing complete liquefaction into a yellow creamy
fluid, which has often  been mistaken for true  pus.  These changes will always
be found to be dependent on the abundant formation  of fat globules and scales
of cholesterine in it.   These  softened atheromatous  patches will be found  to be
situated in a kind of pouch or  depression in the  internal or middle coats of the

                  Fig. 165.                            Fig. 166.
Fatty deposits in internal coats.               Early stage of atheroma.
artery, usually of a more or less oval shape.   At the same time that the changes
just described are going on in the coats of the vessel, an important alteration is 
CALCIFICATION OF  THE  ARTERIES.            477
taking place  in the  connections between the internal  and middle coats at  the
edge of the atheromatous patch; here they become firmly incorporated together,
so that the one cannot  be  peeled away from the other, and the diffusion of the
softened atheroma between the two membranes is arrested.   So also, when the
atheroma is washed  away by the current of the circulation, the infiltration of the
blood  between the coats and out of the pouch thus formed in  the walls of the
artery is prevented.
   The changes just described as taking place in the internal and middle coats
of the vessel are of a  destructive character, and  tend to lead to  its rupture;
but coincident with these, conservative processes  take place  in the external
coat.   This  becomes thickened, indurated, and strengthened by the deposit of
plastic matter, until at last it becomes the sole support of the vessel, round the
exterior of which it forms a thick  and somewhat rugged  wall.   It is especially
opposite the deeper and more eroded atheromatous patches  that this consolidation
of the external  coat takes place, thus preventing
the perforation of the artery in this situation.
   The nature and  seat of these changes  will be
understood by what has been already stated  con-
 cerning them.   Atheroma essentially consists,  as
was first pointed out by Mr. Gulliver, in a fatty
and granular disintegration of the arterial coats;
 the transformation  into fatty and  granular  matter
 taking place both  in  old plastic  deposits, and  in
 the internal and middle coats of the vessel.   The
 fatty matter consists of oil globules and choleste-
 rine  in various  proportions,  (figs. 165,  166) the
 plates of cholesterine being largest and most abun-
 dant in those cases in which the  atheroma is the   Atheroma from old patch.
 softest (fig. 167).  This fatty transformation is one
 to which the fibrous tissues generally are peculiarly subject, and to which those
 that  enter  into the formation of an artery are  especially liable.   All those
 theories  are consequently erroneous which  attribute  atheroma  to  previous
 inflammation, to suppuration, or to a  deposit sui generis in the artery.   The
 primary seat of these changes is the lining membrane of the vessel in the outer
 layer  of which,  corresponding  to  Henle's fenestrated coat,  they are  first  met
 with, as I have often observed after macerating and dissecting diseased arteries.
    The most important consequence of these changes in the  structure of the
 artery is the effect produced upon  the vital properties of the vessel; instead of
 being an  elastic resilient tube, reacting on the contained blood and serving to
 regulate its distribution, it becomes inelastic, and consequently, either gradually
 dilates in its calibre  under the influence  of the outward pressure of the blood
 contained within it; or, becoming incapable of aiding in the distribution of the
 vital fluid, tends to impair the due  regulation  of the supply to the organs to
 which it leads,  and thus  may indirectly occasion a diminution  or  even loss of
 their vitality, giving rise  to  softening, disintegration, or  mortification  of  their
 tissue.
    3d.  Calcification  of the arteries comes  next in order of frequency to their
 fatty disintegration.  This consists in the deposit in  their coats of a quantity
 of hard and gritty earthy and  saline  matters, which, though  commonly called
 osseous, presents none  of the  true characters of bone,  no trace of bone-corpuscle
 or of  vascular canal being ever traceable in them.   Microscopical  examination
 shows  them to  consist of an irregular crystalline, granular mass, without any
 evidence of  organization, composed, according to Lassaigne,  of  50 parts of
animal matter, 47£  of  the phosphate, and 2 of  the carbonate of lime in every
 100   The deposit  always takes place  in  the first instance  in minute sabulous
 
47.8
DISEASES  OF ARTERIES.
Fig. 168.
Fig. 169.
grains or granules; these after a time coalesce, assuming different forms according
to the seat of the deposit and  the age of the individual.
   The laminar form of the deposit is the most frequent, and is principally met
with  in  the larger arteries, such as the aorta, the iliac, and the carotids.   In
                               this variety calcareous  masses and plates  of
                               various  sizes, from a grain of sand  to a shell-
                               like plate an inch in width, is met with in these
                               vessels.  The  thickness of  the  patch  varies
                               from that  of silver paper to two or three  lines
                               across.  Their  shape  is elliptic or  triangular,
                               the largest diameter  being in  the direction  of
                               the axis of the vessel.  The edge of the plate
                               is  ragged,  rough, and  uneven, and  the surface
                               smooth  and incurvated towards the cavity  of
                               the artery; if large,  it is  usually  fissured  or
                               cracked, and  surrounded by much atheroma.
                               These  patches  are situated in the longitudinal
                               fibrous  coat,  and  are chiefly deposited where
                               this structure  abounds, as at the arch of the
                               aorta, the  bifurcation  of the iliacs, and in the
                               carotid  arteries.  The  inner  coat  is usually
                               thickened and  opaque  where it covers the patch,
                               and the middle much  thinned and wasted.
                                  The  annular calcification principally occurs
                               in arteries of  the third magnitude, such  as the
                               popliteal and  the  femoral.   It commences  by
 the deposit  of  granules of calcareous matter  (fig. 168), which are arranged in
 lines running transversely to  the  axis  of the vessel;  these  lines  gradually
 increase in  breadth until they coalesce laterally, the intervening spaces being
 filled up, and the vessel being converted into a rigid tube (fig. 169). This form
 of calcification  occurs  in the transverse  fibres  of  the  middle coat, and is
 accompanied by but little atheromatous matter.
   The tubular  calcification appears to be  an  increased degree of the varieties
 just  described, the arteries being  converted  into pipes or tubes  of calcareous
 matter, with the exception of a few shreds  and patches, and some atheroma
 deposited in its coats  (fig. 146).  It is especially the tibials and coronary arte-
 ries that are liable  to this kind of transformation.  When an artery has thus
 been converted into a tube of calcareous matter, masses of pale, opaque, waxy-
 looking fibrine  are deposited in it, and may block it up  more or less completely.
 These masses not uncommonly undergo subsequent atheromatous degeneration.
   The various  forms  of fatty and calcarous transformation  of the arterial coats
 that  have just been described, are  constantly found associated together  in  the
 vascular system of the same individual, and often indeed in the same vessel.  It
 has been pointed out by Bizot that the symmetry of the  arrangement of these
 morbid  appearances in the corresponding vessels on opposite sides  of the body
 is remarkably great, the arteries of  one  limb being often the exact counterpart in
 this respect to  those of the other.
    Causes. —The frequent co-existence of these various morbid changes in the
 same portion of the arterial system, point to their originating from one common
 cause, under the influence  of which the  coats of the  vessel may become con-
 verted either into fatty or calcareous matter.   Indeed, it is quite evident that
 these are " retrograde metamorphoses," to which all fibrous tissues are especially
 liable, under the influence of want of proper nutritive  activity in the part.  And,
 indeed, any circumstance that induces  a depravation  of healthy assimilation in
 the system generally, will specially tend to occasion a transformation of the  tex-
 ture of the more lowly organized tissues into products still lower in the scale of 
CAUSES  OF  STRUCTURAL  LESIONS.            479
organization.  Under such influences as these, the fibrous tissues of which the
arterial walls are composed, rapidly undergo disintegration and conversion into
fatty, granular, and earthy matters.
  That influence under which the vital forces of the system are most commonly
diminished in activity, is, old age; and this diminution may be looked upon as
natural at any period after the organization has reached its full maturity, whether
this be  early or late.  So frequent, and  indeed constant, are these transforma-
tions of the arterial coats during the decline of life, that they may be considered
as the natural result of the diminution of the nutrient activity consequent upon
advance in years.   Grmelin has found that there is a progressive increase in the
earthy matters contained in the  coats of healthy arteries as the individual  ad-
vances in life.  Thus he has ascertained that the ash of the arteries of a newly-
born child yields 1-86 phosphate of lime;  the healthy arteries of an adult 1-25;
and those of an old man 2-77 of the same salt; whilst the ossified arteries of an
aged man contain 4-01.   There is no precise period of life at which these changes
set in;  age is a relative term, and so soon as the system has passed its full  matu-
rity, in whatever year of life this may happen, there is a tendency for  these
deposits to take place in  considerable quantity.  These senile transformations,
therefore, can scarcely be looked upon as pathological changes in many instances.
But the same process of degradation of tissue may commence at any, even  the
earliest periods of life, under the influence of causes that impair the vital forces;
and it is in this way that phthisis, granular kidneys, chronic gout, constitutional
 syphilis, &c, have a direct tendency to occasion these changes in the arterial
 coats.  It is a favorite supposition with many pathologists, that these changes
result directly from inflammatory action ;  this certainly does not appear to be the
 case, but it is by no means improbable that an artery in which the inflammatory
process has taken place, may thereby have its  nutrition so modified as to become
more susceptible to early and  extensive  degeneration, and that  the  plastic
matters thrown out as the result of the inflammation will be especially liable to
undergo those changes  that ultimately result  in their conversion  into fat and
calcareous matter.
   Some arteries are more liable to these structural lesions than others; thus,
the ascending aorta is most subject to fatty degeneration, whilst the calcareous
transformation is most frequently met with in the  arch and abdominal portion
of the vessel.  The arteries of the lower extremities, viz., the femoral, the  popli-
teal, and  the tibial, are chiefly affected with calcareous deposits, whilst the fatty
are commonly met with in the vessels of the brain;  and some arteries appear to
be exempt  from disease; thus, Tiedemann states that he has never found the
esophageal arteries ossified.  The  difference in the liability of different arteries
to disease is, no doubt, in a great measure to  be accounted for by the  different
degrees of development of the longitudinal fibrous coat in different parts of the
arterial system; this being, I believe, in most instances the primary seat of the
affection.   Thus,  in the aorta, the  coronary arteries, and those  of  the brain, in
which it abounds, we find these transformations frequent.   The distance of the
tibials from  the centre  of circulation, and the consequent diminished nutritive
activity of their coats in old people, may account for the frequency of their de-
generations.  Those points of the arteries likewise upon which the shock of the
onward wave of blood is most directly received, are more subject to  degeneration
than neighboring parts of the continuity of the wall of the vessel.   This is espe-
cially observable at the origins of  the arteries that spring from the arch of the
aorta, and at the bifurcation of the iliacs.  It is also not  improbable that the
increased pressure of the blood upon the coats of arteries that lead to diseased
organs through which the circulation is obstructed, may tend to their degenera-
tion. ^ Sex exercises but little general influence on the liability to disease in the
arterial system; though  it specially tends to the occurrence of those changes in
certain arteries.   Thus Bizot states that the arteries of the  upper extremity are
most frequently diseased in women, and those of the lower  in men. 
480                  DISEASES  OF ARTERIES.
  The structural  lesions that have just been described produce certain local
effects, often of considerable importance, on the parts which the affected vessels
supply with blood.  For the proper and healthy nutrition of a limb or part to
be carried on, two great conditions are required so far as its arteries are con-
cerned.   1st, that the integrity of the structure  of the walls of the vessels con-
tinues perfect; and, 2d, that their channels remain  pervious; for although  the
arterial system possesses remarkable  conservative power in its arrangement and
distribution that tend to counteract these effects, yet, by slow degrees, a dete-
rioration of function and disintegration of structure take place in the part imme-
diately supplied  by the diseased vessel.   Thus, in  the limbs, we have all  the
signs of a defective circulation, coldness of the feet,  cramps, and spasms of  the
muscles; whilst  in organs,  softening of  tissue,  fatty degeneration,  and other
evidences of the  want of a proper supply of blood leading to impaired nutrition
manifest themselves.   Besides these various changes that take place in the parts
to which the  diseased arteries are distributed, ulterior effects are produced upon
the vessels themselves, which may lead  to important consequences.  These con-
sist in ulceration  of the coats of the artery; — their spontaneous rupture;  the
contraction or occlusion  of  the interior of the vessel;  and, lastly, its dilatation
into some of the various  forms of aneurism.
   The ulceration of  arteries, though frequently spoken of,  in  reality seldom
occurs; the so-called ulceration being  in general  an  erosion occasioned by a
patch of softened atheroma and  its investing  membrane having been carried
away by, and into the  current of blood, which then  washes the base of  the
depression thus  produced   in the middle  coat, but  is  prevented  extending
between the coats by  the process of fusion and cohesion which  takes  place in
them around the  patch.   This  apparent ulcer is deepened  by the  deposit
around its  margin of plastic  matter, often in  large gelatinous-looking masses.
When true ulceration of an artery takes place,  it is by destructive action from
 without, and not by any of these disintegrating processes commencing within
the vessel.
   The spontaneous rupture  of an  artery is of  rare  occurrence, and  never hap-
 pens without disease of its coats.  Experiments made by Dr. Peacock, which I
 have  repeated, and the accuracy of which  I  can  fully confirm, prove that a
 healthy artery will sustain a very great  pressure of  water injected into it, with-
 out its walls giving way.   But if these  have  been softened or weakened by
 disease, they may be unable to resist even the ordinary impulse of the blood, and
 if this be driven on by any unusual forcible action  of the heart, as under the
 influence of sudden violent strains or exertions, they may give way.   This oc-
 currence would be much more frequent than it is  in atheromatous and calca-
 reous patches, were it not for the  conservative consolidation of the external  coat
 of the vessel supplying that resistance  which had been lost by the  destruction
 of the internal and middle tissues.  Hence this rupture is most  frequent in
 those vessels, the outer coat of which   is thinnest;  and in which consequently
 it can least supply the place of the others, as in the  arteries of  the brain  and
 the intra-pericardial aorta.
   The contraction and occlusion of arteries  are by no means rare sequences of
 the structural lesions of these vessels.   We have already seen that these  con-
 ditions may arise from inflammation of the coats in any  way excited, as by the
 pressure of tumors;  but, besides this, the structural changes that take place
 may produce  narrowing and closure of  the vessel  in various ways.   Thus the
 diseased patch may project into the artery in such a manner that plastic matter
 and  coagulum are gradually deposited  upon it until the interior of the vessel
 is blocked up; or the irritation of the  morbid products may give rise to chronic
 inflammation in  the  coats,  occasioning contraction, the effusion  of  lymph, and
 their  consequent occlusion.  In  one  or other of these ways, arteries of all
 magnitudes may be gradually narrowed  and at last  completely closed, and yet 
         NARROWING  AND OCCLUSION  OF ARTERIES.     481

the patient survive; and the parts supplied by the  obstructed vessel maintain
their  vitality  in consequence  of the collateral circulation being  sufficiently
active  to  keep  up the supply of blood  to them.   The vessels  that are  most
frequently blocked up in this way are the tibials; next to  these perhaps the
carotids;  the  other arteries are but rarely so occluded.  Yet many instances
have been collected by Tiedemann of this morbid process affecting most vessels;
but more  especially  the iliacs, the brachial, and axillary  arteries, and the
different  branches of the abdominal aorta.  Tiedemann  records from various
sources no less than eight cases in which the abdominal  aorta was  completely
closed, in all of which so full and efficient a collateral circulation had been set
up, that the vitality of the  lower part of the body was  perfectly  maintained,
and in most the morbid state not suspected during life.   Besides these cases,
he states that there are twelve  instances on  record of great narrowing of the
aorta at that point where the ductus arteriosus is implanted into it in fetal life.
These would appear in some way connected with  the closure of the duct, as in
every case the indentation was greatest on the convex part of the aorta, which
had been drawn in towards the mouth of the duct, as if the vital contractile
force  necessary for the  closure of this had extended  itself to the aorta, and
produced a similar action in it.
   When any  of the arterial  narrowings,  or occlusions, occur in  a  gradual
manner  in early life,  or in  a part where the collateral  circulation is  free,  no
ill effects result;  but in an  opposite condition  the  interference with the circu-
lation leads to the local death of the part supplied by the diseased vessel.   This
is particularly the case in the lower limbs of old  people, where  the circulation
is extremely feeble, both as the effect of age and  in consequence of distance
from the heart, and it is in  this way that the true  senile gangrene or mummi-
fication of the limb occurs.  The pathology of this affection  has  already  been
adverted to, but it may not be out of place to state here, that whilst some  have
 considered the gangrene  as  entirely  the result of arteritis, others look upon it
as consequent on  the occlusion  of the vessel from disease  of its  coats, and  each
party has laid  down  principles of treatment in accordance with their  view  of
the pathology of the  affection.   From what has preceded, it would appear that
 the arteries of a limb may be occluded, and that consequently gangrene  may
 result from either condition.  The  occlusion from  acute  arteritis  followed  by
 gangrene, most frequently occurs in the  upper extremities  and  in young  or
 middle-aged people, is preceded by local and  constitutional symptoms of inflam-
 mation, and, in it, the artery presents  on examination the  true inflammatory
 plug.  The occlusion from calcification  and atheroma chiefly occurs in the
 lower extremities, and in old  people, is preceded  by a rigid condition of the
 vessels, by cold feet, cramps,  numbness, and weakness of the  legs, and  after
 removal, the arteries will be found to be converted  into rigid unyielding calca-
 reous tubes, with some deposit of atheroma, and with waxy-looking masses  of
 fibrine filling up their interior.   Besides these two distinct forms of the  disease,
 there is a third and very common variety, in  which a low  form of inflammation
 takes place in previously diseased arteries, and in which we find a  combination
 of the two conditions.
    With regard to the treatment of narrowing, or occlusion  of the  arteries un-
 connected with gangrene, I have little or nothing to  say, except that  if there
be reason to suspect such occurrence in  a limb, care must be taken to keep the
part  warm by  means of appropriate clothing, and if there be much  pain, to
allay this with  opiates.  If  gangrene have come on, it must be treated with re-
ference  to its  cause; when  connected  with  arteritis, it has already been dis-
cussed, but when it occurs from  structural disease of the coats of the vessel,
then  the treatment must be  directed by the existence, or  not, of any complica-
ting inflammation, in accordance with those principles that have been laid down
in discussing the general management of gangrene. 
482
ANEURISM.
                        CHAPTER  XXXVI.

                               ANEURISM.

  When the arterial walls have  undergone more or less fatty degeneration,
whether that consist in the distinct deposit of patches of atheroma, or in a sort
of molecular deposit of fat globules in the tissues comprising their coats, their
natural elasticity and  resiliancy become lost, proportionately to the  amount of
fatty change that has taken place within them.   Hence, as the  artery becomes
less and less able to contract on its contents, and  to recover during the diastole
the tension  exercised  on its  walls  during the  systolic impulse, it gradually
becomes distended by the  repetition of the shocks which ;t sustains, and thus
either complete or partial dilatation of its  cavity takes place.   I believe that
this loss of elasticity  and of power of contracting on its contents, which even-
tually  results in the dilatation  of the vessel, never  occurs  except  as  the result
of previous disease of the coats.  In  the  very numerous specimens  of dilated
arteries that I have examined, I have  never found one that had not undergone
fatty  degeneration, or atheromatous  deposition.    Calcification,  on  the other
hand,  rather prevents dilatation of the artery, by hardening the  coats and con-
verting them into rigid inelastic tubes; but atheroma  softens them, and causes
yielding of that portion of the  vessel affected by it. I have frequently observed
that the whole  of the artery  may be  healthy except  at one  part, where  there
was an atheromatous  patch, and  that  there the vessel was dilated;  or that the
whole of its coats might be calcified  except at  one spot, where atheroma was
deposited, and where  consequently the coats had yielded under the outward
pressure of the contained  blood.   This general  or localized dilatation of the
arteries is  termed aneurism, an affection that is, I believe, invariably dependent
upon  the  coats having been  softened, atrophied, and  disintegrated by fatty
degeneration, and consequently yielding to  the eccentric  pressure of the con-
tained blood.
   Aneurism may be  classified  as follows:
   1.  Fusiform. — True.

   2.  Sacculated.— j " False         I a  Circumscribed.
   3.  Dissecting.-          .........."[p  Diffused.
   1st. The fusiform or tubular aneurism is a  preternatural dilatation of an
artery, all the coats of which are equally  expanded through the whole circum-
 ference of the vessel.  It most frequently occurs in the aorta, but may, though
rarely, be met with elsewhere.  These fusiform aneurisms are not mere dilatations
of the vessel, but there is elongation, thickening, and degeneration of its walls
as well. The elongation of the artery in these fusiform aneurisms is as marked
as its  dilatation, and  is always very considerable.    Thus, the  arch of the aorta
 may attain a length  of several inches, with a considerable space between the
 origins  of the  carotids, the innominata and the subclavian, at  the  same time
 that its walls are greatly thickened, nodulated, and rugged.  Sometimes several
 of these tubular  or  fusiform  aneurisms are met with in the same vessel, with
 healthy portions of the artery  between them.  From these  dilatations sacculated
aneurisms not uncommonly spring.  On examining the structure of a fusiform
 aneurism, it will  be  found  that it is always composed of a uniform expansion
 of all the coats of the artery,  which are at the  same time somewhat altered in
 character;  thus, the  outer coat is thickened, the  middle rigid and inelastic, and
 the inner  one stiffened, rugged, and tuberculated,  by the deposition  beneath  it
 of various plastic and atheromatous masses.   No  coagula, however, are found in 
SACCULATED ANEURISMS.
483
these dilatations, but a few filamentary shreds of fibrine are occasionally seen to
be attached to their inner wall.  The arteries that are usually the seats of these
peculiar  changes are the arch of the aorta, the  iliacs, and  the femorals; this
particular form of aneurism never occurring in any vessels in which the yellow
elastic coat is not largely developed, and hence not being met with in arteries
below the femorals in point of size.
   These fusiform dilatations, especially when  seated in the arch of the aorta,
may attain a very considerable magnitude, and may consequently exercise very
injurious pressure on contiguous parts; thus producing great distress and danger
of life to the patient.  They are usually extremely chronic, increasing but very
slowly, and being compatible with existence for many years,  but  at last they
usually destroy the patient, and they may occasion death in several ways; thus,
if situated in the aorta, the  great mass  of blood in the sac may, by impeding
the circulation, overpower the heart's action, so that it may be unable to  recover
itself, and  a fatal syncope be induced.  Then,  again, death  may result  by their
pressure on  important parts, as on the bronchi or esophagus; this, however,
rarely occurs, unless  it be that a sacculated aneurism, springing from the fusi-
form one, has given way.  When, however, the  tubular  aneurism of the arch
of the  aorta occupies the  intrapericardial portion of the vessel, it not unfre-
quently happens that, owing to the absence of an external coat in this situation,
the  artery may rupture at this point.  It most commonly happens that a  fusiform
aneurism remains in a quiescent state, being a source of discomfort, but not of
death, to the patient, until the sacculated  form of the disease spring  from its
 side, and that this becoming the more formidable  affection,  may destroy life in
 some of the ways peculiar to it.
   2d. Sacculated aneurism. — By the sacculated aneurism is meant  a tumor
that springs from the side of an artery or of a tubular aneurism, with the inte-
rior of which it communicates by a narrow aperture, called the mouth of the
sac.  It is generally  divided into the true and false varieties.   By the  true
sacculated aneurism is meant a partial dilatation  of all  the  coats of the vessel;
by the false sacculated aneurism the dilatation of one, or at most of two coats,
with the rupture of the others.
   The existence of true  sacculated aneurisms has been denied;  thus, Scarpa
doubts the occurrence of such a disease,  and Bizot seems  disposed to coincide
with him.   With  these  eminent  pathologists,  however, I cannot agree, and
though I am willing to admit that many of  the so-called  true aneurisms are not
so in reality, yet I cannot doubt, from repeated observation, that Hodgson  is
right in saying that in their early stages  aneurisms are not unfrequently of the
 true kind.  Thus,  we occasionally meet,  as  Dr. Peacock  has pointed  out, with
small digital pouches springing from  the walls  of some of the larger arteries,
 through the whole of which  the external, middle, and  internal coats can be
 demonstrated by maceration to exist; and in those aneurisms which are formed
 by the  dilatation of a comparatively large  portion of the  arterial wall, it not
 unfrequently happens that the tumor remains of the true kind for some time,
as I have had occasion more than once to ascertain by  careful  dissection.   But
after an aneurism has attained a certain size, its coats become so fused together,
and so closely incorporated with the  neighboring tissues, that their  precise
structure cannot be made out.   Indeed,  for a sacculated aneurism to be of the
true kind, I believe that two conditions are  necessary: 1st.  That the tumor
itself be small; and, 2d. That the mouth  of the sac be  of tolerably large dimen-
sions.   Porter says that he has  never met with a true aneurism larger than  a
small orange, and, certainly, none of those that I have seen, provided they were
of the sacculated kind, have exceeded  this size.   In true sacculated aneurisms,
also, it is necessary that the mouth of the sac, or that portion  of it which com-
municates with the interior of the  artery, should  be of a good size, and  not bear
too great a disproportion to the  wall of the tumor.  I cannot  conceive  a  large 
484
ANEURISM.
sac with a small mouth to be a true aneurism, for, as the mouth of the sac  cor-
responds exactly in  size to that portion of the arterial coats which have been
originally dilated, it is not easy to understand how a large sac can be expanded
out of a small segment of the wall  of the artery; though, as in all cases of true
aneurism, however  small  they may be, the size of the sac greatly exceeds  that
of its mouth, it is clear that there must have been, not only expansion, but a
degree of hypertrophy and overgrowth of the wall of the vessel,  just as in the
tubular aneurisms.
   By false sacculated aneurism is meant that variety of the disease in which
the internal, or the internal and middle coats, have been ruptured, and are  con-
sequently deficient.   These are by far  the most  frequent  forms of sacculated
aneurism, and are those which are met with of so great a size.   In by far the
majority of these cases, the internal coat and the  innermost  layers of the mid-
dle coat have been  destroyed by atheromatous degeneration, leaving  an  erosion
or depression in the interior of the artery, with weakness of  the  corresponding
portion of its wall, which becomes expanded  by the outward pressure  of the
blood.  In these cases the sac is  principally formed by the expansion  of the
outer coat, to which some of the layers of the middle may  still be adherent;
but which is essentially strengthened and  thickened by plastic deposits, and by
adhesions to neighboring parts, which have fused into its composition. In these
cases there is outgrowth, hypertrophy, and new deposit in and upon the external
coat,  as is evidenced by  its  actually  becoming thicker, instead of its being
thinned, as it would be were it only expanded.  The formation of an aneurism
by the herniary protrusion of the internal and  middle  coats through an ulce-
rated aperture in the external coat, has been described; but  though there is a
preparation  in  the Museum of the College of Surgeons,  that is supposed to
illustrate  this fact, I doubt the existence  of such  a form of the disease, and
after careful examination  think that the preparation  in question looks  rather
like an artificial dissection, than a true  rupture of this dense  and elastic coat.
   A false aneurism may  always  be readily distinguished from a true one, by
the greater magnitude that it attains, by the size of the sac being out of all
proportion to  that  of its  mouth, and  on a section of this  being made,  by the
middle coat being seen to terminate abruptly in  a thick and dense ring imme-
diately around  the mouth  and neck of  the sac.   A false aneurism may either
be so from the  very first, the internal and middle  coats having been destroyed
by softening and erosion,  and the external expanded  and hypertrophied into a
sac; or it may originally have  been a true aneurism, some of  the coats of which
having given way, the conversion into the false variety of the disease has taken
place.
   Surgeons generally recognise two  varieties of false  aneurism, the circum-
scribed and the diffused.   By  the  circumscribed false aneurism, is meant that
form of the disease in which  the  blood is still contained within a sac, formed
by at least one of the arterial  coats, however expanded and altered in its struc-
ture this may be.  The diffused form of false aneurism includes two distinct
varieties of the disease.  In one  case  there is rupture of the sac, and  general
and wide-spread  extravasation  of blood into the  cellular tissue of  the  limb or
part.   In the other case it happens that the sac formed by  the  dilatation and
hypertrophy of the outer coat of the artery is ruptured, and the blood, although
effused beyond this, is still confined in  a sac of condensed cellular tissue, formed
by the matting together with coagulum and lymph of the structures into which
the blood has been effused.
   3d.  The dissecting aneurism is a remarkable form of the  disease, originally
described by Mr. Shackleton, in which the sac is situated in  the  wall  of the
artery between its coats.   It originates in consequence of the internal  coat of
the vessel becoming  eroded, and  giving way before any of  that adhesion and
matting together of the tissues around the patch  has taken place, which pre- 
THE  DISSECTING ANEURISM.
485
vents the blood being forced between the different tunics of the artery.  The
rupture, although originating in the internal coat, always  extends  between  the
layers of the middle one, splitting  this up into two lamine, and in some cases
it also separates the middle from  the  external tunics of the vessel.  On exa-
mining the artery in a case of dissecting aneurism, its coats will always be found
to be easily separable from  one another, and to be very lacerable, often appear-
ing soft and sodden as if macerated. For the production of this disease, indeed,
two conditions are necessary.   1st.  That  there be atheromatous disease of the
artery, destroying a portion  of the  internal and of the innermost  layers of the
middle coat; and 2d. That  there be not only a want  of  plastic matter  effused
about the diseased part of the vessel, but also a general  softening of the tissue
of the middle coat, with want of cohesion between the different tunics of the
artery; this indeed may be considered as the essential condition  that disposes
to the formation of a dissecting aneurism, and that causes the disease to  assume
this, rather than the sacculated form.
   The rupture constituting dissecting  aneurism always  takes place longitudi-
nally along the middle coat, and may often extend to a very considerable dis-
tance.  Thus it may reach from the arch of the aorta to the iliacs, or from the
same part to the bifurcation of the carotids.   The disease only occurs, however,
in the aorta, and in its principal branches; in  those  arteries  indeed in which
the middle coat is highly developed, and the yellow elastic tissue abundant.
   These dissecting aneurisms arrange themselves into  three distinct  classes.
1st.  Those in which the blood, after having passed  for a  distance  of  several
inches, or even more, through the  substance of the middle coat, bursts through
the external  coat, and becomes effused into the cellular tissue outside the vessel,
and  around  the  seat  of rupture, or into  the  neighboring  cavities.   In these
cases, which constitute the  most common variety of the disease,  death  usually
rapidly occurs, the  patient feeling  intense pain along the line of  rupture, and
falling into a state  of  syncope.   2d. The external coat may become  so thick-
ened and  strengthened by the deposit of plastic matter,  that it resists the im-
pulse of the blood, which consequently continues  to pass between the layers of
the  middle coat, until it meets a  softened and atheromatous  patch, and then
again bursts  into the canal of the artery.  In this class of cases the patient may
live for  years  after the occurrence of the rupture, the  new channel that the
blood has taken becoming lined with a dense smooth membrane, and resembling
closely the interior of the artery, from which, however, it is separated by a kind
of septum or mediastinum.  The  appearances  presented by the vessel  in  this
form of  the  disease have occasionally been erroneously described as constituting
 a double aorta.  3d. The blood may find its way between the lamine of the
 middle coat, but does not  escape again  by rupture of the external, or by the
 giving way of the lining membrane of the vessel.  A sac is consequently formed
 in the substance of the middle  coat, which may become chronic, but will at last
 give way by external rupture.
   The progression of changes leading to the formation of an aneurism is conse-
 quently briefly as follows:—The coats of the artery undergo fatty degeneration,
 and  atheroma is deposited at one part; this softens, and  the  lining  membrane
 covering it, with perhaps  a portion of the inner  layers of the middle coat,
 becomes eroded; or the walls of the vessel  may be weakened  at this point
 without any destruction of their coats.  Cohesion, however, takes place between
 the  tissues of the vessel at  the eroded or weakened spot;  and the  outer  coat
 becomes strengthened and thickened by the deposit of plastic  matter.  Dilata-
 tion next  takes place at this  point; if of the  entire  coats, a  true aneurism is
formed; if of the  eroded tunics, a false  aneurism occurs: but if no cohesion
have  previously taken place between the different  coats of the vessel, the
blood becomes  effused into and  between them, thus constituting a dissecting
aneurism. 
486
ANEURISM.
   Structure of an aneurism. — An aneurismal sac, if it be composed of a dila-
tation  of all  the coats of an  artery, may be recognised  on dissection  by the
atheromatous and calcareous deposits which are met with in the tissues of which
it is composed.  If it be a false aneurism, it will be found  that  there is little,
if  any, of these deposits in the walls of the sac, that the middle coat  usually
terminates abruptly at its mouth, and that the external coat is greatly thickened
and strengthened by the deposition of plastic matters.   Aneurismal sacs may
vary in size from tumors not larger than a cherry, to growths the magnitude of
a cocoa-nut or large melon.   The mouth, which is oval or round in shape, varies
greatly in size, being always very small in proportion to that of the  sac. Usu-
ally the interior of an aneurismal sac contains a quantity of  decolorized  fibrine,
arranged in  concentric lamine  of but moderate thickness; these  lamine  of
fibrine are of a pale-buff color, dry and somewhat  brittle  where  they are most
closely applied to the wall  of the  sac; the more  external  ones appear to  be
those that are first formed, and occasionally are found to have undergone a kind
of atheromatous degeneration; as we approach the interior of the vessel, they
become softer  and  more colored; and, at last, in the  central  portions dark
masses of coagulum are often met with.  This  decolorized fibrine  appears to
proceed from two sources;  it is partly deposited from the blood which is beaten
up in the interior of the sac, and thus deposits its fibrine much in the same way
as when  it is whipped in an ordinary  vessel; this  is probably the  manner  in
which the  principal  masses are  deposited.  In  some cases, however, it would
appear as if it were  formed  by deposition  from  the wall of the  aneurism; for
the mass not being out of the current of the  circulation, cannot well have been
deposited from the blood, but must in all probability have been the result of the
effusion of plastic matter from the wall of  the sac; under these  circumstances
there is little or any of that stratified arrangement that is so observable in the
fibrine that is deposited from the blood. The  black coagulum that is occasion-
ally met with in the  middle of aneurisms  differs in every way from the lami-
nated  fibrine just described, and is evidently the result of simple coagulation.
The use of the deposited fibrine  appears to be in a great measure to  strengthen
the walls of the sac, and thus to prevent the  too rapid  increase  of the  tumor.
Another  great  purpose that it serves is to lessen the capacity of the sac, and
thus to diminish  the  distending  force  of the  blood which is injected at each
stroke of the heart; the outward pressure  depending as  much on the  area  of
the sac as on the force with which the blood  is driven into it.   Then, again,
the lining of the walls of the sac with  such a tough and elastic material as the
stratified fibrine, must greatly tend to deaden  and break the force of the shock
of the wave  of blood that  is  projected against what  would  otherwise  be  an
unprotected and expanded membrane.   In those cases in which  the laminated
fibrine is small  in  quantity  or altogether  deficient, the  aneurismal  tumor
rapidly increases, with a forcible pulsation that is not met with under other
circumstances.
  Pressure-effects. — As the sac of an aneurism enlarges  it  exercises injurious
and  often fatal  effects by its pressure upon contiguous parts.   These pressure-
effects^ deserve attentive consideration  and study, as they constitute an important,
and, in some instances, the sole element in  the diagnosis of the existence of this
disease.  The compression exercised upon  the veins not unfrequently gives rise
to  narrowing, or even complete obliteration, of the largest of these;  thus occa-
sioning edema of the parts from which they take  their origin, a varicose and
greatly enlarged condition  of the subcutaneous veins, and in some  cases even
gangrene of the limb.  The pressure of the sac, also, on neighboring arteries,
or even on  the upper part  of the very vessel from which  it  springs,  and  its
interference with the  general capillary circulation of a part, is commonly asso-
ciated  with the venous compression, and may considerably increase the  ill-con-
sequences resulting from it.   The pressure upon a  neighboring artery  may go 
SYMPTOMS OF  ANEURISM.
487
on to perforation of the vessel by the sac, and  so a communication may be set
up between  the aneurismal sac  and a neighboring vessel; thus I have known
an aneurism of the aorta perforate and communicate with the pulmonary artery.
By its pressure upon neighboring nerves, an aneurismal sac may give rise either
to great pain in, or to disturbance of, function of the parts
supplied by them;  the nerves themselves becoming, in
some cases, expanded or flattened  out, and ribbon-like
(fig. 170),  and in  other instances rendered tortuous,
waving, and being considerably elongated.  This pain in
the nerves is often one of the earliest signs of the exist-
ence of  an  aneurism.  On the bones  an  aneurism may
produce very important effects by its pressure, eroding or
wasting away the osseous tissue in some instances, and in
others giving rise to true caries.   If the bone be a flat
one, as  the  sternum, the aneurism  may perforate it by
making as smooth  and round a hole in it as if this had
been worked by the  trephine.  Organs and their ducts
in the neighborhood of aneurisms suffer the most inju-
rious effects from the pressure of these tumors, their func-
tions being  arrested, and the passage of their secretions
interfered with;  so,  also, by the pressure exercised on
the trachea and esophagus, respiration and deglutition
may be seriously impeded.
   Aneurisms, though usually single, are not very unfre-
quently multiple.  There may be  more  than one tumor
of this kind in  the same limb; thus the iliac  and femoral
arteries on the  same side may both be affected.   In other
cases, corresponding arteries in opposite limbs  are  the
seat of aneurism; thus, the two  popliteals are not unfre-    Flattening of pos-
quently found  to be the  seat of this disease,  and occa-   tenor tlbia;1 nerve by
  .   ,,          •         .  t    1    •       /»  ,i   i-  t     pressure of an aneu-
sionally an aneurism may take place in one of the limbs,   rism 0f the calf.
and  others  in  the  arteries  of the  interior of  the body.
When more than  one aneurismal  tumor  occurs in  the  same  individual, the
patient is said  to be laboring under the " aneurismal  diathesis."  Numerous
aneurismal tumors  are at times  met with in the  same  person; thus, Pelletan
records a case in which no less than sixty-five were thus observed.
   The duration of an aneurism varies  very greatly.   In young full-blooded
persons it often makes progress with great rapidity, whereas, in elderly people,
of feeble constitutions, or in  those  of a cachectic habit of body, accompanied
with more or less debility of the heart's action, the disease may assume a very
chronic form;  thus, Hodgson relates the case  of an  aneurism  of the  femoral
artery, of twenty years'  duration.   Much also will depend on the  situation of the
aneurism, the size of the mouth of the sac, and the relation of  the sac  to the
impulse  of the blood into it; the larger and more direct the mouth of the tumor,
the more readily will the blood be projected into it at each impulse of the heart^
and the  more quickly will the tumor expand.
   The  symptoms of an aneurism are of two kinds:  those that are peculiar to
this disease, and those that are simply dependent on the presence of the tumor
occasioned by the enlarged sac.  The peculiar or pathognomonic signs are those
that are dependent  on the communication of the sac with the artery.  They con-
sist of signs afforded by the manual and auscultatory examination of the tumor.
Those that are  dependent on the mere size of the growth are the pressure-effects!
It is of course only in external aneurisms that those signs that are ascertainable
on manual examination of the  tumor can usually be recognized.   In internal
aneurisms, in the majority of cases, the auscultatory signs and the pressure-
effects afford the best indications of the presence and nature  of the tumor •
 
488
ANEURISM.
though, when this approaches the surface, much information can be gained by
palpation.
   Symptoms  of an external circumscribed aneurism.—The tumor is  usually
round or oval, distinctly circumscribed, and is situated upon, and in close con-
nection with some large artery.   It is at first somewhat compressible, but after-
wards becomes more and more  solid, as  fibrine  is deposited in it.  The  most
marked sign is perhaps the pulsation that is felt in it from the very first.  This
is of a distensile, eccentric, and expanding character, separating the hands when
laid upon either side of the tumor, by  a distinct impulse from within outwards.
The pulsation is more forcible in  those  aneurisms in which there is but  little
laminated  fibrine, and as this  increases in quantity it  gradually loses its hard
expanding character, being converted into a dead thud, and in some cases ceas-
ing entirely.  When obscure, the compression of the artery below the sac will
cause it to become more  distinct, or it may be increased in force by elevating
the limb or part affected.  When the  artery above  the sac is compressed, the
flow of blood into the tumor is necessarily arrested,  and a considerable quantity
of its more fluid contents may be squeezed out by gentle pressure.   If the hands
are then laid  upon either side of  the  tumor, and the pressure suddenly taken
off the artery, the  blood will  be found  to rush  into and  distend the sac by a
sudden stroke, separating the hands from one another.  This sign may be looked
upon as one of the most  characteristic  of aneurism.
   The bruit or sound emitted by the blood in its passage through an aneurismal
sac, is a sign that was first noticed by Ambrose Pare\  These sounds are of very
various characters, being usually of  a  loud rasping or  sawing nature;  loudest
and roughest in the  tubular aneurisms.   In many cases they are altogether
absent; this especially happens  in sacculated aneurisms with small mouths, or
in those that are much distended with coagula and blood.  The absence of any
sound, therefore, in a tumor must not be taken as an indication of its not being
an aneurism.   The sounds are usually best heard in those tumors that are not
too fully distended with blood;  indeed they are usually more distinct when the
sac is partially emptied of its contents.   Thus, for instance, it not unfrequently
happens that in an aneurism of the ham or thigh no bruit, or but a very faint one,
is perceptible so long as the patient is standing up;  but if he lie down, and ele-
vate the limb so as to empty the sac, then it is very distinctly audible. Another
sign of considerable importance consists in the diminution in the size of the
tumor, and the cessation of the pulsation of the bruit in it, that occurs on com-
pressing the vessel leading to the  sac,  and the immediate and sudden return of
these signs on removing the pressure from the artery.  All the symptoms that
have just been described are peculiar to and  characteristic of aneurism, being
dependent  on the  communication that exists between  the artery and the sac.
Those that result from the pressure  of the sac upon neighboring  parts are com-
mon to aneurism and to any other kind of tumor; but though not of so special
a character as  those that have just  been described, they are of considerable
importance in determining the nature of the disease when taken in conjunction
with the other symptoms.
   One of the most common pressure-effects of aneurism is  the  occurrence of
edema of the limb or part, owing  to the  compression exercised by the tumor
upon the large and deep venous trunks in its vicinity.  The consequent obstruc-
tion to the venous  circulation in the interior of the limb may also give rise to a
distended or varicose condition of the subcutaneous vessels, and in some instances
it may even go on to the production of gangrene.
   The compression exercised by the tumor on neighboring  nerves and  tissues
may, in many cases, be the cause of extreme suffering to the patient.  The pain
 is usually of two kinds, either lancinating and radiating along the course of the
nerve that is compressed, or, when the tumor presses severely upon neighboring 
SYMPTOMS  OF  DIFFUSED  ANEURISM.           489
parts and tissues, more especially if it give rise to erosion of the bones as in fig.
171, an aching, burning,
tearing, or boring sensation
is often experienced in the
part subjected to the pres-
sure.  In other cases again,
important modifications in
the function of parts take
place,  in  consequence of
the pressure that is exer-
cised  upon  their  nerves.
Thus,  for  instance,  the
compression of  the recur-
rent laryngeal will occasion
hoarseness of  voice   and
difficulty of breathing, de-
pending on spasm  of the
glottis. Besides these more
immediate effects, various
remarkable symptoms may be produced by the pressure of aneurisms on different
organs or mucous canals in their vicinity, and by the consequent  interference
with the function of these parts.
   Symptoms  of a diffused,  aneurism.—When an aneurism becomes diffused,
 the sac having given  way, but the blood being still bounded by the tissues of
 the limb, the patient experiences  a sudden and acute pain in the part, and
 usually becomes pale, cold, and faint. On examination it will be found that the
 tumor has suddenly and greatly increased  in size, at the same time that it has
 lost its circumscribed and distinct outline.  The limb may also become edema-
 tous, or will suffer in other ways from the diffused effects of the pressure of the
 aneurismal swelling upon the neighboring veins and tissues.  At the same time,
 the circulation  in  it  being  greatly obstructed, the  limb may become cold and
 livid,  and a sensation of weight and general inutility will be experienced in it.
 Under these circumstances the  aneurismal swelling usually becomes harder, in
 consequence of the coagulation of  the  blood in the cellular tissue around the
 sac, by which indeed the further extension of the  disease is arrested, and a
 fresh boundary  is often formed, so as to  limit the extravasated blood.  If it be
 left to itself, the  tumor will now usually rapidly increase  in  size, with much
 pulsation, and perhaps evidence  of inflammatory action around it, so that at last
 it may so choke and  obstruct the  circulation through the limb as to occasion
 gangrene of it;  or, if it advance towards the surface, external rupture of the sac
 will speedily ensue.
   In other cases, again,  it happens  that when rupture of the sac takes place,
 the effused blood, instead of being  limited by the surrounding cellular tissue,
 becomes suddenly and widely extravasated into the substance of the limb.   When
 this untoward accident happens, the shock and local disturbance are very great,
 and the patient is suddenly seized with a very severe lancinating and numbing
 pain in the part.  This  pain is  most severe in those cases in which the rupture
 takes  place under the deep fascie, by which the effused blood is tightly bound
 down; and may be so severe as to occasion syncope.   In other instances again,
 faintness  occurs from the sudden loss of blood out of the current  of the circu-
 lation  into the substance of the part; the  swelling being  greatest in those in-
 stances in which the blood  is suddenly and largely effused into the cellular tissue.
 If the extravasation happen in a limb,  this will become greatly swollen, hard,
 brawny, and cold.   The superficial veins  are congested, and the circulation in
 the lower parts of the member is soon completely arrested by the pressure of
 the extravasated and  semi-coagulated blood upon its vessels,  more particularly
 
490
ANEURISM.
the larger venous trunks.   In consequence of this, gangrene of a moist kind
usually makes its appearance, and speedily destroys the patient's life.
   Terminations. — Suppuration with sloughing of an aneurismal sac, is not of
very frequent occurrence, but is especially apt to happen in those cases in which
the disease has increased rapidly, or suddenly become diffused, with much heat
and tension of neighboring  parts.   It is peculiarly likely to happen in tumors
of a large size that have become partly diffused, that are filled  with masses of
decolorized  fibrine, and  that are  situated in places where the cellular tissue is
loose and lax, as in the axilla.  The symptoms of this condition  impending, are
swelling, tension with heat, throbbing,  and redness of the  parts around the
tumor, the integuments covering which, pit on pressure, and are evidently deeply
inflamed, at the same time that there is a good deal of fever and general consti-
tutional irritation.  As the suppuration  advances, the ordinary signs of conges-
tive abscess  occur; the  skin covering the  tumor becomes red and livid at one
part, where pointing takes place; and if the surgeon make an  incision into it,
or if the tumor burst, as assuredly it will if left to itself,  a quantity of sanious
pus mixed with large masses of broken-down coagula and fibrine will be let out.
The discharge of the  contents of the aneurismal sac disintegrated by, and mixed
up with  the results of suppurative action, may be followed by so profuse a gush
of arterial blood  that the patient is suddenly exhausted.   Most commonly, how-
ever, no immediate arterial hemorrhage  occurs, but in the  course of a few hours
or days,  as the deeper coagula are loosened,  this sets in, and recurring from time
to time  speedily carries off the  patient.  In some extremely rare cases  it has
happened that the inflammation thus set up occludes that  portion of the artery
that communicates with the aneurismal sac, and that thus a spontaneous cure
results by its obstruction, and by the adhesive inflammation of  the vessel.
   The spontaneous cure of an  aneurism is a matter of very rare occurrence.
The manner in which it happens has  been especially and ably  studied by Mr.
Hodgson, and more recently by Dr. Bellingham, and the pathology of this pro-
cess is of considerable interest from its bearing upon the cure of the disease by
surgical operation.   The spontaneous cure of an aneurism, as has already been
stated, may accidentally, though very rarely, occur  by the inflammation  of the
tumor and consequent obliteration of the artery; but this is not the way in which
it has most frequently been found to happen.   It  is by the gradual deposition
of laminated fibrine  in  the interior of the sac that it is filled up completely.
This process can only  take place in arteries  of  the second or  third magni-
 tude, and never in aneurisms of the aorta; and can only happen in the saccu-
 lated aneurisms, the  fusiform not admitting of it, it being necessary that the
blood flowing through the sac be somewhat retarded in its passage, so as to give
 time for the deposit of its fibrine upon the  interior of the  tumor.  This process,
 which is a very  different one to the coagulation of the blood, is  an increase of a
 natural condition always going on in the sac.  In  all cases of sacculated aneu-
 rism, there is a tendency to the production of  a spontaneous cure, though this
 is so rarely accomplished.   The tendency to it takes place by a contraction and
 partial occulsion of the artery below the  sac, and the consequent diminished
 force of the circulation  through it, by which the deposition of  fibrine is greatly
 increased, at the same  time that the collateral vessels given off above the sac
 often enlarge to a considerable extent, and  thus divert blood away from it that
 would  otherwise have  passed through it.   This condition of the vessel below
 the sac, may be looked upon as the first  and most important  step towards the
 consolidation  of the tumor.  The process is also materially  assisted  by the
 mouth of the sac being small, and so situated that the blood cannot be directly
 driven into  it.
   For the spontaneous  cure to take place,  it is however necessary that the cur-
 rent of  blood should continue to circulate  through the sac.  If it be suddenly
 arrested, coagulation of the blood which happens to be in the sac, may take 
      SPONTANEOUS CURE AND RUPTURE  OF  ANEURISM.  491

place in its interior, which thus becomes filled with  a large  dark soft clot of
blood; but the essential element in the consolidation of the  tumor, the depo-
sition of stratified fibrine, does not take place in this way; the sudden formation
of the  dark  coagulum, which acts  as  a foreign body, is indeed  apt to induce
suppuration  and  sloughing of the  sac and neighboring tissues, hence  it  is
rather prejudicial than otherwise.   But though the blood continue to circulate
through the sac, the deposit  of fibrine will  not take  place unless the  impetus
with  which  that fluid is  sent  into and  through the  tumor is considerably
diminished.  This may happen from some or other of those conditions occurring
in the distal  portion of the artery or the  mouth of the  sac that have  already
been described.  So  also it  has been found  that in those  cases in which two
aneurisms are situated upon  one artery, the second or distal one is very apt to
undergo partial or  even complete  consolidation,  the  blood losing its impetus
in its  passage  through the first sac.   Any constitutional  cause or  condition
also, by which  the  impulse of the  heart is lessened, and the  force of the flow
of blood through the sac diminished, as the  occurrence of phthisis, for instance,
will favor greatly the deposit of laminated fibrine, and the consolidation of the
tumor.
   As the aneurism undergoes spontaneous cure, the pulsation in it gradually
becomes more and more feeble, until it ceases  entirely, the bruit proportionately
lessens, the tumor becomes harder, and at last completely consolidated; at the
same time, the anastomosing circulation is sometimes found to be established in
some  of the collateral vessels of the  limb.  Eventually, the solidified tumor
shrinks in size, undergoing a species of drying and absorption, with ultimate
conversion into a small mass of  fibro-cellular tissue.
   An aneurism may prove fatal in various ways.   It  does  so when internal,
most frequently by the pressure that it exercises  on  parts of importance in its
vicinity, the  patient being destroyed by the exhaustion induced by interference
 with their functions; this is  usually the way  in which aneurisms of the aorta
 occasion death.  Then again, death may result by the  occurrence of syncope,
 more especially if the aneurism be of large size, and  situated near the root of
 the aorta.  External  aneurisms most commonly prove fatal by rupture of the
 sac; this may  either take place into the  interior  of a limb, giving rise to one
 or other of the diffused forms of aneurism, that have just been  described, and
 terminate  fatally by  the  induction of syncope or gangrene; or they may kill
 by rupture occurring on one of  the surfaces of the  body.  When an aneurism
 is about to burst upon the surface, the  skin covering it becomes inflamed; at
 the most prominent point a slough forms, by  a process somewhat analogous to
 that of the pointing  of an abscess; as this loosens  and separates, trickling of
 blood  occurs,  an  occasional  gush  takes place, usually  after  coughing, or any
 exertion, and the patient is exhausted by these repeated hemorrhages.   In other
 cases again,  a  sudden and forcible  gush is immediately fatal  on the loosening
 of the slough.  On  the mucous surfaces, as of the  esophagus or trachea, rup-
 ture occurs  in a similar manner (fig. 172).  On the serous  surfaces, as into the
 pleura and pericardium, the aneurism may burst by a fissure or stellate opening
 (fig.  173) forming in this  membrane.  The rupture of an aneurism is not
 always immediately fatal, the aperture in the  sac being plugged up by a mass
 of coagulum,  as happened in case fig. 172, which  may not be loosened for some
 time, and through which  the bleeding recurs in  small  quantities at intervals.
 An aneurism has been known to give way and discharge blood for some weeks
 before it proved fatal, and it may even happen that after the rupture has  oc-
 curred, no hemorrhage may take place, but death result from the pressure of
 the tumor.  Thus, in the case of the late Mr. Liston, the sac of the  aneurism
 which caused  the death of that great  surgeon, had  actually  given way, a mass
 of coagulum projecting from it into the trachea, but yet death resulted by the 
492
ANEURISM.
irritation induced from pressure upon the inferior laryngeal nerve, and not by
hemorrhage.
  The diagnosis of aneurism may in many cases be effected with the greatest
possible ease; in  other instances  again, it requires a vast amount  of care to

              Fig. 172.                               Fig.  173.
Aperture in oesophagus produced by        Stellate rupture of an aortic aneurism
  pressure of an aortic aneurism.                 into pericardium.
come to a correct conclusion as to the nature of the tumor.   This is easily done
when the  aneurism is superficial, recent,  and circumscribed, the  blood in it
being fluid, and all the signs of the disease well marked.   It is often replete
with difficulty when the aneurism is deep seated,  or if external, when  old and
filled with coagula;  or if  suppurative  action has  taken place about it, or if it
has become diffused.
   In effecting the diagnosis of aneurism we have, in the first place, to ascertain
the  existence or not  of  a tumor, and after  this has  been done, to ascertain
whether it is aneurismal or of some other character.  This  point is most diffi-
cult to determine in internal aneurisms; in the external, this difficulty cannot
exist, for the doubt here is  not as to  the presence of a  tumor, but as to its
nature.  The tumors  with which  aneurisms may be  confounded  may conve-
niently be divided into two classes, those that do and those that do not pulsate.
   1st.  Every pulsating tumor is not an aneurism. — Thus  there may be pulsa-
tion in  various  kinds of encephaloid tumors, or  in  growths  composed  of
erectile  tissue.   In such cases as these,  many of the signs of aneurism are
present;  thus the  size of the tumor may be diminished  by compression, and
the distinct influx  of  blood  into  it may be felt  again  on  the removal of the
pressure, the tumor returning to its  original  size with a  soft swelling pulsa-
tion ; there may also be a bruit,  often  of a loud  and distinct character.   But
these  tumors may generally be distinguished from  aneurisms,  in not being
quite so distinctly circumscribed, in being soft, spongy, and elastic, without the
sensation of fluid that is met with in some forms  of aneurism, or the solid
coagula that occurs in others.  Then again the bruit is either of a soft, blowing,
and more prolonged character, or else sharp and superficial; the pulsation, also,
is not  so distinct, and is more  of the  nature  of a general swelling and heaving
of the tumor, than  of a distinct thump.  Much light is  also occasionally thrown
upon these affections by their being met  with in situations where aneurisms
cannot occur from the absence of any arteries of sufficient  size to give rise  to
it; as for instance, on the head of the tibia, or the side of  the pelvis;  but if it
bo happen, that a tumor of this kind is situated upon or under a large artery in 
DIAGNOSIS  AND CAUSES  OF ANEURISM.         493
the usual site of an aneurism, then the diagnosis  is certainly replete with diffi-
culty, and cannot indeed in many cases be made.  Several instances have of late
years occurred, in which surgeons  of the  greatest skill and  experience have
ligatured arteries, on  the  supposition that  they  had to do with an aneurism,
when in reality it was one of the pulsating tumors just described, that closely
simulated it.
   Pulsation may be communicated to a tumor of  a fluid  character, seated upon
an artery;  here the diagnosis,  though  often  difficult, is more readily made
than  in the last case.  Attention to the history of the case, to the  impossi-
bility of diminishing the tumor by pressure, either directly upon it, or on the
artery leading to it, its fluctuation, and want of circumscription  will usually
point out its nature.   Especial  attention should  likewise be  paid  to  the  fact
that the pulsation is a distinct heaving up and  down of the tumor, and neither
eccentric nor distensile, and that the swelling may often be wholly or partly
separated, by raising it up, from the artery lying beneath it.   By attention to
these points, abscesses in  the  axilla, under the  pectorals, at  the  root of the
neck, and in other situations where pulsation may readily be communicated  to
the fluid mass, can be distinguished from aneurism;  but yet  errors  in diag-
nosis  have happened, and will  continue to  do so from the intrinsic  difficulty
of these cases, and from no want of skill or care  on the  part of the  surgeon:
and those will be most charitable in their criticisms on  the mistakes of others,
who have most frequently had occasion  to experience these difficulties in their
own practice.
   2d.  Tumors that do not pulsate either by their own vessels, or by those  that
lie beneath  them, are not so readily confounded  with aneurism as  the class  of
affections that has just been described.   But yet  it must be borne in mind, that
in some  instances aneurisms even do not pulsate, or but very indistinctly so,
having  become^ filled with a dense and firm coagulum.  The non-pulsating
tumors  that chiefly require attention are  glandular, scirrhous, or ganglionic
swellings, seated over the carotid artery, at the root of the neck, or in  the pop-
liteal  space.   If these be of a fluid character, their fluctuation, unvarying size,
and the want of pulsation in them sufficiently indicate that they are  not  con-
nected with  the artery, from which they may also frequently be separated, and
upon which  they may be distinctly moved.   If solid, they are usually  irregular
and nodulated on  the  surface, and can  frequently be  detached by the fingers
being passed underneath them, and raising them  from the subjacent vessel.  I
believe there is more danger of mistaking a consolidated aneurism  which is
undergoing  or has undergone spontaneous  cure,  and in which there  is conse-
quently no pulsation, for a solid, perhaps a  malignant tumor of some kind, than
the reverse. _ I have  known one  instance  in which the thigh was amputated
for a very painful  solid tumor of the popliteal space which proved on dissec-
tion  to be  a consolidated  aneurism, pressing  upon the posterior  tibial nerve
(fig. 163).
   With rheumatism it would at first appear to be difficult to confound  an aneu-
rism, but in  practice it is not so.  I have known several cases in which the lan-
cinating pains of  aneurism, more especially when  the tumor was  internal, have
been mistaken and treated for rheumatic affections; and I have even known the
pain occasioned  by the presence of a large aneurism of the thigh treated  for
several weeks as  rheumatism.   In such cases as  these, it is of course obvious
that a little care and proper examination will usually serve to establish the diag-
nosis.  The  aneurismal may be distinguished  from  the rheumatic pain by its
having a twofold  character,  being  both  lancinating and  intermittent, as well as
continuous aching, and burning.  When this kind of pain is  persistent, espe-
cially about the back, the side of the head and neck, or  arm, it ought always to
cause  the surgeon's attention to be directed to the condition of the  neighboring
large vessels.                                                             & 
494
ANEURISM.
  The causes of aneurism are divisible into those that predispose to, and those
that excite, the disease.  Aneurism is  predisposed  to by any affection of the
arterial coats that lessens the  elastic  resiliency of the vessel, and at the same
time weakens its resisting power.   The affection that we have already seen does
this to the greatest extent, is  the fatty degeneration of arteries, or atheroma;
under the influence of this  condition,  not only is the natural elasticity lost, but
the walls are so softened that they are readily expanded, either uniformly, or
dilated at one side.  Though calcification destroys the elasticity of the artery,
it  at the same  time makes it rigid and unyielding, and  but  little disposed to
expand under the  influence of the outward  pressure of the blood.
  Age exercises a  powerful predisposing influence on  the occurrence of aneurism,
This disease is excessively  rare before puberty, yet  it is  occasionally met with
at early periods of life; thus Syme mentions a case  of popliteal aneurism in a
boy of seven, and  Hodgson has a preparation of a carotid aneurism in a girl of
ten.  It is during the middle period of life, about the ages of thirty and forty,
that aneurisms are most frequently met with;  at those ages, indeed,  when the
arteries have already commenced  to lose their elasticity, in  consequence of dis-
integrating  changes, whilst, at the same time, the heart has not lost any of its
impulsive force, or the general muscular system its contractile vigor;  and when
the weakened and inelastic  vessels becoming exposed to powerful causes of dis-
tension, may readily give way and be expanded at  some one weakened point.
A forcible, irregular, and occasionally greatly increased action of the heart, is
the immediate  cause of the over-distension and dilatation of the vessels, and thus
of the production of aneurism.  Hence, we find that this disease is  especially
apt to be induced in those  individuals in whom the muscular system is called
upon to  make  sudden, violent, and intermittent exertions; as, for instance, in
men who habitually lead somewhat sedentary lives, occasionally and suddenly
changing their habits, and  indulging in  sports, which they might without risk
have practised  in  early life, such  as hunting, rowing, or a long day's shooting;
but which  cannot be taken up with impunity at  an age when the arteries,
having become weakened, are unable to bear the same strain upon their coats as
heretofore.   I  agree with Mr.  Porter, in  thinking that continuous, steady, labo-
rious employments do not predispose to aneurism, as this disease is seldom met
with amongst those of the  lower  classes, who  labor hard and uninterruptedly,
but it rather occurs in those who, after long periods of comparative inaction, are
occasionally and suddenly called  upon to  make very violent muscular efforts,
disproportioned to their strength, or, at all  events, to their previous habits.  It
is in this way that soldiers, sailors, and members of the higher  classes in society,
are rendered peculiarly liable  to aneurism.  As violent  muscular exertion pre-
disposes  to this disease,  we should necessarily expect  to meet with it more fre-
quently among men  than  in women; and  accordingly, Dr. Crisp finds that of
551 cases of aneurism of all kinds, more than  seven-eighths  occurred in  men.
It is important, however, to observe that different kinds  of aneurism occur with
varying  degrees of frequency in  the  sexes; thus, this affection of the carotid
artery is met with about as often in women as in men, whilst the other external
aneurisms occur in the proportion of 13 cases in males to  every one that happens
in a female.   It is  remarkable, however, that  in  the dissecting aneurism the
proportions are reversed, and for every 1 case in men, 2 occur in women.
   Climate exercises an important influence  on the occurrence  of aneurism,
which is far more frequent in  cold than in  hot  countries.   If  we may judge of
the prevalence of aneurism in a country by the number of published reports of
cases, I should say that  it  is of more common  occurrence in Great Britain and
Ireland than elsewhere; indeed, Boux states that it is less frequent in France
than in England.   In America it  is also of frequent existence, but in the East
Indies it is rarely met with.
   Cachexy induced by any cause, such as syphilis, chronic gout, or rheumatism, 
TREATMENT  OF  ANEURISM.
495
the abuse  of mercury, &c, has a tendency to occasion disease of the coats  of
the arteries,  and thus to predispose to aneurism.  But though mercury and
syphilis are commonly said specially to tend to the production of this disease,
I am not aware that we are  in  possession of any facts that would warrant us in
coming to this  conclusion; though there can be no doubt  that the cachexy
thus induced, may dispose to it equally as if it arose from any other cause.  It
is remarkable that phthisis is  antagonistic  to aneurism, though probably this
may arise from the fact  of  the heart's action  being feeble in this disease, and
that violent muscular exertion  is seldom undertaken by those laboring under it.
Any obstacle to the free flow of blood  through an organ or the capillaries of a
part, exercises an important influence in disposing to aneurism, as  it throws an
increase of pressure  on the interior of the artery.   Dr. Chevers believes that
obstruction in the abdominal  organs  frequently occasions  aneurisms  of the
abdominal arteries.
   The only exciting or direct occasioning causes of aneurism are blows, violent
strains, and wounds of an artery. When an atheromatous artery is concussed by
a blow, the lining membrane covering  the softened patch may be ruptured, the
atheroma being poured out into the interior of the vessel, and thus the external
coat, with perhaps a portion of the middle adherent to  it, becoming exposed to
the pressure of the contained  blood  before it  has been fully consolidated by
inflammation and plastic deposit, the foundation  of an aneurism may roadily be
laid.  In very violent muscular strains or  efforts an artery may occasionally be
 completely torn across,  and it  is easy  to understand  how, under these circum-
 stances, the increased pressure that is  thrown upon its interior may give rise to
 dilatation of an already weakened  portion of the vessel.  Wounds implicating
 arteries, are common causes of those various forms of aneurism that have already
 been discussed  in considering injuries of arteries.

                     TREATMENT  OF ANEURISM.

   The treatment of aneurism is of two kinds — constitutional and local.  In
 many  cases, as in the  various forms  of internal  aneurism for instance,  the
 constitutional treatment can  alone be employed, and in all cases of external
 aneurism it should be  had recourse to  as  an important adjunct to any local
 measures  that  are adopted.   In  the constitutional  or medical treatment of
 aneurism, the  great  object is to  bring about the same condition  as  that by
 which the spontaneous  cure of the disease is effected;  and, indeed, to put the
 patient and the  part in the most favorable state for nature to consolidate  the
 tumor; and though  it  may not be possible in  the great  majority of cases to
 effect a cure in  this way,  at  all events  the disease  may be palliated, and its
 progress  retarded.  The sacculated is,  however, the only form of aneurism that
 can ever be cured by constitutional means;  in the fusiform variety, all that can
 be done is to regard  the progress of the case.
    In  the constitutional  treatment  of aneurism the principal objects to be held
 in view are, in  the first place,  to lessen the force  of the  heart's  impulse, so as to
 diminish  the eccentric pressure upon the  arterial coats;  and, secondly, so to
 modify the condition  of the blood as to dispose it to the  deposition of its fibrine.
 In carrying out these indications, it should be borne in  mind that there are two
 opposite  conditions of  the system in which aneurism occurs;  in one there is a
 plethoric, and  in  the other an  anemic tendency.  The plethoric and irritable
 state  of  system chiefly occurs in young subjects, in whom the progress of the
 disease is acute  and  rapid, attended by much impulse and  excitability of the
 heart, and throbbing of the  arteries  generally.  The  other condition of the
 system principally occurs in  elderly people, in whom there is  a feeble  pulse, a
 quiet  heart, a cachectic  state  of health, and a tendency to  anemia; in such  a
 habit  of  body the disease  makes  slow progress.   In these opposite conditions 
496
ANEURISM.
it is perfectly clear that the same plan of treatment cannot succeed; and that
the constitutional means must accordingly be modified according to the state in
which the patient is.
   In  the acute or hyperemic state, the plan of treatment originally introduced
by Valsalva, and hence  called by his name, by which plethora is removed, the
irritability of the  heart and the force of its action lessened,  and the blood
brought into a  healthy condition, may be  advantageously employed,  in  the
modified manner that has  been recommended and  adopted by some modern
surgeons.  Pelletan and Hodgson especially report very favorably of this treat-
ment, and I have seen several  instances in which it has proved decidedly
beneficial.    As  recommended  by  Valsalva,  this method of  treatment  was
intended to  carry  out  two important points.  1st.  By a process  of gradual
starvation  and  depletion to reduce  the  quantity of  blood in  the  system, the
power of the heart's action, and  consequently the pressure exercised upon the
walls of the  aneurism;  and 2d, after the patient had in this way been reduced,
the plasticity of the blood was to be improved by feeding him up in a gradual
and careful  manner, so that  the tendency to the deposit  of laminated fibrine
might be increased.  Valsalva endeavored to carry out the first of these objects
by subjecting the  patient to small and  repeated bleedings, and by gradually
reducing the quantity of food that was daily taken, until it was lowered  to half
a pound of pudding in the morning, and a quarter of a pound in the evening.
In this way  the patient's strength was reduced until he  could scarcely be raised
up in bed without fainting; the quantity of food was then gradually augmented,
so that the plasticity of the blood might be restored.  It is seldom that surgeons
 carry out Valsalva's plan of treatment in the precise manner indicated by him;
it is most commonly found to be more convenient to modify somewhat according
to the circumstances of the case, though the principles on*which it is conducted
are essentially the same.
   In adopting any constitutional treatment in cases  of aneurism, the first  and
most essential point to be attended to is, to keep  the patient perfectly quiet in
bed and free from all mental or conversational excitement.  The diet should at
the same time be very carefully regulated, being gradually reduced in quantity,
 and being made to consist principally of farinaceous food, with but a very small
quantity of  meat, but  little  liquid, and a  total absence of  all  stimulants.
 Perhaps the best  regimen is  that  recommended by Bellingham, consisting of
 two ounces of bread and butter for breakfast, two ounces of bread and the same
 quantity of  meat for dinner, and two ounces of bread for supper, with a little
 milk and  water, occasionally sipped in  small quantities.  At  the same time
 purgatives should be administered, especially such as give  rise to watery stools,
 and which remove obstructions of the portal  and  renal systems; with this view
 9j. of  the compound jalap powder may be given  twice a week.
   In some  cases, if the heart's action  be particularly strong, small bleedings
 may  advantageously be  had  recourse  to from time to time.   By judiciously
 carrying out this plan  of treatment and modifying it according to the  circum-
 stances of the  case, consolidation of the aneurismal tumor may occasionally be
 looked for;  or, if this be not attained, the progress  of the disease will be  very
 materially retarded.
   When aneurism, however, occurs in feeble, cachectic, and anemic  patients,
 this plan of treatment is altogether inadmissible :  here, the blood being deficient
 in fibrine, and  the system in an irritable state from debility, the  best  results
 follow  such  a course of treatment as will improve the plasticity of the blood,
 and regulate the action  of the heart.  With this view, complete rest, the admin-
 istration of the preparations of  iron, and the exhibition of a dry but nourishing
 meat diet, with the occasional employment of opiates  to relieve pain and  to quiet
 the system, will be attended  by the best results.  In  aneurism occurring  in 
SURGICAL  TREATMENT OF ANEURISM.         497
elderly people, and amongst the poorer classes, this plan of treatment is perhaps
more successful than any other.
  In the local treatment of  aneurism but little  can be done with the view of
checking its progress, except by the employment of direct surgical means.  The
application of ice to the surface of the tumor is said to have acted beneficially in
some cases, but it is a painful remedy, and one that may occasionally be attended
by the inconvenience of sloughing of the skin to which it is applied.  When the
pain attending the increase  of the tumor  is considerable, much relief may be
obtained by the application of belladonna plasters, or the use of an embrocation
composed of equal parts of  oil and of the strong  tincture  of aconite.   These
means comprise the only local measures that  can be adopted in those cases of
internal aneurism, which are beyond the  reach of surgical interference.
           THE  SURGICAL  TREATMENT OP  ANEURISM.

   In all those cases in which it is possible to delay with safety, no surgical pro-
 ceeding should be undertaken for the  cure of aneurism until the patient has
 been subjected to proper constitutional  treatment for some time; the success of
 the more direct  surgical means depending  greatly in the  hyperemic forms of
 aneurism on the heart's  impulse being lessened, and in the blood being got into
 as healthy a state  as  possible;  whilst  in  the anemic  form of the disease, an
 increase in the plasticity of the  blood is essential for the cure of the case; for as
 the occlusion and consolidation  of the  sac, after surgical procedure, depend on
 the same conditions being induced that are successful after medical treatment,
 the same constitutional means should be adopted in one  case  as in  the  other.
 Before proceeding to  the employment of any direct surgical means for the cure
 of an external aneurism, it is necessary to ascertain  that there be  no internal
 aneurism present, and that the heart is free from disease.   From want  of this
 precaution, it has happened that patients have  died on the operating table at
 the moment that the artery was being ligatured, or that they have expired shortly
 afterwards,  from  the disturbance of circulation  consequent upon the  necessary
 surgical procedures.
  _ Surgeons are in possession  of several modes  of treating  external aneurisms,
 viz., by ligature, by  compression, by  galvano-puncture,  by injection and  by
 manipulation.  The employment  of the ligature was the  only means adopted
 by surgeons, for  the cure  of aneurism, up to a very recent  date;  the  use  of
 compression, in the treatment of the disease, as at present employed, being one
 of the  most modern,  as  well as one of the greatest improvements, in surgical
 practice.                                                              °
   The  manner  in  which the  ligature
 should  be applied,  and the various cau-
 tions respecting its  use,  have already
 been sufficiently discussed (page 164 et
 seq.) The question  as to the part of the
 vessel to which it should be applied in
 cases of aneurism, however, remains for
 consideration,  and   this  involves  some
 important points.
   There are three situations in which the
 ligature may be applied : 1st, above and
 below the sac by the old operation; 2nd
 on  the  cardiac  side  of  the  sac,  by
Anel's (fig. 174)  or Hunter's  (fig. 175)
operation; 3rd, on the distal side of the
sac, by Brasdor's or Wardrop's operation  (fig. 176).  The application of the liga-
ture  to the artery on both sides  of the aneurismal sacs, is  seldom practised°at
Fig. 174.    Fig. 175.    Fig. 176.

                3^v
 
498
ANEURISM.
the present day, when the aneurism  arises from disease of the coats  of the
vessel;  but, in those cases in  which  it occurs from  traumatic causes, it may
frequently be adopted as the best means of cure.  The older surgeons, however,
were only acquainted with this mode of treating aneurisms.  They slit up the
sac, turned out the contained  coagula and  masses  of fibrine, and then passing
a probe upwards and downwards, into the artery, through the mouth of the sac,
tied the vessel on either side, immediately above and  below the  aperture in it.
This operation, when performed on  any of the larger arteries, as the popliteal
for instance, was not only so difficult in itself, that surgeons were seldom willing
to undertake it, but was so fatal in its results,  being so  commonly attended by
secondary hemorrhage in consequence of the artery being ligatured in a diseased
part, or by diffuse inflammation, suppuration, and gangrene in  the deeper  tissues
of the limb operated upon, that recovery after  its performance was considered a
marvel, and most surgeons preferred submitting the patient to amputation at
once, than to the risks of so hazardous a procedure.
   The  ligature of the  artery on the cardiac side of  the  aneurism, without
opening the sac, was first done by Anel, in the year 1710, in  a case of brachial
aneurism.  This operation, though attended with the  risk of wounding  or in-
flaming the sac, which was in close proximity to the seat of ligature, constituted
a considerable advance  in the  treatment of the disease, inasmuch as it did not
necessarily lead to the opening up of the aneurismal tumor, and to the attendant
dangers that were inseparable from that mode of procedure. As Anel, however,
performed his operation as a mere  matter  of  convenience in a particular case,
and without the recognition of any new principle of treatment being  involved
in it, it attracted but little attention at the time, and does not appear to have
been repeated by any of the surgeons  of his day.
   It was reserved for John Hunter to  make the great improvement in operative
surgery of ligaturing the artery at a distance from the sac, where its coats were
healthy, and  where there was no danger  of  interference with the aneurism
itself.   In this way the  objections to Anel's operation were avoided, for though,
like Anel, Hunter tied  the  artery only on  the  cardiac side of the sac, yet  he
differed from him in doing so in a healthy part of its course, and at a consider-
able distance above the tumor,  where the application of the ligature would  be
attended  with less risk of hemorrhage, and with  no danger of opening, irri-
tating or inflaming the sac, which are  inseparable from Anel's operation.  The
following are the reasons, given in Sir  Everard  Home's own words, that induced
John Hunter to adopt the operation that is now generally known in surgery as
the Hunterian.   " Mr.  Hunter proposed, in performing this operation, that the
artery should be taken  up at  some  distance from  the diseased  part, so  as to
diminish the risk of hemorrhage and  admit of the artery being more readily
secured should any such accident happen.   The  force of the circulation  being
thus taken off from the aneurismal sac, the cause of the disease would, in Mr.
Hunter's opinion, be removed, and he thought it  highly probable that  if the
parts were left to themselves, the sac,  with  the coagulated blood  contained in
it, might be absorbed, and the  whole of the  tumor removed  by the actions  of
the animal economy, which would consequently render any opening into the sac
unnecessary."
   Hunter's first operation was performed  in December, 1785, in a case of pop-
liteal  aneurism,  in which the femoral artery was ligatured rather below the mid-
dle of the thigh, underneath the sartorious muscle; and since that time  it has
been  universally employed by surgeons, as  almost the  only mode of treating
aneurism, until the introduction of compression in 1842.
   The effects produced upon the aneurismal tumor by the ligature of the^vessel,
according to the Hunterian method, deserve careful attention. The immediate
effects,  on  drawing tight the  ligature, consist  in a cessation of pulsation and
bruit in the tumor, which at the same time subsides, becoming partially emptied 
HUNTERIAN OPERATION FOR ANEURISM.        499
Fig. 177.1
 of its blood.  The supply of blood to the limb being in a great measure cut off,
 it becomes numb  and cold, with a diminution of muscular power.  The more
 remote effects consist in an increase of the activity of the collateral circulation,
 by which the vitality of the  limb is maintained.  At the same time, and, indeed,
 in consequence of this, the temperature of the limb often rises, until it becomes
 higher than that of its fellow.
   The consolidation of the aneurismal  tumor begins as soon as the ligature is
 applied, and is usually completed in a few days, by changes taking place within
 it similar to those that  occur in the spontaneous cure of the disease.  This
 important change is effected by the gradual deposit of stratified and decolorized
 fibrine in concentric layers within  the sac, and not by the sudden coagulation
 of its contents.  For this deposition to take place, it is necessary that, though
 the direct flow of blood through the tumor be  arrested by the ligature of  the
 main trunk, yet that some should be carried in by collateral channels.   This is
 a necessary condition for the success of the ligature, for if it  happen that all
 the flow of blood through  the tumor be  arrested,  coagulation
 of that which happens to be contained in it will ensue, followed
 by  gangrene,  suppuration  of the  sac, and  other unfavorable
 results; the  coagulum appearing to act as a foreign body, and
 to be insusceptible of those changes that are  necessary for the
 consolidation of the tumor.   It is of importance to observe, that
 the proper consolidation of the aneurismal tumor, by  the deposit
 of laminated fibrine, will occur even though a very considerable
 quantity of blood continue to flow through it. In the Museum of
 University College there  is an exceedingly interesting  prepara-
 tion that  illustrates  this  point; it  is  one in which Sir Charles
 Bell ligatured  the femoral  artery for  popliteal aneurism.   The
 patient  died  a  week after the operation from erysipelas; on exa-
 mination it was found, and is shown by the preparation, that the
 femoral artery  was double,  and that,  though  only one portion
 of the vessel had been ligatured, the tumor, which continued to
 be supplied by the other, was completely consolidated.   Hence,
 it would appear that  if one-half of the influx  of blood only be
 arrested, obliteration of the sac by deposition of laminated fibrine
 may be expected to occur.  After the  aneurismal sac has been
 thus occluded, it  progressively diminishes  in size, and is at last
 converted  into a small  fibro-cellular  mass   The  artery that has
 been ligatured  becomes closed at two points — at the part deli-
 gated  (fig. 177 a),  and where it  communicates with  the sac
 (fig. 177 b).  In  both these situations,  it  will be found to be
 converted  into  fibro-cellular tissue,  whilst between them  there
 is an  open space, through the medium  of which the collateral
 circulation is freely, carried on.
   Distal Ligature.—In some cases in which the ligature cannot
 for  anatomical  reasons, be applied on  the  proximal side of the
 aneurism,  as in the arteries about the root of  the neck, it was
 recommended by Brasdor  that an  endeavor should be  made to
 obliterate the aneurism by ligaturing the vessel on its distal side.
 This operation was first practised by Deschamps, and has  been
 especially commented upon by Wardrop.  In principle, it  resembles the Hun-
 terian operation, the object being to arrest so much of the flow of blood through
 the sac,  that  the consolidation of this may take place in the usual way, by the
 deposit of  laminated  fibrine.   In the Hunterian operation, this is effected  by
  i Femoral artery ligatured for popliteal aneurism,  obliterated  at a, the site of tho
ugature, and at b, where the tumor has become consolidated  and absorbed —between
these points the artery is open.                                              cou 
500
TREATMENT  OF  ANEURISM.
deposit from the lessened quantity of blood that flows through the sac;  and,
in the distal operation, it is  sought to be  accomplished in the same way, and
the success  of the operation must necessarily depend, in a great measure, upon
the extent to which the flow of blood through the sac is interfered with. These
operations,  however, are rarely  successful, for, independently of the ordinary
dangers resulting from the application of the ligature to a large vessel, the sac
will continue  to be distended with  and to receive the direct  impulse of the
blood that is driven into it, though it be  not transmitted through it; and hence,
though the  progress of the  aneurism may be  arrested for a time, it will often
speedily increase again, and may perhaps eventually  destroy  the  patient by
suppuration and sloughing.  I have collected  the details of 27 cases in which
this operation has been practised, and of  these I find that in 20 instances a fatal
result speedily followed the operation;  whilst in the remaining 7  cases  the
patient survived the effects of the ligature of the artery, though  he was not at
all cured of the disease  for which the operation was practised.   This operation,
however, we shall consider more in  detail in speaking of the particular cases in
which it has been practised.
   The ligature of the artery for aneurism, by the Hunterian  method, succeeds
best in those cases in  which  the tumor is circumscribed, of moderate size, slow
in its growth, having a tendency to consolidation, and unaccompanied by much
oedema of the limb.  When the aneurism is undergoing spontaneous  cure, no
surgical interference  should be  had recourse  to, but  the case left to  nature.
In this way it occasionally  happens, during the preparatory treatment of the
disease, that the aneurism becomes  consolidated.
   All operations should be avoided when there is any serious disease in the
heart, and  in  cases of  multiple  aneurism where the second tumor is situated
internally;  but it has happened that two aneurisms  in  one  limb, as of  the
popliteal  and  femoral arteries, have been cured by one ligature applied to the
external iliac.  Two aneurisms seated in corresponding parts of opposite limbs,
affecting, for  instance, the two  popliteal arteries, may  be  successfully operated
upon.  But, if two aneurisms be seated on different parts of the body, as the
axilla and groin for instance, at  the  same  time, the aneurismal diathesis would
be indicated,  and it would certainly  not  be expedient to operate.
   In certain cases, the Hunterian operation  seldom succeeds, and these, there-
fore, may be  considered as unpromising  to it.  This happens in those instances
in which it is necessary to apply the ligature very close to the sac, so as indeed
rather to perform Anel's operation, as here there is the double  danger of infla-
ming or wounding the sac, and of interfering with the collateral circulation of the
limb.   Those cases  again, in which  the  aneurism  is very acute in its progress,
increasing  rapidly with forcible  pulsation, having very fluid  contents,  a large
mouth to the  sac, and  consequently the blood driven  into it by a full wave at
each pulsation of the heart, are rarely favorable for the  use of the ligature, inas-
much as  stratification seldom occurs.   When  the aneurism is situated in the
midst of loose and very yielding  tissues,  as  in the  axilla, where  it readily
expands to a large size,  not being bound down  by the surrounding parts, suppu-
ration and sloughing of the sac  are especially apt to occur after the ligature.
When it is diffused widely through  the  limb, with  coldness and  a  tendency to
incipient gangrene,  the circulation of blood through the part is so much choked
that the  deligation of  the  vessel will in  all' probability arrest it entirely, and
thus produce  mortification.   When  arteries  can be felt to  be ossified, it is a
question whether they can be safely ligatured,  as  in all probability  they will be
cut or broken  through by the noose, and the changes necessary for their occlu-
sion  would not  take place.  Porter,  however, recommends  that the ligature
should be applied in such case, though I cannot but doubt the propriety of this
advice.  When  inflammation has been  set up in  the sac, with a  tendency to
suppuration of the tumor, it  is a  debateable question whether the ligature should 
ACCIDENTS AFTER  LIGATURE  FOR  ANEURISM.    501
be applied or not.   In these cases I agree with Hodgson, that the artery should
be tied; for even if the sac eventually suppurate, there will be less risk to the
patient, if this event occur after the application of the ligature, than if it happen
when the artery leading into the  tumor is pervious.
   In some  instances, there  is no resource left to the surgeon, but to amputate.
This is the case  when the aneurism is associated with  carious bone, or diseased
joints, as when the popliteal aneurism has given rise to destruction of the knee.
If the aneurism have attained so great a magnitude  that it has already inter-
fered seriously with the circulation  through the limb, as indicated by conside-
rable oedema, lividity, and coldness of the part, with distension of the superficial
veins, it is a question whether the application of the ligature may not immedi-
ately induce gangrene, and whether the patient would  not have the best  chance
of recovery  by submitting to amputation at once;  this  is more particularly the
case when the  aneurism has become diffused with  impending gangrene, when
removal of the limb must not be  delayed.
   The ligature  fails  from various causes in a very considerable  number of the
cases in which it is employed for the cure of aneurism.  Thus in the 256 cases
of ligature  of the larger arteries for aneurism,  that  have  been collected  and
tabulated  by Dr. Crisp, it would  appear that  the  mortality amounted  to about
22 per cent.  And Porta finds  that out of 600 cases of ligature of arteries for
diseases and injuries  of all kinds, the mortality amounted to 27 per cent.  It
must be borne in mind, that these are  collections of previously  reported cases,
and that if  the unrecorded cases  could be got at, the rate of death  would, in all
probability, be found to be much higher even than that above stated.

        ACCIDENTS AFTER LIGATURE FOR ANEURISM.

   The  accidents that may follow the application of the ligature  in a case of
aneurism, are:  1st, secondary  hemorrhage  from the  seat of ligature; 2d, the
continuance, or the return of pulsation in the sac;  3d, the occurrence of sup-
puration and sloughing of the tumor,  with  or without hemorrhage  from it;
and, 4th, gangrene of the limb.
   1st. Secondary hemorrhage from the seat of ligature presents nothing pecu-
liar, and has already been discussed at p. 171.
   2d.  The  continuance or return  of pulsation in an  aneurismal  sac after the
ligation of  the  artery leading to it, is an interesting phenomenon,  and one that
deserves some attention.  When  the  Hunterian operation  is  successfully per-
formed, though the pulsation in the  sac be entirely arrested, a certain quantity
of blood continues  to be conveyed  into and through it by the anastomosing
channels, and it is  from this  that is deposited the laminated fibrine by which
the  consolidation  of the tumor is  ultimatly  effected.  This stream  of blood
furnished by regurgitation, or by transmission through the smaller collateral
channels, is continuous, and not pulsatory;  occasionally however it is trans-
mitted in sufficient quantity by some more than usually direct  and open anas-
tomosing, or feeding branch, and thus gives  rise to a continuance, or a return
of the pulsation.  It is interesting to observe  that in some of the cases in which
this has happened, there has been a return of the bruit, but that in the majority
no sound appears to have been emitted.
   The period of the return of the pulsation in the sac  after the ligature of the
artery varies greatly.   In by far the majority of cases, at  least two-thirds of
those in which it has happened, a certain degree of thrill or of indistinct pulsa-
tion has been found in the sac shortly after the application  of the ligature; at
all events within  the first  twenty-four  hours.  This  may be  looked upon as
being  rather a  favorable sign  than otherwise, as it is indicative of a free state
of the collateral circulation, and generally soon disappears spontaneously the
sac undergoing consolidation.   Next  in order of frequency are  those cases in 
502
TREATMENT  OF  ANEURISM.
      which the pulsation returns in about a month or six weeks after the ligature of
      the artery, when the collateral circulation has been fully established, and, after
      continuing for some length of time, gradually ceases.   It more rarely happens
      that the pulsation returns between these  two periods;  that is to say, about ten
      days or a fortnight after the  application  of  the ligature, though  in some
      instances the slight vibratory thrill scarcely amounting to  a pulsation, which
      perhaps is  perceptible a  few hours after an artery has been tied, gradually
      strengthens at the end of a week or ten days into as distinct and forcible a beat
      as had  been noticed before the operation.  In some rare instances the pulsation
      has re-appeared after the  lapse of some months, the aneurismal tumor  having
      in  the  meanwhile undergone absorption, when indeed  it may with justice be
      looked  upon  as constituting a secondary aneurism, and as  indicating a recur-
      rence of the complaint.
        The  cause of the continuance, or of the return of the pulsation  in an aneu-
      rismal sac, must be looked for in  too great a freedom  of the collateral circula-
      tion.  Indeed, I consider  it an  essential requisite for the manifestation  of this
      phenomenon  that  there should  be so free and direct a communication between
      the artery on the proximal side  of the  ligature, and that portion of the vessel
      situated between  the ligature and  the sac, or with the  sac itself, as to enable
      the impulse of the  heart to  be transmitted in a pulsatory manner into  the
      tumor.   No regurgitant blood coming upwards from that portion  of the artery
      which is distal to the sac, however free it may be, can communicate an impulse,
      as it never flows per saltum except in the special case of a continuous circle of
      large anastomoses such as  are met with between the carotid arteries within  the
      skull, or in the palmar and plantar arches.  If any of the direct collateral or
      feeding vessels  happen to be sufficiently large  at  the time of the operation to
      transmit the wave of blood, the pulsation in the sac will be continuous,  or will
      return almost immediately after the application of the ligature.  If they be  not
      of  sufficient magnitude for this, they may become enlarged as part of the anas-
      tomosing circulation, and  then the pulsation will return so soon as their  calibre
      is sufficient to transmit a pulsation.   Besides  these  conditions existing  in  the
      size and distribution of the vessels of the part, it is not improbable, as has been
I     supposed by Porter, that certain states of the blood in some individuals may,
      from causes with which we  are  unacquainted, render  it less liable to coagulate
      than usual, and thus dispose to a return of the  pulsation in the sac, which
      remains filled with fluid blood.
        The phenomenon under consideration has been  noticed  in all parts  of  the
      body after the performance of the Hunterian operation, though  it occurs with
      different degrees  of frequency after the ligature of different arteries,  and is
      certainly of more common occurrence after operations for carotid aneurism than
      for any other form  of the  disease.   Thus, of 31  cases in  which  the  carotid
      artery has been tied for aneurism, I find that pulsation  in the tumor continued
      or returned in 9 instances;  whereas of 92 cases of inguinal aneurism, in which
      the external iliac  artery was  ligatured, the pulsation only recurred  in 6 cases;
      and in  several of  these it  is interesting  to note that there were two aneurismal
      sacs in the same limb —one in the groin, the other in the ham; and the pulsa-
      tion, though permanently arrested in the popliteal, recurred in the inguinal
      aneurism.   In  the ham and axilla, pulsation  occasionally though  very rarely
      recurs.  The cause of this difference in the frequency of the recurrence of pul-
      sation  in  different aneurisms, is evidently owing  to the different  degrees of
      freedom of communication that exist  between the  sac  and collateral branches
      in various forms  of the  disease; thus, in a carotid aneurism, the  impulse of
      the heart may at once be  brought to bear upon the contents of the sac, through
      the medium of the circle  of Willis.   But in the case of inguinal, femoral, or
      popliteal aneurisms, the anastomoses, consisting rather of the inosculations of
      terminal branches than of open  communications between large trunks,  are less 
ACCIDENTS AFTER  LIGATURE  FOR  ANEURISM.
503
liable to transmit the blood in a pulsatory stream.   For the same reason, viz.,
the great freedom of the communication between the vessels of opposite  sides,
the pulsation has more frequently been found  to  continue  uninterruptedly and
distinctly, though reduced in force, after the  ligature of the artery in carotid
aneurisms than in those in any other situation.  The cases in which it returns
after the cessation of a few hours only are perhaps as frequent in the groin and
ham,  as in the neck.  In those instances in which the pulsation returns within
the first twenty-four hours  after the ligature, it usually ceases again in a few
days, though it sometimes continues a week or two.  When it recurs at a later
period it is apt to last somewhat longer.
   The prognosis of these cases is  on  the whole favorable, but  few of them
having eventually proved fatal.  Of 26 patients in whom pulsation recurred,
I find that 3 died, and in all of these the fatal result was occasioned by inflam-
mation and sloughing of the  sac.   In  all of the 3 instances the pulsation re-
curred within the first twenty-four hours.  When it  returns at a more advanced
period, there  is little risk to the patient, as it  is usually readily amenable to
proper treatment.
   A  secondary aneurism is  of extremely rare  occurrence; indeed I believe
there are only two unequivocal instances of this affection  upon record, both of
which took place in the  ham; the  original tumor having  disappeared entirely
after operation, the secondary disease  made its appearance after a lapse  of six
months, in one case, and in  the other, after four years.   It is of importance
to distinguish  between  a secondary  aneurism  and  secondary or  recurrent
pulsation in an aneurismal sac. The  term " secondary aneurism" should be
restricted to  those  cases only  in which an aneurismal tumor appears in the
 site of a former one which  has undergone consolidation  and absorption, after
 operation.  The question may be raised as to whether aneurisms of this kind
are in reality secondary, or whether they may not originate  in a portion of the
 artery contiguous to the seat of the former disease having becoming dilated.  It
is certainly not very easy to  understand how an aneurismal sac that has once
 undergone  consolidation and absorption,  can  again  become  dilated  into  a
 pulsating  tumor; and  I think it  most  probable,  although  the  consecutive
 aneurism may be found in the same surgical region as the primary one, that it
 in reality takes its  origin from a slightly higher part of the artery, where the
 same  structural  changes may have been in progress that determined to the
 disease in the first instance, at a lower point.   This kind of double aneurism is
 indeed occasionally met with in the ham as a primary disease.   I have  seen a
 case in which an aneurismal tumor was situated in the ham, and  another at, or
 immediately above, the aperture in  the  adductor muscle;  if the artery in such
 a case as this had been tied, before the  second tumor had  attained any magni-
 tude, we can  easily understand how, when this became dilated, it might have
 been considered to have been a new enlargement  of the  old  sac, whereas, in
 reality, it was nothing more than a new aneurism forming in the close vicinity
 of the old one.
   The enlargement of an aneurismal  sac, without pulsation, after the ligature
 of the artery leading to it, is an interesting phenomenon, and  one that  might
 cause the true nature of  the  tumor to be misunderstood, as it closely resembles
 in its slow and gradual increase  the growth of a malignant tumor.   It is occa-
 sioned by the distension of the sac, by the dark regurgitant blood brought into
 it through the distal end of the vessel, without sufficient force to cause pulsa-
 tion, though with sufficient pressure to occasion a gradual increase in the size
 of the swelling.
    Treatment of recurrent pulsation. — In by far the greater majority of cases
of secondary  pulsation, this phenomenon ceases of itself in the course of a few
days or weeks by the consolidation of the  sac, in the same way as after ligature
of the artery, from.the deposit of lamellated fibrine.  This tendency to consoli- 
504
TREATMENT  OF  ANEURISM.
dation of the tumor may be  much assisted by means calculated to lessen the
force  of the impulse of the blood into the sac, such as rest, the  elevated posi-
tion, and the cautious application of cold  to  the  part; cold, however, must be
carefully applied, lest, as the vitality of the  limb is diminished, gangrene be
induced.  At the same time, direct pressure may be  exercised upon the sac, so
as to moderate the flow of blood into it; this has in  many cases succeeded in
procuring consolidation of the tumor, and may most conveniently be applied by
means of a compress and narrow roller.  This plan is especially adapted to the
popliteal and inguinal  aneurisms, but  cannot  so well be exercised upon those
situated in the neck.   Care must be taken that  the  pressure be not at first too
powerful, lest gangrene result; the object here is not so much to force out the
contents of the tumor or  to efface this, but simply to restrain  and moderate
somewhat the flow of blood into it.
   In  the event of the pulsation not disappearing under the influence of pres-
sure,  conjoined with rest, dietetic means, and  the  local application  of cold, we
must  either  perform the old operation of opening the  sac, or amputate the limb.
Of these measures, I should  certainly advise  amputation, as offering the most
favorable chance to the patient.   The operation of opening the sac, turning out
its contents, and ligaturing the vessel supplying it, is, under any circumstances,
a procedure  fraught with the  greatest danger to the patient, and full of difficulty
to the surgeon, even when he knows in what  situation to seek the feeding
vessel.  How much greater then  must the difficulty be when he  is in uncer-
tainty as to the point at which the  artery enters the sac, and cannot know
whether there is more  than one of  these branches.  In the event, therefore, of
all other means failing, and of the pulsation in the tumor continuing, amputa-
tion is the only resource left to the surgeon.
   3d.  Suppuration and sloughing of the sac___When, after the ligature of its
supplying artery, an aneurism is about to suppurate, instead of diminishing in
size, it increases, with heat, pain, pulsation, and some  inflammatory discoloration
of the skin  covering it.  This  gradually becomes thinned, and at last gives
way;  the contents of the tumor, softened and broken  down by the inflammatory
action and the admixture of pus, are discharged through the aperture in  its
wall,  in the  form of a dark purplish-brown or plum-colored and often fetid fluid,
intermixed with masses of soft dark coagula, or of the  drier laminated fibrine,
which may not inaptly be compared in appearance to portions of raisins or dates.
The escape of these matters,  variously altered, may be accompanied or followed
by the  escape of florid arterial blood.  This hemorrhage, which is the great
source of danger in the suppuration of an aneurismal sac, may occur in a sudden
or violent gush at the time of the rupture of the tumor, by which  the patient
may at once be destroyed; or it may continue in  small quantities, which, after
ceasing, recur from time to time, thus gradually exhausting the patient.  It is
this occurrence of secondary hemorrhage that constitutes the principal danger
after  suppuration of an aneurism, which otherwise is not a source of any very
serious risk  to the patient; about one-fourth only of  the cases in which the sac
has suppurated having had a fatal  termination, and almost all those in which
death  resulted, having proved fatal by hemorrhage.   The patient in the  few
remaining instances has been  carried off by some special accident, such as the
pressure of  the sac on the pharynx or oesophagus, or its finding its way from
the axilla into the pleura or bronchial tubes.  Those  cases are more liable to be
followed by  hemorrhage in which  the suppuration occurs a few weeks after the
ligature of the artery, than when  a longer interval has  elapsed.   That hemor-
rhage does  not happen more frequently after suppuration of the  sac, is very
remarkable, and must be owing to the mouth of the aneurism, where it commu-
nicates with the interior of the artery, either being sealed by adhesion or plugged
by coagulum.   It is owing to this  plugging also  that  in many cases  the fatal
bleeding does not occur at the moment of rupture, but not until a lapse of some 
         SUPPURATION AND  SLOUGHING  OF  THE SAC.     505

days, or even weeks, and then  most usually under the influence of some  incau-
tious movement of the patient, by which the coagulum or adhesion is suddenly
disturbed.   Those cases are most dangerous in which pulsation has returned in
the sac after the ligature of the vessel, but  before the supervention of suppu-
ration, as in these the tumor is so freely supplied with  blood that, if it burst,
fatal hemorrhage will  with  certainty supervene.
   This accident is much more  frequent in  some situations than in others, and
is more liable to occur in aneurisms of the  axilla or groin, than in those  of  the
ham or of the neck.   The cause  of the  greater frequency of suppuration in
axillary and inguinal  aneurisms, is owing to the large  size that these tumors
rapidly attain, in  consequence of the laxity of their cellular  connections, and
the difficulty of their removal by the absorbents of  the  part.   This accident is
also greatly predisposed to, by the blood contained within the aneurismal tumor
undergoing simple coagulation instead of fibrinous consolidation.   The mass of
coagulum, instead of being absorbed, and thus gradually disposed of, as happens
in a properly stratified aneurismal sac, is very apt to break  up,  and  undergo
decomposition, being  converted into  an unhealthy  grumous fluid, that excites
inflammation in the parts with which it is in contact.  This state of things is
especially liable to happen in  those  aneurisms  that are of  very large size, with
thin parietes, and that contain previous  to the operation  much fluid blood  and
comparatively little lamellated fibrine.  In  other cases  again  it would  appear
that this, though  properly deposited, acts as a foreign body, and  gives  rise to
inflammation and suppurative action in the wall of the sac  and the surrounding
cellular  tissue.  Besides this, it has been very justly remarked by Mr. Porter,
that the excessive handling and frequent examination to which an aneurismal
tumor occurring  in a hospital patient is usually subjected, may induce inflam-
matory action and give rise to suppuration in it.
   The  period at which suppuration of the sac  may occur after  the  ligature,
varies from a few days to as  many months.  In the majority of instances it
would appear to take  place between the third and eighth week; later than this
it seldom happens, though  it may do so after the lapse of several  months, as in
a case recorded by Sir A.  Cooper, in which  a carotid aneurism suppurated at
the eighth month.
   Treatment—When an aneurism is suppurating, and is on the point of giving
way, it will be better to make an incision into  it, so as to let out at once  the
broken down and semi-putrefied contents.   Its cavity must then be dressed like
an ordinary abscess, with a view to its filling up by granulation, which, however,
will necessarily be a slow process, in consequence of the great size and depth
of the opening.  During  the whole of this time a tourniquet should  be kept
loosely applied upon the artery above the sac, so as  to be tightened at any mo-
ment that bleeding takes place.  If hemorrhage  have already supervened,  the
case is attended with  immediate danger.  In such a case as this,  the first indi-
cation is clearly  to arrest the immediate  flow of blood, so as to prevent  the
patient dying at once.  This can best be accomplished  by turning out the co-
agula and plugging the sac with lint or compressed sponge, retained in situ by
a firm, graduated compress, and well-applied roller.  The  hemorrhage having
thus been arrested for a time, the surgeon should take into consideration what
steps should be  adopted  permanently to  restrain it.  In  some cases, indeed,
though these are exceptional, the plug and compress  may be sufficient to prevent
a recurrence of the bleeding; but in general it will not do to trust to these means
unless the anatomical relations of the part be such as to preclude the possibility
of adopting any more active measures.
 ^ Various plans present themselves to the surgeon  for the permanent  suppres-
sion of the  bleeding.   The sac  may be  laid open, and an attempt made to liga-
ture that portion  of  the  artery from which the blood  issues.  But this  can
scarcely be expected to succeed, as in the  majority of the cases there would be 
506
TREATMENT  OF  ANEURISM.
little prospect of the vessel being found in such a state as to admit of its holding
a ligature, its  coats being softened and pulpy, even if it were possible to expose
it before the  patient perished of hemorrhage.   Indeed, though this  plan  has
been several times  tried, I am not aware that by it the surgeon has  ever suc-
ceeded in arresting the bleeding from a suppurating aneurismal sac.
  The application  of the actual cautery to the bleeding orifice would, I think,
hold out a better chance, more particularly if the blood were poured out from a
collateral vessel of a small size.  In  this way, Morrison, of Monte Video, suc-
ceeded in arresting the bleeding of an aneurism in the groin that had suppu-
rated.   Should these means, however, not  suffice,  and they are the only ones
that can be  employed in many situations, as in the groin and axilla, there is no
course left but, in those situations in which it can be done, either to ligature the
artery higher  up or to amputate.  The application of a  ligature nearer the centre
of the circulation, even though practicable, appears to me to be of very doubtful
utility, for the probability is, that the circulation  through the limb, embarrassed
as it must have been by the first ligature, and by the subsequent distension and
suppuration of the sac, will be so much interfered with when the artery is tied
a second time, that gangrene will result; or else  if the collateral circulation be
sufficiently active to maintain the vitality of the  limb, that it will  also keep up
the  hemorrhage from the opening in the artery communicating with the sac.
Under these circumstances, the only  course left to the surgeon  is amputation of
the limb, when the aneurism is so situated that it can in this way be removed.
  4th. Gangrene of the limb. — The  general subject of gangrene  of the limb,
following the  injury and ligature of the main artery, has already been described
(p.  174), and  we have, at present, only to consider those cases in which it occurs
after the operation  for aneurism.
  If the aneurismal sac have attained a large size with great rapidity, it may, by
                            its pressure on  the  anastomosing vessels, or on the
                            veins in  its  vicinity (fig. 178), produce  such an
                            amount  of disturbance in the  circulation of  the
                            limb, preventing the influx of arterial, or obstruct-
                            ing the efflux of venous blood, as to occasion a great
                            liability  to the occurrence of  gangrene.   But per-
                            haps the  principal source  of  danger consists in the
                            aneurism becoming  suddenly and widely diffused,
                            more particularly in  those cases in which the ana-
                            tomical relation of the anastomosing vessels is such,
                            as in the ham, that they may readily and uniformly
                            become compressed by  the effused  blood.  In these
                            cases, the additional  embarrassment  induced in the
                            circulation of the limb by the ligature of its main
                            artery will readily induce  gangrene, and hence it is
                            that in diffused aneurism of the  lower extremity,
                            the ligature  of the  artery is so commonly followed
                            by mortification.
                              The loss of blood, either in consequence of second-
                            ary hemorrhage, or in any other way, before or after
                            the application of the ligature, is very apt to be fol-
                            lowed by gangrene; the more so if the  state of
                            things has rendered  it necessary to apply a ligature
                            to a higher point on the  trunk of the vessel than
                            had previously been  done.  This secondary ligature
                            of a  large artery, in cases of aneurism, has, I be-
lieve, been  invariably followed by gangrene of the limb when done in  the lower
extremity, the interference with the collateral circulation by the second ligature
being so great, that the vitality of the part cannot be maintained.
Fig. 178.
  Inguinal aneurism compress-
ing the veins, and thus causing
gangrene of the limb j a, artery;
b, vein, compressed at dj c, aneu-
rism. 
               TREATMENT  OP  ANEURISM BY  COMPRESSION.    507

          Besides these causes, the occurrence of erysipelas, exposure of the_ limb to
        cold, or to an undue degree of heat, or subjecting it  to  the  compression of a
        bandage, may be attended by consequences fatal to its vitality.
          The period of the supervention of gangrene of the limb, is usually from the
        third to the tenth day; it seldom occurs before this period, unless incipient mor-
        tification have already set in before the artery is tied.  Gangrene usually follows
        the  ligature of the external  iliac at an earlier period than  that of any other
        artery.   In cases of aneurism, the gangrene is always of the dark and moist
        variety, owing  to its being commonly dependent  on pressure upon  the large
        venous trunks by the aneurismal tumor.
           The general preventive treatment of gangrene dependent on the ligature of
        the artery for aneurism, must be conducted on  the same principles as when it
        arises after the  ligature of arteries generally.  But some special modifications of
        it are required  so far as the aneurism is concerned.  When the gangrene occurs
        from the pressure of the sac  upon the  accompanying vein,  it has been proposed
        to lay the tumor open, and to turn out its contents, thus removing the compres-
        sion exercised by it.  The danger of such a proceeding consists in the proba-
        bility of the occurrence of hemorrhage from the opening  made into the sac, and
        from the risk  attending suppuration set up in this; but yet, it would  appear
        that  in two cases in which  this practice has been adopted, no bad results fol-
        lowed.  Thus,  Lawrence has  related a  case of diffused aneurism of the popliteal
        artery in which this  plan was  had recourse to with  the  best results, and Mr.
        Benza (" Medical and Physical Journal," vol. lv.) has recorded a case  of popli-
        teal aneurism in which the same practice was adopted, in consequence of great
        oedema and incipient gangrene of the foot; when after the  extraction of a quan-
f       tity of flesh-like fibrine from the sac, the patient made  an excellent recovery.
        These cases would certainly justify the surgeon in adopting such a course when
        the  danger of gangrene is imminent, and dependent on the size and pressure of
        the  tumor.  Should, however, the gangrene show any disposition to extend, or
        should there be hemorrhage from the sac after it has thus been laid open, the
        surgeon  must hold himself in readiness to amputate without delay.  When gan-
        grene has once fairly set in,  there is no reasonable prospect of saving the limb,
        and the sooner amputation  is  done the  better.   The  limb  must always be
        removed high up above the sac, and, if possible, not only at some distance from
        the  parts that have mortified, but above the limb  to  which the serous infiltra-
        tion  that precedes this  condition has extended.   The  upper extremity must
        generally be removed at the  shoulder-joint, the lower, above the middle of the
        thigh.   In these cases there will generally be a considerable amount of hemor-
        rhage, and  many vessels to tie in the stump, in consequence of the enlargement
        of the collateral circulation.

              THE TREATMENT  OF  ANEURISM  BY  COMPRESSION.

           In consequence of the dangers and  difficulties attendant upon the use of  the
         ligature, surgeons have  for many years  past endeavored  to  treat  aneurism by
         compression.   The employment of direct pressure on the  aneurism was almost
         naturally suggested as a means to counteract the extension of the disease by the
         pressure of the blood from  within, and has consequently been applied  from  a
         very early period in the treatment of the affection.  This plan of treatment was
         first employed  by Bourdelot  at the close of the seventeenth century; afterwards
         by Genga,  Heister, Guattani, and others.  These  surgeons made the pressure
         directly  upon the sac; and Guattani and Flajani  relate several cures that they
         effected  in  this way;  but the method was so uncertain in its results, and so dan-
         gerous from irritating and  inflaming  the sac, that  it  fell  into disuse.  The
         French surgeons introduced  a modification of the pressure plan by laying open
         the  sac, clearing out its  contents, and applying  the  pressure directly over  the 
508     TREATMENT OF  ANEURISM BY  COMPRESSION.
ends of the vessel.   Deschamps exposed the artery leading to the sac, and com-
pressed this with an instrument he termed the " presse artere."  These barbar-
ous modes of treatment,  however, were entirely set aside by the facility and
comparative success of the  Hunterian operation, and compression in aneurism
was rarely practised by surgeons  after the  great  step made by John Hunter in
the treatment of this disease.  Yet we find that  John Hunter himself, Blizard,
and  Freen attempted, though with  but little success, to cure this  disease by
pressure on the artery leading to the sac.  Pelletan and Dubois appear to have
been the first  who employed the pressure upon the artery above the sac, instead
of upon the  aneurism itself; this  was in  1810.  Since this  period various
attempts were made methodically to treat aneurisms in this way; but the merit
of having introduced the practice of compression in the  treatment of aneurism
into modern surgery, of having given it a definite place in  our art, and of having
established the true principles on which  it  acts, incontestably  belongs  to the
Dublin surgeons;  amongst whom the names of Hutton, Bellingham, Tufnell,
and Carte deserve  especial mention.  In the early trials of the cure of aneurism
by compressing the artery on the cardiac side of the tumor, the surgeons who
employed this method acted on an erroneous theory, and the principle not being
understood, the practice was bad.  It was  supposed that it was necessary for the
cure to take place that  the whole flow of blood through the artery should be
entirely arrested, that inflammation of the  vessel  at the point compressed  should
be set up, and that the consolidation of the aneurism depended upon the obstruc-
tion of the vessel  consequent upon this inflammation.  This led to compression
being exercised so forcibly, with the view of exciting inflammation in the  artery,
                   that the patient  could seldom bear it for a sufficient  length
       Fig. 179.     of time  to effect a  cure, sloughing of the skin commonly
                   resulting as a necessary consequence  of the severe pressure
                    to which it was subjected. To the Dublin surgeons belongs
                   the very great merit not only of having pointed out the error
                    of this doctrine, but  of having distinctly laid down as the
                    principle of the practice, that the aneurism was cured, when
                    the  artery leading to it  was  compressed, in  precisely the
                    same way  as when a spontaneous cure takes place, or when
                    the Hunterian operation is performed — viz., by the  deposit
                    of stratified  fibrine in the sac, and  by the consequent con-
                    solidation of this (fig.  179),  aided by the contraction of the
                    walls of the sac; and that, as in the case of the ligature of
                    the vessel, it was not  necessary for the whole of  the circula-
                    tion  through the  artery  to  be  entirely and permanently
                    arrested, but merely for  it to be lessened in quantity and
                    force to such an extent as to be compatible with the forma-
                    tion of laminated fibrine in the sac; and it was clearly shown
 by examination after death  that if the pressure were properly conducted, the
 artery was in no way injured  or occluded at the part compressed.   This recog-
 nition of the true principles on which compression of the artery leading to the
 sac cures the aneurism, has led to important results; for, as the severe pressure
 that was formerly considered  necessary is now known not only to be useless, but
 to be absolutely injurious, no amount of  compression is exercised beyond what
 is requisite to restrain and moderate the flow of blood into the sac; no attempt
 being ever made to compress the artery so severely as to lead to its obliteration
 by inflammation.
    Though I have stated generally that aneurisms, when  treated by compression,
 are cured by the deposit of laminated fibrine, I think this remark ought  to be
 confined  to  the  common sacculated  form  of  the  disease.  In  the  tubular
 variety, which is certainly of far less frequent occurrence in the  extremities,
 the cure of the  aneurism  takes place by contraction  of the  sac, and by  its
 
        TREATMENT  OP ANEURISM  BY COMPRESSION.     509

becoming filled  by fibrine  in  a somewhat irregular manner.  Illustrative  of
this mode of cure, there  is  a  preparation in the Museum of
University College (fig. 180).
   The  success  of the  treatment  by  compression depends
greatly upon a scrupulous attention  to a number of  minor cir-
cumstances, which, though  trivial in themselves, become  of
importance when taken as a whole.   During the whole of the
treatment, also, the patient's general health should be attended
to in  accordance with those dietetic and medical  principles
that have already been laid down in speaking of the consti-
tutional treatment of the disease, having for their object, the
increase of the  fibrination  of the  blood.  The irritability of
the heart and arteries must also be subdued,  and  the irrita-
tion of the system lessened, by the use of opiates,  and the
patient should be put into a  comfortable bed, with firm and
well-secured pillows and  mattresses, so that  his  position  be not changed.   As
it is principally  in aneurism of the lower extremity that this plan  of treatment
can  be employed, we shall proceed to  describe the method of its application
here; and, in doing so, I would remark, that much of the success of the treat-
 ment depends on a scrupulous attention  to minute details.
   The limb having  been  bandaged smoothly, with a soft or air pad  upon  the
 tumor, so as to  approximate its sides, and laid comfortably on pillows, the thigh
 should be shaved, and dusted with hair-powder.  The apparatus must next be
 applied, and much of the success  of the treatment will depend upon the kind
 of instrument used.   The  ordinary horse-shoe, or Signorini's tourniquet, was
 the one first employed,  and this will, in many cases,  answer the  purpose per-
 fectly well; but as it is somewhat difficult to regulate  the pressure with this
 instrument, and as it is not unfrequently exercised  too powerfully, it  has gene-
 rally given place, at  the present day, to the very ingenious apparatus  of  Dr.
 Carte,  which, as it substitutes an  elastic force derived  from vulcanized India-
 rubber bands for the unyielding  pressure of the  screw,  accommodates  itself
 better to the limb, and is  less likely to produce injurious compression.  This
 instrument, as well as the other contrivances which have at various times been
 invented for the treatment of aneurism by  compression, are described by Drs.
 Bellingham and Tufnell, in their works on this subject, to which I must refer
 for a fuller account than I can here give. In some  cases the circulation through
 the artery may  conveniently be controlled by the pressure of a weight laid over
 it in  the groin as it passes over the  pubes; usually  from a four to a seven
 pound weight is sufficient for this  purpose.  In this  way, when only one com-
 pressor is applied on the  limb,  the flow of blood may be checkefl during the
 time that the screw is loosened.  Care  must of course be taken that the weight
 do not slip off.   It is best made  of lead, cast in a conical  shape, and may be
 retained  in situ by having a wide leather socket made  to fit it, shaped somewhat
 like the hopper of a  mill;  its broad end should  be upwards, and the  narrow
 end press on the vessel.
   In  applying  the compressor, especial care must  be taken that  it  is well
 padded in every part, so as not to  gall  the  skin.   In some of the early cases
 in which I saw compression employed  in London  by means of the horse-shoe
 tourniquet, much inconvenience resulted from want of attention to this  par-
 ticular.  The tendency to  fretting of the skin is  much lessened  by  powdering
 the limb, and the removal  of the  cuticular  hairs by shaving diminishes mate-
 rially the irritation  produced by  the instrument.   In order to keep up con-
 tinuous pressure, and at the  same  time to  prevent any one part of the skin
 being injuriously galled, it is of very great  consequence that two instruments
 should be used  at  the same time,  so that when one  is screwed  up the other
 should be loose; these instruments need not be placed closely together.   If the
 
510    TREATMENT  OF  ANEURISM BY  COMPRESSION.

aneurism be in the ham, it will be sufficient for  one (fig. 181) to be applied to
the groin, whilst the  other (fig. 182) is put upon the middle of the thigh.  In

                Fig. 181.                               Fig. 182.
Compressor for the groin.                  Compressor for the middle of the thigh.
using the instrument, the great point, as Dr. Tufnell  most properly remarks, is
to control the circulation with the minimum of pressure; in order to  do this
the first instrument should  be screwed  up so that all  pulsation ceases in the
tumor, but still not so tightly as to arrest all the flow of blood through it.  As
the pressure  exercised by this becomes  painful, it must be slightly loosened,
and the second one screwed up.   In this way an alternation of pressure can be
kept up without much pain or inconvenience.   If possible the patient should
be taught how to manage the instrument himself, and will  often find an  occu-
pation and amusement in  doing so.   If however it excite much  pain or irrita-
tion, as it does  in some  subjects,  it may be necessary to  give  opiates.   The
pressure should, if possible, be  continued during sleep, but if it prevent the
patient taking his  natural rest, the suggestion made by Dr. Tufnell, of unscrew-
ing the instrument slightly, and, when the  patient is asleep, gently tightening
it again without awakening him,  may advantageously be adopted;  it is indeed
surprising how very little unscrewing will relieve  the pain  of the compression.
A large cradle should then be placed over the patient's body, so that the weight
of the bed-clothes may be taken off the apparatus, and that the patient may
manage it without risk of disturbance.   Should there still be much uneasiness,
the instrument might be taken off for a  few hours, and compression kept up in
an intermittent manner.   Even under such circumstances as these consolidation
of the sac may ensue.
  The effects upon the  tumor  vary considerably.  In some cases it rapidly
and suddenly solidifies; more commonly, however, this is  a gradual  process,
the aneurism becoming more painful  and solid, with less pulsation and  bruit.
As the solidification takes place, there is usually a good deal of restlessness, a
feeling of general uneasiness, and of constitutional disturbance, which is best
quieted by opiates.   As  the pressure is  continued, and the  tumor begins to
harden, the anastomosing vessels  enlarge, with a good deal  of burning  pain  in
the limb generally, and arterial  pulsations in situations where usually none are 
        TREATMENT OF  ANEURISM  BY  COMPRESSION.    511

felt.  The abnormal pulsation, in these cases, is always found to occur in much
the same situations, the same vessels appearing to undergo dilatation.  Thus
Tufnell has made a remark, which I have had more  than one  opportunity of
verifying,  that in  the  treatment  of popliteal aneurism by compression, three
arteries will be found to be enlarged, one of which passes over the centre of the
tumor, another over the head  of the fibula, and the third along the inner edge
of  the patella; he also states that  the severe burning pain which is felt in these
cases, is  owing to the artery accompanying the  communicans peronei nerve
being enlarged.  After complete  solidification  of the tumor has  taken place,
the compression ought to be continued  for at least forty-eight hours, so as to
secure against the occurrence  of a relapse.
   The duration of the treatment varies very greatly. In some cases the tumor has
become solidified in a few hours or days.   In other instances again the treat-
ment must be protracted for more  than  three  months before  a  cure  results.
Of 26 cases of femoral or popliteal aneurism cured by compression in the Lon-
don hospitals,  the average  time,  according  to  Mr. Hutchinson, was nineteen
days.  Much of course will depend, in this respect, on the  constitution of the
patient, and on the condition of the  tumor; those circumstances which are most
favorable to the spontaneous cure of the aneurism will also influence the rapidity
of  the cure by compression.
   Of the great value of compression in the treatment of aneurism there can be
no  doubt; but yet it cannot be looked upon as taking the  place  of the ligature
in the cure of this disease, except in those cases in which the tumor is situated
in  the  arteries of the  lower  extremity,  below  the middle of the thigh.   In
aneurisms occurring in the vicinity of the trunk, as in the iliac, the  carotid,
subclavian, and axillary arteries, it  is  quite  inapplicable.   Spontaneous aneu-
rism  being extremely rare in the upper extremity, and as  the traumatic forms
of  the disease which occur here, generally require that the sac should be laid
open, it is seldom found necessary to have recourse to it  in this part of the
body, though it may be and has  been  successfully  applied  to  the brachial
artery.
  The great question with regard to compression  appears to me, after all, to be
whether it possesses any special advantages over the ligature, in the treatment
of  femoral and popliteal aneurisms, to which  its employment is necessarily
chiefly confined.   The principal objections that  have been  urged  against com-
pression are that its employment is more  painful  and  tedious than the use of
the ligature, and that those cases that are  unpromising to the  ligature or that
require amputation rather than it,  are equally unfavorable  to compression  and
cannot be saved by the  employment of this means.
  To these objections  I think it  may with justice be  answered, that the  pain
attendant on the  employment of compression  depends very greatly upon  the
skill  and care with which  the apparatus  is applied and managed throughout,
and that much depends upon the kind of instrument that is used, being certainly
much diminished when Carte's  elastic instrument is employed.  With  regard
to the relative tediousness of the treatment under the two plans, it would appear
that in reality there is  but little difference; for although some  cases  in which
compression is used, are prolonged over a considerable space of time, yet they
do not occupy more than  is often consumed when accidents of various kinds
follow the use of the ligature; and it not unfrequently  happens  in compression
what  can never occur after the employment of the ligature, that the patient is
cured of his disease in a few  hours or days.  Taking, however, the average of
the  Dublin cases, we shall find that the  treatment  lasted twenty-five days, and
in the recent  London  cases but nineteen, and  this is not very different from
what  happens with  the  ligature; for of 54 cases  recorded by Crisp, in which
the  femoral artery was tied, the average time for the separation  of the ligature
was eighteen days,  and if to this a week  more be added for the  closure  of the 
512    TREATMENT  OF ANEURISM  BY MANIPULATION.

wound, and for the treatment  of  the various accidents  so  often accompanying
and following the ligature, we should probably be within the mark, and yet only
bring the duration of the treatment of the two methods  to the same level.
  After all, surgeons will eventually be guided in their estimate of the value of
the two  plans of treatment, not so much by the question of submitting their
patients to  a slightly more painful or tedious treatment, as to the comparative
risk of life attendant upon one or other method.   Upon this point the statistics
have yet to be made;  partly because the cases of the treatment of aneurism by
compression have not as yet been  very numerous, and partly because the unsuc-
cessful cases of ligature  have not been so commonly published as the successful
ones.   If, however, we compare the 32 cases of femoral and popliteal aneurism
treated in  Dublin  up to  February, 1851, as given by  Dr. Bellingham (Med.
Chirurg. Transactions, vol. 34) with the results of the 188  cases of femoral  and
popliteal aneurism, recorded by Norris, in which the artery was ligatured, we
shall  find that of the 32 compression-cases 26 were cured; in 1, the ligature
was applied after pressure had failed;  in 2, amputation was performed; in 1,
death  occurred  from  erysipelas;  in 1, from chest disease; and  in 1 case  the
pressure was discontinued.  Thus it would  appear that 6 out of  the  32 failed,
being  in the proportion of 1 to 5-3  cases, and 2 died, being in the ratio of 1 to
16.  Of the 188  cases  in which the artery was ligatured, 142 were  cured, 46
died, 6 were amputated, in 10 the  sac suppurated, and in 2 gangrene of the foot
occurred.   Thus the deaths after ligature were in the proportion of 1  to 4,  and
the failures or serious accidents, of 1 to 3, showing clearly a very considerable
preponderance  in  favor  of the treatment by compression.  Besides  which, in
many patients who recovered after the ligature, various  accidents, such as gan-
grene, erysipelas, secondary hemorrhage, &c, resulted as the direct consequences
of the treatment, and  these do not happen when pressure is employed.
   If the  compression fails, the  ligature  may then  often be advantageously
applied; and as has been shown by the known cases, with a better success than
if compression had not previously been tried, that treatment having caused  the
collateral circulation to enlarge, and thus lessened  the tendency to gangrene.
   It should also not be forgotten that in some cases, such  as when aneurism is
complicated with  heart  disease,  or occurs in a very  broken and unhealthy
constitution, in which the operation necessary for the application of the ligature
would  scarcely, or not at all, be admissible, compression may be safely employed.
   After carefully considering the relative merits of the  two plans of treatment,
I think we  may conclude  that, though in some few cases neither method  can
be adopted, and amputation is the sole resource, yet, that in others compression
can be employed when  it would not be safe to have  recourse to the use of  the
ligature;  and that in all ordinary  cases of femoral and popliteal aneurism espe-
cially,  compression  should be preferred to the ligature, inasmuch as it is not a
more tedious, and an infinitely safer method  of cure.  At the same time it must
not be forgotten that its success  depends very greatly on the continuous care
bestowed upon the case during the progress  of the treatment.

            MANIPULATION, GAL V A NO-PUN CTURE, ETC.

  Mr.  Fergusson has  proposed to treat some aneurisms by a procedure which
he terms "manipulation."   This consists in squeezing the aneurismal tumor in
such a way as  to  detach a portion of the  coagulum within  it,  which, being
carried on with the current of  blood into the distal end  of the artery,  obstructs
this; and thus, by impeding the  circulation through the sac, may lead to  the
gradual consolidation of the tumor.  This procedure has as yet been  employed
to too limited an  extent to enable us to form an  estimate  of its value, and  can
scarcely be considered, nor is it intended  to be of very general application.  To
such aneurisms, however, that  are not amenable to ordinary surgical treatment, 
      TREATMENT  OP ANEURISM  BY  GALVANO-PUNCTURE.   513

as those  situated at the root of the neck, more particularly of the subclavian
artery, it might possibly be advantageously applied.  It is scarcely necessary,
however, to point out the obvious danger  of  rupture  of the sac, or of the
diffusion of the aneurism on the separation  of the coagulum, to make surgeons
adopt due caution in carrying out this method of treatment.
   The attempt to procure consolidation of an aneurismal sac by the employment
of electricity or galvanism is of comparatively recent date.  It appears to have
been first practised by Mr. B. Phillips, about the year 1832.   Little  attention,
however, was  given to this mode of treatment until a few years back, when it
was revived by some of the French and Italian surgeons, especially by Petrequin
and  Burci.  The principle on which  this  operation is conducted  consists  in
endeavoring to produce coagulation in  the  aneurismal sac, by decomposing the
blood contained in it, by means of the galvanic current.   In some instances, the
attempt  to  do this has induced, and, in all, it must occasion the  liability  to
inflammation of the sac and  of  the surrounding structures; as the change that
is sought to be effected in the contained blood, consists  not in the deposit of its
fibrine, but in the coagulation of it en masse.  It has of late been recommended
to conjoin  the employment of compression  of the artery, either above or below
the  sac, with the transmission  of  the  galvanic current through it, there being
in this way less liability for the coagulum  that is deposited to be broken down
and washed away, as  would happen if the current of blood were allowed  to pass
 through the sac whilst it is in the act of forming.
   The coagulation of the blood  is effected  by introducing two  acupuncture
 needles  into the sac  in opposite directions, and keeping them in  contact with
 one another,  after connecting them with a galvanic battery of moderate tension,
 when coagulum  becomes deposited around  one of the needles.   The  operation
 should be continued for periods varying from  ten  minutes to a quarter of  an
 hour, and  requires to be repeated several  times.  Petrequin recommends that
 the  direction of the current be changed from time to time, so that a number of
 clots may be formed in the sac.   In this way a soft mass of coagulum may occa-
 sionally be formed in  the tumor, so as to fill it up more or less completely, and
 to prevent the passage of blood through it.  Occasionally it  happens, however,
 that the blood has continued fluid, and the sac pervious, no coagulation  having
 been effected; and in other instances, again, the  amount of inflammation that
 has  been set up in the sac has been so great as to give  rise to its sloughing, to
 the  occurrence of secondary hemorrhage from it, and to the loss of the patient's
 limb or life.   This inflammation may, in some cases, doubtless,  have been the
 result of the  injury inflicted upon the sac  by the introduction of the needles,
 and by the charring of the tissues by them; but, in other cases, I think it pro-
 bable that it  may have taken place from the rapid coagulation of the contained
 blood, an occurrence  that we have already seen tends especially to inflammation,
 suppuration, and sloughing of the aneurismal sac.   The pain of the operation is
 always very considerable, so  much  so, that patients  who have been subjected to
 it once have refused  to submit to a repetition of it.
   Up to July, 1851, M. Bonnet had collected 23 cases of aneurism treated in
 this way;  of these, 8 were of the  brachial artery, 7 of the  popliteal, 2 of the
 subclavian, and 1 of  each  of the following: the ophthalmic, the temporal, the
 carotid,  the thoracic aorta, the ulnar, and one unknown.   Of these the pro-
 ceedings failed in 13 instances; 9 cases  were reported as successful, but  in 7 of
 these, M. Bonnet states that doubts must  be entertained both as to  the results
 and as to the treatment, for the cure  took place not by galvano-puncture alone,
 but in some by the conjoined influence of  compression and  the application  of
 ice;  and in  others, as the result of inflammation and  suppuration  of the sac.
 There are  consequently only two cases in which the cure can clearly be attri-
 butable to this means alone, and without the occurrence of any serious accident.
   When we compare the galvano-puncture  with ligature or compression, in the
         33 
514       ANEURISMS  OF  THE  LOWER  EXTREMITY.

treatment of external 'aneurism, it is I think impossible to hesitate for a moment
in giving a decided preference to the latter modes of treatment.  Not only is
the principle on which it is attempted to procure  obliteration of the sac in gal-
vano-puncture a vicious and peculiarly dangerous  one, viz., by  the coagulation
of the blood, and the inflammation of the wall of  the sac; but  the results that
have  hitherto been obtained  by this method, are  not such  as  would justify a
prudent surgeon in submitting his patient to experiments of this kind, when he
possesses so certain and comparatively safe a mode of cure as that by deligation
or compression.  In internal aneurisms, or in those cases in which  the disease
is so situated at the root of the neck, that  the artery can neither be ligatured
with  safety nor compressed,  galvano-puncture may perhaps  be  employed with
some advantage, in conjunction with proper medical treatment.
   The injection of aneurismal sacs with a solution of the perchloride of iron has
also of late been practised, with the view of coagulating their contents, but such
treatment  is not  only coarse and  unscientific, but dangerous; and, when com-
pared with the ligature or compression of the artery leading to the sac, must be
looked upon as a retrograde step in surgery.
SPECIAL  ANEURISMS.
                      CHAPTER  XXXVII.

             ANEURISMS  OF  THE LOWER  EXTREMITY.

                  ARTERIO-VENOUS  ANEURISMS.

  Preternatural communications between arteries and veins, though usually
the result of wounds, occasionally happen from disease, ulceration taking place
between  the vessels, and thus  causing an  aperture to lead from one into the
other.  When such communications are  of a traumatic character, they may, as
has already been stated, either constitute an aneurismal varix or a varicose aneu-
rism.   As the result of disease, aneurismal varix only can occur,  varicose aneu-
rism never happening except as a consequence of wound.   These spontaneous
communications have been met with  between the aorta and the vena cava, and
between  the iliac, femoral, carotid, and subclavian arteries, and their accompa-
nying  veins.   In nature, symptoms, course,  and treatment, they so  closely
resemble traumatic aneurismal varix, described at page 168, that their conside-
ration need  not detain us here.

                       INGUINAL  ANEURISMS.

  An iliac or inguinal  aneurism  may arise  from the external  iliac or from the
common  femoral artery; most frequently it springs from the latter, and taking
a direction upwards pushes the peritoneum before it, and thus encroaches some-
what  upon  the cavity of the abdomen.  When first noticed it is a small, soft,
compressible tumor, with pulsation and  bruit, and generally attended by little
pain or uneasiness.  It  rapidly enlarges,  however, and may attain a considerable
magnitude,  being often somewhat lobulated  upon the  surface, owing to the
unequal  constriction exercised  upon it by the fasciae under which it lies.  At 
            TREATMENT OF  INGUINAL  ANEURISMS.         515

the same time it usually becomes more solid, and the pulsation in it diminishes
considerably, or even ceases entirely.   As it increases in size it  compresses the
saphena and femoral veins, thus  giving rise  to oedema of the limb;  and by
stretching the genito-crural and  some of the branches  of the  anterior crural
nerve, occasions considerable pain  in the  thigh and leg.
   These  aneurisms  are commonly of the  circumscribed false variety, though
sometimes tubular; they never become diffused,  for the reason long ago pointed
out by Scarpa, that  the femoral artery, above the edge of  the sartorius muscle,
is invested by so dense a sheath and is so closely bound  down by the neighbor-
ing fascia, that when dilated into an aneurism it does not readily give way.
   The  diagnosis of inguinal  aneurism is not always so easy as might at first
appear.   It has most frequently been confounded with abscess in the groin,
carcinomatous tumors in this  situation,  and with osteo-aneurisma.   The diag-
nosis from abscess must be made  on  general principles, but  in  some instances
appears to be replete with difficulty, as  there are not a few cases  recorded, in
which aneurisms in this situation have been  mistaken and punctured for abscess,
an error that has in  every instance proved fatal.  The diagnosis of an inguinal
aneurism, solidified  by the  deposition of laminated  fibrine, and pulsating  but
indistinctly, from a pulsating encephaloid or osseous tumor in the groin, is sur-
rounded by the greatest difficulty, and cannot, I believe, with the means we at
present possess, be accomplished with absolute certainty.  The fact of  the two
diseases having in two instances been confounded during the last few years, by
two of  the most distinguished surgeons of the day, Mr. Stanley  and Mr. Syme,
is sufficient evidence of the difficulty attending their diagnosis.
    Treatment  of inguinal aneurism. — It  occasionally  happens that inguinal
aneurisms, even of a very large size, undergo spontaneous  cure, or become con-
solidated  by direct pressure conjoined with constitutional treatment; but these
instances  are of such rare occurrence that such a result cannot be  relied on in
any one case.   In the majority of instances the  tumor, though it may have en-
croached on the abdomen, will not have reached too  high for the external iliac
to be ligatured; should it have done  so,  however, the surgeon may have to tie
the common iliac artery, but in some instances even this may not  be  practicable,
when his choice must lie between the slender chance offered  by constitutional
treatment and pressure, and the fearful alternative of ligaturing the aorta.
   The ligature OP the external  iliac was  first  practised by Abernethy, in
1796.   Since  this period it has been had recourse to in at  least 100 instances
for inguinal aneurism (Norris); of these, 73 were cured, and 27 died.  In one
remarkable case, both external iliacs were ligatured successfully at  an interval
of eleven  months, by Mr. Tait.  In some few cases also,  there was  the  compli-
cation of  an  aneurism in the ham with that in the groin.  Of the  92 cases in
which the aneurism was solely seated  in the groin, 70 were cured, and 22 died.
Death resulted from  gangrene  of the limb in 8, from secondary hemorrhage in
4, from  sloughing of the sac in 3,  from tetanus in 3, and from causes of a more
general  character in 4 cases.
   Pulsation returned in the sac in 6 cases; in some not until several weeks had
elapsed after the operation; and in  1 instance only was this phenomenon followed
by death.   Suppuration of the sac was of frequent occurrence, happening in 13
instances,  doubtless owing to the large size that these tumors  are  often  allowed
to attain before being subjected to  surgical interference.  It is remarkable, how-
ever, that  in 3 cases only was this  accident fatal, and in 2  of these 3 instances
the sac had been opened before the operation, on the  supposition  of its being an
abscess.   Secondary  hemorrhage occurred but in 6  cases, 4 of which  proved
fatal; a very small proportion when compared with what happens in  other situa-
tions.  This must doubtless be attributed in a great  measure to the absence of
any collateral branches springing from the trunk of the external iliac, the dis-
tance between  the point ligatured, and the epigastric and circumflex  ilii arteries, 
516       ANEURISMS  OF  THE LOWER EXTREMITY.
Fig. 183.
affording abundant space for the safe obliteration of the vessel.  In 1 of the
fatal cases  pulsation had previously returned in the sac;  in  the other 3 the
patients died on the seventeenth, the twenty-seventh, and the forty-third days,
respectively.
  Gangrene of the limb is the most common cause of death after deligation of
this vessel, occurring in 9 instances, of which 8 proved fatal;  1 being cured by
amputation.  The period at which the mortification supervened varied from the
third to the fourth week.  The principal cause of this gangrene is  narrowing,
or obliteration of the neighboring venous trunk by pressure of the tumor.  In
                           the  accompanying wood-cut (fig. 183) this is well
                            illustrated; the vein opposite  the aneurism being
                            completely closed.
                              It is  a  very remarkable  circumstance  in the
                            history of  this operation that three deaths have
                            resulted  from tetanus, a most unusual  occurrence
                            after the ligature of arteries.
                              The ligature of the external iliac for aneurismal
                            varix in' the  groin  affords a striking contrast with
                            that for spontaneous aneurism; the 4 cases recorded
                            all proving fatal, 2 dying  of  gangrene, and  2  of
                            hemorrhage.   In these  cases, Mr. Guthrie  has  re-
                            commended that the tumor should be laid open, and
                            the artery ligatured above and below the aperture
                            in  it.  But with whatever  rapidity and dexterity
                            such a proceeding were  accomplished in the groin,
                            there will  be  great risk of such a loss of  blood
                            ensuing as to  endanger the  patient's  life,  there
                            being no possibility of commanding the artery above
                            the seat  of disease.
                              Aneurism occasionally takes place in the groin
                            and ham of the same side; here the ligature of the
                            external iliac will cure both diseases.   Of 4 cases
                            in which this  complication occurred, the operation
                            was successful in  3, one patient dying of gangrene,
                            and in him the popliteal aneurism was on the point
                            of bursting at the time  of the  operation.   In 2 of
                            the 3  cases that  recovered, pulsation returned in
                            the inguinal aneurism, but disappeared after a time.
                               Operation. — There are two modes of tying the
                            external iliac  artery; the  one originally practised
                            by Abernethy, somewhat modified  by Liston, and
                            the other  introduced by  Sir A. Cooper.   Aber-
 nethy's  method  modified, consists  in  commencing  an incision two  fingers'
 breadths above, and  somewhat  to the inner  side of the middle of Poupart's
 ligament, and carrying it upwards and outwards  to the extent of about four
 inches, so  that it terminates  at about three  fingers' breadths to the inner side of
 the anterior superior spine of the ilium. After dividing the skin and superficial
 fascia, the fibres of the external oblique tendon  are carefully cut through. The
 internal oblique and the transversalis muscles are then  cut through with great
 caution, when the transversalis  fascia is reached, which is recognized by its dull
 white appearance.  A small  portion of this membrane, at the  lower angle of the
 wound, where it is thinned and expanded  for the passage  of the  cord, is now
 carefully raised with the forceps and scratched  through with the point of the
 scalpel.  A director is then introduced, and passed underneath it, when it should
 be laid open upwards and outwards to the full extent of the wound; the whole
 of the inner side of  the wound is next  drawn towards the mesial line, the peri-
 
        LIGATURE  OF THE EXTERNAL ILIAC  ARTERY.    517

toneum being separated from its loose cellular connections in the iliac fossa by
the surgeon's fingers; it must be kept out of the way by an assistant, who holds
it up with a broad bent copper spatula.   The  artery may now be felt pulsating
at the bottom of the wound, covered by a dense fascia, and having the vein lying
to its inner side,  and somewhat  behind  it.   The investing sheath  must be
scratched through in two situations, and  the needle passed from the inner side
between  the vessels, the ligature being then tied in the usual way.
   In Sir A. Cooper's operation, an incision about three  inches in length is made
a  little above and nearly parallel to Poupart's  ligament, beginning above  the
inner  margin  of the abdominal ring, and ending near the  anterior superior
spine of the ilium.   By this  incision  the tendon of the external oblique is
exposed, and must be divided to the full extent of the  external wound, when
the spermatic cord will be seen passing under  the lower edge  of the internal
oblique and transversalis  muscles.   Some loose  cellular tissue and fascia  has
now to be scratched through, and the finger being passed under the cord, will
come in contact with  the external iliac artery,  close to the spot where the epi-
gastric is given  off  from  it; the upper  side of the incision must now be well
raised by a copper spatula, when the vessel will be exposed, covered by a dense
sheath, and having the vein to  its inner side, the sheath must  be cautiously
opened,  and the ligature passed in either direction.
   On comparing the two operations, it would appear that the principal disadvan-
tage  of  Abernethy's is, that it is apt to leave a tendency to  hernial protrusion,
in consequence  of the abdominal wall  being  much weakened  by the  free inci-
sions through the muscular planes that are necessary; the great advantage attend-
ing it is, that the external iliac may be ligatured at any  part of its course, and
 that, if  requisite, the  incision might be even extended upwards, and the com-
mon  trunk secured.  In Sir A. Cooper's operation,  the line  of incision  lies
directly across the course of the epigastric artery, which, as well as the circum-
flex ilii, if  it arise high, and the circumflex vein, which crosses the iliac artery
at this point, and is often somewhat funnel-shaped, may be in danger  of being
wounded.   The  spermatic cord is likewise somewhat in the way in this opera-
tion.   Dupuytren actually wounded the  epigastric artery in one case, and Hous-
ton had much difficulty from  the  circumflex vein in another instance.  This
operation has also the  disadvantage, that by it, it is impossible to prolong the
incision  upwards so as to deligate any portion of the  vessel except that which
lies immediately above the  crural  arch; but the peritoneum is less disturbed
than  in  the other ease, and there is less tendency to hernial protrusion after-
wards.   As a general rule,  I think we  may conclude, that, in cases of sponta-
neous aneurism,  in  which it might, from the size of the tumor or the diseased
state  of  the vessels, be found  necessary to apply the  ligature to a higher point
than was intended  before the operation commenced, it will  be safer to have
recourse to Abernethy's plan, modified as above described, as  in  this way we
shall  be  able to ligature the  vessel at any part of its course; whilst in cases of
hemorrhage after amputation, or in traumatic  femoral aneurism,  in which the
artery is not likely to be diseased, Cooper's operation should be had recourse to,
more particularly if the patient be thin,  and the abdomen flat.
   In connection  with the ligature of the external iliac  artery,  there  are some
practical points that deserve mention.  Before  the operation the  colon should
be emptied by means of an enema, and the pubes shaved.  The incision in the
abdominal wall must be sufficiently extensive, but should never be allowed to
implicate the external ring, lest it give rise to a tendency to hernial protrusion.
Care should be  taken not to wound the peritoneum, for although two patients,
in whom this was done by Post and Tait, both  recovered, yet it is of course a
dangerous  accident, and should if possible be avoided.   The peritoneum must
not be torn up more than is  absolutely necessary, lest hemorrhage or subsequent
peritonitis  occur,  and  especial care  must be taken that the fascia transversalis 
518        ANEURISMS  OF THE LOWER EXTREMITY.

be properly divided, otherwise the iliac fascia may be stripped up with the perito-
neum, and the artery in this way dragged out of its normal situation into the upper
and inner angle of the wound, occasioning great embarrassment to the operator,
who may not be able  to find  it.  Before attempting  to  pass a  ligature  round
the vessel,  the dense fascia covering it  must  be  scratched  through with the
point of a scalpel, and lastly the  sac must not be injured by having its peritoneal
covering stripped off.
   Ligature of the common iliac. — If the aneurism in the groin extend so
high  that there is  not sufficient  space for the exposure and ligature of the exter-
nal iliac artery, it  becomes  necessary to tie the common trunk.  This may be
done  by extending the  incision  that serves  for the  ligature of the external iliac
upwards and slightly inwards towards the umbilicus, to an extent corresponding
to the degree of obesity of the patient, so that it assumes a somewhat semilunar
form.  Or a  semilunar incision may be made from a point about two or three
inches above the umbilicus, and carried downwards and inwards to a correspond-
ing extent below it.  The incisions  are then successively carried through the
different planes of muscular fibre with great caution and on a grooved director,
until the  transversalis fascia is exposed;  they must be carefully opened and
freely divided, so  as to expose the peritoneum, which now comes bulging into
the wound, pressing forward with its contents.  This must be held aside, drawn
upwards by the fingers of  an assistant, and gently stripped from the iliac fossa
by the surgeon carefully insinuating  his  hand beneath it.  When he arrives at
the brim of the pelvis,  he will readily be conducted to the external iliac artery,
which guides him to the parent trunk.  The ligature must then be passed under
the artery, a slight scratch having been made through the fascia covering the
vessel.
   In planning the incision  for the ligature  of this  artery, care should be taken
that it be not carried too low down or too far forwards; nothing can be gained
by doing so, and there  is  besides  the  additional risk of the circumflex ilii or
epigastric  being  wounded, as  happened to  Mott, and  as  these are  principal
agents in  the  anastomosing circulation, their injury is a  serious  accident.
Should any muscular branches  bleed they had better be ligatured, so as not to
obscure the after-steps of  the  operation.   The fascia transversalis should be
opened at  the  lower  part of the wound, where it is thinned for the passage of
the cord, by pinching up a portion of it with the forceps, and dividing it care-
fully with the edge of the knife laid  horizontally.   It will be found to be much
thicker and denser at the upper and outer  part of the wound,  than in this
situation.   When the peritoneum  is  well drawn upwards to the mesial line by
the assistant's fingers or copper spatulae, the  ureter which crosses the artery in
this  situation  will be carried up with it, so as not to be seen  at all.  In this
 stage of the operation, the patient should be turned on his sound side, in order
 to prevent the intestines falling  over and  pressing  the peritoneum into  the
 wound.
   In determining the length of the  incision, and calculating the point at which
 he would expect to meet with and ligature the artery, it is a matter of the very
 first  importance for the surgeon to remember the different bearings of the parts
 in the neighborhood of the vessels,  and the relative frequency with which the
 origin and termination of the artery correspond with  certain fixed  points that
 may  readily be detected.
   The points of importance  are the relations of the vessels to the  lumbar ver-
 tebrae, to the crest of the ilium and  the umbilicus.  The ordinary place of divi-
 sion  of the abdominal aorta is on the body of the fourth lumbar vertebra, or on
 the intervertebral disk below it;  according to Mr. Quain, this was  the case in
 three-fourths of the bodies he examined, or in 156  out of 196.  In  regard to
 the relations between the situation of the  bifurcation of the aorta and the crest
 of the ilium, we find  it, according  to the same anatomist, to  have ranged in 
LIGATURE  OP THE AORTA.
519
 about  four-fifths of the cases about half an inch  above and below the level of
 the highest point of this part of the bone.   With reference to the umbilicus no
 definite rule can be laid down, but in general terms it may be stated that the
 bifurcation of the aorta is a little to its left.  As a general  rule that given  by
 Hargreave  is perhaps sufficiently good for  ordinary purposes.   If a point  be
 taken  about half or three-quarters of  an inch below, and a little  to the left of
 the umbilicus, and a line be drawn on each side from this point to the centre of
 Poupart's  ligament, we obtain about  the direction of the common and external
 iliac arteries.  On dividing these lines  into three equal parts, the upper third
 will correspond  to the primitive trunk, and the two lower thirds to the external
 iliac, and the junction of the upper with the middle third  to the bifurcation of
 the common iliac artery.
   The point of  division of the common iliac artery, is, in the majority of cases,
 between the middle of the fifth lumbar vertebra and the middle of the sacrum,
 both points inclusive; and if it is not in this situation  the division will probably
 be lower down.
   The length of the vessel varies greatly; according to  Quain, in five-sevenths
 of the cases, it  ranged between one and a half and three inches.
   When we look at the depth at which this  artery is situated, its great size and
 proximity  to the centre of  the circulation, and consider the force with which
 the blood  rushes  through it, we cannot but be struck with the  success which
 has attended its ligature.   Of 17 cases in which it has been tied, 9 were cured,
 and 8  died.   In 11  of the cases the ligature was applied for aneurism, and of
 these  7 recovered.   The 4 that died,  perished rather from  the magnitude and
 extent of the disease than from  the  effects of the operation, and it is remark-
 able, as showing the power of the anastomoses in maintaining the  vitality of
 parts,  that in no instance did  gangrene ensue.   In  two  of the fatal cases, the
 peritoneum was  opened during the operation, and this circumstance doubtless
 contributed to the fatal result.   In both these instances,  also, the  tumor had
 been opened before the artery was ligatured, in one by mistake for abscess, in
 the other by the suppuration and sloughing of the sac.
 _  Ligature of the aorta.—It is impossible  not to contemplate with admira-
 tion the man whose mind was the first to conceive, and whose hand was the first
 to carry out  the determination  to  apply a ligature to the abdominal  aorta, and
 who, guided by  pathological observation and  physiological experiment, dared to
 arrest  at once the circulation through  the main channel of supply to the lower
 half of the body, trusting to the collateral  circulation for the maintenance  of
 the vitality of the parts thus suddenly deprived of blood.   Sir A. Cooper was
 the first to  place a ligature on the aorta, in 1817.  Since that period  the opera-
 tion has been four times performed : viz., by James, of Exeter; by Murray, at
 the Cape of Good Hope;  by Monteiro, at Kio  Janeiro;  and by Mr. South/ of
 London.
   In Sir A. Cooper's case,  the  inguinal aneurism had burst, and the vessel was
 tied about three-quarters of an inch above its bifurcation, by making an incision
 three inches in length  through the abdomen, a little to the left of the umbilicus,
 the fingers  being  passed between the convolutions  of the intestines, and the
 peritoneum covering the artery scratched through.   The patient survived forty
 hours.   James ligatured the aorta much in the same way as Sir A. Cooper did,
 in  a case in which he had previously  employed the distal operation for an
 inguinal  aneurism, but without success, the  patient speedily dying.   Murray
 ligatured the vessel, by making an incision on the left side, in  front of the
 projecting  end of the  tenth rib, and  carrying  it downwards for six  inches,  to
the anterior superior spine of the ilium.  The parts were then carefully divided
to  the  peritoneum, which was separated from the iliac fossa and the psoas muscle
when, with great difficulty, and by scratching with the end of an elevator and
the finger nails, room was made for the passage of the ligature round the artery 
520        ANEURISMS  OF THE LOWER EXTREMITY.

which was tied three or four lines above  its bifurcation.  The patient died in
twenty-three hours.  The most interesting case on record is that by Dr. Monteiro,
who tied the aorta for a large false aneurism on the lower and right side of the
abdomen;  here the incision was made much as in Murray's case, and the artery
ligatured with great difficulty.   The patient lived till  the tenth day, when  he
died of secondary hemorrhage.  In Mr. South's case the artery was tied behind
the peritoneum by an incision on  the left side of the abdomen.   The  patient
died in  43 hours.
  In this operation, there are not  only all the dangers attendant upon the liga-
ture of  arteries of the first magnitude, but also the  risk of producing fatal peri-
tonitis,  whether  the abdomen  be cut through,  or the vessel sought  for  by
stripping up the  peritoneum from the iliac  fossa;  and it appears to me that a
patient  suffering from so large an inguinal aneurism as to justify the ligature of
the aorta, would  have a better chance of  recovery, or rather of prolongation of
life, by  the adoption of proper constitutional treatment, together with pressure
upon the tumor and the distal ligature or compression of the  artery.
  Ligature of the internal iliac.—Aneurism of the trunk of the internal
iliac artery is extremely rare, but its principal branches, such  as the gluteal and
sciatic arteries, are more frequently affected.  The pudic  artery is very  seldom
indeed the seat of this disease, and I am  only acquainted with one  instance in
which it has been met with in this  situation, which is exhibited in a prepa-
ration in the Museum of the  College of Surgeons.  The aneurisms of the  gluteal
and sciatic arteries are more  frequently traumatic, than  spontaneous.  In their
symptoms and diagnosis there is nothing peculiar, though these affections have
been  confounded with pulsating encephaloid tumors of the  gluteal region, as
in a case in which Mr. Guthrie ligatured the internal iliac artery for disease of
this kind.
  Since Stevens first tied the internal iliac in 1812, in a negress laboring under
gluteal  aneurism, this artery has been ligatured six  times;  of these cases 4
recovered, and 3  died.  The success that has hitherto attended this  operation
is certainly remarkable, when we take  into consideration the depth at which the
artery is situated and its great size;  and must, I think, be accounted for by the
fact, that although in these cases the  patient runs the ordinary risks attendant
on  the ligature of the larger pelvic arteries from the exposure and handling of
the peritoneum, yet, that he is saved the danger resulting from the supervention
of gangrene;  the anastomosis between its branches  and that of the neighboring
vessels being so free, and the course  traversed by the  blood  so short, that  no
difficulty can arise in the maintenance of the collateral circulation.
  The steps of the operation necessary for the exposure of the  internal iliac
artery are precisely analogous to those requisite for the ligature of the common
trunk.  When the vessel is reached, it must be  remembered that both the ex-
ternal and internal iliac veins are in  close relation  to it;  the  one  being to  its
outer side, the other behind it.  As these vessels are large, and their coats thin,
it is necessary that they should be separated by the finger-nail, or the blunt end
of an aneurism  needle, before the ligature  is  passed round  the  artery; care
must also be taken not to put the vessel too much on the stretch in applying the
ligature, lest the  ilio-lumbar  artery be ruptured.   As the length  of the artery
varies much, usually ranging between one  and two inches, and as when it is
short it has a tendency to be placed deeply in the pelvis, it would, I think, be
more prudent, and  occasion  less chance  of secondary hemorrhage, for the sur-
geon, under such circumstances, to ligature the common trunk

            FEMORAL AND POPLITEAL  ANEURISMS.

  We have, in the preceding section, considered  aneurisms affecting the groin,
which are by no means of very unfrequent occurrence.  Aneurisms of the thigh 
FEMORAL  AND POPLITEAL  ANEURISMS.         521
are, however, much less frequently met with, but those in  the ham are very
commonly encountered.  Thus, out of 551 cases  of aneurism  recorded  in  the
British medical journals of the present  century, Dr. Crisp has found that 137
affected the popliteal, and only 66 the femoral artery.  Of these 66, 45 wero
situated either in the groin or upper part  of the  thigh, and 21 only were truly
femoral, or femoro-popliteal.  The reason of this difference in the frequency of
the occurrence of aneurism in different parts of the vessel, may be accounted for
by attention to its anatomical relations.  In  looking at the  main artery of  the
lower extremity, in  its course from Poupart's ligament to where it terminates in
the anterior and posterior tibials, we see that it may be  divided in relation to the
muscular masses that surround it  into three principal portions.  1st.  That which
is situated between  Poupart's ligament and the anterior margin of the sartorius,
which may be considered inguinal.  2nd. That which intervenes between this
point and the aperture in the adductor tendon, which may be considered femoral.
And, 3rd, that division of the vessel which  corresponds to the ham, and which
may be considered popliteal.   Of these three  divisions, the  first and last  are
comparatively superficial,  and  being unsupported  by muscle, readily expand,
while the  central portion of the  artery is closely  surrounded on all sides by
muscular masses, and is less likely to be dilated into an aneurismal tumor.  We
also  find that the inguinal portion of the vessel is closely and firmly invested by
a dense and resistant fibro-cellular sheath, and is well supported by the fascia
lata; whilst in  the  popliteal space the artery is merely surrounded  by the ordi-
nary cellular sheath, and  receives no aponeurotic support.   This difference in
the connections of these two parts of the vessel may, to a certain extent, explain
the  greater frequency of aneurism in  the ham than in the  upper part of  the
thigh.
   Aneurism of the profunda femoris artery  is of extremely rare  occurrence;
indeed,  I am not acquainted with  any recorded case.  The only instance with
which I am acquainted, is that represented  in fig.
184, taken from a patient who died of pneumonia,
under Dr. Garrod's care, very shortly after admission
into  the Hospital.   On examination after death  a
large tumor of the thigh, which had not been  very
closely examined during life, proved to be a circum-
scribed aneurism of the profunda artery.
   Femoral and popliteal aneurisms commonly occur
about the middle period of life, and are almost in-
variably met with  in males, being at least twenty
times more frequent in them than  in women.  Both
sides are affected with equal frequency, and occa-
sionally at the  same  time.  According to  Crisp,
sailors would appear to be more liable to this variety
of the disease than any other class.   These aneu-
risms are most  frequently sacculated;  in  the  ham
they are always so,  but in  the thigh they are some-
times tubular.
   The  symptoms   of femoral aneurism  present
nothing peculiar, the tumor usually enlarging with
considerable  rapidity,  with  all the  characteristic
signs of the disease, and assuming a pretty regular
ovoid shape.   Popliteal aneurism  usually commences with stiffness  and a good
deal  of pain about the ham and knee, which I have more  than once  seen mis-
taken for rheumatism; there is also a difficulty in straightening the limb, which
is generally kept semi-flexed.  The tumor increases usually with great rapidity
Fig. 184.«
1  1, Common femoral; 2, superficial femoral;  3, profunda; 4, aneurism. 
522       ANEURISMS  OF  THE LOWER EXTREMITY.

and  has a great tendency to become  diffused;  these  conditions will, however
materially depend on the side of  the artery from which  it springs; when from
the anterior aspect, next the bone, it increases slowly, being compressed by the
firm structures before it.  In this case, however, there is the great danger that
by its pressure upon the bones and knee, it may give rise to caries and destruc-
tion of the joint.  When it springs from the posterior part of the artery, where
it  is uncompressed, it increases  rapidly, and may speedily diffuse itself.  The
diffusion of an aneurism in this situation may take place in two directions.  If
it be femoro-popliteal,  it may give way into the general cellular tissue of the
thigh, the blood diffusing itself as high perhaps as Scarpa's triangle.  When it
is confined to the ham, it may either give  way under the integuments, and into
the superficial structures of the limb, or else under the deep fascia  of the le°-
where it will compress the posterior tibial  nerve and artery.  In all  cases  the
diffusion of popliteal aneurism is likely to  be followed by gangrene of the limb.
  The diagnosis of popliteal aneurism has to be made  from  chronic abscess,
from bursal  enlargements, and from solid tumors.   From  chronic abscess, no
serious  difficulty can Well be  experienced; but it  may happen that when an
aneurism has suppurated, considerable  difficulty arises in determining its true
nature; whether it is  merely an  abscess or not.  On  such  cases as these  the
state of the circulation in the lower  part of the limb will throw much lio-ht.
Bursal tumors, often of large  size and multilocular, are not unfrequently met
with in the ham, but I have never found any  great  difficulty in  determinino-
their true  nature, their elasticity and  roundness, together with their mobility
and want of pulsation, being  sufficiently indicative  of  their  character.  The
most serious  diagnostic difficulty may arise  from  confounding solidified aneurisms
of the ham with solid tumors, either  of a sarcomatous  character, or  springing
from the tibia and femur: and I  have  known one case of aneurism  in this con-
dition, in which amputation was  performed on  the  supposition  of its being a
solid tumor (fig. 163).
  The treatment of femoral and popliteal aneurism  may be conducted either
by ligature or compression of the vessel leading to the sac.  As a general rule,
for the reasons already stated, compression should be employed in preference to
the ligature; but yet the  cases may  arise when,  from the failure of compression,
or for other reasons, it may be  necessary to ligature the femoral artery.
  In looking at the femoral  artery,  it  might at  first be supposed that the com-
mon trunk, situated superficially between the inferior edge of Poupart's ligament
and  the origin of the profunda, would be  the most convenient situation for the
application of the  ligature;  but  experience has shown that deligation of the
vessel here is in the highest  degree unsuccessful.  This arises from the short-
ness of the trunk, rendering it necessary to tie  the artery between and in close
proximity to those collateral branches that will constitute the most direct and
immediate  agents in the anastomosing supply,  viz., the  circumflex ilii and the
profunda, so  that  the  internal coagulum would not readily form.   In addition
to this, however, a number  of small inguinal branches, such as the superficial
epigastric and circumflex ilii, the superficial and deep external pudic, and very
commonly  one of  the  circumflex arteries  of the thigh, more  especially  the
internal, arises from the  common trunk in its short course, and these vessels,
though small in size, constitute a source of great embarrassment to the surgeon
during the  operation, for if wounded near their origin they bleed most  furiously,
and  are  a  cause of considerable danger  afterwards, by interfering  with  the
proper plugging of the vessel.   Of  12 recorded cases, in which this artery has
been tied, it would. appear that  3 only succeeded, whilst in the remaining 9
instances secondary hemorrhage  occurred, which proved fatal  in  3,  and  in 6
was  arrested by the ligature of  the external iliac.   This operation, I think,
therefore, ought to be banished from surgery, and in all those cases of aneurism
that are  situated above the middle  of the thigh, and in which sufficient space 
LIGATURE  OF THE SUPERFICIAL  FEMORAL.      523
does not intervene between the giving off of the profunda  and the upper part
of the sac for the application of a ligature to the superficial femoral, the external
iliac should be tied unless compression can be employed.
   Ligature of the superficial femoral. — The superficial femoral artery,
in its course from the origin  of the  profunda to the aperture in the tendon  of
the adductor, is divided by the crossing of the sartorius muscle into two portions
of unequal length, which have different relations to  neighboring structures.
The upper division of the artery, which lies above the anterior margin of tho
muscle, is of most interest to  the surgeon, as it is in this part of its course, that
it is invariably ligatured in cases of aneurism.   It is true that John Hunter, in
the  operation  that he introduced for popliteal aneurism, exposed and tied the
vessel  in  the  lower third of the thigh, but his example has not been followed
by modern  surgeons, on  account  of  the  far greater difficulty in reaching the
vessel here  than in the first part of its course.
   The  superficial  femoral,  where it  lies in  Scarpa's  triangle, being merely
covered by the common  integument, the superficial fascia,  and the fascia lata,
may be reached by as simple an operation as any that the surgeon has to perform
for the  ligature of the larger  vessels.  An incision from three and a half to four
inches in length,  should  be  made from a point, two  inches below  Poupart's
ligament,  and  as nearly as possible midway between the anterior  superior  spine
of the ilium, and  the  symphysis pubis,  and  carried downwards in a direction
parallel to the axis of the limb.  The skin and superficial  fascia, having been
divided, the fascia lata, which is here very thin, is exposed and opened to the
same extent as the incision in the integuments; the inner  margin of the sar-
torius now comes into view, and immediately to the inner side  of, and perhaps
slightly overlapped by this,  is the  sheath of  the  vessels;  this  must now  be
cautiously opened, the  long saphena  nerve being respected, and the  aneurism
needle unarmed passed between  the artery and vein, from within  outwards,
about four inches below Poupart's ligament; it should  then be threaded,  with-
drawn, and  the ligature tied.   The edges of the wound must now be brought
into contact with a couple of stitches and two strips  of plaster;  the limb being
semi-flexed, somewhat  raised, laid on its  outer side, and wrapped in soft flannel
or cotton  wadding.   The severe pain which is usually complained of  about the
knee after  the tightening of the ligature, may best be relieved by a full dose
of opium.
   In this operation there are  several points  of considerable importance that
require special attention.  The ligature  should  always be employed about four
inches below Poupart's ligament,  so that  sufficient space may intervene between
the  origin of the profunda,  which is usually from one or two inches below the
crural arch, and the point deligated, to admit of the formation of a proper
coagulum in the vessel.   It has, indeed, happened that the ligature  has  been
placed within  three quarters of an inch of the origin of the profunda, without
any injurious consequences  resulting.  The  proper point, however, for the
delegation of  the  artery  is that indicated, which  is usually the very spot at
which the sartorius crosses it; though, if this muscle be very broad, it may be
necessary to draw it to the outer side, and the vessel tied below  it.  In cutting
down upon  the artery, the saphena vein, or any parallel branch, should if pos°
Bible be avoided.  After the sheath has been opened, it will sometimes be found
that rather a large muscular  branch  is given off from  the artery at about the
part where it was intended to ligature it; if  so, this  must be carefully avoided,
as well as any small veins that cross  the main trunk in this situation.
   Ihe femoral vein which lies behind and  somewhat to the inner side of the
artery, is best  avoided by passing  the needle from within outwards between the
two vessels, the inner side of the sheath being at the  same time put upon the
stretch by drawing upon it with a pair  of forceps.   After  the needle has  been
brought up on the outer side  of the  artery, a small  portion  of  the sheath will 
524        ANEURISMS  OF THE  LOWER EXTREMITY.

sometimes  be found to be  pushed  up by  it; this  must be  divided  by being
carefully touched with the point of the scalpel, and the  needle  thus  carried
round the vessel.
   Wound  of the femoral vein  is without doubt the most serious accident that
can happen  in the operation for ligature of the superficial femoral artery, and
is one of which there  is especial risk when this operation is had recourse to for
aneurism, as in this disease the fine cellular tissue which naturally connects the
two vessels often  becomes thickened and indurated, in  consequence of inflam-
matory  action having extended upwards from the  sac  to the  sheath  of the
vessels.  It  is best avoided by passing the  needle  in  the way that  has  been
already recommended, unarmed, and without the employment of force.  This
accident is almost invariably fatal, there being but very few instances  on record
in which  patients have survived  it;  death  usually  resulting  from  diffuse
phlebitis, or the supervention of gangrene.   The true cause of the fatal result
in these cases was first pointed out by Mr. Hadwen, who showed that  when the
vein is  wounded  by the aneurismal needle, it is transfixed at two points, between
which the  thread is drawn across; and when this is tied, a segment of the vein
is necessarily included with the artery in the noose.  It is  this inclusion of the
ligature within a portion of the vein, where it acts  like a seton, and  keeps up
constant irritation, that prevents the  occurrence  of  adhesive phlebitis, and
occasions diffuse  inflammation  in the interior  of the vessel; and it  is conse-
quently this circumstance, and not the mere wound of the vein, that determines
the  great  fatality of this  peculiar accident.   Guided by this  view  of the
mechanism  of the injury,  the indications in its treatment become obvious.
They consist in  removing the ligature  at  once, and thus, by taking  away the
main source of irritation, converting the wound into a simple puncture of the
vessel,  which readily assumes adhesive action.   The surgeon should  therefore,
as soon as the accident is perceived, withdraw the ligature, and  opening the
sheath  about half-an-inch  higher  up,  re-apply it  to the artery there.  The
hemorrhage  from the punctured vein readily  ceases on the application  of  a
compress.
   The  ligature of the femoral artery for popliteal aneurism, is an operation that
has been so frequently performed, that surgeons seldom  think of recording cases
of this description, unless they present complications  or sequelae of unusual
interest or severity, hence but little importance can be attached to any statistical
deductions from  reported cases as to the fatality of this operation, although they
may serve as a rough  estimate  of the  proportion maintained between  the dif-
ferent accidents, such as hemorrhage, gangrene, &c, that  follow it.  That the
ligature of the femoral artery is attended with more success than that  of any of
the other large trunks, can admit of no doubt.   This is not  only in accordance
with  the general experience of surgeons, but is confirmed by the statistics of
published  cases, even without making allowance for the probability of more of
the unsuccessful than  successful having been recorded.   Thus of 110  instances,
collected by Dr. Crisp, in which the femoral artery has been ligatured for popli-
teal aneurism, only 12  are  reported to have  died; amongst these,  4 deaths
occurred by secondary hemorrhage, 3 by gangrene, and the others by phlebitis,
tetanus, chest  disease, &c.   Higher rates  of mortality are,  however, given by
other authors; thus, Norris states  that nearly 1 in  4 die  after this operation;
Mr. Hutchinson  finds that of 33 cases recently operated on in London, 10 were
fatal, 5 deaths resulting from gangrene.
   The  occurrence of secondary hemorrhage after the ligature of the superficial
femoral is a troublesome accident, and  one in which the  surgeon, to  use Mr.
Fergusson's  expression,  "will  most assuredly find himself in  an  eventful
dilemma;" and in which it is necessary that his line of action should have been
well considered before-hand, as he may not have much  time to spare  for reflec-
tion when  such  an event has taken place.   In these cases four lines of treat- 
             LIGATURE  OF  THE FEMORAL ARTERY.          525

ment present themselves, viz., the employment of pressure; the ligature of the
vessel at a higher point; the deligation of the bleeding apertures in the wound,
or amputation of the limb.
   Pressure  may be  applied by placing a graduated compress of lint or com-
pressed sponge over the bleeding orifice, and fixing it there  firmly by a horse-
shoe  tourniquet.    This means,  although  extremely uncertain,  occasionally
succeeds; should it not do so, however, and bleeding recur a second time, it is
useless  to continue it, as experience has shown that the hemorrhage will con-
tinue until the patient is worn out.
   The ligature of the superficial femoral at a higher point, or if the artery has
been tied  too high for this, the deligation  of the external iliac, presents itself
as a probable means of arresting the hemorrhage.   Such an operation, however,
is fraught with danger, and has, I believe, invariably been followed by gangrene
of the limb.  It might at first be supposed that the limb would  not be placed
in a worse situation after the ligature of the external iliac, whether the  super-
ficial  femoral had  been previously  tied or not,  the  anastomosing channels
remaining  the  same in either case.  But  in reality it is not so;  for although
the blood might  find  its way through the epigastric, the circumflex ilii, the
gluteal  and sciatic arteries, into the  profunda and its  branches, yet from this
point the difficulty of its transmission through the limb would  be materially
increased.   If the superficial femoral be  open, it serves as a direct and easy
channel for the  conveyance, to the  vessels of the leg and foot, of the  blood
brought by  the  anastomoses.  But when  the superficial femoral is tied, this
blood must find its way through a second chain of anastomosing vessels,—those
intervening between the branches of the profunda and the articular arteries  of
the knee;  and here the real difficulty would  arise, its impulse not  being suffi-
cient to overcome the obstruction to its passage through these small channels,
which might not improbably be still  further obstructed by the pressure of  the
aneurism.   Should the anastomosing circulation be sufficiently free to maintain
the vitality of the  limb, it is not  improbable  that the recurrent  blood would
escape from the distal side of the  ligature, and thus  keep up the hemorrhage
exactly as  in a case of wound.  It appears indeed  that the femoral  artery, in a
case of secondary hemorrhage after  the application of the ligature, is in very
much the same condition as an  artery which has  been wounded, and in which
the bleeding, having been suppressed for some days, has returned with violence;
and I think the best course for the surgeon to pursue is the same practice that
he would follow in the event of secondary hemorrhage occurring from a wounded
vessel, viz., by cutting  down upon the bleeding part and  applying a ligature to
 it.  That such an  operation is surrounded with difficulties cannot  be doubted •
 but yet none would present themselves that care and skill might not overcome!
 The  surgeon would certainly have to cut into a part infiltrated with blood  in
 which  the  different tissues  could  not readily be  distinguished, and the vessel
 when reached would  be found to be soft, friable, and granulating,  yet by free
 dissection above  and below the wound, a portion of it might at last be exposed,
 where  its  coats would  hold a ligature; or should this not be found, the wound
 might be firmly plugged from the bottom with compressed sponge; or the bleed-
 ing aperture touched  with  the  actual  cautery.   Should these means  fail, it
 would, I think, be safer to amputate the  limb, than to endeavor to arrest  the
 hemorrhage in any other way.
    Gangrene of the limb is perhaps the most frequent source  of danger after  the
 ligature of the femoral artery for popliteal aneurism.  It seldom  occurs, how-
 ever, unless the tumor be of considerable  magnitude, have become diffused, or
 otherwise  interfere seriously with  the  circulation  through the limb   I have
 however, seen it follow after the operation  where the popliteal aneurism had  not
 attained a larger size than that of an orange;  but, in this case, there was much
 oedema of  the limb, and congestion  of  the veins before  the operation, and on 
526        ANEURISMS  OF THE  LOWER EXTREMITY.

examination afterwards, it was found that the popliteal vein had been obliterated
by the pressure of the tumor.   The gangrene may, in some cases, be prevented
by the treatment that has been pointed out at page 176.  When it has fairly
declared itself, there  is necessarily no  resource left  but amputation, and  this
operation is sufficiently successful;  for I find that of 14 cases in which  it was
done there were 10 recoveries, and but 4 deaths.
  The return  of pulsation in the sac after  the operation  for popliteal aneurism
is by no means of frequent occurrence,  but yet, it has been  met with in some
instances, and secondary aneurism has  also been found in this situation.   In
these cases  the patient should be put upon a careful dietetic plan, the limb be
kept  elevated  and at rest, and pressure  applied by means  of a compress and
bandage, or a horse-shoe tourniquet.   In this way cures  have been effected by
Wishart, Turner, Briggs, and Liston.   In  conjunction with such treatment, or
in the event of its not sufficing, the compression of the common femoral artery
as it passes over the pubes, would  in all probability effect a cure.  Should it
not do so, and the tumor continue to increase, threaten to suppurate, or to occa-
sion gangrene, amputation would be the sole resource.
   In the case of double  popliteal  aneurisms, the artery has been occasionally
ligatured with advantage  on both sides, either simultaneously, or, more safely,
consecutively.   But these cases appear to  me to be  especially adapted for the
employment of pressure, so as to avoid  that disturbance  of the balance of the
circulation which is certain to ensue when one vessel is ligatured, and which
may act injuriously upon the opposite aneurism.  When the popliteal aneurism
is conjoined with a similar disease of the groin, the ligature of the external iliac
is the proper  course to pursue, and will  effect a cure of both affections.
   When a circumscribed popliteal aneurism  suddenly  becomes diffused, the
patient is seized with faintness or sickness, with pain, numbness, and a hot trick-
ling sensation in the limb, the temperature of which falls at the same time  that
its bulk increases, and the integument assumes a white, shining, mottled appear-
ance, with more  or  less purplish discoloration.   This condition usually occurs
after a circumscribed aneurism has existed in the ham for some weeks or months,
and on the occurrence of some sudden  exertion.  In some cases, however, the
disease appears to have been diffused from the very first, the coats having given
way, and extravasation having taken  place into the cellular tissue of the limb,
without the previous consolidation of the parts around the artery, or any attempt
at the formation  of a sac.   In these cases the extravasation into  the limb  may
either be  conjoined with  much oedema, or it may be confined to  the  cellular
tissue of the  ham, and to the upper and back part of the leg, or extend down-
wards under the  muscles of the calf.  When the patient comes under the obser-
vation  of  the surgeon, the  tumor is found to be  solid, elastic,  and irregular,
without pulsation or bruit, the limb cedematous, cold, and congested.  The diag-
nosis of this  form of aneurism is  often extremely difficult, and  there is great
danger of confounding it with simple extravasation into the calf, with abscess,
or, possibly, with malignant tumor of the leg.
   The danger attending on popliteal aneurism is greatly increased by its becom-
ing diffused.   Under these  circumstances the ligature of  the  artery usually
affords but a slender prospect  of success, the  collateral vessels being so  com-
pressed and choked by the pressure of  the effused blood as not to admit of the
circulation being carried  on through them; hence, in many of these cases, the
only resource left is amputation.
   The question of amputation in cases of diffused popliteal aneurism is not very
 easily submitted to any very positive or definite rules, except in those instances
 in which the impending gangrene is so evident as not to admit of doubt.  There
 are,  however, certain  general considerations that may guide the  surgeon in
 coming to a decision on this point.
   In some cases the sac has either  given way to a very limited extent, or else its 
            FEMORAL AND  POPLITEAL  ANEURISMS.         527

 walls having become thin and expanded, are yielding rapidly under the pressure
 of the blood, becoming fused with the surrounding parts.   Here we should liga-
 ture the artery without delay; for, although it is but seldom that a limb can be
 saved when once the blood has become infiltrated into the general cellular tissue,
 yet it is possible, such a fortunate occurrence may happen.
   In other instances the aneurism has not from the first been very distinctly cir-
 cumscribed.   It has followed the infliction of some mechanical injury, and in the
 course of a week or two has acquired a considerable size, without definite or dis-
 tinct limitation, being solid or but little compressible.  Such a case as this can
 scarcely be considered, strictly speaking, a diffused aneurism; but yet, if by cir-
 cumscribed we mean that the blood is  contained in a defined cyst with walls, it
 scarcely complies with such a definition, the fluid blood being  rather prevented
 escaping widely by a temporary barrier of coagula entangled in  the loose cellular
 tissues of the part, and the vessel being ruptured to a  considerable extent, or
 completely torn across.  Here we are certainly justified in  having recourse to
 compression or ligature with a good prospect of success.
   When the  ham is occupied with a large, rapidly-increasing tumor, extending
 perhaps some way down the calf and up the thigh, and encroaching on the knee,
 the skin covering it being more or less discolored, there being no pulsation per-
 ceptible in the tibials, and the veins of the limb being full and even somewhat
 congested, the foot cedematous, and several degrees in temperature  below that
 of the opposite limb, the difficulty of coming to a decision  is considerable.
   In such a case as this, I think the existence or non-existence of pulsation of
 a distensile character would  be  a circumstance of very great importance, and
 may  serve to guide  the surgeon.
   If there be distinct impulse of a distending character, which can be arrested
 by compression of the femoral artery, with some diminution of the size of the
 tumor, it is an evident indication of the transmission of blood through the sac,
 and that this contains some  fluid blood.   Under these circumstances, it will,
 when the  artery is  tied, subside  to a considerable extent, thus allowing more
 space for the  conveyance of the collateral circulation, and it would  be but right
 to give the patient the chance of preserving his limb by ligaturing the vessel.
   If, however, the tumor have, from the very first that it attracted the patient's
 notice, been more or less solid and incompressible; and though it may at  an
 early period of its existence have  pulsated, if this pulsation  has suddenly ceased,
 the aneurism at the same time  having undergone rapid and great increase  of
 bulk  with  much tension and lividity of the integuments,  oedema and coldness
 of limb,  with a tendency perhaps to vesication and ulceration of the skin cover-
 ing the tumor, there is no resource left but  amputation.
   It  must, however, be borne in mind that the aneurism may  become diffused,
 and extensively so, without any very great change in the shape and size of the
 limb.  It  is only when the  sac  ruptures in such a position that the blood is
 effused into the general cellular tissues of the limb or under the skin, that much
 tension of the integuments and increase in the  bulk of the  part takes  place.
   When the rupture occurs in a part of the  sac that is more deeply seated,
 so that the blood is  extravasated  underneath the deep fascia  of the \e&, it is
 bound down by  this and  the superincumbent muscles,  and  deep-seated dis-
 organization of the  limb may be  the  result, without much, if any, change  in
 its bulk  or in the color of the integuments, but with deep-seated  pain, which
 is excessive.   There must  always  be  considerable risk  in such  a case  as
 this  of confounding the arterial  disease with solid tumor,  and  the diagnosis
 can only be effected  by a reference to  the early history of the case,  and  more
 particularly to the  existence or not of pulsation at this period.   Indeed, the
 existence or  non-existence of pulsation  in  these  cases,  is of the very utmost
importance in reference to the  question of  treatment.   The pulsation may
have  ceased in a case  of diffused popliteal aneurism, in  consequence of the 
528        ANEURISMS  OP  THE LOWER EXTREMITY.
blood that has been extravasated being so confined and  bound down  by the
fascia and muscles  under which  it is effused, that  it compresses or seals the
mouth of the artery leading into the sac, to such  an  extent as to arrest the
passage  of blood through it, either wholly  or  so  that it enters in a feeble
stream, of insufficient force to communicate impulse to the fluid that has  been
extravasated  into the  limb.  This pressure may, as in the  case of which an
illustration has  been given  (fig.  170), be  confined  to  the deep parts of the
limb and not give rise to much, if any, general tension of it, the blood being
confined below the  deep fascia, where it communicates the sensation of  a  hard
solid  elastic  tumor, devoid  of  pulsation;  attention should  consequently not
be too exclusively directed to the state  of general tension of the surface  of a
limb, as this is by no means  necessarily an indication of the  state of the parts
beneath.  But the  surgeon  should rather look to the  presence  or absence of
pulsation.  If pulsation still exist, the blood  continues to find its way into the
sac, and most probably through  it,  the  tension of the parts not having yet
reached its maximum.  If  there be no pulsation,  he may be sure that the
entrance  of  blood  into the  diffused aneurism has  ceased in consequence of
compression exercised on  the mouth of the  artery leading to it, by the tense
condition of  the surrounding and enveloping tissues re-acting on the mass of
blood effused beneath  them.  In such  a state of things as this, the vitality of
the lower part of the limb can only be maintained  by the blood that may find
its way through the anastomosing channels; and this may, if  the tension of the
limb be not general, the extravasation being  confined to below the deep fascia,
be sufficient for this purpose.  If surgical  interference be delayed in  such a
case as  this, the deep fascia will soon give way by rupture  or  ulceration, and
the blood will be  infiltrated into the general cellular tissue of the limb, and
then, by compressing those collateral branches that  have hitherto maintained a
feeble circulation in it, will infallibly occasion gangrene.  If, on the other hand,
ligature of the  main artery  be  had  recourse to, the anastomosing circulation,
which may have been  barely sufficient to keep  up a feeble vitality in  the leg
and foot, will be so much interfered with that gangrene of the limb  inevitably
ensues.   The only resource, therefore, that is left in these  cases is to amputate
at once, in order that the patient may be saved the  shock of the constitutional
disturbance occasioned by the setting in of mortification, as well as the pain and
risk of a previous unnecessary operation.
   When gangrene  threatens; the leg and  foot  having become cold, the skin
being either pale,  tallowy and mottled, or  discolored,  of a purplish  hue, with
perhaps vesications and much oedema, whether the ligature have been previously
applied to the femoral artery or not, or (whatever the condition of the aneurism
may be, whether circumscribed  or diffused,) the patient  will  stand  a better
chance of ultimate recovery by having the  limb  removed at  once  above the
knee.   The part at which amputation should be performed is a point deserving
some consideration  in  these cases.  If the  femoral artery have been ligatured,
the thigh should be amputated on a level with the ligature, the artery being
cut just above this.  In this way the double risk that the patient would other-
wise run of secondary hemorrhage from the seat of the ligature, as well as from
the face of the  stump, will be reduced  to a single chance of hemorrhage  from
the stump.   If the amputation be the primary operation, it should be  done at
the lower third  of  the thigh, provided the extravasation be confined  to below
the knee;  or higher up, if the effused  blood  have extended above this joint.
   Aneurisms of the tibial arteries are  extremely rare, except as the result  of
wound,  but  yet they are  occasionally met with; and  in the museum  of
St. George's Hospital  is a  preparation of a small aneurism of the posterior
tibial.   These  arteries  may, however, require ligature  either for injury or
disease.
   Ligature of the  tibial arteries___The posterior tibial artery may be 
ANEURISM OP  THE  INNOMINATA.             529
tied in two parts of its course; either behind the ankle or in the  calf of the
leg.  Behind the ankle, it may be reached by making a semilunar incision three
inches long, about three-quarters of an inch behind the inner malleolus, towards
which its "concavity should  look.  After dividing the integument and  super-
ficial fascia, the deep fascia,  which is usually single, but may be double, must
be laid open; this closely invests the vessel, nerve, and tendons  in  this  situa-
tion ;  under it the artery will be found, accompanied by two veins,  from which
it must be  separated before the ligature is passed.   Anterior to the vessel, and
nearer the bone, are the tendons of the flexor digitorum communis, and tibialis
posticus; behind, is the nerve and the tendon of the flexor proprius pollicis.
  In  the middle of the leg, the posterior tibial artery should only be tied  for
wound in that situation.  Under such  circumstances  no regular operation can
be performed, but  an  incision of sufficient length, taking the wound for its
centre,  should be  made through the  gastrocnemius and soleus, parallel  to
their fibres, when,  after these have been cut through, the  deep fascia will be
exposed.   This must next be  opened, when the  artery will be  found, accom-
panied by its veins, and having the nerve to the  outer side.  From the  depth
at which the vessel is  situated, and  the free  incisions that it is necessary to
make through muscular parts, it is extremely difficult to apply the ligature  in
this situation.   The later steps of the  operation  may be  much  facilitated by
flexing the leg on the thigh, and extending the foot so as to relax the muscles.
  The anterior tibial may be tied in several  situations, but the same remark
applies to this as to the posterior tibial, that it should not  be ligatured except
for  injury.  The difficulties of the operation are  lessened as the  ankle  is
approached, where  the  artery becomes superficial, and may easily be secured.
In the upper third of the  leg it lies  deep between  the  tibialis anticus and
extensor communis digitorum muscles,  surrounded by veins, and  having its
nerve to the outside.   If it  be ever found necessary to tie  it in this situation,
the incisions requisite to expose it should be made at least  four or five inches
in length, and especial care should be taken  not to cut into the  muscular sub-
stance, but to get into the first intermuscular space to the  outside of the  tibia,
at the bottom of which the vessel will be found.   In  the middle third  of the
leg, the artery is  crossed by the extensor pollicis, and will be found between
the tibialis anticus and this muscle;  it is best reached  here by keeping well to
the outside of the tibialis anticus.
  The dorsalis pedis may be felt pulsating, and may readily be  secured, as it
runs forwards from the ankle joint  to  reach  the  space between the first and
second metatarsal bones, lying between the tendon of the extensor pollicis and
that of the extensor brevis digitorum.
                     CHAPTER  XXXVIII.

     ANEURISMS  OF THE NECK  AND  UPPER EXTREMITY.

                ANEURISM  OF  THE  INNOMINATA.

 ^ Aneurisms  of this artery may either be of the tubular or the sacculated
kind, and usually give rise to a train of serious and dangerous symptoms from
their pressure upon important parts in their neighborhood.   Indeed, a glance at
the relations of this artery will show the important effects that must be produced
by the pressure of a tumor springing from it.  Before it lie  the left innominata 
530                 ANEURISMS  OP  THE NECK.
vein and  the  superficialis cordis nerve;  to  its left is found the trachea, and
more posteriorly, the  oesophagus;  on its right are  the innominata vein of that
side, and  the  summit of  the pleura costalis; externally and posteriorly it is in
relation with the par vagum, and more posteriorly and internally it  lies before
the right recurrent laryngeal nerve.
   The general symptoms  of an aneurism of  this artery are the existence of a
pulsating  tumor of a  globular shape behind the right  sterno-clavicular articula-
tion, attended with pain, and, perhaps, oedema of the right side of the face and
arm, with some difficulty in respiration, laryngeal cough, and dysphagia.   The
tumor is usually soft  and compressible, filling up more or less completely the
hollow about  the  sternum, and  even rising as high in the neck  as  the  lower
margin  of the cricoid cartilage; it pushes forwards, first the sternal, and after-
wards the clavicular portion of the sterno-mastoid muscle, and has occasionally
been seen to extend into the posterior inferior triangle of the neck; and indeed
is generally most distinctly defined towards its brachial aspect.  In some cases
no tumor  rises into the neck, but the sternum, clavicle, and costal cartilage of
the first rib, are found to be considerably pushed forwards beyond their natural
level.   In the space  around the  right  sterno-clavicular articulation, and about
the upper part  of the  sternum, there will be dulness on  percussion.  In very
many instances  there is no bruit, but merely a  strong impulse with the heart's
sounds, as distinct or even more so  than in the cardiac region, but in other cases
there is every variety of bruit.
   The most important symptoms are occasioned perhaps by the pressure effects
of the tumor  upon the  neighboring parts, affecting the pulse, the venous  circu-
lation, respiration, and deglutition.
   The pulse is usually influenced, being much smaller and feebler in the  radial
artery of  the  affected than of the sound side, and in some instances being com-
pletely  arrested;  owing,  doubtless, to  the occlusion  of the  subclavian.   The
pulsation  in the right carotid and its  branches  is  also frequently  much less
powerful  than in the opposite vessel; these  signs commonly occur before any
external tumor is seen or  can be felt, and hence  constitute an important element
in the early diagnosis of the disease.
   Enlargement  of the  superficial veins of the neck and right upper extremity
is of frequent occurrence, the external jugular being the vessel that is usually
first dilated;  at a more advanced period the  superficial subcutaneous veins of
the upper part of the right side of the chest often become tortuous, and form a
dense  plexus  in this situation, while many anastomose with  the cephalic and
thoracic veins above, and the  superficial epigastric  below.   As the pressure
increases, oedema commences in the right eyelids and hand, and may speedily
extend  to the whole of the head, face, and arm, which become hard and brawny
in consequence  of serous infiltration.  In  one case  I have seen the left arm
become suddenly cedematous, the left innominata vein being pressed  upon.   In
these cases the  eyes become staring and  prominent, and the lips,  nose, and
features livid and turgid  with blood, as well as cedematous, so as materially to
alter the patient's expression of countenance.
   Pain of a dull aching character is experienced in the situation of  the tumor,
from the compression of the neighboring structures.   But early in the disease,
and among some of the first  symptoms,  the patient  often experiences sharp
shooting pains, apparently of a rheumatic or  neuralgic character, in the arm and
the side of the head and face.   This is from pressure  upon, and irritation  of,
the cervical and  brachial plexuses  of  nerves, and  taking the course of the
ascending and descending filaments of the former, the pain shoots up the side
of the head and neck, over the shoulder and upper part of the chest;  or, from
pressure  upon the brachial plexus, radiates down the hand and arm,  being
usually especially severe  about the elbow and fingers.  At the same time the
muscular  power of the right arm commonly  becomes impaired. 
TREATMENT OF  BR A C H I 0-C E P H A L I C  ANEURISM.   531
  Dyspnoea is of very common  occurrence, and very varying degrees of inten-
sity, from  slight difficulty in breathing up to fatal asphyxia.  It may proceed
Fig. 185.
  Aneurism of the innominata artery, compress-
ing  and stretching  the recurrent laryngeal
nerve, and pushing the trachea to the left side.
(Back view.)
either from  irritation of the larynx,
in consequence of compression of the
recurrent nerve; or, from pressure on
the trachea,  or  the right  bronchus.
When  dependent on laryngeal irrita-
tion, the voice  is hoarse,  husky, or
whispering;  and  there is a dry, croupy,
and paroxysmal cough, usually accom-
panied  by expectoration   of  frothy
serous  mucus.   In  these cases, after
death  the  recurrent nerve  will be
found to be  stretched out and greatly
elongated by the pressure of the tumor
(fig.. 185).   Compression of  the tra-
chea, which becomes  flattened  and
curved  over  to  the left side by the
protrusion of the tumor, is a common
cause of dyspnoea,  and is  not unfre-
quently associated with the laryngeal
irritation.   More rarely by  far, the
right bronchus  is compressed by the
extension  of the tumor downwards.
   Dysphagia is of sufficiently frequent
occurrence, and  varies from slight un-
easiness in deglutition to an  impossi-
bility in swallowing anything except fluids.  I have never seen it occur without
its having been preceded  by dyspnoea; and in every instance  that has fallen
under  my observation,  it has been  associated  with laryngeal  irritation.  This
coincidence of these two symptoms  is readily explained by the  anatomy of the
parts;  the recurrent nerve lying as it  does between the artery and oesophagus,
must suffer compression before the mucous canal can be interfered with.
   The prognosis of brachiocephalic aneurism is in the highest degree unfavor-
able, though the disease frequently  does not run a rapid course.   If it  extend
upwards and outwards, the tumor may acquire a very large size before any very
important organ or part is  implicated; but if it press backwards and inwards, it
may prove fatal at an early period.   I know of  no case in which such an aneu-
rism, if left to itself, has undergone spontaneous cure, and but  few instances in
which the rupture  of the sac has taken  place.  The most frequent cause of
death  is by asphyxia, from spasmodic closure of the larynx induced by irritation
of the recurrent nerve; or by pressure on the trachea.
    Treatment. — There are several instances on record in which a properly con-
 ducted course of constitutional treatment has  cured a patient; thus a case of
 Mr. Luke's was permanently cured by small and repeated  bleedings, conjoined
with the administration of digitalis.  In connection with such treatment, distal
pressure might  be employed, as in a case that derived benefit from this  plan in
Mr. Syme's hands.
   In aneurism  of the innominata, the vessel is so short and the sac so situated,
that it is impossible to attempt to apply a ligature on the cardiac side of the
tumor. What resource then  does surgery offer in these cases  beyond the em-
ployment of constitutional and dietetic means ?  It  may be answered to this,
that if these measures  fail in arresting the disease, our choice must lie between
two alternatives; leaving  the  patient to his fate, or having  recourse to the
application of the ligature  on the distal side of the tumor.  On looking on the
innominata artery with reference to the distal operation, we are struck  by two 
532
ANEURISM  OF THE  INNOMINATA.
peculiarities  in  the vessel, which must necessarily  modify  to  a considerable
extent not only  the seat of the operation, but the principle on which it is con-
ducted.  The first peculiarity to which I allude is the  shortness  of the trunk,
which makes it  impossible to apply the ligature to the vessel  itself, but renders
it necessary to deligate one or  both of its terminal branches.  The other pecu-
liarity is, that under no circumstances can  these vessels be so ligatured as to
arrest the whole of the blood sent into the  artery; for although the circulation
through the  carotid may be entirely stopped, yet it is impossible, from the seat
and extent of the disease, to tie the  subclavian at any  point except beyond the
scaleni, all that  blood  which is destined for  the supply  of the  branches of this
vessel — viz., the vertebrals, the thyroid axis, the internal mammary, and the
first intercostal,  must therefore continue  to  be propelled into and through the
sac.  Three  distinct modifications of the distal operation have  been  proposed
and resorted to  for the cure of aneurisms in this situation.  1st,  the ligature of
Fiq. 186.                Fig. 187.                   Fig. 188.
the subclavian alone; 2nd, of the carotid alone; and, 3rd, of both vessels, with
an interval of greater or less extent.
  The ligature of the subclavian  only (fig. 186) has been practised in 3 cases,
the results of which are exhibited in the accompanying table; 2 were fatal, and
the partial success of the third may be fairly attributed, in a great measure, to
the accident of the carotid being occluded.   The  results of this practice have
certainly not been sufficiently favorable to justify the  surgeon in repeating  an
attempt of this  kind, opposed as it is  to the known principles on which the
distal operation effects a cure.   For  supposing, as we may safely do, with Mr.
Wardrop, that only one-third of the blood that is sent into the innominata finds
its  way through the extra-scalenal portion  of the subclavian, the  remainder
being destined for its branches and the carotid in equal  proportions, what fact
can be adduced or principle laid down  by which we  can expect to obtain the
cure of an aneurism in close  proximity to the heart, by cutting off so small a
proportion as one-third  of the supply of the  blood sent into it ? 
DISTAL  OPERATION IN BRACHIOCEPHALIC  ANEURISM.        533
ANEURISMS OP  INNOMINATA TREATED BY LIGATURE OF SUBCLAVIAN  ONLY.
OPERATOR.	SEX.	AGE.	RESULT.	CAUSE OF DEATH.	REMARKS.
1. Dupuytren. 2. Laugier. 3. Wardrop.	m. m. f.	40. 57. 45.	Died on ninth day. Died a month after opera-tion. Died two years after operation.	E x h a ustion, following cough, and secondary hemorrhage. Asphyxia. Exhaustion.	Subclavian ligatured immedi-ately above clavicle, tumor diminished, but pulsations continued. Aneurism of sub-clavian, with dilatation of innominata and aorta. Vessel ligatured immediately above clavicle. Aneurism of brachio-cephalic; aorta was dilated, and right carotid ob-literated by the pressure of the tumor. Subclavian ligatured beyond scaleni; the pulsations in and size of tumor diminished, and respiration became freer; on the ninth day pulsation re-appeared in right carotid, in which it had previously been absent. (We may ascribe success of operation to this circumstance.)
  The ligature of the carotid only (fig. 187) has been  practised in 9 cases, as
recorded in the annexed  table, and in 1 case  only does the disease appear to
have been materially benefitted, and in that instance the good effects can scarcely
be attributed to the operation, but must rather be looked upon  as an effort of
nature to effect a spontaneous cure, the sac becoming inflamed and suppurating,
ANEURISMS OF  INNOMINATA TREATED BY LIGATURE OF CAROTID  ONLY.
OPERATOR.	SEX.	AGE.	RESULT.	CAUSE OF DEATH.	REMARKS.
1. Evans. 2. Mott.	m. m.	30. 55.	Recovered. Died seven months after operation.	Asphyxia.	The tumor diminished for a few days after operation, but at the end of seven days in-flammation of the sac set in, followed by obliteration of the arteries of the right upper ex-tremity and the branches of the carotid. At the end of a year the tumor still existed, with constant pulsation. The next year the sac suppurated and discharged much pus. Dis-ease arrested, but not cured. After the operation the radial pulse in the affected side dis-appeared, and the tumor in the neck was much dimi-nished. After death, no ex-ternal appearance of tumor, but internally it was as large as a double fist.
 
534
ANEURISM  OF  THE INNOMINATA.
ANEURISMS OF INNOMINATA TREATED BY LIGATURE OF CAROTID ONLY.
OPERATOR.	SEX.	AGE.	RESULT.	CAUSE OF DEATH.	REMARKS.
3. Aston Key.	f.	61.	Died a few	Narrowing of	Aneurism of innominata and
			hours after	vertebral ar-	of arch of aorta found. The
			operation.	teries, brain not receiving suffic ient	orifice of left carotid nearly occluded, and vertebrals smaller than natural.
'				blood for the maintenance of its func-tions.	
4. Fergusson. 1 1 j	m.	56.	Died on sev-enth day.	Pneumonia	Tumor and pulsation de-creased after operation. Tu-mor nearly filled with firm laminated coagulum; no plug in carotid.
5. Morrison.	m.	42.	Recovered	Suddenly,	Aneurism of innominata and
			from opera-	cause not	carotid found. Arch of aorta
			tion, died	stated.	diseased. Right carotid di-
			twenty		lated into a sac as high as
			months af-		part ligatured, and plugged
			terwards.		by dense fibrinous laminae.
6. Campbell.	m.	48.	Died on nine-teenth day.	Pneumonia.	Tumor began to disappear after the vessel was ligatured. After death, aneurism of in-nominata and transverse por-tion of arch, and dilatation of descending aorta as far as diaphragm were found.
7. Hutton.	m.	47.	Died on sixty-	Bronchitis, in-	Tumor diminished after liga-
			sixth day.	fl a mmation, suppuration, and ulcera-tion of sac, into trachea.	ture. Size and pulsation less. After death, tumor contained purulent matter, and grumous blood; had opened into tra-chea. Right carotid and sub-clavian contained firm coa-gula.
8. Dr. Wright,	m.	70.	Died on six-	Hemiplegia.	Tumor solidified by laminated
(Montreal.)			tieth day.		fibrine. Subclavian pervious
					with canal through tumor
					leading to it.
and the arteries of the arm and head on the side affected having been obliterated.
Mr. Key's patient died in consequence of the  left carotid being  occluded, and
the brain being deprived of its proper supply of blood.
  In 3 cases both the carotid  and subclavian arteries have been tied (fig. 188).
In the most favorable of these, that  by Fearn, two years elapsed between the
ligature  of the  carotid  and  that of the subclavian, the patient dying three
months after the second operation,  the sac apparently filled with laminated
coagulum, and appearing to be undergoing  spontaneous cure.  The third case
is remarkable as  being  the  only instance in which both the vessels were tied
simultaneously, and from the patient having lived for six days after the occlusion
of all the arteries supplying the brain except the left vertebral. 
DISTAL OPERATION IN  BRACHIOCEPHALIC  ANEURISM.        535
ANEURISMS OF INNOMINATA TREATED BY  SUCCESSFUL LIGATURE  OF  CAROTID AND
                            SUBCLAVIAN.
OPERATOR.	SEX.	AGE.	CAROTID LIGATURED.	SUBCLAVIAN LIGATURED.	REMARKS.
1. Fearn. 2. WlCKHAM. 3. Rossi.	f. m.	28. 55.	Carotid liga-tured, Aug. 30th, 1836. Carotid liga-tured, Sept. 25th, 1839. Carotid and subclavian.	Subclavian ligatured, Aug. 2d, 1838. Subclavian, Dec. 3rd, 1839. Simultane-ously.	Died three weeks after second operation from pleurisy. Sac of aneurism of innominata filled with dense organized coagulum; except a channel the size of artery for the pas-sage of the blood. Tumor diminished after liga-ture of carotid, and dyspnoea ceased for a time, but symp-toms returning, subclavian was tied. Relief of symp-toms ensued, but tumor in-creased, and patient died two and a half months after first bursting of the sac. Death in six days. Occlusion of left carotid and right ver-tebral arteries; circulation of brain carried on by left vertebral merely.
  Having thus given a resume of the cases of aneurism of the innominata, in
which the operation of ligaturing the artery beyond the sac has been performed,
the question arises whether any or all of these operations should retain a place
in surgery.  This question may be examined in two points of view: 1st. As to
the principle on which these  operations are  performed;  and 2nd. As to their
results in practice.  For the success of the distal operation, it is requisite either
that there be no branch given off from the sac, or between it and the ligature;
or that the current of blood through the  sac  may at least be so far diminished
as to admit of the deposition of  laminated fibrine in sufficient  quantity to fill it
up  by a process similar to what happens in a case of aneurism treated by the
Hunterian method.   In order that this be  accomplished, it is certainly neces-
sary that the greater portion of the blood  passing through it be arrested, for if
the current that is still kept up through it is too free,  the tumor will continue
to increase, as we have seen happen  in those cases of inguinal aneurism in
which the femoral artery is ligatured  below the epigastric and the circumflex
ilii, the current through which is sufficient to feed the  sac in such a way that a
cure could not be accomplished.   If,  therefore, but one  of the vessels  leading
from the brachio-cephalic, as the subclavian beyond the scaleni, be tied, and but
a third of the blood  circulating  through  the  main branch be  arrested, are we
justified in hoping that the circulation through the sac would  be so influenced
by the deprivation of this small  quantity, that the remaining two-thirds  of the
blood,  which would  still  pass through for the supply of the  carotid and  the
branches of the subclavian, would gradually deposit those fibrinous laminae, by
which obliteration of the tumor is to be effected ?  Should we not rather expect
that the larger current would be  too powerful to allow of the formation of these
layers, and would continue to distend the sac in  such a way as  to prevent its
contraction ?   Surely if the comparatively small  and feeble streams  of blood,
that pass  through the epigastric and  circumflex ilii, are sufficient to interfere
with the cure of an inguinal aneurism after the distal ligature of the femoral, 
536            ANEURISM  OF  THE  INNOMINATA.
the strong current that sweeps through the carotid and large branches springing
from  the subclavian with  the  full force derived from  close proximity to the
heart, will be sufficient to prevent all lamination in an aneurism  of the innomi-
nata.   That the arrest of the circulation through one  of these vessels only, is
not sufficient  to influence  materially the  growth of the  aneurism, is evident
likewise from what is not unfrequently observed after death in cases of this kind
— one or other of the vessels being found compressed  and obliterated by the
pressure of the sac, and  yet no  alteration in the tumor resulting.   These cases,
which are tolerably numerous, would of themselves have been sufficient to have
proved that something more than this amount of obstruction is required in order
to effect proper stratification of fibrine in the sac; and  if  we turn to the result
of the twelve cases, in which either the  carotid or the subclavian has been liga-
tured, we shall find that in one  case  only, that operated  on  by Mr. Evans, of
Belper, has a cure been effected; and in  this instance how was it accomplished ?
According to the principle on which it was attempted to be established ?  Cer-
tainly not, but as will be seen by attention to the details of the case, and as has
been already pointed out with much acuteness by Mr. Guthrie, by the accidental
setting up of inflammation in the artery extending to the sac, and thus oblite-
rating it.
   In  the only case, that  of Mrs. Denmark, in which Mr. Wardrop  tied the sub-
clavian for the cure of aneurism of the brachio-cephalic,  there is some reason
for doubt whether the arrest of the  progress of the  tumor was  owing to the
ligature of the  subclavian  artery, or whether it was  not much influenced by
the obstruction which existed in the  carotid  for nine  days after the operation,
during which time  so  abundant a deposit  of laminated fibrine might  have
occurred as to arrest the progress of the disease for some length of time.  In
this case, also, Mr. Guthrie supposes  it probable that  the obliteration of the
tumor might lead to its inflammation.
   From a careful  consideration of all  the  circumstances of the cases in which
ligature of one vessel only  has been employed for brachio-cephalic  aneurism, we
are I  think fully justified in concluding that in 6 of the cases the fatal result was
much accelerated, occurring as a consequence of the ligature of the vessel; in 2,
the progress  of the disease was in no way interfered with; in 1 it  was arrested,
the patient living for two years;  and in  1 case only the disease was cured.  The
improvement in  the  2  last cases was the result of accidental  circumstances,
which were unexpected and unconnected in any way with  the principles on
which the operation was undertaken.   These results would not  in my opinion
justify any surgeon in again undertaking either  of these operations.
   We have yet to consider the operations in which  both arteries are ligatured.
This  double  operation may either  be performed with  an interval between the
application of the two ligatures, sufficient  for the establishment of a collateral
circulation; or, the two  vessels may be  ligatured simultaneously.  The former
plan has been adopted in two cases, the  latter only in 1; not a sufficient number
for any safe deduction.  In 1 of the 2 cases in which  an interval intervened
between the two operations, that by Mr. Fearn, the tumor seems to have under-
gone  a cure, being  filled with  dense  laminated fibrine;  but the patient died
eventually of pleurisy.   In other cases, by Mr. Wickham, no good results fol-
lowed the operation, death occurring  from bursting  of the tumor.   In the case
in which both vessels were ligatured  simultaneously,  death occurred in conse-
quence of the left carotid and right vertebral being accidentally occluded, and
the cerebral circulation being then solely  dependent on the left vertebral.  As
I have just said,  these cases are not sufficiently numerous or free  from modify-
ing circumstances to enable us to draw any inference from them, we must there-
fore revert to the  principle on which this operation should be undertaken.  This
will differ materially according  to whether the two arteries are  ligatured simul- 
ANEURISM  OF  THE  CAROTID.               537
taneously, or with  a sufficient interval for the re-establishment  of  collateral
circulation.
  If an  interval of two years, as in the first case, or even of two-and-a-half
months, as in the second instance, be  allowed  to  elapse between the ligature
of the carotid and that of the subclavian, the operation reduces itself essentially
to that of the ligature of a single artery, which, as has already been  shown, is
insufficient to induce these changes in the sac that  are necessary for the accom-
plishment of a  cure.  If the patient survive the effect of the ligature of the
carotid  for  a few  weeks,  sufficient  time will  be  afforded for the  proximal
end of the subclavian, the vertebral artery, and the thyroid axis to have taken
upon themselves a  great increase of development, — the collateral circulation
being carried on by them and not by the left carotid;  so that by the  time that
the subclavian comes  to be  ligatured beyond the scaleni, the  sac will still con-
tinue to be  traversed by a current of blood for the supply of the branches of
the subclavian,  dilated to much beyond their normal size, in consequence of the
 task of supplying the right side  of the neck, face, head, and brain, being prin-
 cipally thrown  upon  them.  This  current through the proximal end of the
 subclavian, increased as it would be by  the whole  of that blood which is
 destined to supply the  place of that which  should  pass  by the carotid, would
 place  the sac  in nearly the same condition as if  the  subclavian also had been
 ligatured, and would  consequently, for the reason  that has already been given,
 be too powerful for us to expect a cure to take place in the course of its stream.
    It now remains for us only to consider the simultaneous ligature of both ves-
 sels— an operation that has been but  once performed, and  then under such
 circumstances as to preclude our reasoning  upon it, the patient having died from
 accidental occlusion of  the left carotid and right vertebral arteries.   In reason-
 ing upon the  simultaneous  ligature  of  the two vessels, we must consider two
 points—1st. In what  conditions  do we place the sac ?   And,  2d, Is the danger
 of the patient much increased ?
    So far as the sac  is  concerned, it is impossible to place it in a better condition
 for the deposit  of  fibrinous matter; two-thirds of  the  blood flowing through it
 being arrested, and that only traversing it  which is destined for  the  supply of
 the branches of the subclavian.  It is by  no means improbable that  even this
 stream  may yet be too large and forcible to allow the process of occlusion to
 take place;  but yet it is impossible still further to diminish it, and if the aneu-
 rism be sacculated, and  project from one side of the artery, particularly if to its
 internal or mesial aspect, it  is by no  means  impossible that it might be suffici-
 ently removed  from the stream to allow of consolidation of its contents.
    Would it add to  the  danger of the patient  to  ligature these two  vessels  si-
 multaneously rather than separately ?   I think not:  if the risk of a double ope-
 ration is to be incurred, I cannot think that  it would be positively increased by
 the two being performed at  once, instead  of at separate intervals.  The  whole
 of the vessels that  serve to maintain the collateral circulation in  the head and
 upper extremity — the vertebral, inferior thyroid,  supra and posterior scapular,
 and cervical, being left uninterfered with.

                    ANEURISM  OF THE CAROTID.

    Aneurismal varix  of the carotid artery and of the jugular vein, as the result
 of punctures and  stabs in the neck, has been  met with in a sufficient number
 of instances to establish the  signs and treatment  of such a condition; and an
 instance is related by Mr. Macmurdo, in which  a communication was established
 between these  vessels as the result of disease; but I am not acquainted with
 any case of varicose aneurism of these vessels  having  been recorded.  The
 signs  of aneurismal varix  in this situation  present nothing  peculiar, and the
 treatment must be entirely of a  hygienic  character, no operative interference 
538               ANEURISM  OF THE CAROTID.
being likely to be attended by any but a fatal result.   It is the more desirable
not to interfere in these cases, as the disease does not appear to shorten life.
   Spontaneous aneurism of the carotid is  not of very unfrequent occurrence;
in Dr. Crisp's table of 551 aneurisms, 25 were of the  carotid, and it ranks in
order of frequency between those of the abdominal aorta and of the subclavian.
It occurs more frequently in the  female,  than  any other  external  aneurism:
thus, of the 25  cases  alluded  to, 12 were in  women; owing probably to  it
seldom being the result of violence,  but generally arising  from disease of the
coats of  the vessel.   This aneurism  is also remarkable as  occurring at earlier
ages than most others; thus,  Hodgson has  seen it in a girl of ten; and Sykes,
of Philadelphia, in one  of eighteen.  The right carotid is much more com-
monly affected than  the  left, and the upper portion of  the  vessel than the
lower; indeed, the bifurcation is  the most common seat of aneurismal dilata-
tion.  The root of the right carotid not uncommonly is dilated, but I have never
seen or  heard of a case  in which the left carotid, before  emerging from the
chest, has been affected.
   A carotid aneurism, in  the  early stage, presents itself as a  small, ovoid,
smooth  tumor, with distinct pulsation and bruit, and  a  well  circumscribed
outline.   It is commonly soft and compressible, diminishing in size on pressure,
and expanding again with the usual aneurismal dilatation.   As it increases in
size, it becomes more solid, occasions shooting pains in the  head and neck, and
by its pressure on the pharynx, oesophagus, and  larynx, occasions difficulty in
deglutition and respiration.   Sometimes the salivary glands are much irritated.
After  a time, the cerebral circulation becomes  interfered with, giving rise to
giddiness, impaired vision of the corresponding  eye, noises in  the  ear, and  a
tendency to  stupor.   These symptoms may each be owing to compression of
the  jugular, or to difficulty in  the transmission of the  blood  through the
tumor.   The size that  these  aneurisms  may attain varies  greatly;  usually
they are confined to the space under the angle of the jaw, but not unfrequently
they may occupy the greater  part  of the side  of the neck.   If allowed to
increase uninterfered with, death may happen,  either by  the rupture of the
sac externally, or into the pharynx, or oesophagus;  by asphyxia, from  pressure
on the larynx or recurrent nerve; or by  starvation, from  compression of the
oesophagus.
   The diagnosis of carotid aneurism is without doubt  more difficult than that
                               of any other form  of external aneurism; the
                               best  proof that this is so, may, I think, be found
                               in the fact that out  of 39 recorded cases in
                               which the carotid artery has been ligatured for
                               supposed aneurism  of it or its branches, in  8
                               instances no such disease existed; solid cysts, or
                               other tumors of the neck, having been mistaken
                               for aneurism, and this by surgeons of great and
                               acknowledged repute.
                                 The diagnosis of aneurism of the lower part of
                               the carotid  from similar disease of other arteries
                               at  the root of the neck, as of the subclavian,
                               vertebral, and brachio-cephalic, and the arch of
                               the aorta, is surrounded by difficulties which can
                               only be cleared up by a careful stethoscopic ex-
                               amination of the part. In some aneurisms of the
                               arch  of the aorta also, the sac rises up into
                               the  neck,  so as  closely  to simulate  a carotid
                               aneurism,  as in  the  annexed  cut (fig.  189),
                               and  this greatly  increases the  difficulty of the
diagnosis.  The principal affections of the neck,  however, with which aneurism
 
DIAGNOSIS  OF CAROTID  ANEURISM.           539
of the carotid may be  confounded, are varix of the  internal jugular, enlarged
lymphatic glands, abscess, tumors, cysts in the neck, and pulsating bronchocele.
  From varix the diagnosis may readily be made by attention to the following
circumstances : — that  in varix the tumor is always  soft; does not  pulsate ex-
pansively ; diminishes in size  during a deep  inspiration, and on compressing
the vein  on its distal side.
  Glandular  tumors of the neck  are often very difficult to distinguish  from
aneurism, more particularly when  the artery passes  through and is embraced
by the tumor, so that the whole mass distinctly moves at each  pulsation.  In
these cases also there may be an apparent diminution in the size  of the tumor
on  compression,  by the  artery within  it being emptied,  or  by the growth
receding into some of the cellular interspaces of the neck.   But in the  great
majority  of instances,  attention to the  globular, oval, and nodulated feel of
glandular swellings, the possibility of raising them up and pushing them away
from the vessel, which may best be done by feeling  the  carotid with the ends
of the fingers of one hand, and then  pressing upon  the tumor with the other,
will clear up the true nature of the case.
   From abscess of the neck the diagnosis must be made on general principles;
the  co-existence of ill-defined hardness and of enlargement of the glands, of an
inflamed state of the  skin, the ready detection  of fluctuation, and  the absence
of  expansive pulsation in the  tumor, will show that  it is  not aneurismal, how-
ever similar  its other characters may be.  It  is also of importance to observe
that an  aneurism that fluctuates is always forcibly distended with strong pulsa-
tion and can be materially diminished by pressure; neither of which circum-
 stances  can  possibly occur in abscess.   But if abscess may be mistaken for
aneurism, the converse also holds  good,  and an aneurism may,  unless care be
taken, be mistaken for abscess;  a  far  more fatal  error.  And there is one
variety of false aneurism, that to which  Mr. Liston  has invited special atten-
tion, against which the surgeon must be  carefully on his guard, on  account of
the  many points of resemblance between it and  aneurism; I mean  the case in
which an artery has given way into the  sac of  an abscess.   In this case, fluc-
tuation  and   pulsation will exist, though not  perhaps  of a distending  kind.
An  important diagnostic mark will be, however, that the  outline of an aneurism
is distinctly defined and  limited, while that of an abscess never is.   Aneurism
of the internal carotid has been found by Syme to simulate very closely abscess
of the tonsils.
   Tumors of various kinds, carcinomatous, fatty, and  elastic, may occur in the
neck, and cause some little embarrassment in the diagnosis from aneurism :  thus
Lisfranc, O'Reilly, and Kerr  of Aberdeen, have recorded cases in which  the
artery has been ligatured in such cases by mistake for aneurism.   The diagnosis
of such  tumors as these must be effected on ordinary principles.   I  have in
several instances met with  a  small, hard, distinctly circumscribed tumor, lying
directly  upon the carotid artery and apparently connected with it, and receiving
pulsation from it, usually produced by a fit of coughing or laughing.  This tumor,
with the true nature of which I am unacquainted, remains stationary, and does
not  require any operative interference.
   The thyroid body is not unfrequently  the seat of  pathological changes, that
have been and may be mistaken for aneurism.  These consist chiefly in a limited,
circumscribed enlargement of one  of the  lobes of the gland, which extends late-
rally over the common carotid, and receives pulsation from it.   The most puz-
zling cases, however, and those in which mistakes may most easily be made, are
instances of pulsating bronchocele, in which these tumors have  an active and
independent pulsation or thrill.   In these instances,  however, there are three
points that will almost invariably enable the surgeon to effect  the diagnosis.
Thus, the tumor, although principally confined to one lateral lobe, always affects
the  isthmus more or less.  Then again, in bronchocele, that portion of the tumor 
540
ANEURISM  OF  THE  CAROTID.
is  most firmly fixed which stretches towards the mesial line, whilst in carotid
aneurism the firmest attachment is under the sterno-mastoid muscle.  The third
point of difference is, that on desiring the patient to make an effort at degluti-
tion, the enlarged thyroid body moves with the pharynx and trachea, and being
raised from the neighborhood of the vessels, the pulsation in it ceases, whilst no
effect is produced on an aneurism.   Cysts  in the thyroid body are of more com-
mon occurrence than pulsating bronchoceles, and sometimes equally difficult of
diagnosis.  Dupuytren has pointed out that when these cysts  are  tapped, the
pulsation often  becomes  stronger, and the fluid, which on first flowing is of  a
serous character, may at  last become pure arterial blood, so that the  surgeon
may suspect that he has punctured an aneurismal tumor.
   Aneurisms  of the carotid are usually of slow growth, and may sometimes exist
for a considerable number of years without giving rise to any special inconveni-
ence ; this is more  particularly the case when they are seated at the bifurcation
of the artery; when at the root, they are more likely to be attended by injurious
pressure-effects.
   Treatment. — Since the time that Sir A. Cooper firstligatured the carotid, in
1805, the  only means  on  which the  surgeon relies for the cure  of aneurism of
this vessel is, deligation  of the artery at  a  distance from the sac.  When  the
aneurism is so situated that a sufficient extent of healthy vessel exists  between
the sternum and the base of the tumor to  admit of the application of a  ligature,
the Hunterian operation may be  practised.  If, however, the root or lower  por-
tion of the artery is  so  involved that there is  no room to apply the ligature
between the heart and the seat of  the disease, the distal operation may be  per-
formed.
   Ligature  of the Carotid. — When the surgeon can  choose the seat at
which to  ligature  the artery, he usually  selects that part of the vessel which
bisects the angle formed by the anterior edge  of the sterno-mastoid and  the omo-
hyoid muscles.  The artery is reached  by  making an incision about three inches
long over  its  course upon the anterior edge of the sterno-mastoid, which is the
direoting line, and  a sure guide to the  artery.  After dividing  the integument,
the subcutaneous fascia, and cellular tissue, the sheath of the vessel is  exposed.
This must then be carefully opened, any branches of the descendens noni being
 avoided, and  the ligature passed from without  inwards, between the  vein and
 artery.    In  performing  this operation, subcutaneous vessels  are  occasionally
 wounded, which  may bleed pretty freely;  if  so, they  should be ligatured.
 When the sheath is opened, the jugular vein sometimes swells up considerably,
 so as  to obscure the  artery, but by being drawn aside with a retractor, or  com-
 pressed  by the assistant's finger, all difficulty from this source  will cease.   The
 pneumogastric is not seen, being drawn aside with the vein.   If the  aneurism
 have attained a very considerable size, extending low in the neck,  and not  leav-
 ing, perhaps, more than one  inch  of clear space above the clavicle for the sur-
 geon to  operate in, the  difficulties  are necessarily very greatly increased, and
 here the best plan will be to divide the tendon of the sterno-mastoid muscle,  so
 as to  give additional space.  The external portions  of the sterno-hyoid and
 sterno-thyroid muscles may likewise be cut  across for the same purpose.  The
 jugular vein in this situtation lies considerably to the outside of the artery.
    After ligature of the  carotid  artery, the  blood is so freely conveyed to the
 distal side of the vessel, by the free communication subsisting between the  arte-
 ries of opposite sides within the  cranium, that a continuance and return of pul-
 sation in the sac is of common  occurrence.   This condition,  however, usually
 disappears after a  time by the gradual consolidation of the tumor, and indeed
 may generally be looked upon as a  favorable sign, being very seldom associated
 with those cerebral symptoms that, as will immediately be explained, commonly
 prove fatal after this  operation.  It is  interesting to observe that the  collateral
 Bupply, after the ligature of the common carotid, is not afforded by any of the 
LIGATURE  OF THE  CAROTID  ARTERY.          541
branches of the corresponding vessel of the opposite side, but by the subclavian
artery of the same side.  In a case related by Porter, in which the right carotid
had been tied, the subclavian and vertebral arteries on the same side were ^ en-
larged to at least double  their natural diameters, and the chief communications
outside  the skull took place between the superior and inferior thyroid  arteries,
which were enlarged; whilst inside the cranium, the vertebral took the  place of
the internal carotid.
   Suppuration of the sac is not of very uncommon occurrence after the ligature
of the carotid for aneurism, sometimes even after so considerable an interval as
eight months, as happened in a case related by Post.   In the majority  of these
instances, the patient  eventually does well, but death  may result  by the tumor
pressing upon the pharynx and larynx, or by the occurrence of secondary hemor-
rhage, which may  take  place either  from the part  to which the ligature  is
applied, or from the suppurated sac.  In the first instance it usually occurs about
the period of the separation  of the ligature, in the second it may happen at a
considerably later period, even after many weeks.  Besides these, which may be
looked upon as  the  ordinary accidents  following the application of a ligature for
aneurism, deligation of the carotid  artery occasionally gives rise to serious and
even fatal disturbance of the circulation within the cranium.
   Many experiments have  been made by Meyer, Jobert, and others upon the
lower animals,  with the view of determining the effect produced on the brain
by the ligature of the carotid arteries; but the deductions from these are  of no
value whatever when applied to the human subject, for the simple reason, which
appears to have been strangely overlooked, that in many of the lower animals on
which the observations were made, as the dog and rabbit for instance,  the com-
mon carotid arteries are  of secondary  importance so far as the cerebral circula-
tion is concerned, being  destined principally for the supply of the  external parts
of the head, the  brain deriving its chief supply from the vertebrals; whilst in
other animals, as the horse, the brain derives nearly the whole of its blood from
the carotids, and but a very small quantity from the vertebrals.  Hence, in one
case, the  carotids may be ligatured without danger, whilst  in the other  their
deligation  is inevitably  fatal.  On turning to  the result of observation on the
human  subject, we find, according to Dr. Norris, that the carotid artery has been
ligatured in  149 instances, and that  of these, 32 were fatal, 18  of the deaths
resulting from cerebral  disease.  The proportionate  frequency of deaths from
 this condition, according to the cause that led to ligature, may be seen  by refe-
rence to the following table:—
TABLE OP LIQATURE OF CAROTID FOLLOWED BY  FATAL  CEREBRAL DISEASE.
CAUSE OF LIGATURE.	NUMBER OF CASES.	DEATH FROM CEREBRAL DISEASE.	DEATH FROM OTHER CAUSES.
	38 30 42 18 6 15	7 6 3 1 1	5 2 5 1 1
Erectile and other tumors			
			
	149	18	14
  By this it will be seen that the most common cause of death after the ligature
of the carotid, is cerebral disease induced by the operation, as was, I believe
first  pointed out by Dr. N. Chevers;  and that this result appears to have fol-
lowed the Hunterian more frequently than  the distal operation.  We should
necessarily expect, that in those cases in which both vessels had been ligatured 
542
ANEURISM  OF THE CAROTID.
there would have been a greater tendency to cerebral disturbance than in those
in which one only had been deligated.   It would, however, appear, as is shown
by the annexed table, that of the ten instances in which  the double operation
has been performed, death  happened but in one case from  this cause, and in
another in which such disturbance took place, a fatal result did not occur.
CASES OF LIGATURE  OF BOTH CAROTIDS.
OPERATOR.	AGE.	DISEASE.	DATES OF LIGATURE.	RESULT.
1. Preston.		Epilepsy.	Right carotid tied Aug. 23. Left carotid, Nov. 14.	Recovered.
2. Preston.		Epilepsy.	Tied at interval of month.	Recovered.
3. Macgill.		Fungous tu-mor of both orbits.		Recovered.
4. Mussey.	20.	Aneurism by anastomosis of scalp.	Left carotid, Sept. 20. Right carotid, Oct. 2.	Recovered.
5. Langenbeck.		Hemorrhage from superi-or thyroid.	Both at the same time.	Died next day.
6. MOLLER.	4*.	Erectile tu-mor.	Sept. 13, and Jan. 28.	Recovered.
7. Kuhl.	53.	Aneurism by anastomosis of scalp.	Left carotid first. Right forty-one days after.	Recovered; convulsions after each operation.
8. Mott.		Disease of parotid.	Interval of fifteen minutes.	Coma and death in a few hours.
9. Ellis.		Secondary hemorrhage following gunshot.	Interval of four and a half days.	Cured.
10. J. M. War-ren.		Erectile tu-mor of face.	Tied left, October 5. Right, Nov. 7.	Cured.
  After  a  careful examination of this  subject, I think we are warranted in
coming to  the following conclusions:—1st. That the ligature  of one  carotid
artery is followed in about one-fifth of the cases  by cerebral disturbance, more
than one-half of which are fatal.  2d.  That when both carotids arc ligatured
simultaneously, death has hitherto always resulted, as in the two cases in which
Mott  and Langenbeck ligatured  these  vessels with an  interval  of but a few
minutes between each operation.   3d. That when the two carotids are ligatured,
with an interval of some days or weeks, the  operation is not more frequently
followed by cerebral disturbance than when only one is tied.   4th.  Pathological
investigation has shown that if the vessels be gradually and  successively oblite-
rated, the patient may  live, although  one carotid and one of the vertebral arte-
ries have been occluded by disease and the other carotid  ligatured, as in a case
related by Kossi.  And, lastly, as in a case recorded by Dr. Davy, an individual
may even live for a considerable time, though both carotids  and both vertebrals
be occluded,  the cerebral  circulation being  maintained through the medium of
the anastomoses of the intercostals and internal mammary arteries.
  The cerebral  symptoms that arise from the  ligature of one or both carotids
may be such as  depend upon  a diminished supply of blood  sent to the brain; 
              DISTAL  LIGATURE  OF THE CAROTID.           543

consisting of twitchings, tremblings, or convulsive movements, syncope, or gid-
diness, with paralysis, sometimes with complete hemiplegia of the side opposite
to that of the ligatured vessel, troubled vision,  and deafness; in other cases
again, they appear to  arise from increased pressure upon the brain, drowsiness,
stupor, coma, and  apoplexy supervening;  and to the third  order of symptoms
belong those  that are of an inflammatory character, usually coming on a few
hours after the operation.
   The cause of these symptoms is certainly the disturbance of the cerebral cir-
culation, induced by the ligature of the carotid.   When a considerable portion
of the supply of blood to  the brain is suddenly  cut off, two  sets of symptoms
may ensue, one immediate,  the other  remote.   The immediate symptoms are
those that generally result from functional disturbance of the brain, consequent
upon too small a supply of arterial blood.   They consist of syncope, trembling,
twitches,  giddiness, impairment of sight, and at last hemiplegia.  After this
condition has been maintained for a few days, the  nutrition of the organ becomes
materially affected, and softening of the cerebral substance takes place, giving
rise  to a new and  more serious set of symptoms, indicative of this pathological
condition; such as convulsions, paralysis,  and death.  In other cases congestion
may come on, either  by the  interference  with the return of blood through the
 jugular vein, or as a  consequence of that venous  turgidity that we so commonly
observe after  the  ligature  of a main arterial trunk,  or perhaps as the  result  of
apoplectic effusion into a softened portion of the  organ inducing coma.
   Inflammation of the brain may come on immediately after the application of
the  ligature, being apparently at once induced by the disturbance of the circu-
lation.   In other  cases it occurs at a later period, as  the result of alteration in
the  structure of the organ.
   Besides the brain, it not uncommonly happens that the lungs are secondarily
affected after ligature of  the carotid.  To this condition  special attention has
been directed by Jobert  and  Professor Miller.   The lungs  appear to become
greatly congested, and have a tendency to run into a low form of inflammation.
The cause of this  congestive  condition of the lungs is extremely interesting.  It
cannot be owing to the simple obstruction of the passage of the blood through
the  carotid, causing a disturbance in the balance of the circulation, and thus a
tendency to internal  congestion; for if this were the cause, we ought to meet
with it generally after the ligature  of the arteries of the first class.  Nor can it
be owing to any injury sustained by the eighth  nerve during the deligation of
the  artery; as in many of the instances in which it  is stated to have  occurred,
there was no evidence of that nerve having been  exposed or damaged, and every
reason to believe  the contrary, from the known skill of the  operators.   I am
rather inclined to look upon the  unusually  frequent occurrence  of  pulmonic
 congestions after ligature   of the carotid,  as the secondary  condition consequent
upon a derangement  in  the functions of  the  brain and medulla oblongata,
 primarily induced by the  disturbed state of the  circulation through that organ.
 For we know that any cause that  depresses the  activity of the nervous centres
tends  to  diminish proportionately the freedom  of the respiratory movements,
 and thus, by interfering  with the due performance of the act of respiration,
 disposes to congestion of the lungs, just  as we observe  happens in injuries of
 the  head  in apoplexy, and in the operation of the sedative  poisons.  It would
 appear from the detail of some of the recorded cases, as  well as from Jobert's
 experiments, that blood-letting is of considerable service in the removal of this
 condition, and should consequently not be omitted.
   Ligature of the carotid,  on the distal side of the sac.—Aneurism of the carotid
artery, occurring low in the neck, does  not admit of the application  of a liga-
 ture on the cardiac side of the tumor.  What, then,  is to be done in such a case
as this? — should it be  left to the remote  chance of a  spontaneous cure, or
Bhould it be subjected to  surgical interference ?  The occurrence of spontaneous 
544
ANEURISM  OF THE  CAROTID.
cure in carotid aneurism has never yet, I believe, been met with.  The surgeon,
therefore, must endeavor to treat the disease by ligature.   In this way two plans
of treatment are open to him — either to deligate the innominata, or to tic the
carotid on the distal side  of the tumor.  The first alternative may fairly be set
aside, for  not only are the cases in which it is possible to find room between the
sternum and the sac extremely rare, but even-were such an instance to present
itself, no surgeon would, I think, be justified in undertaking an operation which
has never yet succeeded in the most skilful hands; we are consequently reduced
to the  alternative of ligaturing  the  artery on the distal side of  the sac.   But
although  this operation is the only alternative that presents itself, yet  its appli-
cation  in  practice  is  attended by serious difficulties and perplexities; for the
surgeon must be able  to satisfy himself that it  is actually an aneurism of the
root of the carotid  with which he has to do, and that it is not the trunk of the
innominata  or the  arch of the aorta that  is affected.   The difficulty in doing
this is  far greater than would at first appear;  for, on examining the details of 8
cases in which the distal operation  has been performed for supposed carotid
aneurism, 3 must be excluded; as, after death, the  tumor was found to arise
from the  aortic arch.   In the annexed table will be found the result of 5 cases,
in which  the carotid artery has been tied for  aneurism of its  root on the distal
side of the sac.  I have  excluded a 6th case, as there is reason to believe that
in it the artery was not ligatured, but a portion of the sheath accidentally tied
instead —an accident  by the way,  that Sedillot has seen happen,  and which
Norris relates also  to  have occurred at the  New York Hospital; and which I
have known happen to a most excellent surgeon in the  case  of ligature of the
femoral.
ANEURISMS OF ROOT ON CAROTID TREATED BY LIGATURE ON DISTAL SIDE.
OPERATOR.	sex.	AGE.	RESULT.	CAUSE OF DEATH.	REMARKS.
1. Wardrop.	f.	63-	Recovered.		Tumor diminished until fifth day, then inflamed, suppu-rated, and burst. The patient recovered, and was alive three years after operation.
2. Lambert.	f.	49.	Successful so far as aneu-rism was concerned.	Hemorrhage from upper portion of artery.	Tumor diminished after opera-tion,and became consolidated; sac filled with firm coagulum, and lower part of artery closed; ulceration into artery, just above part ligatured; dilated where ligatured.
3. Bush.	f.	86.	Recovered.		Suffocation was imminent be-fore operation; tumor be-came rapidly diminished after ligature. Alive three years afterwards.
4. colton de Noyou.	f.	63.	Recovered.		Tumor and pulsation dimin-ished. Alive and well three years after.
5. Lane.	m.	36.	Died 68th day.	Inflammation of lungs.	Tumor filled with layers of coagulum. Ulcerated open-ing communicating with apex of left lung.
  On analyzing the 5 cases in which the trunk of the common carotid has been
ligatured on the distal side of an aneurism of  the root of that vessel, there are
several points of interest that arrest our attention; thus we find that in every 
   ANEURISM OF INTERNAL CAROTID AND ITS BRANCHES.   545

case the tumor, immediately on the ligature being tightened, underwent a con-
siderable diminution in  its bulk with corrugation of the integuments covering
it, and considerable subsidence in the force of its pulsations.  In one case, that
of Mr. Bush, respiration, which before  the  operation had been attended with
great  difficulty,became easy; and in another, that of Mr. Wardrop, inflammation
of the sac, unattended however by any bad consequences, took place.  It  is not
safe to deduce any general conclusions from  so small  a  number of cases.   But
yet the result  of  these is  so uniform that I have no hesitation in stating it as
my opinion, that whether we regard the principle  on which this  operation is
founded, the amount of success  that has  hitherto attended it, the necessary fatal
result of these cases if left to themselves, or the absence of any other means that
hold out  a reasonable hope of benefit, the surgeon is justified in resorting to the
ligature of the trunk of the common  carotid on the distal side of the sac, in
cases of aneurism, limited to the root of that vessel.
  Aneurism of Internal Carotid and its branches.—The internal carotid
artery may be the subject of aneurism before or after it has passed through the
carotid canal and  entered the cranium.   The symptoms of these two classes of
cases differ necessarily in almost every respect, as likewise do the termination
and the susceptibility of the case to surgical interference.
  When an aneurism affects the trunk of the internal carotid before its entrance
into the cranium, the symptoms presented by this disease do not materially differ
from those of aneurism at the bifurcation, or of the upper part of the common
carotid, except in one important respect, which was I believe first pointed out
by Mr. Porter, of Dublin—viz., tendency to the  extension of the tumor inwards
towards the pharynx, and to its protrusion into that cavity.  The reason of this
is obvious; when  we consider the  anatomical relations of the  internal carotid
artery, we at once see that its pharyngeal aspect is  that which, if one may so
term it, is the most superficial, between which  and the surface the smallest
amount of soft part intervenes —nothing  lying between the vessel and  the
mucous membrane except the  thin, paper-like  constrictor, some  lax  cellular
tissue, and a few filaments of the superior laryngeal nerve;  whilst externally
there is interposed between it and  the  integument, the layers of the  cervical
fascia the margin  of the  sterno-mastoid, the digastric and three styloid muscles,
and the styloid process.
  When  dilatation, therefore,  of the vessel takes place, it has  a necessary
tendency to push  forwards that part of its  covering where it meets with least
resistance, and this being to the pharyngeal side, more or less prominence will
consequently be found in  this  cavity.   In a case that  occurred to Mr. Syme
this was especially well marked, the aneurism of the internal carotid simulating
closely an abscess of the tonsil.   In two cases  related by Mr. Porter, in  the
17th  volume  of the "Dublin Journal," this was  one of the most  marked
features,  the «appearances of the tumor (as seen by the mouth) were  most
alarming; the pulsation could be distinctly seen, and the blood almost felt under

e\erT2Zn^    "'' * "*"* "*' t0 giVG ™*> and burst into the mo^

vnththT^^ °*the8G CaTS d°e! n0t  differ from that of aneurisms connected
with the  carotid arteries, and seated at the upper part of the neck •  but we J*
not in possession of a sufficient  number of £11£ enable us to TeLr^Zl th
  bTwf SS1°n What the r^Ult °f SUrSical interference in them is lik ly
to be.   If we could give an opinion from the  limited number of cases at present

 P nLV of'the r3 "J t^ ^ ***»* n°fc t0 entertain a ^ «
^t^^lgrfto^Hsss: nt00' as-applied to, Ve cases-
m*™\.     c xu  """'& ™ #lue  situation ot the  aneurism against  the  mucoim 
546                  subclavian aneurism.
sion of the artery leading into it, which, in accordance with the principles that
have been laid down in speaking of the Hunterian operation, is necessary.
  After the carotid artery has passed through the carotid canal, and has entered
the cavity of the cranium, it or its branches may occasionally be the subject of
aneurism;  but *as  the consideration  of these intracranial aneurisms  does not
fall within  the province of the surgeon, it need not detain us.

           ANEURISM  OF THE SUBCLAVIAN ARTERY.

  Aneurisms of the subclavian  occur in order of frequency between  those  of
the carotid and of the brachio-cephalic.  They  are most frequently met with on
the right side, in the proportion of  nearly three to one, and this would appear
to be in a great measure dependent on their being occasioned by direct violence,
or of repeated and  prolonged exertion of  the  arm; thus they commonly occur
from  falls, blows upon the  shoulder, or  excessive fatigue of this  extremity.
From the fact of the aneurisms arising from external violence, we should expect
to meet with  them  most frequently in males, and this we do in a remarkable
manner.   Of  32 cases, I find only 2 occurring in  females, and in both these
instances the disease resulted from injury.  The  disease may be seated in any
part of the vessel  on the right side, though most  commonly it is  not dilated
until after  it has got beyond  the scaleni.  On the left side it never occurs before
its emergence from the thorax, and then, as on the  right, aneurism  most  com-
monly happens in the third part of the course  of the vessel.
  An aneurism  of the  subclavian artery is  characterized by a pulsating  com-
pressible tumor of an elongated or ovoid shape, situated  at the base of the
posterior inferior triangle of  the neck, immediately above the clavicle.  If it be
small, it will disappear behind this  bone  on the shoulder  being  raised;  as it
increases in size, it fills up the whole of  the space between the clavicle and the
trapezius,  often attaining a very considerable bulk.  In consequence of the
pressure which it exercises on the brachial plexus of nerves, there is pain, often
attended by numbness, and extending down the  arm and fingers, usually with
some weakness of these parts.  In some instances there is a spasmodic affection
of the diaphragm, owing to irritation  of the phrenic  nerve.  The external
 jugular vein is  commonly distended and varicose, with  oedema of the hand and
arm, or even of the side  of  the body.   The tumor does not increase rapidly in
size, owing to its being tightly compressed by  the surrounding parts, and as the
disease never extends inwards, it does not interfere with  the trachea or oesoph-
agus.  In  some cases it has been known to extend downwards and  backwards,
so as to implicate the pleura and the summit of the lung.
   The diagnosis of these aneurisms is usually easy, and presents no point of a
special character.  As they increase in size they may become diffused, and burst
either externally or into the pleural sac.   In some  instances a spontaneous cure
has been observed.
   The treatment of subclavian aneurism is in  the highest degree unsatisfactory.
 The attempt at  obtaining consolidation of the tumor by constitutional means,
 by galvano-puncture, or  compression, have hitherto failed, except in some very
 rare instances.  A case is reported by Mr. Yeatman  of the  cure of subclavian
 aneurism by Valsalva's plan  in eighteen  months; and another by Dr. Abeille, in
 which the tumor was  consolidated by  galvano-puncture.   Manipulation, as
 recommended by Mr. Fergusson, has succeeded in  the hands of Mr. Little, and
 undoubtedly deserves a trial in these  cases,  when we  consider the extreme
 danger and almost universal want of success that attends other  means of cure.
   The ligature  of  the brachio-cephalic,  and of the subclavian itself, before, be-
 tween, and beyond the scaleni muscles, has been practised for the cure of this
 form of aneurism;  it has likewise been proposed to apply the distal operation to
 the treatment of this disease, and to amputate at the shoulder-joint. 
SUBCLAVIAN  ANEURISM.
547
  When an aneurism is situated on  the right subclavian artery on the tracheal
side  of the scaleni, there is no way in which the flow of blood through it can
be arrested, except by the ligature of the brachio-cephalic artery.   When it is
situated beyond  the  scaleni, or even between these muscles, the ligature of the
vessel  has  been practised in  the first part of its course before it reaches  these
muscles.   For subclavian aneurisms on the left side,  in these  situations,  no
operation conducted on the Hunterian principle would be practicable.
	CASES OF LIGATURE OF BRACHIO-CEPHALIC.			
	AGE	NATURE OF		
OPERATOR.	AND SEX.	DISEASE.	RESULT.	REMARKS.
1. MOTT.	m.	Subclavian	Died on 26th	Tied an inch below bifurcation.
	67.	aneurism.	day.	Ligature separated in four-teen days. Hemorrhage in twenty-five, stopped by pres-sure. Recurred in twenty-six.
2. Graefe.		Subclavian	Died on 67th	Ligature separated in fourteen
		aneurism.	day.	days. Died of hemorrhage.
3. Hall.		Subclavian	Died on 5th	Coats of artery were diseased
		aneurism.	day.	and gave way. Wound plugged without success.
4. Dupuytren.			Died.	Case referred to as occurring
5. Norman.			Died.	in the practice of Dupuytren.
6. Bland.	m.	Subclavian	Died on 18th	Hemorrhage came on on the
	31.	aneurism.	day.	seventeenth and eighteenth days. Ligature applied to upper portion of artery.
7. LlZARS.		Subclavian	Died on 21st	Ligature separated on seven-
		aneurism.	day.	teenth day. Hemorrhage on nineteenth.
8. Hutin.	m.	Hemorrhage	Died in 12	Punctured wound in axilla, for
	26.	from axilla after liga-ture of sub-clavian.	hours.	which subclavian was tied; secondary hemorrhage, and then b. c. ligatured.
9. Arendt.		Subclavian	Died on 8th	Inflammation of lung, pleura,
		aneurism.	day.	and aneurismal sac.
  ^'v'rThe artery was cut down uP°n> but not hgatured, by Porter, Post, Aston Key
 and Hoffman.                                                              ■"

   Ligature of the brachio-cephalic—Let us now proceed to examine the
 results that  have  attended these operative procedures.  The brachio-cephalic
 artery, as may be seen by the accompanying table, has been ligatured 9 times
 and  in  every instance with a fatal  result.  In 4 other instances, the operation
 has  been commenced, but abandoned owing  to unforseen  difficulties, and this
 by three of the most skilful operators that their respective countries can boast
 of   Although  in  reasoning on the propriety of performing an operation, it  is
 not in general worth while taking the  difficulties that a surgeon may encounter
 into  consideration  provided  the operation be  at last practicable;  yet, when we
 consider  the fact of the ligature of the brachio-cephalic having been attempted
 and in consequence of unforeseen and insurmountable difficulties left unconcluded
 in so large a proportion as one-fourth of the  cases, and these in  the hands of
 surgeons who were as well able as any  to accomplish whatever was in the power
 of operative surgery to do, we may well hesitate upon  the difficulties that beset
 the operation itself, before proceeding  to the consideration  of its results.  The
difficulties to which I  allude, do not consist merely in the position and anatomical
relations  of the  vessel,  but rather in the condition  in  which the artery  and 
548
ANEURISM  OF  THE SUBCLAVIAN.
adjacent structures  may be  found after  the vessel is  exposed.   Thus, in Mr.
Porter's  case, the aneurism, which was a large one, occupied the whole  of the
posterior inferior triangle of the neck, being  nearly  six inches broad; as no
pulsation was traceable in the vessels beyond  the aneurism, it was useless to
attempt the ligature on the distal side.  On exposing the brachio-cephalic, that
vessel was  found  to be diseased, and  it  was not thought desirable to pass the
ligature round it.  In consequence of the exposure of the artery, however, the
pulsation  in the tumor gradually diminished,  and at last  ceased  entirely, its
bulk  also becoming less.
   In  Mr. Key's case, in which it was impracticable to pass  the ligature, it was
found after  death that the  brachio-cephalic was diseased, being dilated  imme-
diately after its  origin into  an oblong tumor, which occupied the whole  of the
artery.   It is  remarkable that in this case, as in Mr.  Porter's, inflammation
seems to have  taken place in the artery in  consequence  of the necessary hand-
ling to which  it was subjected, and  that the pulsation in the sac consequently
diminished.
   It  would thus appear, that even after  the difficulties of  the  operation have
been  surmounted, (and these, from the depth of the vessel, its proximity  to the
centre of the  circulation, the  neighborhood of large veins, which may become
turgid, and a wound of which not only obscures the line  of incision  with venous
blood, but  induces a  risk of the entrance  of air  into  the circulation,  are of
serious magnitude,)  and the  artery has been exposed, its coats may be found so
diseased, or its calibre so  increased, that  it may be undesirable or impossible to
pass a ligature round it.   The failure in  deligating the  artery would, however,
as we shall immediately  see, appear to be  less disastrous in  its consequences
than  success in that attempt; for of the 3 cases that have just been referred  to,
in which this  attempt was  made and did  not succeed, 1  was cured of the
disease, the artery being obliterated  by adhesive inflammation; and in another,
Mr. Key's  patient, an  attempt to set up this action  appears to have been  made,
the tumor becoming solid and ceasing to pulsate, whereas in every case in  which
the vessel was  ligatured, a fatal result speedily ensued.
   The results of the ligature of the vessel are in the highest degree discouraging;
for of the 9 cases in which it has been done, not one recovered.  Death occurred
from  secondary hemorrhage in 4  cases, from inflammation of lungs  or pleura in
2, and in 3 from causes that  are  not mentioned.
   In  one case, that  of Hall, the artery was  transfixed by the aneurism needle;
hemorrhage  occurred  at  the time, which was  arrested  by  plugging,  and did
not recur,  the patient dying from  other causes.   In 3 cases,  those of Mott,
Bland, and Lizars, the hemorrhage came  on shortly after the separation  of the
ligature; but in Graefe's (the most successful) it did  not occur  for fifty-one
days after this, the cicatrix in the artery having then probably given way under
the influence of some imprudent movement on the part  of the patient.  With
such results as these, there can, I think, be  but one opinion as to the propriety
of such  an operation being again had recourse to.   As its performance has
hitherto  in  every instance entailed  death, and, in all  cases but one, a speedy
death to the patient, it should without doubt be banished from surgical practice;
and I can think of no circumstances that should induce a surgeon, in the face
of the consequences that  have hitherto invariably followed the application of a
ligature to  this artery, again  having recourse to such a procedure.
  Ligature of the  subclavian.—If  the aneurism be situated on the right
subclavian  artery, between or beyond the  scaleni, that vessel has* been ligatured
on the tracheal side of these muscles;  on the left side this operation is not prac-
ticable, on account of the  depth at which  the artery is situated.   When we con-
sider  the  anatomical relations of that portion  of the right subclavian,  which
intervenes  between  the brachio-cephalic  artery and the  tracheal edge  of the
scalenus anticus muscle, we are at once struck with the great difficulties of this 
LIGATURE OF  THE  SUBCLAVIAN.             549
undertaking; and when we reflect on the position  in which the ligature will be
placed between the onward current of blood in the brachio-cephalic on the one
side, and the regurgitant stream  conveyed by the vertebral, the  thyroid  axis,
the internal mammary and intercostal, into the subclavian, immediately beyond
the seat of deligation on the other side, we could scarcely, in  accordance with
those principles on which the formation of a coagulum within a ligatured vessel
takes place, anticipate any but the most disastrous results.
   In reference to  the mere difficulties of  the operation, Mr. Fergusson justly
characterizes it as the  most serious in surgery;  the proximity of the  common
carotid artery on one side, the internal jugular vein on the other, the vena inno-
minata below, the par vagum  and numerous  small venous trunks  in front, the
recurrent laryngeal  nerve and pleura behind, constitute relations of sufficient
importance to justify Mr. Fergusson's opinion.  But supposing these difficulties
overcome, and the ligature applied, this must be situated, as has just been stated,
in such a position, with a strong current of blood  flowing upon either side of it,
as to render the formation of  an internal coagulum, and consequently occlusion
of the artery, impossible, and thus to lead inevitably to the occurrence of a fatal
hemorrhage on the separation of the ligature.   Besides the danger of secondary
hemorrhage  from these  causes, there would be the additional  risk of the coats
of the artery being diseased, as we commonly find them in a more or less morbid
state in  the immediate vicinity of aneurisms; and thus being rendered insus-
ceptible of healthy inflammation, ulceration  and sloughing would  take  place
along  the track of the  ligature, thus causing  the probability of a recurrence of
hemorrhage.  Thus, in  Colles's case, it was found on exposing the subclavian
artery, that the aneurism had extended in such a way towards the carotid, that
it was doubtful whether any  part of the affected vessel continued sound.   On
exposing it  fully, it was found that only a space of the vessel three lines in
length remained free between  the sac and the bifurcation of the brachio-cephalic,
and it was in this narrow space that the ligature was applied.
   The subclavian has been ligatured on the tracheal side of the scaleni muscles
in 7 cases, all of which have proved fatal, 6 from hemorrhage, and 1 from inflam-
mation of the pericardium and pleura.
   The cases are as follow:—
SURGEON.	sex.	AGE.	date of death.	cause of death.
COLLES. MOTT. Hayden. O'Reilly. Partridge. Liston.1 Liston.2	m. f. f. m. m. m. m.	33. 21. 57. 39. 38.	4th day. 18th day. 12th day. 13th day. 4th day. 13th day. 36th day.	Hemorrhage. Hemorrhage. Hemorrhage. Hemorrhage. ■ Pericarditis and pleurisy. Hemorrhage. Hemorrhage.
  Thus it will be seen, that if this operation is bad in principle it is most unfor-
tunate in  practice.   This table is, to my mind, conclusive as to the merits of
the operation, the patient having in every case but one  been  carried off by
secondary hemorrhage from the distal side of the ligature, in consequence of
the close  proximity of numerous collateral  branches (fig. 190),  and in this
exceptional case the  operation, although performed  with the utmost delicacy
and skill, proving fatal  from pericarditis  and  pleurisy before  the period  at
which  secondary hemorrhage might  have been  expected.   Mr. Liston, in one
case, ligatured the root of the common carotid, as well as that of the subclavian,
  1 In this case the carotid was also tied, but the hemorrhage came from the subclavian
(fig- 191)-                           3 Fig. 190. 
550
ANEURISM  OF  THE  SUBCLAVIAN.
hoping in this way to diminish the  risk  of the supervention  of this fatal
hemorrhage, by arresting the current  of blood which, by sweeping  into tho
                                                 carotid past the mouth of the
                     Fig. 190.                     subclavian, necessarily washed
                                                 away  any   coagulum   that
                                                 would otherwise have formed
                                                 in  this  artery.   But his ex-
                                                 pectations  were not realized,
                                                 hemorrhage  taking  place as
                                                 usual, and  from that portion
                                                 of the artery which lay on the
                                                 distal side of the ligature (fig.
                                                 191), the blood having been
                                                 carried  into  this part of the
                                                 vessel in a retrograde course,
                                                 through the connection exist-
                                                 ing between its vessels arising
                                                 from it at  this  point, and
 those on the opposite side of the head and neck, as  illustrated by the annexed
 cut, taken from the preparation  of the case in the University College Museum.
                                            Indeed this is the great danger to
                  Fig. 191.                  be apprehended after ligature of
                                            the subclavian artery on  the tra-
                                            cheal side of the scaleni, depending
                                            as it does on  the  anatomical  rela-
                                            tions and connections of the vessel,
                                            which no skill on the part of the
                                            operator can in any way lessen, and
                                            which,  in my opinion,  ought cer-
                                            tainly to  cause this operation to be
                                            banished from surgical practice.
                                              When  an  aneurism  is situated
                                            on the" subclavian artery, in the
                                            posterior  inferior  triangle of the
                                            neck, it  is  necessarily impossible
                                            to  ligature that vessel  beyond the
                                            scaleni, as there would not be suffi-
                                            cient room for the exposure of the
                                            artery,  which, even  if laid  bare
 would in all probability be  found in too diseased a condition to bear the appli-
 cation of a ligature.
  ^ Thus it will be seen, that in every case in which an aneurism of the subcla-
 vian  artery has been subjected to operation, whether by ligature of the brachio-
 cephalic or of the subclavian itself internul to the scaleni, the result has been  a
 fatal  one.   As this unfortunate  termination  to every case that has yet been sub-
 mitted to  surgical interference is in no way to be attributed to want of skill on
 the part of the operators, who arc, without exception,  men greatly distinguished
 for the possession of this very quality, but is solely dependent on certain anato-
 mical peculiarities in the arrangement of these vessels, by which their success-
 ful ligature has been rendered impossible, a repetition of these attempts, which
 may  hasten the patient's  death, can scarcely be  considered justifiable.   What
 then  are we to do ?  Are we to  leave patients laboring under aneurism of the
 subclavian artery to inevitable death, without making an effort to save them ? or
 does  surgery offer other  modes  of treatment besides those just mentioned, by
 which we may hope to arrive at more successful results ?
   Without mentioning manipulation, or galvano-puncture, which is  certainly
 
                LIGATURE  OF  THE SUBCLAVIAN.             551

deserving of further trials in combination with appropriate constitutional treat-
ment, three modes of treatment present themselves : —
  1st.  Compression  on the artery where it passes over the first rib, and conse-
quently on the distal side of the tumor.
  2d.  Ligature of it on the distal side, above or below the clavicle.
  3d.  Amputation at the shoulder-joint, and the distal ligature of artery.
  1st.  Compression  of the  artery on  the distal side of the sac  could only be
effected where  it crosses the first rib, and consequently would only be applicable
to aneurisms of the first part  of this vessel.   This plan has  never been  tried,
partly, perhaps, on account of the difficulty in applying pressure in this  situa-
tion, and partly, probably, on  account  of the want of  success that has attended
procedures of this kind when applied  to vessels in other situations.
  The difficulty in applying the  compression might, I think, be overcome  by
the use of the  instrument of which  a  representation is given by Bourgery; and
the efficiency of the  compression would be materially increased by the employ-
ment of the galvano-puncture at the same  time, and in this way a coagulum
might be formed in the sac.   Although much ought not  to be expected  from
this mode of treatment, yet I think  it might with propriety be tried in cases of
this kind that  have been  mentioned.
  2d.  Dupuytren ligatured the axillary artery under the pectoral muscles,  for
a case of subclavian  aneurism,  two  arterial branches being divided in the
incisions through the fat  and  cellular tissue,  and the patient  died on the ninth
day.   This is the only instance, to my knowledge, in which the distal operation
has been  attempted for the cure of this disease.  It could not be expected to
succeed;  for between the ligature and the sac are the large and numerous alar,
acromial, and  thoracic branches of the axillary artery, which would  continue
to be fed by a  current sent through the tumor, and  thus preclude  the  possi-
bility of its  contents  being sufficiently stationary for ultimate contraction  and
cure to result.   Laugier performed  the  distal operation in a supposed case of
subclavian  aneurism, which  afterwards  turned out  to be  one of the  brachio-
cephalic artery.
  Ligature of  the subclavian artery  in the third part of its course, on the distal
side of the tumor has been suggested, and may, perhaps, hold out some  pros-
pect of success in cases of aneurism situated between  or internal to the scaleni.
In an aneurismal sac springing from the artery in  this  situation, the principal
current of blood would, in  all  probability, be that which is destined for the
supply of the upper extremity.   Some of the branches arising from the artery
before it has passed  beyond the scalenus  anticus would, doubtless, be  more or
less compressed, and  thus obliterated,  by the  tumor, or might be obstructed by
an  extension of the laminated fibrine  over their orifices.   If, therefore, the
supply to the upper extremity could be cut off, there  might be a possibility of
those changes  taking place within the sac which are necessary for the oblitera-
tion of its cavity.  The principal obstacles  to this desirable  result would  ne-
cessarily be the transversalis colli and humeri arteries; which, being the two
vessels that are  more  particularly destined  to carry on the circulation in the
upper extremity after the ligature of  the subclavian, would necessarily,  if not
occluded, undergo dilatation,  and thus continue to draw too large a current of
blood through  the sac for stratification  of its contents  to take  place; and if
occluded, there would be danger of gangrene  of the  arm from insufficient vas-
cular supply.   These difficulties are met by a plan of  procedure, the suggestion
of which has  originated, I believe, with Mr. Fergusson, but which has not, to
my knowledge, been had recourse to as yet.   It is, 3d, the amputation of the
arm at the shoulder-joint, and then the distal ligature of the artery — a des-
perate undertaking  truly, but for a desperate  disease it must be  remembered,
and one that has never yet, under ordinary surgical treatment, been cured.
  The artery might be ligatured before the amputation.   " It is known," says 
552         ANEURISM OF  THE  AXILLARY  ARTERY.

Mr. Fergusson,  "that amputation at the shoulder-joint  is  generally a  very
successful operation;  so  far as this wound is  concerned, then, there  might be
little to apprehend, but the effect on the tumor is not so easily foretold.  Liga-
ture of the axillary artery on the face  of the  stump  might here be  reckoned
like Brasdor's operation, — yet there is a vast difference, for in the latter case
the same amount of blood which  previously passed towards the upper extremity,
would  still find  its way down, and probably part of it would  run  through the
sac; whereas, were  the member removed,  as the  same  quantity would no
longer be required in this  direction, the  tumor might possibly be  much more
under  the control of pressure.  The value of such a suggestion remains yet to
be tested, however, and  it would be futile  to reason  upon it at  present.  It
might be a judicious venture  first to tie the axillary or subclavian under the
clavicle, and then, if it  were found that the aneurism still  increased, ampu-
tation  might be  performed, either immediately before or after  the separation of
the ligature."
   Were a case of aneurism of the  subclavian artery internal to the scaleni, to
present itself to me, the plan that I should adopt would  be,  first  the employ-
ment of pressure on the vessel on the distal  side of the tumor, if  practicable;
should this not succeed, I would, if the disease were situated between, or inter-
nal to  the scaleni, ligature the  artery in the third part of its course, and did
that not succeed in checking  the increase of the aneurism, perform amputation
at the shoulder-joint as recommended by Mr. Fergusson.  Should the aneurism
occupy the artery after it has  passed the  scaleni, I would  not attempt the
ligature of the  artery below the clavicle, as it is an operation, the  result of
which is not very satisfactory, and would not prevent a large current through
the sac for the supply of the  collateral circulation of the arm,  but at once have
recourse to amputation at the shoulder, and  then ligature the vessel, as near as
possible to  the  sac.   It  is true that  even  in this  case the ligature would be
below the branches that are  given off  under the pectoral muscles, but as the
arm would be removed, they could not undergo any increase of activity for the
supply of the collateral circulation of the upper extremity.

             ANEURISM OF  THE  AXILLARY  ARTERY.

   This artery,  though less  commonly the  seat of aneurism  than other  large
vessels, such as those  of the  ham, the groin,  and the  neck, yet is sufficiently
frequently diseased,  owing partly to  its situation;  for  its  proximity to the
shoulder-joint causes it  to be subjected to the very varied, extensive and often
forcible  movements, of which that articulation is  the seat;  and partly to the
artery being deficient in that support which would be  afforded it by an invest-
ing sheath, such as is commonly met with in arteries of corresponding magnitude.
Amongst the most frequent causes of  axillary aneurism,  may be mentioned
falls upon the shoulder or upon  the outstretched hands, and in many cases the
efforts made at  reducing old standing  dislocations; instances of which are re-
corded by Pelletan, Flaubert, Warren, and  Gibson; the head  of  the bone in
these  cases having probably contracted adhesions to the artery, in  consequence
of which the vessel was torn during  the efforts at  reduction.  Axillary, like
subclavian aneurism, occurs more commonly on  the right than on the left side,
and is met with in especial frequency  amongst men;  of 37 cases, only 3 have
occurred in women.
   In axillary aneurism there are three sets of symptoms, attention to which will
usually enable the surgeon to recognize the  disease; these are, the  existence of
a tumor in the axilla, the pain that it occasions, and the affections that it gives
rise to in the limb.
   The precise  situation  at which an  aneurism of the axillary artery presents
externally, will  depend upon  whether it springs from that portion of the  vessel 
     SYMPTOMS AND DIAGNOSIS OF AXILLARY ANEURISMS.  553

that lies above, beneath, or below the pectoralis minor muscle.   If from above,
it will appear as a tumor seated immediately below the clavicle  and  occupying
the  triangular  space  between the upper margin of the lesser pectoral and that
bone; if it be lower  down, it will raise  the  anterior fold  of the axilla, being
prevented extending much out of this space, by the dense fascia that stretches
across from one  side to the other.  The tumor, which is at first soft and com-
pressible, has a whizzing bruit, and its pulsations, which are expansile, may be
arrested  by pressure  upon the subclavian artery, where it passes over the first
rib.   It  usually  increases with  great  rapidity, owing to  the  little resistance
opposed by the loose cellular tissue in this situation, and most commonly extends
downwards and forwards, causing the hollow of the axilla to disappear.  In some
rare instances,  however, the tumor has been known to take  a direction upwards
under the  lesser  pectoral, and into  the  cellular interval above that muscle, or
even underneath  the clavicle into the acromial angle between it and the trape-
zius.  Such a course  for the aneurism to take is fortunately rare, as it presents
serious inconvenience in the ligature of  the subclavian, and there is more than
one  instance on record in which the sac  has  been punctured in the attempt to
pass the needle round this vessel.  When the aneurism is seated high up, it not
unfrequently happens that  the  clavicle  is pushed  upwards by the pressure of
the  tumor  beneath it — a complication of considerable  moment in reference to
the  operation, the difficulties  of which  are greatly increased by it.   The pres-
sure of  the tumor may give rise to  serious  consequences upon neighboring
parts; thus, it  may occasion a carious state of the first and second ribs, and the
compression of the brachial plexus of nerves  will occasion pain and numbness
in the upper extremity.  In some cases  the brachial artery beyond  the  tumor
would appear to  be obstructed, no pulsation being  perceptible in  it; and the
compression of the axillary vein  may occasion oedema of  the  hand and arm,
with some  diminution  in the temperature of the limb, which, if the  tumor
attain a very, large size, may even amount to symptoms indicative of  impending
gangrene.
   The diagnosis  of axillary aneurism is  usually readily made;  there being but
two  diseases with which it can well be  confounded, viz. chronic  enlargement
and suppuration in the  glands of the axilla, and pulsating tumor of the bones
in this  region.   From  glandular or other abscess, the  diagnosis is  generally
easy; but I have seen some cases in which, pulsation being communicated to
their contents by the  subjacent artery, it was somewhat difficult to distinguish
the nature  of the tumor.  Here, however, the history of the case and its speedy
progress to pointing will indicate its  true nature.   From medullary tumor, or
osteo-aneurism  of the head of the humerus, the diagnosis is not always so easy,
and  there are at least two instances on record  in which the subclavian artery has
been ligatured for disease of this kind, on the supposition of its being an aneu-
rism.  In  these  instances it  has, however, generally been  observed that the
tumor first  made  its appearance on the forepart of the shoulder, and not in the
usual situation of axillary  aneurism;  that it was from  the first firm, smooth,
elastic, but nearly incompressible; and that although it presented distinct pul-
sation, there was  no true bellows sound,  but rather a thrilling bruit perceptible
in it. The  most important diagnostic mark, perhaps, is the fact of these tumors
forming a  prominence  in situations in which aneurisms of the axillary artery
would not  at first  show themselves, as at the upper, outer, or  anterior part of
the shoulder.   In more advanced stages, when the substance  of the bone has
undergone absorption, and its shell has become thin and expanded by the out-
ward pressure of  the tumor, there is often a  dry, crackling, or rustling  sound
perceived on pressure, which is never met with in cases of aneurism.
   Treatment of axillary aneurism.— I am not acquainted with any instance in
which an aneurism of  the  axillary artery, not arising from wound  or injury,
has undergone  spontaneous cure, or been consolidated  by constitutional treat- 
554         ANEURISM  OF  THE  AXILLARY  ARTERY.

ment.  Nor is it probable that compression can ever be made applicable to aneu-
risms in this situation, inasmuch as the pressure that is brought to bear upon
the subclavian must necessarily at the same  time influence the whole or the
greater part of the brachial  plexus of  nerves, to such an extent as to be unen-
durable by the patient.   The ligature of the artery is, therefore, the surgeon's
sole resource in the treatment of these cases.  The part of the vessel universally
selected for the application of the ligature is, in accordance with the Hunterian
doctrines, that which lies on the first rib beyond  the  scalenus anticus muscle;
this part presenting the  advantage of being sufficiently  removed from the seat
of disease  to insure the probability of the coats  of the artery being in a sound
state, of being by far the most accessible, and, when deligated, of allowing the
collateral circulation by which the vitality of  the arm is to be maintained, to
remain uninjured.  Notwithstanding these obvious advantages presented by the         I
ligature of the subclavian over that of the axillary artery — in other words,
of  performing Hunter's instead of Anel's operation for the cure of spontaneous         \
axillary aneurism — there would appear to be a tendency in the minds of some
surgeons, to advocate the latter instead of the former of these operations;  and
to substitute for  one that offers the advantages that have just been mentioned,
a procedure that is  not only much more difficult in its performance, and that
interferes with the collateral circulation, but  that is practised upon a diseased
part of the vessel, in dangerous proximity to the sac.
   Ligature of subclavian  in third part of its  course. — In order to
apply a ligature to  that portion of the subclavian  artery which intervenes
between the acromial edge of the scalenus anticus and the lower border of the
first rib, the patient should be placed in a recumbent position, the arm depressed
as much as possible, and the head turned somewhat to the  opposite side.  The
integuments  of  the lower part of the neck should then be put on the stretch
by being drawn  downwards  over the clavicle, and an incision about four inches
in  length made upon the bone through the integument, the  superficial fascia,
and  the platysma.   When  tension  is taken off the part, this  incision will be
 found to traverse the base of the inferior triangle of the neck; a vertical inci-
sion should then be made at right angles to and falling into the centre of the
first, and the two flaps of integument and fascia should  then be turned up.  A
 quantity of loose cellular tissue will now be exposed, in  which a venous plexus,
and the lower end of the external jugular vein, will commonly be found.  These
 vessels should be carefully avoided, and the cellular tissue dissected or scratched
 through with the point  of a  knife and a blunt probe; should any vein be
 wounded,  a double ligature must be passed underneath it, or either end tied.
 If the transversalis colli or  humeri arteries, as occasionally happens, should in-
 conveniently traverse  this place, they must be  drawn  out of the way with a
 blunt hook.  By the  combined action  of cutting and scratching through the
 cellular tissue, the external edge of the scalenus anticus is  reached;  this is the
 udirecting line" down which the finger is run until the tubercle of the first rib
 is  felt.  This is the guide to the artery, which will be found immediately above
 and a little behind it,  covered, however, and bound down to the rib by a dense
 fascia.  This must now be very carefully opened with  the edge of the knife,
 and  the needle passed  from before backwards.  In doing this, attention must
 be paid to the brachial plexus, situated above and behind the artery.
    There are several points in connection with this operation that deserve special
 attention.  In the first place it is necessary that the shoulder should be depressed
 as far as possible, so as to bring the superior margin of the clavicle down.  This
 is  a matter of much importance; for if the clavicle be thrust upwards by the
 pressure of a large aneurism, the surgeon will have to find the artery at the bot-
 tom  of a deep narrow  wound, instead of on a  comparatively plane surface.  A
 case occurred to Sir A. Cooper, in which the attempt to ligature the subclavian
 artery for a large  aneurism of the axilla was forced to  be abandoned, in conse- 
LIGATURE OF  THE  SUBCLAVIAN.
555
quence of the  clavicle  being thrust  up to  too great a height to enable him to
reach the vessel.   The  extent of the difficulty occasioned by this elevation of
the clavicle must necessarily depend in a great measure upon the height at which
the subclavian  artery happens in any particular case to  be situated in the neck.
It is not uncommon to find it pulsating so high in the neck, that no amount of
elevation of the  clavicle  by subjacent axillary aneurism could  raise that bone
above the level of the vessel.  In the majority of cases, however, in 17 out of
25, as shown by Mr. Quain, in his work on the Arteries, it is either below the
level  of  the bone, or but slightly raised above it; so that if  the clavicle were
thrust upwards and forwards, the vessel would be buried in  a deep pit behind
it.  Dupuytren was of opinion that the artery coursed high in  persons who were
thin,  with slender, long necks; whereas, in thick,  short-necked persons, with
muscular shoulders, it was deeply seated.  I have often verified the truth of this
observation  both in dissection and  in examining the  pulsations of the  vessel
during  life.  In  order  to obviate the difficulty that  has occasionally been expe-
rienced in reaching the artery when thus buried behind an elevated clavicle, it
has been proposed by Mr. Hargrave to saw through the  bone.
   The most serious objection that can be raised against this practice is the fact
of the clavicle being sometimes a part of the wall of the aneurism; but supposing
the surgeon  could satisfy himself that this was not the case, I cannot see any
objection to  this procedure, provided any very great and insurmountable diffi-
culty presented itself in getting the ligature round the vessel without it.
   In passing the needle round the subclavian,  care must be taken that some of
the lower cords of the brachial plexus be not included in the  noose, and indeed
the mistake has more than once been committed  of  tying these nervous trunks
instead of the vessel: thus, Mr. Liston, in the first successful case of ligature of
the subclavian in this country, passed the thread  round the lower nervous cord;
but immediately perceiving his error, turned it to account by  drawing aside the
included nerve, and thus more readily exposing the artery.  Dupuytren, in  a
case  of  aneurism of some  years' duration succeeded,  after  an operation that
lasted one hour  and forty-eight  minutes, and which he describes as the most
tedious and difficult he ever attempted, in passing a ligature round the vessel,
as he believed.  After the death of the patient, which occurred from hemorrhage
on the fourth or fifth day, the fourth  cervical nerve alone was  found included in
the noose.   In a case  related by Porter, it is stated that the artery communi-
cated such distinct pulsation  to the  inferior nervous trunk, that there was no
means of ascertaining whether it was the vessel  or  not, except by passing the
needle under it.
   In some cases, as has already been stated, the sac passes upwards below the
clavicle  into the inferior posterior triangle of the neck; when this is the case,
the surgeon incurs  the risk  of puncturing it from  its close proximity to the
artery, as it lies on the  first rib.   This accident happened to  Mr. Cusack while
ligaturing the subclavian  in the third part of its course, for a  diffused aneurism
of the axillary artery.  An alarming gush of blood took place, which was arrested
by plugging the wound, but the hemorrhage recurred on the tenth day, and the
patient died.   In a case related by Mr. Travers, in which the sac was punctured
by the needle,  which was being passed round the artery, the  blood, which was
arterial,  did not  flowjoer saltum, but in a continuous  stream.   "The hemor-
rhage," says Mr.  Travers, "was more terrific and uncontrollable than I have ever
witnessed," and was not commanded by drawing the ligature tight.  It was  so
great that it was  doubtful whether the patient would leave the theatre alive, and
was only arrested by plugging the wound with sponge-tents.   The patient died
of inflammation of the pleura.   On examination, the aneurismal sac was found
to have  a pouch-like  enlargement upwards, overlying the  artery, where it had
been  punctured.
   If it be found  that the sac encroaches upon the neck,  rising above the clavicle, 
556        aneurism  of the  axillary artery.

or that the artery is not sound in the third part of its course, it may be neces-
sary to ligature it between the scaleni, by dividing the outer half or two-thirda
of the scalenus anticus.   This operation should not be considered as one distinct
from the ligature of the vessel in the third part of its course, but rather as an
extension of that proceeding, if it be found, for the reasons just mentioned, un-
advisable to tie the artery on the first rib; in this  way it has been practised by
Dupuytren and Liston.   In its first steps,  as far indeed as the exposure of the
scalenus anticus, it is the same as that for the deligation of the vessel in the
third part of its  course.  When  this muscle  has  been exposed, a  director
must be pushed under it, upon which it is to be divided to the extent of half or
two-thirds its breadth, when it retracts, exposing the vessel. ^ During this part
of the operation, some danger may be incurred to the phrenic nerve, and the
transversalis colli  and humeri arteries; but if ordinary care be taken, this will
not be very great.   The phrenic nerve, as I have found by very frequent exami-
nations on the dead body, lies altogether to the tracheal side of the incision, if
that be not  carried beyond one-half the breadth of the muscle; and  should it
appear to be in the way, may readily be pushed inwards towards the mesial line,
being  only  loosely invested by cellular tissue.   I  have, however, seen one  in-
stance in which the right subclavian  artery was  ligatured for a spontaneous
cylindriform aneurism of  the axilla, and the  patient died  on the eighth day, of
pneumonia; on examination after death, the edge of the scalenus was found cut,
and the phrenic nerve divided.  Had the  pneumonia in  this case anything to
do with the injury to the  nerve ?  I do not think it  improbable, as division of
one phrenic by paralyzing to  a certain extent the diaphragm, and so far inter-
fering with the respiratory movements, must necessarily have a  tendency to
induce congestion  of the lung, which would readily  run  on to inflammation of
that organ.  I have likewise heard of one case in which incessant hiccough fol-
lowed this operation, and after death the phrenic nerve was found reddened and
inflamed,  having probably in  some way been interfered with during  the expo-
sure of the  vessel.
   Another important point in reference to  the ligature of the vessel in this part
of its  course is the frequency with which a branch  arises from the subclavian
artery between the scaleni.  When this peculiarity exists, there would probably
be but a slender chance  of the occlusion of the artery by ligature in this situa-
tion.   The transversalis colli and humeri arteries, though  in some danger, whilst
crossing over the scalenus anticus, may be avoided by keeping the incision in the
muscle between and parallel to these vessels.  One principal danger in ligatu-
ring the subclavian artery at any point above the first rib, certainly arises from
interference with the fine cellular tissue which lies between it and the scalenus
muscles, separating it from the pleura, and which is  continuous with the cellu-
lar membrane of the anterior mediastinum, being indeed the deep portion of the
ascending layer of  what Sir A. Cooper has described  as  the " thoracic fascia,"
and which tends to form the  superior boundary of the chest,  being continuous
in the neck with the deep cervical fascia.  After the deeper layers of the cervi-
cal fascia have been opened, this fine cellular membrane presents itself, and if
inflammation be excited  in  it, the morbid  action will readily extend by mere
continuity of tissue into the thorax by the anterior mediastinum, invading ulti-
mately the  pleura  and pericardium.  Hence, whenever it is  practicable,  the
surgeon  should keep the point of the  needle close  to  that part of the artery
which lies upon the first rib, as there is less  risk here of opening into the deep
cellular tissue of the neck.
   The general  result of the ligature  of the  subclavian artery in the third part
of its course, for spontaneous aneurism in the axilla, is by no means satisfactory.
Thus, of 47 cases  of aneurism of  the  axillary artery, not  dependent upon any
external wound, in which the artery was ligatured above the clavicle, I find 23
cures against 24 deaths.   This result is so unfavorable, and so different, indeed, 
LIGATURE OF  THE  SUBCLAVIAN.             557
from what I had anticipated, that I was led to analyze carefully the causes of
death.   I find them as follows: —

     Inflammation within the chest, &c......10 cases.
     Suppuration of the  sac     ......      6   "
     Hemorrhage  .........    3   "
     Gangrene of hand and arm     .....      1   "
     General gangrene ........    1   "
     Not stated.........3   "

                                                              24   «

   Thus it will be seen that the  two most frequent causes of  a  fatal result fol-
 lowing the  operation for axillary aneurisms, are not those that are usually met
 with after the ligature of the larger vessels.   It would therefore appear to be
 owing to some special  condition, dependent either upon the application of a
 ligature to  the subclavian artery in the  third  part of its course, or upon the
 situation and nature of  the disease  for which that operation is had recourse to;
 and the important point to be  determined is, whether these  conditions are the
 accidental or the necessary consequences of the application of a ligature in this
 situation for the cure of aneurism in the axilla.
   The inflammation of the contents of the thorax proved fatal in  9 out of 22
 cases,  or 1 in 2-5, and is the most frequent cause of death, though not, I believe,
 the most frequent untoward complication of this  operation.  It might at first be
 supposed that in this respect the operations on the subclavian artery resembled
 other  of the greater operations,  after which pneumonia is so common a sequela;
 but on closer examination it will be  found that this is not the case, that the
 inflammation, when attacking the thorax or its contents after ligature of this
 artery for axillary aneurism, is  not confined  to  the lungs, but very commonly
 affects the pleura and pericardium as well as or  even  in preference to these
 organs.  It would, therefore, appear probable  that it arose from causes that are
 essentially connected with this disease or operation. These are referable to three
 heads.
   1st. Inflammation of the deep cellular tissue at  the root of the neck, extend-
 ing to the anterior mediastinum, the pleura and pericardium.  This would ap-
 pear to have been the cause of the supervention  of inflammation in a patient of
 Mr. Key's, and has  been especially adverted to by that excellent surgeon in the
 relation of the case of a patient on whom he performed this operation.
   2d. The  sac  may, by  its pressure inwards, encroach  upon and give rise to
 inflammation of that portion  of the pleura that corresponds  to its posterior
 aspect.  This occurred  in a case in which Mr. Mayo, of Winchester, operated,
 and is more liable to happen if suppuration has  taken place in  the sac; when
 this happens, adhesion may take place between it and the pleura,  or even the
 tissue of the adjacent lung, and the contents of the suppurated tumor be dis-
 charged into the pleural  cavity  or air-tubes, and so coughed up.   Of this curi-
 ous mode of termination there are at least two cases on record, one by Mr. Bullen,
 in which the patient  recovered; the other by Dr. Gross, in  which the patient
 died from the escape of the contents of the sac into the cavity of the pleura.
   3d.  Division of the phrenic  nerve would necessarily, by interfering with the
 respiratory movements, induce  a  tendency to  congestion  and inflammation of
 the tissue of the lungs;  and although such an accident must be a very rare one
 in cases of ligature of the subclavian for axillary  aneurism, yet it undoubtedly
 has occurred, as I have myself  witnessed in one case.
   Suppuration of the sac is the most common, though not the most fatal acci-
 dent after ligature of the subclavian for spontaneous axillary aneurism.   It was
 the immediate cause of  death in 6 cases, and occurred in 2 of the patients that 
558        ANEURISM  OF THE AXILLARY ARTERY.

died of inflammation of the chest; and  took place in 6 cases that recovered, in
all 14 cases out of 45, or nearly 1 in  3, a much higher proportion than is gene-
rally observed in cases of ligature for aneurism.
  What is it that occasions this greater  frequency of suppuration of the sac in
these than  in  aneurisms in  other situations?   The only cause to which it
appears to be attributable is the great laxity of the  cellular membrane in this
situation, which  allows  the tumor to increase  so rapidly in  size as to excite in-
flammatory action in the surrounding tissues, which  may speedily run into sup-
puration.  So long as the contents of the tumor continue fluid, they will neces-
sarily excite less irritation on surrounding structures; but when once they have
become solidified, whether by the gradual deposition of laminated fibrine, dur-
ing  the progress of the disease,  or more suddenly, in consequence  of those
changes that take place in  the contents of an aneurismal sac after the ligature
of the artery leading to it, the indurated mass acting like any other foreign body
sets up inflammation in the cellular tissue that is in  immediate contact with it,
and thus disposes it to run into suppuration.   The  more speedily the solidifica-
tion takes place, the more disposition will  there be  to  the occurrence of this
accident, the  neighboring parts being unable to accommodate themselves to the
sudden extension and compression they  are compelled to undergo.
   The  period at which suppuration of the sac may be expected to occur in cases
of  axillary aneurism, after the ligature of the subclavian, must necessarily in a
great measure be dependent on the state of the sac at the time  of the operation.
If  inflammatory action  have  already set up  around it, it may happen in a few
days after the artery has been tied.  But if this morbid  action  have not already
 commenced, the period at which suppuration may most probably be expected is
 between the  first  and second  month.   The period  at which  suppuration and
 rupture of the sac take place does not influence  the probable termination of the
 case to any material extent; as in the cases that proved fatal, death occurred
 at  various periods between the seventh day and the second month;  in Aston
 Key's  case, on  the ninth day, in  Mayo's,  on the  twelfth,  in Belardini and
 Graefe's, at the end of the  first  month, in Rigaud's at the sixth week, in B.
 Cooper's in the second month.  The recoveries, likewise, took place at all periods
 after the ligature of the vessel, between a  few days,  as  in Porter's, and  six
 weeks, as in Halton's case.
   An  axillary aneurism that has  suppurated may  either burst  externally  or
 into the lungs or pleura, or both.  It  is most usual for it to burst externally;
 the tumor enlarging, with much pain and tension, a part of the skin covering
 it becomes inflamed, fluctuation can here be felt, and if an incision be not made
 into it, it will give way, discharging most usually a quantity of dark-colored
 pus, mixed up with more or less broken down and disintegrated coagulum and
 fibrinous  deposit, and perhaps sooner or later followed by a stream of  arterial
 blood.
    Occasionally, but more rarely, the sac extending backwards becomes adherent
 to the  pleura, and may give way into that  cavity, or  by pressing upon, may
 become  incorporated  with the lungs.   Of  this remarkable  termination,  two
 instances are recorded, in one of which recovery took place.
    The first case of the kind is one in which Mr. Bullen  ligatured the subclavian
 artery  for axillary aneurism.  Eighteen days  after the  operation the tumor
 began  to increase, and to take on the symptoms that are indicative of suppura-
 tion.   On the twenty-sixth day six or eight ounces of bloody pus were expecto-
 rated during  a  paroxysm of coughing, and  the tumor suddenly  diminished to
 one-half its size;  it was now punctured, and five  ounces of the  same kind of
 matter  let out with great relief.  When the patient coughed, air passed into and
 distended the sac  through an aperture between the first  and second ribs, near
 their sternal  extremities, through which the contents of the tumor had  escaped
 into the  lung.  The  discharge from the  external aperture greatly decreased, 
     ACCIDENTS  AFTER  LIGATURE OF THE SUBCLAVIAN.  559

the cough lessened, and finally, three months after the operation, the patient
was quite well.
   Dr. Gross  tied the  subclavian artery for axillary aneurism  on the 18th of
February.  After the performance of  the operation the contents of  the tumor
solidified, and its volume progressively  diminished.  On the 15th of March, the
patient suffered from  fever, and slight tenderness on the  apex of the tumor
was perceptible.   On  the 16th, he was suddenly seized with intense pain in the
chest, which was particularly severe at the base of the right lung, and extended
up towards the axilla.  The respiration  throughout the right lung was bron-
 chial, and there was dulness on percussion over the lower ribs; the aneurismal
 tumor had suddenly disappeared at the time of the attack.  On the 18th, the
 patient  experienced a sensation, as if a  fluid was passing  from the pleuritic
 cavity into that of the aneurismal tumor; and,  upon auscultating,  a plashing
 sound was heard at every inspiration, the noise resembling that produced by
 shaking water in a closed vessel.   On the 20th he died.   Upon dissection the
 aneurism was  found to  communicate by  an aperture, one  inch  and three-
 quarters in length, by  an  inch and a half in width, with the pleural  cavity;
 this opening was  situated between the first and second ribs, and was obviously
 the result of ulceration and absorption, caused by the  pressure  of  the tumor.
 Both ribs were denuded of their periosteum.   The right side of the  chest con-
 tained nearly three quarts of bloody serum, intermixed with laminated clots
 and flakes of lymph; the former of which had evidently been lodged originally
 in  the  aneurismal sac (Norris,  in  American journal,  1845, p. 19).  Besides
 these cases, a somewhat similar one has been recorded by M. Ncret, of Nancy.
  A patient was admitted into the hospital, laboring under hemoptysis, and  on
  examination was  found to have an aneurism of the left subclavian artery as
  large as a  chestnut.   He died shortly after admission, and on examination the
  aneurism was found  to communicate with a large  cavity in the upper part of
  the lung.
    The  cause of  death in Dr. Gross' case  was probably the fact  of  the sac
  opening and  discharging its contents into the pleural cavity.   This does not
  appear to have occurred in Mr. Bullen's, in which a communication was esta-
  blished directly with the lung, the contents of the abscess finding exit  through
  the air-tubes, as is the case, occasionally, in  hepatic abscess, adhesion having
  previously taken place between the opposed surfaces of the pleura.
    The principal danger, and the most frequent cause of death after the suppu-
  ration of the sac, is the supervention of profuse arterial hemorrhage.  This may
  either  occur from the distal  extremity of the artery opening into the sac, or
  from one of the large branches which serve to support the collateral circulation
   round  the shoulder,  such as the subscapular or posterior circumflex, coming off
   either  immediately  above or below  the sac, or  from  the sac itself.   When
   hemorrhage does  not  take place  after  the suppuration of the sac, it  must be
   from the fortunate  circumstance of the occlusion of the  main trunk,  where it
   opens into the tumor.   It can scarcely be from the occlusion of the principal
   collateral branches, as  there would, in this event, be a difficulty in the preser-
   vation  of the vitality of  the  limb.   It  is easy to understand, that if the  sac
   sprint from the axillary, at a little distance above the orifices of the subscapular
   and circumflex arteries, all that portion of the main trunk which intervenes
   between the tumor and these vessels might be occluded, and thus hemorrhage
   be prevented on suppuration taking place; whilst the collateral circulation
   would take place uninterruptedly through these vessels.   If this portion of the
   artery have not been occluded by inflammatory action, the safety of the patient
   must depend upon  the  accident  of  a coagulum or piece  of laminated  fibrine
   being fixed or entangled in the mouth of the sac.  This may prevent for a time
   the  escape of arterial blood,  which,  on  such a plug being loosened, may break 
560        ANEURISM OF  THE  AXILLARY  ARTERY.

forth with impetuosity, and either at  once, or by its recurrence at intervals,
carry off the patient.
   Another danger may be superadded  in these cases on the suppuration of the
sac and the supervention of hemorrhage, namely, the  occurrence of inflamma-
tion of the pleura,  lung, and  pericardium,  from  the extension inwards of the
morbid action going on in the  sac.
   Secondary hemorrhage does not frequently occur in cases of ligature of the
subclavian artery in the third part  of its course, except as a consequence of
suppuration of the sac.  I am only acquainted with two cases in which it proved
fatal from the  hemorrhage  taking place  from this artery at the part ligatured.
One of these  happened  to Liston, and  the  preparation  is  preserved in the
Museum of the College of Surgeons (No. 1695).  In this  case, it may be seen
that the artery was  diseased at the  point ligatured, and that  the bleeding
occurred, as usual, from the distal side of the ligature. ^
   Gangrene of the hand and arm is but seldom  met with as a sequela of the
operation we are considering.  This  is  doubtless owing to  the freedom of the
anastomosing circulation between the  branches  of  the transversalis colli and
humeri, and those of the subscapular, circumflex, and thoracic acromial arteries;
as well  as between the superior  thoracic  and  the branches  of  the first and
second intercostals  and internal  mammary,  by which the vitality of the limb is
readily maintained.   The principal  risk from gangrene would doubtless arise
from the subscapular  artery being in  any  way occluded or  implicated in the
disease, as it is  on the anastomosis of this vessel that the limb is mainly depend-
 ent for its supply of blood.   But, at all  events, this  danger is small, the only
 case in which  it appears  to have given rise to a fatal termination being one  in
which Mr. Colles tied the artery;  gangrene of the limb coming on after much
 constitutional disturbance of a low type, with rapid, weak pulse, thirst, sweats,
 restlessness,  and delirium.  In  Blizard's case, there was sloughing of the sac,
 and pericarditis, the gangrene being confined to two  fingers; and  in Brodie's
 case, it occurred in  both the lower as well as in the upper extremity, and must,
 therefore, have proceeded from some constitutional cause, altogether independent
 of the mere arrest of circulation through the subclavian.
   The case of  an axillary aneurism becoming inflamed, and threatening to run
 into suppuration  before the surgeon  has had an opportunity of  ligaturing the
 subclavian artery, is one that is full of important practical considerations, and
 one that admits of  little delay, for  if  the  sac rupture,  or  be  opened, fatal
 hemorrhage  is  the necessary and  inevitable result.  It  would obviously  be
 impossible, in a case of spontaneous  aneurism, with any fair chance of success,
 to lay open the tumor, turn  out the coagula,  and ligature the vessel above and
 below the mouth of the  sac; the coats of the  artery being not only diseased,
 but still further softened by inflammation and supervening suppuration, would
 not be in a condition  to hold  a ligature.   There are two other courses open,
 viz., the ligature of the vessel, or amputation at the shoulder-joint, and in the
 selection of one or  other  of these, the surgeon must be guided by the progress
 the disease has made, the condition of the limb as to circulation and temperature,
 and whether the contents of the tumor are solid or fluid.
   If the tumor be of a moderate size, and  circumscribed, the arm of a good
 temperature, and not very cedematous, the  ligature  of the  artery may hold out
 a reasonable chance of  success.   It  is true  that this is but  a chance; for as the
 blood will, immediately after the noose  is tied, be  carried  by the supra and
 posterior scapular arteries into  the subscapular  and  circumflex, and by them
 into the axillary at no great distance from  the mouth of  the  sac, or  enter,
 perhaps, directly into  the mouth of the latter  if the profunda  or circumflex
 should chance to take their origin from  the  dilated  portion of the vessel, the
 only safeguard against  the  supervention  of hemorrhage as soon  as the sac has
 burst or been  opened  or has discharged its contents, will be the occlusion  by 
LIGATURE OF THE  AXILLARY ARTERY.         561
inflammatory action of that portion of the artery that intervenes between these
two collateral branches and  its mouth, or the accidental entanglement in  the
latter of a mass of laminated fibrine.  Yet under the circumstances, as to  the
condition of tumor and limb that have just been mentioned, it would  be  but
right for the surgeon to give the patient a chance of preserving his limb.
   Should, however, hemorrhage occur on or after the discharge of the contents
of the  sac,  the subclavian having previously been ligatured, what should be
done ?   If the bleeding be moderate, an attempt should be  made to arrest it by
plugging the wound, and by the application  of a compress and bandage.  If it
recur, or is  so profuse as to threaten the life  of the patient, what course should
the  surgeon then pursue ?  Two lines  of procedure are open to  him: either
 cutting through  the pectoral  muscles so  as to lay the sac open  fully,  and
 attempting  to include the bleeding orifice between two ligatures, or amputation
 at the shoulder-joint.
   If a surgeon were  to  undertake the first of these alternatives in a case of
 spontaneous aneurism, of which alone we are now speaking, he  would, in all
 probability, find the part in such a condition as would prevent the possibility
 of his completing the operation he had commenced.  After laying open a large
 sloughing cavity, extending under the pectoral muscles, perhaps as high as the
 clavicle, and clearing  out the  broken-down coagula and grumous blood it  con-
 tains, in what state would he find the artery ?   Certainly, the probability would
 be strongly against its being in such a condition as to bear a  ligature, even if it
 could be included in one.  Its coats, in the immediate vicinity of the sac, could
 not, in accordance with what  we know to  be almost  universally the  case in
 spontaneous aneurisms of large size or old standing,  be  expected  to be in
 anything like a  sound, firm state, and would almost certainly give way under
 the pressure of the noose; or the vessel  might have undergone fusiform dilata-
 tion, as is very common in this situation, before giving rise  to the circumscribed
 false aneurism, in which  case it would be impossible to surround it by a ligature;
 or, again, the subscapular or circumflex arteries might arise  directly from, and
 pour their  recurrent blood into the sac or the dilated artery, and lying, as  they
 would, in the midst  of inflamed and sloughing tissues, no  attempt at including
 them in a  ligature could be successfully made.   Under such circumstances as
 these, the  danger of the patient would be considerably increased,  by the irrita-
 tion and inflammation that would be occasioned by laying open and searching
 for the bleeding vessel in the sac of an inflamed, suppurating, and sloughing
 aneurism,  and much valuable time would  be  lost in what must  be a fruitless
 operation;  at the close of which it would,  in all probability, become necessary
 to have recourse  to  disarticulation at the shoulder-joint, and thus remove the
 whole disease at once.   I  should, therefore, be disposed  to have recourse to
 disarticulation at the  shoulder-joint  at  once, in all cases  of profuse recurrent
 hemorrhage, following sloughing of the sac  of an axillary aneurism, which could
 not  be arrested  by direct pressure on the bleeding orifice, after the subclavian
 has been tied.
   There is another form of axillary aneurism that requires immediate amputa-
 tion at the shoulder-joint, whether the subclavian  artery have previously  been
 ligatured or not;  it is the case  of diffuse  aneurism of the armpit, with threatened
 gangrene of the  limb.
   Ligature of the axillary artery. — Should  ligature of  the axillary
 artery at any time be required, the vessel may be  secured in  two ways, in the
 space that  intervenes between  the lower margin of the  clavicle and the  fold of
 the axilla.
   The first is by an incision, either straight or somewhat semi-lunar, parallel
 to and immediately below  the inferior border  of the clavicle;  this must be
 carried through  the pectoral  muscle,  and when  this is  divided,  some  loose
 cellular  tissue, in which the thoracica suprema  artery  ramifies, is exposed.
         36 
562
ANEURISM  OF  THE  FORE-ARM.
This must be scratched through cautiously, until the fascia covering the vessels
is reached.  On opening this, which must be done in  the most careful manner,
by making a small aperture in it and then  passing a grooved director under it,
the vein first  comes into view.   This must be  drawn downwards, when  the
artery will be found immediately above and behind it in the deep hollow formed
by the clavicle above, and  the edge of the lesser pectoral below.  This opera-
tion is an exceedingly difficult one, on account of the  depth and narrowness of
the wound and the muscular character of its walls, as  well  as  from the embar-
rassment  occasioned  by the numerous  venous and  arterial  branches which
ramify  across  the space  in which the artery lies.   After the  vessels  have
been  exposed, the passage  of the ligature around them will  be greatly facilitated
by bringing the arm to the side of the body, so as to take off all tension in the
wound.
   The  safer and  simpler  operation  consists in making an incision from  the
centre of the clavicle  directly downwards,  in the  course of the vessels, to  the
middle of the anterior fold  of the axilla.  In this  way  the skin, superficial
fascia, and pectoralis major must be  successively divided.  The lesser pectoral
will  then   be  exposed, and  the  artery may  either  be ligatured  below  this,
without further division of muscular substance, or if it be thought desirable to
deligate it under this, the muscle must be  cautiously  cut through.  When this
is done a very distinct and firm fascia will  come into view; this, being pushed
up, must be  carefully opened,  when the artery and  vein will be seen lying
parallel to  one another, the artery not being  overlapped by  the vein, as  it is
higher up.   The vein having  been drawn inwards, the  aneurismal needle
 must be carried from above downwards between it and the artery.   The great
 advantage of this operation is, that the wound  is open and free, and that, con-
 sequently, the artery can  be more readily reached in any part  of its course.
 The  disadvantage is the  great division  of muscular  substance that it entails.
 This, however,  need  not leave any permanent weakness  of the  limb, as by
 proper position ready and direct union may be  effected between the parts.

       ANEURISM  OF  THE ARM,  FORE-ARM,  AND  HAND.

   Spontaneous aneurism  rarely occurs  below  the  axilla, but yet it may  occa-
 sionally be met with  at  any part of the  upper  extremities.  Thus  Palletta,
 Flajani, Pelletan, and others, relate cases of spontaneous aneurism at the  bend
 of the arm; and Liston states that he  once tied the brachial artery in an old
 ship-carpenter, who, whilst at work, felt as if something had snapt in  his  arm.
 Mr. Pilcher has recorded  a case of aneurism under the ball of the right thumb,
 which  was produced  by  repeated though slight blows with the  handle  of a
 hammer used  by the patient, a working goldsmith, in his  trade;  the radial and
 ulnar arteries were  tied  immediately above the wrist, and  the disease  thus
 cured.  Aneurism  has also been met with in this  situation after attempted
 reduction of the thumb.   Spontaneous aneurism in the fore-arm is of extremely
 rare occurrence.   I am only acquainted with  one, that recorded by Mr. Todd,
 as occurring  in a  woman twenty-eight years of  age, which had existed for
 several years  before the  brachial was ligatured, when pulsation in the tumor
 ceased, though it continued solid and  hard  for some months after  the  ope-
 ration, and in 1849,  a  man was admitted into  University  College Hospital,
 for  a  tumor  that  presented  all  the  characters  of aneurism, and  that was
 situated  in the upper third of the ulnar artery of  the  right fore-arm.   The
 brachial  was  ligatured by Mr. Arnott, when pulsation  and bruit ceased  in
 the  tumor, though some enlargement of  the arm  continued for some  time
 afterwards.
    Rare as spontaneous aneurisms are in these  situations, the traumatic forms  of
 the  disease are, as has already been stated (page 178), of  frequent occurrence, 
       ANEURISM OF THE ARM, FORE-ARM, AND HAND.   563

and may require the ligature of the brachial, or of either of the arteries of the
fore-arm.
  In cases of aneurism in this situation, direct pressure  might be  tried with
advantage, provided they are of small size and unattended by inflammation of
the superjacent integuments.  Compression  to the trunk  of the  artery above
the tumor is rarely applicable on account of the pain that is induced by the
pressure upon  the  neighboring  nerves which  cannot be isolated from the
artery.
   Ligature of the brachial artery.—The brachial artery may be ligatured
in the  middle  of the arm, which is considered the  seat of election of this
operation, by making an incision about three inches long, parallel  to and  upon
the inner edge  of  the biceps, which is the " directing line;" the fascia, which
is exposed, must   be  opened  carefully to  a corresponding  extent, when the
median nerve will commonly be seen crossing the wound; this  must be drawn
downwards with a blunt hook, when the artery, accompanied by its two veins,
will be exposed; these vessels must then be separated from one  another, and
the ligature passed and tied in  the usual way.   In performing this operation
the principal point to attend to is to cut down upon the inner edge of the biceps,
which will be the sure guide to the artery.  If the surgeon keep too low, he
may fall upon the ulnar nerve  and the inferior profunda artery, which  might
possibly be  mistaken for the brachial;  but by taking  care to expose the  lower
fibres of the biceps in his early incision, he will avoid this error.
   In the upper part of the arm, the brachial artery, where the  axillary termi-
nates in it,  will be  found lying immediately behind, and covered by its  vein.
On drawing this to the inner side, the artery will be seen, the plexus of nerves
being somewhat above and behind it.  In ligaturing the artery in this situation,
care must be taken to divide the integuments, which  are extremely thin, with
great caution;  when by rotating the arm outwards and bending the elbow, the
artery will be  thrown forward and  rendered less tense, so that a ligature can
easily be  passed around it.
   At the bend of the arm, the brachial artery may be reached by making an
incision about  two  inches in  length in  a direction   downwards  and  inwards,
about half an inch  internal  to the edge  of the tendon of the  biceps.   After
carrying it through the skin and fascia, the  vessel will be found  accompanied
by its veins, in  the triangular space bounded externally by  the biceps tendon,
and internally by the  pronator teres.  In performing  this operation, the  veins
at the bend of the  arm, with  the  filaments of the internal cutaneous  nerve,
must be divided to some extent, though they should be spared as  much as pos-
sible.   The artery will be found  about half  an  inch to the  inner side of the
tendon, accompanied by the median nerve, which is to its ulnar side.
   The radial and ulnar arteries should never, I think, be ligatured above the
middle third of the arm except in cases of direct wound; any attempt at deli-
gating them at the upper part  of the fore-arm, will not only be attended with
great difficulty, but with the danger of  crippling the muscles in this situation,
and thus  impairing the  after movements of the arm, and may always have the
ligature of the brachial  substituted for it.
   The  radial  artery may be ligatured  near  the  wrist, by making an incision
about two inches in length, half an  inch  to  the outside of the tendon of the
flexor carpi radialis, the "directing line;" when, after  the division  of the super-
ficial and deep fascia,  the artery, accompanied by its two veins, will be exposed,
and may be tied in the usual way.
   The  ulnar artery above the wrist, may be readily ligatured  by  making an
incision about two inches in  length, a little above, and one-third of an inch to
the radial side  of the pisiform bone, parallel  to  the  tendon of the flexor carpi
ulnaris, which  is the "directing  line" to the vessel.   After dividing the  fascia
covering it, the artery, with  its two accompanying veins, will be found to the
radial side of the ulnar nerve. 
564      ANEURISM  BY  ANASTOMOSIS,  AND NEVUS.
                       CHAPTER XXXIX.

           ANEURISM BY  ANASTOMOSIS,  AND NEVUS.

  Aneurism by anastomosis, is a disease of the  arteries, in which the vessels
become excessively elongated, tortuous, and serpentine; sometimes they assume
a varicose condition, being dilated into small  sinuses, and are always very thin-
walled, resembling rather veins than arteries in structure.  This kind of dilata-
tion of the vessels will give rise to pulsating tumors, often of considerable size,
and of a very active and dangerous character.   They may be situated in almost
any tissue or organ of the body, but are most  commonly met with  in the sub-
mucous and subcutaneous cellular tissue, and most frequently occur in the upper
part of the body,  especially about the  scalp,  orbit, lips, and face; but they have
been met with in other  situations, such as the  tongue, and even in internal
organs, as the liver, and I have seen very active  growths of this  kind on the
nates  and  foot.   In  some  cases, aneurism by anastomosis occurs in bones, in
which it forms a special disease, and is not uncommonly associated with enceph-
aloid.   Indeed, there is certainly a great tendency for aneurism by anastomosis
and encephaloid to run into  one  another, the limits  between them not being
very clearly defined, especially when occurring in  connection with osseous tissue.
It will generally be found that the arteries leading  to, though at a considerable
distance from the aneurism by anastomosis, are tortuous, enlarged, with thin and
expanded coats, and pulsate  actively; in fact, constituting that condition  that
goes by the name of cirsoid dilatation of the vessels.
   Aneurism by anastomosis forms tumors of varying magnitude  and irregular
shape; they are usually of a bluish color, have a spongy feel, are readily com-
pressible, not circumscribed, and with large  tortuous vessels running into and
from them on different sides.   Their temperature  is generally above  that of
neighboring parts; and a vibratory or purring thrill, amounting in many cases
to distinct pulsation, may be felt in them.   This  pulsation or thrill is  synchro-
nous with the heart's beat, may be arrested by compressing the tumor or arteries
leading to it, and returns with an expansive beat on  the removal of the pressure.
The bruit is often loud  and harsh, but at other times  of a soft and  blowing
character.   These growths  rarely occur in  infancy, but generally make their
appearance in young adults,  though they may be  met with at all periods of life,
and often as the consequence of  an injury of  some  kind.
   It is of importance to effect the diagnosis  between ordinary aneurism and that
by anastomosis.   In many cases  the  situation  of the  tumor at a distance from
any large trunk, as on the scalp, the outside of the  thigh, or the gluteal region,
will determine this.  Then again the  outline of the growth is less distinct than
in true aneurism; and tortuous vessels will be felt leading to it from  different
directions.   The swelling also is doughy, and very  compressible; but when the
pressure is removed, the blood enters it with a whizz and thrill, not with the
distinct pulsating stroke that is found in aneurism.  The pulsation, not so forcible
as  in aneurism, is more heaving  and expansive.   The bruit is  louder, more
superficial, sometimes  having a cooing note.  By pressure on the arteries leading
to the tumor, these signs are usually not entirely  arrested, though diminished in
force, the blood entering  it from  the neighboring  parts, and in a less direct way.
   The treatment of aneurism by anastomosis  must  depend upon  the  size and
situation of the growth.  When it is  so placed that it can be ligatured or ex-
cised, as on  the lip, or  when of small  size, about the  neck, face, or  scalp, it
should be removed in one or other of these  ways.  I always prefer, in  cases of
nevus, the ligature applied, as will immediately be described,  as being the safest, 
NEVUS.
565
and upon the whole the readiest mode of getting rid of such a tumor.  If ex-
cision be practised, it is necessary to be very careful to cut widely of the disease;
if it be cut into, fearful hemorrhage may ensue, which can only be arrested by
pressure, and which in several instances has proved fatal.
  If the disease be very large and extended, as is  commonly seen on the scalp,
or when deeply seated, as  on the orbit, neither ligature nor  excision of the
tumor  can be practised, and it becomes necessary to starve it by cutting off its
supply of blood.   This may be done either by ligaturing the principal branches
leading to it, or the  main trunk of the limb or part. The simple ligature of the
arterial branches  leading  to the tumor  has never, I believe, been followed by
success, at least in 10 recorded instances in which it has  been  had  recourse to,
the disease has not in one instance been cured.   It has, however, been success-
fully conjoined by Dr. Gibson, in  2 cases  of aneurism  by anastomosis of the
scalp, with incisions made round the tumor  at intervals between  the principal
feeding arteries, which at the same time were tied.
   The main trunk leading  to the tumor has been ligatured  in a considerable
number of cases.   The brachial and femoral arteries have been tied for disease
of this kind situated on the extremities, and in some instances with success;
but the carotid is the vessel that has been  most frequently deligated in conse-
quence of the  tumor being so commonly situated on the scalp and in the  orbit.
This operation has been done in 20 recorded cases, and in 5 instances both  the
carotids were ligatured at intervals of several weeks.   In all of those cases  in
which the double operation was performed, the patients ultimately recovered.
In some  of the  cases  in which one  carotid alone was tied, the  disease  being
seated upon  the scalp, was not cured, and it was afterwards  found necessary to
have recourse  to ligature of  the  tumor, to excision, and  to  other means  of
removal; indeed, when seated upon the scalp, this disease appears  to be  more
intractable than in any other part  of the body, owing probably to  the freedom
of the arterial supply  from  the numerous  vessels that ramify in  this region.
Here, however, much benefit might be derived after ligature of the carotid,  by
adopting the plan suggested  by Dr. Gibson, of tying the feeding arteries, and
making incisions  between them down to the bone.   The ligature  of the carotid
has answered best for diseases of this kind  in the orbit; of 6 instances in which
 the artery has  been  tied for aneurism  by  anastomosis in this situation, in 5 a
 cure was accomplished.

                                  NEVUS.

   This  disease,   under  which those various affections are included, termed
 mother's marks,  erectile  tumors, and vascular growths, constitutes an important
 and interesting section of surgical affections.  It appears to consist essentially
 in an  excessive development of  the vascular tissue of a part, and differs greatly
 as to nature, cause, and  treatment;  according  as  the  arterial, the  capillary, or
 the venous elements of the tissue predominate.  The predominance of the arte-
 rial tissue we  have already considered, under the  head of  aneurism by anasto-
 mosis, it now remains for us to describe the capillary and venous nevi.
    Capillary nevi appear  as slightly elevated but flat spots on the skin, of a bright
 red or purplish  tint, and having occasionally granular or papillated elevations,
 with some larger vessels  ramifying on their surface.   They often spread super-
 ficially to a considerable extent;  they are usually situated on the face, head,
 neck, or arms, but occasionally,  though more rarely, on the  back, the nates, the
 organs of generation, and the lower extremities; they are, I believe, always con-
 genital, though often at  birth of a very small size, not larger than a pin's head,
 from which they may spread in the course of a few weeks or months to patches
 an inch or two in diameter.  In many  cases no inconvenience  results from this
 disease, except the  deformity it entails, but occasionally, more especially when 
566      ANEURISM  BY ANASTOMOSIS,  AND NEVUS.

the growth is at all prominent, there is a great disposition  to  ulceration  of an
unhealthy and hemorrhagic character.  When bleeding occurs, it is usually in a
trickling stream, and  without any degree of force.
   Venous nevi are of a dark purple or reddish color, usually very prominent, and
often forming distinct tumors of considerable size, which may  either be smooth
and ovoid, or else somewhat lobulated.  On compressing a growth of this kind,
it  subsides to a certain  extent, feeling doughy, soft, and inelastic, and on the
removal  of the pressure fills up again.  In  some  cases, when consolidated by
inflammation, or containing  cysts, it cannot be  lessened in bulk  by pressure.
These  nevi  are usually about the size of half a walnut, but sometimes  much
larger.   I have removed them from the nates  and the back fully as large as an
orange.  They less frequently  occur upon the head and face than the capillary
form of the disease;  most of the  instances  that I have seen have been met with
in the lower part of the body,  about the nates, back, lower  extremities, and
organs of generation.
   Subcutaneous nevi  are occasionally met  with, of a mixed character, forming
soft, doughy, and compressible tumors, which may be recognized by being capable
of diminution by pressure,  on the removal  of which they slowly fill out again to
as large a size as before; they also become distended when the child screams or
struggles, and are usually of an  oval shape, smooth, and uniform.  The skin
covering the tumor is often unaffected ;  at  other times it is implicated in an oval
patch on the most prominent part of the growth, and occasionally the surround-
ing veins are bluish and enlarged.
   In structure, the capillary nevi appear to be  composed of a congeries of small
tortuous vessels, of a capillary character;  the venous nevi appear made up of
thin tortuous veins, dilated into  sinuses and  small pouches.   In the midst of
               these  masses, cysts are  not uncommonly found, sometimes con-
               taining clear, at other times, a dark, sanguinolent fluid.  These
               cysts are probably venous sinuses, the openings into which have
               become occluded.
                 The treatment  of nevi may be conducted on three principles.
               1st, by  means  calculated  to excite  adhesive  inflammation in
               them, and  so to  produce  plugging and obliteration of the vas-
               cular tissue of which they are composed;  2d, by agents that de-
               stroy the growth; and 3d, by removal with the  knife or ligature.
               Each  of these different plans  of treatment is  peculiarly appli-
               cable when the disease assumes certain forms, and affects certain
               situations.
                ^ 1st. When the disease  is  of small size, and occurs in such
               situations that its destruction by caustics, or removal by knife or
               ligature, would  be attended by serious deformity, as when  it  is
               seated about the eyelids, upon the tip of the nose, at the inner
               angle between the eye and the nose, or about the corners of the
               mouth, it is best to endeavor  to procure its obliteration, by ex-
               citing the  adhesive inflammation in  it.   This  may be done in
               various ways.  If small, the nevus may be vaccinated.   If larger,
               the most convenient  plan consists, perhaps, in passing a number
               of fine silk threads across the tumor in different directions, and
               leaving them in for  a week or two at a time, until they have
               produced sufficient inflammation along their tracks, then with-
               drawing them, and passing them into other parts of the tumor.
               In this way its consolidation may gradually be effected.  Another
               very useful plan is to break up the substance of the growth sub-
               cutaneously, by means of a cataract needle, or  tenotome, and in
               the intervals  between the different introductions of this  instru-
ment to keep up pressure upon it.  In other cases, again, passing acupuncture
 
                       LIGATURE  OF  NEVUS.                   567

needles into  it, and then heating them by means of a spirit-lamp, or injecting
the perchloride of iron into it by means of a small glass syringe with a screw-
piston  rod and a fine sharp-pointed nozzle (fig. 192), will induce the requisite
amount of inflammation. In all these different ways the surgeon may succeed in
curing the  disease.
   2d.  When the nevus is small, very superficial, of the capillary character, with
an exceedingly thin covering of cuticle, and so situated,  as upon the arm, neck,
or back, that a moderate amount of scarring is of little consequence, it may most
conveniently be  removed by the free application of nitric acid.   This should be
well rubbed on by means of a piece of stick, and after the separation of the
slough produced by it, its application must  be repeated  as often as there is any
appearance of the granulations springing up, which will occasionally happen at one
angle  of the  wound, and is indicative of a recurrence of the vascular growth.
   3d.  When the nevus is of large size, constituting a more or less distinct tumor,
and is of a somewhat venous character,  it may occasionally be excised.  In doing
this, however, care should be taken to cut wide of the disease,  and no operation
with the knife should be undertaken unless the growth  be either so situated, as
upon the lip, that the parts  may readily be brought or compressed together, or
upon the nates  or  thigh, and  of a very indolent and venous character.  As a
general rule, it  is  far safer, and more convenient, to extirpate the growth with
the ligature, and this, indeed,  is the mode of treatment that  is most generally
applicable to tumors of this kind  in whatever situations they may occur, as it
effectually removes them without risk of hemorrhage, and leaves a sore that very
readily cicatrizes.
   The ligature requires  to be applied in  different ways, according to the size
and situation of the  tumor.  In all cases, the best material for this purpose is
firm, round, compressed whip-
 cord.   This should be tied as                    Fie. 193.
 tightly as  possible, and knot-
 ted securely, so that there may
 be no chance of any part  of
 the tumor escaping complete
 and immediate  strangulation.
 It is  well, if possible, not  to
 include in  the  noose  any
 healthy skin, but  to  snip
 across with a pair  of scissors
 that  portion of integument
 which intervenes between the
 cords  that are tied together;
 at the same time  care must
 be taken to  pass the  ligatures
 well beyond the limits of the
 disease.
    When the tumor  is small,
 an  ordinary double  ligature
 may be passed across  its base,
 by means of a common suture
 needle, and  the noose being cut  and the thread tied on either side, strangula-
 tion will be  effected.   When of larger size, and  of round shape, the most con-
 venient plan of strangulating  the tumor is that recommended by Liston.   It
 consists in passing, by means  of long  nevus-needles, fixed in  wooden  handles,
 and having  the  eye  near their points, a double whipcord ligature, in  opposite
 directions across the tumor; then cutting through either noose, and tying together
 the contiguous ends of the ligature until the whole of the growth is encircled and
 strangled  by them.  In doing this, a few precautions are necessary : thus, the
 
568       ANEURISM BY  ANASTOMOSIS,  AND NEVUS.

first nevus-needles should be passed across the tumor unarmed (fig. 193 a), and
used to raise up the growth  somewhat from subjacent parts.  The second needle
                         armed (fig. 193 b), as represented in the annexed wood-
        Fia. 194.         cut, carrying the whip-cord ligature by means of a piece
                         of suture silk, should be  passed  across the  tumor in
                         the  opposite  direction  to, but underneath  the first
                         needle;  the needle (h) being withdrawn, the ligature
                         is carried across, and the first one having been armed
                         in the same way, carries its noose through the tumor
                         as it  is  drawn out.   The  two nooses having then
                         been cut, an assistant must seize,  but not  draw  upon
                         six of the ligature ends; the surgeon then having
                         divided  the intervening bridge of  skin, ties pretty
                         tightly, in a reef-knot, the two ends that are left  hang-
                         ing out;  as soon  as  he has done this, he proceeds to
the next two, and so on until he gets to the last (fig. 194).  When he ties these,
he must do so with all his force, especially if the  tumor is large, as by drawing
on them he tightens all  the other nooses, and drags the knots towards the centre
of the growth, which is thus effectually strangled.  He  then  cuts off the tails
of the ligature.   After the tumor has  sloughed away, which  happens in a few
days, if properly and tightly strangled, the sore is  treated on ordinary principles.
If the  nevus is altogether subcutaneous, the skin covering  it should not be
sacrificed, but  being divided by a crucial incision, may be turned down in four
flaps, and the ligature then tied as directed.  In some situations, as in  the ante-
rior fontanelle, it may be dangerous to  pass  the threads  across the base of the
tumor, lest the membranes of the brain which lay immediately beneath it be
wounded.   This difficulty I have readily overcome, by making a  puncture on
one side of the tumor, and then pushing an eyed-probe conveying the whip-cord
across its base through the soft spongy  tissue of which it is composed, and cut-
ting down upon its point, where it projects  on the opposite side of the tumor
drawing it through; the second threads are tied in the same way, and the mass
firmly strangulated.   Although I  have seen convulsions follow the ligature of
nevi in this situation, I  have never met with a fatal result.
   In some cases, the  nevus is so flat and elongated that the application of the
quadruple ligature, as above described,  cannot include the whole of it.  Under

               Fia. 195.                           Fig. 196.
these circumstances, I have found the ligature about to be described eminently
useful, having successfully employed it  in  a great number of instances.   Its
great advantage is,  that while  it completely and very readily strangles  the
 
LIGATURE  OF NEVUS.
569
tumor, it  does not inclose an  undue quantity of integument,  and thus does
not produce a larger cicatrix than is necessary for the eradication of the disease.
It is applied in the following way :—a long triangular needle is threaded on the
middle of a whip-cord about three yards in length;  one half  of this is stained
black with ink, the other half is left uncolored.  The needle is  inserted through
a fold of the sound skin, about  a quarter of an inch from one end of the tumor,
and transversely to the  axis of the same.  It is  then carried through, until a
double tail, at least six inches in length, is  left hanging from the point at which
it entered; it is next carried across the base of the tumor, entering  and passing
out beyond its lateral limits, so as to leave a series of double loops about nine
inches in  length on each side (fig. 195).   Every one  of these loops should be
made about three-quarters of an inch apart, including that space of the tumor,
and the last loop should be brought out through  a fold of healthy integument
beyond the tumor.  In this way we  have a series of double loops, one white,
and the other black, on each side (fig. 195).  All the white loops should now be
cut on one side, and the black loops  on  the other, leaving  hanging ends of
thread of corresponding colors.
   The tumor may now be strangulated  by drawing down and knotting  firmly
each pair of white  threads on one side and  each pair of black ones on the other.
In this way the tumor is divided into segments, each of which is strangulated,
by a nose and a knot: by black nooses  and white knots on  one side, by white
nooses and black knots on the  other (fig. 196).
   The cicatrix resulting from the removal of  a nevus is usually firm  and
healthy, but in some  instances I have  seen it  degenerate into a hard warty
mass requiring subsequent excision.   The  ligature may be used successfully at
all ages.  I  have repeatedly tied large  nevi in  infants  a month  or two  old,
without meeting with any accident.
   It has  been proposed by Mr. Curling to ligature the nevus subcutaneously,
by passing a thread around its base, under the skin, and then tightening it.
This may succeed when the  growth is of small size, and  is useful when so
situated  that  a cicatrix is  objectionable.   Mr. Startin  has very  ingeniously
proposed a plan, which I have advantageously adopted in some cases, of elastic
subcutaneous  strangulation, by fixing a vulcanized india-rubber ring, put upon
the stretch, on  to the noose   of the ligature, and  then keeping  up  steady
traction upon it.  The annexed cut (fig. 197) represents  a nevus with  two
ligatures  (a, a) passed subcutaneously round  it, in opposite directions,  and
attached  to india-rubber rings (b, b), to which tapes are tied, by  which  the
traction is made.
                                 Fig.  197.
HEMORRHAGIC  DIATHESIS.
  In  connection with diseases of the arteries, it may be stated that, in some
constitutions, it is found, though, fortunately, very rarely, that there is a great
tendency  to  very troublesome, indeed almost  uncontrollable, bleeding  from
trivial wounds;  life  being put in jeopardy, or even lost, by the hemorrhage
resulting from the extraction of a tooth, the opening of an abscess, lancing the
gums, or some equally slight, unimportant surgical  nrocedure.   The blood in 
570          DISEASES OF  THE  NERVOUS  SYSTEM.
these cases does not flow in a jet, but continues to trickle in an oozing stream,
apparently from the capillaries rather than the arteries of the part.  This dis-
position is usually congenital, and in most cases hereditary; in other instances
it appeared to result from the acquirement of some peculiar cachectic or scor-
butic condition.  The precise condition  on which this hemorrhagic tendency is
dependent has not  been very clearly made out.   When hereditary, it occurs in
individuals who are robust, strong, and  otherwise  healthy.  When acquired, it
is usually met with in individuals who  have  been depressed in power by over-
work, bad and insufficient food, or venereal excesses;  and is evidently  owing to
defective nutrition.  In all cases, the blood is thin and watery, apparently defi-
cient in fibrine, and the capillaries easily lacerable  and not  sufficiently contrac-
tile.  In such cases as these, care  must be taken not  to  make any surgical
wounds if they can possibly be avoided;  though  it is a remarkable fact, that
this  condition seems  only to have been  met with after trivial injuries  of the
kind above mentioned, and not to have been encountered in any really serious
surgical case.  In  the treatment of the  diathesis little  can be  done.   It has
been proposed  to  administer  saline hydragogue  purgatives, with  a view of
inspissating the blood. I should, however, imagine that  an  improvement of the
general  health, by careful attention to food, exercise, etc. would  be  the best
means of increasing the plasticity of this  fluid.   In the  event of actual bleed-
ing occurring in such cases as these, the employment of pressure, or the appli-
cation of the actual or electric cautery,  will constitute the best means  of arrest-
ing the hemorrhage.  In  some cases  the electric cautery  may be advantageously
substituted for the knife, when it is  desirable to remove  parts in  persons suffer-
ing from this diathesis.  By this means,  the smaller amputations even may be
performed, as has been successfully done  by  Mr. Marshall.
                           CHAPTER  XL.

             DISEASES  OF THE  NERVOUS  SYSTEM.

  Inflammation of the nerves, or neuritis, is not of very unfrequent occurrence,
being usually the result of rheumatic inflammation, of  wounds, or strains.
When rheumatic, it principally affects the  nerves of the  face and  of the lower
extremity.   The symptoms consist  of tenderness  on pressure along the course
of the  nerve, with  severe continuous  pains, ramifying down its trunk and
branches, with occasional violent  exacerbations,  especially  on moving or touch-
ing the part, and at  night; there is usually swelling along the course of the
trunk, and  some constitutional pyrexia.  When chronic,  this condition may
readily  be   confounded with  neuralgia, of which, indeed, it  constitutes  one
variety.  On examination after death, in  these  cases, the  sheath of the nerve
will be found injected and swollen, and the nervous tissue softened.  The treat-
ment consists in  the employment  of antiphlogistic means;  cupping or the
application of leeches, according to situation, poppy or belladonna fomentations,
and local emollients.  When rheumatic, the acetous extract of colctncum is the
best remedy that can  be administered; when  of  a  more  chronic and  nocturnal
character, the iodide  of potass, either alone or in combination with sarsaparilla,
may advantageously be given. 
NEURALGIA.
571
                              NEURALGIA.

   In this disease, pain in the course of a nerve or greatly increased  superficial
sensibility, is the characteristic symptom.  It is of all degrees of severity, some-
times moderate, at others unendurable, even by those who possess the greatest
fortitude; when severe, it usually comes on suddenly, with a kind of shock, and
continues of a  sharp darting or tearing character, coursing along  the trunk or
ramifications of the  affected nerve, the distribution of which may often be
distinctly indicated by the direction the pain takes.  It is often accompanied by
other sensations, such as a tickling, smarting, or creeping feeling on the affected
surface; in some  instances  relieved by pressure,  in  others increased  by the
slightest touch, or movement of  the part.   Occasionally there is  spasm  in the
muscles supplied by the affected  nerve ; in others, heat and redness of the sur-
face, with increased secretion from the neighboring organs, as a flow of saliva
or tears, when  the nerves of the eye or jaw are implicated.   The duration of an
attack may vary from a few moments to many days  or months, the  pain being
most commonly intermittent or remittent, often  irregularly so, but  in some
instances  the periodicity is well marked.
   This disease may affect almost  any part of the  body; it is most commonly
seated  distinctly in  the trunk and  branches of a nerve.   The  divisions of the
fifth pair  are especially liable to be affected; it may extend to the whole of the
branches  of this nerve on one side of the head and  face, or more commonly it is
confined to one of its principal divisions, such as the infra-orbital, which is espe-
cially liable to be affected by it; in many instances it is seated in the temporal
and dental.  Not unfrequently some of the terminal twigs  merely, of one of
these nerves, become  the seat of intense pain; thus, occasionally, the  affection
is found limited to a patch on the cheek, brow, or temple; from which it scarcely
ever shifts.  The posterior branches of the dorsal spinal  nerves, and the inter-
costals, are also very commonly affected, though  not to the  same extent as the
fifth pair.  In other cases the whole of an organ, or part, becomes the seat of
neuralgia, though no one  nerve  may appear to be  distinctly implicated; thus,
the  testes, the  breast, the uterine organs, or one of the larger joints, as the hip
or knee, is  occasionally the seat  of severe  suffering  of  this kind.   An extreme
degree  of cutaneous  sensibility is  a marked  feature in the affection, in some
cases the  patient wincing and suffering severely whenever the skin is pinched
or touched, however lightly.
   The causes of this very painful disease, are very  various; in many instances
they appear to be purely  of  a nervous character;  depressing influences of all
kinds being especially likely to  produce it; thus,  debilitating  diseases, mental
depression, and particularly exposure to malaria, are  common occasioning causes;
those forms of the disease that arise from  malarial influences, or from exposure
to simple  cold  and wet, usually assume a very intermitting or periodical charac-
ter,  and are commonly seated in the nerves of the  head.  The hysterical tem-
perament  very  frequently disposes to the spinal and  articular forms of neuralgia.
Various sources of peripheral irritation, as loaded bowels, the  irritation of worms,
and  carious teeth, may be recognized as producing some  of the more obscure
varieties of the disease.
   Neuralgia may also arise from  any compression exercised upon the trunk of a
nerve, and thus indeed some of the  more intractable forms of the affection have
their origin.  Thus, the pressure of a tumor of any kind,  or of a piece of dead
bone, may give rise to the most intense pain in the part supplied by the  irritated
nerve;  and it  is not improbable  that in many of the cases of neuralgia in the
branches  of the fifth, pain may be owing  to periosteal inflammation, or other
disease of the osseous canals, through which these nerves pass.
   The diagnosis of neuralgia, though  usually effected without any difficulty, is
in some cases a little embarrassing, as  the pain may occasionally  simulate that 
572          DISEASES  OF THE  NERVOUS  SYSTEM.

of organic disease or inflammation of a part.   From organic disease of the part
that is the seat of suffering,  such as  the hip, the knee, the testis, or the breast,
this disease may usually be distinguished by the co-existence of cutaneous sen-
sibility, the existence of the hysterical  temperament, and  the absence of the
other signs that  would  accompany lesion of structure in the part affected.
From inflammation the diagnosis is usually sufficiently easy by attending to the
intermittent character of the neuralgic pain, its occurrence in hysterical tempera-
ments,  and in the  absence of  the  constitutional  symptoms of inflammation.
But occasionally when local inflammatory irritation is  conjoined with the neu-
ralgia, the diagnosis is truly difficult.   Here the presence of cutaneous sensibility
and the relief of the pain by firm  pressure will  indicate neuralgia; whereas, in
inflammation  there  is no tenderness of surface,  but the suffering is aggravated
by deep pressure.
   The  treatment of neuralgia must have reference to the cause of the disease,
and will  be successful or not  according as this may be more or less readily
removed.   So long as the conditions that primarily occasion the disease subsist,
the pain is likely to continue ;  and if these conditions are  irremovable the dis-
ease may be looked upon as necessarily incurable, though the suffering may be
alleviated by appropriate means.  When arising from any central nervous affec-
tion, there may be  the fear of the ultimate occurrence of disease of a  more
serious type, such as epilepsy, insanity, &c.
   When occurring in the  hysterical  temperament,  the administration of the
more stimulating and  stronger preparations of iron, such as the  sulphate, the
sesquichloride, or the mistura  ferri  comp., either alone or in combination with
quinine,  with attention  to the state of the bowels and of the uterine functions,
 and a general  tonic regimen calculated to brace  and improve the general health,
 such as sea-bathing, the  cold douche,  or sponging  will be found to be of essen-
 tial service.  In some of these  cases the combination of zinc, especially the vale-
 rianate with the fetid gums, will remove the disease when iron does not influence
 it much.   At the same time the application or inunction of belladonna or aconite
 plasters  and liniments  may be of service.  When  the  neuralgia is distinctly
 periodical, quinine  in  full  doses,  or the liquor  arsenicalis, will usually effect a
 speedy cure.  When rheumatic, occurring in debilitated subjects, and attended
 by distinct nocturnal exacerbations of pain, no remedy exercises so great an
 impression upon it as the iodide of potass, especially when administed  in com-
 bination with quinine.
    In the more severe and  protracted forms of the disease, relief  may be occa-
 sionally obtained by attention to the state of the liver and digestive organs, by
 a course of some of the more purgative mineral waters, and  by the occasional
 exhibition of aloeties or croton oil, followed by the administration of tonic reme-
 dies.  In  many cases, all  these means, however,  are  unfortunately unavailing,
 and the sufferer  is doomed to an existence of  constant pain, except when  the
 disease appears to cease  of  itself, or has its intensity blunted by the administra-
 tion of the more  powerful sedatives, such as morphia internally, or aconite or
 atropine externally.  In these distressing cases, the  sufferer is ready to grasp at
 any means of relief that is  held out to him, and section  of the affected nerve is
 not unfrequently recommended as a last chance of  the  removal of the disease.
 It  is clear, however, that such an operation, though occasionally  productive of
 temporary relief, cannot in many  cases  be expected to benefit the patient mate-
 rially; for by it the cause  of  the  neuralgia is not removed, and  it can conse-
 quently  only be of service when the pain is peripheral, occasioned by some local
 irritation existing between  the part cut and the terminal branches of the nerve.
 If dependent on  any central cause, or on local irritation existing higher up than
 the point divided,  it must  eventually be useless.  Thus, if the source of irrita-
 tion exist in the dental branches  of the infra-orbital, the division of this trunk
 might be useful; but if the pain be occasioned by any pressure  to which  this 
■
NEUROMA.
573
nerve may be subjected in its passage through its canal by a carious state of the
bones, or by disease of  the periosteum, it would be unavailing; though it is a
remarkable fact that  it not unfrequently happens after these operations that
there is a temporary cessation in the pain for a few weeks or months.  In some
of these cases, however, the pain shifts its seat from the branch operated on to
another division of the same trunk; thus, if the infra-orbital be  divided, the
submental becomes the seat of pain.   Or this may ascend, as it were, to the
point at which the nerve was divided;  as, in amputation for neuralgia of the
knee, the pain may return  to  the  stump, and  again when this is removed a
second or even third time.
   The nerves on which this operation has been  most frequently performed are
the infra-orbital and the submental.  Should  it ever be thought necessary to do
it, it would be proper not only to divide the nerve but to excise a portion of it,
otherwise reunion will speedily take place, and the continuity of the nerve being
re-established the operation will fail.  The procedure simply consists in cutting
down on the  trunk where it escapes from the foramen, isolating and dissecting
out a portion of it; in doing this, no great difficulty can be experienced by any
one possessing moderate anatomical knowledge.
   [In a recently published paper Dr. Carnochan, of New York, strongly advo-
cates the performance of a novel operation for the cure of aggravated cases of
tic-douloureux of the  face,  or neuralgia of the second branch  of the fifth
pair of nerves. He believes that in such cases the " key of the operation is the
removal of the ganglion of Meckel, or its insulation from the encephalon."  In
the operations which  he reports, Dr. Carnochan, after making  free incisions on
the face, perforated both  the anterior and posterior walls of the  antrum, and
removed the  ganglion of Meckel from its position in the spheno-maxillary fossa.
He at the same time  exsected a portion of the superior maxillary nerve an inch
and three quarters, or two inches in length, dividing  the trunk of the  nerve
across, immediately below the foramen rotundum.
   The examination of the portion of nerve removed, in  every instance revealed
similar  appearances.  The trunk was thickened, vascular, and enlarged; the
neurilemma and nerve proper being alike affected. The result of the three ope-
rations reported was satisfactory in the highest degree;  no unfavorable conse-
quences followed, and the patients were completely relieved of their agonizing
complaint.
   An operation somewhat similar to the above has been repeatedly and success-
fully performed by American surgeons for the excision  of the  inferior dental
branch of the lower maxillary nerve.  To effect this an incision should be made
over the perpendicular ramus of the lower jaw, and the masseter muscle divided
in the direction of its fibres down to the bone.  The crown of a trephine should
then be applied upon  the bone at a point immediately below the entrance of the
nerve into the dental  canal.   The trunk  of the nerve to the  extent of half an
inch or more in length may thus be easily exposed and removed.   The  relief
afforded to the patient has, as far as we are aware, in every case been prompt
and enduring.]

                               NEUROMA.

   By neuroma is meant a tumor connected with a nerve.  These growths have been
well described by Mr. R. W. Smith, in a recent Monograph on the subject, in which,
indeed, the principal  part of our knowledge of this subject is contained.  These
tumors vary in size from a millet-seed to that of a melon, are usually solid, and
composed of fibrous tissue, but when they attain a large bulk, cavities may form in
them, containing a yellowish or brownish serous-looking fluid, apparently owing
to the  disintegration of the central portions of the mass.   In shape they are 
574         DISEASES  OF THE NERVOUS "SYSTEM.

usually oval or oblong, their long axis corresponding to the course of the nerve
                     (fig. 198);  they grow  slowly, and  are  movable  trans-
       Fig. 198.        versely, but not in  the direction of the nervous trunk on
                     which they are seated;  they have no  appearance  of ma-
                     lignancy, and  however large they become never contract
                     adhesions to  the integument nor involve  its structure.
                     These  tumors commonly only affect  the nerves  of the
                     spinal system,  but  Berard has met with  one  case of the
                     disease on a ganglionic nerve.
                       Most commonly the  tumors are  single,  and then  are
                     usually attended with very severe lancinating or neuralgic
                     pain, which extends, however, only to the parts below the
                     tumor, and is  commonly of a paroxysmal character. This
                     pain is evidently owing  to the stretching of the nervous
                     twigs as they pass  along the convexity of the growth.
                     When single and painful, these tumors commonly go by
                     the name of  the painful subcutaneous tubercle, and  are
                     then usually met with from the size  of a  pin's head to
                     that of a cherry-stone, commonly seated  upon the  limbs,
                     and most frequently  in connection with the nerves of the
                     lower extremity; but they may be situated  upon the arm,
                     the trunk, or even  on  the scrotum  and  cheek, where,
                     however, they are  not so commonly met with.  Wherever
                     they occur they are acutely and intolerably painful on
                     being touched, and are usually tender as  well.
   In structure, the painful subcutaneous tubercle resembles exactly the ordinary
 neuromatous tumor, being composed  of a white or greyish fibrous mass developed
 in the neurilemma, and having nervous  filaments stretched through or over it-
 The nervous trunk above and below the tumor is  normal; it  is only where it
 comes in contact with it, and is exposed  to its pressure, that it  undergoes the
 change indicated.  It is a very remarkable  fact, that though neuromatous tumors
 when  single, or when but two or  three exist, are most acutely  painful, yet, that
 when  they are generally diffused over the body they lose their  sensibility and
 are unattended by any inconvenience, except such as arises from their numbers
 and bulk.  The number of these masses thus formed is often  amazingly great;  #
 thus, in one of Mr. Smith's cases, he counted in the two lower  extremities alone
 more than 250 of these tumors, besides  those  in other parts of  the body.   In
 another case related by Mr. Smith, there were upwards of 200 small neuromata
 scattered over the sides of the chest and abdomen, 450 on  the right lower ex-
 tremity, and upwards of 300 on the left, altogether probably not  less than 2000
 of these growths in "this unprecedented case."
   Traumatic neuromata may arise from the wound, or partial division of nerves,
 and occasion the most intense agony.   Sometimes growths of this description
 of a fusiform shape, and varying from a cherry-stone to a pigeon's  egg  in size,
 are met with in  stumps after  amputations; in many instances  unattended by
 inconvenience, but occasionally giving rise to a very severe degree of pain.
   The treatment  of painful  neuromata whether of an idiopathic, or traumatic
 character, or existing in stumps,  consists in their excision.   After  removal, the
 part supplied  by  the  nerve,  which is usually necessarily divided, becomes
 paralyzed for a time, but may eventually regain its sensibility.   In some cases,
 however, by cautious dissection, the tumor may be removed from the nerve that
 is in contact with it, without cutting this across. This has been done by Velpeau
 in the case of a neuroma of the sciatic nerve.  When these tumors are numerous,
 they should not  be interfered with, and if unattended by pain, they need  not
 be excised unless their bulk prove inconvenient.
 
TETANUS.                           575
                              TETANUS.

  Tetanus is a disease consisting  essentially in an excited state of the spinal
cord and the medulla oblongata, in fact of the whole true spinal system, giving
rise to painful and continued spasms of the voluntary muscles and the diaphragm,
alternating with incomplete relaxation  and usually terminating fatally.   This,
which is one of the most serious  and distressing diseases to which the  nervous
system is liable, is, in the  great  majority of instances, of a traumatic nature,
being the consequence of some wound  that implicates or irritates a portion of
the peripheral nervous system; the local irritation so produced, being propagated
to, and exciting the nervous centres, the excitation of which becomes persistent,
and continues after the local cause has been removed, inducing reflex muscular
movements in various parts of the body.  The irritation of the nervous system,
however, that induces tetanus, may arise from  other  sources  besides  surgical
wounds, occasioning  the  idiopathic form of the  disease; thus, for instance, the
presence of worms in the intestinal canal, exposure to cold and wet, and even
the uterine irritation following abortion, have been known to occasion it. These
causes, however, rarely give rise to it in this country, and we must consequently
regard it as a disease chiefly arising from traumatic lesion of some kind.
   Tetanus may be occasioned by injuries  that  do not give  rise  to breach of
surface; thus I have known it occur in a child who was suddenly thrown down
upon its back by another at play;  and Dr. Reid mentions a case produced by
the stroke  of a whip.  But certainly in the great majority of cases, it is directly
occasioned by a wound of some kind; and  then it will generally be found that
a nervous  twig has  been  lacerated, divided, or inflamed, thus  in a  case of
 tetanus following  a wound  of the knee, in a patient, who died in University
 College  Hospital,  a small branch  of the internal cutaneous nerve was  found  to
 have been injured  and was inflamed; and, in another patient  who  died of
 tetanus  about sixteen days after treading  on a rusty nail, a  black speck was
 found in the internal plantar nerve, where it had been wounded by the  nail.
 In another case under my care, in which tetanus resulted from a bruise of the
 back, and terminated  in death, the injured nerve (a dorsal branch) was found
 lying bare and reddened in the wound, and on tracing it up to the spinal cord,
 its sheath was found to  be much injured, ecchymosed, and with a large vessel
 running down it.
   The  kind of wound, as well as its  situation, doubtless influences  materially
 the occurrence  of the disease.  Though  it certainly more  frequently follows
 punctured, torn,  and lacerated, than clean-cut  wounds, yet it occasionally
 complicates these, even when the  result  of surgical operations; thus, it has
 been known to follow the removal of the breast, amputations, the ligature of the
 larger arteries, and the operation for hernia.  It is the common belief, both  in
 the profession and  out  of it, that wounds of the hands and feet, and more
 especially  of the ball of the thumb and of  the  great toe, are  more likely to be
 followed by tetanus  than those in other situations.  I think  the  truth of this
 opinion may be doubted; though it is not improbable that  tetanus may occur
 more frequently after injuries  of these regions, simply because punctured and
 lacerated wounds are more common here than elsewhere.  It cannot well be
 supposed to be owing to  the tendons and fascia that abound here, as it is seldom,
if ever, met with after operations for tenotomy, which are so commonly prac-
tised on the feet.
   Tetanus is especially apt to occur in feeble and debilitated  individuals, and,
indeed,  may be looked upon as a disease of debility;  hence any condition that
lowers the tone of the nervous system is especially likely to occasion it.   Thus,
in  unhealthy tropical climates,  as  in  some of the  West India Islands, and
amongst the marshes of  Cayenne, it is said to  occur  with peculiar frequency,
the  most trifling scratches or punctures being  followed  by the disease.  The 
576          DISEASES OF  THE  NERVOUS SYSTEM.

exposure also of the wounded on the field of battle to  cold, wet, and night air,
is especially liable to occasion it.  Thus,  after the battle of Bautzen, where the
wounded were left on the field during the night, exposed to severe cold, Larrey
found on the following morning that more than  one hundred were affected by
tetanus.   It may occur at all ages, but I  believe is most frequently met with at
the early and advanced periods of life.   I have at least most commonly seen it
either in very young or in old people;  most frequently, certainly, in the young.
In this country it rarely opcurs amongst infants,  but in hot climates it is said
not  unfrequently to be  met with shortly after birth, from the  irritation occa-
sioned by the ligature of the umbilical cord.
   Tetanus at times  appears  to  occur epidemically.   No  case  may occur in a
hospital for a year or two, and then  several will happen at or about the same
time.  This I have often observed.
   Tetanus may take place at any period after  the  infliction of the wound that
occasions it.  In hot climates  especially  it  may occur very speedily; thus,
Dr. Robinson  relates the  case of a negro servant  in the West Indies, who
scratched his finger with a broken  plate, and died of tetanus in a quarter of
an hour.  It is very seldom, however,  in temperate climates, that it supervenes
before the fourth or fifth day.  Larrey, who had great experience of  this  dis-
ease during Napoleon's  campaigns  in  Egypt, met with it most frequently be-
tween the fifth and fifteenth days after the infliction of the wound.  According
to the experience of the surgeons  of  the  Peninsular  War, under whose obser-
vation many  hundred  cases  came,  the disease  does not show itself after the
twenty-second day;  but though  this  may be the general rule, Sir G. Blane
has related a case in which it took  place as late as a month after the infliction
of the wound.  It is stated that it may occur  after the cicatrization of a wound
is completed; when  this happens the disease must rather be looked upon as
being of an idiopathic  character, accidentally occurring in a person who has
been recently injured.
r Tetanus  may be  acute or chronic, being  in some instances  fatal in the
 course  of a few hours, but  usually lasting  for several days.  If the patient
 survive this time, the disease will commonly run on to the eighth or tenth  day,
 and occasionally even for a longer period than this ; thus, S. Cooper mentions a
 case in which it continued in a soldier for five weeks  after amputation.  As a
 general rule, the more acute the case,  the more dangerous is  the disease.  In
 chronic  cases there is good hope of the patient's recovery.
    Symptoms. — The  invasion  of the  disease is often preceded  by a general
 uneasiness  on  the  part  of the patient, a sensation of fear, or a  sense of
 impending mischief.  Abernethy  was  of opinion that tetanus  was usually
 ushered in by a disturbed state of  the digestive organs, the stools being offen-
 sive, and indicative of much gastric irritation.  When the  disease sets in gra-
 dually, it may  be somewhat difficult  of recognition in its  early stages;  if it
 comes on suddenly, its  nature is immediately evident.  It is a remarkable fact
 that the  cramps do not begin in the parts injured; but, wherever this may be
 situated, they are always first noticed in the muscles supplied  by the portio
 dura of the seventh; and  throughout, it is  principally these  and the muscles
 of  respiration  that  are  affected.   The  first  symptoms usually consist in the
 patient  being unable to open  his   mouth widely, to take  food  or drink, the
 muscles  about  the temples, jaw, and neck,  feeling stiff and  rigid;  this con-
 dition has given to the  disease the  popular term of lock-jaw.  As the affection
 advances, the countenance assumes a peculiar expression of pain and anguish,
 the features are fixed or convulsed from time  to  time, and  the  angles of the
 mouth drawn up, constituting the  appearance  called the "risus sardonicus."
 When fairly set in, the disease is marked by spasms of the voluntary muscles
 of  the most violent character, with much pain and partial remissions.   The pain
 is of that kind that attends ordinary cramp in the muscles, as of the legs, and 
TREATMENT  OF  TETANUS.                 577
is usually very severe.   The spasms are often of a jerking character, the patient
being suddenly thrown  up, or twisted on one side;  the breath being drawn
with a loud sobbing catch from  spasm of the diaphragm, and  from the same
cause there is usually violent pain experienced in the epigastric region, darting
across to the spine.   The muscles  of the  trunk are usually affected  next in
order of frequency to those of the head and  neck, the body being bent back-
wards so as to form a  complete arch; more rarely it is  drawn forwards,  and
still less frequently to  one side.  In  some cases  the body becomes  perfectly
rigid, like a piece of wood, the belly being drawn in, and  the chest expanded.
It is said that in severe  cases the spasms have  been  of  so violent a character,
the muscles have been ruptured, teeth broken, and the  tongue lacerated.   In
the numerous cases of tetanus that I have unfortunately witnessed, it has never
fallen to my lot  to see  any effects of this kind produced, the  spasms, indeed,
not in general being of  a very violent, though of a continuous, and very painful
character.
   The  intellectual faculties  are not disturbed  in these  cases, and the mind
continues clear to the last.   In most instances there  is a  good  deal of heat of
surface, and  quickness of  pulse, not  from any  febrile disturbance, for  this
disease is unattended  by symptoms  of pyrexia, but apparently  simply from the
violence of the  muscular contractions.   The prolongation  of  life appears to
 depend greatly  upon  the intensity  of the  convulsive movements: the more
 severe these are, the  sooner does death result.  The fatal termination occurs
 not so  much from any great physical lesion, or disturbance  of  important parts,
 as from exhaustion, consequent on the frequency of the tetanic spasms.
    The  morbid appearances found after death  throw little  light on the nature
 of this affection.  Indeed, the only morbid condition that is constantly found,
 is a degree of inflammation of a nervous twig leading from and implicated in
 the wound, that has occasioned the disease.  This morbid  state I have never
 found wanting.  In all cases of fatal tetanus that I have seen in which a careful
 dissection has been made, these signs of inflammation of a nerve communicating
 with  the  wound have  been  found,  and the  vascularity, which is often  very
 intense, may be traced up  the neurilemma often to a  considerable  distance;
 besides this, there is usually a degree of congestion of the brain  and spinal cord,
 with some bloody fluid in the ventricles and in the subarachnoid space.  Nothing
 in any way of a special character  has been  revealed by these investigations,
 which, as yet, have not elucidated the true nature  of tetanus, any more  than
 that of many other nervous diseases, such as hysteria and chorea.
    The treatment of tetanus is of a local and of a constitutional character.   The
 local treatment has for its object the removal  of the irritation that has induced
 the tetanic condition.    It is  true that when once tetanic excitement has  been
 set up  in the cord it  has  a tendency to continue, and  cannot be removed by
 the mere abstraction or cessation of the local irritation that gave rise to it in the
 first instance.   It is, however, only reasonable to  suppose that other  treatment
 will  succeed best if local irritation be  removed, and, indeed, so long as  this
 continues to keep up the centric nervous disturbance, no general means can be
 expected  to succeed; as they will  have not  only to combat already existing
 disease, but also to overcome  the continuous  excitement  maintained by the
 local disturbance.  Hence, it is of  use to get the wound into as healthy a  state
 as possible, and to see that it is clean, free from foreign bodies, and not inflamed.
 In order  effectually to  remove  all  local disturbance, amputation has been  had
 recourse to, but though this may have succeeded in checking some of the more
 chronic forms of the disease, yet other and  milder local means  have sufficed
 equally well, and in the majority of cases it  has  had no effect, and  hence so
 severe an operation can scarcely be recommended for adoption.   The division
 of the injured nerve, if there be one that has been punctured or lacerated, has
 occasionally proved successful.   Thus, in a case of tetanus  following injury of
        37 
578          DISEASES  OF  THE NERVOUS  SYSTEM.
the supra-orbital nerve, Larrey cut this across, and the patient was cured.   In
a midshipman, in whom tetanus came  on the day after the sole of the foot had
been wounded by treading on a rusty nail, Murray divided the posterior tibial
nerve, and thus cured the patient.  In those cases in which no special nerve
appears to have been injured, Listen's  recommendation of making a /\ shaped
incision  down to  the bone, and above the part, so  as to insulate it completely,
may be advantageously followed. After the nerve has been divided, or the part
properly insulated, some  solution of atropine  may  be  applied to it, so as still
further to lessen local irritation.
   In the constitutional treatment of  the disease, it  is necessary to bear in mind
that tetanus is an  affection of debility,  the violence  of the spasmodic paroxysms
giving an appearance of false strength to  the patient, and  that the principal
source of danger and death is from fatigue induced by the energy of the mus-
cular movements and the consequent want of rest.   The means adopted should,
therefore, have for their object the removal of irritation and the support of the
patient's strength, to enable him to hold up against the disease.
   The  first thing to  be done  is  to clear  the bowels well out with a dose of
calomel and scammony, or a drop of croton oil, aided, if necessary, by turpentine
enemata.  The patient should then be kept perfectly quiet in  a  room by him-
self, a screen, or muslin curtains, as  recommended  by  Dr. Marshall Hall, being
drawn round  the bed: noise or movement of any kind  increasing the spasms
greatly.   With the view of allaying the  spinal irritation, the most  effectual
means consist perhaps in the plan recommended by Dr. Todd, of applying an
ox's gut or gullet  filled with ice along  the whole  length of the spine.  This is
a powerful depressing agent, and, unless  care be taken,  may lower the heart's
action too much, or  indeed completely extinguish it.   It  may, however,  be
applied with  safety for six, eight, or  ten  hours, the  condition of the patient
being looked  to in the meanwhile.  Sedative or antispasmodic agents are seldom
of much service.   I  have seen many  drugs  of this  kind employed, without
producing any material effect in  lessening the  violence of the convulsions.   In
some cases, however, the inhalation  of ether  and chloroform materially lessens
their severity and gives the patient temporary  ease; and  there are instances on
record from which it would  appear that these agents have occasionally effected
a cure.   Mr.  Miller speaks highly of the cannabis  indica pushed to narcotism,
3 grains of the extract, or 30 minims  of the tincture being given every half
hour or  hour.  In one case, at Dr. Garrod's suggestion, I tried atropine cnder-
mically on a  blistered surface, and gave conium internally in large doses, and
although the patient, an  old man, eventually died exhausted, yet these agents
appeared to exercise  a marked  influence in  diminishing the  violence of the
spasms,  and  I should  be induced to attach much  importance to their adminis-
tration.   Dr.  Elliotson has spoken highly of the preparations of iron, especially
of the carbonate, in these cases.  At the same time that measures such as these
are had  recourse  to, it must not be forgotten that the disease is one of great
exhaustion, and that  the patient will  die worn out, unless he be supplied with
plenty of nourishment.  Beef-tea  and wine should, therefore, be  administered
by the  mouth, and nutritious enemata by the rectum,  and  in this way the
powers of life may be supported until the violence of the  disease expends itself.
In the  more acute forms of tetanus  all remedies appear to  fail, the patient
speedily being destroyed  by the disease.   In the  subacute or chronic varieties
recovery may take place, and it is  in these cases that sedatives, such as conium
and cannabis  indica, have been of use.  I am, however,  disposed to think that
in these chronic  cases much may be done  by  simple,  and little  by specific
treatment — clearing out the bowels  by turpentine enemata, the internal admin-
istration  of calomel with some sedative, and keeping up the powers of the system
till the disease wears itself out. 
PERIOSTITIS. — OSTEITIS.
579
DISEASES  OF  THE  ORGANS  OF  LOCOMOTION.
                         CHAPTER  XLI.

                       DISEASES  OF  BONES.

                            PERIOSTITIS.

  Inflammation of the periosteum is of common occurrence, as the result of
injuries, as a consequence  of syphilis and rheumatism, or as a natural  process
dependent on  disease of the  subjacent  bone.  It  often affects the membrane
covering the  shaft  of a bone, and very  commonly attacks the  articular end,
becoming associated with inflammation of the contiguous joint.   When acute,
the membrane becomes thickened, soft, and vascular, and loosens from the sub-
jacent bone.   When chronically inflamed, the periosteum becomes  thickened
by the deposit of plastic matter within and beneath it, and the subjacent bone
usually participates in the changes, undergoing hypertrophy and induration.
In some cases, but rarely, suppuration and  death  of the layer of bone imme-
diately subjacent to the affected membrane take place.
  The symptoms of periostitis consist of a hard but somewhat puffy swelling,
not distinctly circumscribed, and attended by much pain in the part, especially
at night, with tenderness on pressure.
  In the treatment of the acute form of the affection, the free application of
leeches, with hot fomentations, and the exhibition of  calomel and opium, will
arrest  the disease, and give relief to the patient.  In the more chronic form,
the continued administration of the iodide of potass will take down the swelling,
remove the  nocturnal pains, and  materially improve the local condition of the
part.  Added to this, the occasional application of leeches and repeated blister-
ing  will be  of essential  service.   If  there is much  thickening, considerable
relief will be afforded by the free division of the periosteum down to the bone,
either  through the skin or by means of a tenotome slid under it.

                               osteitis.
   Inflammation  of bone may  arise  from the  same  constitutional causes as the
preceding disease,  but most  commonly occurs as  the result of injury, either
accidental or inflicted by the surgeon in an operation.  When a portion of bone
is inflamed, the periosteum and medullary membrane participate  in the morbid
action, and, together with the affected osseous structure, becomes highly vascu-
lar; at the same time the inflamed bone becomes expanded and softened, partly
in consequence  of  changes induced in its  organic constituents, and partly in
consequence  of the cancellated  structure becoming more cellular from inter-
stitial  absorption ; the cells becoming filled  with a sero-sanguineous fluid.  The
compact structure  of inflamed bone undergoes a  peculiar kind of laminated
expansion, so that a section of it presents an appearance of concentric parallel
layers.   When the inflammation is chronic, the bone is likewise expanded, but
instead of becoming looser in  its texture and softened, as in the acute form of
the  disease, it becomes very dense, indurated, and compact; looking and cutting
more like ivory  than ordinary bone.   Sometimes considerable elongation, with-
out  much or  any  thickening, will take place.  I  have seen as the result of
chronic osteitis the tibia one and a half to two inches  longer than its fellow. 
580
diseases of  bones.
  The symptoms of osteitis  consist of enlargement of the affected  bone, with
deep-seated  pain  and great tenderness in the limb;  the pain, as in periostitis
is greatly increased at night, and, when the disease  is  chronic, is much influ-
enced by the state of the weather.
  In the treatment of the acute cases, our principal reliance must be on  local
leeching, with  calomel  and opium; in the more chronic form of the affection,
when the bone has  become thickened and enlarged, nothing of a curative kind
can be adopted, and the only remedy consists in the administration of iodide of
potass  for the  relief  of the  pain, with perhaps  the  occasional application of
leeches.  After a time, when all morbid action ceases, the hypertrophied  bone
does not give  rise  to any very serious inconvenience, except such  perhaps as
may be occasioned by its bulk.
  Osteitis is principally of importance to the surgeon from its connection with
other more  serious diseases of bones, in  which it not unfrequently  terminates.
These conditions  are  suppuration of the  bone, its  ulceration, caries,  and
                      suppuration  of  bone.

  Suppuration  of bone may occur in two forms, the acute and  the chronic.
The acute  form  of  suppuration (osteo-pyelitis)  is  invariably of a diffused
                character.  It usually arises as the result of injury inflicted
     Fig. 199.    on bones  in  operations, as for instance in amputations, or the
                excision  of joints, but sometimes occurs in connection  with
                compound  fractures.  In it, the medullary membrane  is pri-
                marily affected, the  inflammation  rapidly extending through
                the whole of the medullary  canal  and adjoining cancellous
                structure, which speedily becomes filled with pus.  Mr. Stanley
                observes that the medullary membrane in this disease becomes
                vascular  like the  conjunctiva in chemosis,  and is often black
                and  gangrenous  (osteo-myelitis).   This purulent infiltration
                of the interior of the bone is  very apt to give rise to phlebitis
                and pyemia, and hence becomes a most formidable affection,
                the pus finding its way into the veins  of the bone, and  from
                thence into the general   current of the circulation.   Osteo-
                pyelitis, phlebitis, and  pyemia constitute a  pathological se-
                quence that is by no means  an uncommon cause of death  after
                operations implicating the medullary canal.  When the diploe
                of the skull is affected, the  sinuses and cerebral veins may be
                found after death highly inflamed and  filled with pus.   In a
                case in which I excised  the  elbow-joint, the patient died of
                pyemia, and after death the  interior of the humerus was found
                to be inflamed and  filled with pus, and the axillary vein in a
                state of suppuration  (fig. 199).
                  The invasion of this disease, after an operation, is indicated
by great and deep-seated pain, with much  swelling, tension,  oedema, and gene-
ral  redness of the limb  or stump.   The wound becomes sloughy,  all discharge
from it ceasing,  rigors occur, and the symptoms  of pyemia  speedily  set in.
The treatment must be directed to the constitutional  condition induced by the
affection.
  The more chronic form of suppuration of bone  usually assumes a circum-
scribed character,  and leads to the  formation of abscess.  These abscesses are
usually met with in the  cancellated structure, and occur with especial frequency
in the head and lower  end of the tibia.  In  some instances they  are  tolerably
rapid in their formation, but  in  the majority of cases are excessively chronic.
When of a more acute character, they are probably the result of the softening
of tubercle previously deposited  in the bone; and  forming  in the cancellous 
suppuration  of  bone.
581
Abscess in the head of
     the Tibia.
Fig. 201.
structure, are very apt to undermine the contiguous cartilage of incrustation and
eventually to burst into  the neighboring joint (fig. 200).  When of a  more
chronic character, they are usually of very small size,
and are deeply seated in the substance of the head, or
in the medullary canal of the bone; the  osseous sub-
stance covering them having long been  the seat of
chronic inflammation, becomes greatly thickened and
indurated.   Most commonly the quantity  of pus con-
tained in these abscesses is extremely small, and it is
often mixed with cheesy  or tuberculous matter, or
contains portions of necrosed bone intermingled with
it.   In some cases, however, Mr. Stanley has observed
that abscesses of bone are  large,  containing  a con
siderable quantity of fluid.
   The symptoms of chronic abscess of bone are usually
of the following character.  The  patient, after the
receipt of  an injury, perhaps, has noticed that at one
spot the affected bone has become swollen  and pain-
ful ; the skin covering it preserving its natural color
in the majority of  cases,  but  in some instances  be-
coming red, glazed,  and  cedematous; the pain, which
is of  a lancinating and  aching  character  is usually
remittent, often ceasing  for days, weeks, or months,
 and then returning  under the influence of very trivial causes, with its original
 severity.  It is especially troublesome at  night, and is always  associated with a
 degree of tenderness of the part; and indeed, in the  intervals
 of its accession, it will  be found on  careful examination that
 there is always  one tender spot in the enlarged and indurated
 bone.  The persistence  of these signs will  usually point to the
 existence of a small circumscribed abscess under the thickened
 wall of the bone.  But it must be borne in  mind that the same
 local symptoms may be induced by the presence of a small por-
 tion of dead bone confined within an impervious casing, or even
 that they  may arise from the simple pressure of osseous  struc-
 ture, thickened by chronic inflammation.  For all practical pur-
 poses the  diagnosis  is of little consequence, as the treatment is
 the same, whether the pain and other symptoms arise from the
 confinement of a few drops of pus, the  inclusion of necrosed
 bone, or the pressure of the hypertrophied  osseous tissue.
   The proper treatment of circumscribed abscess of bone has
 been pointed out by Brodie.  It  consists in  trephining the bone
 with  an instrument having a small crown, so as to  make an
 aperture for the exit of the pus, of this  size (fig. 201, 1).  So
 soon as a vent has been given  to  this, which is  often cheesy,
 and occasionally very offensive in its character, the  patient will
 experience  great and permanent relief.  In performing  this
 operation, there are  several points that deserve special attention.
 The bone  must be exposed by a  "J" or V  shaped incision, made
 over the spot which has been found to be  uniformly tender on
 pressure;  and  to this the  trephine  should be  applied.  The
 trephine should have a small and deep  crown of this size and
 shape (fig. 201), and it is well always to be provided with two
 instruments of the  same  shape  and  size that will exactly fit  the  same  hole,
 lest one become disabled by the density  and  hardness of  the osseous case
 that  has  to be  perforated, as I  have seen happen.   When  the trephine
 has penetrated  to  a sufficient  depth, the button  of bone may be removed 
582
DISEASES  OF  BONES.
by  means  of an  elevator;  but care  should be  taken not  to  perforate the
whole  thickness of the  bone.   The diseased cavity will  very commonly at
once be  opened  in  this  way, a small quantity of pus  escaping, which  may,
however, readily  be  overlooked, as it is carried away in streaks with the blood,
which  flows freely from the cut bone.  Should no pus escape, perhaps a portion
of dead  bone, or some dark gritty masses  of disorganized osseous tissue are
exposed; if  so, they must be removed with a gouge.   But if neither  of these
conditions are found,  the surgeon  must not  be  disappointed, but  pierce the
neighboring  osseous tissue in different directions by means of a perforator, when
perhaps  the  abscess will  be  opened; should it not be  so, the patient will still,
in all probability, be materially benefitted by the removal of  the circle of bone,
and the  consequent relief to the compression of the osseous tissue.  After the
operation, the cavity left must be dressed from the bottom with wet lint, and a
poultice be  afterwards applied;  it will gradually fill up with fibrous tissue,
leaving the limb unimpaired in utility and strength.

                                 CARIES.

   By  caries some surgeons mean a kind of ulceration of bone; others, again, a
 species of disintegration  of the osseous tissue; and Stanley includes under this
 term the various changes consequent on the chronic suppuration of  the cancel-
 lous structure.  But caries, I think, properly means a disease of the bone charac-
 terized by increased vascularity,  softening, and ultimate disintegration of the
 osseous tissue.  It appears to consist in a breaking down of the organized portion
 of the bone, in  consequence of which the earthy matters become eliminated in
 a granular, molecular, and almost diffluent form in the pus formed by the inflam-
 mation of the surrounding more healthy structures.
   On  examining a  portion of carious  bone, it will be found to  be porous and
 fragile, of a grey, brown, or blackish color; in parts broken down in  softened
 masses, and  at others  hollowed out into cells, which  contain a reddish-brown
 and oily fluid.  The process of wasting which goes on in the bone, appears to
 be partly the result of ulceration,  and partly of disintegration of its  tissue.  In
 many  cases,  small masses of dead bone  lie loose  and detached in the carious
 cavity.  Around this carious portion, the bone, as well as the medullary and
 periosteal membranes, is  usually extremely vascular; and, in many cases, hard-
 ened compact masses  of osseous  tissue will be found deposited around, or even
 forming the exterior wall of the carious  cavity.   These  changes are most com-
 monly met with in the cancellous  structure, but the compact tissue may likewise
 be affected.   As it so frequently occurs in the cancellated tissue, it is commonly
 met with in the heads of bones; and here the disease is extremely dangerous,
 being apt to undermine and destroy the contiguous articular cartilage,  and thus
 implicate the joint.   This caries of the articular ends of bones is consequently
 a most serious affection, and is a very frequent cause of incurable joint disease,
 such  as suppuration and destruction  of cartilage, followed  perhaps by partial
 anchylosis.  Any bone may be affected by caries, but it is  perhaps more fre-
 quently met with in the short and cancellous bones.
   Caries occurring in strumous  constitutions, and affecting the short  bones, as
 those  of the tarsus, or the  cancellated heads of the long bones, as the tibia,
 usually, if not always, commences  in  the  centre  of the bone, which becomes
 congested, softened, and disintegrated, in many cases without any external cause,
 but apparently  simply from  the  diminution of vitality in those parts of the
 osseous structure which are farthest from the periosteum, and which do not, like
 the deeper structures of a long bone, receive a supply of blood from an internal
 or medullary membrane.   In these cases, the inflammation of the soft  investing
 parts,  and the destruction of the joint, which usually ensues, is consecutive to
 the disease in the bone. 
            SYMPTOMS  AND  TREATMENT  OF  CARIES.        583

   The symptoms indicative of the occurrence of caries are of a very equivocal
 character, and are not unfrequently, in  the early stages, mistaken for those  of
 ordinary phlegmonous abscess or rheumatism.  They consist of pain in the bone,
 with a good deal of redness and swelling in the soft tissues covering  it; abscess
 at last forms, often of considerable size, and on letting out the pus, the character
 of the  disease will be recognized, as the bare and rough bone may be felt with
 a probe, which sinks into depressions upon its surface, which, though  rough,
 yields readily to the pressure of the instrument.  The  cavity of the abscess
 gradually contracts,  leaving fistulous openings, which discharge a fetid pus,
 usually dark and sanious, intermixed with granules of bone, and containing a
 superabundance of the  phosphates.  The fistulous openings are generally sur-
 rounded or concealed by high spongy granulations, and the neighboring skin is
 duskily inflamed.  Caries usually occurs in constitutions that have been debili-
 tated by struma or syphilis, often without any other apparent cause.   In syphi-
 litic constitutions it  is  apt, however, to affect the surface  of the bone, disinte-
 grating and eroding this in  a remarkable manner.   This condition has  been
 described by Stanley as true ulceration  of bone, and  he regards it  as distinct
 from caries, and analogous to ulcers of  the soft parts.   Here the disease does
 not  penetrate deeply, but leaves the surface rough and porous, with a good deal
 of inflammation in the soft parts around the affected  bone.  He states, that it
 only occurs  in adults, and in  males, and  is very chronic  in its character; it is
 met with primarily in the bones of the  spine, but also occurs on the articular
 surfaces in advanced stages of joint-disease.
   The treatment of caries must be conducted in reference to the constitutional
 cause  that occasions  it,  the removal of which is the first and most essential ele-
 ment in effecting a cure.  If it arise from syphilis, this must be eradicated ;  if
 from struma, the general health must be improved.  By the removal of causes
 such as these, the disease will often cease spontaneously, and even undergo cure,
 more especially in young subjects.   Hence, it  is well not to  be in  too great a
 hurry to interfere, by operative means, in the caries of the small bones of chil-
 dren.   I have often seen cases, especially of caries of the bones  of the hands
 and feet, in  which an operation for the  removal of  carious bone was apparently
 indispensable, get  well  spontaneously by change of air, and attention  to the
 general health of the child;  the disintegrated particles  of the  diseased  bone
 being  eliminated piecemeal.
   In the first  stage of caries,  which is inflammatory,  measures should be taken
 by means of appropriate local and constitutional antiphlogistics to subdue the
 activity and limit the extension of the disease; and when this has fallen into a
 chronic stage, constitutional alteratives should  be employed.  Amongst these,
 cod-liver oil, the iodides, and change of air, more especially to the sea-side, when
 the  patient is young, should hold the first place.
   When, however, the  disease has fallen into  a  chronic condition,  and nature
 seems  unable to eliminate the carious bone, all  reparative action having ceased,
 or being inefficient for the restoration of the integrity of the part, an operation
 becomes necessary.  When the operative procedure has reference  to the diseased
 part itself, it is impossible to be too careful in delaying it  until the acute stage
 of the  disease has passed, and the inflammation  in the bone and surrounding
 tissues has subsided into a chronic state.   Unless this be done, the excited action
 set up  by the operation  will infallibly give fresh impetus to the disease, which
 will  make more rapid progress, and may perhaps terminate in diffuse suppuration
 of the bone.
  The  operations practised upon carious bones  are  of three kinds;  consisting
 either in simple removal of the diseased portion of bone; — in the excision of
the carious  articular end; — or, in the amputation of the whole  of the bone
affected.
  The  removal  of the carious portion of bone is best  effected by means of the 
584
DISEASES  OF  BONES.
gouge.  This instrument is especially useful in those cases in which short, thick
                bones, or the articular ends  of  the  long bones, are affected,
    Fig. 202.    without the neighboring joints being implicated.  In applying
                the gouge, the diseased portion of bone should be exposed by
                a crucial incision; and if necessary, its cavity opened by a small
                trephine.   The gouge, fixed  in  a  short, round handle  is  then
                freely applied, and the diseased tissues scooped and cut out.
                In  order to do this  efficiently it is desirable to be furnished
                with instruments  of different  shapes and sizes, so that there
                may be no difficulty in hollowing or cutting away every portion
                of bone  that is implicated.   I  have found the gouge-forceps
                (fig. 207), a very useful addition to the gouge in clearing away
                angular fragments and projections of bone, and thus removing
                the whole of the diseased structures.   In some cases Mr.  Mar-
                shall's osteotrite (fig. 202) will be found a very serviceable in-
                strument, clearing away the softened carious bone without risk
                to the surrounding healthy structures.
                   In removing the carious  bone with these instruments, the
                surgeon may be sometimes at a  loss to know when he  has cut
                away enough.   In this he may generally be guided by  the dif-
                ference of texture between the diseased and healthy bone; the
                former cutting soft  and gritty, readily yielding before the in-
                strument, whilst the latter is  hard  and  resistant; so that when
                all the disease is  removed the walls  of the cavity left  will be
                felt to be compact and smooth.  In some cases it is true that
                the  healthy bone may have  been softened by  inflammation;
                should there be any doubt as  to the condition of what has been
                gouged out, it may be solved  by putting the detritus into
 water, when, if carious, it will either wash white  or black: whereas, if healthy,
 but inflamed, it will preserve its red tint.  In operating  on young children  espe-
 cially, it is well not to have the gouges too sharp, lest  the inflamed, but other-
 wise  healthy, though somewhat softened bone be cut away together with the
 disintegrated caries.   The cavity that is left should be lightly dressed from the
 bottom, and allowed to heal by granulation, when it will gradually fill up by
 fibrous material deposited in it.
   When the caries affects the articular ends  of the  bones, as those that  enter
 into the formation of the elbow or shoulder-joints, it may be so situated as not
 to admit of removal  in the way just indicated, but to require excision of the
 diseased articulation : these operations we shall consider  in a subsequent chapter.
 When the caries involves  a bone  so extensively that neither of the preceding
 plans can successfully be put into  operation, it becomes necessary to  remove
 the disease either by the resection of  the whole of the bone, if it be of  small
 size,  or  by the amputation of the limb, if of greater magnitude, or if it affect the
 neighboring joints  extensively.  Thus, for instance, resection of the os  calcis
 may  be required  for caries  of that bone, whilst if the whole of the tarsus  is
 affected, amputation is the only resource.
   In  some cases  of  chronic  disease of the tarsus, however, large portions  of
 different bones may successfully be removed; and indeed I look upon these
 operations of gouging away and scraping out carious  bones as preferable to the
 more formal operations of excision of special bones.   In a case of very extended
 disease  of the  outer side of the ankle and foot, I removed three inches of the
 fibula,  the greater part of the astragalus, the upper and outer part of the  calca-
 neum,  and the whole of the cuboid,  leaving a  large  triangular cavity in the
 bones, which readily filled up, a most excellent limb resulting.
 
NECROSIS.
585
                               NECROSIS.

  The transition from caries to necrosis is easy;  caries may be regarded as the
granular disintegration or molecular death of the osseous tissue, conjoined with
suppuration of the surrounding healthy parts; whilst necrosis must be looked
upon  as the death of the osseous  tissue as a whole, a condition indeed closely
resembling that of gangrene of the soft parts.  Whilst caries, however, chiefly
affects the cancellous structures, necrosis  is met with  in  the compact tissue of
bone, and far more frequently occurs in the shafts than in the articular ends of
the long bones.  It is, however, occasionally found in the cancellous structure;
thus  in the head of the  tibia, or in the os calcis, small masses of necrosed bone
are not unfrequently found lying in the midst of carious or suppurating cavities.
The different bones are affected by necrosis,  with varying degrees of frequency.
The  tibia, at its anterior part  is most frequently  diseased;  the femur in its
lower third is also very commonly affected.  The lower end of the  humerus is
not so often necrosed; but not uncommonly the phalanges of the fingers from
whitlow, — the cranium from syphilis, — the lower jaw, from the emanations
evolved in  the manufacture of phosphorus  matches, — and the clavicles and
ulna, from injury or constitutional causes, are found affected by necrosis.
   The causes of necrosis are of very various character.  We have just seen that
it is predisposed to by the structure of  particular parts of bone,  and is more
frequent in some bones  than in others :—amongst the more constitutional causes,
 we may rank  in the first line those cachectic conditions of the system that result
from scrofula and syphilis, and those debilitated states of constitution that so
 frequently  follow upon typhus fever: in these various states,  the bone may sud-
 denly lose its vitality, more especially if the limb be subjected to slight accident,
 as concussion, or to exposure to some degree of cold.  In some cases the disease
 results from the vitality of the bone being destroyed by the extension of inflam-
 mation to it from the neighboring tissues, as in some cases of whitlow, or by the
 bone becoming exposed  by a neighboring abscess.
   Traumatic causes frequently give rise to necrosis.  Thus the denudation of a
 bone by its periosteum  being stripped off, may lead  to  its death; but though
 the  bone thus injured often loses its vitality, yet, if the membrane  be replaced,
 its  life may be  preserved; or even when exposed, adhesions may take  place
 between it  and the neighboring soft parts, or granulations be thrown out by its
 surface, which eventually form another periosteum.  Necrosis frequently occurs
 as the result of the detachment and denudation of a portion, of bone in cases of
 bad compound fracture; so also the application of certain irritants, as  the fumes
 of phosphorus, may occasion this disease, and  hence it  has occasionally been
 found that  in lucifer-match manufactories, necrosis of the lower jaw is of  fre-
 quent occurrence as a consequence of the acrid fumes that are eliminated getting
 access  to the bone through  carious teeth, or being applied to the exposed
 alveoli.
   In whatever way it originates, the necrosis may affect the outer laminae of
 the  bone only, when it may be denominated peripheral; or the innermost layers
 that surround the  medullary canal may perish, and then  it may be termed cen-
 tral; or the whole thickness of a shaft, or of the substance of a short  bone, may
 lose  its vitality.    The  portion  of  bone that  is  necrosed, called the seques-
 trum, presents peculiar characters, by which its nature  may at once be recog-
 nized.   It  is of a  dirty  yellowish-white color, and  has a dull opaque look,  and
 after exposure to the air, it gradually becomes of a deep brown or black tint;
 the  margins are ragged, and more or less spiculated, and the  free surface toler-
 ably smooth, but its attached surface is very irregular, rough, and uneven, pre-
 senting an eroded or worm-eaten appearance.   When the sequestrum forms in
 the  cancellous structure, it is  usually of a blackish-grey color, irregular  but 
586                    DISEASES  OF BONES.

somewhat ovoid  in  shape, as if the bony matter had been partially dissolved
away, and here is frequently conjoined with caries of the surrounding bone.
  The symptoms of necrosis are divisible into two distinct periods.  In the first
the bone dies and undergoes separation, and  an attempt is made by nature at
the expulsion of that  portion of it which  has  lost  its vitality.   In the second
period the reparative  processes for the  restoration  of the proper length and
shape  of the shaft  are  carried on: the particular character of the symptoms
depends however not only on the stage, but also in  a great measure on the seat
and extent of the  necrosis.   In all cases it is ushered in by symptoms of local
inflammation of a more or less intense and painful character; the skin becoming
glazed, cedematous,  and of a  purplish-red tint; abscess, often  of large size,
and discharging  great quantities of fetid or bloody pus, forms in the limb, and
burrows widely, in proportion to the extent of the necrosis, amongst its cellular
planes.  If the suppuration be  not so extensive  as to jeopardize life, as occa-
sionally happens when  the thigh is  the seat  of disease,  the  patient sinking
into rapid hectic, the suppurating cavity will  gradually contract, leaving fistu-
lous and sinuous tracts, often of great length and extent, leading to rough and
bare bone, discharging a fetid and ichorous  pus, and having their orifices sur-
rounded by protuberant and glazed granulations.  All these symptoms of inflam-
mation, abscess, and wide-spread suppuration, have  for their ultimate  objects
the separation and  elimination of  the dead bone, and the proper formation of
new bone, as a substitute for that which has died.
   In the peripheral necrosis of the shafts of  the  long bones, as of the femur or
tibia, the inflammatory symptoms just indicated  are well marked, and the dis-
ease usually  runs a rapid course up to the period of the formation  and discharge
of the abscess.   In the case of central  necrosis, the  pain is  usually more severe
than  in the former case, and  is  peculiarly  deep-seated and throbbing, being
especially  intense at night.   The limb  becomes  very cedematous, red,  and
glazed; the  bone  enlarges greatly, and abscess at last forms, which  spreads
widely in the planes of cellular tissue, undermining the muscles, and producing
general destruction of the limb, the tissues of which become rigid and condensed,
having sinuses leading down through them.  On  introducing a probe into these
channels,  the  instrument passes tbrough  apertures in the bony case, termed
cloaca (fig. 203), at the  bottom of which the dead bone will be felt rough and
bare.   Though this is the general condition that occurs in central necrosis, it
occasionally, but rarely  happens, that  a  small  portion  of some of the internal
lamellae of the bone dies, and being included in a greatly thickened case of new
bone, gives  rise to symptoms of  osteitis,  or closely resembling circumscribed
abscess of bone, but not to those characterizing necrosis.
   When the whole thickness of a shaft dies,  the  symptoms are always of a very
acute kind, the extent and gravity of the  inflammatory and suppurative condi-
tion being proportioned  to that of the amount of bone that loses its vitality.  It
is  a  remarkable fact, however, that the articular ends usually escape, though
these sometimes even become affected, and  the joints involved.  When the
short cancellated bones or the  articular ends  of long bones, become the seat of
necrosis, it commonly happens that the disease is far more  chronic than in the
cases described; abscess forming, which at first  may not reveal its true nature,
or  being preceded  by continual  pain, may be looked upon as  a disease  of a
rheumatic character.  Suppuration at last occurs,  sometimes  rapidly  opening
into  the  neighboring joint, and  disorganizing it with extreme  constitutional
disturbance, but more commonly it runs a very chronic course.  On passing
the probe down the  fistulous openings that lead  through the  indurated and
thickened 6oft parts, an aperture may usually be  felt in the bone, at the bottom
of  which lies a necrosed mass  not larger than a hazel-nut, surrounded by carious
bone.
   Acute necrosis often attacks the long bones, especially the tibia and femur. 
PATHOLOGY OF NECROSIS.
587
In these cases violent and deep-seated  pain  occurs in  the  limb, which swells
greatly   Abscess soon forms along the whole line of bone;  great constitutional
disturbance ensues, and, unless the limb be amputated,  death  will  usually
speedily result.   This  form of necrosis  chiefly occurs in young and cachectic
subjects.   On examination after removal, the bone will be found white,  opaque,
and dead-looking; the periosteum  is detached, new bone is deposited,  the sur-
rounding  parts infiltrated, and, usually, abscess around the bone to its whole
length.   In many cases the articular ends escape, the  necrosis being confined
to the shaft of the bone, which will be found to be detached from one  or both
epiphyses.   To these the periosteum of the shaft, greatly thickened, will con-
tinue to be adherent, and would have formed the organ for  the reproduction of
the bone, had the limb admitted of being saved.   In extreme cases, the articu-
lar ends even are involved, and  the joints secondarily affected.
   The process of the separation of the dead bone, and of the formation of a new
osseous tissue to supply the place of that which is necrosed, is one of the most
interesting phenomena that the surgeon can study.   The separation of the dead
bone, or its exfoliation, is precisely similar  to the mode in which a slough in
soft parts separates, the time required being  the only difference.  Inflammatory
action is set up so as to form a true line of demarcation and of separation in the
substance of the bone that is still living, and that is immediately contiguous to
that which has lost its  vitality.  In this  way a groove is  gradually deepened
around the edge  of the  sequestrum, by the  absorption,  or rather disintegration
of the  earthy matter of the living  bone, which is carried off by the pus formed
in the course of this process; pus that, according to B. Cooper, contains 2£ per
cent, of phosphate of lime.   Along this gradually deepening line of separation,
plastic  matter is thrown out, from which granulations  are formed which consti-
tute a barrier as it  were between the living and dead bone,  and extending into
the under  surface of the sequestrum, become so implanted in the hollows and
depressures which are there found, that this may continue to be firmly attached
to the  subjacent living bone  after all  osseous connection between them  has
ceased.   This  process of exfoliation may often be  beautifully  seen  in  the
separation  of the outer  table of the skull in cases of necrosis of that  bone.
When  occurring between the shaft and  articular  ends of a long  bone,  the
process is  precisely similar, though the line  of separation is  not quite  so
regular.
   When once the dead bone has been  detached  by the formation  of this line
of separation,  nature  adopts steps for its  ultimate  removal from  the  body,
there being no evidence that  it  ever, under any circumstances,  undergoes
absorption.  Miescher has shown that the  detachment  of small scales  of bone
may take  place  by the  disintegration of their substance by  a process of
" insensible exfoliation," as he  terms it.  This process is a purely mechanical
or physical one, and probably goes  on in all dead bone that is in contact with
pus, just as we see  it  take place in the ivory pegs used in the treatment of
ununited fracture.   It is  this disintegration of the surface of the dead, together
with the absorption of the margin of the  living bone, in the formation of the
line  of  separation, that explains the fact  that the  sequestrum will  always be
found to be of much smaller size than the cavity in which it is  lodged.   The
ultimate expulsion  of the  loosened or exfoliated  sequestrum is effected by
the  growth of the granulations below it pushing it  off  the surface, or  out
of the  cavity in which it  lies.   When  the  necrosed  bone is  peripheral, it
will  be readily thrown off in  this way, although it may for a time be fixed
and entangled by the mere pressure and extension of the granulations.   When
the sequestrum is  invaginated within old or new bone,  the process of  elimina-
tion  is  necessarily  very tardy, and may be difficult  or impossible without sur-
gical  aid.   The time required  for the exfoliation and  separation of dead bone
varies greatly.  When superficial and  small in size, a few weeks may suffice; 
588
DISEASES  OF  BONES,
Fig. 203.

but when affecting the long bones, or especially those of the ilium, the process
                  may be extended over several years, and may terminate in
                   the death of  the patient from exhaustion  before  it is con-
                  cluded ; the  constitution  being harassed and worn out  by
                  hectic induced by profuse  suppuration.   Or the disease may
                  fall into a chronic state,  the limb  becoming  rigid,  with
                  much condensation of tissues, with fistulous apertures lead-
                  ing down to exposed  but  attached bone, and thus being a
                  source of  constant annoyance  and suffering to the patient.
                     The reparative process  adopted by nature for the resto-
                  ration of  the integrity of  the bone, a portion of which  has
                   necrosed,  varies according to the extent of the loss of sub-
                   stance.   When  the outer lamellae alone are necrosed, new
                   bone  is  deposited by the  surrounding periosteum, and  the
                   depression that has  formed on the surface  of the old bone
                   is filled up by a kind  o'f cicatricial fibrous tissue, which ulti-
                   mately ossifies.  If the whole of the inner lamellae of the
                   shaft die, constituting  central necrosis, the outer  layers of
                   bone become greatly consolidated and thickened by osseous
                   matter deposited from the periosteum, in which, in the ma-
                  jority of  cases, the circular or oval apertures termed cloacx
                   form for the ultimate extrusion of the sequestrum (fig. 203.)
                   In some  cases,  however,  no  cloacae form,  the dead bone
                   continuing to be incased in  the thickened outer layers.
                   When the whole of a shaft dies, the  reproduction  takes
                   place from various sources, principally from the periosteum,
                   and perhaps the medullary membrane, if that is left, which
                   become thickened, vascular, and detached from the necrosed
                   bone.   That the  periosteum  takes the  principal  share
in  the  reproduction is  evident  from  the fact  that where it  is  deficient or
has been destroyed, apertures (cloace) are left in  the case of new bone.  Then
again the soft tissues of  the  limb generally, if thick, as in the thigh, contribute
to  the  formation  of plastic  matter, which gradually ossifies, and  so tends to
strengthen the new case; and, lastly, the  articular ends of the old bone still
preserving their vitality, throw  out sufficient osseous  matter  to consolidate
themselves firmly to the  new shaft that  is formed.  Thus it will be  seen that
the new bone is formed by the vascular  and healthy tissues generally that sur-
round the seat of  disease, though in this reparative action the periosteum and
medullary membrane take the chief share.   In acute necrosis there is no time
for reparative action  to  take place, but the  periosteum will be found much
thickened and vascular, separated from  the dead bone, and occasionally lined
with scales of  new ossific matter, the first  step  towards the reproduction of a
new shaft.
   The new bone which is deposited on those  parts of the surface of the shaft
from which scales of the old osseous tissue have  been separated, or that enve-
lopes the sequestrum when the whole thickness of the shaft necroses, is at first
rough, porous, cancellated, and very vascular;  after a time it gradually becomes
more compact and harder, at the same time that it assimilates in bulk and shape
to the bone, whose place it takes.   When the new bone is deposited around the
sequestra so as to envelope these in  a kind of case, apertures of  an oval or cir-
cular form, cloacae, are formed in it;  these serve for the escape of the discharges,
and  it is eventually through  these  that the dead bone  is extended; they are
said to correspond with points at which destruction of the periosteum has taken
place.   The  case of new bone, which necessarily exceeds in circumference the
old bone, as this is included within it, gradually contracts both  in  texture  and
in size,  becoming firmer and  smaller after the removal of the sequestrum;  and
 
OPERATIONS FOR  NECROSIS.
589
the cloacae closing so soon as all  dead bone has  been extruded, it eventually
acquires the proper size and shape of the bone; the medullary canal even  be-
coming lined by a proper membrane forming in it.
  The new bone  usually forms with a rapidity  that keeps  pace with  the death
and separation of the old  bone.  In acute cases  of necrosis in which amputa-
tion has been performed but a few weeks  after the setting in of the disease, a
thick layer of new bone will sometimes be found under the  periosteum; but in
some instances, when the whole of a shaft is necrosed, the  new case is not com-
pleted, or has not become attached to the articular ends  before these are  sepa-
rated from the shaft. In other cases again, though complete, it has not sufficient
strength to resist the contractions  of the muscles  of the limb;
under these  circumstances, it may spontaneously fracture, as    Fig. 204.
happened in a case of necrosis of the thigh  lately under my
care in the hospital, or become shortened or bent.   In other
instances  again,  when  the periosteum is deficient, new bone
does not form (fig. 204); but as the sequestrum separates, the
limb becomes shortened, loose, deformed, and useless.
   In the treatment of necrosis, the indications  to be accom-
plished are sufficiently simple, though the mode in which  they
have to be carried out often requires much patience  and  skill
on  the part of the surgeon.
   The first point to be attended  to is to remove  any  constitu-
tional or  local cause that has occasioned or keeps up the dis-
ease ; unless this be done,  it is clear that the whole of the rest
of  the treatment must be ineffectual;  thus, for instance, if the
death of the bone appear to result from  scrofula or  spyhilis,
those conditions must  be  corrected.  So, again, if it arise in
the lower jaw, from the fumes of  phosphorus, the patient must
necessarily be removed from their influence ; or, if it be threat-
ened in consequence of denudation of bone, the best  mode of
prevention will be to lay down the flaps of integument, and so
cover the exposed surface.
   After the cause has, in  this way, been removed or  counter-
acted, the separation of the sequestrum should  be  left, as much
as possible, to the unaided efforts of nature.  The less the sur-
geon interferes with this part of the process the  better, for as
has been justly observed by Wedemeyer, the boundaries of the
necrosis are only known to nature, and the surgeon will most pro-
bably either not reach,  or pass altogether beyond them.  Here
much patience will be required for many weeks or months, and
the utmost that the surgeon can do is to attend to the state of
the patient's health, treating him carefully upon general  principles, removing
inflammatory mischief,  by appropriate antiphlogistic  means, opening abscesses
as they form in the limb, and, at a later period, supporting the patient's strength
by  good diet, tonics, and general  treatment, calculated to bear him  up against
the depressing and wasting influence of continued suppuration, and of the irri-
tation induced by the disease.
   So soon as a sequestrum has been detached  from the  adjacent or underlying
bone, by the proper extension of the granulating line of separation, the surgeon
must proceed to its removal.  In most  cases it is sufficiently easy, when  the
necrosis is superficial, to ascertain that this separation has taken place, as the
flat end of a probe may be pushed under the  edge of the  detached lamina.
When,  however, the sequestrum  is deeply seated, it  is not always  so easy to
ascertain that the separation  has occurred, though, in the majority of cases, the
introduction  of a probe through  one of the fistulous  openings  leading  to  the
necrosed bone, and firm pressure exercised upon this, will enable the surgeon to
 
590
DISEASES  OF BONES.
I
detect that degree of mobility which is  characteristic of its being loose.  In
other cases, however, the sequestrum, though completely removed from all osse-
ous connections, still continues to be fixed by the pressure of the surrounding
granulations, and by the extension of its spiculae into the  corresponding cavities
of the new osseous case.   This especially happens when  the  necrosis  is central
and  invaginated, and  the  cloacae leading to it of such  small size that but a
limited portion of it is exposed.   Here a more careful examination will be re-
quired, and its looseness may sometimes be determined by pressing upon it with
a probe  in a kind of jerking manner, or by introducing two probes through
different cloacae, at some  distance  from one another, and  alternately bearing
upon the exposed bone with one or  other of them.   Then, again, if the  sound
elicited by striking the end of the probe against the  sequestrum, is a peculiarly
hollow one, the  detachment of the  bone may be suspected.  The duration of
the  disease, also, will probably throw some  light  upon  the  probable state of
things inside the new case.
  The separation of the sequestrum having been ascertained, the surgeon must
adopt  measures for  its extraction.  If the  necrosis is peripheral, all that  is
necessary is to make an incision down to it through the soft  parts, and then to
remove it with a pair  of forceps, or to tilt  it off the  bed of granulations on
which it is lying, by introducing the end  of  an elevator beneath its edge.
  When the necrosis is central, the sequestrum being imbedded in the new case,
or covered in by old bone,  the operative procedures for its removal are  of a more
complicated character.   The difficulties here consist  in the depth from the sur-
face, and the obstacle offered by its passage through the soft parts in some cases,
and  in others, in the length and magnitude of the sequestrum in proportion to
the  small  size of the cloacae, and  the manner  in which it lies, in  a parallel
direction to these openings.  In  cutting down upon  the bone the surgeon must
be guided by the direction and the course of the fistulous tracks that lead to the
principal apertures in the new case, the incisions being carried in the axis of the
limb, and carefully directed away from large  blood-vessels and nerves.  In many
instances, however, the hemorrhage  is somewhat  abundant, in consequence of
the injected state of the tissues furnishing a copious  supply of blood,  and their
rigid condition  preventing retraction of the vessels; this,  however, may be
arrested by the pressure  of an assistant's  fingers, and will soon gradually cease
of itself.  The bone having been  freely exposed, it will sometimes be found that
        Fig. 205.         Fig. 206.         Fig. 207.           Fig. 208.
the cloacaa are of sufficient size to admit of the ready extraction of the seques-
trum.  But in the  majority of cases, this cannot  be done  at  once, and the
apertures must be enlarged, either with the gouge or the trephine, according to
the density of the new case, and amount of room required.  Occasionally, when
two cloacae are close to one  another, the intervening bridge  of bone may very
conveniently be removed by means of cutting pliers, of different shapes, as in
figs. 205, 206, and  208, or by means of a Hey's or a straight narrow saw (fig.
209), and space thus given for the extraction of the sequestrum.  Very conve- 
                   OPERATIONS  FOR  NECROSIS.               591

nient pliers, for this purpose, are those represented in fig. 207.  They are made
by Mr. Coxeter, with gouge ends, and hence may be termed  gouge-forceps.   I
have found them extremely serviceable in many operations upon the bones.

                                 Fig. 209.
Care, however, should be taken not to remove more  of the new case  than is
absolutely necessary, as the aperture so made  in it will not be filled up  again
by osseous matter, but will  be closed  by fibrous tissue, and thus  the ultimate

                                 Fig. 210.
soundness of the limb might be endangered.  For the extraction of the seques-
trum the most convenient instrument is a pair of strong necrosis forceps, well
roughened  at  their extremity, and straight or bent  as  the  case may require
(fig. 210).   Occasionally the sequestrum is so shaped and placed that it cannot
be seized with this instrument; under  these  circum-
stances, it will be useful to drive a screw-probe (fig. 56)
into it, by which  it may either be extracted, or so fixed
as to admit of seizure, and removed by the forceps.  In
some  cases, additional and convenient  purchase may be
given to the dead bone,  by fixing a bone-forceps, such as
represented in fig. 211, firmly into it.  If the sequestrum
is too large to be  removed entire through  the cloaca, it
may perhaps best be  extracted  piecemeal, having been
previously  divided by passing the points of narrow, but
strong, cutting pliers into the interior of the bone. ^ After
the removal of the sequestra, a smooth, hollow cavity will
be left in the new case, from the bottom  and  sides of
which blood usually wells up  freely, issuing abundantly
from the vascular bone,  and from the  granulating mem-
brane lining its interior.  Should this  hemorrhage be at
all troublesome, pressure will always sufficiently arrest it.
Lint must then be lightly introduced into the bottom of
the wound and the part elevated;  a good deal of inflam-
mation  is frequently  set up  after these operations,  but
that must  be combated on general principles.   If  the
sequestrum have been a long one, and involve the greater
part of  the shaft of the bone, it  may happen  that  the
new case has not  sufficient strength to maintain the limb
of its proper length and shape,  and  that it will bend or
break under the action  of the forces and weight to which it  is subjected.   In
 
592
DISEASES  OF  BONES.
order to prevent this accident, it will be necessary to put it up in light splints
or in a starch bandage.  After the removal  of the  dead bone, the fistuhe will
speedily close, and the limb eventually regain its normal size and shape.
   If the necrosed bone be so situated that it cannot be removed, occupying too
great an extent and continuing  to be firmly fixed, and if, at the same time  the
patient's health have  been worn down by constant discharge, and symptoms of
hectic come on; or, if the limb have generally been greatly disorganized by the
morbid  processes going on in it, amputation must be had  recourse to as a last
resource.   It is especially in the lower third of the femur that  these severe
forms of necrosis occur, necessitating amputation of the limb.  As an idiopathic
disease, necrosis of the tibia is  rarely met with requiring  this operation  but
when it is the result of bad compound fractures, or of other serious injuries  the
removal of the limb may become imperative.   In acute necrosis, however of
the lower end of the thigh or of the tibia, involving the contiguous joints and
attended by extensive  abscess of the limbs,  amputation is imperative.
   Amputation may also be required  in necrosis for hemorrhage from the sinuses
and abscesses, the bleeding being either the result of  general oozing from their
walls, or arising from the laceration of a large arterial trunk by the point of  a
rugged sequestrum.   In other cases, again, removal of the limb may be rendered
imperative by the implication and suppuration of a neighboring joint.
   Resection  of the whole of the necrosed bone may, in some cases, be advan-
tageously performed; thus, in the case of necrosis of the ungual phalanx occur-
ring from whitlow, where, by the removal of the dead bone, the end of the finger
may be preserved, so also in  necrosis of some of the  metatarsal and  tarsal bones,
resection may be  advantageously practised.   When  the ilium  and  pelvic bones
are affected, it is seldom that any operative measure  can be had recourse to with
advantage.    In some cases, however, if the disease be limited to a portion of the
crest of the ilium, or to the  tuber ischii, the dead bone may be removed.  In
these cases it, however, not uncommonly happens that disease of a similar kind
exists elsewhere, about the  sacrum or  spine,  that  will  eventually destroy the
patient.  In a case in which I removed a portion of the crista ilii for necrosis
that was apparently confined to  that bone, it was found, on the patient dying
some weeks  afterwards of  erysipelas,  that  the lumbar vertebras  were also
diseased.
   Necrosis  of the flat bones, such  as the  sternum, scapula, and  bones of the
pelvis, is an  excessively tedious process, there  being but very little tendency to
the formation of the line of  separation, and the detachment of the sequestrum,
which will  continue bare, rough,  and adherent  for many years.    Should it be so
situated that it can be removed, it must be excised, even though not detached;
but, unfortunately, in  the pelvis, it  often happens  that the  necrosed portion  is
so deeply  placed  that  it cannot be safely  excised:  here we  must  leave  the
patient to  the chance of the bone being at  length so loosened  as to admit of
extraction.
   Necrosis of the cranial bones occurs as  the result of injury, of scrofula, or
syphilis.   In this form of the disease there is the special danger of inflammatory
action extending to the brain and its membranes.   When  attacking the vault
of the skull, the  necrosis is usually the result of syphilis, is often confined  to
the outer table, which may exfoliate in large  plates, and is less liable than in
some other situations to give rise to cerebral disease.   When affecting the lower
part of the frontal bone, the outer wall of the frontal sinus, or the supraorbital
ridge, the disease is generally strumous, and the process of separation is extremely
slow; and it will  usually be  necessary for the  surgeon to remove,  by  means of
the trephine, gouge, or cutting  pliers, the attached, but rough and dead, bone.
When the  petrous  portion  of the temporal bone is  the seat of necrosis, death
will usually result from encephalitis.   When  the mastoid process is attacked,
the sequestrum will often separate, and may be removed. 
STRUCTURAL CHANGES IN  BONE.
593
  Necrosis may affect the alveolar process, the body or the ramus of the lower
jaw.  In  these cases, the dead  bone may usually, the separation having taken
place, be  extracted through the mouth without the necessity of incising the
integuments covering it; but, when very extensive, it may require to be  removed
by external incision.
  The patella is  rarely necrosed.   I have, however, met with one instance of
primary necrosis of this bone  leading to disorganization of the  knee-joint, and
necessitating amputation.
  When the ribs are necrosed, abscesses and sinuses will often form to a consi-
derable extent on the side of the chest.  These must be laid open, and the dis-
eased portion of bone scraped  away by the gouge.   In doing this, care  must, of
course, be taken  that  the adjacent intercostal  space  be  not punctured by an
unfortunate slip of the instrument,—an accident that is best avoided by pro-
tecting the gouge well with the finger.
                        CHAPTER  XLII.

                 STRUCTURAL CHANGES  IN BONE.

  The bones are liable to various structural changes, by which their size, shape,
and consistence are modified, or in  consequence of which they become the seat
of tumors of various kinds.
  Hypertrophy of bone usually results from inflammation of the osseous tissue,
but in some cases  it may occur apparently without having been preceded by
any signs indicative of this condition; it then resembles in character some of
the forms of exostosis that will presently be mentioned.   Atrophy of bone some-
times occurs as a natural  result, in old age.   In  other cases, again, it happens
as a consequence  of fracture,  the nutritious artery of the  bone, as  has been
pointed out  by Mr. Curling, having been torn across, and one of  the fragments
consequently receiving insufficient vascular supply.  Atrophy of bone also com-
monly occurs from disuse, as is the  case in old dislocations.   In cases of hyper-
trophy, the  bone is not only enlarged in circumference, and also perhaps in
length, but  indurated, becoming specifically heavier.  In atrophy, on the other
hand, it is thinner, lighter, and  more porous than usual,  the compact structure
disappearing, and the cancellous being expanded.
  Rickets is a disease of early life, usually being met with in  scrofulous children,
and never occurring after the age of puberty.   In it the  structure of  the bones
is changed,  the earthy matter  being deficient and  the organic material  in excess,
so that the bone continues to be soft, flexible, and cartilaginous in structure, at
an age  when  its  tissue  ought  to  have undergone proper  consolidation.   It
appears to be  atrophied, and the cancellous structure to  be  expanded into cells
of varying magnitude, which  contain  a  brownish-red serous fluid.   In conse-
quence of the change of structure and the loss of firmness in the bones in this
disease, considerable distortion of the body takes place.   The head early appears
large and expanded; indeed, Killian states that the rickets always first appear
in the head, the forehead  being especially protuberant;  according to  Mr. Stan-
ley, this arises not from  enlargement of  the cranial bones, but in consequence
of the want  of development of those of the face;  the head thus appearing large
from its disproportion to the small face.  The  shape   of  the limbs is much
changed  and distorted, in consequence of their yielding  to  the pressure of the
superincumbent weight; the pelvis becoming contracted, and the thighs and legs
       38 
594
STRUCTURAL  CHANGES  IN  BONE.
bent either forwards or outwards.   The joints are  usually swollen, the articular
ends of the bones appearing enlarged.   In early life the chest will be observed
to be deformed in a peculiar manner, being narrowed above, where the upper
ribs are contracted and pressed in, out  expanded below,  apparently from the
weight of  the  abdominal viscera, which are often tumefied, and  in these cases
drag  on the lower ribs.  As puberty advances, lateral  curvature of  the  spine
commonly takes place.   In ricketty  children there is a general delicacy of
appearance, and often a strumous habit of body, though, according to Bokitan-
sky, they are not usually tuberculous; if they live, however, past the age of
puberty, they may eventually become sufficiently  powerful  in frame.
   The treatment of rickets must  be conducted on the same general  principles
that guide us in cases of scrofula;  pure air, good food, and plenty of it, regular
exercise, and the administration of tonics,  especially the  preparations of iron,
with scrupulous attention to the general habits of life of the child, will generally
improve his condition to the utmost  limits compatible with the powers of his
constitution, and  by improving the nutrition of the system tend to the  more
healthy deposition of osseous matter.  In some cases the administration of lime-
water with milk seems to  be of service in supplying those elements that are
required by the system.  It is of much importance in  preventing deformity in
these cases  not to allow the child  to walk  or  stand  much, but to  let it take
exercise in donkey-panniers or hand-chairs, and  to  support those limbs  that
have a special tendency to  become excurvated, with  properly constructed steel
supports, which will be  found  of much use, provided they are not too heavy, or
interfere with the action of the  muscles.  Methodical friction  should also be
employed, so as to stimulate the muscles; as these become more  vigorous, their
osseous attachments have a tendency to become stronger.
   Mollities  and  fragilitas  ossium.   Osteomalacia. — A very  rare but most
destructive and dangerous  disease of the bones, characterized by softening and
fragility of the osseous structure,  is occasionally met with.   This affection has
of late years been studied with much attention by Curling,  Solly > Stanley, and
 Maclntyre, and it is  principally  from the  labors of these gentlemen that we
are acquainted with its true pathology.
   In this disease the bones are bent, their epiphyses swollen, and their shafts
broken in various parts of the body.   Occasionally, though very rarely, only
one is fractured; but in  other cases, as in Tyrrell's, there may be as many as
 twenty-two  fractures;  or,   as  in  Arnott's, thirty-one.   These  fractures  are
 unattended by any attempt at the  formation of callus.   The  body becomes
 singularly and distressingly distorted.   On examining the bones after  death
 they will  be found to be light, soft, and somewhat gritty; bending,  and at the
 same time  readily  snapping across;  occasionally  they are   expanded and
 thickened.  This happens especially with  the skull, which becomes often con-
 siderably increased  in substance.  On cutting the bones, which are soft, and
yield something  like cartilage, the  knife usually encounters a  kind of  gritty
 sensation.  On making a section of the  bones they appear of a deep reddish-
 brown, or maroon color, and will  be  seen to contain cavities of various sizes,
 small or large, but always  of a circular or oval shape,  and generally filled with
 an oily, red, and  grumous fluid;  though sometimes they contain clear serum.
 On examining this red grumous  matter under  the  microscope, Solly remarks
 that,  as it shows a  cell development, it is  probably  an adventitious morbid
 product, and not simply fatty matter  altered by  the effusion of blood into it;
and  Dalrymple has shown that this material is  composed  of granular matter,
 nucleated cells, and a few caudate corpuscles;  he therefore believes  it to be  a
 disease essentially malignant  in its  nature, but  differing  from other malignant
 affections; for " instead of progressively  reproducing and developing themselves
 without limitation, the  new and morbid  formations which replace the original
 and sound structure, seem to have been at an early age of their existence removed 
RICKETS. — MOLLITIES  OSSIUM.
595
by absorption  and carried  out  of the  system" (Maclntyre).   The  bone itself
has been  found by Solly on microscopical examination to have  its laminated
structure  absorbed,  the osseous corpuscles  diminished in  number, and  the
Haversian canals enormously distended.
  In chemical composition the  diseased bone has been found by  Dr. Leeson to
be composed  of 18-75  animal  matter, 29T7 phosphate and carbonate  of lime,
and 52-08 of water in every hundred parts.
  The cause of the complaint seems altogether unknown; it would appear  that
in many  cases  it is connected with a rheumatic  tendency, as  in every  case
recorded,  the  affection  has been preceded or accompanied by  severe pains, or
distinct rheumatic attacks.  It most commonly, though not invariably, occurs
in females, a fact  pointed out by  Killian, and  exclusively attacks adults,
commencing even at very advanced ages.
   One of the most important points connected with this affection is the condition
of the urine  in it.   In all cases that have been  recorded, this excretion has
been seen to contain large  quantities  of earthy matter.   Solly  pointed out that
this is  the  phosphate of lime, which has been absorbed from the bone,  and
thrown out by the kidneys  in the urine; and  sometimes  the elimination of these
matters is so abundant that it forms, as in one of the cases which he relates,  a
solid calculus clogging up  the interior of the kidney.  In Dr. Maclntyre's case,
the  earthy matters   of the bone appear  to have  been, in  the  first instance,
absorbed, and carried off from the kidney by  the urine, but afterwards an animal
matter  of  a  peculiar  and  apparently previously  undescribed character, was
discharged  in great  abundance.  He says,  that on adding  nitric  acid  to the
urine " a  slight yellowish opacity was the first announcement of a change going
on in the mixture; this gradually deepened in tint, with increasing consistency
of the fluid, till the whole congealed into a bright and somewhat resplendent
mass, presenting very much the appearance of a heap of nitrate of urea scales,
blocking  up the tube.  It  further resembled  that substance in liquefying on the
application  of heat, and again concreting on  cooling, but no crystalline arrange-
ment could be perceived, the sparkling  appearance  being evidently due to
numerous air-bubbles entangled in the mass.  Perfect  redissolution took place
when the tube was  held  for a few minutes in the  flame  of  a  spirit-lamp, or
plunged  into hot water at 160°  or  170°, the ordinary coagulating point of
albumen; and the fluidity thus acquired  persisted under ebullition,  however
prolonged."   (Med. Chirurg. Trans, vol. xxxiii. p. 29.)
   The symptoms of this disease are, in the early stages, of an extremely obscure
and insidious  character.  The  patient complains, in the first instance, of pains
of a wandering character  about the  limbs and trunk; these assume usually  a
rheumatic character, though they have been  observed  to be of  a  much more
severe, persistent, and intractable nature, than  in  any form of  that affection.
The patient becomes debilitated, unfitted for exertion, and emaciates.   Sponta-
neous fracture now occurs  in some bones under the  influence of the most trivial
causes; others become  bent, and the body consequently greatly mis-shapen and
distorted, occasionally  in  the  most  wonderful  manner.  The  urine will be
observed  to present some of the abnormal characters above described, and death
eventually results from  general exhaustion.
   The diagnosis of  this affection has to be made in the early stages from rheu-
matism.   This is not so easy, and, indeed, is at first impossible;  but after  a
time, when  the peculiar phosphatic condition of the urine, and the fragility or
distortions of the osseous  system manifest themselves, the true  nature of the
affection  reveals itself.   From rickets  the  diagnosis  may  usually be  pretty
readily made, by observing that, whilst rickets is a disease of childhood, osteo-
malacia is an affection peculiar to adult or advanced life.   The  occurrence of
severe pains, and  the greater amount of distortion, with the tendency to spon- 
596
STRUCTURAL  CHANGES  IN BONE.
taneous fracture, which is observed in this disease, is never noticed in ricketty
children.
  With regard to treatment,  but little can be done;  the  administration of
tonics, and a  general  supporting plan of treatment, may arrest for a time the
progress of this terrible affection; but when once it is declared, it usually pro-
gresses from bad to worse, and  at last  destroys the patient.   Opiates may be
employed to allay the  pain, and in Dr. Maclntyre's case some temporary advan-
tage appeared to result from  the administration of alum; but no remedy has
appeared  to  exercise  any decided or continuous advantage in this complaint,
which there is reason  to believe, with Solly, is of a truly malignant character.
   Tubercle of bone. — The deposit of tuberculous matter in bone plays an im-
portant part in many diseases  of this tissue  in  children and young people of a
scrofulous habit of body, being a common cause of some of the most intractable
forms  of chronic osteitis, circumscribed  abscess,  caries, and necrosis.  As tuber-
cle is  almost invariably deposited in the cancellous structure, it is a frequent
cause  of those forms of inflammation of the articular extremities of long bones,
that terminate in the  destruction of  the contiguous  joint.   In the short bones,
as those of the tarsus, it commonly leads to caries and necrosis, and forming, as
it often does, in the bodies of  the vertebrae, it very frequently gives rise to some
of the most destructive diseases of the spine, attended by the formation of large
lumbar and iliac abscesses.  When once tubercle has been deposited in a bone,
it usually sets up a low  form of inflammation in the surrounding osseous tissue,
which rapidly runs into a carious condition, with the formation of curdy pus, in
which masses of half-disintegrated tubercle may be  seen.   If this destructive
action takes place with great rapidity, portions of  the  bone will be found to
necrose in small masses,  which lie  at the  bottom  of  these tuberculous and
carious cavities, as may commonly be observed in some forms of strumous caries
of the os calcis and head of the tibia.   When the tuberculous deposit has been
very extensive, and is of a more acute character, it may cause inflammation and
disintegration of  the whole of the articular end of a long  bone, with separation
of the epiphysis.  These destructive changes may take place with great rapid-
ity: I have seen them happen, in  a lad whose  thigh  I  amputated  for acute
tuberculous  infiltration  of the lower end of the femur, in less  than a month
from the  first occurrence of the complaint, the patient,  at the time of the ope-
ration, being nearly exhausted by hectic, induced by the abundant discharge
from the  diseased bone, and from immense abscesses in his thigh.
   When,  on  the  contrary, the tuberculous matter is deposited in small quantity
in  an  otherwise healthy bone, it may, as it undergoes softening,  dispose to the
occurrence of circumscribed  abscess, at the same time  that  chronic thickening
and condensation of  the  surrounding bone  takes place.  It is in consequence
of this condensation  of the peripheral portion of the  bone  by the  deposit of
fresh  layers of osseous tissues  under and by the inflamed periosteum, and the
 difficulty  that the tuberculous abscess necessarily  experiences  in  traversing
these  hypertrophied  osseous  structures, that it  is so apt, when deposited in the
vicinity of a joint, to work its way through the cartilages  into the cavity of the
articulation; as on this surface no fresh deposit  or condensation of osseous tissue
 can take place, and consequently no  additional obstacle be  offered to the onward
progress  of  the  tubercle, or rather  of  the curdy pus into which it has become
transformed.
   The presence of tubercle in osseous tissue thus not only gives rise  to destruc-
tive changes in the bone and  adjacent articulations, but will occasion inflamma-
mation and  extensive suppuration in the neighboring soft parts; indeed, some
 of the largest  chronic  abscesses  that  form  in the  body,  those connected with
 diseased  dorsal  or lumbar vertebrae, owe their  origin, in the  majority of cases,
to  the deposit and disintegration of tubercle in the  bones.  When once tuber-
 cle in bone has given rise to caries and perforation of the osseous tissue covering 
TUBERCLE OF  BONE.
597
it, together with plastic infiltration, and abscess and sinuses  of the soft parts,
these conditions  will  continue in a permanent manner;  the fistulous  tracks
leading down to the bone and the cavities in it, remaining open so long  as any
tuberculous matter is  left at the bottom of them;  and in this way the patient
may eventually be exhausted by the  copious and continuous discharge from
these osseous vomicae.  In  some  favorable cases, as the result  of natural pro-
cesses, and in  others  by those operations that the surgeon practises for caries,
the whole of the tuberculous matter may be disintegrated, and thus eventually
eliminated, a true vomica being left in the bone, or scooped out by the  gouge,
and then the  fistulous track, whether in the soft parts or in bone, having no
longer this kind  of foreign  body lying at its bottom, will gradually close, not
by the  contraction of its osseous walls, which is of  course  impossible,  but by
the deposition of  a fibrous tissue  by which the cavity is occluded.
   Nelaton has pointed special attention  to the pathology of tubercle of bone,
and to the important part that it plays in  the diseases of the osseous structure.
 He describes  two forms of tubercle in this  situation;  the first is the encysted
variety, which occurs in the form of small masses, of an opaque white or yel-
 lowish color, contained in  the cyst, which  is soft, vascular, and spongy, appa-
 rently of a cellular structure.  This variety is stated  by Nelaton to be the most
 common.  I  have certainly not found it so, but have most frequently met with
 the infiltrated opaque  tubercle.  The other form in  which tubercle  occurs,
 according to Nelaton, is an infiltration into the  cancellous structure  of bones.
 This may be  in the form of semi-transparent granulations of a greyish or rosy
 tint, opalescent and slightly  transparent; occasionally,  these granulations  are
 firm, so as almost to resemble cartilaginous deposits in the interior of  the bone.
 The osseous structure, in the midst of which this kind of  tuberculous matter
 is deposited, does not appear at first  to undergo any material alteration.   The
 other form of tubercle is that in which it is infiltrated as opaque puriform mat-
 ter of  a pale  yellow  color, soft,  and without vascularity (figs. 212, 213).   The
 osseous  tissue, under the influence of this disease, often becomes, as Nelaton

              Fig. 212.                               Fig. 213.
observes, more condensed than  natural, the cells  being obliterated so as to
resemble the compact substance  of bone.   In some cases it may continue thus
chronically  thickened  and indurated, but in other instances the tuberculous 
598
STRUCTURAL  CHANGES  IN  BONE.
Fig. 214.
inflammation will give rise to rapid and destructive inflammation of the sur-
rounding osseous tissue, which becomes excessively vascular, and crumbles down
into a carious state, with some necrosed masses intermixed.  In other instances.
a°ain, as is not unfrequently observed in  some  of the forms of  caries of the
spine, or of white swelling, slow suppuration takes place in the interior of the
                                bone, and  on the sides or in the centre of the
                                abscesses  thus  formed, hardened and  white
                                ivory-looking masses and knobs of osseous
                                tissue may  be   seen to  be  deposited, these
                                apparently consisting of the tuberculous bone
                                that  has undergone  some special  modification
                                of structure.
                                  The treatment of tubercle of bone resolves
                                itself into that of its effects.   As its existence
                                cannot be recognized except by the changes
                                that  it induces in the bone, the treatment must
                                be directed exclusively to these.  Thus, if it
                                occasion circumscribed abscess, that must be
 opened; if caries, the diseased cavity and tissue must be scooped out, or re-
 moved in accordance with the principles already laid down; and, if  disease of
 the neighboring  articulations result, it  must be managed as will hereafter be
 explained.
    It is of importance, however, to recognize the dependence  of these various
 affections on a tuberculous state of the bone; for, as this is  always  of  a scro-
 fulous  character, it should necessarily occasion the constitutional measures that
 are employed to be specially  directed  to the removal of this cause.  Thus, good
 food, sea-air, the  administration of iron, of the  iodides, and cod-liver oil, will
 form  most important elements in the  treatment, without which,  indeed, it
 cannot be brought to a successful  termination.  The progress of these cases is
 generally  excessively tedious.   Stanley gives,  indeed,  two years as the  time
 required for a strumous bone to recover  itself, and in very many instances this
 period may even be exceeded.   In this,  as in all other of the chronic inflamma-
 tory affections of the bone, it is of considerable moment to continue the means
 of cure until  the disease  is fully recovered from, for relapse  will occur with
 special readiness in the tubercular affections, if  the  patient be allowed to use
 the diseased limb or part too soon.
                          TUMORS  OF  BONE.

  Exostosis. — By exostosis is meant the growth of a bony tumor from some of
the osseous structures of the body.   The  causes  that  immediately give rise to
this disease are usually extremely obscure.  There  can be no doubt that, in
some instances, it is predisposed to by syphilis, scrofula, or cancerous affections;
and that in other cases, again, it is hereditary; but, in general, it occurs without
any distinct or appreciable exciting cause.
  Exostoses are of two kinds:  the one hard and compact, the other softer, and
more spongy.  The hard, or ivory exostosis, is  a  structure that differs both in
appearance and composition from true bone. It is extremely compact and white,
having a granular section  closely resembling  that of  ivory,  and presenting
somewhat radiating fibres.  In  chemical composition,  it is found to differ from
healthy bone in containing more of the phosphate and less of the carbonate of
lime, and also in the proportion of animal matters being smaller.  This kind of
exostosis principally grows from  the flat  bones,  and as it is generally of small
size, seldom produces much  inconvenience, unless it be  by projecting into and
compressing important parts;  thus, Cloquet  relates the case  of  a tumor of
this kind growing  from the pubes, and perforating the bladder, and they are 
TUMORS OF BONE.
599
occasionally found to project into the orbit, or from the inner table of the skull,
upon the brain.   When  these  bony tumors are left to themselves, they usually
become stationary after a time.   In some instances they have been  known to
necrose, and to slough away, as it were, from the parts in which they are situated.
Of this termination Hilton and Boyer relate instances.
   The spongy, cancellous, or cellular exostoses grow rapidly, often attain a con-
siderable  size,  and are  very commonly multiple.   When  numerous, they will
often be found to be somewhat symmetrical  in their arrangement.   Not unfre-
quently they stretch across  from one bone to another, bridging over joints, and
thus giving rise to  anchylosis;  in  shape,  they vary greatly, sometimes being
globular, at others spinous.  In  structure  and  chemical composition, they are
identical with cancellated bone.
   The symptoms of exostosis are simply those produced by a hard, thick, and
slowly-growing tumor, connected with a bone, and pushing forwards the soft
parts covering it.   In  many cases,  it produces  serious inconvenience by  its
pressure,  either upon neighboring organs or mucous canals, or it may occasion
ulceration of the skin lying above it.
   Treatment. — If an exostosis  is so situated as  to occasion inconvenience or
deformity, it will be  necessary to remove it; and as it is a local disease, there
is no fear of its returning, provided this be  fully done.   If, however, the whole
of it be not taken away,  it may grow again, and Stanley accordingly recommends
that if it  be so situated,  as upon the cranium, that its base cannot be extirpated,
potassa fusa or nitric acid  should be applied to the part that is left, so as to
produce exfoliation  of it.  The removal of these tumors is best effected by a
Hey's or  chain saw,  or cutting pliers.  In  some situations, as when close upon
 joints, or springing from the cervical vertebrae, they cannot be interfered with;
and in other cases,  as occasionally happens in  the neighborhood of the orbit,
their density and hardness may be such, that the saw can scarcely work its way
through them.   There is a  peculiar kind of exostosis occurring from the upper
surface of the last phalanx of the great toe, pushing  up  the nail, and giving
rise to great inconvenience.  This may be  removed by exposing its base and
 cutting it off with a pair of sharp pliers, without amputating the toe.  There
is a species of bony growth, called osteoma, consisting  of  a uniform elongated
mass of new bone, deposited on some of the osseous surfaces, somewhat resem-
bling  a node, and differing from ordinary  exostosis in  not being pedunculated,
 that does not admit of removal, and is not amenable to any treatment.
   Enchondromatous, or  osteo-cartilaginous  tumors are  often met with.  These
 have already been described when  speaking of  enchondroma and its pathology
 (p. 398),  and need  not, consequently, be more  than adverted to here.  They
 usually require the  resection or amputation  of the affected bone, according to
 the attachments and size of the growth; but Stanley states that in some cases,
 where  the  cartilaginous tumor of bone is  of small  size,  it may be influenced
 and eventually dispersed by the local application of iodine and mercury.
    Cystic tumors of  bone of various kinds are commonly included under the
 terms osteosarcoma and  spina ventosa, which terms having also been occasionally
 applied to various other solid growths, whether of a fatty, fibrous, gelatinous,
 or cartilaginous character, as well as  to  various kinds   of malignant tumor
 springing from bones, have  occasioned much  confusion in the pathology of
 these  affections.   The  cystic  tumors  of  bone have  been well described by
 Nelaton.   They consist of cysts, having various kinds of fluid and solid contents.
 The cysts may be unilocular, and  these are commonly filled with solid matter,
 or multilocular, and they then contain fluid.  The solid masses are usually of a
fibrous or fibro-cartilaginous character, filling up completely the cavity in which
they are situated, and then  attaining a very considerable size.   They occur prin-
 cipally about the jaws and articular ends of long bones,  especially the humerus,
the femur, and the tibia.   The cysts with  fluid or semi-fluid contents attain a 
600
STRUCTURAL  CHANGES  IN  BONE.
Fig. 215.
Cystic tumor of lower end of femur.
much larger size than  the last, being often met with as large as a cocoa-nut or
a foetal  head.  On a section being made  of them, they are  found to be com-
                                posed of a multilocular cyst, each cavity havin«'
                                distinct walls,  and  often communicating with
                                others.  The fluid contained within these cysts
                                is of various characters, thin and serous, sero-
                                sanguinolent, viscid, or dark-colored, often asso-
                                ciated with masses of fibrous  tumor, appearing
                                as  if it proceeded  from  the central softenin»
                                of  these  large  growths.   The same situations
                                are affected by  the compound as by the single
                                cysts, but they are also met with in the shafts
                                of  long bones.  From whatever part they pro-
                                ceed,  their walls  are composed  of expanded
                                bone, not  uniformly thinned,  but thickened
                                and noduled  at various parts, whilst it is per-
                                forated at others (fig. 215).
                                  These  cystic tumors  principally  occur  in
                                adults, being rarely met with in children. They
                                constitute  smooth,  round, or  oval  growths,
                                increasing slowly but steadily, with little or no
                                pain,  the  skin covering them  being of the
                                normal color,  and the veins usually blue, en-
                                larged, and tortuous.  When a certain size has
                                been attained, so that the  shell of bone is ex-
                                panded into a very thin lamella, and before it
                                is perforated, pressure on the tumor occasions
                                a peculiar crackling or rustling noise like that
produced by pressing together  a broken egg-shell, or the crackling of tin-foil.
Under  this the elasticity or even semi-fluctuation of the tumor may be felt.
This fluctuation is particularly marked  after a time, when the osseous envelope
has become still more expanded, or is partially or wholly absorbed.
   Treatment___When  the  contents are  solid,  there is usually  no means  of
ridding the patient of the tumor, but by the removal of the whole growth;  by
excision, if it is favorably situated for such procedure, as in the jaws;  by ampu-
tation, if in the limbs.   When the contents of the tumor are fluid or semi-fluid,
it must, if large, be treated in the same way as the solid  growths  are; but, if
small, or if of moderate size, so as  not to  have materially affected the integrity
of the  bone, then  it may suffice to remove one  side of the  wall of the cyst by
the trephine or by  excision; and then stuffing the cavity with lint, allowing it
to granulate, and its walls to contract.   This plan has proved especially success-
ful in some of the cystic tumors  of the  lower jaw.   And I have had occasion to
practise it with success in a small cyst forming in the  outer condyle  of the
humerus.
   Hydatids---Cavities are occasionally,  but very  rarely,  found  in bones, in
which large numbers of hydatids  are lodged;  according to Stanley, both the
acephalocyst and the  cysticercus cellulosa have been found in this tissue, but
most  frequently the first.   In  these  cases a  cyst  forms  in  the bone, which
becomes thin  and  expanded, resembling  the  ordinary  fluid cyst tumor, but
which, on  examination, is found to contain these entozoa.   The treatment, as
Mr. Stanley observes, must depend  on the situation and extent of the disease;
if it is a long  bone that is  affected, and  that  is much expanded, amputation
must be had recourse to;  if a flat  bone, the cavity must be  scooped out, and
dressed from the bottom with stimulating  applications,  so as to get it to fill
with healthy granulations.
   Malignant osteoid, osteo-cancer or osteo-cephaloma are true  malignant tumors 
OSTEO-CANCER.
601
of bone, constituting very  serious but not very  rare forms  of cancer.   Two
distinct forms of cancer of bone are included in this disease.  In one form the
morbid growth is central, springing from  the medullary canal;  in the  other it
is peripheral, being attached to the compact osseous substance.  Encephaloid
of bones is harder  and  more fibrous-looking than the same affection elsewhere.
The cancer-cell  also is not so well marked, and indeed may be absent altogether.
   In the central cancer of bone, the  tumor is found to grow in the substance
of, or to spring  from, the interior  of  the medullary canal  of the bone.   It is
usually situated  at  or about the articular ends, expanding the bone, which be-
comes completely enveloped and incorporated  in  the structure of the growth,
either in the form of osseous rays  diverging from the centre of the tumor, or
more rarely as a thin shell of bone  surrounding the mass, as in the more simple
growths springing from this tissue.   Under either circumstance it is important
to bear in mind that  this form  of  disease is never localized, but always invades
the whole of the bone; the freedom of communication  between the upper and
lower ends of a long bone is so great,  that, as has been shown by Richet, water
injected at one  end exudes  in a few seconds at the other.  Hence the juices of
a malignant structure might easily traverse the whole length of the bone, and
we accordingly find  on examining the osseous tissue at a distance  from the
tumor, that there are red patches in it here and there indicative of its infiltra-
tion with the morbid structure.
   In the peripheral form of cancer of  bone, which is probably the most common
variety, the osseous tissue is not so completely invaded; for, although the dis-
 ease may be situated upon,  or be in intimate  contact with, the  outer layers  of
 the bone, which are  incorporated in it, it  does  not extend into the cancellous
 tissue, or the medullary canal.   The  tumor appears to  spring from the perios-
 teum, and after removal and maceration, stalactitical projections and  radiating
 fibres may be traced into it from the outer layers  of the bone.   In this form of
 osteo-cancer, the muscles that are attached to  the affected portion of  bone will
 often be found  to be extensively infiltrated with cancer-cells.
   These tumors, whether central  or peripheral, are chiefly of the encephaloid
 species of cancer, and are met with in all stages of development and of decay.
 Occasionally, some colloid, and more rarely  melanotic matter is intermixed;
 but scirrhus,  I  believe, is never found in bone.  They most frequently occur in
 the head of  the tibia and the lower end  of the  femur; occasionally in the
 humerus and in the jaws,  more especially about  the  antrum.  It is a remark-
 able fact,  long ago  pointed out  by  Petit,  and more  recently  insisted  on by
 Richet, and  which  I  have often had  occasion  to verify, that although the
 epiphysis  may  have been  completely converted into encephaloid  matter, the
 cartilage of incrustation and of the neighboring joint (fig. 217) never  becomes
 implicated;  and this, although the growth may eventually involve  and include
 the whole of the rest of the articulation, by extension to the capsule and its soft
 parts.  When internal organs become secondarily affected in  these cases, the
 deposit will generally be found in the lungs.
   The symptoms  of these tumors are  as follow: there is  a rapidly-growing
 enlargement of the bone, usually with much lancinating pain, having a globular
 shape, feeling elastic, and  sometimes  semi-fluctuating.   The skin  covering it,
 at first pale, with  numerous reticulated and blue tortuous veins, afterwards
 becomes  discolored, being eventually  implicated  in  the morbid mass.  In
 some cases fracture of  the  bone takes place at the affected  part  (fig. 216); the
 neighboring  tissues  are speedily  contaminated, the lymphatic glands become
 enlarged, cancerous cachexy sets in, and the patient eventually sinks.   In other
 cases, again, the  disease  being central, the progress,  especially in  the early
 stages of the disease, is less rapid, though it  at  last  develops  itself with fear-
 ful violence.   So long  as the disease  is confined  within the walls of the  bone,
 it develops itself but slowly, and does not show much disposition to  affect the 
602
STRUCTURAL CHANGES IN  BONE.
constitution.   I had lately a patient under  my care, a man whose thigh I am-
putated for cancer  of the  head  of the tibia, that  had  existed  for four years
Fig.  216.
Fig. 217.
  Osteocephaloma of the head of the hume-
rus with spontaneous fracture of the  shaft,
in which I amputated successfully at the
shoulder-joint.
  Section  of tumor — upper  end  and
head of humerus destroyed, but carti-
lage of incrustation unaffected.  Tumor
divided by white vertical lines,—the pe-
riosteum; inside which  only were the
osseous spiculse found.
without  contaminating  the  neighboring parts,  whose  constitution  appeared
sound, and who made a  good recovery.   But when once the  soft parts become
engaged, the system is speedily contaminated.  In some instances, pulsation of
a thrilling kind, with or without a blowing murmur, is distinctly perceptible,
especially in an  advanced stage of the  affection, when  the vascularity of the
tumor is greatly increased.
  The diagnosis of osteo-cancer has to be made from other tumors of bone, and
from  aneurism.  The malignant growths of bone may readily be confounded
with those various  forms of  non-malignant disease that are commonly included
under the term  spina ventosa.  In making the diagnosis, we  may reasonably
come to the conclusion that the growth is  cancerous, if it occur in  early life
before puberty, or between this period and  the  early adult age;  if it increase
with great rapidity, and with much pain, especially  of a lancinating character;
if, to the touch, it present a somewhat diffused pulpiness, with much elasticity,
great tension,  and, at points, a  semi-fluctuating  feel; and, more especially, if
the veins are greatly enlarged  and tortuous, the neighboring  lymphatic glands
involved, and  cachexy ultimately setting in.  These conditions differing from
the slow growth, the more circumscribed character and  more solid  feel of the
non-malignant tumors, which  have no   tendency to the implication  of neigh-
boring structures, and which occur at later  periods of life, usually enable us to
make the  diagnosis.   There is  one tumor, however, viz., enchondroma, which 
OSTEO-CANCER.
603
occasionally in the rapidity of its growth, closely resembles the malignant dis-
eases.   Here the diagnosis is  confessedly extremely difficult, though the more
solid character, the less degree of elasticity, and the absence  of lymphatic  en-
largement, or implication of contiguous tissues, will often enable us to establish
the true nature of a tumor before its removal.
   The  diagnosis from  aneurism is necessarily unattended  by any difficulty so
long as the sac is pervious to fluid blood, and presents the  characters  that  are
met with  in this condition.   But if the sac have become  consolidated  by  the
deposit of stratified lamina, and thus have  assumed the characters of  a solid
tumor,  it  may readily  enough be mistaken for a tumor springing  from  the
osseous structures, and  amputation has occasionally been performed on  this sup-
position.   In  these cases, however, the history of the  progress of the  disease
will do more to elucidate  its true  nature than anything  else, attention being
more especially paid to the early symptoms  of the tumor,  when the aneurism
was still filled with blood.
    Treatment. — No means are of any avail in cases of osteo-cancer except the
removal of the  part diseased by amputation or excision.  These operations  are
however  not very promising,  as there are  few forms  of cancer in which  the
disease returns more  rapidly  in a secondary manner, than that of the bones.
The rapidity of recurrence will, however, greatly depend upon the form  of  the
disease, the time at which amputation is performed, and on the part where it is
practised.  It  should always if possible be  had recourse to in the earliest stage
 of the disease,  before  glandular or constitutional  infection has set in.  If the
 glands are enlarged, and cachexy has already occurred, little can be expected in
 the way of ultimate cure, but yet I have  known  cases in which, even under
 these unfavorable circumstances, the patient has made a good recovery; his
 life having been prolonged for months.  I believe  that  return is much more
 speedy and certain after amputation in the  peripheral than in the  central form
 of osteo-cancer, provided in the latter the whole of the bone has been  removed,
 owing to the more extensive contaminations of the soft parts in the former than
 in the  latter case.   The  selection of  the line at which amputation should be
 performed is of great  importance, and the result will materially depend upon
 the judgment displayed in this. If the limb be removed in  the continuity of
 the diseased bone there must necessarily be a great probability of the very rapid
 return of the morbid  action in the  stump, and  this  probability amounts  to a
 certainty in those cases in which the disease is central, and in which the whole
 of the medullary  canal and cancellous structure  are  implicated, and infiltrated
 with cancer.   In  cases of peripheral osteo-cancer, this  return in the same bone
 may not take place; indeed, I have  seen one case  of the kind  in which  the
 disease affected the lower end  of the tibia, and  that  bone was amputated in its
 upper third; in this case, after a lapse of some months, fatal  recurrence of the
 disease took place in the pelvic bones, but not in the stump.   As, however, the
 peripheral is more rare than the central form of the disease, and  as  there  are
 no means of ascertaining the  precise kind  before  removal,  the rule, I think,
 should be definite to amputate at or above the next  joint; at the hip-joint, in
 cancer of the femur; in  the thigh, for that of the bones of the leg; and at the    «
 shoulder,  when the upper arm is affected.
    Where the lower part of the femur, however, is involved, amputation through
 the trochanters may sometimes be substituted for disarticulation at the hip joint,
 the latter operation being so formidable and so fatal that the  surgeon may think
 it advisable not to subject the patient to so serious  a  risk;  or the amputation
 might  be performed through  the trochanters, and then the  head of the bone
 extirpated from the acetabulum.  In  this way the severity of the operation and
 the extent of incised surface would be lessened, whilst the whole of the diseased
 bone would be removed
    In the peripheral form of osteo-cancer, however, the muscles inserted  into the 
604
STRUCTURAL  CHANGES IN  BONE.
affected bone often become speedily contaminated by the disease, and this con-
tamination may spread widely through the substance of any particular muscle.
Hence I think the rule in these cases should be to amputate not only above the
diseased bone, but, if practicable, above the origins of the muscles in the neigh-
borhood of the disease; thus if there be a malignant tumor of the bones of the
forearm, amputation should be done above the humeral attachments of the mus-
cles of the forearm.
   The propriety of excision  of some bones, as of those of the face, in this dis-
ease must depend on whether the morbid deposit is limited  to  the  structures
that can be excised.   This operation can rarely be  advantageously practised in
malignant tumors, there being in general too great  an implication of the  soft
structures in the neighborhood to make such a proceeding justifiable.
   Sanguineous tumors are occasionally met with in bones; according to Stanley
they are  of two kinds.  1st. Those in which the tumor is composed of a vas-
cular substance, having the general characters of erectile tissue, and bearing on
section a close  resemblance  to  certain nevi (fig. 218).   This tumor may be
removed without  the liability to reproduction.  The 2d form of sanguineous
tumor consists of a cyst formed in  the cancellous structure of a bone, and  con-
taining either fluid or coagulated blood.  According to  Stanley, this tumor ex-
pands the osseous walls, and  will gradually cause ulceration of the skin and pro-
fuse hemorrhage.   The treatment consists in the amputation of the limb, or the
excision of the affected bone, as was successfully done by Travers, who removed
a clavicle that was the seat of this disease.
     Aneurism by anastomosis of one of the parietal bones.     pulsation communicated
                                                    to them from a neighbor-
ing artery; but the true pulsating tumors of bone owe their pulsations to some
inherent peculiarity of structure, which appears to consist either in the develop-
ment of a vascular tissue of abnormal cbaracter, or else in the simple  enlarge-
ment and dilatation of the vessels of the bone.  In the first, and most frequent
class of cases, those in which new tissue is developed  in the  osseous structure,
we usually find them partake of an encephaloid character; a creamy, curdy, or
brain-like, soft and very vascular mass is formed as  an essential and principal
constituent of  the tumor.   This might consequently with propriety be termed
an encephalo-osteo-aneurisma.  This abnormal mass will be  found to present
every shade  of transition  from true encephaloid cancer  to  a purely  vascular
tissue of an  erectile character.   In the second, and more  rare form of the dis-
ease, a structure  is developed in the bone which originally, and, in many cases 
OSTEO-ANEURISM.
605
throughout, is a vascular, erectile growth, closely resembling capillary nevus in
its structure, composed of an infinity of blood-vessels, interlacing in every pos-
sible way, so as  to form a soft, reddish-yellow tumor.  In other cases, again, a
hollow cavity is formed in the bone, scooped out of the cancellous structure and
filled with blood, which is partly liquid  and partly coagulated, and into which
arterial branches freely open.  The shell  of bone surrounding  this cavity is
very thin and expanded, being usually  absorbed  at  one point, where it often
becomes at last perforated.  This is the form of disease that constitutes the true
aneurism of bone.
   These various kinds of  pulsatory tumor of bone have been met with  in
almost all parts of the body;  most commonly the  cancellous  articular ends  of
the long bones, more particularly of the tibia, the radius, the  humerus, and the
femur, have been found affected.  The pelvic bones  are also  not unfrequently
the seat of these growths, and they have been encountered in the cranium, the
ribs, and indeed in connection with  most of the osseous  structures.
   In its early symptoms an osteo-aneurism closely resembles the ordinary forms
of spina ventosa, being oval in shape, uniform, and  elastic to the touch, grow-
ing slowly, without  enlargement of  the veins or discoloration of the skin, cha-
racters that it  possesses in common  with most  other  tumors of bone.  The
special signs by which it is individualized, however, are  its pulsation and bruit:
the pulsation is very distinct, superficial, and commonly of a thrilling character;
in other cases it is  directly impulsive,  and distinctly expansive; the bruit is
most usually soft and blowing, but not unfrequently  harsh, loud,  and  whizzing.
In some cases the bruit is absent, though the  pulsation continues  distinct; this,
according to Nelaton, is most frequently the case  in  true  osteo-aneurisma.   In
the pulsating encephaloid form of the  disease, I have heard the bruit peculiarly
loud, rough, and superficial.  On compressing the main artery leading to the
part of the limb in which the tumor is situated, all movement and bruit  com-
monly cease in it, and it lessens in size.   By pressing upon the tumor when it
is thus  diminished, it will  commonly be found to have a bony margin, with a
central depression, more especially in  those cases in which there is no encepha-
loid entering into its  composition, the  growth being apparently composed of
erectile and expanded osseous tissue, filled with  fluid blood.  In some cases,
however, the  tumor is fed by several  arterial branches, which may be felt dis-
 tinctly pulsating under the skin.  This  is more  particularly the case when it
 occurs  upon the bones of the  pelvis and the scapula, and then  the  bruit and
 pulsation cannot be made to cease in it.  All  these  signs are commonly some-
 what intermittent, appearing perhaps  in the earlier stages of the disease, and
 disappearing as it advances;  or the reverse may occur, the pulsation  and  bruit
 becoming distinct as the disease increases  in size and  meets with more  resist-
 ance in its outward growth.
   Diagnejsis. — It is of considerable  importance in many cases to diagnose  the
 different forms of pulsating tumor of bone from one another, some being of  a
 truly cancerous character, whilst others  appear to consist of simple  expansion
 of the vascular element of the bone, with atrophy of its osseous substance, and
 consequently the  prognosis also in the  two  conditions is very different.  The
 true osteo-aneurism has so many signs in common with  the pulsating encepha-
 loid tumor of bone, that in  many  cases it is almost impossible to  effect  the
 diagnosis; yet it is well to bear in mind  that the malignant form of the disease
is not unfrequently multiple, occurring, with pulsation  and bruit, in  more situ-
ations than one; thus I have  seen  growths of this kind, with their  signs well
marked, springing both from the pelvis  and ribs.  The true  osteo-aneurism is
 only met with in the articular ends of long bones, whereas the  malignant dis-
ease, though  commonly occurring in  these situations, is also frequently found
seated  in  other  parts of the  body.   Besides these, there are  two  conditions
which, in many cases, will  enable the surgeon to  determine that the  pulsating 
606
STRUCTURAL  CHANGES  IN  BONE.
tumor is an osseous aneurism; viz., the absence of all bruit, though the pulsa-
tion be distinct, and the detection by firm pressure, and  after the tumor has
been diminished  by the  compression of the artery leading to it, of an osseous
margin around its depressed centre.
   From ordinary aneurisms, the diagnosis of these affections is, in many cases,
attended by almost  insuperable difficulties.  So great  are these, that there are
many cases on record in  which the most experienced surgeons of the day have
ligatured arteries for tumors that were supposed to be aneurismal, but which
have turned out to  be pulsating growths connected with  bone.  The  principal
points to be  attended to  in  effecting  the diagnosis, are the situation of the
tumor, which may  occur away from the ordinary sites of aneurism, in parts of
the body where  there is no vessel large enough to give rise to such a disease,
as for instance, about the head of the fibula or the side of the pelvis.  Then,
again, its incorporation with  the subjacent bone, the want of a distinctly limited
and circumscribed  outline, and the existence  in many cases of plates of bone
in  the wall of the tumor, giving rise, perhaps, on pressure, to  the  peculiar
rustling  or crackling sound characteristic of bony growths, will enable the sur-
geon  to  come to a conclusion as to the true nature of the  tumor.   In this he
will be further assisted by  its giving on compression  a soft, doughy, or spongy
feel, or appearing as a depression  surrounded by an osseous  margin.   In many
cases also the less impulsive character of  the beat of the tumor, the peculiar
shrill and tremulous whizz in the  pulsation and bruit, will throw much light on
the nature of the disease.   But yet it cannot be doubted, that when tumors of
this kind occur  in some  of the  ordinary situations of aneurism, as about the
brim of the pelvis, and in  the popliteal space, that the diagnosis is surrounded
with  difficulties  that no amount  of surgical skill  or tact may be able to over-
come.  From ordinary tumors of bone, the  existence of pulsation and bruit will
always suffice to distinguish the growths under consideration.
    Treatment. — Incision into a pulsating tumor of bone, or any attempt to re-
move it without  its osseous connections, is  clearly contrary to the rules of good
surgery; and when it has  been practised, the hemorrhage has been of the most
alarming and dangerous  character.  Resection has been had recourse to in some
instances, as when  the disease has been seated  on the  cranial bones, but without
success.   Liston, in a tumor of this kind  growing from  the scapula, which he
called " an ossified aneurismal tumor of the sub-scapular  artery," excised the
greater portion of  the bone  from which it sprang;  but fungous growths reap-
peared  in the wound, by which the patient was at last exhausted.  When the
disease has proceeded to such an  extent as to  produce extensive alteration in,
 and destruction  of the  tissue of the bone affected, amputation of the limb  is
 the only resource left to the surgeon.  This operation is  also called for in those
 cases in which the disease returns after other means, such as the ligature of the
 artery,  have been practised.   In these  cases, if the disease partake at all of the
 encephaloid character, the limb must be removed at a point above the affected
 bone.
   The  result of the ligature of the main artery leading  to  the tumor depends
 greatly upon the nature of the growth.   When it is partly composed of en-
 cephaloid or other  solid  tissue, but little good  can result  from this proceeding,
 the tumor continuing to increase  by an inherent growth, that will continue  as
 long as the vitality of the limb is maintained; and we accordingly find that  in
 all such cases in which  this operation has been practised,  the progress of the
 tumor has either  not been  retarded, or if the  pulsations have  been stopped,
 and its size lessened for a time, the activity of the symptoms  has speedily re-
 turned,  and amputation  been rendered necessary.   When, however, the tumor
 has partaken more of the  characters of true osteo-aneurism, then  a more favor-
 able result has followed  the ligature of the main artery of the limb.  In a cat;e
 of this kind seated in the radius, in which Roux ligatured the brachial artery, 
SYNOVITIS.
607
a complete cure resulted.   The  same also occurred to Lallemand; and in a
patient of Dupuytren's, there was no return of the disease  for six years, when
it recurred, and amputation  became necessary.   These results  are  sufficiently
satisfactory to justify the surgeon in having recourse to the  ligature, or perhaps
the compression of the main artery of the limb, in those  cases in which  the
tumor could be ascertained not to partake of the nature of encephaloid.
                        CHAPTER  XLIII.

                      DISEASES OF  JOINTS.

  The various joints of the body may become the seat of inflammatory affections
of an acute or chronic character, of strumous disease, or of various other morbid
conditions, such as more or less permanent rigidity, or anchylosis, the formation
of foreign bodies  within  their cavities, or  their  malignant degeneration.  In
studying these various articular affections, it must be borne in mind that a joint
is  composed  of a number of different tissues, of synovial membrane, cartilage,
ligament, bone, and  capsule, or  investing fibrous  expansion.   In  any of these
structures the disease may primarily begin, though eventually the morbid action
often spreads to other tissues besides  that which was  originally involved.   The
merit of having been the first to point out the true  mode of studying  these
affections in reference to the  different structures in which they have originated,
and to have set aside that coarse pathology which, under  the  general terms of
" arthritis" and of " white swelling," confounded together these various diseases,
is certainly due to the labors  of Sir B. Brodie.

                              SYNOVITIS.

  Inflammation of the synovial membrane, the most common perhaps of all the
articular affections, may be acute, subacute,  or chronic in  its characters.  What-
ever form it assumes, synovitis usually results from exposure to cold, especially
in rheumatic  or syphilitic  constitutions.  In these cases  it commonly happens
that more joints than one are implicated at the same  time; and the  affected
articulations are most frequently those that  are  most exposed by the thinnest
covering of soft parts, and by being especially subjected to transitions  of tem-
perature, such as the  knees and  ankles.  Injuries of joints,  as blows, bruises,
wounds, or sprains, will also  frequently occasion this inflammation; but when
arising from this cause, it is seldom of an unmixed  kind, being usually associated
with inflammation of the other textures that enter into the composition of the
articulation.
   As uncomplicated acute synovitis is never a fatal affection,  it is seldom that
we have an opportunity of studying  its  pathology.   It would, however, appear
from the result of the examination of joints  in cases of synovitis from injury, as
well as from the result of experiments of Richet, Bonnet, and others, who have
induced traumatic synovitis in animals, that there  is in the  first instance  an in-
flammatory congestion and vascularity of the membrane, attended by loss of its
peculiar satiny polish.   The  synovia is then increased in  quantity, as well  as
altered in quality, becoming  thin and serous, and after a time intermixed with
plastic matters that are  poured out with it.  If the disease progress favorably,
these products are more or  less completely absorbed.  If, however, as is more 
608
DISEASES  OF  JOINTS.
rarely the case, the inflammation goes on  to  an unfavorable termination, the
vascularity and swelling of the synovial membrane  increase, until  at last  it
becomes so turgid and distended with blood and  effused fluids, that a kind of
chemosis  of  it  results;  a thin,  purulent-looking fluid,  composed  of granular
corpuscles floating in a serous liquid, is poured out, and disintegration, with
thinning and erosion of the cartilage, and probably complete destruction of the
joint, ensues.   In other cases, granulations are thrown out on the looser  por-
tions of the membrane, which, becoming injected with blood-vessels,  constitute
fringed and villous membranous expansions, lying upon the subjacent, disinte-
grated,  and eroded cartilage.
   The termination of synovitis will depend mainly on its cause.   When of a
simple  uncomplicated character, arising, as the  result,  perhaps, of rheumatic
influences, it will  in  most cases terminate in complete resolution.  In other
instances, however, plastic matter may be thrown out, that either  assumes the
form of warty vegetation or concretions within the joint, or of bands stretching
across its interior, or incorporated with its capsule, occasioning more or less per-
manent stiffness. When synovitis arises from wound it usually goes on to sup-
puration within the joint, superficial erosion or disintegration  of the  cartilage,
and eventually,  if the limb be not removed, to complete disorganization of the
interior of the articulation, and to more or less complete anchylosis.   The same
happens in the puerperal inflammations of joints, and in those that arise  from
pyemia, in which cases the morbid action commencing on the synovial membrane
extends downwards to the cartilages, eventually leading to destructive  disorgani-
zation of  them.
   The symptoms of synovitis consist  of pain and heat of the joint,  with disten-
sion and fluctuation of it.   If it be large and exposed, the pain is severe,  espe-
cially at night, being greatly increased by moving or pressing upon the articu-
lation ;  it is usually sharp, but when  the disease  occurs  in rheumatic or gouty
constitutions, of a  gnawing character.   In purulent  synovitis occurring  from
pyemia, it is  usually very superficial,  indeed almost cutaneous.  On laying the
hand on the joint it will be felt to be hot.
   The swelling of the affected joint  is considerable, and evidently depends on
the accumulation of fluid within the  synovial sac, the extreme outline of which
is rendered apparent by  the tension to which it is subjected.   Thus in the knee
it rises  up high in the thigh under the tendon of the quadriceps  extensor, in
the elbow under that of  the triceps.  There is but little if any effusion into the
surrounding tissues, and hence the outline of the joint can be distinctly felt,
and undulation  perceived in it.   The  limb  is usually  semiflexed, as giving the
patient most  ease, and the joint cannot be  moved.   The  constitutional febrile
disturbance is  tolerably  severe, especially if the affection occur in  a rheumatic
constitution.
   The disease, at first acute, may terminate in a subacute or  chronic  form; or
subacute at its  commencement, it may fall  into a chronic  condition.   Chronic
synovitis is characterized by all the symptoms of the acute variety of the disease,
but in a less  severe degree.   The swelling and weakness of  the joint are the
most conspicuous local conditions. In some  cases, the swelling  from accumulated
serous fluid is so considerable as to constitute a true dropsy of the joint, hydrar-
throsis.   This accumulation of fluid, partaking in  various degrees of the charac-
ters of  serum and synovia, is usually preceded or accompanied by  evidence of
synovial inflammation; but, though this  generally happens, it is not  invariably
the case.   Richet, in particular, has recorded instances from which it would
appear that inflammation is not a necessary, or invariable accompaniment of the
affection, the synovial membrane being indeed preternaturally white, and looking
as if it had been washed or soddened; and though these cases are rare, those
that commonly present themselves to the surgeon being of a  decidedly inflam- 
HYDRARTHROSIS.— SYNOVITIS-
609
matory character, yet their  occasional occurrence is  sufficient to establish the
existence of a passive, as well as an inflammatory form of the disease.
  The presence of an abnormal quantity of fluid in the joint is always readily
perceived by its fluctuation and undulation, by the deformity that  it produces,
and by the peculiar shape that it communicates to the part.  Thus  in the knee,
which is the most common seat of this affection, the patella will be felt to float,
as it  were, on the subjacent liquid; and the capsule  of the joint projects  dis-
tinctly in three situations, viz., on either side of the ligamentum  patellae, and
above that bone.   In the elbow, there is a soft and fluctuating swelling on either
Bide of the olecranon, and under the tendon of the triceps;  and in the shoulder
there is a general soundness and distension of the articulation.   It is said, that
in some  cases, the distension of the joint has been so great, that the synovial
membrane has been ruptured, and the fluid poured forth into the  surrounding
cellular tissue.  In  these cases, it is probable, however, that some destructive
change in the synovial membrane preceded its rupture.
   The chronic subacute synovitis and hydrarthrosis usually terminate favorably;
but, occasionally, more particularly in strumous constitutions, the  disease runs
on to suppurative destruction of the joint.   This, however, is rare, but  yet its
occurrence, in some instances, should make the surgeon careful not to confound
the fluctuation of the serous accumulation with that of the purulent collection.
In the latter instances there will always have been the precursory symptoms of
inflammation.
   The treatment of synovitis depends partly on the severity of the  symptoms,
and partly on the cause of the disease.   If the inflammation be acute and arise
from injury, it requires to be actively treated by venesection, if the patient is
young and strong; but in all instances by the free and repeated application of
leeches to the inflamed articulation, followed by fomentations and  accompanied
by perfect rest of the part on a splint, or on pillows properly arranged.  In some
 instances the  cold irrigation will be found  to be of essential service;  at  the
 same time saline purgatives with antimony must be given, and the patient kept
 on a low diet.
   If the disease is of a rheumatic character, leeches must be applied, followed
 by hot fomentations, and rest of the part in the elevated position;  at the same
 time, colchicum, with salines, if there be much febrile disturbance, and if there
 be much pain at night, in combination with  Dover's powder, should be adminis-
 tered.   In some instances, where colchicum disagrees, great benefit will result
 from the administration of Dover's  powder and calomel,  in small but frequent
 doses.  When the disease is of syphilitic origin, leeches are not often required;
 but the application of blisters, followed by calomel and opium, will be attended
 with marked success.
    When the synovitis is of a subacute or chronic character, the same principles
 of treatment must be adopted, modified according to the  intensity of the affec-
 tion.  In these forms of the disease, rest is perhaps the most important element
 in its treatment, everything else  proving nugatory unless this  be  attended to;
 the limb is usually best fixed by leather splints, buckled on so that they may be
 removed in order to make the necessary applications to it.   In these cases
 repeated blisterings over the whole of the joint constitute perhaps the most use-
 ful local means that we possess; in a more  advanced stage, counter-irritation by
 means of stimulating embrocations, together with douches, either of warm sea-
 water or of some of the sulphurous springs, such as those of Harrowgate,  Aix, or
 Bareges, will prove  most useful; and when all  inflammatory action has been
 subdued,  and weakness  of the joint merely is  left,  this should  be properly
 strapped with soap-plaster, spread upon  leather.   Among the internal remedies
 likely  to  be of most  service, may be mentioned the iodide  of potass, either
 alone, or in  some bitter infusion.
    In hydrarthrosis, rest and repeated blistering will usually promote the removal
        39 
610
DISEASES  OF  JOINTS.
of the fluid.  In addition to this, the employment of pressure and friction, with
absorbent remedies, as the iodine or mercurial ointment, conjoined with the in-
ternal administration  of  the  iodide of potass, or a  mild  mercurial course, will
often procure the absorption  of the fluid.   If these means fail, we have a very
powerful means of cure at our command  in the subjection of the joint with tinc-
ture of iodine.  This plan, a sufficiently bold one, has been much employed  in
Paris by Jobert and  Velpeau,  and  in Lyons, by Bonnet.   These surgeons use
the tincture diluted with two or three parts of water.   A small trochar is intro-
duced into the joint,  a moderate quantity of the serous fluid is let out, but not
all, and then a corresponding quantity of the iodine solution is thrown in; and
after being left for a few minutes, allowed to escape.  Inflammation of the joint,
which is  a  necessary result  of this procedure, comes on.   This  is then treated
by ordinary antiphlogistic means, and, according to the statements of the French
surgeons, has  in no  case been followed by any serious  consequences, but  in
several instances by a complete cure without anchylosis;  a  new and healthy
action having been imprinted on the  synovial membrane.   The mode of treat-
ment does not  appear as yet to have met with much support in this country, yet
it certainly deserves  a trial, though it should not lightly be had recourse to, as
it is evident that the induced inflammation might exceed the expected limits.
After dropsy of the joint has been removed, the articulation is  usually left  weak
for some length of time, in consequence of the stretching to which its ligaments
have been subjected; here cold douches and an elastic bandage will constitute
the  best modes of treatment.

                               ARTHRITIS.

   By arthritis, is meant  inflammatory disease of an acute  or chronic kind, of the
whole or greater part of the structures  that enter into the formation of a joint.
This affection  may commence  in the synovial membranes, and  then spread to
the  other articular tissues, or it may begin in the  cartilages  or bones, and in
some rare instances  it may perhaps take its origin  in  the fibrous capsule sur-
rounding the articulation ; whether it can ever commence in the ligaments is a
question that is not as yet satisfactorily  determined.
   In arthritis, the principal changes  are undoubtedly found to take place in the
cartilages, at the same time it must not  be supposed that  all morbid appearances
 that are found in these structures are the result of inflammation, as erosion and
 absorption of their tissue may take place, independently of any diseased action.
 The long-continued disuse of a joint, as in the treatment of fractures, may occa-
 sion this; and in old people  it is very common to meet with  a porcellanous or
 ivory-like deposit on the articular ends  of  the bones, which, however, does not
 prevent the joints being used, though it may occasion stiffness  and pain in them.
 According to  Quekett this  porcellanous deposit is  of  two kinds, one consisting
 of unorganized earthy matter; the  other, of true  bone, having the Haversian
 canals filled with phosphate  of lime.
   In  acute  arthritis the cartilages are usually found ulcerated and eroded in
 patches of  varying  size, exposing bone, which is rough and  vascular.  The
 remains  of  the cartilage are  softened, inelastic,  opaque, and  thickened, and
 separate  easily from the subjacent bone, which can be felt rough and  grating.
 The synovial  membrane is  usually  thickened and  very  vascular;  the vascu-
 larity being most  distinct about those parts, where the erosions and grooves
 in the cartilage are deepest, and often assuming a dentated or  fringed appear-
 ance.   In other parts, especially about  the circumference of the joint, masses
 of plastic matter  are deposited underneath, and upon the synovial membrane;
 these are smooth  and  semi-transparent, having a somewhat fatty  look; the
 ligaments are relaxed, vascular, and softened, and the interior of the joint filled
 with thin, flaky, and light-colored pus.   The capsule and the  cellular tissues 
PATHOLOGY OF ARTHRITIS.
611
around are thickened, and either infiltrated with pus, or clogged with the same
kind of plastic matter that is seen in the interior of the joint.   The  articular
end of the bone is enlarged, soft, and vascular;
and  in  strumous cases may be  the seat of            Fig. 219.
tuberculous infiltration (fig. 219.)
  The changes  that take place  in the carti-
lages in this disease have excited much atten-
tion amongst  surgeons, and a  good deal of
difference of opinion exists as to the mode in
which they are induced.   Many surgeons
hold  the  doctrine that cartilage being extra-
vascular,  the  changes that  take place in  it
are accomplished through the medium of the
contiguous  synovial membrane  or bone,  and
consequently are secondary to disease of these
tissues.  We may, I think, conclude -that this
disease of cartilage  may arise in three ways:
1st.  Through the  medium  of  the  synovial
membrane; 2d.  Through the medium of the
subjacent bone; and 3d. By means of changes
taking place in the cartilage  itself.
   1st. The destruction  of  cartilage, as the
result of synovial disease, may best be studied
in cases of  wound of a joint.  In these cases
it will  be found,  if the joint  be examined
before complete disorganization  of it has oc-
curred, that the diseased action  spreads from
the synovial membrane, where it is most in-
tense, downwards into the substance of the cartilage, which, superficially diseased,
becomes more healthy the deeper the examination of it is carried.  Immediately
under the swollen, gelatinous-looking, brightly-injected synovial membrane, the
cartilage will be found to be reddened, roughened, and softened.   On examining
a thin  slice of  this, it will  be  found to be composed of granular matter and
nuclei of cells whose walls have disappeared.   At  a little greater  depth than
this it will  present an  opaque matrix, with cells, some perfect, others imperfect
or  disintegrating, and  below  this level we shall come to healthy white  cartilage,
with clear matrix and well-formed cells.
   The disorganization of the  cartilage will eventually go on  to its  complete
removal, and to the exposure of bare  and roughened bone.   It is in this way
that  destruction of joints as the result of  punctured wounds, pyemia, or  puer-
peral inflammation, results.
   Aston  Key advocated the doctrine that a peculiar disease was set  up in the
synovial membrane by which a fimbriated or fringed vascular network or tissue
was  formed, by means of which  the cartilage was  absorbed; and that as this
membrane  extended,  so  did the  removal  of the  cartilage  go on.  , That an
appearance of this kind in inflamed joints is of common occurrence is  doubtless
the case, but Goodsir has  shown that Key erred in attributing the disintegra-
 tion  of the cartilage to this  membrane; for he states that a fibrous tissue forms
in  a  diseased joint as the result of the  disintegration of the cartilage, and that
this, which is connected either with the  synovial or osseous surfaces, speedily
 becomes vascular.   So far, therefore, from being the organ by which the  carti-
 lage  is removed, it is the result of prior disease in this structure.   At the same
 time it cannot, I think, be doubted that a villous injected state of the synovial
membrane  will modify the nutrition of the  subjacent  cartilage in such a way,
 that disintegration,  erosion,  and apparent ulceration of it will ensue.
   2d. Disease of cartilage  primarily dependent on  morbid action in the sub-
 
612
DISEASES  OF JOINTS.
jacent bone is, I believe, one of the most frequent modes of the disorganization
of joints in strumous subjects, and most certainly leads to those rapidly destruc-
tive  affections of joints, in which amputation or excision is required.  In these
cases, either as the result of violence, or from constitutional causes, the articular
                                    ends of a bone, or the whole of a bone if
                                    it be one  of the tarsal, becomes congested,
                                    inflamed, carious, or necrosed, sometimes
                                    infiltrated with tubercle.   (Fig. 220, a.)
                                    In consequence of this disorganization of
                                    the osseous tissues, the  incrusting carti-
                                    lage becomes  detached,  its under  or  at-
                                    tached surface softened, and  at last per-
                                '""  foration takes place.  (Fig. 220, b.)  This
                                    process of  disintegration  and at last per-
                                    foration and erosion of the cartilage, takes
                                     place  in a direction  from below upwards.
                                     So soon  as perforation  occurs, the whole
                                    of the interior of the joint becomes acutely
                                     inflamed and  suppuration is  set up in it,
                                     the ligaments loosen, and complete disor-
                                     ganization  ensues (fig. 220).  On examin-
 ing the diseased patch of cartilage in  such cases  as these, it will be found to
 correspond to  the carious or tuberculous  bone, from which it is separated by
 some  bloody fluid; it will also be seen that the  under edges of  the erosion or
 perforation in the cartilage  are separated to some extent from  the  subjacent
 bone, from which they readily peel off, and that they are bevelled off towards
 the aperture.
   3d.  That cartilage is susceptible of  primary change of the nature of inflam-
 mation or ulceration, induced by the action  of  its own vessels, is the opinion of
 Brodie, Mayo, and Liston, all of whom have  observed  true vascularization of
 cartilage.   This  condition, however, is extremely rare, and is certainly not one
 of the more common  forms of joint-disease,  seldom occurring  except  in  the
 more chronic stages of arthritis.
   These,  however,  are  not  the  sole  changes that  take place in  cartilage in
 arthritis; the observations of Goodsir, of Rainey, and of  Redfern, all point to
 the fact that cartilage, like other extravascular tissues, is subject to other trans-
 formations, independent of the prolongation of vessels  into it.   The changes
 that ensue are, according to Redfern, of the following  kind:—The cartilage-
 cells enlarge, become rounded, and granular-looking, and instead of containing
 two or three nuclei, a considerable number are  enclosed in the cell-wall; even-
 tually these corpuscles break up and are disintegrated.   The matrix of the  car-
 tilage now softens, and according to Redfern, splits up into fibres or bands which
 become nucleated.  A species of fatty degeneration  also, as pointed out by
 Rainey, takes place, and helps to soften and break down the structure of the
 cartilage.  In  the more advanced  stages of disease of cartilage, we find masses
 of porcellanous deposit attached to the ends of the bones in plates and layers,
 taking the place of the eroded cartilage.
    In other cases, again, a soft,  pulpy, and vascular fibro-plastic  deposit of a
 greyish,  ashy, or reddish-brown color, with whitish  streaks of a firmer material
 running through it in various directions, takes  the place of the cartilage  that
 has been  removed, or that has undergone  fibro-cellular  degeneration.   On ex-
 amination  under  the  microscope, this will  be found to  be composed of plastic
 material, with  cartilage-corpuscles intermixed, and with  the subjacent bone in
 a state of disintegration and softening.  This condition  of joints I  believe to be
 analogous to the  "pulpy degeneration of  the synovial membrane"  of  Brodie.
 It would appear, from the microscopical examinations that I have  made of this
 
           PATHOLOGY AND  CAUSES  OF  ARTHRITIS.        613

material, in various cases after the removal of joints, to which  my attention was
first directed  by Dr. Quain, as occurring in a patient of his, whose elbow-joint I
excised, that  it is either fibro-cellular degeneration of the cartilage, or an imper-
fect  attempt  at  repair set up in the articulation, after the removal of the carti-
lage by previous disintegration and disease.  On making a vertical section of
the surface of the diseased articulation in the case alluded to,  it was found that
the pulpy and villous substance covered the  bone to the thickness of a line and
more in  some parts.  The  bone was  found to have its  cells filled with  oil-glo-
bules, but surrounded by  tolerably healthy osseous tissue,  showing  the usual
laminae and  bone-corpuscles.   Nearer the diseased surface the laminae and cor-
puscles became less distinct, and, still  nearer, the cells  of the bony tissue
appeared to  be  surrounded merely by a layer of  fibrous texture, in which irre-
gular particles of bone were observed.   These particles, which were elongated,
irregular in  form, and  rounded off at the angles, were very aptly compared, by
Dr. Quain, to crystals in a state of solution.    At the diseased surface, the place
of the cartilage and synovial membrane  was occupied by  a fibrous  texture
 abounding in cells, larger  than pus-cells, nucleated  and spherical, containing
 numerous granular particles.  Irregular masses of cartilage, undergoing the same
 process of softening as the bony particles already  mentioned, appeared  in this
 fibrous texture.   Tbe morbid appearances found  in this case  were so character-
 istic  that they may be taken as  the type of this peculiar morbid condition, which
 I have since repeatedly met with in other articulations  besides the elbow, more
 particularly  those of tbe fingers and the knee, and which always, I believe, con-
 stitutes an incurable form  of disease.   I have only met with this condition  in
 instances  in  which the  articular  affection has been  of very  old standing, and
 fallen into a truly  chronic  state.
   When repair takes place in a joint, the cartilages of which have been eroded
 or destroyed, it is  by the articular ends of  the bones becoming  connected, and
 the surface from which the cartilage has been removed filled up by fibro-cellular
 tissue, forming  a kind  of cicatricial material that leaves the joint permanently
 stiffened.  In other cases again, porcellanous  deposit takes the place  of the
 eroded cartilage, and, in some instances, the exposed osseous surfaces may grow,
 or become soldered  together, forming a permanent anchylosed and immovable
 state of the  articulation.   Under no circumstances does cartilage, when once
 destroyed, become regenerated.
    Causes.—In  some instances, acute  necrosis  of  the shaft of one of the long
 bones, as of  the tibia, will run  on to destructive action in the terminal articula-
 tions, the cartilages becoming undermined,  softened, and  perforated.   It not
 unfrequently happens that the  arthritic disease is the result of a morbid condi-
 tion  of the articular ends of  the  long bones, or of  those short bones  that enter
 into the formation  of the joint; this we especially see in diseases of the  foot,  of
 the elbow, of the knee, and hip;  but it is a  condition that, I believe, may occur
 in any joint.  The bones usually become, in the first instance, the seat of tuber-
 culous infiltration; this  runs into  unhealthy suppuration,  which gives rise  to
 caries and limited  necrosis (fig. 213, a); as the diseased action approaches the
 articular surface, the incrusting cartilage becomes loosened, detaches, and at the
 same time gradually disintegrates, and becomes perforated (fig. 213, b), nutrition
 in it being  arrested or modified by the morbid  state of the  subjacent  bone.
 When once  the cartilage becomes affected, the whole of the interior of the joint
 speedily suppurates, and is destroyed.   In other cases, inflammatory congestion,
 but without  the formation of tuberculous  matter,  takes  place  in the articular
 ends, which become somewhat expanded,  and then, without any suppuration
 occurring  in the osseous  structure, the cartilage gradually separates or peels off,
 and becomes softened and necrosed.   This condition is often met with in dis-
 ease  of the tarsal articulations.
   Diseased  action  is very seldom primarily  set up in the ligaments of the joint, 
614
DISEASES  OF  JOINTS.
though  these  structures commonly become elongated, softened, and  destroyed,
as a consequence of other forms of articular disease.   But though primary inflam-
mation of the ligaments is so rare an affection as to have been denied by many,
yet it certainly does occasionally occur.   This is especially seen in the hip-joint,
where the inflammatory affection may commence in the ligamentum teres; illus-
trative of which there is a very beautiful model in the University College
Museum.
  Inflammation may commence in the fibrous capsule of the joint: this we find
more particularly to be the case when the affection is of a  rheumatic  character;
in these cases inflammation, running into suppuration and  slough of  this struc-
ture, will commonly spread  to the internal parts.   In some instances, this form
of disease gives rise to  the  deposit of masses  and layers of bone in the cellular
structures outside the articulation.
  Arthritis commonly results from wounds of joints, or injuries, such as sprains
and  fractures occurring in their vicinity, more particularly  in young people, and
in those of a lymphatic constitution.  It also occurs as a not unfrequent accom-
paniment  of pyemia (p. 381), and of some of the  morbid conditions of the puer-
peral state.   The puerperal inflammation of joints is of a  very destructive cha-
racter, most generally speedily terminating in suppurative disorganization.   One
or several joints may be affected, and the knee is the one that I have seen most
frequently and seriously involved.  Puerperal arthritis probably depends  upon
a purulent infection of the blood as the result of uterine phlebitis.   Arthritis
not  unfrequently occurs as a consequence of scarlatina, and I have especially
seen the knee-joint affected  in a destructive manner after this disease.  In some
forms of albuminuria there is also a great tendency to inflammation of the joints,
and  indeed I have so frequently seen  that form  of renal dropsy which follows
scarlet fever accompanied by serious inflammation of some joint, as almost to
look upon one condition as the sequence of the other.
  The symptoms of arthritis that are most marked are the pain, heat, swelling,
and  peculiar position  of the joint.  The pain is often severe, tensive, and throb-
bing ; so acute is it sometimes that the patient screams with agony, he cannot
bear the bed to be touched, the  room to be shaken, or the slightest  movement
communicated to the limb : any attempt at examination of the joint in such cases
being attended with insupportable agony.  There are usually nocturnal exacer-
bations, and the pain is commonly referred with especial severity to one particular
spot in the joint; thus it is generally felt at the inner or under side of the knee-
joint, and at the outer aspect of the hip.   The  heat of the diseased joint is
considerable, and is  often  accompanied with  more  or  less superficial redness.
The swelling is uniform, involving the whole  of  the articulation, and not pro-
jecting at certain parts of it, as when the synovial membrane alone is affected;
it is generally not very considerable, and has a soft and doughy, rather than a
fluctuating, feel.  As the  disease advances,  however, the  swelling generally
increases suddenly, and to a considerable  extent, either in  consequence of the
irritation of the synovial  membrane, or of the accumulation of pus within or
around the joint. In many cases the synovial membrane gives way, and the pus
from the interior of the joint becomes widely diffused through the  muscular
interspaces of the limb, forming enormous abscesses  and long sinuous tracts.
The position of the affected limb is peculiar, and  that attitude is  insensibly
adopted in which the patient will have  the  greatest amount of ease; thus the
knee is semi-flexed and turned outwards, the thigh  is adducted, and the elbow
is bent.    Spasms or  startings of the  limb, often of a very sharp and painful
character, come on at times, more particularly at  night.
  The constitutional disturbance is very severe, and of an actively febrile type.
As  the  disease  progresses,  suppuration takes place  within the joint, which
becomes hot and red, with a good deal of throbbing pain, and at last fluctuation
is perceived where the coverings are thinned.  In  some cases the suppuration 
           PATHOLOGY AND  CAUSES  OF ARTHRITIS.       615

occurs with very great rapidity, and  luxation  of the head  of the bone takes
place.  In other cases an abscess forms external to the articulation, and extensive
purulent collections become diffused through the limb.   As  the  joint becomes
loosened by the destruction of its ligaments, the bones become mobile, and grate
against one another where the incrusting cartilage has been removed, thus givin°-
rise to very severe suffering.  The cartilages may however in  some cases be very
extensively destroyed, and yet no grating take place; this is  owing either to the
destructive action being  limited to  the  edge  of the incrusting cartilage, the
opposing surfaces being sound, or else to the interior of the articulation being
filled up with plastic  matter after the removal  of the cartilages.  But  though
abscess, either within the joint or external to it, usually forms when the bones
grate and the cartilage disintegrates,  yet it occasionally happens  that these con-
ditions may take place — those symptoms that  are indicative of  the  erosion of
the cartilage, such as painful  startings of the  limb, grating, and  preternatural
mobility of the joint, — and yet no abscess forms;  all the symptoms subsiding
under proper treatment, and the joint recovering, though perhaps with a certain
degree of anchylosis.  If suppuration take place, the constitutional disturbance
usually partakes of the irritative  type, the patient  suffering  severe pain, and
being worn out by want of rest.  Hectic may occur  and death from exhaustion
and  irritation, unless  the diseased part be removed;  in other cases  it falls into a
state of chronic  thickening, with perhaps fistulous openings leading down to the
diseased structures, and in some of the more favorable instances the patient may
recover, with a permanently rigid joint.
   Abscess may  form external  to, but close upon, the capsule of a joint, and
closely simulate  disease of the articulation. In these cases the absence of serious
constitutional disturbance, the irregularity of  the swelling,  greater on one side
than the other, the absence of all rigidity about the  joint, and  of other severe
local symptoms, such as  pain, starting, looseness, or grating, will  enable the
surgeon  to effect a correct diagnosis.
   In the treatment of acute arthritis, perfect rest of the articulation is of the
first moment.   Unless this  is secured no after-treatment  can be  of any avail.
The limb should be comfortably supported on  pillows, or laid upon a well-made
and  softly-padded  leather-splint;  at the same time blood should be freely taken
away by cupping or leeching the affected part, and this  local depletion must be
followed by assiduous fomentations.  In the acute stage of the disease the internal
remedy from which the most essential service may be derived is the calomel and
opium pill (gr. ij. and gr. ^) every fourth or sixth hour, at  the  same time that
a strict antiphlogistic regimen is persevered in.  After the violence of the symp-
toms has been  subdued, the  joint may be  repeatedly blistered; but in many
instances most benefit will be  derived by the application of  the  actual cautery.
This agent, when properly applied,  yields much more certain  and successful
results than any other form of counter-irritation with which I am acquainted.
The patient having been  anaesthetized, a cauterizing iron  heated to a black-red
heat should be rapidly drawn over the diseased articulation in a series of parallel
lines, across which an equal number of cross bars are again  drawn so as to char
but not destroy the true skin.  A good deal of inflammatory action is thus  set
up, followed by  slight suppuration.  When this has subsided, the application of
the hot iron may, if necessary, be repeated; in this way the deep gnawing pain
will  usually be readily removed, and  suppuration of  the joint may be averted.
For  counter-irritants to be of any use, they must be employed before suppuration
has set in;  I believe that it is only torturing the patient unnecessarily  to have
recourse to these agents when once pus has formed in the articulation. In order
that full benefit should be derived from this plan of treatment it must be perse-
vered in steadily for a considerable  length  of time, and  should be conjoined
with a moderately antiphlogistic and  alterative  treatment. With this view, the
bichloride of mercury in doses of from £ to T\j of a grain may be advantageously 
616
DISEASES  OF  JOINTS.
given with the compound decoction of sarsaparilla, or, if there be much debility,
with  the  compound tincture  of bark, nourishment, and even stimulants  being
conjoined with it, in proportion  to the advance of the debility.  When suppura-
tion has taken place in this joint, more particularly if the skin  covering it be
reddened  at any one part, the abscess should be freely opened.
  In  some cases, even when abscess has formed, the joint being perfectly loose
and grating, by perseverance in  the above plan of treatment, both local and con-
stitutional, a good and useful limb may be left; and although there be mobility
and grating, provided there  be  no sign of abscess, the surgeon should  never
despair of obtaining a satisfactory result.
   The practice of making free  incisions  into a suppurating joint, as advocated
by  Mr. Gay, is a great improvement on the former method of merely puncturing
it.  If a  small  aperture only is made, air gets  admixed with  the pus, which
becomes offensive and irritating, and being unable to escape freely, sinks to the
bottom of  the  articulation  with debris  of the  disintegrated   cartilages, &c,
giving rise not only to much local mischief, but  to  proportionate constitutional
disturbance.  By  freely laying  the joint open, all  this is prevented;  exit is
given to the pus through one or two incisions  that extend the whole length of
the articulation;  no  constitutional disturbance can occur from  pent-up and
putrid matter, and the joint has a better chance of healthily granulating.
   After the formation of abscess the prognosis is more unfavorable, when large
 joints such as the knee or hip are  affected; or, when  those  are implicated
which are important to life, such as the articulations of the vertebrae; so like-
wise, when the articular ends of the long bones  are  affected it is seldom that
the joint  can recover itself, as we have caries  or necrosis complicating its  dis-
ease and keeping it up.  When  the articulation is very sinuous as in the carpus,
or  when a number  of small joints communicate with one another, if not directly
by synovial membrane, at  all events indirectly through the medium of ligament
and of fibrous tissue, as in the tarsus, a cure can scarely be  anticipated.   In all
these cases, hectic  and  great  constitutional irritation usually come on; or the
 joint becoming useless  or  cumbersome, its removal must be practised either by
excision or amputation.
   The result will at last in a great measure depend upon the state of the bones
that  enter into  the conformation  of the joint.   If these be sound, or not
primarily  affected, and the patient's constitution has  got over the  effect of
the occurrence  of suppuration  in  the joint, anchylosis more or less complete
may  be  confidently looked  for.   But if the articular  ends of the  bones be
primarily or deeply implicated, then excision  or amputation will be the only
alleviation.
   When  an inflamed joint appears to be  disposed to undergo a cure, its repair
by anchylosis must be facilitated  by keeping it in a proper position, such as
will be most useful  to  the patient in after-life;  the straight one for the knee
and hip, and the semiflexed  for the elbow.   At the same time it may be useful
to  strap the joint firmly in the  proper position in the way recommended by the
late Mr. Scott, when it  is  the knee  that  is affected, or when the hip or elbow
are implicated, fixing it well by means  of starch bandages.  Scott's plan of
treatment consists in spreading on pieces  of lint, the strong  mercurial oint-
ment, to every ounce of which  3J of camphor has been added; strips of soap-
plaster spread upon leather are then cut  of a proper length and  breadth, and
the joint  firmly and accurately strapped  up, the limb  having previously been
bandaged  as high as the joint that is strapped.  This dressing  may be left on
for a week or two until it loosens or gives rise  to irritation; over the whole a
starch bandage may be applied. In many cases, I have found  it advantageous
to  strap  up the joint with a plaster composed of equal parts  of the  emplast.
ammoniaci cum  hydrargyro and the emplast. saponis  or belladonna?.   These
applications not only fix the joint and  promote the absorption of the  plastic 
STRUMOUS  DISEASE  OF  JOINTS.
617
matter that is deposited around  it, but by acting  as  gentle  counter-irritants
remove the remains of the inflammation that may be going on within it.

                 STRUMOUS DISEASE  OF  JOINTS.

  By "white-swelling" is meant a very chronic form of arthritis occurring in
scrofulous subjects.   These diseases present peculiar characters; the  affected
joint is enlarged and rounded, the bony prominences being effaced by a uniform,
doughy, semi-elastic, or pulpy swelling, occupying the interstices of the articu-
lation.  The integuments covering it  preserve their white  color, and there is
usually but little pain felt except in moving the limb, and the position is always
that in which  the patient has most ease, the joint being generally  semiflexed.
There is a degree of stiffness and rigidity in the joint, and  in  consequence  of
the  wasting of the  limb from  disuse, the affected articulation appears more
swollen than it really is.
  This condition has not in many  cases any definite starting-point, but appears
slowly to supervene  upon some slight injury, as a twist, or blow, or strain ; at
other times  it  commences with  a subacute synovitis,  assuming its peculiar
characters by occurring in  a  strumous constitution, and is especially liable to
happen in children and females.  The general health does not appear at first
to suffer much, but as  the disease  advances symptoms of irritation and hectic
declare themselves.  This affection is always characterized by a special tendency
to run on to suppuration.  This tendency may be checked by proper treatment,
but in the  great majority of cases it  at last passes into this  condition.  The
 joint suffers from  exacerbations  of intercurrent  attacks of inflammation, the
limb swells  and becomes cedematous, and  abscess finally forms in and  around
the joint; often around, before it takes place within.   When this is  opened, the
constitutional  symptoms  become  more  severe,  hectic  speedily sets  in,  and
strumous deposit takes  place in  other organs, such as  the lungs, which at last
carries off the patient.
   In this affection the  tissues immediately external to the joint, as  the fibrous
capsule and the investing cellular membrane, are  always much thickened  and
infiltrated with  fatty and plastic  matter;  this gelatinous infiltration having a
great tendency to run into unhealthy suppuration greatly adds to the mischief
that ensues.  In the  interior of  the joint we find much the same kind  of
changes that have been described  as  characterizing acute  arthritis; the carti-
lages have lost their polish, their  elasticity, and their firm  hard section, being
softened,  eroded,  and  disintegrated; the  synovial membrane is removed in
parts, and is here and there vascularized;  in others  it is replaced together with
the  cartilages, either by large  quantities  of the semi-transparent  gelatinous-
 looking fatty  deposit, or  by the pulpy grey or brownish fibro-cellular  material
that  is met with  in  arthritis.  The  ligaments  are inflamed, softened,  and
destroyed, being converted  into somewhat similar materials; and the interior of
the joint is filled with a purulent-looking synovial fluid, thin and yellow, usually
 containing a  large  quantity  of fatty matter.  The bones  undergo important
 changes in this disease, the articular ends becoming  expanded and enlarged;
 and though this was denied by Crowther, Russell, and  others, it is affirmed by
 more modern  surgeons, and I have  had repeated  opportunities of determining
the fact.  In  all the cases that  I have examined the osseous tissue has under-
gone important changes, the compact structure becomes thin and expanded, and
the  cells of the cancellated, filled with a bloody and fatty serous fluid.  It is
 softened, often cutting readily with the knife, and  owing to the deposit of fat
 presents a more homogeneous section than healthy bone.  In many cases, tu-
 berculous matter is deposited in it.   From this it would  appear that the princi-
pal changes that take place in a joint affected with  white swelling  consist in a 
618                    DISEASES  OF JOINTS.
kind of fatty degeneration of the  tissues that enter into the formation  of the
articulation, associated with an unhealthy strumous inflammation  of the parts,
and  the consequent  deposition of considerable  quantities of semi-transparent
and lowly-organized plastic matter which, in its turn, has a tendency to undergo
the same structural change, or to run into unhealthy suppuration.
   In the treatment of white swelling, we must  bear in mind that we have to
manage a truly scrofulous inflammation and its effects.  Our first object should
be to prevent, if possible, the occurrence of suppuration.   In the early stage,
when the affection has come on  insidiously, without any very active symptoms,
we must trust to general anti-strumous  treatment, to the influence of diet, of
sea-air,  and the administration of alteratives,  cod-liver oil, and iodine.  In the
local treatment,  rest, with perfect immobility of the articulation, is the most
important  element, without which  all the rest is futile.  The limb should be
put into such a position  as is not only most easy to the patient, but that would
leave the most useful member  in  the event of a stiff joint resulting.   If the
symptoms  are of rather  an acutely inflammatory kind, leeches may be applied;
these, however, must be used as sparingly as possible, being  confined either to
the earlier  stages of the  disease, or to the subdual of any more active  intercur-
rent inflammation.   Rest is best secured by  leather or gutta-percha splints in
the earlier  stages, and at a later period, by the application of the starch bandage
to the limb.  This kind  of application will be found to give the most efficient
support, and will keep the whole of the limb perfectly motionless, so  that the
patient  can take open  air exercise, and walk with the  aid  of crutches, without
the risk of injuring the diseased joint.   In  this respect, the starch bandage
presents great advantages over the short leather splints generally used.  It may
readily be cut open opposite the diseased joint, so as to admit of the application
of proper dressings to it.  The actual cautery is extremely beneficial  in  these
cases applied  as directed (p. 615), or caustic issues may be put in, at a little
distance from the articulation, so tbat there may be no risk of the inflammatory
action penetrating to it.
   After all inflammation has, in this way, been removed, and nothing but thick-
ening and  stiffness of the joint are  left, measures must be adopted for removing
these conditions, and restoring the  flexibility of the articulation by frictions
with somewhat stimulating and  counter-irritant embrocations, and  eventually its
strength, by douches of sea-water.   The swelling  and puffiness that are  left,
together with the debility dependent on relaxation of the ligaments, are perhaps
best remedied by the use of Scott's strapping; but pressure should not be ap-
plied so long as there is  evidence of active inflammation going on  in the  articu-
lation, which it would certainly increase.
   If abscess forms, this  must be freely opened by an incision of a proper length,
the  joint poulticed, and the  patient's general health  attended to, so as to pro-
mote the evolution of granulations,  and  the prevention of hectic.   In  these
cases, if the limb can be preserved, its after-utility, and the patient's comfort,
will mainly depend upon the position in which it is allowed to anchylose

                  ANCHYLOSIS,   OR STIFF  JOINT.

   Anchylosis is invariably the result  of  the  destruction of a joint by chronic
inflammation, being the  only mode in which nature can effect its repair, and
consists in  tbe more or  less  complete consolidation of the parts around and
within  the articulation.   It is  of  two kinds: the  incomplete, or fibro-cellular,
and the complete, or osseous.   In the incomplete, or fibro-cellular anchylosis, the
stiffness of the  joint  may be dependent  on thickening and induration of its
fibrous  capsule, or on the formation of fibroid bands as the result of inflamma-
tion within the  joint, or in  consequence of  the  cartilages and synovial mem- 
ANCHYLOSIS.
619
brane being in part or wholly removed, and their place supplied by a fibroid or
fibro-cellular tissue,  by which  the
articular ends  are  tied  together.                 Fig. 221.
It may also be materially increased
by  the tonic contraction of  the
muscles around  the joint.    The
complete or osseous anchylosis is of
two kinds : in one, all the soft parts
within the joint are  destroyed, and
the osseous surfaces have coalesced,
or  are  fused together  by  direct
bony union.  This  is  most  com-
monly seen  in the  hip,  knee,  and
elbow (fig.  221).   In  the  other,
there has been fibro-cellular deposit,
or degeneration within  the  joint,
and the bones,  united  partly by
this, are also tied together by arches or bridges of osseous matter, thrown out
external to the articulation, and stretching across from one side to the other.
It has been supposed that these  masses proceed from the ossification of the
ligaments, or even the muscles; but, from  the  inequality of their  appearance,
it is evident that they are new and  accidental formations.   In the incomplete
anchylosis there is always some degree  of mobility, however slight, and, indeed,
perhaps only perceptible on deep and close  examination.  In the complete form
of stiff joint, the  articulation is perfectly rigid and immovable.  It not unfre-
quently happens, in old standing cases  of diseased joint, that more or less com-
plete anchylosis is taking place at one part of the articulation, whilst caries or
necrosis of the bones is going on at others.  Under such  circumstances, exci-
sion or amputation will, probably, be the course to be  pursued.
   The treatment of anchylosis  is, in  the first instance,  of a precautionary nature,
—that is to say, that when the surgeon finds that the establishment of anchy-
losis  is, as it were, the  natural means  of  cure adopted by nature in a deeply-
diseased joint, his efforts should be  directed to seeing that the joint  becomes
anchylosed in such a position as will leave the most useful limb to the patient:—-
thus, if it be the hip or knee,  that the anchylosed joint be in the straight posi-
tion ; whilst if it be the elbow, that it  be placed at a right angle.
   When once  the anchylosis  has occurred, the treatment  to  be adopted will
depend partly on  the degree  of stiffness, whether it  be fibrous or osseous, and
partly on  the object to be attained, whether this be  merely the  restoration of
mobility in a part anchylosed  in a good position, or the  remedying of the de-
formity occasioned by faulty anchylosis.
   1st. In attempting to restore the mobility of a joint anchylosed in a good
position, as  of a straight but stiff knee, the surgeon may usually succeed if the
anchylosis be only of a fibrous character, (when some degree of movement will
always  be  perceptible  in the part,) by  the  employment  of  passive motion,
frictions, and  douches, more particularly with warm salt water or the mineral
sulphureous springs.  In the more  obstinate cases, and where the immobility
appears to depend, in some degree, at least, on  fibrous bands stretching across
the  limb, an attempt might  be  made to  divide  these  subcutaneously. _ In
doing this  no mischief  can result, for the synovial structure of the joint
having been destroyed,  no dangerous  amount of inflammation  can be set up
in it.                                                         . .      .. „
   2d.  When fibrous anchylosis has taken place in a faulty position, — it, for
instance, the knee be bent,  or the elbow straight, the first  thing to be done is
to place the limb in such a position  that it will  be useful to the patient.  This
may most  readily  be done  by chloroforming  the  patient, and then forcibly
 
620         ON  EXCISION  OF  JOINTS AND  BONES.
flexing  or extending the limb, as the case may require, when with loud snaps
and cracks it will usually come into proper position.  Should any of the tendons
in the vicinity of the joint appear to be particularly tense, they may be divided
subcutaneously.   The inflammatory action that follows this forcible extension
or flexion of the limb is usually but of a very trivial character;  an evaporating
lotion and rest will speedily subdue it.  Indeed, it is surprising what an amount
of violence  may be inflicted  on an anchylosed joint without any  bad  conse-
quences ensuing.  After  the limb has been restored to  its proper position,
passive  motion and frictions may tend to increase  its mobility.
   3d. When osseous anchylosis has taken  place, and the position of the limb
is a good one, it will generally be wiser for the surgeon not to interfere; except
in the case of the elbow-joint, which, under these  circumstances, may be excised
with  advantage, so  as  to  substitute a movable for an immovable articulation.
If the position be a faulty one, the  osseous union may be divided, or a wedge-
shaped  piece of the bones may be taken out, and the position of the limb thus
rectified.
   4th.  Amputation  may be  required in cases of faulty  anchylosis with so
much atrophy of  the limb as to render this useless, or in cases in which there
is necrosed or carious bone co-existing with anchylosis and rigid atrophy of the
muscles of the limb.
                        CHAPTER XLIV.

              ON EXCISION OF  JOINTS  AND  BONES.

  To the surgeons of this country is undoubtedly due the merit of originating
and  carrying out the practice of excising diseased joints and bones with the
view of saving a limb,  by the removal  of those morbid structures that would
otherwise  have necessitated amputation.  Although the older surgeons, dread-
ing amputation, on account of the  difficulty they experienced in arresting the
hemorrhage from a  stump, had  recourse to various gouging, scooping, and
scraping operations in cases of diseased  bone,  yet they never attempted the
excision of a joint, or indeed  the resection  of a whole bone.  The articulated
ends  of bones were first excised in a compound  dislocation  of the elbow as far
back  as 1758, by Wainman of Shripton, and afterwards by White, Bent, and
Orred in cases of compound dislocation of the  humerus.  In 1762, Filkin of
Northwich excised the knee  for disease, and in 1775, Justamond cut out the
olecranon and  two inches  of the ulna  for diseased  elbow-joint.   The  first
distinct publication  on the subject was  by Mr. Park, in  1782, the  object of
which was to show that in some of those  affections of the  knee and elbow for
which amputation had hitherto been considered  indispensable, surgery possessed
another resource " in the total extirpation  of  the articulation, or the entire
removal of all the bones which form the joints,  with as much as possible of the
capsular ligament."   In the  same year,  Moreau excised the ankle-joint, and
some years subsequently, the head  of the  humerus and the knee-joint.  The
new practice made few converts, however, and  in  1805, Mr. Park, in  another
publication expresses his mortification that  it had not met with the success in
this country that it deserved, and that if it had  not been for  the Moreaus in
France  it would have fallen into complete oblivion.  Although these operations
continued to be occasionally performed, it was not  until a quarter  of  a century
later that they were again prominently brought before the profession, and the 
ON EXCISION OF JOINTS  AND BONES.          621
second revival was  due to the Edinburgh surgeons, chiefly to  Liston  and to
Syme.  Since then, they have continued to gain in favor, and  now constitute
that department  of surgery which has  been termed the  conservative, or more
correctly the preservative.
   Before proceeding to  discuss  the  different resections in  detail,  we  must
endeavor to lay down some general rules for their performance in those cases in
which they are alone admissible.
   The excision of an articulation  may be practised for the following reasons: —
   1st. As  a substitute for amputation in cases in which  the joint is so exten-
 sively diseased, that  the  patient will  be worn out by  the  discharge or pain,
 unless it is removed.  Here a useful limb may be secured by  the sacrifice of
 the diseased part.
   2d. In  some cases of articular disease in which amputation would not be
 justifiable, excision may be done  in order to hasten the cure, and thus to save
 years of suffering to  the patient.
   3d. Excision  may be  done in cases in which amputation is not practicable :
 as in disease of the hip-joint or temporo-maxillary articulation.
   4th. As a substitute for other and less efficient treatment, in  order to restore
 the utility of a limb or joint; as  in osseous anchylosis of the  elbow, or faulty
 anchylosis of the knee.
    5th.  Excision may be required in bad compound dislocations and fractures
 into joints, especially in gunshot  injuries;  as of the head of the humerus and
 elbow.                                              .
    As a general rule,  such resections  are  more required  for  diseases of the
 articular ends of bones than for simple disorganization of a joint.   If only the
 soft structures of a joint are involved, it usually happens that without the
 necessity  of resection a useful limb will result — if in  the upper extremity with
 fair mobility of the articulation — if in  the  lower, with more  or less complete
 anchylosis, not perfect mobility perhaps, but  yet sufficient  for  a fair  basis of
 support.  But when  the  constitutiou  is  very strumous,  or  the  bones very
 extensively affected, we  can scarcely look for recovery of the limb to such an
  extent as to become useful to the patient.
    For  resection  to succeed, the following conditions  appear to  me to be
  DGCGSSRl'V " ——
    1st.  That the disease  be not too extensive, so that its removal would entail
  such an  amount  of mutilation of the  limb, as to render  it less  useful to the
  patient than an artificial member would be.  This is especially  important in the
  lower extremity.   If the bones are so extensively affected as  to  require to be
  shortened by a considerable extent —for several inches —a limb would be left,
  that instead of serving as a proper basis of support to the patient,  would only
  be  an  incumbrance.  In  the upper extremity, length and strength are of less
  consequence than in  the lower;  the preservation of the hand is the chief
  thing to aim at,  and if this be  effected, the bones may be encroached on to a
  greater extent than is proper in  the lower limb.
     2d.  The disease for which resection is practised should be allowed to become
  chronic before any operation is undertaken:  for this there  are two reasons.
  First, because in  the acute stage of disorganization  of a joint, it is not always
  possible to say, however unpromising the  case may appear, whether anchylosis
  may not  result, so  that as useful a limb would be left as  could be obtained by
  resection. And, secondly, if the joint be excised whilst acute and active disease
  is going  on, inflammation and diffuse suppuration  of the medullary  canal is apt
  to set in_a condition very apt to be followed by phlebitis and pyemia.  In the
  only fatal instances of resection of the elbow-joint that I have witnessed, death
  resulted  from this cause, the operation having been performed whilst the articu-
  lar affection was acute.
     3d.  The  soft parts about the joint must  be in  a sufficiently healthy state. 
622          ON EXCISION OF  JOINTS  AND  BONES.
There are two morbid conditions connected with the soft parts that may inter-
fere with the success of resection.   First, they may be so thinned  and per-
meated  by sinuses, and so adherent  to  the bones,  that an insufficient covering
would be left.  Or, secondly, the long-continued existence of strumous disease
in joints and bones may give  rise to a  great deposit of lowly-organized  plastic
matter around the articulation.   This material becomes insusceptible of healthy
organization, and slowly suppurates.  Sinuses form in it, the integuments cover-
ing it become blue and doughy, and  the soft parts around the seat of operation
fall into a state of strumous disorganization that prevents alike the formation of
a  false  joint, of osseous anchylosis,  or of the healing of the wound, and  thus
leads inevitably to the ultimate amputation of the limb.
   4th.  The  state of the patient's constitution must  necessarily influence the
surgeon materially in his  determination whether to resect or to amputate.  If
the constitution be tolerably sound, or if the general health has given way, pro-
vided that it has  done so as the simple  consequence of pain, irritation, and
continued  discharge, resection will have a fair prospect of  success.   But if the
patient be  very  highly strumous, or decidedly phthisical, there will be little
prospect of his being  able  to bear up through the  long convalescence that
follows  resection.   A^slight degree of pulmonary disease, however, that appears
to be rather the result of the  long-continued irritation of the local affection than
of any constitutional  taint, need not be a bar to these operations.  In such cases,
I have several  times had occasion to observe that  the general health improved
rapidly after the removal of  the local disease.
   5th.  The extremes of life are unfavorable to resections.  In very early child-
hood, these operations are seldom necessary, the natural processes usually suffi-
cing, with very little assistance, in eliminating diseased bone, and the disorgan-
ized joints admitting readily  enough of anchylosis.   If the disease is too severe
for this, it will usually be found to be associated with so strumous a constitution
as to interfere with healthy reparative action of any kind.  At advanced periods
of life, destructive joint disease is not very common, and when it does happen,
it is generally not in constitutions fitted to stand up against the prolonged drain
consequent  on these operations.   It is at the  early adult age that the diseases
most frequently occur that render resections necessary, and at which these ope-
rations are best borne.
   When a bone, as the os calcis, has  been entirely removed, it is never of course
regenerated, but its place is occupied by a firm fibrous cicatrix.
   When partial excision of  a bone  is  practised, the result varies according to
the tissue that is removed.   If a  portion of the  compact  tissue is cut away,
callus is thrown out.  If it is the cancellous structure that  is scooped out, the
 cavity left is filled up by a dense fibrous mass, which may eventually ossify.
   When a joint has  been excised, cither osseous or ligamentous anchylosis may
take place, and the  surgeon  should endeavor to secure osseous union in some,
fibrous in other cases.   Thus, when the knee has been excised, as a sound and
firm  limb  is desirable, osseous anchylosis should if possible be brought about;
whilst  in  the  upper extremity, where  mobility is  of more  use than strength,
 ligamentous union is most  desirable.  In these cases, the  ends of the bones
become rounded,  and are united by  a dense mass of fibrous tissue which enve-
lopes them, and  to  which the  insertions of those muscles that are naturally
 connected with the articular  ends that have been removed, become attached.
   The  instruments  required for resection are of a somewhat varied character;
strong  scalpels and bistouries, straight and sharp-pointed.  In addition to these,
I have  found  a strong-backed, probe-pointed bistoury, with a limited  cutting
 edge, of great utility in clearing  the bones.   The  pliers should be  of various
 sizes and shapes (figs. 205 to 208), and gouges will be found useful for scooping
 out suspicious patches  on the cut osseous surfaces.   For ordinary purposes, a
 small amputating saw will, I  think, be found the most convenient instrument for 
                  EXCISION OF  THE  SHOULDER.              623

dividing the bones, but in some cases a narrow keyhole saw, or that introduced
by Mr. Butcher (fig. 222), will answer best.  The last instrument is especially

                                 Fig. 222.
useful  when  it is intended to cut the bone obliquely, or  when  the space  is
limited;  for,  as the  blade  is narrow and  its angle can be changed at pleasure,
any  required direction  can be communicated  to  the cut.   The  chain-saw  is
perhaps not used so frequently as it might be.
  With regard to the steps of the operation, they must of course vary with the
different resections, but there are some general rules that may be laid down  as
applicable to  all cases.
  1st.  The incisions through the soft parts  should be sufficiently free to expose
thoroughly the bones to be removed.   By  making them, as far as practicable,
parallel to tendons, blood-vessels, and  nerves, parts  of importance may readily
be avoided.
  2d.  As little of the bone as possible should be removed.  It is seldom that
the shaft need be encroached upon, and care should always be taken to avoid
opening the medullary canal.  It  is of importance, also, not to mistake rough-
ened deposits of new for caries or necrosis of the old bone.
  3d.  The gouge may  be applied to  any  carious or tuberculous cavities,  or
patches, that appear  upon the surface of the freshly-cut bone, and, in this way,
shortening of the bone by  the saw may be materially avoided.
  4th. Skin, however redundant, should seldom if ever be cut away.   The
flaps, at first too  large, soon shrink down to a proper size, and if trimmed are
very apt to become too scanty.
  5th. After the operation, light dressings only should be  used.  As healing
always takes place  by granulation, no accurate closing  of  the wound is neces-
sary, but  it is  sufficient to lay the limb on  a pillow, or well  padded splint, and
to apply water-dressing.  When it begins to granulate, more accurate attention
to position is required.
  6th. The constitutional after-treatment  should be  of a nourishing or stimu-
lating character.  As there will be a great drain on the system, and a  prolonged
confinement to bed, the strength must  be  kept up under it by good diet.  These
operations are always of a serious character, in many cases fully as much, or even
more so, than the amputation of a corresponding part, owing to the large wound
that is  often inflicted, in  the more extensive division of the bones,—to the
necessity of making the incisions in  the midst of diseased or injured  struc-
tures— and to the more prolonged character of the  after-treatment.   Hence it
is of especial  importance that the general  health should be carefully maintained
after these operations.
  Excision of the shoulder-joint is not so commonly required as that of many
other articulations; disease of this joint not being of very frequent occurrence,
and, when it happens, often terminating in false anchylosis, without  suppu-
ration taking place.  When abscess and necrosed bone are met with  about the 
624          ON  EXCISION  OF JOINTS  AND  BONES.
shoulder,  it will frequently be found that the coracoid  or  acromion processes
                                               are  at fault  rather  than  the
                                               joint itself, and extraction of
                                               sequestra  formed  there  may
                                               prevent excision of the articu-
                                               lation.   When  practised, it
                                               has usually been required for
                                               strumous   disease,  especially
                                               occurring in young people.  It
                                               has not unfrequently,  of  late
                                               years,  been  performed,   and
                                               with very considerable success,
                                               for gunshot injury of the head
                                               of  this  bone.   M. Baudens
                                               relates  14  cases in which it
                                               has  been  practised  for these
                                               injuries  during the Crimean
                                               campaign,  and  of  which  only
                                               1 proved fatal.   The articula-
                                               tion  may  most readily be ex-
                                               posed by making a semi-lunar
                                               flap  about three  inches  in
                                               length, commencing at the pos-
                                               terior part of the acromion, cut-
 ting across the line of insertion of the deltoid, and carried up to the inner side
 of the coracoid process.  Or the  surgeon may adopt T ~T or l~l  shaped inci-
 sions.  I think, however, that the  elliptical, or \J shaped is preferable, or less
 muscular fibre is sacrificed by it.   By a few touches  of the scalpel a large flap
 composed of the deltoid muscle may thus be raised, and the diseased articula-
 tion fully exposed.   As  the  capsule  and the  ligaments  are  destroyed by the
 morbid action that has taken  place in them, the head of the  bone may readily
 be turned out of the glenoid cavity; and being freed by a  few touches of the
 knife, and isolated by passing a spatula behind it, may be removed with a narrow
 saw (fig.  224).   In doing this, the shaft of the humerus should be encroached
 upon  as  little as possible, not only that  the  bone may not be  shortened more
 than is necessary, but in order that wound  of the  circumflex arteries may be
 prevented, which will certainly happen if the incision be carried too low down.
 After the removal of the head of the bone, the glenoid cavity must be examined;
 if this be carious, it may be removed most  conveniently  by means of gouge-
                            forceps and the  gouge,  care being  taken  that all
                            diseased bone is  thoroughly scooped away.  After
                            the operation, the flap must be laid down, and re-
                            tained in position by  two points of suture, and the
                            arm well supported in a  sling,  the elbow especially
                            being  raised.  The wound  unites  by  granulation,
                            and though the deltoid muscle does not recover its
                            full utility, a very excellent limb and most useful
                            fore-arm and hand are left to  the  patient, as may
                            be seen by the accompanying drawing (fig. 224),
                            taken from a lad whose shoulder-joint I removed
                            some years ago.   I last  saw this  boy about four
                            years after the operation had  been performed, and
                            then found that the upper end of the humerus had
                            been drawn up underneath and between the  acro-
                             mion and  coracoid  processes, where a  false  joint
              The arm was extremely useful, and the parts below the elbow well
Fig. 224.
had formed. 
                EXCISION  OF  THE ELBOW JOINT.             625

developed.   The upper arm was two and a half inches shorter than the other.
The  excision of this  joint is not devoid of danger.  Velpeau records 13 cases
of death following it, and states that many more have occurred.
   The scapula has occasionally been excised in part, or in whole, for gunshot
injury or disease.   Most commonly these operations have been practised  after
the arm had been removed at the shoulder-joint, the state of the scapula requir-
ing its ablation at a later period, an operation that I saw admirably performed
about ten years ago by Mr. Fergusson.  Occasionally, however, the scapula has
been excised without previous  amputatien of the  arm.   Thus Liston removed
three-fourths of the bone for a vascular tumor springing from it.  South excised
the whole of the body of the scapula by sawing through its neck, and Syme has
recently taken  away the bone with its  processes entire.  Operations  such as
these are rarely required, and when called for can scarcely be performed in  ac-
cordance with any positive  rule,  the  operator varying the extent and  arrange-
 ment of his incisions according  to the extent of the disease, the situation of
 sinuses, &c.  In whatever way practised, there is one rule, however, that should
be attended to, viz., that the axillary border of the bone should be the last to be
 interfered with, on account of the  hemorrhage that may be expected from this
 situation.
   The Clavicle has  been partially or wholly  excised by Travers, Mott, and
 others.  In caries or necrosis  of this bone, portions of it may be gouged away
 or extracted without  much difficulty; but when in consequence of  the  growth
 of tumors, the  removal of the whole or greater part of the bone is required, the
 operation is one of the  most hazardous in surgery, as a  glance at the anatomy
 of the parts lying beneath the bone, and encroached upon by the morbid growth,
 will  indicate.  In Mott's case 40 ligatures were applied.   The sternal end of the
 clavicle has been excised by Mr.  Davie of Bungay in a case in  which dislocation
 backwards had resulted  from deformity of the spine, and  the luxated end gradu-
 ally  pressing upon  the oesophagus,  threatened the life of the patient.  The bone
 was  cut through by  means  of a Hey's saw  about an inch from its sternal end,
 and  the sterno-clavicular ligaments having been divided, the portion of bone
 was  forcibly elevated, and at last extracted.
   Excision of the elbow-joint has been more frequently  practised than that of
 any  other of the articulations, and the result has upon the whole been far more
 satisfactory.  This operation  may be required, 1st, for a chronic disease of the
 joint; 2d,  for osseous anchylosis; and 3d, for injury.  In those cases in which
 it requires to be excised for disease, it will generally be found that  after disease
 has existed for a considerable time in
 the joints, the limb will be useless, and
 the soft parts around it swollen, spongy,
 and perforated by fistulous  openings.
 In other cases there will, however, be
 very little  external  evidence of  mis-
 chief, merely one or  two fistulous aper-
 tures leading down to the condyles and
 to the olecranon, the joint being  permanently lexed and swollen, and the arm
 so useless that it cannot support the weight of the hand.  On  exposing the arti-
 culation, perhaps caries, with complete destruction, and with or without  necro-
 sis  of the articular ends, the loose  pieces of dead bone lying in the cavity of the
 olecranon, or in one of the condyles, may be  found.  Most commonly the radius
 is the last bone that is affected, the ulna and  opposite side of the humerus being
 generally first diseased.  If osseous anchylosis have occurred, whether in the
 straight or bent position, excision  of a portion of the consolidated bone may also
 advantageously be practised,  as in these cases a useful and movable articulation
 may be substituted for  one that is rigid and  fixed.  In cases of compound frao-
        40
 
626          ON  EXCISION OF  JOINTS  AND BONES.

ture or dislocation of the elbow-joint, more  or less complete resection of the
protruding, and possibly splintered fragments, may be required.

                                  Fig. 226.
   Excision of the elbow-joint is a very successful operation.   I have only lost
one patient out of ten cases in which  I have done this operation.   The princi-
pal danger after excision  of the  elbow-joint probably arises from diffuse suppu-
ration of the humerus.  I have seen this  happen in  two fatal cases; and in a
third, in which the patient lost his life, it is probable that death, which was
attributed  to pneumonia, remotely occurred from the same cause.   The elbow-
joint may be excised in three ways:  1st. By an t— shaped incision (fig. 225);
2d. By the H  incision;  and  3d, By a single longitudinal incision (fig. 226).
Of the two first, I prefer  the h- shaped, as it leaves a better result, with less
cicatrix, than the  H  incision.
   The patient having been laid  prone, the perpendicular cut should be made
parallel to, and a line or two to  the outer  side of the ulnar nerve; being com-
menced at least two  inches above the olecranon, and  carried down to about the
same distance below it.  The  transverse incision  should then be made directly
across the olecranon,  to the outer side of the joint, and  extended as far as the
extremity of the outer condyle (fig. 225).   The two triangular flaps thus made
must be dissected up, the knife being carried close to the bones.   Or the  trans-
verse incision may be dispensed with, and the bones readily exposed and turned
out by  the 3d method, that of the  single perpendicular incision (fig.  226).
This must be of sufficient length to allow of the sides being held well apart, and
then it constitutes the simplest plan of excising the elbow that can well be
devised. After the bones have been fairly exposed, they must be cleared to the
inner side of the joint;  in carrying the incisions in this direction,  the edge of
the knife should always be kept against the bones,  and their sinuosities closely
followed, so that the ulnar nerve  being dissected  out from behind the inner
condyle, may escape  injury.   If the incisions are  properly planned, and the
knife kept in contact  with the bone, the nerve ought not to be exposed during the
operation, more particularly as it  is usually imbedded in a quantity of plastic
tissue.   When  the posterior part of the joint has  been laid  bare in this way,
the knife  should be  carried  round the tip of the olecranon, and  this process
then removed with cutting pliers.  By forcibly bending  the joint,  pushing the
forearm upwards, and lightly touching the ligaments with  the point of the knife,
the interior of the articulation will be  fully exposed.  If the whole of it is dis-
eased, the surgeon must, of course, excise  it  completely; if it is only partially 
EXCISION  OF  THE  WRIST.
627
affected, it is better also to practise complete excision than to limit the removal
to those portions only that are  implicated.  By means  of a small narrow saw,
the articular end of the humerus is  separated from  the rest of the bone; the
upper end of the ulna and head of the  radius may either be removed in the
same way, or by means of cutting pliers.   There is never any necessity to place
a spatula before the bones, as the parts of importance anterior to the joint could
not easily be wounded, being completely protected by the  brachialis anticus.
Tne ulnar nerve will occasionally, however, be  in some  danger, and it must be
guarded or drawn on  one side  by a bent copper spatula.   In  this operation it
is of great consequence, so far as the after-utility of the arm is concerned, not
to remove more  of the bones  than is  absolutely necessary;  the  shaft of the
humerus, for instance, should never be  encroached upon, but it will be quite
sufficient to limit the  excision to the articular surface;  should  any carious por-
tions  of  the bone  extend beyond this, I think it  is better to scoop them out
with the gouge than to remove them in any other  way.  The excision of the
ulna and radius should not be carried  so low as to divide the insertions of the
brachialis anticus and biceps.
   In  some  instances, no vessels  require ligature,  though there may  be free
general oozing;  but most commonly one or two must be tied.   In some cases,
it is said, that the bleeding has  proved extremely troublesome.   This, however,
I have never seen.   After the  operation, the limb should be laid upon pillows
nearly in  the extended position, so  that  the cut portions of bones are in  close
approximation with one another.  If the excision has been practised through a
single straight incision, there will be but little if any gaping of the wound, the
flaps falling closely together.  If  any  transverse cuts have  been practised, the
edges cannot so readily be brought  into  apposition.  At the end of a week or
ten days, when granulations have  sprung up, it may be put in a slightly bent
leather splint, and as the healing process goes on, this  may gradually be  flexed,
until  at last it is brought to  a  right angle.   The fibrous union that takes place
between the bones will be closer, and a more compact and useful  false joint will
form, than if the osseous surfaces be  too widely separated in the first instance,
and be allowed to unite by a  lengthened ligamentous tissue.    Until the con-
traction of the cicatrix has  fully taken place and the  neighboring tissues are
quite firm, the joint  should  be  supported by  one lateral leather splint, on the
inner side of the arm.  Much of the success in the result of excision of this, as
of other joints, will depend upon the care and attention bestowed on the after-
treatment of the case.   The position of the parts and the relation of the bones
to one another should be scrupulously attended to, bagging of matter prevented,
and exuberant granulations repressed.   At the same time the patient's strength
must  be kept up by constant attention to  diet, fresh  air, &c.  In  this way good
ligamentous union  will  take place.
In  a  case  which  I had once  the                Fig. 227.
opportunity of examining, about six-
teen months after  the operation, it   ,
was found  on dissection  that  the  .
ends of the bones were rounded and  ^
firmly united by a dense ligamentous
structure.  In this way a most excel-
lent and useful limb will result with
but little deformity, as  may be seen
by the accompanying cut (fig. 227),
which was taken nearly two years after operation from  a patient of mine.  A
coachman, whose elbow-joint I  excised, was able to drive, to lift a pail of water,
and to do all the duties of his employment nearly as well as if the arm had been
left in its normal condition.
  Excision of the wrist is not an operation that has found much favor with sur-
geons.  Most commonly when the carpus is diseased the morbid  action rapidly
 
628          ON  EXCISION  OF  JOINTS AND  BONES.
extends with great constitutional irritation to all the small bones that enter into
its formation, and although in some cases a few of these may have been success-
fully taken away, yet methodical excision of the whole of the joint has not been
followed by very satisfactory results, having either been attended by persistence
of the disease in the soft parts, or followed by a stiff and useless hand and arm.
A great objection to excision of the wrist consists  in  the  superficial  character
of the articulation, and its close connection with the flexor and extensor tendons;
hence, when the wound cicatrizes, consolidation of these and  of their sheaths
is apt to result, and loss  of that utility of hand,  the preservation of which should
be the great object in the performance of the operation, is entailed.
   The operative procedure varies according to  the amount of disease.  When
only a few of the carpal bones are diseased, they may readily enough be removed,
through an extension of any fistulous openings  that exist over them.  But when
the lower articular ends of the radius  and  ulna are implicated, a more formal
operation  is required; and one that is not unattended by some little difficulty,
on account of the necessity of saving the extensor tendons of the fingers and
thumb. Those tendons,  however, that are inserted into the metacarpus, such as
the supinators, and the radial and ulnar extensors, may be divided; for, as  an-
chylosis will, under the  most favorable  circumstances, result, their preservation
can be no  object.
   The surgeon  has the choice of two modes of exposing the radio-carpal articu-
lation.  A horse-shoe flap, with its convexity downwards, may be made  on  the
dorsal aspect of the joint, and then dissected up without dividing the extensor
tendons of the fingers;  the articulation is thus  freely exposed; the carpal bones
may be removed,  and the  lower ends of the radius and  ulna clipped off.  Or a
longitudinal incision may be made on either side of the joint, the lower ends of
the radius and ulna removed, and the carpal bones that are diseased, extracted.
Of the two operations I prefer the former, as it gives more room;  but even  by
it, the removal  of the bones without cutting across the extensor tendsns is a
troublesome procedure.  In whatever way performed, excision of the wrist-joint
is not a very satisfactory procedure, and in  most of the cases in which  it  has
been done, secondary amputation has been required; the wound not healing, or
the hand being left in a useless state.
   Excision of the ulna or radius.—One or other of the bones of the forearm has
occasionally been excised with advantage; leaving a sufficiently useful limb with
good  power in  the hand.   Dr. Carnochan, of  New York, and Mr. Jones, have
successfully excised  the whole  ulna.   Dr. Butt  of Virginia, has removed  the
                                                       whole radius.1  In a
                        Fig. 228.                       case which was under
                                                       my  care  about  two
                                                       years  ago,  I also  re-
                                                       sected successfully the
                                                       whole radius with the
                                                       exception of its articu-
                                                        lar  head, which  was
                                                       sound,  and a  useful
                                                       arm,  of which the  an-
                                                       nexed figure is a good
                                                       representation, was left
                                                       (fig. 228).  These ope-
                                                       rations do not require
any specific rules for their performance; the bone is exposed by a long incision,
and then carefully dissected out from the parts amongst which it lies.

   1 [The excision performed by Dr. Butt was not that of the radius, as stated in the text,
but a resection of the ulna. The report of the case is somewhat confused, and it seems as
if only the lower  three-fourths of the bone were removed.  See Philadelphia Journal of the
Medical and Physical Sciences, for 1825.]
 
           CONSERVATIVE  SURGERY OF THE  HAND.        629

   Conservative surgery of the  hand. — In the removal  of diseased or injured
portions of the hand, it is, as a  general rule, of the greatest consequence to
sacrifice as little as possible of the healthy or uninjured structures.  In all ope-
rations on the hand, indeed, we must have  two great principles in view, — the
preservation of the utility of the member, and the maintenance, so far as prac-
ticable, of its symmetry.  Utility is necessarily the primary consideration ; but
if a part is not useful, it may, as in the case of the head of the middle metacarpal
bone in amputation of the corresponding finger, be sacrificed for the purpose of
preserving the symmetry of the maimed limb.  The hand is the organ  of pre-
hension and of touch, and in all operations applied to it we should endeavor as
far as practicable  to maintain its efficiency in both these respects.   It is also of
importance to bear in mind that two great  classes of actions can be carried out
by the hand; those that require force, and those that require delicacy of manipu-
lation rather than strength.  By a surgical operation we may sometimes succeed
in preserving one, though we are compelled to sacrifice  the other, and  in  this
respect, our procedure  should be  a good  deal  influenced  by the occupation of
the patient.  Thus, by partial excision, we may leave a hand that would enable
a clerk to hold his pen, but that would  be  almost useless to a laborer or black-
smith.
   In  looking at the hand in a surgical point of view, we may consider it as being
composed of two  constituents — the hand proper, and  the thumb; the thumb
being an accessory hand, an opponent to the  rest of the member, through the
medium of which the  movements of ab- and adduction  are chiefly performed,
and without which the member is susceptible of a comparatively limited utility,
being capable of  little  beyond flexion and extension.  Hence the thumb is of
equal importance to the rest of the hand, and the preservation of its three bones
is as much to be  considered as that of the remaining sixteen that enter into the
conformation of the metacarpus and fingers.   In  all cases of  injury or disease
implicating the thumb, every effort ought to be made for its preservation. Even
if it be left stiffened and incapable of flexion, it will be a most useful opponent
to the rest of the hand.   Should it  be found necessary to shorten it, care must
be taken that as little curtailment as possible be practised — a portion of a pha-
lanx,  or its metacarpal bone even, is of essential  utility  in giving strength and
breadth of grasp  to the hand.  In  cases of  disease, a very useful member may
be left by the removal of a portion or the whole of the ungual phalanx, of the
metacarpo-phalangeal articulation, or even  by the  excision of the metacarpal
bone, the phalanges being left behind.  These various  operations  are easy of
performance; an  incision through the diseased and disorganized  soft parts will
expose the necrosed bone or carious joint, which  must be removed by cutting-
pliers or a narrow saw.
   When the thumb has been forced back or badly lacerated by powder-flask or
gun-barrel explosions,  it may often be saved by being replaced and maintained
in position on a splint, with light water-dressing over it;  and should amputation
be required, it must be done in accordance with the rule just mentioned, viz.,
of saving as much as possible of the injured part.
   In the conservative surgery of the fingers, the preservation of flexion and
extension in the  part left, is the  main thing  to be aimed at;  a rigid stump is
always in the way.   The  preservation of these  movements becomes more im-
portant in proportion as the palm is approached.  It is of more consequence
that the proximal phalanx, which carries the rest with it, should  be capable of
beino- bent into the palm, than that the distal can be flexed on the second.  If
the proximal phalanx  can  be  bent down, a very small degree  of movement in
the distal one will be sufficient to furnish pliability enough in the finger to make
it a useful member; but if the proximal one is stiffened, no amount of mobility
in the distal phalanx can make it useful.
   In  preserving  these movements it is necessary to be particularly careful of the 
630          ON EXCISION  OF JOINTS  AND BONES.
sheaths of the tendons.  If they be in any way opened or injured, it will gene-
rally be found either that the tendon sloughs, or that it becomes consolidated,
and matted to its sheath in such a way that all movement is  lost, or at least
greatly impaired.
   The only phalanx that can be excised with advantage is the  distal  one.  It
often happens in the destructive disorganization that results from whitlow, that
this necroses; when, instead  of amputating the  end  of the finger, it maybe
removed by an incision on its palmar aspect.  Disease  of the phalangeal articu-
lations usually leads to amputation of the affected finger.   The rules for per-
forming these various  operations have already been laid down at pp. 25-26, to
which I must refer the reader.
   Resection of the metacarpal bone, either of the thumb or index finger, without
the removal of the corresponding digit, is  occasionally required, more particu-
larly in cases of injury; and may readily be done by making a longitudinal
incision over the dorsal aspect of the  bone to  be removed, carefully detaching
it from surrounding parts by keeping the edge  of the  knife close  against the
bone, avoiding the tendons, and then, either disarticulating, or, what is prefer-
able, cutting across the neck of the carpal end of the  bone, turning it out, and
separating it from any distal attachments it may retain.  After  the removal of
the metacarpal bone of the index finger in this way,  but very little deformity
results.
   Conservative surgery of the lower extremity. — In all conservative operations
that are practised on the  lower extremity, it is of essential importance that a
good  basis of support, of sufficient length and stability, is left to the body.
These operations  differ thus  in some  important respects from those  that are
practised  on the upper extremity.   In  the latter, the preservation  of the hand,
even though in a mutilated condition, is the  thing  that the surgeon  aims at;
and  provided this be  attained, it  matters  comparatively little  how much the
arm may  be shortened or  impaired in power.  In the lower extremity,  however,
strength,  length, and solidity are essential to the patient's comfort; and, unless
these can be secured, his  interests are better considered by the removal of the
limb, and the  adaptation of  some artificial contrivance, than by his being left
with a shortened, wasted, and crippled member, which  is unequal to support the
weight of the body.
   Resections of the Foot. — In  looking at the division of the foot into its three
great component parts — toes, metatarsus, and  tarsus,—we shall  perceive that
firmness of gait is given by the foot resting on the heel behind, and the ball in
front, formed by the projection of the broad line of  the  metatarso-phalangeal
articulations, more particularly that of the  great toe, — whilst elasticity is com-
municated to the tread by the play of the toes and metatarsal bones.   The elas-
ticity of the foot may be lost without any very serious inconvenience to the
patient; but the preservation of stability and  firmness of gait  are of essential
importance; and, as these are secured by the heel, the  ball of the great toe, and
the breadth of the anterior part of the foot, these are the most important parts
to preserve in all resections of this part of  the body.
   The foot is frequently  the seat  of strumous disease; to this it is disposed by
the alternations of temperature to which it is  subjected, its  liability to sprains
and injuries, and by the cancellous  and spongy structure of its bones, together
with its extensive articulating surfaces.  When  affected by strumous inflamma-
tion it becomes  painful, the patient  being  unable to bear upon the toes  or
anterior ball of the foot.   Swelling takes place  of a uniform character, tender-
ness at some point opposite the bones or articulations that are  chiefly  involved,
and  eventually abscess forms, leaving  sinuses through which  the  probe passes
down upon softened and carious bone.   These evidences of disease are usually
much  marked about the dorsum and sides, the sole being often comparatively
free from disease;  an  important point in reference to operation. 
            CONSERVATIVE  SURGERY  OF  THE  FOOT.        631

  In studying the conservative surgery of the foot, it  must be  borne in mind
that at least six distinct and separate  articulations exist between  the different
tarsal bones, and between these and the metatarsus; that any one  of them may
be distinctly and  separately affected, and that, as they  vary very greatly in size,
complexity, and importance, the danger to the foot will differ much according
to the articulation that is the  seat of disease; it will  also, as a general rule, be
found that the prospect of successful excision of tarsal or metatarsal bones, will
be much influenced according as the  operation opens up large and complicated
synovial surfaces  common to  many  of the bones, or  is confined to a synovial
surface of more limited  extent.  The smaller synovial membranes, disease of
which is seldom attended by serious  risk to the whole foot, and which  readily
admits of the application  of excision, usually with removal  of the  contiguous
bones, are the following: — 1st, that  between the metatarsal bone of the  great
toe and the internal cuneiform ; 2nd,  that between the fourth and fifth metatarsal
bones and the cuboid; 3rd, the  calcaneo-cuboid; 4th, the posterior calcaneo-
astragaloid.  The remaining two synovial membranes are of large size and com-
plex  in their arrangements, dipping,  as they do, deeply into the foot, and corre-
sponding to the  articular surfaces of many bones, their  disease is always of
serious, and often fatal importance to the  preservation of the member.   They
are,  1st, that membrane which extends between the astragalus  and scaphoid
into the anterior  calcaneo-astragaloid articulation, and 2nd, the large and com-
plex  anterior tarsal  synovial  membrane, which comes into  relation with the
scaphoid,  the  three  cuneiform bones, the  cuboid, and the second and  third
metatarsal bones.
   Strumous  disease may commence  either in the bones, or in the articulations
 of the foot.  The bones that are most frequently the seat of primary disease are,
the calcaneum, the astragalus, the scaphoid, the cuboid, and the metatarsal bone
of the great toe.  When limited to one or two of these bones, excision is usually
 practicable;  but  when the morbid action extends, through the influence of the
 connecting articulations, to other bones of  the tarsus or metatarsus, partial
 amputation will be required.
   Primary disease of  the  articulations of the foot is a frequent cause of opera-
 tion, and the particular operation required will in a great measure depend upon
 the  extent of the implication of the  synovial membranes of the foot.   When
 the  calcaneo-astragaloid or the calcaneo-cuboid  articulations  are alone affected,
 resection of the  bones  and joints implicated  will often  be attended by very
 satisfactory results;  but when the large anterior tarsal synovial membrane is in
 a state of chronic disease, either as  the result of primary morbid action set up
 in it, or secondarily to diseases of the scaphoid, the cuneiform, or of either of
 the  metatarsal bones connected with  it, then resection  is scarcely admissible, and
 Chopart's amputation offers the best means of relief.   The inflammation of the
 large and complicated anterior tarsal synovial membrane commonly  commences
 in disease of the scaphoid.  It may  usually readily enough be recognized in its
 earlier stages by the pain and swelling that take place across the  line of articu-
 lation between the  scaphoid and  cuneiform bones, the pain being greatly in-
 creased by bending the foot  down, and extending across the whole breadth of
 the foot.   For, although usually most severe at the inner side, which is the first
 affected, yet the  external section of  this complicated articulation, that between
 the  external cuneiform  and the cuboid, becoming involved,  causes  suffering to
 be experienced on the  outer  side of the foot as well.  In the more advanced
 stages of this particular disease, the foot assumes a remarkable bulbous or clubbed
appearance; the symmetry of the heel and the outline of the ankle is unim-
paired, but the forepart and dorsum of the foot are greatly swollen,  glazed, and
possibly perforated by sinuses discharging thin unhealthy pus.  I look upon this
disease of the anterior  tarsal synovial membrane as a distinct affection of the 
632          ON EXCISION OF  JOINTS AND  BONES.
foot, requiring to be diagnosed from the other strumous inflammations, and in
its advanced stages requiring Chopart's amputation.
   The phalanges and articulations of the toes  seldom require  resection;  as a
general rule their amputation is preferable.  The only case  that I am acquainted
with in which resection of a phalanx is required, is when an  exostosis has formed
under the nail of the  toe, pushing it up, when the removal of that portion of
bone from which  it springs, is the best course to pursue.
   The great toe  not unfrequently requires  removal in whole or in part;  but,
entering largely as it does into the formation of the arch of the foot, no more
of it should be  taken away than is absolutely necessary.  It is  especially of
importance that  the ball of the  great toe be, if possible, preserved; and occa-
sionally this may be effected by excision of the metatarso-phalangeal articulation
rather than by the amputation of the member.   With regard to the removal of
the  toe and its metatarsal bone, I must refer to p.  55.   Whenever  it is  practi-
cable the proximal end of the bone should be saved, in order that the insertion
of the tendon of the peroneus longus may be preserved.
   The other metatarsal bones with their  toes occasionally require  removal.
This is more particularly the case with the fifth.  The middle metatarsal bones
cannot advantageously be taken away, leaving merely the first and last; but the
two, three, or even the whole four of the  external  metatarsal bones may be
advantageously resected, and a useful foot be left.    Mr. A. Key has recorded  a
 case in which, in consequence of injury, he  amputated the four outer metatarsal
 bones, the cuboid, and the  external and  middle cuneiform, leaving merely the
 line of bones supporting the great toe.   The first  metatarsal bone was left, sup-
 ported only by the slender articular surface of the internal cuneiform, but it
 soon got firmer attachments, and a very good foot resulted, by which the patient
 retained in a great measure his elasticity  of  tread.
   The os calcis,  from its exposed situation, large  size, and spongy structure, is
 more frequently the  seat  of caries and  necrosis  than any of the  other tarsal
 bones;  and very commonly the  morbid action is limited to this bone; in other
 instances it  extends into  the  calcaneo-astragaloid or calcaneo-cuboid articu-
 lations.
   When  the disease  is situated in the posterior  or lateral parts of the bone,
 the  neighboring articulations are  seldom involved, and then  the removal of
 the  morbid structures  by gouging will usually succeed in  effecting a cure.  I
 have frequently had  occasion in this way to scoop out  great portions, some-
 times the whole of  the  interior of the calcaneum,  with the most excellent
 results.
   If the upper  or anterior portions of the bone are  diseased, so as to involve
 its  articulations  with the astragalus and cuboid, its excision should be practised.
 The operation is a very successful  one, and leaves a flat but useful foot.  Occa-
 sionally, however, after the removal of the bone,  disease is set up  in the neigh-
 boring parts requiring amputation; this I  have seen  more than once happen;
 and, of 10 cases collected by Mr. M. Greenhow, it became requisite in 2  even-
 tually to  remove the foot.
    The excision  of the os calcis is usually performed by turning a heel-flap back
 as in disarticulations at the ankle joint, and then carrying incisions forward into
 the sole of the  foot, by which another flap is turned up, and thus the calcaneo-
 cuboid  articulation exposed and  opened (fig. 30);  after which the knife is car-
 ried between the astragalus and calcaneum, and  that bone detached.   By this
 operation the sole of the foot is  somewhat extensively incised and cicatrices are
 left over  the heel.
    In order to avoid this inconvenience, I have  found  that disarticulation of the
 os  calcis may readily be performed in the following  way.   The  patient lying
 on   his face, a   horse-shoe  incision  is  carried from  a little  in  front of the
 calcaneo-cuboid  articulation round the  heel, along  the  sides of  the  foot, to 
CONSERVATIVE  SURGERY  OF  THE FOOT.        633
a corresponding point on the  opposite side.   The elliptic  flap thus formed is
dissected up, the knife  being carried close to the
bone, and the whole under surface of the os calcis           Fig. 229.
thus  exposed.   A perpendicular incision about
two  inches  in length is then made behind the
heel, through the tendo Achillis in the  mid line
and  into the horizontal  one.   The  tendon is then
detached  from its  insertion,  and the two lateral
flaps dissected up,  the  knife  being kept close  to
the  bones  from which the  soft parts  are  well
cleared (fig. 229).  The  blade is then carried
over the upper and posterior part of the os calcis,
the  articulation  opened, the interosseous ligaments
 divided, and then  by a  few  touches  with  the
 point, the bone is  detached from  its connections
 with the cuboid, which, together with  the  astra-
 galus, must  then be examined, and if any disease
 is met with the gouge should be applied.   By
 this operation all  injury  to  the sole is  avoided,
 and the open angle of the wound  being the  most
 dependent, a ready outlet  is  afforded for the dis-
 charges.
   The astragalus  though often diseased is rarely
 affected without the  neighboring  bones partici-
 pating in the morbid  action.   It is so wedged in
 between the arch of the malleoli above,  the calca-
 neum  below, and the  tarsal  bones in  front, that
 it is not long before disease spreads from it to the
 contiguous  articulations  and osseous  structures.
 Disease primarily  originating  in   the  astragalus
 may spread in three directions: upwards into the
 ankle-joint, downwards to the calcaneum, and for-
 wards  to the scaphoid, and  thence through the large anterior synovial mem-
 brane  to the rest  of the  tarsal bones.   The  treatment will vary according to
 the  direction  and  extent of  the  disease.   It  may  be arranged under four
 heads.
   1st. When the  astragalus alone is  diseased, either gouging or excision may
 be required.  If the morbid action be limited to the outer side of the bone, or
 to its head, it is possible that by freely opening up the sinuses and applying the
 gouge, the caries may  be entirely removed.   But this  operation is not so satis-
 factory here as  elsewhere  in the foot, as it is  by no means easy to avoid opening
 the  astragalo-scaphoid articulation, and if this is done,  disease will  almost
 inevitably extend through the  tarsal articulations.   Excision  of the  astragalus
 alone,  though sometimes required for disease, is perhaps more frequently called
 for  in those cases of  compound dislocation in which the bone, having been
 thrown out of its  bed, eventually  becomes carious or necroses.  The operation
 may readily enough be done by making an incision across the outer and anterior
 aspect of the ankle, exposing the bone,  cutting across its neck with pliers, and
 then with strong forceps forcibly elevating it from its bed and detaching it by
 the cautious application of the knife, more particularly to the inner side, where
 the plantar arteries are in danger.  The result of  this operation is very satis-
 factory, a good  and movable  articulation may be left between the malleoli  and
 calcaneum, and the limb is but little shortened.
   2d.  When the  disease has  extended  from  the  astragalus  to the malleolar
 arch, excision of the  ankle-joint will  be required.   This  operation  may con-
 veniently be performed in the following way.   A semi-lunar incision about four
 
634          ON EXCISION  OF JOINTS  AND BONES.
inches in length should be made along the outer and anterior aspect of the joint,
                                                        round the lower bor-
                       Fig. 230.                         der  of  the   exter-
                                                        nal   malleolus   (fig.
                                                        230), and should be
                                                        carried    sufficiently
                                                        forwards to give space
                                                        without dividing the
                                                        extensor  tendons or
                                                        the   dorsal  artery.
                                                        The peroneal tendons
                                                        having been divided,
                                                        the lower end  of the
                                                        fibula should be cut
                                                        across and detached.
                                                        The astragalus which
                                                        will now be exposed,
                                                        should  then be  se-
                                                        parated from its con-
 nections, which, if it be much diseased, may usually be readily done.   If not
 deeply affected it will be more firmly held, and  should be then cut across with
 pliers, and each fragment lifted out of its bed.  The foot  should  now be well
 drawn to the inner side, the lower end of the tibia carefully isolated, the knife
 being used with great caution and kept close to the  bone, lest the posterior
 tibial artery be injured.  When the ligamentous structures attached to the bone
 have been separated, the inner malleolus may be cut off with bone forceps, and
 as much  as  necessary of the  lower end of the  tibia removed with a narrow-
 bladed or a chain-saw.  Should there be any disease in the  articular surfaces of
 the calcaneum or scaphoid this must be gouged  away.  The part should then
 be lightly dressed, and the limb placed on a Liston's splint.
   3d.  When the disease has extended  to the  calcaneum from the astragalus,
 amputation  at the ankle-joint may be required, or should the surgeon  prefer
 it, he  may excise  both the  diseased bones, as has been successfully done by
 Mr. T. Wakley.
   4th. If the disease has extended from  the astragalus to the scaphoid, and
 thence into the  anterior range of tarsal joints, the foot will  have  become so
 extensively disorganized, that partial resection will be of  little or no service,
 and disarticulation of the ankle-joint should be practised.
   Excision of the cuboid bone either in whole or in part may  be required; when
 the whole of the bone is taken away, the fifth metatarsal  bone with the little
 toe will probably also require removal.
    The scaphoid is very commonly the seat of primary disease,  and as this bone
 is connected in front with the  large tarsal synovial membrane and  posteriorly
 with  that which is common to the calcaneo-astragaloid and  astragalo-scaphoid
 articulations, the greater part of  the tarsus is  apt to  become speedily involved
 in the morbid action.  The extent of this implication is such that excision of
 the primarily diseased bone would probably seldom be attended by much  benefit,
 and Chopart's amputation or disarticulution at the ankle-joint becomes neces-
 sary.   Next to disease of the astragalus, I look upon  strumous inflammation of
 the scaphoid as most destructive  to the integrity of the foot.
   In chronic disease of the ankle and tarsal bones, it will occasionally happen
 that an excellent and useful limb may be left after excision of a less formidable
 kind  than those  just described.   In a lad  who was  some time since under my
 care with very extensive  disease of these parts of old standing, I removed the
 lower three inches of the fibula, gouged away a considerable  portion of the end
 of the tibia, and  of the  astragalus, calcaneum, and  cuboid, removing  a whole
 
EXCISION  OF  THE KNEE-JOINT.
635
handful of carious bone.   Yet a perfect cure  resulted, the patient recovering
with a strong and useful foot.
   The malleoli alone seldom require resection.  Should  either of them do so,
the operation may readily  enough be accomplished,—in the outer malleolus, by
dividing the bone with cutting  pliers, but in the inner malleolus, more  care is
required in avoiding the flexor tendons, the artery, and nerve, and the bone had
better be cut across with a chain-saw.
   Excision of the knee-joint may be required either as a substitute for amputa-
tion in cases of  extensive  dis-
ease and disorganization of the                   Fig. 231.
articulation, or may be practised
in  some cases of deformity re-
sulting from old disease  or in-
 jury by which  the  limb  has
been rendered  useless.   This
operation,  originally  practised
 at  the close of the last century
by Park, Filkin, and the  Mo-
reaus, fell into  disfavor until it
was revived in  1850,  by  Mr.
 Fergusson, since  which time it
 has been extensively practised.
   Excision of  the  knee-joint
 may be performed by making a
 horse-shoe  incision  with  the
 convexity  downwards,  extend-
 ing from the side of one condyle
 of the femur across the tube-
 rosity of the  tibia to a corres-
 ponding point on the  opposite
 condyle (fig. 231).   By this incision, the ligamentum patellae is divided, and
 that bone turned up in the elliptical flap;  the crucial ligaments  are then to be
 cut across, any remaining lateral attachments divided, and the bones cleared for
 the saw.  In doing  this  the  limb must be forcibly flexed, and  the knife care-
 fully applied to the  posterior part of the head of the tibia;  for this purpose a
 blunt-pointed resection knife is the best.   The  articular surfaces must  now be
 sawn off.  This may best  be done by Butcher's saw.  The lower end of the femur
 should first be removed, and then a slice  taken off the tibia by cutting from
 behind forwards, the blade of the saw being turned horizontally; care should be
 taken not to remove  more bone  than is absolutely necessary, lest the limb be too
 much shortened.  As not unfrequently happens, carious cavities will be found
 extending below the level of the section that has been made.   When this is the
 case, it  is better to apply the gouge to them than to saw the bone below their
 level.   It is usually sufficient to remove from one-third to  three-fourths of an
 inch of the tibia, and  about one inch to an inch and a half of the femur (figs.
 232 and 233).   Should, however, the operation be required, for disease of the
 limb consequent upon the deformity resulting from  badly reduced fractures or
 dislocations about the  knee, as  has been done successfully by Mr. Humphry of
 Cambridge, it  may be  necessary in order to get the limb into good position, to
 remove a wedge-shaped piece from one of the bones.
    If  the patella is  much diseased, it  must be removed; if  it be only  slightly
 carious, it may be scraped or gouged out, and  in accordance with that principle
 of conservative surgery by which  no sound part is removed, it should  be left,
 becoming consolidated with and strengthening the joint.   The anterior articular
 surface  of the femur, which  extends  some way up  the fore-part of that bone,
 
636          ON  EXCISION  OF JOINTS  AND BONES.
may advantageously be sliced off, so as to leave an osseous surface instead of a
cartilaginous one, for the patella to attach itself to.

                Fig. 232.                           Fig. 233.
  In some cases no ligatures will be required, but usually two or three of the
articular arteries furnish sufficient hemorrhage to require restraint.   The patel-
lar flap when laid down will  often appear inconveniently long and thick, but it
is better not to curtail it, unless the bones have been shortened more than usual,
as it will contract and eventually fit in well.
  I have  always found  the operation as I have  just described it, easy of per-
formance  and good in  its results, but various modifications are adopted by dif-
ferent surgeons.  Thus, some make two parallel incisions on either side of the
patella or an  H shaped incision, and thus open  the articulation from the side.
That excellent surgeon, Mr.  Jones, of Jersey, who has had great experience in
this operation, has advised  that the skin be dissected up by means of a semilunar
incision, and then that  the ligamentum  patellae  be preserved  by being pushed
with the patella and the quadriceps extensor  tendon to one side, the joint then
opened and the bones sawn.   Others again advise that the patella be removed,
and Mr. Holt has recommended that after the excision the soft parts of the ham
be perforated to allow the discharges to drain through.   The successful  issue
of the operation will mainly depend on  the care  taken in the after-treatment of
the case.
  After the operation, the limb should be at once put up securely in a Liston's
splint, and well-supported.    During the  after-treatment,  when  granulations
spring up, it may most  conveniently be placed in a long leather trough, extend-
ing from  beyond the foot  to the pelvis, and well padded, particular attention
being paid to the  position  of the limb, and  especially to the prevention of any
bowing outwards which is apt  to take place.  In order to prevent displacement
it has  been proposed to divide  the hamstring  tendons; this, however, I have
never found necessary, nor does it seem to me to be advisable to complicate the
operation by such an addition to it.   The protuberance of the flap, if at all exces-
sive, may be diminished by the  pressure of a  many-tailed bandage.  In this
way osseous  anchylosis will  ensue, and a good and useful straight  limb result.
In  two cases I have succeeded in getting a good limb with a partially movable
joint; both  these  cases were  in children,  and  I am disposed to think that in
young patients this result may often be satisfactorily attained.  In adults, how-
ever, osseous anchylosis should always be aimed  at.
  In determining  the  propriety of performing  this operation, there are two
points to  be considered : —
  1st. The danger attending it; and 2d, the nature of the result.
  The danger attending excision of the knee-joint is not great when compared
to that which follows the operation, amputation  of the thigh, instead of which
it is  practised, or  indeed  capital  operations   generally.   According  to Mr.
Butcher,  the  operation  has been performed 82 times since its revival in  1850
up to 1857.   Of these 15 proved  fatal, and in  8 amputation of the thigh was
required, of which 1 case had a fatal issue.   In  some instances there is reason 
EXCISION  OF  THE KNEE-JOINT.
637
to believe that the unsuccessful result was owing to want of due attention to the
after-treatment of the case.  I think, therefore, we are warranted in concluding
that this  operation, though serious, is not attended by any very great amount
of risk to the patient.
  The 2d point that has to be determined, is as to the utility of the  limb  after
the operation, the propriety of performing which, depends  in  a  great degree
upon whether the limb that is left is more useful than an artificial one.
  On this point, the result of recorded cases is in favor of the operation.   In
one of Mr. Park's  cases, operated  on  in  1783, that surgeon states that the
patient, a sailor, seven  years after  the operation,  "was  able to go  aloft  with
considerable agility, and to perform all the duties of a seaman."   In some of
the later cases the result has been equally  good.   One of Mr. Jones' patients, a
boy, "could run and walk quickly  without any aid of a stick, could stand on
the limb alone, and pirouetted  and hopped two or three yards without putting
the sound limb to the ground."  In several of my own cases an excellent strong
and straight limb has been left, useful for  all ordinary purposes.
   After the operation,  osseous anchylosis  takes place with a firm  cicatrix, the
limb is shortened  by from two to three inches, but by means of a high-heeled
shoe this inconvenience is greatly remedied.  It  has been  urged against the
excision of the knee-joint that convalescence is tedious and prolonged, but this
argument  can  with justice  have but  little weight; if a useful  limb can be
preserved to the patient, it can  matter but little  if a few additional weeks are
devoted to the procedure by which  it is obtained;—and, indeed, it is a question,
whether in many cases  the patient may not be able to walk  just  as  soon  after
the excision of  the  knee-joint  as  after amputation  of  the  thigh;  for as has
been very properly remarked, though the  amputation wound may be healed in
three or four weeks, it  may be as many months before an artificial limb can be
worn.
   Excision of the head of the femur has of late years been  a good deal talked
about  and practised in some cases of hip-joint disease.   This  operation  may,
however, most conveniently be considered  in connection with that  affection
(P-657).
   Amputation in joint-diseases. — In those cases  in which excision of the dis-
eased joint is not advisable, in  consequence of the acute character of the arti-
cular disease, the existence not only of considerable suppuration, but of  great
local and constitutional irritation, or the peculiar nature of  the joint affected,
amputation may be the sole resource  left to the surgeon.   It is especially in
articular disease of the fingers and toes, of the tarsus, carpus, ankle, and knee,
that this operation is required;  and though much  less frequently practised now
than formerly, yet the  cases of destructive disease of joints  requiring amputa-
tion are amongst  the  most  frequent  in operative surgery,  and will  doubtless
continue  to be so.   The surgeon,  however, must  be  careful whilst he avoids
continuing to make ineffectual attempts to save the limb at the great hazard of
the patient's life, not to amputate until it is clear that  all  other means  have
failed, the patient  continuing to lose ground, so that a further perseverance in
local and constitutional treatment would probably  end in his  death, excision not
being  practicable.  So far from amputation being an opprobrium to surgery in
such cases as these,  I look upon it as one of the  greatest triumphs  of our art,
that by  a simple and  easy operation which removes the spoiled and useless
limb, the life of the patient may  be  saved,  and  his health speedily restored.
It commonly happens that a patient who has been racked with pain, and  been
wasting  in body for weeks before  the local source of irritation was removed,
sleeps soundly  the  night after the  operation, and  rapidly gains  flesh  and
strength.
   As phthisis not unfrequently co-exists with the  advanced  forms of strumous
joints, the  question of amputation under these circumstances becomes one of 
638
DISEASES  OF  JOINTS.
very  considerable  importance.   If the  phthisis be  rapidly progressing, and
there be  a  strong  hereditary tendency to the disease, or if it have advanced
to softening of the lung, and the formation of vomica, it would be useless to
operate.   If, however, the phthisis be of a very slight and  incipient character,
and be apparently due to the local irritation  of and discharge from the diseased
joint, to  the  confinement  to bed that  it  necessitates, and  to  the  general
depravation  of health  that ensues,  amputation may not only be  safely, but
advantageously practised; and I have performed it in many such cases, to the
manifest advantage of the patient.

                 LOOSE  CARTILAGES  IN  JOINTS.

   It sometimes happens that in the interior of the joint  the synovial membrane
assumes a warty condition, as the result of chronic irritation of the articulation.
For this condition,  which gives rise to occasional uneasiness and puffiness about
the joint, with  a crackling  or creaking sensation when  it  is moved, but little
can be done beyond the application of discutient plasters and the use of elastic
bandages.
   Loose  cartilages, as they are termed, are  not  unfrequently met with  in the
different  articulations.   These in  many  cases are not  truly cartilaginous, but
appear to  be composed of masses of condensed and indurated fibroid tissue, not
very dissimilar in  structure  to the warty synovial  membrane just referred to.
In other cases, however, it is probable that they may be  of a truly cartilaginous
formation.  These  bodies vary in  size from a barley-corn to a chesnut; when
small, being rounded in  shape;  when  large, being somewhat flattened  or de-
pressed on the surface; they are smooth, sbining, and  usually of a yellowish or
greyish white color.  They  are most  frequently met with in the knee, but not
uncommonly occur  in the elbow or the joint  of the lower jaw, and occasionally
in the shoulder.  Most commonly only one is  found, but their  number may
range from this up  to fifty or sixty.
   They commonly give rise to very severe pain in particular movements of the
limb.  This comes on  suddenly, prevents the patient either  straightening or
flexing the  joint completely, and  is  often so intense as to cause faintness or
sickness.  It is usually followed by a degree of synovial inflammation  and by
relaxation of the ligaments.  These attacks of pain and of sudden irritability
of the part come on at varying intervals, as the result of movements  of it; they
commonly happen in the  knee whilst  the  patient is walking.   It is difficult to
say to what  this severe pain is due.   Richet thinks  it  may be owing  to the
synovial  membrane being pinched between the foreign body and  one  of the
articular surfaces.   In some cases  the loose  cartilage can be  felt by carrying
the finger over the  joint,  when it may be detected  under the capsule, slipping
back perhaps when  pressure is  exercised upon it.
  The treatment consists in supporting the joint  with  an elastic bandage or
knee-cap,  so  as  to limit its movements, and  thus  prevent  the liability to the
recurrence of the  attacks of pain.  Any inflammatory  action  that has been
excited requires to be subdued by proper antiphlogistic treatment.
  If it occasion great and  frequent  suffering, so as to interfere seriously with
the vitality of the  limb, and if the cartilage appear  to  be of large size, and
single, means  may be taken  for its extraction.  No operation, however, should
be undertaken with this view so long as the joint is in an irritated state, as the
result of a  recent  attack of pain; this  must be first subdued, ami then the
operation may be proceeded  with.   The extraction may be effected by directing
the patient in the first instance to make those movements by which he usually
gets  the cartilage  fixed  in  the joint.   So soon as the surgeon feels it (as this
operation  is commonly  required in the knee) he should push it to one side of
the patella,  where he  must  fix it  firmly with his fore-finger  and thumb; he 
NEURALGIA OF  JOINTS.
639
then draws  the skin covering it to one  side, so as to make it tense, and cuts
directly down upon  the cartilage by a sufficiently free incision  to  allow of its
escape.   The wound  which, when the  skin  is  relaxed,  will  be somewhat
valvular, is  then closed by a strip  of plaster, and the limb kept at rest for a
few days until it has united.  Severe  inflammation of the joint less frequently
follows  this  operation than  might have been expected, the  synovial membrane
having  probably undergone  some modification of action  that renders it little
liable to this process.   It does however happen that acute synovitis may set in,
and this has terminated  in suppuration  of the joint,  requiring  amputation,
or  leading to anchylosis; hence  it is an operation  that should not lightly be
undertaken.
   It has been  proposed by M. Goyrand,  in order to  obviate the dangers of an
 external wound into the  joint, to  remove the loose cartilage by subcutaneous
 section; this he proposes to accomplish in a way that I have seen  practised by
 Mr. Liston;  viz., by passing  a tenotome obliquely under the skin after fixing
 the foreign body in  the  way that has already been described, dividing the
 synovial membrane freely, and  then  squeezing the  cartilage  into the cellular
 tissue outside  the joint, where it may be allowed to remain until removed by a
 fresh incision  after that  in  the  synovial membrane has healed, or left and be
 eventually taken up by the absorbents of  the part.
   A useful  modification of this  method  consists in fixing the loose cartilage,
 dividing the capsule subcutaneously over it, and then pressing the  foreign body
 into the opening  thus made, retaining  it there by a  compress and plasters.
 Adhesion speedily ensues, and eventual absorption of the loose cartilage.

                        NEURALGIA  OF  JOINTS.

    Severe pain  may  occur in joints without  organic disease, either from the
 pressure on  a nerve leading to the articulation or distributed in its vicinity, or
 from some neuralgic  condition  of the joint itself.   Thus there may be severe
 pain in the knee in consequence  of pressure being exercised upon the obturator
 nerve,  or the joint generally may be excessively painful — especially in  girls or
 young  women — owing to some hysterical condition or uterine irritation, the
 nature of which  in  many cases  is not very  clear.   It  is  this  class  of cases,
 occurring in hysterical females, that should especially be considered as neuralgia
 of the  joints, to which  the attention  of the  profession has principally been
 directed by  the labors of Sir B.  Brodie.
    In  these  cases it is generally found that the hip,  knee, ankle, or shoulder is
 the joint affected — the hip and  the knee  being especially liable to it — severe
 pain is complained  of  in it;  and it is  rendered comparatively useless, often
 with a good deal of distortion.   On examination it will  be found that the pain,
 which  is commonly very severe, is superficial and cutaneous,  not existing in
 the interior of the articulation or increased by pressure of the articular surfaces
 against one another,  and is not strictly confined to  the joint, but radiates for
 some distance around it.  This  pain is often  intermittent in its character, and
 is  frequently  associated with neuralgia elsewhere, as in the spine;  and not
 unfrequently with uterine irritation  or disease.  At the same  time it will be
 observed that all the  signs that  ought to  accompany  a severe attack of inflam-
 mation in  a joint, such as would  be  attended by a corresponding amount of
 pain,  are  absent; there  being  no painful startlings of the  limb  at  night, or
 constitutional  fever and irritation; and the suffering being increased by causes,
 such as mental and emotional disturbance, that do not influence organic  disease.
 Attention  to  these various  circumstances will usually  enable  the surgeon to
 diagnose the  nature  of the attack without much difficulty;  the only cases in
 which  he will  really experience  any, being those in which the tissues around
 the joint have  been thickened, indurated, and altered in their characters by the 
640
DISEASES  OF THE  SPINE.
application  of issues, moxae, &c.;  or by some slight articular ties  having at
some time existed, but been cured.
   The treatment must be of a general character, directed especially to re-estab-
lish  a  healthy condition of the uterine organs.  If there be amenorrhcea, and
anemia, aloetics, and the preparations of iron  must be given; if uterine irrita-
tion or ulceration  exist, this must be removed by proper local means, and the
general health attended to.  The most efficient  treatment that can be directed
to  the affected joint, is, I think, the  application  of  cold douches and  the
employment of electro-magnetism,  which I have found  to  cure cases in which
all other means had failed; the application of atropine  and aconite  may be of
service to allay the pain when especially severe.
CHAPTER  XLV.
DISEASES  OF  THE  SPINE.
   Caries of the vertebre.—This disease, which consists, in its full development,
in destruction  of the bodies  of the vertebra?, with disintegration of the inter-
vertebral fibro-cartilage, most commonly occurs in young children, sometimes
but a  few  months old; but is not  unfrequently met with at all ages up to that
                                        of thirty.  It is always,  I  believe, a
                                        strumous affection, consisting  essen-
                                        tially in  tubercular infiltration of the
                                        bodies of the vertebrae,  followed, as
                                        commonly happens,  in this  morbid
                                        condition,  by congestion, caries, or
                                        necrosis  of the  osseous tissue that is
                                        in contact with, or the  seat of, the
                                        deposit.   In consequence  of  these
                                        changes  going  on  in  the bodies of
                                        the  vertebrae, they become  thinned,
                                        eroded,  and  gradually hollowed out
                                        anteriorly.   The disease is  usually
                                        limited to the bodies of the vertebrae,
                                        leaving the spines, the arches, and the
                                        tubercles unaffected;  but in some in-
                                        stances even these structures, which
                                        are of a more compact character, be-
                                        come eventually implicated.  In this
                                        way the bodies of from three to  six or
                                        eight of the vertebrae maybe destroyed,
                                        the corresponding intervertebral fibro-
                                        cartilages, which derive  their supply
                                        from the contiguous bones, becoming
                                        disorganized, as these undergo de-
                                        struction.  These changes  commonly
                                        occur about  the middle dorsal ver-
tebra?; if  extensive, they may implicate  the upper or lower dorsal,  or  upper
lumbar, and always give rise to angular projection backwards  of  the diseased
 
CARIES OF  THE  SPINE.
641
part  of the spine,  corresponding  in  extent to the amount of  destruction of
the vertebrae (fig.  234).   The  mechanism of this excurvation, which  is the
most marked feature in this disease, is easily understood by reference  to the
pathology of the affection.  The bodies of the vertebrae being thinned and weak-
ened, at last give way under the pressure of the weight of the  upper part of tho
body, and the remains  of the disintegrated bodies being fused  together, cause
the upper  part  to  bend  over,  and  the  spines  to  project  posteriorly.  The
degree of bending  forwards and  of  posterior excurvation  corresponds  to the
amount of  the destruction of the bodies of the vertebrae.  It is seldom that the
spinal  marrow  becomes compressed  or  injured  during the  progress  of  this
disease.  In  some   cases,  however, more  particularly  in adults,  it  becomes
softened opposite the seat of curvature, and thus paralysis may be occasioned.
   The symptoms of the disease, when it  is fully developed, are well marked;
but  in children it  often comes on very insidiously, commencing with a  degree
of weakness in the  back, with an inability to stand upright, and with a tendency
to lean the body forwards, or to  support it by resting  the hands on the knees, or
seizing hold of  anything that will  serve as a temporary support.   On examina-
tion, a few of the  spines about the  middle of the back will be found  to be a
little more prominent than the rest, and on pressing or tapping upon them  pain
 will be complained  of.  The child usually  becomes stunted in its  growth, and
if the  disease is not arrested by proper treatment, continues more or less hump-
 or round-backed for life.   In  other cases it will  run on to the formation  of
 abscess,  as will immediately be described, strumous manifestations occurring
 elsewhere, and death eventually resulting.
   In  adults, the symptoms will vary somewhat according to the seat  of the
 affection.  It is most dangerous  and rapidly fatal when the  cervical vertebrae
 are implicated, for, as the bodies of  these are shallow, caries  readily penetrates
 to the spinal  canal, and the cord may thus  be  irritated.   When the dorsal or
 lumbar vertebras become diseased, the affection is not of so immediately  serious
 a character to the life,  though it, may be to the figure, of the patient.  In adults
 it often  commences with pain  in  the loins or back, apparently of a rheumatic
 character, shooting round the  body or  down the  thighs.  On examining the
 spine, which feels weak to the patient, tenderness on  pressure  or on tapping will
 be experienced at one point, and he will wince when  a sponge wrung out of hot
 water is applied to this part, although there may be  no  appearance of excurva-
 tion.  The lower limbs  now become weak, and the patient walks with a peculiar
 shuffling, tottering gait, the legs being outspread, and the feet turned out.  The
 weakness of the limbs is especially marked in going upstairs,  and may be tested
 by directing the patient to stand unsupported on one leg, and raise the other so
 as to place the  foot upon the seat of  a chair, which he will probably be  unable
 to do.   The deformity of the spine now slowly increases, the patient becomes
 unable  to stand, and spasms of  the muscles of the lower extremity come on,
 together with a tendency to relaxation of the sphincter ani, and  retention  of
 urine.   Abscess now commonly  makes its appearance, and in some cases  it
 occurs before  any of the  other signs, except pain and weakness of the spine,
 but certainly before any deformity has taken place.   When  the abscess forms,
 as Mr. Stanley has  observed, the pain and irritation  of the spinal cord are usually
 lessened for a  time.
   It must not, however, be supposed that  abscess necessarily  forms in all cases;
 indeed, the  formation  of  matter will, I believe, chiefly depend upon whether
 the disease of the vertebrae be tuberculous or not.  Simple congestive or inflam-
 matory caries  of the spine may take place  to  a very considerable  extent, and
 yet no suppuration occur, the  bodies of the vertebrae undergoing erosion, and
 absorption, and  coalescing so  as to  become  fused together  into one soft and
 friable mass of bone,  across which bridges  of osseous tissue  are  sometimes
 thrown  out,  so  as to strengthen the otherwise weakened  spine.   In these  cases
        41 
642
DISEASES  OF THE  SPINE.
masses of porcellanous deposit will not  unfrequently be found intermixed with
and  adherent to the carious bone.   Indeed, this  anchylosis and fusion of the
bodies of the diseased vertebrae may be looked upon as the natural mode of cure
of angular curvature  of the spine;  the only way in which  it can take place
when once it has advanced to any considerable extent.
  When abscess forms  in  connection with diseased spine, it is probably the
result of the continued irritation of the tuberculous deposit, and it may become
the most prominent and marked feature  of the affection, giving rise almost to a
distinct and independent disease.   The situation and course  of these abscesses
depend entirely upon  the  part of the spine affected; thus,  for instance, when
the  cervical vertebrae  are  diseased, the  abscess may come forwards behind the
pharynx, and may occasionally extend under the sterno-mastoid muscle to the
side of the neck, where it  opens; sometimes, though very rarely, it may pass
into the  chest, and in  other cases down into the  axilla.   When the disease is
seated in the  dorsal vertebrae, it usually passes forwards  under the  pillars of
the  diaphragm  down  the  side of the aorta  and the iliac vessels into the iliac
fossa, and  then presents through the anterior wall above Poupart's  ligament.
In other cases, again, when the lower dorsal or upper lumbar vertebrae are dis-
eased, the  pus gets into the sheath of the psoas muscle, thus constituting the
common affection termed "psoas  abscess;" and passing along this, under Pou-
part's ligament, presents in  the thigh; or it may continue its  course downwards,
burrowing under the muscles of this region, until it reaches the  popliteal space,
and even pass from this some distance downwards on to the calf or ankle.   I
have seen an  abscess opened by the side of the tendo achillis, which took its
origin in disease of the dorsal vertebrae (fig. 135).   In other cases, again, these
abscesses take a different course, and, descending into the  sub-peritoneal cellu-
lar tissue of the pelvis, may present by the side of the rectum in the perineum,
or pass out of the sciatic notch, and  down by the side of  the trochanter.  The
quantity of  pus contained  in these collections is sometimes  enormous,  and
abscesses of this description attain a greater magnitude than  those of any other
part  of  the  body.   In other cases the abscess  may follow the  course of both
psoas muscles, and project on either groin, at the same time.
   The diagnosis of caries  of the spine is made at the first sight of a patient
affected  by the disease, when once the  angular deformity has taken place.  It
is,  however, difficult before excurvation  occurs, being only  indicated at  this
period by the existence of pain in the back, and by some symptoms of spinal
irritation.   At this stage it may be mistaken for spinal or intercostal  neuralgia,
for rheumatism, or for chronic nephritis.   The persistence, however, of a con-
tinuous fixed pain in the back should always lead  to a suspicion as to the true
nature of the disease,  lest the grievous error be committed of treating as mere
neuralgia or rheumatism, what may turn out to be incurable disease of the spine
itself.  Here the tenderness on  pressure, the increased sensibility to the appli-
cation of heat, with a tendency, though it be very slight, to projection of some
of the spines, the feeling of weakness in the back, and especially the occurrence
of these symptoms in  early childhood or youth, at a period when the other dis-
eases rarely occur, would lead one to suspect the true nature of  the affection.
   The diaejnosis of the connection between abscesses in the situations mentioned
and those arising from diseased spine, is not always easy, as purulent collections
of various kinds may form in  the  different planes of cellular tissue in  the
neighborhood  of the vertebral column, without any disease  existing  in it, and
these often attain a very considerable bulk before they present externally, which
they usually do in the groin.  Abscess in the groin may arise  from the following
causes:  1st, from large lymphatic collections in the subcutaneous or intermus-
cular planes of cellular tissue; 2d, from  disease  of the cellular tissue around
the  kidneys; 3d, from pericoecal abscess (on right  side only); 4th, from iliac
abscess,  whether forming  merely in  the iliac fascia, or dependent on  disease of 
PSOAS  AND ILIAC  ABSCESS.                643
the pelvic  bones; 5th, from hip-joint disease, the abscess being pelvic; 6th
large  buboes or glandular abscesses;  7th, from an empyema perforating  the
pleura and  finding its way down behind the diaphragm.  The diagnosis of these
various  collections may, however, with a little caution, be readily made from
the ordinary form of spinal abscess that descends  along the psoas  muscle.   In
the first place, in all  these cases there is  an absence of that dorsal pain  and
tenderness, with more or less excurvation, which, though not invariably present,
is commonly met with in psoas abscess.  Then, again, if the collection be peri-
nephritic, there would have been previous, or there  are co-existing, symptoms
of renal disease.   If it occur  in the cellular tissue around the coecum, the pus
will be peculiarly offensive, will present itself in a less distinct manner, and  will
probably be associated with symptoms of intestinal  irritation.   In those rare
cases  in which an empyema has found  its way between the layers of the abdomi-
nal muscles, and presented in  the groin, the stethoscopic signs will point out the
nature of the affection.   In  abscess connected with  disease of the  hip-joint,
there will be special evidences of the source of the pus.  The only real diffi-
culty consists  in diagnosing large  psoas  abscess  presenting in the thigh or in
other parts of the lower extremity, and dependent on  disease of the vertebral
column, from  iliac  abscess  taking  its origin in the loose cellular tissue of the
iliac fossa,  whether it be connected or not with disease of the corresponding
bone; and in these cases the difficulty is often not a little increased in conse-
quence  of  the iliac abscess finding its  way into the sheath of the psoas.
   In iliac  abscess, the disease usually  commences at or after the  middle period
of life,  always  in adults; and, as Mr. Stanley has observed,  usually presents
itself externally, immediately above Poupart's  ligament, being conducted  for-
wards to this situation by the  fascia iliaca. Psoas abscess, on the contrary, most
commonly  occurs in the  earlier  periods  of  life;  extends down  into  the thigh
along the course of the psoas muscle, so that it always presents below  Poupart's
ligament.  It is also commonly associated with  some indication of irritation of
the muscle in the sheath of  which it is situated; thus, there is an inability to
stand upright, to extend the leg, and pain is complained of in walking.   Psoas
abscess, also, in many cases, occurs suddenly, the patient finding, on washing
himself in  the morning, that he has got a large soft tumor in  the upper part of
the groin, whereas iliac abscess comes on more gradually, and presents in a more
diffused and less circumscribed manner.
   The prognosis in caries  of the  spine  is  always bad; the deformity always
continuing more or less  marked;  and the  patient, though he may eventually
recover, by anchylosis taking  place, continues hump-backed in after-life.  Very
commonly the disease terminates in abscess and death.  It was long ago remarked
by Boyer, that the most fatal  cases  were generally those in which the spine  pre-
served its  straight position;  whereas, when it was much curved, death seldom
resulted.  The truth of this remark I have had frequent occasion to verify; and
the circumstance would appear to be owing to the fact, that when the spine con-
tinues straight at the same time that the bodies of the vertebrae are tuberculous
and  carious, anchylosis cannot occur, the spinal  canal is opened, and the cord
irritated; whereas, when they have fallen together, and very considerable  gib-
bosity has resulted, anchylosis more readily  takes  place, and thus an  imperfect
cure is effected.
   Treatment. — In infants, the utmost that can  be done is to direct that they
should be laid prone upon a pillow  or small couch constructed  for the purpose;
that the general health should be attended to by tonics suited to their age;  that
they should have the advantage of country or sea air; and that some counter-
irritant, as the tincture of iodine, should  be applied  by the side of the  spine.
In children that are  somewhat older, and  in  adults, great advantage may be
derived by strictly forbidding them to walk,  stand, or  sit erect; confining them
rigidly to the prone couch, and adopting a general plan of tonic treatment.   At 
644                 DISEASES OF  THE  SPINE.
the same time counter-irritation may be applied with great advantage  by means
of caustic issues or moxae to either side of the spine.  In fact, the principles of
treatment in these cases are extremely simple: the improvement of the general
health by good diet, tonics, and sea air, in order to remove the strumous condi-
tion with which this disease is always associated, and the employment of counter-
irritants suited to the age of the patient, to lessen the local  action in  the verte-
bra), is all that can be done. Rest in the horizontal position is the most  important
element in the treatment; if the patient be  allowed to stand upright or to sit,
the weight of the head and shoulders will tend to curve forward  the  weakened
spine, and by their pressure increase the already existing irritation in it.  The
horizontal position relieves the diseased  parts of this additional source of distress.
In these cases the prone position is preferable to the supine, and the patient, if
old enough, should always be laid upon  a properly constructed prone couch, such
as was introduced into practice by the late Mr.Verral.  This  position is certainly
the best, for not  only is the  projecting angle formed  by the excurvated spine
not injuriously compressed, as it would be in  the  supine or lateral position, but
the patient is  more comfortable; and it is far easier to make  the necessary appli-
cation in the way of issues and  moxse  than  could  otherwise be done.  At the
same time, the back not being the lowest part of the  body, there is a less ten-
dency to congestion of the spinal  veins,  and to consequent increase of the
inflammatory softening of the  bones.  When the disease has in  this way been
arrested, for which many months—at least twelve or eighteen—will be required,
the patient may be allowed to get up and  move  about, by wearing proper stays
so as to support the trunk.   It  is of considerable importance in the  treatment
of this disease, that the patient should not be allowed to get or sit up too soon,
before the  consolidation of the diseased vertebrae has taken  place,  otherwise
he will to a certainty  suffer a  speedy relapse, or the  excurvation will greatly
increase.
   If debility  of  the lower limbs or  paraplegia should come on, the administra-
tion of the bichloride  of  mercury in doses from  the twentieth to the sixteenth
of a grain has been strongly recommended by Latham and Stanley.  Issues will
also be of  use in relieving the  nervous symptoms, though they  may have had
little effect on the disease of the bones.
   When abscess has formed the surgeon should be in no hurry to open it; but
in accordance with the  principles laid down when treating of those affections, he
should delay  doing so, lest  injurious fatal constitutional irritation be  set up.
When it becomes necessary, from  the  approach of the matter to the  surface to
give exit to it, this should be  done by valvular incision, closed,  as soon as the
pus has been discharged, by means of hare-lip  pins, or  in the  way described
(page 347).   The hectic or constitutional irritation  that supervenes about  this
period, must of course be treated on general principles.
   Disease of the atlas and axis, and of the  atlas and occiput, constitutes one
of the  most serious forms of vertebral caries.   In these cases  there  is pain,
swelling, with great difficulty or absolute inability in moving the  head; after  a
time induration of the cellular tissue,  with swelling and fluctuation behind the
pharynx come on, pushing forwards its posterior wall against the nasal aper-
tures, causing the tongue  to be extruded, occasioning much difficulty  and dis-
tress in breathing, and giving rise  to  a peculiar nasal tone in the voice.  The
abscess may point here, or extend  outwardly under  the  muscles of  the neck.
Patients affected by this disease truly  present a  remarkable as well as  distress-
ing  appearance.   The  neck being perfectly rigid, they are  unable to turn the
head, but when they want to look round have to twist the  whole body; at the
same time, the weakness in the neck usually  compels them  to support the head
with both  hands, putting  one under the chin, the other under the occiput, and
so holding it.  The disease often terminates fatally by luxation of the vertebras
forwards, compression of the cord and sudden asphyxia, or more slowly by hectic 
LATERAL  CURVATURE  OF THE  SPINE.          645
and gradual interference with the  respiratory functions.   The treatment must
be conducted on precisely the same principles as that of angular curvature, by
absolute  rest, counter-irritation and tonics.  As  groat  and immediato danger
may result from the sudden displacement of the vertebrae,  and the consequent
compression of the cervical cord, the head usually requires to be steadied by
machines calculated to support it and limit its movements.
   Disease of the sacro-iliac articulation occasionally occurs.  I have had several
cases under my care at the University College Hospital, in which the symptoms
and post-mortem appearances of the disease were well marked.   It commences
with pain, tenderness  over the junction between the sacrum and the ilium; this
is followed by weakness, difficulty in progression, abduction of the limb on the
affected side, and some elongation of it from swelling of the affected articulation,
and thus a tendency to displacement forwards and downwards of the whole side
of the pelvis.  After a time abscess forms, which usually  acquires a very con-
siderable size, extending  under the  gluteal muscles, and  at last, after many
months,  or even a year or two have elapsed, pointing by the  side of the coccyx
or into the rectum.  Most frequently this disease terminates in death by hectic,
consequent  on opening the abscess.  Sometimes, but  very  rarely, anchylosis
may take place, and  then  the  limb on the  affected side may continue perma-
nently lengthened, for the reason already adverted  to.   In  the treatment the
same principles of rest and counter-irritation must be carried  out that constitute
the basis of the management of all similar affections.

              LATERAL  CURVATURE  OF  THE  SPINE.

   This affection, on account of the frequency of its occurrence, and the tedious-
 ness of its cure, has received a good deal of attention from various surgeons, and
 much has been written upon it by those who have
 specially devoted themselves to its treatment, but          Fig. 235.
 yet, the  whole of its pathology  and management
 lie in a very narrow compass.
    Lateral curvature  of the spine  most commonly
 commences at an early period of life, usually between
 the ages of twelve and eighteen;  seldom before the
 one, and not very commonly after the other; it rarely,
 if ever, occurs but to females, at least I have never
 heard of, or seen a marked case of the kind in lads.
 It appears to consist simply in a relaxation of the
 ligaments and muscles of the spine, in consequence
 of which the vertebral column,  being no  longer
 able to support the weight of the  head, neck, and
 shoulders, becomes curved to one side, a correspond-
 ing deviation taking  place in the opposite direction
 at a lower portion of the spine, in order to preserve
 the equilibrium between the two sides of the body
 (fig. 235).   The first curve usually takes place in
 the upper or. middle  dorsal region, the convexity
 tending towards  the right side; the second, or
 compensating curve,  occurs in the lumbar region,
 the convexity looking towards the left.   In some
 instances there is a quadruple curve.  At the same
 time that these lateral curves take  place, there is
 always a tendency to rotation of the bones  of the
 spine  upon  one another, in  such a way  that the
 bodies of the vertebrae that form the dorsal  curve,
 are twisted slightly to the left, whilst those that enter  into the formation of the
 
646
DISEASES  OF  THE SPINE.
lumbar curve  are  slightly turned to the right.  This twist is sometimes slight,
but in such instances it is very marked, so that there is a  double curvature, lateral
and rotatory.  On examining the bones and intervertebral fibro-cartilages after
death, even in cases of very considerable distortion, no disease will appear in
them,  except, perhaps, that the bodies  of some  may have  been  slightly com-
pressed where they form  the principal concavity  of the arch.  The ligaments
appear to be  stretched, relaxed, and somewhat weakened in these cases; and
the muscles are usually pale, flabby, and apparently wanting in power.
   From  a consideration of the pathology of this affection, and from the par-
ticular age at which it manifests itself, before the bones have become completely
ossified,  or the ligaments have acquired their due degree  of rigidity, its me-
chanism becomes sufficiently apparent.   The  spinal column being composed of
a number  of separate bones,  possesses no  firmness in itself, or power of self-
support, but is maintained in the erect position by the close manner in which
its separate elements are knit together by ligamentous  and muscular structures,
and by the way in which, when thus bound together as a whole, it is supported
on either side by the strong mass  of the  erector spinae muscles.   The proper
tension  of these   ligamentous supports,  and  muscular  masses, is especially
necessary for it to maintain  the weight of the  head  and shoulders, which is
thrown on the cervical and upper portion of the dorsal  spine.  If, from any
cause, the ligaments become relaxed, and  the  muscles  lose  their tension, or if
the weight of the  upper  part of  the  body increase disproportionately to  the
 augmentation in the strength  of the ligaments and muscles  that  support  the
 spine, the vertebral column  will  necessarily  give way under the  pressure to
 which it is subjected in a direct line  from above downwards, and will conse-
 quently become curved.  Most commonly, indeed almost  invariably, this takes
 place  in a lateral direction, the spine yielding more readily  in  this  than in  any
 other.   In some rare cases, however, the lower portion of the cervical, or upper
 dorsal region, will project backwards in an angular manner, and in  other cases,
 of still less frequent occurrence, there  may be incurvation  of  the  spine in the
 lumbar or dorso-lumbar region.
   These various kinds of deformity, as has already been stated, chiefly occur in
 girls about the age of puberty; at a time of life  when the tonicity of the mus-
 cular system not  unfrequently becomes  lessened by the  occurrence of anemia
 and those states of impaired health  that so frequently attend the establishment
 of the uterine function;  and before  the osseous and ligamentous structures of
 the body have fully developed.  At this period of life,  also, it frequently
 happens that the  spine  becomes rather suddenly elongated  by a rapid increase
 in growth taking place, or that it becomes overweighted by the system deve-
 loping itself, and  the shoulders and bust becoming stout and expanded.  Indeed,
 so frequent  is the occurrence of  a  certain degree of lateral curvature  of the
 spine from  these  various causes,  about  the  age of puberty in  girls, that few
 escape a tendency to deviation, of so slight a  kind, however, as not to admit of
 recognition as a disease.   But if this tendency be allowed  to go on unchecked,
 or if  it be increased by injurious habits, amongst which  all one-sided postures
 in which the body is twisted, as in playing some musical instruments, or in lean-
 ing over a table  in drawing  and  writing, the slight  deviation may rapidly in-
 crease until it assumes the true characters of  lateral curvature of the spine.  I
 do not think that there is any evidence to show  that  this is either a strumous
 or a ricketty affection; indeed, so far as my observation goes, I should certainly
 say that strumous girls are less liable to the disease than  those of  a nervous  or
 bilious temperament.  A ricketty tendency would, of course, increase the dis-
 position to  the affection,  but I  think  it is very rarely associated with  it.
 Amongst the more common predisposihg causes  must  undoubtedly be reckoned
 the indolent and sedentary  occupations,  and the luxurious enervating habits
 that are commonly encouraged in  girls in the higher  ranks of life, and which, 
LATERAL  CURVATURE  OF  THE  SPINE.         647
by preventing due muscular development, at the same time  that  they induce a
general loss of tone in the system, may directly occasion the disease.
  The signs  of this affection, when  it is well marked, are distinctly obvious.
The serpentine character of the curve,  its double nature, the convexity on
one side looking to the right shoulder, and  on the other, to the left loin, will
render its nature evident.  Most commonly it commences in a gradual manner,
the first condition that frequently attracts attention being  the prominence of
the right scapula, which is  supposed to be " growing out;" or the sterno-
clavicular articulation on  the  same side, or some  of the cartilages of the ribs
have been observed to project.   Whenever the surgeon is consulted for such
symptoms as these, he should at once examine the  spine, which he will  gene-
rally find to have an inclination  to the right  side.  In  the early stages of  the
disease, when the deviation  is not very distinctly marked, the readiest mode of
determining  it is to let the patient stand upright,  taking care  that the  feet are
well placed together, and that the attitude is  not  forced, but  natural;  the sur-
geon should  then run  his finger down the back  from  one spinous process to
another, touching each as he passes it with a pen  dipped in ink;  in this way,
when he  has reached the lower  part, he will have  mapped out the course of the
vertebral column, and  thus may see at  a
glance  the  nature  and  extent of  its dis-            Fig.236.
placement.   At  the same time he will pro-
bably  observe  that  the two hips  do  not
 exactly  correspond,  the left  being  some-
 what thrown  out.  Very commonly there is
 a good  deal  of neuralgic  tenderness  about
 the spine,  and at this early  stage  there
 may  be anemia and symptoms of impaired
 nutrition.   As  the  disease advances,  the
 curvature becomes  more  distinct,  and  at
 the same  time, owing to the torsion of the
 column,  assumes a  slightly angular  cha-
 racter where most convex.   The  ribs on
 the right side are thrown out  and bulging,
 and carry up the scapula with  them, whilst
 those  on  the left are  sunk and depressed
 (fig. 236).   In fact, the whole of the right
 side  of the  chest and body partakes in the
 projection of the spine  on  that side,  and
 thus adds much  to the  general  deformity;
 whilst the left side  of the chest is corres-
 pondingly hollowed  and sunk in.   When
 the disease   has  advanced  in   this way,  it
 always occasions great general  debility, ema-
 ciation, and  pallor, the nutrition of the body being impaired partly by the com-
 pression  to which the thoracic  and abdominal organs are subjected, and partly,
 doubtless, by irritation set up in the  spinal  cord, induced by the curvature.
   During the early part  of the disease  the spine preserves its  flexibility, and
 whilst the curve is still recent,  and the patient young, if the weight of the head
 and shoulders be taken off, it will at once resume its straight direction.   Thus,
 if  the patient be lifted off the ground by raising  her up with  the hands under
 the axillae, or if she be  laid down on her face on a flat couch, the  back will fall
 into a straight position, or  may readily  be made to  do so by slight  traction.
 After the disease, however, has existed for some years, or if the patient has
 passed that age at which consolidation of the bones and ligaments takes  place,
 the distortion will continue  permanently  in whatever  position she is placed.
 This is not only owing to the deformity of the  spine, but to  the ribs, and liga-
 
648
DISEASES OF  THE  SPINE.
mentous  and muscular  structures generally of the trunk, having become fixed
in their abnormal position.
  The treatment of lateral curvature of  the  spine should be conducted  on
rational principles, and  when  divested of  the  mystery with which  some inte-
rested specialists have  surrounded it, becomes as simple as that of any other
chronic surgical affection of  the  bones, joints, or  muscles.  There are three
principles of treatment  that require  to  be carried  out  in the management of
these cases.  The first is the improvement  of the general health; unless this is
effected,  nothing can be done; the second is  to strengthen the muscles of the
spine; and the third, to take away as much as  possible the weight of the head,
neck, and upper extremities.  The administration  of some of the milder prepa-
rations of iron, with a course of aloetics for the regulation  of the uterine func-
tion, is of  great moment; at the same time  a nourishing diet of  animal food
should be allowed, and  the  patient encouraged to  take exercise in the open air.
By these means the nutrition  of the system will  be improved, and the  tone of
the muscles greatly restored.   The muscular power may be more  directly
strengthened  by having the back well sponged with  cold  salt or  vinegar and
water every morning, and methodically rubbed from top to bottom.  The fric-
tion should be principally directed to the  erector spinae muscles on either side
of the vertebral column, and may be  done either  with the naked hand,  or with
some slightly stimulating embrocation.    At  the same time, if the patient's
strength will permit of  it, but not otherwise, the use of the hand-swing  may be
allowed, or calisthenic  exercises practised; these, however, should  not be con-
tinued if they induce a feeling  of fatigue or  exhaustion.   Whilst this plan is
being persevered in, the  patient  should  be  made to  lie recumbent for a few
hours daily, sitting or standing as little as possible.  By these means, assidu-
ously continued for some  length  of time, the  muscles of the back  may be
strengthened, and the increase of the deformity prevented;  and in this  way the
slighter  cases of lateral curvature, those  in which  there is rather a tendency to,
than  a full development of  the disease, may be cured.
   When the affection  is further  advanced, though  the spine still continues
flexible, there being decided projection of the ribs on one side, with prominence
of the  shoulder and  hip, with  apparent  difference  in the length of the limbs,
and much impairment  of the general health, more decided measures of treat-
ment must be had recourse  to.  In these cases, as in those just described, the
constitutional powers must be carefully attended  to on ordinary medical princi-
ples ; iron, and good living, with fresh air, being the basis of the treatment.  At
the same time that we endeavor to improve the strength of the system in this
way,  and that of the muscles of the back,  specially  by cold bathing and fric-
tions, it is essential that we adopt means to take off the weight of the head and
shoulders, and to prevent its continuing to keep  up, and to increase the deformity.
This  may be done in  two ways:  by keeping  the patient in  the recumbent posi-
tion,  or by allowing her to go about, wearing proper supports.
   The  recumbent  position in the treatment of lateral curvature  of the spine,
though  a valuable  means as  an  adjunct  to other  measures, has  been greatly
abused, by being employed  as an exclusive plan.   This,  I think, should not be,
except when the patient is unable to stand or walk with comfort, as happens in
some of  these cases, when it  may be necessary to confine her for a  time to this
position, until the  proper muscular power is restored by other means.  These
instances, however, are  very rare;  too much so  to constitute the  rule in the
treatment.   Whenever the recumbent position is employed, prone seems to me
to be far preferable to the supine, for reasons mentioned when speaking  of angu-
lar curvature of the spine;  and the best  couch for the purpose is certainly Ver-
ral's.  The patient should be kept on this during the  intervals  of  exercise, not
being allowed to sit or stand,  even at meals; she will very soon become accus- 
SPINA  BIFIDA.
649
Fig. 237.
tomed to a position that, at first appears constrained, and will, probably, speedily
be enabled to sleep on it.
  The best mechanical contrivance for supporting the weight of the  head and
shoulders, is Tavernier's belt, either  in  its original form,  or as modified  and
represented in the accompanying wood-cut (fig. 237).   By it, the projection of
the right shoulder may be gradually brought
down, the left one raised,  and the weight of
the whole of the upper part of the body sup-
ported.  By this contrivance alone, properly
and carefully adjusted  to the condition of
the deformity, many patients may be treated
 without the necessity  of any  confinement
 whatever; the spine  being gradually restored
 to its proper direction by very gradually in-
 creasing the  pressure  and  support  of the
 instrument, at the same time that the gene-
 ral health is  carefully attended to, and the
 patient has the  benefit of sea-air.   In the
 majority of cases, however, I think it is well
 to conjoin the use of this instrument with
 that of the prone couch; the patient sleeping
 on the couch, or reclining on  it at meals
 and when in the house, whilst she wears the
 belt  out  of  doors, and for  the  purpose of
 exercise; taking care to apply it and take it
 off in the recumbent position.   In this way
 many severe  cases of spinal curvature may
 be successfully treated without interfering
 with the patient's education, or her usual
 habits.  In long-standing cases of deformity
 of the spine,  when its flexibility is lost, and
 the projection of the ribs has become per-
 manent, the  patient will derive great com-
 fort and support from the use of this excellent instrument, and the increase of
 the disease may thus be  prevented, even if direct amelioration  be not effected.
                           SPINA  BIFIDA.

  It occasionally happens from congenital malformation that the spinous pro-
cesses of some of the vertebrae are deficient, and their laminae either absent or
separated; in consequence of this the meninges of the spinal cord in this situa-
tion are unprotected, and project through the aperture in the bones, giving rise
to a tumor at the part where the arrest of development in the osseous structures
occurs.  This tumor is usually of an  oval shape, its long axis corresponding to
that of the  spine.   It  is generally met with about the size of a walnut or an
orange, but occasionally attains an immense bulk, equal to that of a child's head.
In some cases this tumor  is lobulated, having  an imperfect septum stretching
across it • in other instances two or more of these tumors have been met with in
the spine.   The skin covering it is  usually of its normal color, but when the
tumor is of considerable size it may have a bluish or congested appearance,  and
admit of a certain degree of transparency.   On examining the tumor  which is
hard though elastic when the child is  held upright, it will be found  that it
becomes  soft when  the  child is laid horizontally.   It usually becomes tense
during expiration, and  softer during inspiration.   In some cases fluctuation is
perceptible  and by pressure the  bulk may be lessened.   Spina  bifida may be
met with in any part of  the vertebral column; it is, however, almost invariably 
650              DISEASES  OF THE  HIP-JOINT.
found in the  lumbar region, the cases in which it appears higher up being of
very rare occurrence, but instances of the kind are mentioned  by Cruveilhier.
When it occurs high up in the cervical or upper dorsal spine, it has been found
that the spinal cord  and nerves are usually adherent to the walls of the tumor •
when in the lumbar region this is not the case.
  The prognosis of this affection is  necessarily unfavorable, the  child usually
dying, at an early age,  of convulsions.   In other cases the tumor increases in
size, gives way, and  death results from spinal meningitis.
  In the treatment of spina bifida but little can be done in the way of operation
when the tumor is of very large size, and the skin covering it inflamed or ulce-
rated ;  or when a large  portion of the bones appears to be  deficient.   In those
cases, however, in which the child is otherwise healthy and strong, the tumor
being of small size at its base, or pediculated, and in which little pain or other
inconvenience arises from pressing upon  it, some means may be adopted  for
relieving or curing the  deformity.
  The simplest mode of relief is  to employ pressure on the tumor, by means of
a compress and bandage; or, what is better, an air-pad, similar to those used for
umbilical hernia,  and kept in place by an elastic india-rubber band.  In addition
to pressure exercised in this way, the recommendation of Sir A. Cooper may be
followed, and  the tumor punctured with  a grooved needle from  time to time,
care being  taken, however, to prevent the ulceration of the punctures by cover-
ing  them with collodion.  In this way,  by the  combination of puncture and
compression, cases have been cured.   All other plans of treatment, by which
the  tumor is  opened and air allowed  to enter it, are fraught with danger, and
will, I believe, be inevitably followed by the death of the child from inflamma-
tion of the meninges of the  cord  and convulsions.
                        CHAPTER  XLVI.

                    DISEASE  OF  THE HIP-JOINT.
                                                                    •
   Hip-disease presents so many points of peculiar and serious importance that
it is usually, and not improperly, considered  as a distinct affection, apart from
other joint-diseases.   Like all these it may be of an acute, subacute, or chronic
inflammatory character, most commonly occurring in strumous subjects; indeed
I think its connection with scrofula  is generally more distinctly marked than
that of most  other affections of the joints.  It almost invariably occurs before
the age of puberty.   Out of 48 cases of this disease, of which I have  taken
notes, I find  that in 16 only did it take place at or after fifteen years of age,
and of these,  in 6 cases only did it happen above the age of twenty; thus it may
be considered essentially a disease of childhood  or early  youth.   It commonly
comes  on from very slight causes; over-exertion  in a long walk, a sprain  in
jumping, a fall, or sitting in the wet, are usually the circumstances to which its
occurrence is attributed.
   All  the inflammatory affections attacking  the coxo-femoral articulation are
usually confounded under the term " Hip Disease " or " Coxalgia."  This is too
general an expression; and we shall find included under it several distinct forms
of disease that differ  from one  another in pathology,  symptoms,  result, and
treatment.  On looking at the hip-joint in a surgical point of view we find it to
be composed of three distinct parts;  viz., the soft structures, the acetabulum,
and the head of the femur.  Any one of these may be principally or primarily 
        SYMPTOMS AND  PATHOLOGY  OF HIP DISEASE.     651

affected, and we may accordingly divide hip-joint disease into the three distinct
forms of arthritic, acetabular, and femoral.
  This division is not a purely pathological one, but is of a practical character,
especially in its bearing on the question of excision.
  Before  proceeding to describe each separate form of coxalgia, we may consider
briefly the four pathological  conditions which are more or less common to each
variety of the  affection; viz.,pain, suppuration, dislocat'wn, and anchylosis.
  1st. Pain.—The pain in hip-joint disease varies greatly according to the form
the affection assumes.  In the more chronic forms of the disease  it is at first
slight, and, perhaps, rather referable to the knee than the hip; this is particu-
larly the case in the femoral variety.   In the arthritic  form it is always very
acute, seated in the joint itself and greatly increased by any movement, however
slight, of the  limb.  In the acetabular form of the disease  the pain is  not at
first referred to the joint but rather to the iliac fossa or side of the pelvis;  it
afterwards becomes severe,  gnawing, and deeply  seated in the articulation.
However slight  the pain  may be, it is always  greatly increased on moving the
limb, on  pressing  the  surfaces of the articulation  together, or by abduction.
Hence  the usual position  of the  patient with  the foot  raised and  merely sup-
ported on the  point of the toes, the knee and hip being flexed and adducted.
   2d. Suppuration is not a necessary consequence of inflammation of the hip-
 joint, though in  strumous subjects  it more commonly occurs than not.  We
often see the arthritic variety of the disease run its course without suppuration,
but in the acetabular and femoral, abscess always forms  sooner or later.   These
abscesses usually form behind the joint,  under the  gluteal muscles; they may
open in this situation or burrow under tbe fascia lata, and present on the outer
aspect of the thigh below the tensor vagina? femoris.  Sometimes they occur in
front of the joint under the pectineus, and in the acetabular form of the disease
they  are commonly infra-pelvic, forming in the iliac fossa, and presenting above
 or  under Poupart's ligament, or passing down  by the side of the rectum or
through the sciatic notch, and thus finding their way downwards upon the back
 of the thigh.
   3d. Dislocation.—In  the advanced  forms of hip-disease,  dislocation  of the
 head of the femur commonly occurs and may arise from three causes :—1st. The
 destruction of the joint, the capsular ligament  having given way in consequence
 of inflammatory softening and ulceration, and the head of the bone being thrown
 out of the cavity by  the  action of the surrounding muscles.  2d.  Caries and
 partial absorption of the head of the femur may have taken place, so that it no
 longer fills up the cotyloid  cavity, and the ligaments  being at the same time
 destroyed, it  slips out on  to the dorsum ilii.   3d. A fungous fibro-plastic mass
 may  sprout up from  the bottom of the cavity and thus tend to push the bone
 out of it, and after it has  been so extruded, this growth will completely fill the
 acetabulum.
   The occurrence of dislocation is, in the great majority^>f  cases, preceded by
 the formation of abscess in and around the joint; but in some instances it hap-
 pens in consequence apparently of the softening of the ligaments, the head of
 the bone beino- thrown  out of the acetabulum, without the  supervention of
 abscess or any sign of suppuration.  In these  cases a false joint may be  formed
 upon the dorsunfilii,  where the head of  the bone lodges.  When it is lying in
 a suppurating cavity it will  always be found to be  in a carious state, and then
 no attempt, or at least an imperfect one,  is made at the  construction of  an arti-
 culation  around it.
    Dislocation takes  place chiefly in the femoral variety  of the  disease,  in
 which the head  of the  femur  is more  or less  destroyed, and the  acetabulum
 filled with fibro-plastic deposit.   In the acetabular form, the head of the bone
 is  not thrown out of the cavity, which is carious, and which becoming  at last
 perforated, may allow the upper end of the femur to slip into the pelvic cavity. 
652
DISEASES  OF  THE HIP-JOINT.
  4th. Anchylosis may occur either with or without previous suppuration.   If
the joint has suppurated and the head of the bone is thrown on the dorsum ilii,
a false joint may eventually form, or osseous anchylosis in a more or less faulty
position take place.   If the head of the bone continue in the acetabulum with-
out suppuration, osseous anchylosis (fig. 221) may ensue with but little short-
ening of the limb.
   The Arthritic form  of hip-joint disease may commence in  any of the  soft
structures of the joint, in the capsule, the synovial  membrane, the  cartilages,
or the ligamentum teres.   Mr. Aston Key believed that  the ligamentum  teres
was very frequently the starting-point of inflammation  of the hip-joint,  and
other surgeons have referred  its origin  to  each of the other structures men-
tioned.   Without denying the  possibility of disease sometimes commencing in
the ligaments, illustrative of which we have a beautiful model  in  the Museum
of University College, I believe  that it more frequently  commences  in the car-
tilage  incrusting the head of  the femur, for though it is extremely  difficult to
prove  this,  opportunities of dissecting this form of  hip-disease  in its early
stages being very rare, yet the symptoms that attend it  so closely resemble those
accompanying  the diseases of  this  structure  in other  joints, that it is difficult
not to infer that this may be the case  in the hip.
   In this form of the disease  the patient is seized with  signs of acute inflam-
mation of the  joint, coming on  pretty rapidly, and with great constitutional
disturbance and pyrexia.  The pain in the joint in these cases is of the most
excruciating character, accompanied by spasms  and twitchings of the limb, and
marked  by nocturnal  exacerbations.   The suffering  is  so intense, that  the
patient cannot bear  the slightest movement of the limb; a fit of coughing, the
weight of the bed-clothes, or the shaking of the bed by a person leaning against
it, will give rise to the  most intense agony; and in the intervals of his suffering
the patient is in constant fear of a return of the  pain, to which he looks for-
ward with much anxiety.  In these  cases the limb is everted, abducted, per-
fectly helpless, and  motionless;  the nates will  be found flattened, and there is
usually some fulness about the anterior  part of the joint, under the pectineus
muscle, or to its outer side, above the trochanter.   There is also sometimes true
elongation of it  in consequence of  the capsule becoming distended with fluid,
and pushing  the head of the bone downwards.   On measuring the limb, in
order to ascertain its true length, it is necessary to examine the two together,
and to place the sound in exactly the  same position as  the diseased one; unless
this be  done,  error will very  probably creep  in,  for  on measuring the lower
extremity, from the anterior superior  spine to  the lower border of the patella
or  the inner malleolus, it will be found to be of greater length when adducted
or  extended than when abducted or bent.
   In some  cases the distension of the capsule with synovial fluid, as the result
of the inflammation in the joint, may be so great as to lead to its rupture, and
to the sudden dislocation of the  head of the bone on to the dorsum  ilii, with
great pain and much shortening; this, however, is of very rare occurrence, the
dislocation  seldom taking place until  after abscess has formed within the  joint,
and the articulation has been  thus destroyed.   In this, the acute form of hip-
disease, various terminations may take place; the result depending greatly upon
the constitution of the  patient, and  the manner in which  the affection is treated.
Under the  most favorable circumstances, as the inflammatory action  is subdued,
the disease falls into the subacute condition,  and recovery gradually but very
slowly  takes  place,  with  a  limb  that continues  somewhat stiff  and partially
anchylosed, as well as wasted and somewhat shortened  from disuse.  Sometimes,
 complete anchylosis occurs without  the previous formation  of abscess.  In
other, and  the majority of instances, abscess forms, and  then  the patient may
 either be worn out by  the continued  irritation  of diseased  bone, or  by the pro-
 fuseness  of the discharge; or  great shortening taking  place  either by the 
          SYMPTOMS  AND  PATHOLOGY OF HIP  DISEASE.     653

absorption of the head of the bone, or its dislocation out of the acetabulum, the
cavity of the abscess may ultimately contract,  the carious portions of bone exfo-
liate, and the sinuses close after years of  suffering.  Under the most  favorable
circumstances, when  once the joint has  been acutely inflamed, a year  or  two
will elapse  before the  patient can  use his limb with any degree of security.
The safety of  the patient depends in a great measure on preventing  the occur-
rence of suppuration.   If the constitution be of a very strumous character  this
can rarely be done,  but if tolerably healthy,  the  disease may be  prevented
passing on to this stage, and then the patient may recover with a useful,  though
somewhat stiff and crippled limb.  If suppuration occur, it is very seldom that
an adult patient recovers, hectic and exhaustion speedily carrying him off.  The
life of children  may, however, be saved even under these circumstances;  but
they will be left permanently lamed.
   In the acetabular form of the disease, the first serious symptom is often
abscess in the iliac fossa, with pain around  the hip  rather than  in  the joint
itself.  This however becomes tender on pressure, the patient cannot bear on
the limb, but no alteration in its  length takes place, although it becomes  greatly
wasted.   The abscess which was at first intra-pelvic  soon passes  down under
Poupart's ligament, or finds its way by the  side of the rectum, or through  the
sciatic notch into the gluteal region.  Hectic comes on, the sufferings become
greatly increased, and death from  exhaustion speedily ensues in this, which I
believe to be the most fatal form  of hip-disease.
   In the femoral form of coxalgia, the disease usually commences  in a very
insidious  manner.   It assumes a subacute character, and is chiefly met with in
young children.  The  first symptom that usually attracts attention is that the
child limps and walks  in  a peculiar  shuffling, hopping manner; he  does  not
stand firmly upon both feet, but rests on the toes of the affected one, the knee
of which is bent.  On examining the condition of the  limb it will be seen to be
everted, somewhat  abducted, slightly flexed upon  the thigh, with  the knee
partly bent, and apparently shorter than the other.  This  shortening, however,
is apparent and not real; for on  laying  the child on  its back, it will be found
that the pelvis is placed obliquely; the anterior  superior spine on the affected
side being raised to a higher level than that on the sound  one, and at the same
time turned somewhat forwards;  measurement of the  limb from this point to
the ankle, will show that  there  is  no alteration  in its length.   The  obliquity
of the pelvis, which is of very early occurrence in diseased hip, is owing to the
child lifting the foot off the ground in order to avoid  pressing on it in walking
or running,  and  in doing this he  is obliged to raise, not only the limb, but  the
corresponding side of the pelvis.  This apparent  shortening will commonly give
place, after  keeping the child in bed for a few days, to a simulated elongation
of  the limb; the pelvis on the affected side descending below its natural level.
At the same time that these symptoms are noticed, the child usually  complains
of  pain in the hip, especially on pressing over the pectineus muscle,  or  behind
the trochanter;  this  is increased by standing, walking, or any attempt to bear
upon the joint; abduction  also,  and rotation of the limb outwards, is particu-
larly painful, and  any concussion of it, as  by striking the heel or knee, will
greatly increase  the  suffering.   At this  stage of the disease, the patient will
often refer to the knee rather  than the hip as the seat of pain, and a careless
surgeon might be misled and treat the wrong joint;  the more so as there is  not
unfrequently a good deal of cutaneous sensibility about the inner side  of  the
knee-joint.  This pain appears to be seated in the obturator nerve, the articular
branch of which sent to the hip-joint becoming implicated in the disease, com-
municates a radiating pain that is felt at the extremity of  the  long descending
branch which is  distributed to the knee.   On turning  the child upon  its face it
will be observed that  the nates are somewhat flattened, the fold being  in a great 
654
DISEASES  OF  THE HIP-JOINT.
Fig. 238.
S>>
measure  obliterated, and, if it be a female, the vulva  on the affected side will
be seen to be placed at a lower level than on the sound one.
   As the disease advances, abscesses may form at any part in the vicinity of
the joint.  They most commonly occur under the glutei muscles, but sometimes
at the anterior part, under the pectineus muscle.   When in this situation, they
occasionally give rise to very severe suffering down the inner side of the thigh
by exercising pressure upon the obturator nerve, which  may sometimes become
tio-htly stretched over the subjacent cyst of the abscess. It is about this period
that true shortening of the limb takes place, which at the same time becomes
adducted and inverted, thus assuming  a very different position to what it pre-
sented in the early stage of the disease.  The different positions into which the
limb falls in the two  stages of the complaint  are evidently due to alterations in
the muscular action brought to bear upon it.   In  the early stage, these strong
external rotators, which are in close relation with the joint, become irritated by
the extension of inflammatory action to them,  or by the pressure to which they
are exposed by the distended capsule; and hence, being  called into increased
action, the limb is  everted, at the same time that it is slightly flexed and adducted
by the irritation to which the psoas and iliacus are subjected.   As the disease
advances, these muscles become wasted, undergo fatty degeneration, absorption,
or disintegration, by  the formation of abscesses underneath and around them;
hence, the action of the adductor muscles being no longer counterbalanced, the
limb  is drawn upwards and forwards, and turned inwards (fig. 238).
   The  shortening of the limb  may arise, in very chronic cases, from general
atrophy  of the member, consequent upon disuse; and this, no doubt,  in  all
                                                   instances, after a time, in-
                                                   fluences its condition. Most
                                                   commonly, however, it  oc-
                                                   curs from absorption of the
                                                   head of the bone, and in
                                                   other cases from its dislo-
                                                   cation upon the dorsum of
                                                   the ilium.  In these cases,
                                                   the remains of  the  dislo-
                                                   cated head  can be felt
                                                   through the thin and weak-
                                                   ened muscles  in its  new
                                                   situation, and  in other in-
                                                   stances  may be felt lying
                                                   at the bottom of a cavity in
                                                   a carious state (fig. 239).
                                                     After the formation of
                                                   abscesses, the health, which
                                                   may  up to this  time have
                                                   kept pretty good, speedily
                                                   gives way, exhaustion and
                                                   hectic  coming on, and the
                                                   patient,  perhaps,  at  last
                                                   sinking from  the  wasting
                                                   influence of the diseased
                                                   bone, and the discharges it
                                                   occasions.
   In making the diagnosis of coxalgia, care must be taken not to confound it
 in its early stages with an ordinary attack of rheumatism; a mistake that  not
 unfrequently happens;  the alteration in the shape and position of the limb, the
 obliteration of the fold of the nates, and  the  limitation of the pain to the one
 joint, will usually prevent the surgeon falling into this error.  With disease of
 
TREATMENT  OF  HIP-DISEASE.
655
the knee care must be taken not to confound hip disease, in consequence of the
pain in the early stages being commonly referred to that joint; here the absence
of any positive sign of disease about the knee, and the existence of all the signs
of disease in the hip that have already been noticed, will enable the  surgeon to
diagnose the true seat of the affection.   Lateral curvature of the spine, accom-
panied by neuralgic tenderness in  the hip, occasionally  gives rise to apparent
shortening of the limb with pain and rigidity; but in these cases the existence
of the spinal affection, the superficial  nature of the pain, and  the  absence of
increase of suffering when the joint is firmly compressed, or of painful startings
at night, will indicate the true nature of the affection.  Abscess  may occasion-
ally, though rarely, form in the vicinity of the hip without that joint being
diseased.   Should this take place  towards the anterior aspect of the articulation
under the pectineus muscle, it may, by its pressure upon the  obturator nerve,
occasion pain in the thigh and knee, as in  those cases in which  the  articulation
is affected; here, however, the sound state of the joint at its posterior and  outer
part,  the absence of all obliquity of the pelvis, and of the other signs  of the true
hip-disease, will enable the diagnosis to be effected.
   The  treatment of disease of the hip must be conducted with reference to the
 form of the disease, the acuteness of the  attack, and the severity of the local
 and constitutional symptoms.   In  all cases  this affection must be managed in
 accordance with those general  principles that guide us in the treatment of in-
 flamed joints.
   When the disease is of the acute arthritic kind, the patient must of course be
 kept in bed, and be treated with calomel and opium, pretty freely administered,
 having a full  dose of opiate  at  night, in order to prevent the  painful startings
 of the  limb.  The inflamed joint should be leeched, or, if the  patient can bear
 it, cupping-glasses may be applied behind the trochanter; it must also be com-
 fortably arranged upon pillows, so  as to be kept in as easy a position  as possible,
 and great relief will be afforded to the patient by the application of hot poppy
 fomentations.   When the inflammatory action has been somewhat subdued, the
 joint may be conveniently fixed  by means of a leather splint or  the starch
 bandage.  Of the two, I prefer the starch bandage, as being  more easily applied,
 and forming a better fitting and more secure casing to  the limb.  In applying
 it, the  limb should be bandaged from the  toes upwards, well padded about the
 knee with cotton wadding, and  the bandage carried in  repeated turns  round
 the hip and body in the form of  a spica;  at the posterior part of the hip  it
 should be strengthened  with a piece of pasteboard lined with calico, sufficiently
 long to extend down the whole of the back of the thigh to  below the knee, so
 as to support that joint  also.   It  is of much importance to do this, as otherwise
 the hip cannot be kept  immovable.   In applying this, or any other apparatus,
 in the more' acute form of the  disease, the patient will commonly require to
 have chloroform administered, as  the pain  occasioned  by the  necessary  move-
 ments  would  otherwise be too severe to be borne.  After the starch bandage has
 well set, a trap  may be cut in it opposite any part of the joint to which it may
 be thought necessary to make applications, and the perineal aspect of the appa-
 ratus must be well lined and covered with oiled-silk, so as to  prevent its being
 injuriously soiled.  In  this way  the  limb may be immovably  fixed in a proper
 position by a light and  firm apparatus that  will seldom require  to be changed
 during the treatment of the case.
    When the disease has fallen into a somewhat chronic condition, or from the
 very first of the subacute or femoral variety, a different and less active line of
 treatment requires to be pursued.  In these cases, rest and perfect immobility
 by means  of the starch bandage are indispensable; in  conjunction with this,
 the  employment of counter-irritants, more particularly  the caustic issue, will
 be attended with great advantage; the issues may readily be applied through
 traps,  cut in  the apparatus behind the trochanter, and at  the forepart  of the 
656
DISEASES  OF  THE HIP-JOINT.
joint opposite the pectineus muscle.   At the same time a course  of moderate
alteratives and tonics conjoined, will be found most advantageous.   To children
a powder composed of a grain of mercury and  chalk, two  grains  of carbonate
of soda,  and three of rhubarb, with or without  half a grain of quinine, may
be administered  twice a day.   To adults, the  bichloride of mercury in small
doses with sarsaparilla or bark will be found most useful.  This alterative plan
must be  persevered in for a sufficient length of  time, and as  the symptoms of
inflammatory action subside, and those of strumous disease  manifest themselves
more unequivocally, cod-liver oil, with the iodides pf potass or of  iron, may be
advantageously substituted.
   During the whole of the treatment, the general health requires careful super-
vision, the diet must be attended to, and should be as nutritious as possible,
the state of the  bowels regulated, the skin kept in good action  with a flesh-
brush, and  the  patient  reside  in well-ventilated apartments.   It will  very
generally be found that the liver is peculiarly apt to get out of order in this
disease,  the patient  becoming jaundiced  and feverish; these complications
must be  treated on general principles.  As the  health improves, a change to
the  sea-side will  be  attended with great advantage, and the patient  may be
allowed to move about on crutches, having the foot suspended in a sling, as in
the case of  a fractured thigh.   Under such  circumstances  the best result that
                          can usually be looked for is  a stiff joint (fig. 240);
         Fig. 240.          but  even if this forms, the patient's condition will
                          be far from unfavorable,  for the want of movement
                          in the hip becomes  counter-balanced by the greatly
                          increased mobility of the lumbar vertebrae, enabling
                           the  patient freely to rotate the pelvis.
                             As  abscesses form  they should be opened early;
                           no good resulting by  delaying to  give exit to the
                           pus, which only spreads more widely, disorganizing
                           the soft structures,  and means  should  be taken, by
                          tonic  remedies  and nourishing food,  to keep  off
                          hectic.  If dislocation  has  taken place, and the
                           limb consequently becomes  a good deal shortened
                          or deformed, being  perhaps  adducted  and inverted
                          so far as to be twisted  over  the other,  or drawn up
                           upon the abdomen,  much may be  done  to lessen the
                          deformity  by putting  the patient  under chloroform,
                           bringing down  the  limb, and fixing it in a starch
                           bandage.  Anchylosis may thus  be sometimes got
                           in a good position, and  the patient's  condition be
                           greatly improved.   It is a question whether an at-
                           tempt at reduction should be made in these cases of
                           consecutive dislocation, as it is very rarely that it
                           would prove permanently successful, the acetabulum
                           being  either filled   up  with  fibrous  matter,  or
                           the  head  of the  bone  so  diseased  and lessened
                          in size, that it would  not  remain in  its cavity
                          when  put back.  Occasionally,  however,  the re-
                           duction may be successfully effected.   In a woman,
under my care, at the hospital, with spontaneous dislocation of the  hip of about
a  month's  duration, reduction was effected by  means of the pulleys, and the
head of  the bone replaced in  the  cotyloid cavity, where it remained for some
weeks; becoming, however, displaced again in  consequence of its being neces-
sary to remove a  bandage that was applied,  as she became affected with inflam-
mation of the chest, and could not bear its  pressure.  If anchylosis is likely to
occur,  the surgeon must endeavor to secure it with the  limb in a straight posi-
 
           EXCISION  OF THE  HEAD  OF  THE FEMUR.        657

tion.  After a stiff joint has formed,  the  mobility of the lumbar vertebrae will
be found to be greatly increased, so that at last the patient will walk with little
inconvenience, rotating the pelvis on  them.   If the anchylosis be  not osseous,
and especially if the head of the bone be still in the acetabulum, the limb may
be  straightened by  forcible extension under chloroform, and the  heel  thus
brought to the ground.
   The excision of the head of the femur, in  some forms of hip-disease, has of
late years been much discussed.   This subject has more especially had attention
directed to it  by the  writings of Fergusson, H. Walton, and H. Smith.   " But
even yet," says Mr. Fergusson, who is one of its greatest advocates, " experience
as to the results of this operation is so limited, that I can scarcely say more on
the subject than express a belief, that in some instances of disease, and of gun-
shot injury of the neck or head of  the  bone, such a proceeding might  be  of
service."   The cases  requiring it are necessarily not very numerous.  It may,
however, be stated, that when the disease is of the femoral kind, being limited
to the head and upper end of the femur, the acetabulum and  pelvic bones not
being involved, but the head of the bone displaced from its  cavity, and lying
in  a carious or necrosed  condition  on the dorsum of the ilium, with sinuses
leading down  to it, the patient's general  health reduced  by hectic, consequent
upon the  profuseness of  the discharge and  the irritation of the disease, the
surgeon would certainly be justified  in cutting down upon, and removing the
source of  all  this mischief, with  a  view of preserving the  patient's life, in
accordance with those general principles that guide  us in the management  of
diseased bone in other  situations.  The cases, however, in which this peculiar
combination  of circumstances occurs, and in which such  an operation  would
consequently be required, are rarely met with.  The great objection to the ope-
ration, in the  majority of instances, being the extension of disease to the coty-
loid cavity and the bones of the pelvis, involving them  to a considerable extent,
and in such a way as to prevent the complete removal of the diseased osseous
structures.  Even if  the  patient's life  be not endangered,, the removal of the
carious bone may be rendered  necessary in  order to obtain sound  anchylosis
between the upper part of the femur and the pelvis, and thus to secure a  useful
 limb to the patient.
   In hip-disease the acetabulum will be found to possess far greater reparative
 powers than the head of  the femur,  so that  even when diseased  it may recover
itself; its  disease, when moderate, is therefore no absolute bar to the perform-
 ance of excision of the head of the femur.
   In many cases examination with a  probe will enable the surgeon to detect the
 existence of disease in the bones of  the  pelvis, as well as  in  the  head of the
 femur; but in other  instances it may not be  possible for him to do so, the probe
 not being  able to reach the carious bone, owing to  the quantity of dense plastic
 matter that is thrown out around it.   Under these circumstances, the question
 as to  the propriety  of performing the operation may, to a certain extent, be
 determined by the position of the head of the femur.  If this has been dislo-
 cated early in the disease, and be lying in a  carious  condition  upon the dorsum
 ilii, the probability is that the  morbid  action is confined to it, the  acetabulum
 being filled up with  fungoid plastic matter.   If, however, the  displacement has
 been of recent occurrence, it is not unlikely that the osseous  surface  of the
 cotyloid cavity is involved.  If the head of the bone still continue in its socket,
 the operation should not, generally, be undertaken;  for in these cases, if the dis-
 ease is far advanced, the  morbid action will  almost invariably  have  extended to
 the bottom or sides of the acetabulum.   But even in such a case as this, those
 excellent  surgeons,  Mr. Jones  of Jersey, to whom modern  conservative sur-
 gery is so deeply indebted, and Mr. Hancock, have successfully removed  not
 only the head of the femur but a large portion of the diseased acetabulum.
   The operation itself is not difficult of performance, the carious head of the
        42 
658
DISEASES  OF  THE HIP-JOINT.
femur, lying at the bottom  of an  abscess or of sinuses, may readily be exposed
                                    by a X shaped incision over it (fig. 241).
              Fig. 241.              When it is exposed it may be turned out
                                    by drawing the  limb  over the opposite
                                    thigh, rotating it inwards and pushing it
                                    upwards, when  it may  be cut off through
                                    the  neck  or trochanter by means of an
                                    ordinary saw, or what  is  better, by pass-
                                    ing  the  blade of Butcher's  saw behind
                                    and cutting forwards.   In planning the
                                    incisions, care  must of  course be taken
                                    not  to cut too far forwards, lest  the an-
                                    terior crural nerve be wounded;  or too
                                    freely backwards, lest a gluteal artery be
                                    injured.  After the operation the wound
                                    must  be  dressed  in a simple manner, and
                                    a long  splint  applied.   Mr. Fergusson
                                    recommends that the extension  should
                                    be made from the opposite thigh, round
                                    the upper part of which a laced socket
                                    is fixed,  to which the band is attached
 (fig. 242).   In  such cases  as these, much advantage will be  derived by the use
 of the bracket thigh-splint.  Shortening of the  limb will necessarily result, but

                                  Fig. 242.
as this has already occurred, being the inevitable consequence of all disease of
the hip that gives rise to the dislocation of the bone, it need scarcely be taken
into account; the operation being rather  done with the view  of saving the
patient's life in  the only way that is practicable, than to improve the  length of
the limb.
   The result of excision of the hip-joint depends on the extent of osseous dis-
ease.  When the head of the bone is solely the seat  of caries, lying  dislocated
on the dorsum ilii, the operation may be done with  a fair prospect of success.
When the acetabulum is but slightly implicated, a portion of its lip being pos-
sibly diseased, the gouge may be successfully applied to this, and the result of
the operation will not be materially changed.  But if the pelvic bones be pri-
marily or chiefly affected, and more particularly if the head of the femur be still
lying on the cotyloid cavity, with perhaps perforation of the  bottom of this and
intra-pelvic abscess, little good can be expected  or result from an operation for
the  proper performance of which  it would be necessary to remove the greater
part if not the whole  of the acetabulum, and  thus open up the cavity of the
pelvis.   But that such a desperate  operation as this even may be performed with
a successful result, is proved by the interesting cases to which reference has just
been made; and as the "acetabular" form of hip-disease is  necessarily fatal if
left to itself, these cases may encourage surgeons  in attempting  to save the
 
CHRONIC RHEUMATIC  ARTHRITIS OF THE HIP.    659
patient by the only alternative  open to them.   The statistics of the operation
are not very perfect, but as far as  I can ascertain it has  been performed 38
times, with 14 deaths as its direct result.

                CHRONIC RHEUMATIC  ARTHRITIS.

   A peculiar disease has  of late years  been described by Mr. Adams and Mr.
R. W. Smith, to which  the name  of " chronic rheumatic arthritis" has been
given.  It commonly affects the hip, but has been met with in the temporo-
niaxillary articulation, and also occurs in the shoulder; at least I have met with
cases of disease of this joint presenting all the characters of this affection during
life, though as there has been
no opportunity of examining                   Fig. 243.
the  state of the  parts  after
death, it  is  impossible  to
speak positively as to the true
nature of the disease. Chronic
rheumatic arthritis  is an  ac-
tive disease of the bones and
fibrous expansions about the
 joint, being especially charac-
 terized  by considerable  in-
 crease in the size and by al-
 teration  in the shape  of  the
 osseous  structures, which be-
 come  porous  in some  parts,
 porcellanous  in  others, with
 thickening of the fibrous cap-
 sule of  the joint, deposit of
 masses or plates of bone  in it, and  ultimate destruction of the cartilages  and
 synovial  membranes.   The suffering attending the  disease is  considerable, it
 greatly cripples the utility of  the joint, at last produces incomplete anchylosis
 of it, and is incurable.

         CHRONIC  RHEUMATIC ARTHRITIS  OF THE  HIP.

   This form of the disease commences with a degree of pain and stiffness about
 the joint, increased at night, and especially in damp or cold weather, presenting
 in this respect the ordinary characters of a rheumatic affection; as the  disease
 advances, the pain  is much  increased  by standing or walking, and the  move-
 ments of the joint become gradually more and  more  impaired.   The  patient
 experiences the greatest difficulty in bending the body forwards from the hips;
 he  consequently is unable to  stoop, or to sit in  the ordinary position, being
 obliged  to keep  the limb straightened in  nearly a direct  line with the  trunk.
 The difficulty in walking, in standing erect, in stooping, and in  sitting increase.
 The limb becomes shortened to the extent of about an inch or more, owing to
 changes that take place in the head of  the bone.    The pelvis also assumes an
 oblique   direction, and hence  the  apparent  shortening becomes  considerably
 greater.  The knee and foot are everted, and the  heel raised.  The shape of the
 hip also alters considerably;  it becomes  flattened posteriorly, the folds  of the
 nates disappear, but the trochanter seems to project, and on examination seems
 larger and thicker  than natural.  On  rotating the limb it will be felt that the
 movements of the bone are extremely  limited, and crackling or osseous crepi-
 tation will often be felt around the joint.   As Mr. Smith remarks, the  lumbar
 vertebrae acquire  great mobility,  the thigh  on the affected side  is wasted, but
 the calf  retains its  natural size and firmness.
 
660
DISEASES  OF  THE  HIP-JOINT.
  On examination after death, it will be found that the joint, the bones, and the
surrounding parts have undergone remarkable changes.   The capsular ligament
is thickened, and the synovial membrane is of a bright red color, vascular, and
fringed in  some parts, whilst it has disappeared in  others.   The ligamentum
teres is destroyed, and the head of the bone denuded of membrane, the vascular
fringes being attached  around the  neck.  The  head of  the  bone becomes
remarkably altered  in  shape, being  flattened,  greatly increased  in  size,  or
placed more or less at a right angle with the  shaft, sometimes  elongated, and
always very irregular and tuberous.   The neck is more or less absorbed, and in
some cases appears as if it had undergone fracture.   The  acetabulum generally
becomes enlarged, sometimes of a more or less circular and flattened shape; at
others, projecting at its rim, narrowed, and embracing tightly the head of the
femur (fig. 236).  Both  it and the upper part of the  thigh-bone become porous,
and perforated with numerous small foramina.   Stalactitical  masses of bone and
porcellanous deposits are commonly thrown out about the base of the trochanter,
but more particularly along the  intertrochanteric line within the capsule of the
 joint, and  not unfrequently in the soft tissues around it.   In many cases the
apparent increase in the size of the  head of the bone is dependent on the depo-
sitions of these masses of osseous tissue  upon  it, rather than on any expansion
or osteoporosis of  the upper articular end of the femur.  These masses of bone
constitute  one of the most important  characters of  the  disease, and it is their
presence that communicates the peculiar  crackling that is felt in the hip during
life.  The  muscles and soft structures in  the vicinity of the joint are necessarily
wasted, partly from disuse and partly from  the  pressure of the morbid masses
of  bone.
   This disease most frequently occurs amongst the poorer classes, and is almost
invariably met with in  males.   It usually occurs about the age of fifty, though
 sometimes earlier.  I have seen two instances of it in individuals little  more
 than thirty years of age, one of  whom was  a female.  It is an incurable  affec-
 tion, and, as it is commonly attended by much suffering, constitutes a source of
 great discomfort to the patient.
   It occasionally happens that individuals laboring under this affection, meeting
 with a fall or contusion on the hip, present many of the signs of fracture of the
 neck of the  thigh-bone,  such  as shortening, eversion,  with some  crepitation
 perhaps, and inability to move the limb.   The diagnosis  may in general readily
 be  effected by attention  to the history of the case, and  by eliciting the fact that
 the symptoms have  existed to some  degree before  the  accident, although the
 pain and immobility may have been increased  by it.
   In the treatment of this affection little can be done.  Rest and  the habitual
 application of warm or stimulating plasters  will afford relief,  and,  in  many
 instances,  the administration of the iodide of potass with sarsaparilla will lessen
 the nocturnal pain.  Mr. Smith recommends an electuary composed of guaiacum,
 sulphur, tbe bitartrate and carbonate of potass, and ginger, with a small quantity
 of  rhubarb, and I have certainly  seen benefit result from the  administration of
 this  remedy in  some cases.   When the  disease  is once fairly established, and
 has assumed a very chronic character, nothing can be done except to mitigate
 the pain by some  such  means  as those  recommended, conjoined with rest and
 careful attention to the general health.
   Chronic rheumatic arthritis has also been  described by Mr. Smith as occasion-
 ally  affecting the temporo-maxillary articulation in individuals of rather ad-
 vanced life.   This disease is mostly symmetrical, and  gives rise to an enlarge-
 ment of the condyle of the jaw,  which can be felt under the zygoma, attended
 with much pain in opening the mouth, a sensation of cracking or grating  in the
 joint, and some enlargement of the lymphatic glands by the side of the neck.
 The pain  is  generally increased  at night, and  influenced by the  state  of the
 weather.  The face becomes distorted,  the affected side of the jaw projecting 
DISEASES  OF  THE  BURSJE.
661
and being pushed towards the opposite  side, but when both joints are affected
the chin  projects, the  entire jaw  being drawn  forwards.   This  distortion  is
chiefly owing to the destruction of the articular eminence; for when this takes
place, the external pterygoid muscle draws the jaw forwards and to the opposite
side; but when both  articulations are equally  affected, these muscles displace
it directly forwards;  the glenoid cavity  becomes enlarged,  the fibro-cartilage
disappears, and the condyle is sometimes greatly thickened  and flattened, and
always rough, being devoid of cartilage.  In such cases as these there is little
to  be  done by medicine, but  the treatment must be conducted on  the same
principles as in the same affection when attacking the hip.
   When affecting the shoulder, chronic rheumatic arthritis  gives rise to  con-
siderable enlargement of the head of the humerus, wasting and rigidity of the
deltoid, and inability to move the elbows upwards, except by the rotation of the
scapula on the  trunk.   In fact, the scapulo-humeral articulation being fixed, all
movements of  the shoulder are  effected through the medium  of the scapula,
which becomes  more  mobile than natural.  The articulation is the seat of much
pain, lancinating at times, but generally gnawing and intermittent, being de-
pendent on  the state of the weather,  and  greatly increased in cold and wet
seasons.  The  whole of the arm  becomes wasted and weakened in power.  In
 two instances 1 have  seen this disease in young and otherwise robust and healthy
men, between twenty and thirty years of age, coming on without any apparent
 cause.   In both cases the joint  continued  permanently rigid, though the pain
 was relieved by the use of  the iodides and local counter-irritation.
                       CHAPTER  XLVII.

       DISEASES  OF THE APPENDAGES OF  THE  JOINTS.

                    DISEASES  OF THE BURSAE.

  The bursae which naturally exist, either under the skin, beneath the muscles
and ligaments, or around tendons, are subject to various diseases.   Not only do
the normal bursae become affected, but these sacs are sometimes developed from
continued friction in  situations where they are not naturally met with, and here
also they may undergo disease;  thus, for instance, bursae  have been  found to
be formed at the projecting point of a hump-back, on  the prominent parts  of
club-feet, or at the extremity of  stumps.
  In the following situations bursae  naturally occur, and may consequently be
expected to be met with in a diseased state.  Behind the angle of the lower jaw,
on the symphysis of the chin,  on  the angle of the thyroid cartilage, on the
acromion, external and internal condyles of the humerus, olecranon, styloid pro-
cesses of the ulna and radius; on the dorsal surface of the metacarpophalangeal
articulations, as well  as on their  palmar surfaces, and on the dorsal aspect of the
phalangeal articulations; on the anterior superior spine  of the  ilium, the great
trochanter, the tuberosity of the ischium, the lower superior and outer parts of
the patella, on each condyle of the  femur, the tuberosity of the tibia, the  two
malleoli,  the calcaneum, the dorsal aspect of the toes, and on the plantar aspect
of the  heads of the first and  fifth metatarsal bones.  Besides these situations
they occur under the deltoid, the gluteus maximus, between the lower end  of
the scapula and the latissimus dorsi, and in the ham. 
662
DISEASES  OF  THE BURSiE.
  The continued  irritation of bursae  by the pressure that is  exercised upon
them, may cause them to inflame, to enlarge, to become thickened, or to undergo
various changes in  structure.   This enlargement of the bursae in  particular
situations is  often connected with special employments, by which  continuous
and severe pressure is exercised upon certain parts of the  body; thus frequent
kneeling will occasion enlargement of  the bursa patellae, hence  called " house-
maid's knee."  Miners are occasionally subject to an enlargement of the bursa
lying over the olecranon, hence called " miner's elbow," and in  any situation a
new bursa may be formed by continuous pressure and friction conjoined.
   The contents of enlarged bursae vary greatly; they may be composed simply
of a serous fluid of a clear straw color; at  other times this becomes dark and
brownish, with much cholesterine intermixed, and  may contain a  number of
whitish bodies, of a fibrinous or cartilaginous appearance, about the size of grains
of rice and not unlike them.   On examination under the microscope, I have
found these  granular bodies composed of a fibro-plastic material, in some cases
resembling imperfectly-developed granulation cells ; they would  therefore appear
to consist, as Sir  B.  Brodie long ago pointed out, of masses of lymph that have
either been deposited in the shape in which they are found, or that have been
divided and  broken  down, after being originally formed in larger masses.  The
wall of the enlarged bursa is sometimes thin, at others greatly thickened by the
deposit of concentric layers of plastic material within it.   In  some cases  the
deposit of plastic matter may go on into the interior of the bursae, until their walls
assume a very great thickness, and almost a cartilaginous  hardness, and indeed
may continue to increase until the cavity is completely obliterated, and a dense
fibrous tumor formed in its place.
   Enlarged burse  are readily recognized; forming, whilst their contents are
thin and serous, indolent  oval  tumors  with  distinct  fluctuation;  commonly
 occurring in the situation of some  of the normal bursae.   As they  become
 more solid they become elastic and hard, and often crackle on being pressed
 when they contain the rice-shaped bodies;  but at  last acquire all the characters
 of an ordinary solid growth, as the deposition  within them increases.  Not un-
 frequently these enlarged  bursae inflame; or, indeed, an attack of inflammation
 in them may be the  first cause of their enlargement.  In either case they become
 hot and tense, the skin covering them  is  red, often doughy, and cedematous;
 and  although there is no connection  between the bursa and  the  neighboring
 joint, yet it may happen that the inflammatory action spreads to the latter, from
 simple continuity of tissue.  Suppuration very frequently occurs in an inflamed
 bursa; the tension increases, the oedema  and redness become more considerable,
 and tbe pain assumes a throbbing character.  When the  bursa is opened, thick
 pus often mixed with shreds of sloughy  tissue is  evacuated.
    The treatment of these  bursal tumors must  depend entirely upon their nature
 and actual condition.  When inflamed,—rest, the application of leeches, followed
 by tepid lead-lotions or poultices, and general antiphlogistic treatment will com-
 monly subdue the increased action in them.   If suppuration  take place,  they
 must be  freely opened and the pus evacuated.  When in  an indolent condition,
 the surgeon has  the choice of various plans of treatment,  conducted on different
 principles.   If the sac be thin, the fluid of a serous character, and the disease
 recent, it may often be removed by blistering, more particularly when it occurs
 in the ham  or under the deltoid muscle.   In  some cases it may conveniently be
 obliterated by puncturing the cyst and  then  employing pressure upon it.  The
 surest mode, however, of  closing the  sac consists in exciting inflammation in it,
 either by the injection of the tincture of iodine  as recommended by Velpeau,
 or by passing a small seton through it.  The injection is readily effected by tapping
 the  cyst with a moderate-sized trochar and  then throwing in  about 3J of the
 compound tincture.   Inflammation will  be excited, some discharge will usually
 take place,  and on its cessation the walls of the cyst will have become aggluti- 
TREATMENT OF  ENLARGED BURSuE.
663
Fig. 244.
nated together.  In these cases I generally prefer, however, as the most certain
method, the introduction of a seton composed of a double silk  thread.  This
may conveniently be passed through the canula after tapping the sac, in the way
figured in page 348; a poultice  should afterwards  be applied, and the threads
left in for about six days.  Discharge will take place through  the aperture by
which they have been introduced, and which may, if necessary, be  enlarged;
the cyst  gradually contracts  around them, and after their removal  it will be
found to be closed.   When the cyst contains a number of the rice-like bodies,
the seton may still be used, but it should be thicker than that just recommended,
and the aperture by which it is introduced should be very free in order to admit
of the escape of the pus and granules.
   If the walls of the  cyst  are very thick, or its contents  semi-solid, or if the
tumor have become solid, it must be dissected out.  This operation is most
commonly required  for  solid bursal  tumors, situated over the  patella or the
tuberosities of the ischium; from both of these situations they may be removed
with facility.  In dissecting out these  solid bursae, an operation by the  way
 which is occasionally required on both knees, care should be taken not to make
 the incisions too wide of the disease; and more especially, to avoid separating
 the attachments of the fascia of the limb from the edge of the patella, otherwise
 the layer of cellular tissue leading into the  popliteal space will be opened up,
 and deep infiltration  and abscess of the limb, sometimes even of a dangerous
 character, may result.   Enlarged bursae, especially those situated  over the
 patella,  not unfrequently inflame and suppurate;  under such circumstances a
 free incision  should be made through their wall and the contents  mixed with
 pus let out.
   When the bursa that lies towards the plantar surface  of  the head  of the
 metatarsal  bone of  the great toe becomes  enlarged, or
 when a new serous sac is  formed upon the inner and
 posterior  aspect  of  this  bone,  the  disease  termed a
 bunion  occurs.   In this affection the enlargement of the
 bursae is usually secondary to an alteration in the shape
 and position of the great toe, which, in  consequence of
 the  pressure of narrow, pointed  boots, has been thrown
 outwards in an oblique direction, so as to  lie  over, or
 under, some of the contiguous digits (fig. 244) ; in this
 way a sharp angle is formed at  the junction between the
 first phalanx and the metatarsal bone  of the great toe.
 This angle being constantly pressed  upon by the  boot,
 becomes irritated, and,  for its protection, the bursa that
 is  there  naturally situated becomes  enlarged, or an
 adventitious  one forms.  From time to time the bursa
 and the projecting angle become irritated and inflamed,
 and the morbid action thus set up may  run  on to suppu-
 ration of a very troublesome kind, a thin, unhealthy pus  being formed, which
 is  discharged through  an opening that  speedily  becomes fistulous, and may
 degenerate into a most  troublesome, indolent sore.
    In the treatment of  this affection,  the first thing to be done is to change the
 direction of the  toe, by wearing properly-shaped  boots.   The  faulty position,
 which appears to be the primary cause  of  the  affection, may perhaps be  more
  effectually remedied  in some  cases,  by the division of  the  external lateral
  ligament of the metacarpo-phalangeal  articulation, or  of the tendon of the
  adductor pollicis, or the inner head  of  the  flexor brevis pollicis; the toe,  when
  restored  to  its  position,  being for  a  time kept fixed  upon an under-splint.
  Pressure upon the bunion may at the same  time be prevented,  by wearing oyer
  it a piece of amadou spread with soap plaster, and  perforated  in the centre with
  an aperture corresponding to the size of the tumor.  If accidental inflammation
 
664
DISEASES  OF  THE BURSJE.
be excited in the part, it must be allayed by the application of leeches, warm
foot-baths, and poulticing; the  cutaneous irritation that is  left may best be
removed by painting the surface  with a strong solution of nitrate of silver.

                              GANGLION.

   Two  distinct kinds of ganglion are met with: the simple, situated upon the
sheaths of tendons, and the compound, consisting in a dilatation of the sheath
itself.   The  simple ganglia consists of cysts, varying in size  from a cherry-
stone to a large marble, and containing a clear transparent fluid of  a yellowish
color, which is  sometimes  thin  and serous, at  others, gelatinous  and semi-
coagulated.  They occur as a  smooth, globular, elastic, and tense tumor, usually
situated on the back of the  wrist, where it forms a distinct round  projection •
they may also occur on the dorsum of the foot.  In both situations, they are
distinctly connected with  the sheaths  of  the extensor tendons, and, indeed
Paget looks upon them as  being  cystic  transformations of  the  fringe-like
processes of synovial membrane lining the sheaths  of the tendons.  As they
increase in size, they often give rise to  painful sensations in  the parts below
them, by pressing upon neighboring nerves; thus, a ganglion  at the back of
the wrist often produces pain and weakness in the hand, by compressing some
of the branches of the  musculo-spiral nerve that are stretched over it.
   The  compound  ganglia  are chiefly met with in the palm  of the hand, and
the dorsum, sole, or inner side of the foot.   They consist of a dilatation of the
sheaths of the tendons in  these situations, and may often attain a very con-
siderable  bulk, and then  usually become irregular in shape, owing to several
tendons being implicated by them.   Often in this form of ganglion, the sheath
is simply thickened as well as dilated, and  the contained fluid is clear and
yellowish, though  usually thinner than in the simple ganglion.  The sheath
itself is vascular, and lined by a red, fringed, and velvety membrane;  the fluid
may then be dark  and  bloody, and  contain  masses of buff-colored  fibrine or a
large number  of granular bodies,  like those met with in certain forms  of
enlarged bursae.  These I have found to be composed of imperfectly-developed
granulations, in which the remains of blood-vessels were visible, probably thrown
off from  the inner wall of the vascular sheath.   This form of the disease, at
times, puts on almost a malignant appearance, is extremely chronic  in its char-
acters, and  may occupy a very extensive surface; in a  case  of the kind  that
was under my care, some  time ago,  the dorsum  and greater part of the  inner
side of  the foot were involved.
   The  treatment of these diseases must depend upon their character and size.
When  small and  simple, as on  the back of the wrist, they may commonly be
got rid  of by being ruptured  by  forcible pressure with the thumb, or by a blow
with  the back of  a book, or by being tightly compressed, by means of a six-
pence wrapped in a piece  of  lint, and  firmly strapped upon the swelling.  If
they do not disappear in this way, the better plan is to puncture them by means
of a valvular opening,  to squeeze out their  contents, and then to employ pres-
sure.   If they give rise to much pain and weakness, and do not disappear by
the  means indicated, they may be  dissected out, if it be thought advisable to
have recourse to this somewhat severe procedure, which is not  altogether unat-
tended  with the risk of inflammation  extending up the sheath of  the tendon.
I have,  however,  on  several  occasions  done  it,  without  any  troublesome
consequences ensuing.
   A  ganglion situated in the palm of the hand, and extending  under  the
annular ligament  some little distance up the flexor tendons of the  fore-arm, is
a very  troublesome disease.   Mr. Syme recommends that  the  cyst should  be
laid open, and the annular ligament divided.   This seems to me  an unneces-
sarily severe procedure, and I have  in several instances  cured the affection  by 
DISEASES  OF  THE  MUSCLES.               665
milder means; in one, by injecting a small quantity of tincture of iodine into
the cyst through  a puncture in the palm, and in two or three other cases by
the use of  the  seton;  and this  is  the  plan that I  should recommend for
adoption.
   In  the side or sole of the foot, these ganglionic  tumors, when of large  size,
and filled with semi-solid  fibrinous matter, may require  to be dissected out.
   Inflammation of the sheath of the tendons — tenosynovitis — is occasionally
met with as the result of strains and twists of the hand, about the wrist, of the
extensor tendons, or the long head of the biceps.  In this affection there is
swelling of a puffy character, with  tenderness  upon pressing upon or moving
the part; and usually a  peculiar  fine  crackling sensation is communicated to
the surgeon's hand when he examines  the  affected part.   This crackling is
especially marked in those cases  in which the inflammation and effusion have
become chronic, when the disease appears to partake of the nature of a diffused
 ganglion.
   The treatment, when the disease is acute, consists in leeching and blistering,
 with  rest of the part; when it  is chronic, the  application of blisters and the
 mercury and ammoniacum plaster will  be found most useful.
                       CHAPTER,  XLVIII.

           AFFECTIONS OF  MUSCLES  AND FASCIAE.

  Strains of muscles, especially of those of the back and loins, attended by
pain, weakness, and some rigidity, are not  unfrequently  met with as the result
of sprains or injuries of various kinds, more especially  in rheumatic constitu-
tions.  They may be best remedied by the  use of Corrigan's iron, dry cupping,
stimulating  embrocations,  and the  internal administration of  colchicum or
guaiacum.

              CONTRACTIONS  AND   RETRACTIONS.

  Under the head of muscular contractions are included various deformities,
such as squint, wry-neck, club-foot, club-hand, some  of  which are congenital,
others acquired.   In  all of these  conditions, the deformity is primarily owing
to an affection of the  muscular system, and not to disease of the bones or liga-
ments, which are only secondarily implicated.  The causes of these deformities
are very various, but they may be referred  to three  heads.
   1st. The continuous faulty or abnormal position of a limb, as in an unreduced
dislocation, or an anchylosed joint, will be  followed  by  the disuse of a certain
set of muscles, which consequently become shortened and  atrophied, and acquire
a rigid state.  This condition is consecutive to the  displacement, but renders it
permanent; it is apt to  occur after fractures, if the parts are kept for too long
a time in one position, and more particularly if bound and matted together by
the pressure of tight  bandages.   A somewhat similar cause sometimes operates
on the foetus in utero; an abnormal position in the  uterine cavity being very
frequently  the immediate occasion of some of the varieties of  congenital club-
foot.
  2d. Irritation being set up in the central portions of the  nervous system, may
produce deformity by deranging the proper antagonistic action of certain groups
of muscles.  This condition gives rise to many of the congenital, as well as the 
666
SPECIAL  DEFORMITIES.
non-congenital deformities.  It may act by producing more or less complete
paralysis of one set of muscles, the contractility of their antagonists continuing
normal, and thus  the relative balance of action  being destroyed, the stronger
will draw the  part over  to  their side.  The influence of this want of proper
balance of parts in paralysis, producing deformity, may be well seen in palsy of
the portio dura, where the face is distorted by being drawn  to the sound side;
or in squint, where the  external rectus being paralyzed, the eye is drawn  in-
wards.  According to Mr. Tamplin, deformity from paralysis is never congenital,
though it  is not unfrequently met with in  the  non-congenital  cases.  Central
irritation may occasion deformity in another way, by producing  tonic or perma-
nent spasm of one set of muscles, the other remaining perfect in their contract-
ility, but over-balanced by the continued contraction of their antagonists.  This
would appear to be the case in some forms of squint.
   3d. Peripheral nervous irritation may occasion contraction of the muscles and
deformity.  This  we  commonly see happen in  cases  of contraction occurring
from the irritation of worms  in the intestinal canal, in the so-called hysterical
contractions from uterine irritation, etc.  From all these various causes contrac-
tion  and deformity may arise.   In some cases  deformity will  cease after the
removal of the cause;  but  in other  instances, in which it has been of long
duration, the  deformity will continue, owing to  the  muscles having fallen into
a kind of rigid atrophy, being shortened and wasted, and consequently unfitted
for the proper exercise of the  actions of the part.
   The general treatment  of deformities consists in removing the cause of the
contraction in those cases in  which it is dependent  on central, peripheral, or
nervous irritation that admits of remedy.  Thus, if squinting arise from pres-
sure upon the brain,  the eye will resume  its straight direction when  the con-
gested vessels are relieved, or the effused fluids absorbed; or if a contraction of
the ham-string muscles  arise  from the irritation of worms in the intestinal
canal, a dose  of purgative  may cure the affection.  When, however, the deform-
ity is of a congenital or more permanent character, the employment of orthopcedic
means and the division of the  tendons  is the only mode of restoring the natural
condition of the part.  This orthopoedic department of surgery owes, in a great
measure, its existence to the labors of Delpech and Stromeyer, and its perfection
to those of Little and Tamplin.
   By tenotomy, as at  present practised, is meant the subcutaneous division of a
tendon by means  of a very narrow-bladed knife  (fig. 245) introduced obliquely
through a puncture by its side.  In doing this, it should be borne in mind  that
the normal anatomical relations of parts are  often a good deal disturbed in cases
of deformity; and thus tendons may  be  approximated to arteries  and nerves
from which, in the healthy  condition  of the limb, they are  widely separated.
The tendon  may most  conveniently be divided, in  the  majority of cases, by
introducing the blade beneath it sideways, and then turning the edge against
it, scratching through it  by a kind of sawing  movement, whilst the parts are

                                  Fig. 245.
made tense by an assistant.  A drop or two of blood only are lost in this simple
operation, and, as  the divided tendon  retracts  with a kind  of snap, a gap will
be left between the two ends, of  from half an inch to an inch in width, accord-
ing to the previous amount of tension in the part.  If the muscles have been
contracted for  some  years, it will  commonly be found that the fasciae in the
neighborhood of the tendon have become rigid and unyielding, forming  cords
or bands  stretching across from the side of the gap.   If these are very tense, 
TENOTOMY. — SQUINT.
667
they may be divided in the same way; but  in many instances it will be found,
after a  lapse of a short time, that  they will yield, and consequently will not
require  division.  After the section has been made, the small puncture should
be closed with a strip of plaster or some  lint  soaked in collodion.  The part
should then be left without any apparatus being applied for three or four days.
At the expiration of this time, lymph will have  been thrown out, and then
proper  mechanical  contrivances  may be adjusted  for gradually restoring the
normal  position of the limb or part; if  this be  done too soon, the  cicatrix will
be extended at too early a period after the deposit of the  plastic matter, and
the division will become weakened and too much elongated.   The  divided ten-
don  unites like one  that has been  ruptured, by plastic matter that gradually
assimilates to and at last closely resembles its substance.   Tamplin states that,
on examining the tendo achillis of a boy who died twelve months after it had
been cut  across, no  trace of injury could be noticed, except a slight globular
appearance opposite the seat of  incision.
   In cases  of congenital malformation,  the question frequently  arises as  to
whether tenotomy should be performed  in early infancy, or delayed to a more
advanced  age.  As a general rule, I think  that the sooner these operations are
done the better; they are not more difficult  at an early period of life than at any
other, no  danger attends them, and by being performed during infancy, there
is a  far less chance of the deformity being  permanent, than if  the operation is
delayed for some years.

                       SPECIAL  DEFORMITIES.

   By squint or strabismus is meant a want of parallelism in the  position and
motion  of the  eyes.   Most commonly a  squint  is convergent, the  edge of the
cornea  being buried under the inner angle of the lids, more rarely the divergent
form is met with.   In convergent strabismus, one eye only is generally  affected,
but  in some cases both are implicated, though one eye is almost invariably worse
than the other; and  this gives an appearance as if there were an alternation of
squinting in the two eyes.   In order to ascertain which eye squints, the  simplest
plan is  to direct the  patient to look at a distant object, when the sound eye only
will be directed towards it, the affected one being turned inwards.
   Squint may arise  from a variety of causes;  it not unfrequently comes on in
children after infantile complaints, such as measles or scarlatina,  and as Sir C.
Bell has  observed, commonly depends  upon weakness of the external rectus,
owing to some paralytic affection of  the sixth nerve, seldom upon spasm of the
internal rectus.  In many cases it is indicative of disease of the brain or nervous
centres, occasioning  paralysis or irritation  of the  motor nerves of the eye; in
other instances it may occur from the irritation of worms in the  intestinal canal,
and not unfrequently is dependent upon some disease of the eyelids or eyeball.
Thus'the various  inflammatory affections of the conjunctiva and  eyelids may
occasion it; or, it may, as not unfrequently happens, when it occurs in adults,
be dependent on the difference in the focal  length  of vision, owing to amaurosis
or the failure of sight in one eye; and lastly, in children it may be induced by
habit or imitation.
   The  treatment of  squint must to a certain extent be influenced by its cause.
Thus the removal of congestion of the brain or the expulsion of worms from the
intestines  may cure the  affection;  or,  if it have followed simple  debility in
children,  it will disappear as their strength improves, and they will thus out-
grow it.  If, however, the deformity be of a permanent character, it may readily
be remedied by the simple operation that was introduced by Dieffenbach.  The
operation for squint should not I think be performed until the child has attained
its eighth  or tenth year, as it is not very easy to do it satisfactorily before this
period, owing  to the restlessness of infants; and, in very many instances, the 
668
SPECIAL  DEFORMITIES.
squint gradually disappears as a child grows older without any operative pro-
cedure being had recourse to.  Indeed, in many cases it may be better to defer
it till the adult age  is reached.   On the other  hand, it  should not be delayed
too long, lest some contraction of the features or deformity in  the other eye  be
left, and thus a very satisfactory result be not obtained.   The operation is suffi-
ciently simple; it may most conveniently be done by bandaging the sound eye,
and then directing the patient to look outwards with the  affected one; a fold of
the conjunctiva  near the inner canthus  is  then seized  with the forceps, and
snipped transversely with a pair of rather sharp-pointed scissors.   By dilating
the wound slightly with  the  scissor blades, the tendon  of the internal  rectus
will be exposed, which may be seized with the forceps,  and readily cut across;
or, a very convenient plan consists  in passing a curved  director underneath it,
raising  it upon this, and then  dividing  it  either with  the scissors or a small
curved  bistoury.  During the operation  the  eyelids must  be held apart by an
assistant, who may if necessary use the eye speculum for this purpose.  After
the operation, a piece of wet lint should be laid upon the eye, and if any fungous
granulations  spring  from the  wound, they must  be  snipped off or touched with
the nitrate of silver; some double  vision may be left, but this gradually wears
off.   Mr. Critchett advocates the subcutaneous section of the muscle in strabis-
mus, as being less likely to be followed by those  inconveniences and deformities
that attend its  division  in the ordinary way, viz.,  depression of the caruncle,
slow  healing, an unsightly cicatrix, and often  more or less prominence  and
eversion, that are as disfiguring as the condition for  which the operation is done.
    Wry-neck, torticollis, or Caput obstipum may arise either from spasm or from
paralysis of one  of  the  sterno-mastoid muscles, the  head in  the first instance
being drawn to the  affected side, in the second, to the opposite one.   Although
wry-neck is  usually owing to contraction of the sterno-mastoid muscle, yet in
some cases  the trapezius is also at fault,  more especially its anterior border and
clavicular  margin.   It usually comes  on in childhood, and  not  unfrequently
commences with an ordinary stiff  neck from cold;  after existing for some time
it becomes conjoined with a certain amount  of twist of the cervical spine, and a
tendency to lateral curvature.  Besides these, which may be considered the true
forms of wry-neck, deformity in this situation may  occur from diseased cervical
vertebrae, or from the traction of the  cicatrix of a burn.  These, however,  are
peculiar conditions  depending upon causes that are irrespective of the state of
the muscles, and may readily be distinguished from  the true form of the disease.
   The treatment of  torticollis arising from permanent spasm of one of the sterno-
mastoids, which  is the common form of the affection, may best be conducted by
dividing the inferior attachment of the muscle, and thus allowing the head to
regain its proper position.  The division  of  the  muscle is a somewhat delicate
operation, on account of the  important structures that  lie immediately  behind
it. By making the incision, however, through it, from behind forwards, close to
the sternum and along the clavicle, there can, if ordinary care is employed, be
little risk of doing any damage, as these bones carry the lower attachment of the
muscle forwards, and separate it from  subjacent parts.   The tension  also into
which it is thrown by its spasm draws it away from the carotid sheath.  In several
instances in which I have had occasion to  perform this  operation, no difficulty
whatever has been experienced in dividing the sternal attachment of the muscle,
which is usually very tense  and  prominent, by passing an  ordinary  tenotome
behind the tendon, with  its flat side towards it, just in front of the upper margin
of the sternum, and then cutting forwards, whilst the muscle is put well upon
the stretch. ^  In dividing the clavicular insertion, the safest plan  I think con-
sists in making a puncture with a scalpel upon and down to the clavicle in the
cellular space, that lies between the two attachments of the muscle, and then
pushing a long, blunt-pointed, narrow-bladed tenotome between that bone  and
the insertion  of  the muscle, dividing  this in a direction  forwards.   After the 
CLUB  FOOT.
669
operation the head should be  drawn  to  the  opposite side by means of proper
apparatus.   In this way the curvature of the  cervical vertebrae  may gradually
be corrected;  should  it, however, have existed for a considerable time, it may
have assumed a permanent character; and a twist in the neck will continue for
life.   After the division of the tendon the deep  fascia  of the  neck will some-
times be found stretching across in firm  and tense bands; these, however, had
better not  be interfered with, as  they will generally yield, and  much risk  of
injuring the subclavian and carotid vessels would  attend any attempt at their
division.
   In those cases in which the wry-neck  appears  rather to be dependent  upon
paralysis of one sterno-mastoid, than spasm of the other, electricity,  and the
application of strychnine to the blistered surface  over the muscle, will be found
most useful.   In spasm of both  sterno-mastoids, the head is thrown  forwards,
the muscles projecting in great relief.  In these cases the disease will usually
be found to have had a rheumatic origin.
   Club-foot.—Deformities of the feet are commonly single; but not unfrequently
they affect both extremities.   They appear to be more frequent in boys than in
girls.   Four varieties of club-foot are  recognized; — the  talipes equineus, in
which the  head is elevated; the talipes calcaneus, in which the anterior part of
the foot is  drawn up;  the  talipes varus, in which the foot  is twisted inwards;
and the talipes valgus, in which it is twisted outwards.   These  conditions may
occur in the simple forms just mentioned, but most commonly the varus is com-
plicated with the talipes equines,  and not unfrequently the valgus with the cal-
caneus.  Bonnet, of Lyons, has  made a classification of  talipes, according as it
is occasioned by an affection of the internal or of the external  popliteal nerve.
When the  muscles supplied by the internal popliteal are  affected, we have the
talipes  equineus, equineo-varus,  and varus.   When the  external popliteal  is
affected we have the calcaneus and valgus.
   On dissecting a foot affected by talipes, it will be seen that but  little alteration
has taken place in the condition of the bones.  In some  preparations of this
kind, that  are in the University College Museum, these are nearly in a normal
condition (figs. 247-250).  Ipdeed, in the talipes  equineus and  calcaneus, they
 are scarcely, if at all, altered, but in the varus and valgus,  if of old  standing,
 the astragalus will generally be found atrophied, more  particularly about its
 head, which may be somewhat twisted, and the scaphoid and cuboid will be seen
 to have undergone similar changes.   The  ligaments  are necessarily somewhat
 altered in  shape, being lengthened on the convexity, and shortened on the con-
 cavity of the foot; the direction of the tendons is altered, and the muscles not
 only of the foot, but of  the leg and thigh, are generally  atrophied from disuse,
 so that the limb in old cases is withered and shortened; indeed, so great an in-
 cumbrance may it occasionally become under these circumstances, that amputa-
 tion  of the leg may be insisted on by the patient, and may with propriety be
 performed by the surgeon.
    Talipes equineus is characterized by elevation of the heel, and great tension
 of the  tendo achillis, so that  the foot is extended in nearly a straight line with
 the leg, and the patient walks on his toes, which are placed at a right angle  to
 the foot (figs. 246, 247).  In this deformity there is no lateral displacement.
 According to Mr. Tamplin it is never congenital.  It most commonly arises from
 disturbance  of the nervous system, during teething, or from the irritation of
 worms  in  children.   In adults  it  may come on  from some  disease, such  as
 abscess in  the calf of the leg, by which the  gastrocnemius muscle is crippled.
 It is the  most important of all the forms of  club-foot, as it  commonly com-
 plicates the other species. The treatment consists in dividing the tendo achillis,
 and bringing the heel well down.
   The tendo achillis is best divided about an inch above its insertion into  the
 os calcis.   The patient should be laid prone, and the surgeon grasping the foot 
670
SPECIAL  DEFORMITIES.
extends it forcibly, so as to throw out the  tendon in good relief, and  make  it
tense; he then slides a tenotome  beneath it, and cuts slowly through  it from
Fig. 247.
                    beneath upwards, bearing well
                    upon the foot; as the division
                    proceeds,  he  will hear the
                    tendon cracking as its fibres
                    are successively cut through.
                    The division snould never be
                    made from above downwards,
                    as the  posterior  tibial  artery
                    or   its  malleolar  branches
                    might readily be wounded.
                       The talipes calcaneus is an
                    extremely rare variety of club-
                    foot.   In  it the  heel  is de-
                    pressed, the toes and anterier
                     part of the  foot  being ele-
                    vated (fig. 248) ; it is always,
                     I  believe,  congenital,  and
                     arises from contraction of the
extensor tendon.   In order to bring down  the foot,
the tibialis  anticus, the  extensor  communis, the
extensor pollicis, and the peroneus  tertius, may all
require to be divided as they pass over the dorsum;
a straight splint should then be applied, and the foot drawn down to it.  A
minor  degree  of  this  affection  consists  in a  peculiar  projection  upwards
                                       of one or two of the toes associated
                Fig. 248.                with some tension of the extensor ten-
                                       don ; by dividing this, and keeping
                                       the foot  on  a flat splint, this deformity
                                       may commonly be corrected.  In some
                                       cases, however, the  toe is  so promi-
                                       nent, and  the contiguous  ones are
                                       squeezed under  it in such a manner,
                                       that the foot  is completely crippled,
                                       and amputation of the displaced digit
                                       is required in order to  restore the
                                       utility of the member.
                                          Talipes varus. — In this deformity
                                       the  foot is  twisted  inwards, and the
                                       sole is contracted, the patient walking
               side of  the  foot,   where  the  skin covering the  tarsal end
               metatarsal  bone often  become   excessively  dense  and firm,
               occasionally forms  (figs. 249, 250).   In  most  cases there  is
some elevation of the heel, the affection  partaking somewhat of the equineus
character.   It is the  most  common  form of congenital deformity, both feet
being  found similarly affected; but it  may  be non-congenital, and  then it is
limited to one.   The treatment consists in  the division of the tendo achillis,
together with the tendons of the  tibialis anticus and  posticus, which are  the
muscles principally at fault.   In most cases the plantar fascia is contracted, and
requires division wherever it feels tense and  projecting.  In the section  of the
tibialis posticus tendon in the sole of the foot there is much danger of wounding
the posterior tibial artery, which lies  close to it.   The best  way to  avoid this
vessel is to  puncture the sheath of the tendon with a  sharp  scalpel introduced
directly downwards, and then  to divide it in  a  direction forwards, away from
the vessel, with a blunt tenotome.  There will also  be less risk of this accident
on  the outer
of  the fifth
and  a bursa 
CLUB-FOOT.
671
occurring if the tendo achillis be divided first, so that the others may be ren-
dered more tense, before their section is undertaken.   But in cutting through

                 Fig. 249.                              Fig. 250.
 the tendo achillis there is also some risk of wounding the artery, as in bad cases
 of varus these two structures lie nearly parallel to one another, the tendo achillis
 being drawn out of the median line towards the inner ankle.   Indeed, in one
 instance, I have seen the posterior tibial artery punctured during the division
 of this tendon, or rather in an attempt  to divide  some tense bands that lay be-
 neath it; the bleeding, which was  very free  and in a full jet, was, however,
 readily stopped by pressure, no  bad consequences resulting.   The proper plan
 of treatment, when such an accident occurs, is, when the artery is merely punc-
 tured, to cut it completely across, and then to apply firm pressure, by means of
 a  pad  and bandage, over the bleeding orifice.  Mr. Tamplin states that he has
 seen no ill effects follow this accident.   If a circumscribed false  aneurism has
 formed, it must  be laid open, the clots turned out, and the vessel tied.  No ex-
 tension  of the foot  should be  practised for some time in such cases, lest the
 coagulum be disturbed.
   In ordinary cases  of varus, after a lapse of four or five days, Scarpa's or Lit-
 tle's shoe, or Aveling's Talivert may be applied;  or the foot  be well abducted
 by means of a wooden splint, fixed to the outer side  of the leg, and provided
 with pegs, so placed that the toes can be drawn up, and the foot well turned out
 by rollers and tapes attached to them.
   Talipes valgus —flat or splayfoot — is the anti-         Fig. 251.
 thesis to varus.   In  it there is a tendency in  the
 first instance to the obliteration of the arch of  the
 instep, so that the sole becomes perfectly flattened;
 and as the disease advances, a tendency to eversion
 of the foot usually takes place (fig. 251). When it has
 advanced to this extent the toes and anterior part
 are often somewhat raised, so as  to  constitute  the
 variety termed calcaneo-valgus.   In  this kind  of
 deformity the ligaments of the sole of the foot,
 which bind the bones together so as to form the
 arch, are weakened  and elongated,  and the pero-
 neal  and  extensor tendons commonly tense.   It
 is not so frequent a form of club-foot as the other
varieties, and commonly affects only one extremity.
When both feet  are everted there is usually knock-
knee as well.   The treatment consists in the division of the tendons of the pero-
neus longus, and brevis, behind the outer ankle; and of that of the extensor
 
672
SPECIAL DEFORMITIES.
communis on the dorsum.  Scarpa's shoe may then be applied, and the arch of
the foot restored by wearing  a pad under the sole for some considerable time.
The talipes calcaneo-valgus is not a  congenital affection;  and as it commonly
arises from a partially paralyzed state of the gastrocnemius, the treatment is not
very satisfactory.
   In talipes calcaneo-valgus the projection of the heel backwards is obliterated,
and the outer side of the foot curved round towards  this, so that the little toe
approaches the point of the heel.
   Weak ankles not uncommonly occur in ricketty children  ; the ligaments being
relaxed,  the joints appearing to be  swollen,  and the child unable to walk or
stand without great difficulty.  Under these circumstances, attention to the state
of  the general health, douching with  salt-water, the application of an elastic
India-rubber bandage round the ankle, or the  use of light iron supports, will be
found most useful.
   The deformity  termed genu-valgum, knock or X  knee, usually affects both
extremities, though it is generally more fully developed in one than the other.
In it the knee forms the apex of a triangle, the  base of which would  be repre-
sented by a line drawn  from the trochanter to  the outer ankle.  It is usually
conjoined with some curvature of the bones of the leg.   It is not a congenital
affection, but commonly occurs in consequence of children  being put upon their
feet too early, the limbs thus giving way under the weight of the body.  Brock
states that out of 221 cases that he examined, 17 originated about  the period
of  the first dentition;  and about 200 between that age and the 15th or 18th
year.  Some occupations are said to predispose  to it, smiths being  especially
liable to the disease.   In it there is  relaxation of the  internal lateral ligament;
the biceps, the external lateral ligament, and often the vastus externus are very
tense; and the patella thrown outwards.  The external condyle of the femur
will generally be found to be small and the  hollow of the ham to  be obliterated.
The  treatment consists,  in the  slighter cases, in applying a well-padded splint
along the outside of the leg and thigh; this  must extend from  the trochanter
to the outer ankle, being fixed to a pelvic band  at the upper part, and into a
boot  below.   Where it corresponds to the knee  it should be provided with a
hinge, and should have a broad well-padded strap passing from  its under side,
over the inner side of the knee, and  attached by buckles to the upper part of
the splint, in such a way that by tightening these the knee may be drawn out-
wards.   This apparatus should be constantly worn for many months, and if pro-
perly adapted may effect a cure.
   When the deformity is of old standing, and the parts  about the outer side
of  the joint very tense, the  biceps tendon may require division.  In doing this
care must be taken not to injure the  peroneal  nerve.   In some cases the vastus
externus and contiguous portion of  the fascia lata may also be advantageously
divided,  and the padded splint then applied as directed.

              CONTRACTIONS  OF THE KNEE-JOINT.

   Contraction of the knee-joint is one of the most  distressing  deformities to
which the human frame is liable.  If severe, the leg is bent at  nearly, or per-
haps at quite, a right angle with the  thigh.    It is fixed in this position, so that
the patient cannot put the sole of the foot, or  even the points of the toes, to the
ground;  hence  the limb becomes useless for the purpose of progression, and,
from  want of exercise, atrophies.   But a leg with a  badly-contracted knee is
worse than  useless — it  is a  positive incumbrance;  for, as  the foot cannot be
brought  fairly  to  the  ground, the limb projects behind  in a most  awkward
manner,  swaying as the body moves  round, constantly in the way, and liable to
injury.   From want of exercise, the nutrition  of the limb thus affected becomes 
CONTRACTIONS OF  THE  KNEE-JOINT.          673
impaired; the foot is usually habitually cold, the circulation in it languid, and
the toes become liable to chilblains and troublesome ulceration.
   In the less severe form of contracted knee, the inconvenience, though not so
great as that  just described, is yet very considerable; for, as the patient  can
never bring the heel or sole to  the ground, he  rests insecurely on the tips of
his toes, and walks but  unsteadily with the aid of a crutch or stick.
   This deformity may be of two  kinds — 1st, it may consist of simple flexion
of the  leg on the thigh,  at a greater or less angle, and  with more or  less
mobility, according to the  degree of anchylosis; 2d, in  addition to this, there
may be horizontal displacement of the bones, the head of the tibia being thrown
backwards, the  femur and  patella remaining in situ, but apparently projecting
more than is natural.
   In examining a case  of contraction  of the knee-joint, the patient should be
 placed on his  face, with the thigh extended.   The leg on the affected side will
 then be raised more or less perpendicularly,  and the amount of contraction may
 be judged of by the angle that it forms with the thigh.  The degree of mobility
 also may readily be ascertained.   In this way a more correct idea of the amount
 of contraction can be obtained than by examining  the patient whilst lying on
 the back, when, in consequence of the thigh being flexed on the abdomen, the
 extent of the angular deformity cannot be so well  determined.
    Contraction of  the knee-joint  may arise from a great  variety of pathological
 conditions.   Some of these are altogether external to the joint, being seated in
 the nerves or  muscles of the limb; whilst others, and the majority, are dependent
 on some morbid change that has  taken place within the  joint itself in its liga-
 mentous or osseous structures.  As the contraction depends on such very varied
 causes, the treatment,  having reference to  the cause as well  as to the actual
 morbid conditions, must be equally diversified.
    Contraction from nervous irritation is usually associated with general hysteria,
 of which  it is but a local  symptom, and  commonly occurs  in  girls  and young
 women.  In  this form of contraction there is no evidence of disease within the
  joint; no  redness, swelling, or other sign of inflammation; but there is great
  pain and tenderness about  it.   This pain, as usual in  hysterical cases, is super-
  ficial and  cutaneous,  and radiates to some distance beyond  the  articulation.
  Any attempt at straightening the limb  not only greatly increases the pain, but
  also calls the muscles about it into such  forcible  action that it is impossible  to
  improve its position.   These  local symptoms are connected with the ordinary
  signs of an hysterical temperament, with spinal irritation, and often with uterine
  derangement.                                                      ...
    The treatment of these  cases of hysterical contraction of the knee is simple.
  The  first thing to be done is  to straighten the limb.  This can only be effected
  by putting the patient under the influence of chloroform, when, all sensibility
  being suspended, the muscular opposition, which  is partly voluntary, and  no
  doubt in some measure reflex, is no longer called into action, and the limb falls
  of its own accord almost into the straight position, in which it must be retained
  by means of a long splint, lest the retraction  recurs with returning conscious-
  ness; and then, the hysterical condition being removed by treatment calculated
  to improve the general health, the tendency to the return of the deformity will
  be obviated.                                                      .     „  ,
    We occasionally  see contraction of the  knee from spasmodic action  ot  the
  hamstrings,  arising from  some  irritation applied to the  nerves at a distance
  from the°part.  Just as we have spasm of  the  internal rectus of the eye occa-
  sioning squint, so long as the irritation that gives rise to the spasm lasts;  so
  we  may  have spasm of  the  hamstrings,  with contraction of the  knee  as a

  C°Most commonly, however,  the joint itself is at fault, owing either to inflam-
         43 
674
SPECIAL  DEFORMITIES.
matory action of a subacute character going on within it, or to the chronic and
permanent changes induced by former inflammatory attacks.
   In inflammation of the knee, the patient naturally and instinctively places
the limb in the semi-flexed position, as being that in which there is least ten-
sion exercised on the structures that enter into the joint, and consequently that
which is most congenial to his feelings.   This position, which is immediately
assumed on the occurrence of acute and active inflammation in the joint, comes
on more gradually in cases of subacute inflammation, and here the symptoms
of disease in the joint may be so slight that the  contraction may be  considered
the chief ailment, and  engross too exclusively the surgeon's attention.
   The next class of cases that we have to consider are those  of a more chronic
and intractable kind, lasting often for years, dependent upon structural lesions
of a deep and  important character in and  around the joint, and requiring very
active surgical interference for their cure.  These chronic  forms  of  contracted
knee appear to arrange themselves in four distinct varieties, being dependent—
1st, on consolidation and contraction of the ligamentous structures in or around
the joint;  2d,  on permanent contraction of the muscles; 3d, on both these con-
ditions conjoined; and 4th, on osseous anchylosis.  Each of these varieties will
require separate consideration, as each demands a special mode of treatment for
its cure.
   Those cases of contraction of the knee that depend on  consolidation of the
ligamentous structures  in and around the joint, resulting from  former inflam-
matory attacks, are not only the most numerous, but the most readily amenable
to treatment.  In these cases the knee is usually fixed at, or near, a right angle,
and admits of but very limited motion, to such a degree only, in most instances,
as will allow the foot to move to the extent of two or three inches. _ The  ham-
string muscles are not tense, even  when the  knee is  extended to its utmost;
and, indeed, in some cases are flaccid, and feel soft.   Not  unfrequently the leg
admits of  extension up to a certain point, with as much freedom as natural, and
 then the further movement of the  limb is checked by a sudden  stop.  If this
 be not dependent on the tibia coming in contact with  an  anchylosed patella, it
 is owing to shortening  of the crucial ligaments, or to the formation of adhesions
 within the joint.   In this form of contraction, the knee is often much distorted,
 owing to the head of the tibia being  partially dislocated backwards, or having
 its axis directed more or less to one side, most commonly inwards, constituting
 a kind of genu valgum. These distortions are, I believe, dependent on soften-
 ing and consequent relaxation either of the  ligamentum patellae, or of one  or
 other of the lateral ligaments.   When the head  of the tibia is displaced back-
 wards, it will most generally be  found that the ligamentum  patellae has been
 either partially absorbed, and thus weakened, or is elongated, the patella being
                                           drawn  upwards  or  to  one  side.
                  Fig. 252.                  In  either way  the  action of  the
                                           extensor  muscles  of  the  thigh
                                           upon the head  of  the  tibia  is
                                           weakened, and that bone  being
                                           consequently brought  under  the
                                           influence of the hamstrings, with-
                                           out a counterpoise, is drawn back-
                                           wards (fig. 252).  In those cases in
                                           which there is  lateral  rotation of
                                           the tibia,  the faulty position may
                                           have arisen from the attitude that
                                           the  limb has been  allowed  to as-
                                           sume during the progress  of the
                                           disease in the joint.
                                              In the treatment of this form of
 contraction of the knee, simple extension of the limb will often  prove sum-
 
CONTRACTIONS OF  THE  KNEE-JOINT.          675
cient.  This may either be done gradually by means of the screw splint behind
the knee, or forcibly and at once under  the  influence of chloroform.   I prefer
the latter method, not only as being  the speediest, but  as  being perfectly safe
and effectual.   The  mode  of effecting forcible extension is as follows : — The
patient being fully under the  influence of chloroform,  and lying on his  face,
the surgeon, standing above him, seizes  the foot of the  affected limb with one
hand, whilst with the other he steadies the limb just above the knee.   He now
extends the limb gradually but forcibly; as it comes forwards  the bands of ad-
hesion in and around the joint will  be  felt and heard to give way with loud
snaps and cracks, distinctly audible  at  some distance.  Should there be much
resistance within the joint, the surgeon  may apply his own  knee or elbow to the
upper surface, and thus increase the force with which the  limb is acted upon.
In this way I have  never  found any contractions of the kind now under con-
sideration  able  to resist the  surgeon's  efforts, or any difficulty in effecting  at
 once the extension  of the limb.  Nor have I ever seen any evil consequences
 result;  indeed, it is  surprising what an  amount of force a joint that has been
 contracted for any length of time may  be subjected to without inconvenience.
 In these cases it would appear as if the  synovial membrane  lost its suscepti-
 bility to inflame, just as we find is  the case with serous membranes that have
 been the  seat of chronic inflammation and  its consequences.  Beyond some
 pain for a  few  days, and slight heat, easily subdued  by  cold evaporating lotions,
 I have never seen any ill results arise;  but then care must be taken that no in-
 flammatory action is going on within the joint at the time  of this manipulation,
 as it certainly  would be followed by injurious results.   After the extension has
 been made, the limb should be  fixed on a long splint, well padded, some eva-
 porating lotions applied, and the patient kept  in bed for a
 few days, when, with the  aid of a starch bandage, he may    Fig. 253.
 walk about.
    After extensio..  has been effected,  the  position of the   \
 head of the tibia backwards may still occasion considerable   \
 deformity and weakness of the limb (fig. 253).  This con-    '.
 dition  is best removed by the  use of the  instrument of
 which the following sketch (fig. 254) is a good representa-
 tion, and was  designed and constructed by that excellent
 surgical mechanician,  Mr. Bigg.   The diagram (fig. 253)
 represents the limb of a patient whose  tibia has become
 displaced  backwards, the angular contraction  having been
 remedied.   In the  centre of the end of the femur and the
 head of the tibia,  two letters (X and  Z) are placed to de-
 signate the axis of each bony head,  beneath  and above
 which the  displaced joint has formed its  abnormal axis.
 The  dotted  lines  represent  the leverage  formed  by  the
 cylindrical  surface of  the tibia and  femur.   The arrows
 are placed in such a direction as the bones would  take in
 resuming their normal position.
    It will  readily be seen that  any instrument  capable of
 acting in the  mechanical directions shown by the arrows,
 would accomplish not only the restoration of the joint, but
 extend, if contracted, the extremities of both  femur  and
 tibia.
    Fi"\ 254 shows the application of the instrument by
 which this can be effected.
    An additional advantage that this instrument possesses
 over any other with which I am acquainted, is the appli-
 cation of  spring power, by means  of which flexion of the
 knee becomes an element towards its restoration.
 
676
SPECIAL  DEFORMITIES.
  Instead of arresting  muscular action, and  thus  giving rise to atrophy of the
limb, movement  is conducive to the  perfect  action of the apparatus, so  that
the patient experiences but little  inconvenience from  its use, all the ordinary
positions assumed by the knee in walking, sitting, or standing, being preserved.
  By this form of apparatus, then, three important  points  are secured,  viz.:
                               replacement of the head of the tibia; extension
            Fig. 254.            of the  angle of  the  leg;  and  free  muscular
                               action during the period of  treatment.
                                 Fig. 254. A  and B are three levers, composed
                               of metal, corresponding in  their  direction  to
                               the perpendicular position  of the  femur and
                               tibia.  C and  D are  two axes, placed exactly
                               coincident with the   centres of  the  articular
                               ends of  the  bones.   E and F are two powerful
                               springs,  whose action takes place in  opposing
                               directions, similar to the  arrow-indicators  in
                               fig. 253.   Thus F presses  the  lever B in  an
                               anterior direction, bearing the end  of the  tibia
                               forward, whilst E presses the lever A in a pos-
                               terior  direction, bearing the end  of the femur
                               backward.   As  C  and D are  found acting
                               above  and below  the  actual  axis of the knee-
                               joint, they mutually influence the point formed
                               by the apposition of the heads of the tibia and
                               femur;  and as it has already been explained
                               that the  femur really offers a fixed resistance,
                               and  the tibia moves beneath it, the  head of the
                               latter bone is turned  anteriorly in a semi-circu-
                               lar direction consequent on the upper centre (C)
                               being  a  fixed  point, and the lower centre (D)
                               rotating around it.  G is an  elastic knee-cap;  H,
                               a padded plate.  When the ligaments are tense,
                               there is a chance of pressing the anterior surface
                               of the tibia  against the posterior surface of the
                               femur.   This is readily obviated by having the
                               shaft (A) made to elongate, when the centre (C)
                               being a little lowered, pushes the lever (B) down-
                               wards,  carrying  the  tibia  with  it  and  thus
                               separating the  osseous surfaces of the joint.
   The next  class of cases of contracted knee  that we have to consider  are
 those in which the hamstrings are  at fault, either alone or in addition to  those
 results of chronic inflammatory action within  the joint that we have just been
 describing.   In these  cases  the hamstrings will  be  found to be tight, and in
 proportion as the leg is extended on the thigh, they will become tender, until
 at last all further extension is resisted, apparently by  their  traction, and not by
 any sudden check or stop within the joint itself.
   Of the  division of  the  hamstring tendons I need  say little.  It is as simple
 an operation as any in surgery, unattended by any difficulty or danger, provided
 the surgeon introduces the tenotome parallel and close to the side of the tendon
 to be divided, and cut in a direction from the inside  or  popliteal aspect towards
 the skin.   After the division of the tendons,  it not  unfrequently happens that
 tense aponeurotic bands will be found  to  stretch along either side, or perhaps
 down the  centre of the popliteal space.  This  may lead to the erroneous idea
 on the part of the surgeon that he  has  not  fairly cut the  tendons across;  but
 this is an error. The bands alluded  to are condensed, sharp-edged prolongations
 of the fascia lata, formed during the period  of contraction of the joint by the
 
            DEFORMITIES  OF  THE ARM  AND HAND.        677

retraction and thickening of this membranous expansion.   Such condensations
as these  had better be left  untouched, as they will readily stretch out under
gradual extension, or be ruptured by forcible traction of the limb.  If, on  the
other hand, the surgeon  be tempted by  their apparently superficial  and safe
position to proceed to their division, he  may be led into a serious dilemma by
being brought more readily in contact with the popliteal vessels than is desirable
or safe.  In  these cases the anatomical  relations of parts are so much altered
by the narrowing of the popliteal space, and by the projection of the head of
the tibia  backwards or by  its lateral  rotation, that the  surgeon is  unable to
calculate with  sufficient nicety the  precise  position of the large vessels  and
nerves in the  neighborhood of which  he is about to  act, and he might thus
injure one or other of these at a time that he thought he was operating at a safe
distance from them.
   After  the  division of  the hamstrings, the knee does  not  commonly come
readily into  the  straight position, but forcible extension  will  be required to
break through  the adhesions within  and  around  the joint.   This may be done
at once without inconvenient results, or  it may  be deferred for a week if  the
surgeon thinks better to delay extension after tenotomy.
   Osseous anchylosis of the knee is not of very frequent occurence.  The only
remedy in such cases would be the operation practised  by Dr.  Rhea Barton,—
of sawing out a wedge-shaped portion of the anchylosed bones, and then bring-
ing the limb into the straight position.  Judging by the  excellent results that
have followed resections of the knee-joint, such  an operation is not unlikely to
be attended by good success.   Should there  be much atrophy of the  limb with
shortening of it,  and possibly necrosed bone with old sinuses and  occasional
abscesses about the knee, amputation will  place the patient in  the condition of
most comfort.

             DEFORMITIES OF THE  ARM AND  HAND.

   Contractions of the arm are  not of very frequent occurrence, except  as  the
result  of  burns.   I have however met with three distinct  forms  of contraction
of the fore-arm: — 1st.  The  case in which  there is anchylosis  of the  elbow-
joint, the fore-arm being bent usually at a right angle with the arm, the result
of chronic disease of the articulation.   Here, if the anchylosis  be incomplete, a
very useful limb may be restored by breaking down  adhesions under chloroform
by forcible flexion and extension, and then  using passive motion, friction,  and
douches.  If the  anchylosis be complete, the bones should be resected, and a
false joint allowed to form.  2d. The biceps may by its contraction occasion a
permanent flexion of the arm.  In  such cases division of the tendon may be
practised, due  care being taken of the  artery and nerve.  This operation is
most safely done  by introducing the  tenotome to the inner side of the tendon,
slipping it under, and cutting upwards  and outwards, the artery being guarded
and pushed to the inner side by the pressure of  the left forefinger.   3d.  The
fore-arm  may be forcibly pronated and flexed as the result  of chronic  inflamma-
tion  of the radio-humeral articulation.  Here forcible supination and extension
under chloroform is the best remedy.
   A deformity resembling club-foot has  occasionally, though very rarely, been
met with in the hand.   The contraction may occur in two directions;  either in
the sense of  preternatural  flexion,  or  in that of abnormal extension of  the
member.  It  is  always  congenital,  and  has been principally described  by
Cruveilhier, Voillermier, and Smith  of Dublin.   In most of the cases that have
been met with, there was a certain amount of deformity of the  lower end of the
radius  with congenital  dislocation of the wrist;  and in Mr. Smith's case there
was an accessory semi-lunar bone in the carpus.   Little, if anything, can be
done by  surgery  for the relief of this deformity, though  some benefit might 
678
SPECIAL  DEFORMITIES.
possibly  result from the  division  of any  tendons that were  preternaturally
tense.
  A tendency to contraction  of the fingers, which are drawn into the palm of
the hand, is occasionally noticed; most  commonly this commences in the little
finger, and thence gradually extends to the ring or middle finger, which become
so forcibly and firmly curved inwards, that  their extension is not practicable.
It commonly results  from frequent and continued pressure on the palm of the
hand, as in leaning  on a round-ended stick  in walking, or in  those trades in
which an instrument requires to be  pressed  into the hollow of  the hand.  On
examining the contracted fingers, projecting ridges will be felt extending from
the palm to their anterior aspects; and on endeavoring to straighten them, these
ridges will be found to become  stretched, and  the  palmar fascia to be rendered
tense.   The skin covering these ridges is usually healthy, but sometimes adhe-
rent to them.   So  firmly are the fingers contracted, that by no effort  can they
be extended.
   The cause of this contraction of the fingers has given rise to a good deal of
difference  of opinion amongst  surgeons.  Dupuytren appears to have  been the
first who endeavored, by dissection, to ascertain  its true  character.  He found,
on examining a hand that was  the seat of this disease,  that  after the removal
of the skin, which was  loose and  flaccid, the contraction continued as before,
and this, therefore, could not be its seat; but that  the palmar fascia, which was
exposed, was tense and diminished  in size,  whilst, from  its  lower aspect, some
cord-like prolongations  passed  up  by the side of the  fingers,  and  that when
these  were divided, the contraction was immediately removed, the tendons, the
bones, and the joints being perfectly sound.   He considered these fibrous cords
to be the digital prolongations of the  palmar fascia, and consequently looked
upon this membrane as the seat of the disease.  M. Goyrand, who has  carefully
dissected hands affected in this way, states that these fibrous cords, which he
also looks upon as the seat of the affection,  are not prolongations of  the palmar
fascia, but are ligamentous structures  that extend  from its anterior inferior
aspects to the sheaths of the flexor tendons, into which they are inserted oppo-
site the  second phalanx; being an hypertrophied condition of the subcutaneous
filaments of fibro-cellular tissue that naturally exist in this situation.
   The treatment of  this deformity consists in dividing each tense digital liga-
mentous prolongation by a subcutaneous incision.  This should be  done oppo-
site the  second phalanx, where  it is usually  most tense; but, if the other finger-
 joints be affected, a  separate section may be  required  opposite each  phalanx.
 Should  the skin be adherent to the fibrous band, it must be divided with it, and
the finger then extended. 
FUNGUS OF THE DURA  MATER.             679
DISEASES  OF  REGIONS.
                      CHAPTER  XLVIII.

            DISEASES OF  THE HEAD  AND NECK.

                 FUNGUS  OF THE  DURA  MATER.

  Sometimes without external or apparent cause, at others in consequence of a
blow or fall, a fungous tumor  grows  from  some part of the dura mater, usually
on the vertex or the parietal regions.  As it increases in size it produces absorp-
tion  of the cranium covering it;  the bone becomes  thinned  and expanded,
crackles like parchment on pressure, sometimes without being raised above its
proper  level, but  more  usually pushed up by the pressure  of  the  growth be-
neath, which at last protrudes under the  scalp.  More usually this  perforation
of the cranium is gradual, but in  some cases it would  appear to have been sud-
den,  the first intimation  the patient  had  of the existence of disease being the
presence of a tumor under the scalp.   When the skull is perforated, the sharp
edges of the circular opening can  be distinctly  felt;  and the  tumor that pro-
trudes pulsates distinctly, as evidenced both by the finger and the eye.
   Symptoms of cerebral disturbance,—loss of  sight, double vision, deafness, or
epileptic fits, with  fixed pain  in the head, — usually precede, for a considerable
time, the external appearance of the tumor.  In some rare cases no such symp-
toms indicated the existence  of intra-cranial disease, and the first evidence of
the disease has been the sudden  protrusion of a pulsating  tumor through the
skull.  If the tumor is compressed,  and especially if attempts be made to push
it back under the bone,  giddiness, syncope, and convulsions are produced; and
as the disease makes progress, death from paralysis and coma ensues.
   The result of the treatment of  fungus  of the dura mater is not very satisfac-
tory; but yet as the disease would appear to be almost of necessity fatal, if left
to itself, something should be  attempted, not, however, until the tumor has
fairly appeared  through the  bones.   The scalp covering it should be turned
back by a crucial incision, and  the  tumor exposed.  The aperture in the skull
through which it has protruded, may then, if necessary, be enlarged by the use
of the trephine, or Hey's saw, so as  to lay bare  the full extent of the base of
the tumor, which must then be carefully  dissected away from the dura  mater.
   Fungus  of the cranium may occur which at first closely resembles the dis-
ease  just described.  It differs from it, however, in this respect, that the tumor
is devoid of pulsation and cannot be  pushed back.  It is vascular, in structure
resembles the pulp of a red gooseberry, or a broken-down mulberry.  In a case
of this kind which I had an  opportunity of seeing some years  ago, the growth
was successfully removed  by  my friend Mr. B. Phillips.
   Hernia  Cerebri, resulting  from wound  or ulceration of the dura mater, has
already been described (p. 290).   Encephalocele or  congenital hernia of the
brain is a  rare malformation,  usually speedily fatal.  Mr. Z. Lawrence finds
that of 39 instances in which it occurred, 21 were males, 18 females;  that the
protrusion  may vary from the size of a pea to that of a tumor exceeding the
child's head •  that the occiput is its chief seat, — of 79  cases, 53 being in this
situation.  In 6 instances, the subjects of this malformation reached  an adult
a«-e • in  all the remaining cases they died early, or were still-born.   Surgery
offers little in  these  cases, though in one instance the protruding portion of
brain was successfully sliced off, the patient surviving. 
680          DISEASES  OF THE  HEAD  AND NECK.
  Encysted Tumors of the Eyelids.—Small cysts are not unfrequently met with
lying between the tarsal cartilage and the conjunctiva.   At  first they occasion
no inconvenience, but as they increase in size they cause the conjunctiva cover-
ing them to become injected, papillated, and granular,  thus  at last occasioning
a considerable amount of irritation  and lachrymation.   These tumors may be
removed either by being dissected out, or by being obliterated by inflammation
set up in them.  If the tumor is to be dissected out, the eyelid must be everted,
and the cyst, having been exposed by dividing the conjunctiva covering it with
a fine scalpel, must be drawn forwards with a hook and removed by a few touches
of the knife.  This little operation is, however, at times somewhat troublesome,
and in preference to it I always induce the obliteration  of the cyst by exciting
inflammation in  it.  This may most conveniently be done by everting the lid,
and then making a crucial  puncture into the  cyst with a lancet; the contents
having escaped or been squeezed out, and  the part well  dried with a piece of
lint, a pointed silver probe dipped in nitric  acid  should be quickly introduced
through the puncture, the  inside  of the cyst  stirred up and a little sweet oil
having been poured over the lid, it may  be replaced.   Some induration will be
left in  the  site of the cyst for a few weeks, but as that  subsides  the tumor will
be found to have disappeared.
   Puncture of the Lachrymal Sac. — This operation is frequently required in
those cases in which, the nasal duct having become obstructed, the lachrymal
sac becomes distended by the accumulation of the tears, inflames, and either
threatens suppuration, or, having given way, a fistulous opening  has  been left,
below the  under  angle of  the eye, through which tears often escape — the
ordinary fistula lachrymalis.  If a fistula have not already formed, the sac  being
merely distended, the passage through the nasal duct may sometimes be restored
by  the careful introduction of a very fine silver probe into it through the puncta,
or the sac may be injected through the same orifice by  means of one of Anel's
syringes.   Should these measures not prove successful, the permeability of the
duct may be restored by catheterism from below;  for this  purpose a steel  probe
or sound, bent nearly to a right angle  at about one inch  from the extremity,
should be passed into the nostril beneath the inferior turbinate bone; by a slight
to and fro movement, the point of the instrument may be made to  enter the
orifice of the duct, and then  by directing the handle downwards and inwards it
will pass up along the canal into the lachrymal sac.
   Should these  means, however, not prove successful in restoring a passage for
the tears, or should a fistula have formed, the sac must be punctured and a style
                                             passed into it from above.  This
                  Fig. 255.                   operation  may be performed in
                                            / the following way.  The patient's
                                       ,/V head being well  supported on
                                       /  /   the breast  of an  assistant, and
                                       ' /    the lower eyelid having been put
                                       /     well on the stretch  by traction
                                             with the  finger  at  the  outer
                                             angle, the surgeon feels for the
                                             tendo oculi, the under surface of
                                             which is the guide into the lach-
                                       f    rymal sac.  In many cases, how-
                                       I      ever, owing to the swelling and
                                       /      induration  of parts this tendon
                                             cannot be felt, and then the guide
                                       1      must be the edge of the orbit
                                       '      below and  a  little to the  outer
                                             side of  the puncture.   Having
ascertained this, he rests the little  finger  on  the  cheek, and holding a strong
 
DISEASES  OF  THE  EAR.
681
narrow-bladed bistoury between the fore-finger and  thumb, with the flat  of the
blade parallel to the face and the  edge turned outwards he passes the point
downwards and  inwards well under the tendon of the orbicularis, the handle
resting against the middle or outer third of the eyebrow (fig. 255).  He then,
by carrying the handle inwards and somewhat forwards until it rests against the
bridge of the nose, causes the point to take a direction backwards, downwards,
and  slightly inwards, for about three-quarters of an inch, when the nasal duct
will  be fairly entered, which may be known by the bistoury supporting itself.
The  style may then be introduced along the blade, which should be firmly pressed
inwards.
   Extirpation of the Eyebull.—This operation may  be required for cancer of the
eyeball, either of an encephaloid or melanotic  character (fig. 256).  It  is also
occasionally called for when in consequence of
injury or disease one eye has become disorgan-           Fig. 256.
ized  and the vision of the other is  sympatheti-
cally affected, and can only be preserved by the
removal  of the globe that is  already useless.
The  operation may be performed in the following
way: —
   The surgeon standing in front of the patient,
makes an incision through the outer commissure
of the lids as far as the edge of the orbit.  The
eyelids are then well everted  and  held apart
with a wire speculum.  The surgeon next passes
a double hook into the globe and draws it well
forward;  then  with a  curved broad  pair of
scissors he divides the conjunctiva at its upper part, and then proceeds to  cut
across the several muscles of the orbit, and lastly the optic nerve.   Should any
of the structures within the orbit now present an  unhealthy or suspicious  ap-
pearance he clears them out.  The  hemorrhage, which is  usually rather abun-
dant, may be readily arrested by a pledget of dry lint pressed into the orbit and
retained by means of a circular bandage.
   If the lachrymal gland is diseased,  it must  of course be removed with  the
eyeball.  If sound, it may be left, as it atrophies and gives no trouble.
   Extirpation of the lachrymal gland  may be  required for cancerous degenera-
tion.  This operation may be performed from the outer or from the inner side
of the lid. Whenever practicable it should be done from the inner aspect.   It
may be performed in the following way: The outer commissure of the lids  having
been divided as  far as the edge of the  orbit, the upper eyelid is everted  by an
assistant; the surgeon  then divides the conjunctiva covering the tumor, and
fixing a hook in it draws it forwards, and with a few careful touches of the knife
divides its attachments.  After the removal of the  tumor the lid drops  into  its
normal position, and the commissure is closed by a  suture.

                       DISEASES OF THE  EAR.

   Inflammation of  the external ear, otitis, or  ear-ache, is usually a rheumatic
affection, and is characterized  by intense pain, generally associated with hemi-
crania — a kind of combination, indeed, of inflammation and neuralgia.  This
pain is much increased at night by  warmth of  the  bed, and is generally  accom-
panied by throbbing and noises in the ear.  The treatment, at first antiphlogistic,
generally and locally, may advantageously, after a  time, give place to quinine
and  the iodide of potass, with the external application of aconite.  Occasionally
the affection runs on to the formation of abscess in the meatus externus, attended
by excessively painful throbbing.   With the view of relieving this, leeching,
poulticing, and early lancing will be required.
 
682          DISEASES  OF THE HEAD  AND  NECK.
   Otorrhoea, a fetid discharge of a muco-purulent character, usually occurring
in strumous children, and often associated with enlarged glands under the angle
of the jaw, may be  of two kinds; either proceeding simply from the mucous
surfaces  and being  inflammatory, or it may be connected with necrosis of the
petrous portion of the temporal bone, being associated with disease and destruc-
tion of the tympanum, and necessarily of the  internal ear.   In  the first  case,
astringent  injections containing  some of the chlorides in solution may advan-
tageously be used, and will commonly arrest it.   If, however, it  proceed  from
disease of the bones, it is necessarily of a far more  serious character, and the
membranes at the base of the brain becoming irritated by the extension of the
morbid action  to  them, convulsions  and death usually eventually result.  In
some of  these cases, phlebitis of the sinuses and of the cerebral veins ensues,
and proves fatal to the patient.
   The external ear is occasionally the seat of special affections;  thus, in idiots,
hypertrophy of this structure  is occasionally met with; and in gouty subjects,
tophi, or gouty concretions, are occasionally deposited in it.   Paget, Brack, and
Panzetta have described a fibrous tumor that occasionally forms in the lobule of
the ear, from the irritation produced by piercing it, and as "one of the penalties
attached to the barbarism of ear-rings."  These tumors are of a semi-malignant
character,  like the warty growths of cicatrices, and, after excision — which is
their only  treatment — are somewhat apt to return.
   We not uncommonly find that the meatus becomes blocked up by accumula-
tions of wax, dark, indurated, and  pipe-like; or forming balls and masses that
lie in contact with  the tympanum.   These chiefly occur in  individuals of the
bilioso-phlegmatic temperament, and are a common source of temporary deafness
amongst young people.   They not only impair the sense of hearing  materially,
but are very apt to give rise to noises in  the head, and  crackling sensations on
opening and shutting the mouth.  Their presence is best ascertained by exami-
nation with a well-constructed ear-speculum; those introduced by Mr. Toynbee,
of a double convex shape, are the most useful.   The treatment of these concre-
tions consists in softening the wax by the introduction of a little glycerine into
the ear  for a few nights, and then  repeatedly washing out  the meatus by the
injection of tepid soap and water, or water  containing a little soap liniment,
thrown in with a  large syringe;  as  the  fluid regurgitates from  the tympanum,
it will at length bring away the dark and hardened ceruminous masses.
    Polypi are occasionally met with, situated rather deeply on one  side of the
meatus: they are usually hard and  fleshy looking, though sometimes soft and
gelatinous, as in  the nose; sometimes pediculated, but at others situated on a
broad base, they produce serious inconvenience by obstructing the external
 ear, and require  to be pulled off by means of forceps, or, if too firmly fixed
for this, cut off  with scissors; the surface  from which they  spring  should
then be  touched with the nitrate of silver, so as  to prevent a recurrence of the
growth.
    Occasionally the cuticle of the external ear, and that covering the tympanum,
becomes thickened and  indurated, assuming a dull white  appearance, which
 then may give rise to some amount of  deafness.  Under these circumstances,
 glycerine, the citrine  ointment, or the  solution of the  nitrate of silver, will be
 extremely useful  in restoring the healthy action of the integument of the part.
    It is not my intention  to enter into the general pathology of the various kinds
 of deafness, or to  discuss  the causes of this affection.  It may be stated generally,
 however, that it  may arise from obstructions of the external ear from disease,
 ulceration and perforation of the tympanum, from  various  inflammatory affec-
tions, chiefly of a subacute and chronic  character,  of  the internal and  middle
 ear; from  paralysis of the acoustic nerve, dependent  on cerebral  lesions, or local
 paralysis; and, lastly, from obstruction in the Eustachian tube, or from disease
of the throat.  Mr. Toynbee has especially shown that many cases of so-called 
DISEASES  OF  THE  NOSE.
683
Fig. 257.
"nervous" deafness, together with singing, ringing, boiling, and other noises in
the head, are in reality dependent upon chronic inflammatory affections of the
internal and  middle ear, and that the treatment best adapted for their  cure
consists in constitutional and local  means  of an  alterative  and antiphlogistic
character.
                      DISEASES  OF  THE  NOSE.

   Epistaxis, or bleeding from  the nose, is very common in  children and in
young people about the age of puberty, more particularly in girls antecedent to
the menstrual period; it may either be of an active or passive character, but is
most usually dependent on congestion of the mucous membrane.   It may com-
monly be stopped with-
out much difficulty by
the use of domestic re-
 medies, but occasionally
 it is so copious, amount-
 ing to many ounces, as
 to exhaust the patient
 and to require surgical
 interference.    In  the
 majority of  cases  the
 application of cold water
 and ice to the  forehead
 and bridge of the nose,
 with  rest, and a  free
 aloetic purge,  will ar-
 rest the bleeding.   If,
 however, it do not stop
 in this way, it will  be
 necessary to plug the
 nostrils.  In many cases  it may be sufficient to plug the anterior nares with a
 pledo-et  of  lint; very commonly,  however, the  posterior nares require to be
  plugged as well.   This is best done by carrying a long piece of strong whip-
  cord aloncr the floor of the nose through the posterior nares into the  pharynx,
  by means of Bellocq's sound;  or, if this be not at hand, by threading the  cord
  through an elastic  catheter, and carrying this into the pharynx, then seizing
  the cord as it appears behind  the  soft palate, and drawing it forwards into the
  mouth, at the same  time  that the catheter is taken out of the nostril.  In this
  way the string will  pass  through the nose, round the back of the soft palate,
  into and then out of the  mouth (fig. 257).  To the centre of the piece of string
  that hangs  out between the lips, a plug of lint, about the size of the end of the
  thumb,  should be firmly  tied;  this is then drawn up into the posterior nares by
  pulling on the end of the ligature that  hangs from the nose, being guided m
  its passage behind the palate by the fingers introduced into the mouth.  When
  the bleeding has ceased, it may readily be withdrawn by means of  the string
  that hangs out of the mouth.                                 .      .      ,
     The mucous membrane  of  the nose is not unfrequently chronically inflamed,
  especially in  strumous children; that portion of the membrane covering the tur-
  binate bones becoming  thick, soft, and  vascular, and  projecting like a broad
  fringe from their surface.   It is usually of a bright-red color  and covered with
  muco-pus.   This swelling at  all times produces snuffling and a peculiar intona-
   tion of voice, but increases in wet weather, and  then may become so great as
   seriously to obstruct the breathing.  The treatment consists in attention to the
   general health;  more especially to the eradication  of the strumous diathesis.
   Much benefit may also be derived by the local application or injection of astrin-
   gents, as a strong solution of  the nitrate of silver applied by means of a camel s-
 
684
DISEASES  OF  THE NOSE.
hair brush, and sulphate of zinc and oak-bark lotions snuffed up, or injected by
means of a proper syringe.   In many instances, when this  disease occurs in
strumous children, change of air will effect the greatest amount of benefit.
  Abscess occasionally forms either on the mucous membrane or on the septum,
and thus may lead to necrosis of the cartilages and bones, with much discharge
and fetor, separation  of these, flattening  of the nose, depression of its bridge,
and great deformity.  These various forms of abscess, followed by necrosis, are
commonly syphilitic,  and then are associated with ulcers and a foul and fetid
discharge, which has a tendency to  cake  upon  their surface, forming dark and
rugged crusts, and constituting the different kinds of ozoena.  The septum may
be  the seat of chronic ulcerations  consequent upon  the irritation of decayed
teeth, producing  disease of the antrum,  and  escape of morbid secretion from
this into the cavity of the nose, and this "coming in  contact with the septum,
produces thickening and ulceration  of it.  The treatment of these  conditions
must  be conducted by the local  application of nitrate of silver, black wash, and
the chlorinated lotions;  the general treatment consists usually in the adminis-
tration of the dilute mineral acids, the iodide of potass, and sarsaparilla.  Ulcers
and fissures of a less serious character, though very painful and chronic, often
occur at the  angle  of the ala and septum, or between the ala and tip; their
treatment consists in touching them from  time to time with the nitrate of silver,
or in  the  application  every night of the white precipitate or citrine ointment, at
the same  time that the general health is attended to, cachexy removed, and the
strength restored, by the administration of iron, bark, and sarsaparilla.
   Lipoma is a chronic hypertrophy of the cutaneous and  subcutaneous struc-
tures, and of  the  cellular tissue of  the nose, forming a large reddish-blue, vas-
cular-looking, soft, tremulous, and lobulated mass,  enveloping the end of the
nose, and producing excessive deformity  of it.   There are all degrees  of this
disease, from mere clubbing of the end of the organ to the formation of a set of
pendulous lobular tumors attached to it.  The  sebaceous glands and crypts
appear to be the structures chiefly implicated  in this disease.   The patient's
appearance may be greatly improved by  the removal of these growths.   This
may be done readily  enough by making an incision  down the mesial line to the
alar cartilages, and then  dissecting  it off these on either side;  especial care,
however,  being taken in doing this not to encroach upon the nostril.  This is
best avoided by directing an assistant to  keep his finger  in it whilst the dissec-
tion  is being prosecuted, so  that he may warn  the  surgeon of the too near
approach of the knife.   The surface is then left to granulate and cicatrize.
   The nose is frequently the seat  of lupus and various forms of epithelial cancer,
many of the deformities of this feature being referable to this affection ;  indeed,
lupus may be looked upon  as  almost specially affecting this organ, destroying
one or both alae, the columna, or perhaps  the whole of the nose.  The considera-
tion  of the nature and treatment  of these affections  in  this situation presents
nothing special;  but that of the cure of the deformities induced by them, which
is full of interest to the surgeon, will be considered in detail when we come to
speak of the plastic  operations that are practised on the face.
   Tumors of very different structures and composition are  met with in the nos-
trils, and to all of these which  possess the common characters of being pendu-
lous and blocking up these passages, the  term polypus is given.  Thus surgeons
commonly speak of the  benign,  the soft, the  gelatinous or mucous polyp, as
well as the sarcomatous  or fleshy, and the malignant polyp.   The term however
should properly be confined to  a  soft and pendulous  mucous growth, the fleshy
and malignant polypi being merely varieties of  fibrous  or encephaloid tumors,
springing from the bones  in  the nasal fossae, or from the ethmoidal and sphe-
noidal cells.
   The true mucous nasal polyp, is a soft, moist, gelatinous tumor, of a greyish-
yellow color when lodged in the nasal fossae, but when it descends into the ante- 
             NASAL  POLYPI. — MODE  OF  REMOVAL.          685

rior nares, or beyond them, and  is exposed to the air, it becomes of a reddish-
brown  or  purple  tint, and somewhat shrivelled on the  surface.  It is usually
lobulated, pedunculated, or bottle-shaped, and not very vascular except at the
root, where  it is  permeated by  largish thin-walled vessels that bleed freely on
the slightest touch.   In structure  it is homogeneous, and  composed of the
elements of mucous membrane, covered by tesselated and ciliated  epithelium,
the ciliae of which may often be seen under the microscope in active movement
after the removal of the growth, beating about the blood-corpuscles  and fluid in
which  it  lies.  These  tumors may grow from all  points of the surface of the
turbinate  and ethmoid bones, and have indeed occasionally, though  very rarely,
been observed  to project into  the nose from the frontal sinuses and antrum.
Most frequently they grow from the inferior spongy bone towards the outer side
of the  nostril, sometimes from the roof of the nares, but never take their origin
from the septum.  These polypi are usually numerous and of all sizes; as they
increase, they commonly extend forwards into the anterior nares, but when of
large size, they may  be  seen to reach into the  posterior  fauces, hanging down
behind the palate.
   The symptoms occasioned by the presence  of these polypi, depend on their
interference with respiration and speech; and on the visual changes  they occa-
sion.   The respiration through the affected nostril is impeded, the patient being
unable to blow  through it when directed to  do  so, and his speech  is thick and
nasal.   There is snuffling and mucous discharge from the nostril, and all these
symptoms are worse  in damp than in dry weather.  On examining the interior
of the nose, by opening  the nostril widely with the forceps or nasal speculum,
and then  directing the patient to blow down, the lower end of the polyp may be
distinctly seen, and  if large, will descend on a level with, or even  beyond the
nasal  aperture.   By the introduction of a probe, the  size and  extent of the
tumor, together with the position of its pedicle, may be readily ascertained.   As
it grows, it impresses changes  on  the  shape of neighboring bones, producing
expansion and flattening of  the  nose, inducing caries of the spongy bones, and,
interfering with the  flow of tears down the nasal duct, occasions  a  watery state
of the  eyes, which,  together with the change of shape in the features, and the
peculiar character of voice and respiration, enables the surgeon at once to recog-
nize the nature of his patient's disease.  Polypi  chiefly  occur in young adults
after the age of puberty; but they are not unfrequently met with at later periods
of life.
   The diseases with which  nasal polypi may be  confounded are, 1st. Chronic
thickening of the mucous membrane covering the spongy bones; from this the
absence of any pedunculated growth around which a probe can be passed, toge-
ther with the florid  red character of the thickened membrane, and  the fact of
this almost invariably occurring in strumous children, are sufficient  to distin-
guish them.  2d. Abscess of the septum; from this the history of the case and
the fact of the polyp never being attached to this part of the nose, will establish
the diagnosis.   3d. There  is a peculiar malformation of the septum consisting
in a deviation of it to one side,  that may at first  be a little puzzling; but here
the examination of both nostrils and the discovery of a depression  on one side
of the  septum corresponding to the projection on the other, will reveal the true
nature of the case.  4th. The fibrous and malignant tumors of the nostril will
be found  to differ sufficiently in consistence and  appearance  from the ordinary
polypi  to prevent their  being confounded with them in many cases; but yet in
some instances, much care will be required in coming to a definite opinion as to
their true nature.
  Nasal polypi  may generally be most readily removed by avulsion, with forceps;
occasionally, but rarely, when they are very large with a broad base, and espe-
cially when extending into  the throat, they require the application of the liga-
ture.   In removing  these growths  by the forceps, instruments of  good length 
686         DISEASES  OF THE NOSE AND  CHEEKS.
but very slender construction should be used, those generally sold are too thick ■
the interior of the blades should be  properly serrated, and  have a longitudinal
groove, so  that the root of the tumor  may be tightly grasped.  The patient
should  be  made to sit on rather a low chair, and as there  is generally a good
deal of bleeding, a towel should be pinned over his  clothes, and a basin placed
before him to  receive the blood and expectorated matters.   The surgeon then
having ascertained by the introduction of a probe, or by means of the blades of
the forceps the situation of the pedicle of the polyp, grasps this firmly and pulls
it off  with a twisting movement of  the  hand.   He proceeds in this manner,
twisting off rather than  pulling away polyp after polyp, until the whole of  the
nostril  is cleared, which may be ascertained by examination and  by directing
the patient to compress the sound,  and to blow  through the  affected side of  the
nose.   The bleeding, which is often very free, stops on the application of cold
water.   At about the end of a fortnight the patient  should  be examined  again,
as it not unfrequently happens  that  small  polypi, which had been prevented
descending into the  nares by the  presence of the larger ones, now come down
and require removal.  These procedures must be had recourse to  from time to
time until  all tendency to fresh formations of this kind has ceased.
   The ligature is chiefly required  for those  polypi that pass into  the pharynx
through the posterior nares.   They may best he tied  by passing a loop of  strong
whipcord,  by means of a double canula, through  the nose, and then, expanding
the  noose  round the tumor in the  throat and making it grasp its pedicle, knot
it tightly.   In some instances the polypi attain a great size, producing absorp-
tion of the nasal bones,  of the nasal  process of the superior maxilla.  In such
cases it may be necessary, in order to extract them, to slit up the nose and pos-
sibly clip away with  forceps the osseous surface from which  they spring.
   The fibrous polypi may grow to a large  size, extending into the throat, and,
perhaps, finding their way from the  nose  into situations where they are little
expected.  Thus  they have  been met with in  the pterygo-maxillary fossa,  and
have been known to pass into the orbit through a hole in its inner  wall.
   Malignant  tumors of an encephaloid character occasionally form  in the nos-
trils, chiefly  in children and young people,  and, being attended by great  expan-
sion of the bones, with a fetid discharge of bloody matter and disintegrated por-
tions  of the growths, may end by speedily exhausting  the patient. In such
 cases the surgeon may make an attempt to  extract the growth by slitting  up the
nose, but  it  is seldom that anything very effectual  can be done  by operation,
and it should  be borne in mind, that some of the malignant  growths that  pro-
 ject into  the  nostrils take their origin  from inside the cranium,  or the sphe-
 noidal cells, and that the nasal portion is only the external protrusion as it were
 of a deeply-seated tumor.
    Calculi are occasionally met with  in the nasal fossae, where  they simulate a
 foreign body;  and here extraction  may be practised with a pair of forceps.  But
 sometimes these rhinolites  are situated  under the mucous membrane.   In  two
 cases I have dissected round  calcareous bodies of this kind, about  the size of
 cherry-stones,  from under the  mucous membrane of the ala of the nostril in
 children.
   The frontal sinuses, though rarely,  are occasionally the seat of disease.
 Abscess may  form here with  much pain  and expansion,  and possibly caries
 of their anterior wall, attended by the local  signs of inflammation and with
 danger of concomitant inflammation  of  the membranes of the brain.   Under
 such  circumstances  it may be proper for  the  surgeon to consider  the  advisa-
 bility of removing by a small trephine the anterior  wall of  the  sinus, and  thus
 giving exit/ to the retained  pus.   There  are a  few cases recorded in surgical
 writings, of polypi springing from these  sinuses, and finding  their way down
 into the nose  after producing expansion of it and much  inconvenience.   Here 
CONGENITAL  MALFORMATION OF  LIPS.        687
Fig. 258.
likewise the propriety of trephining and so extracting the morbid mass would
have to be considered.
  The cheeks are  occasionally the seat of
encysted  tumors  and   cancerous  growths,
either springing from their inner surface, or
taking their origin  as  lupoid  ulcers on  the
outside.   The encysted tumors in this situa-
tion may readily be removed by a little simple
 dissection.  The cancroid  ulcers and tumors,
 such as represented in fig. 258, seldom admit
 of operative interference.
   One of  the  most  troublesome  surgical
 affections situated in the cheek, is a salivary
 fistula, occurring in consequence of injuries,
 abscess, or operations, by which  the  parotid
 duct has  been opened  so  as to cause a trick-
 ling of saliva through the external aperture
 that has been made into it.  If the fistulous
 opening  be recent, the lips  of the external
 wound may be brought together and made to
 close,  whilst the  internal aperture  is free.
 If it be of old date, a seton composed of a few threads may be passed into the
 fistula from the inside of the mouth, so as to allow the saliva to find its way
 along this, whilst  union of the external orifice is attained by paring its edges
 and Wringing it together with hare-lip pins.   My colleague, Mr. Marshall, has
 succeeded in closing  an  aperture of this kind by restoring the canal by means
  of a wire heated by galvanism, and then getting the external orifice to contract.
                     DISEASES  OF THE LIPS.

  The lips frequently require  surgical interference.  They may be the seat of
tumors of various kinds, encysted or erectile,  which require extirpation  by
the knife or ligature.  In dealing with these, the  surgeon must be  guided by
the circumstances of the individual case, but he  should, if possible, avoid cut-
ting through the whole  thickness of the lip, and if compelled to do so, he must
act°as will be described when we come to speak of cancer of this region.   These
growths more frequently occur on the lower lip.   When  encysted, they  are
usually small  transparent tumors, with thin  walls, containing a  glairy straw-
colored fluid.  These should always be dissected out; mere excision of a por-
tion of the wall being followed by recurrence of the disease.
   Erectile tumors of the lip are usually of an active character, and may either
be excised, if of  moderate extent  and implicating the whole thickness of the
lip; or if of large  size and projecting from  the mucous surface, they may be
safely ligatured.  I have had  under my care some cases  of nevus of the upper
lip, implicating the whole substance of the part, and have successfully removed
them by the repeated application of the potassa cum calce.                  .
   Hypertrophy to a great extent occasionally occurs in this  situation.   This  is
often of an cedematous character, being kept up by the irritation of fissures
or cracks; if  so,  these  must be cured, when the  size of  the lip will gradually
diminish again.   Sometimes,  however, it becomes permanent, continuing alter
the cure of the fissure; under these circumstances it may be necessary to excise
a portion  of the lip, and  then to bring the edges  together by means of sutures

 ^ Congenital malformation of the lips is of common occurrence.  Contraction
or even complete closure of  the  orifice  of the  mouth has been met with  at 
688
DISEASES  OF  THE LIPS.
birth;  such a condition must be remedied according to circumstances by the
skill of the surgeon.
  By  far the most common malformation  in  this situation, is the  condition
termed hare-lip.   This consists of a  perpendicular fissure through  the  upper
lip.  A similar condition has been described in the lower lip, but I have  never
seen such a  case,  or met  with anybody who has.   In  hare-lip, the cleft is
usually on one side only; and then it  is said to be single, and most frequently,
so far as I have observed, occurs upon the left side.  Not  unfrequently there is
a fissure on both sides of the mesial line;  and then the hare-lip is said  to be
double.  The cleft never passes through  the mesial line.   When double, the
fissure is deeper on one side than the other, and usually extends into the nos-
tril, though  sometimes it  stops short of that.   In  these  cases, the nose is
usually flattened and expanded, and between  the  fissures there is always  a cen-
tral or median lobule, consisting of  the inter-maxillary bones in a rudimentary
condition; to this  a small  triangular piece of lip is commonly attached.  In
many cases this is pushed forwards,  and tilted on its base, so that the alveolar
border projects forwards.  Sometimes the projection  is  so considerable that it
is attached to the tip of the nose.
   The cleft in hare-lip corresponds to the line of junction between the embry-
onic inter-maxillary bones and the superior maxilla.   The fissure when single,
may be confined to the lip,  but in the majority of cases it extends to  the upper
 jaw.  In other cases again, the fissure extends back  into the palate;  this more
frequently happens when the hare-lip  is double, and in these  cases every variety
of  palatal deformity is met  with.
   The cure of hare-lip can only be effected by a properly conducted  operation.
In the performance of this, the first point that has to be determined  is the age
at which it should be done.  On  this there  has been, and is still, a  good deal
of  difference of opinion.   Surgeons  generally are,  however,  I think, agreed
 that the operation should not be performed during dentition; at all events not
 during the cutting of the incisor teeth, when there  is  much local excitement
 and general irritability of the nervous system; but  they are not  agreed as to
 whether it should be done before  or after  dentition.  In support of the opinion
 that it is more prudent to wait until  after this period, it is  alleged that very
 young infants are  especially  liable to convulsions;  that the performance of
 operations in them is troublesome;  and that it interferes with suckling.  These
 statements, however,  are not  carried out by  what we meet with in practice.
 I think that there is no evidence  to show that there  is any danger in operating
 during early infancy; indeed, I  believe  that very  young  children, those but
 a few weeks or months old, bear operations remarkably well.   I have repeatedly
 operated at these tender ages, not only for hare-lip, but for hernia, the removal
 of tumors, nevi, the division of  tendons, &c, and  have never seen any bad
 result follow.  Besides this, the performance of the operation is easier at a very
 early age than when  the child has reached its  first or second year; when its
 intelligence being more developed, it  knows what it  has  to  suffer, and screams
 and struggles more than a very young infant does, whenever it sees the surgeon,
 or  he  makes  an  attempt to examine the wound or dressings.  After the opera-
 tion, also, the child will, when young, take to the breast without  difficulty and
 with  the  greatest avidity.   The act of  suction  is  advantageous, as in it the
 sides of the  incision are more closely compressed and brought together.  At
 very early ages union of  the wound takes  place with great readiness and
 solidity, and  as no time has been given for  the rest  of the features  to become
 distorted, there will not be that permanent flattening and deformity of the face
 which is apt  to continue after the hare-lip is cured if the operation be deferred
 to a more advanced age.  For these various reasons I agree with Dubois and
 Fergusson, that the operation had best be performed early, and, if possible, at 
OPERATION  FOR  HARE-LIP.
689
about the sixth week after birth, or from that to the third month, which may,
I think, be considered the time of election for this procedure.
  In the treatment of hare-lip, there are  three  points  that  require  special
attention:
  1st. To procure union by the  direct adhesion of  the cut edges of the fissure;
2d. That the union should be attended by as little deformity as possible; and
3d. The avoidance of all traction  on the line of incision that may interfere
with these results.
  These principles of treatment  are carried out by paring the edges of the fissure
freely, bringing them together by means  of  the twisted  or interrupted suture,
and taking off all tension  by means of strips of plaster and the cheek-compressor.
But the details of the treatment vary so much, according as the fissure is single
or double or complicated by more or less projection of  the inner-maxillary por-
tions, that the steps  of each operation require to be separately described.
,   The operation for  single hare-lip is  performed in the following way: — The
child having  been  well  pinned in a jack-towel that swathes it tightly, the
surgeon, sitting down, places  his feet on a stool so as to raise them,  and cover-
ing his knees with a piece  of tarpaulin, holds the child's head firmly between
them.  He then, putting the lip on the stretch by seizing the extreme edge of
the cleft with a pair of artery forceps, pares the edges of the cleft by transfixion
with a narrow-bladed bistoury, or fine scalpel,  from above, downwards, first on
one side, then on the other, taking care that the incisions unite  neatly and
cleanly above the upper angle of the  fissure, which  must be well cut out;  and
that they extend sufficiently far outwards to cut away the rounded portion of
 the prolabium which forms  the side of the base of the fissure.  Care should be
 taken that enough is cut away; there is more danger usually of taking too little
 than too much.
   In single hare-lip, where the  lips are very lax, the incisions may be straight,
 but in double hare-lip they should be somewhat concave  inwards; in this way
 there is less likelihood of an  unseemly notch being left (fig. 260).
   Fine hare-lip pins,  made of soft iron wire, with steel points, should  then be
 deeply introduced through the lip from one side of the fissure to the  other.   At
 a very early age one pin may  be sufficient; at a later  period two are required.
 If two are used, the lower pin should be introduced first underneath,  or through
 the cut  labial artery, in  such  a way that its pressure may stop the bleeding
 from this vessel, which is  often rather free.  In  passing this pin,  great  care
 should be taken to bring the  opposite sides of the fissure well  in contact, so as
 to  be on a level below, that no  irregularity may be left in the  prolabium; the
 twisted suture is then applied in  the usual  way, first round the lower pin, and
 then round  the  upper  one,  and lastly the  two are
 united by a few cross  turns (fig. 259).  The pins are        Fig. 259.
 then cut short, and  a piece of plaster put under their
 ends to prevent excoriation of the  skin.  In addition
 to the pins and twisted suture, I invariably introduce
 one point of interrupted suture through the mucous
 membrane of the  lower part of the fissure, just  inside
 the mouth;  and I look upon  this  as  of great conse-
 quence  in order  to prevent  the notching, which is
 otherwise very apt  to occur,  in consequence of that
 portion of the incision between  the lower pin and the
 edge of the lip being  kept  open by the child in suck-
 ling, or protruding its tongue against it.  At the end of
 about the third or fourth day, the pin may be removed
 by oushing it through the lip  by a gentle rotatory movement, in such a way
 that the cut end does not tear or lacerate the aperture in the lip.  The sutures
 may be left on for two or three days longer; the lip being supported by a strip
        44
 
690                  DISEASES OF  THE LIPS.

of adhesive plaster, or by a piece of lint soaked  in collodion, which I have found
to form a firmer and  more secure  support than the plaster, and should indeed
be continued for about a fortnight after the operation, so as to prevent stretch-
                                  ing of the cicatrix  and notching of its lower
             Fig. 260.             part.  The point of interrupted suture may
                                  be left in for about six days.   If the fissure
                                  be wide, and child restless, so  that there is
                                  danger of the parts being dragged upon dur-
                                  ing its screaming or crying, it is a very good
                                  plan to apply the  spring cheek-compressor,
                                  invented by Mr. Hainsby, here represented
                                  slack (fig. 260).
                                    The operation for double hare-lip is per-
                                  formed on  the same  principles as  that for
                                  the single  form of the disease, viz., of pro-
                                  curing union by adhesion between the oppo-
                                  site  surfaces.  The difference in the opera-
                                  tions consists in dealing with the intermedi-
                                  ate portion  of the lip and alveolus.  If this
                                  portion of the lip be small or fixed to the tip
                                  of the nose, as in  fig. 262, it should be cut
                                  off, as  it would prevent the lateral segments
                                  coming into proper apposition;  but if large,
it should be well  pared  on either side, and transfixed by the hare-lip pins, and
thus be interposed between and united to  the pared lateral surfaces; indeed, it
is always advisable  not  to remove this, unless it be  awkwardly situated, as in
fig. 261, when  left, though the union may not appear quite so perfect and uni-
form as it would if the  lateral halves had been directly united, yet eventually
the case will turn  out  better;  the central portion becoming  developed, and
forming the natural  mesial projection of the lip, which is lost when the lateral
halves are  directly united.  In some of these  cases great nicety is required in
planning the  incisions,  and  in the  introduction of the  sutures.    The central
portion  is  most advantageously pared  in  a somewhat concave manner, so that
the freshly cut edges of  the lateral halves  are received into and more accurately

                 Fig. 261.                          Fig. 262.
fitted upon it.   When  the intermediate alveolus is small and rudimentary, and
more particularly, if it be very prominent, it had  better be cut off with a pair
of bone-nippers, and the lip brought together over the cut surface.  Most com-
monly there will be free  bleeding from the dental artery deep in the bone, and
which requires  to be touched with a red-hot needle or wire before the hemor-
rhage  from  it will  cease.  Whenever practicable, however, this central portion
should be saved, as by its removal  not only are the incisor teeth sacrificed, but
 
          OPERATION FOR HARE-LIP  WITHOUT  PINS.      691

a gap is left which causes some deformity in after-life.  If the intermediate por-
tion  be large and not  projecting, it should be  left, and the edges of the lip
brought together  over  it.   If it be projecting  and  large, it should be bent
forcibly back; this is  best  done by seizing it with a pair  of necrosis forceps
covered with wash-leather.   If, by any chance, union by the first intention fail,
the lip tearing open, the granulating surfaces must be brought in contact with
one  another  again, when they will  in all  probability cohere  as readily as they
would have done in the first instance.
   Treatment by Simple Suture.—During the last few years I have been in  the
habit of treating hare-lip of all kinds, double as well as single, with the simple
interrupted suture alone, without using  any pins.   I have  in this way treated
most successfully many cases  in  children, whose ages have varied  from a few
days to four years, with most satisfactory results, and with less marking of  the
lip than I have ever seen attend union by means  of the twisted suture, to which
I now generally prefer it as being  equally safe, more simple, and followed by
less  scarring  of the lip.
   When the fissure  is single,  the edges, having  been pared  in the usual way,
should be brought together by two points of suture, the first passed deeply near
the free edge, and in such a way as to  compress the  cut coronary artery;  the
other nearer the nasal angle.  These sutures should be of thick well-waxed den-
tist's twist, that will not cut out too  readily.  A point of fine interrupted suture
should then be inserted through the mucous membrane inside the lip.  The lip
may then  be  supported  by two narrow strips of plaster, one placed between the
sutures, the other between  the upper suture and the nose.   On the third day
the  upper suture should be taken out, but the lower one may be left in for a
day  or two longer, when it and the one through the mucous membrane may be
removed together, unless the latter has  already cut its way out.   The lip must
then be supported for a few days with a  strip of  plaster.
   In the  ease  of double hare-lip the same plan is to be adopted, first on one
side, then  on the other; but  in these  cases,  as the  gaps are wider, and  the
tension, more particularly when the intermaxillary prominence is  very pro-
jecting, is apt to be considerable, it is necessary to  support the cheeks, and
thus to prevent undue  traction  on the stitches, by means of the cheek-com-
pressor.   In  this way all risk  of the stitches  cutting out before union is com-
pleted  is avoided, and excellent and solid union will  speedily be obtained even
in the worst cases  of double hare-lip, with  great intermaxillary projection and
fissured palate.
   Ulceration is not unfrequently met with  on the prolabium, frequently of a
simple character, though chronic, when it will commonly yield to the application
of nitrate of silver and to proper constitutional  treatment, more especially the
administration of the preparations of arsenic.  Not unfrequently warty growths
and  various forms  of epithelial cancer and cancroid  diseases appear upon  the
lips.  These affections  are  not removable by  therapeutic means, and require
surgical interference.
   Cancroid ulcers of the lip either  commence as warty growths, which  gradu-
ally  ulcerate  like  the  ordinary forms of tubercular  lupus, or beginning as  a
crack or fissure  become  indurated,  the  edges having a tendency to spread,  the
submaxillary glands  to become involved, and  the  disease eventually  to  prove
fatal by the  pain, exhaustion, and  constitutional irritation induced  by  them.
These ulcers almost  invariably occur in men, affect the lower lip, and are met
with after the middle period of life.  Of 14 cases in which I have operated,  7
were above sixty,  and 4 between fifty and  sixty years of age; in one case only
did the disease occur under  thirty.   This disease is at first  entirely local, often
being induced by some irritation, as by a rugged, broken tooth, or by smoking
a clay pipe, and when removed does not, I believe, very commonly return.  At
least, of the  very many cases that have  been  operated upon at the University 
692
PLASTIC  SURGERY  OF THE FACE.
College Hospital, I have  only known  one patient return with a recurrence of
the disease, and I do not recollect any case of secondary affection  of this de-
scription apply to that institution from other hospitals; I cannot, therefore, but
come to the conclusion that the operation for cancer of the lip frequently rida
the patient permanently of disease.
   When  the  glands under the jaw are enlarged in these cases, it may be a
question whether the  operation should  be done; but I think  decidedly that
extirpation  of the  disease and  removal of the  enlarged  glands, provided the
surrounding soft parts are not involved,  should  be practised, if the patient be
otherwise in a good state of health, as he will  thus be placed in a more  favor-
able condition  than he was  before the operation, and will have a better chance
of prolongation of life.
   When once the true nature of  the  disease has been ascertained, the  opera-
tion should be performed with as little delay as possible; but before it is done,
it is well that any very prominent or broken tooth should be removed, and the
tartar cleared away from the incisors.  The  operation requires  to be somewhat
modified according to the situation and extent of the affection;  if this be tole-
rably limited, a V shaped cut,  extending  widely around it, and carried suffi-
ciently low to include any indurated prolongation of the absorbents, should be
practised; the edges of the cut should then be brought  together by two hare-
lip pins with a twisted suture, just as in the case of a simple hare-lip.  When
the disease occupies a considerable longitudinal extent, but does not dip down
very deeply, a slice of the lip should be shaved off, including the whole of the
morbid structure;  and it is often surprising, under  these  circumstances, how
little deformity will result, so soon as the disease is removed, the tissues of the
lip speedily rising to their natural level, and thus preventing any material de-
formity being left.   In some  cases the disease occupies a square surface, and
then it is necessary to excise a large portion of the  lip; when  this is done, a
considerable gap will be left, which requires to be filled by some plastic  opera-
tion, such as we shall  immediately consider, which  may most  conveniently be
done at the time that the excision is practised.

                 PLASTIC  SURGERY  OF  THE FACE.

   By  plastic or reparative  surgery is meant those  processes by which  mutila-
tions are  repaired,  and  loss  of structure  replaced.  As these operations are
principally practised for  deformities of the face, we may conveniently discuss
them here.  It has been long known to surgeons that parts of the body may
retain their vitality sufficiently to become again adherent when attached  but by
a very narrow tongue of  tissue, to the part from which they have  been all but
separated.  This has often been  observed in cases  of injuries of the face and
fingers, portions  of  which have been nearly completely severed, and yet have
united again on being  replaced.  But there are even a sufficient  number of
cases  on record to show that  certain parts, when  completely separated, may,
after being replaced, again become adherent.   The  most remarkable instances
of this kind are those  related by Dr. Hoffacher, and which are attested by
Chelius and  Velpeau.   Dr. Hoffacher  was officially  appointed to attend as
surgeon at the duels which were at one time frequent amongst  the  students at
Heidelberg, and, as at  these encounters broad-swords were  used,  he had an
opportunity of seeing a considerable number of incised wounds, and has  related
no less than 16 cases in which portions of the nose, lips, or chin, had been
sliced off, and being put on  again, contracted adhesions.   Amongst the most
 remarkable of these, is a case in which the end of the  nose was sliced off by a
 cut with the  broad-sword, and fell under a chest of  drawers; it was not found
 for some  time, but on  being recovered and washed, was stitched  on, when it
 became firmly attached.  In another instance, a dog  that was  in the room 
PLASTIC  SURGERY  OF THE FACE.
693
snapped up the detached portion of the organ as it fell to the  ground, but the
nose being immediately taken out of the animal's  mouth and put on again,
became firmly fixed!
  In order that union should take place between parts that have been separated
completely or nearly so, and the rest  of the body, it  is necessary that they be
soft and vascular, and more especially that their structure be of a  homogeneous
character, such as is met with in the tissues of the  face; where  no very  large
blood-vessels, nerves, tendons, or bone  are found.  It is the  same in plastic
operations, which succeed best under  similar conditions of tissue, and which
are conducted on the same principle as  an attempt at union in a partially severed
structure.
   Union in plastic operations  is effected by primary adhesion between  the flap
of skin that  is partially detached, and the raw surface on which it  is laid and
attached.   Should, however, this mode of union fail from  any accidental cir-
cumstance, the surgeon need  not despair, as the  parts may unite  by adhesive
inflammation or even through the medium of granulation in a very satisfactory
and complete manner.
   For proper union to be effected it is  necessary that the edges be cleanly and
evenly cut, so as to adjust themselves accurately to one another.  This may
often be most skilfully effected by making the  incision  in the part that is  to
receive the flap somewhat  oblique or bevelled,  thus securing  a more accurate
adaptation of the edges.
   After the  flap  has been  formed and the part in which it is to be transplanted
properly pared, the  operation should be delayed  a few minutes  until all bleeding
has ceased.  This is of much importance, as the interposition  of  a  layer  of co-
 agulated blood will materially interfere with union.
   In bringing the parts into apposition great care must be taken  that no undue
 traction or constriction be exercised, lest their circulation be interfered with, and
 their vitality be endangered.
   The parts may be maintained in apposition by sutures,  collodion, or the  appli-
 cation of  a strip  of isinglass plaster.  The sutures should be as fine as possible,
 introduced with a small needle, and  knotted on the sound parts.    Occasionally
 fine hare-lip pins may advantageously be used.   In  some instances instead  of
 sutures a small spring forceps (fig. 52), termed  a " serrefine," may be employed,
 but most  generally interrupted sutures are the best.   The use of  collodion is of
 great  advantage in plastic  surgery, as it  not only secures adhesion, but  by ex-
 cluding the air lessens the chance of suppuration.
   For a plastic procedure  to succeed, it is  absolutely necessary that no morbid
 action be going on in the seat of operation, and not only that none be actually
 in progress but that all have  ceased for some considerable time.  This is more
 particularly  the case when the deformity for the remedying of which it is prac-
 tised has resulted from syphilitic or  cancerous ulceration.  In both cases it  is
 necessary to see  that the constitution is sound as well as  that all local disease
 has been  eradicated; otherwise the irritation of the operation might set it  up
 a°ain and the new flap be invaded and destroyed.  From want of this precaution
 I have more than once  seen  disappointment result.   As  a general rule, plastic
 operations practised for the repair of mutilations from injury are more successful
 than those that are had recourse to after disease.
   The patient's  general health must be in a sound state lest the adhesive action,
 on which the success of the  operation is dependent, be interfered with.   No
 routine system of treatment should be adopted, but a  few days of rest, good
 diet  and a  dose or two  of  aperient  medicine, may be  prescribed before the
 operation is  proceeded with.   In  the  after-treatment of the  case  a nourishing
 but unstimulating regimen should be observed.
   In  performing these various plastic  operations  three methods  have been em-
 ployed.   In  the first,  the  flap of skin  that is  intended to  repair the lost 
694
PLASTIC  SURGERY  OF THE FACE.
structure  is transplanted from a distant  part, as  the arm  for  instance.   This
operation, which was introduced by the Italian surgeon, Tagliacotius, and hence
commonly called  by his  name, has in  a  great  measure fallen  into  disuse, on
account of the difficulty of its execution,  and the great uncertainty of obtaining
a successful result.  The second plan  consists in transplanting the  reparative
structure  from some part in the neighborhood of the organ  to be repaired;
the skin from the forehead, for instance, being used for the formation of a new
nose ;  that from  the chin for the restoration of the lost lip.   This procedure,
which seems first to have been adopted by the natives of India in restoring the
loss of the nose, is the method that is most commonly employed in this country
in plastic  operations on the face.  The third method consists in loosening the
skin by a process of subcutaneous  section to some  distance around the part to
be repaired, and  then drawing it forwards with or without incision through its
substance. This gliding operation is chiefly practised for the closure of fistulous
openings.
   It is principally for deformities and loss of the nose and lip that plastic opera-
tions are  of much  service; they may, however, occasionally be had recourse to
in other situations, as about the cheeks  and eyelids, but seldom with an equal
amount of success.  In the practice of this very interesting branch  of surgery
there is much opportunity for the display of manual dexterity, on which, indeed,
almost the whole success of the operation depends, and a vast deal may be done
in apparently the most unpromising  cases  by management, skill, and patience.
In  these  operative procedures the names of Serres, Dieffenbach, Liston, and
Jobert, deservedly take the first rank.
   The only plastic procedures the performance of which can be reduced to dis-
tinct rules, are those for the restoration of a lost nose, rhinoplastic, and for partial
loss of a  lip, cheiloplastic.  As these operations are commonly practised for loss
of the part from cancroid, strumous,  or syphilitic disease, especial  care must be
taken before they are commenced, that all morbid action has entirely ceased for
at least a year or two, lest the irritation of the operation set  it up  again, and
thus the  new flap be invaded and destroyed; I have more than once seen much
disappointment ensue from want of attention in this respect.
   When  the operation is performed for cancroid disease, ablation of the morbid
part may be done at the moment of operating — the affection being a local one;
when for struma or syphilis, the disease is constitutional, and care must be taken
 that all morbid action has thoroughly and completely ceased.

                    RHINOPLASTIC  OPERATIONS.

   Restoration of Columna. — When the columna  and a portion of  the  septum
 are  destroyed, a large gap  is left at  the  nasal  aperture, and the nose becoming
 flattened in consequence of its tip falling in, great deformity necessarily  results.
 The upper  lip also losing  that amount of support which it receives from the
 columna, becomes pendulous, projecting, and thickened at the end, thus adding
 to the disfigurement.   The restoration  of  the columna is effected from this
 thickened and prominent upper lip, which, by being reduced in size, is rendered
 far more shapely.  The operation consists in cutting through  the whole length
 of the lip from above downwards on either side of the mesial line so as to leave
 a tongue about  one-third  of an inch in width.  This is  then turned up, and
 its end being well pared, and the under  surface of the tip of the nose properly
 vivified,  it is fixed there by means  of a fine hare-lip pin  and twisted  suture,
 which should be left in for about four days.  Union takes place in a few days,
 but until this is firm the new columna must be properly supported with narrow
 strips of plaster fixed to the cheeks on  either side.  No twisting of this  small
 flap  is required, as the  mucous surface speedily becomes  cutaneous, and vice
 versa.  The division in the upper  lip  must be treated in the same way as an 
FORMATION OF  A NEW NOSE.
695
ordinary hare-lip, and unites without difficulty, lessening greatly the deformity
in this part.
   Restoration of Ala.—When  one ala only is  deficient, the rest of the nose
being sound, a flap of skin of the proper shape to restore the deformity may be
raised from the  cheek and applied to the edges of the part requiring it, pre-
viously  pared, and fixed there by a few points of fine suture.  If the loss  of the
substance of the ala be very considerable, or if it extend to a part of the body
of the  nose, then  it is more efficiently restored by bringing a long narrow flap
from the forehead in the  way that will  immediately be  described.  In the
majority of cases  the destruction of the ala and of the body of the nose is so
considerable, that other plans than those just  described are required for the
repair of the deformity.   The  methods that may be had  recourse to are the
Tagliacotian and  the Indian operations.  Occasionally fistulous  openings are
met with through the nasal bones leading into the interior of the nostrils.  Such
apertures as these are, perhaps,  best closed by paring the edges and then  bring-
ing forward a flap of neighboring skin by the gliding operation.
   Restoration of Nose. — The  Tagliacotian operation  consists in taking the
integument and cellular tissue required for the repair of the lost organ from the
inside of the arm.  Here a flap of sufficient extent should be marked out and
 dissected up with its subjacent  cellular tissue, leaving it merely attached  to the
 limb by a root at its distal  end.  No attempt at fixing this flap to the nose
 should  be made for at  least a  fortnight, during which  time it should be kept
 upon a piece of  wet lint, and  allowed  to thicken, granulate, and become vas-
 cular, so  as  to  fit itself for adhesion to the new surface to which it  is to be
 applied.  The remains  of the  deformed nose having then  been properly pared
 and the flap shaped, they must, after all bleeding has ceased, be properly adjusted
 and fixed to one another by points of suture.   The arm must then be  closely
 attached to the  head so  as  to be  as nearly as possible immovable.   At the end
 of about ten days when  adhesions have taken place, the  connecting  medium
 may be cut  across and the part left to be supported by the vitality that  it may
 gain from the new surface to which it is now attached.  This process is com-
 paratively seldom had  recourse to, for  obvious  reasons.   The uncertainty  of
 maintaining the vitality in the  flap, the extreme  tediousness of the prolonged
 constrained position in  which it is necessary to keep the patient, and the great
 difficulty of guarding against movements of the arm, especially during sleep, and
 which, however slight  and involuntary, would be  sufficient to disturb  union
 between the opposed surfaces  and occasion the failure of the operation, have
 caused  this  plan  of procedure  to fall  into disuse; and it is now, I believe,
 universally abandoned  by surgeons in this  country, having been replaced  by
 the more certain procedure of  borrowing the skin for the  new nose from the
 forehead.
   This, the Indian operation, a  knowledge of which was brought to this country
 by Mr. Carpue, in 1814, is extremely successful in its results, though requiring
 a good deal  of nicety  for its  proper  execution.  The operative  procedures
 required  by this  method  are  somewhat complex, and may conveniently be
divided into three distinct periods; the 1st consisting in the dissection  of the
flap from the forehead, and  its  attachment to  its new situation; the 2d, the
separation of the  root of the flap where it is turned down  from  the forehead,
and the formation of a proper bridge to the nose; and the 3d, the formation of
the  columna nasi.
   1st.  In the shaping of the flap, care must be taken that it is of sufficient size,
as durin"- the after part of the treatment, it often has a tendency to shrivel,
and more inconvenience usually results from  its not having originally been
made large enough  than the reverse.   The size  adapted to the particular face
may best be judged of  by moulding a thin piece  of gutta  percha  to the nose,
then flattening  it out by dipping it in hot water, and using  this as the  guide 
696
PLASTIC  SURGERY  OF THE  FACE.
for marking the outline of the flap upon the  forehead.  This  should be traced
with tincture of iodine, which will not wash off so readily as ink by the flow of
blood, which is often rather free.   This flap should be of the shape in fig. 263,
                                     taking care  that it  is  rather square at
               Fig. 263.               the  angles, and not too much rounded
                                     off.  The  size will  necessarily vary ac-
                                     cording to the character of the counte-
                                     nance, and the extent of loss that has tu
                                     be  repaired.  When the whole of  the
                                     nose  requires  restoration, it is usually
                                     necessary to make  it  about two and a
                                     half to three inches in length, by about
                                     the  same in width at the broadest part.
                                     It may either be taken from the middle
                                     of the forehead, or  obliquely from  one
                                     side.  If the latter,  the right side is the
                                     most convenient.   It  must now be  dis-
                                     sected off the forehead; in doing  this
                                     care must be taken not to remove  the
                                     pericranium, but at the same time to cut
                                     the flap  as thick as possible, especially
at its root between the eyebrows.  It must also be but little handled, and, above
all, not pinched, either with fingers or forceps.  The dissection should be com-
menced at the root,  so that the outline may not be obscured by blood; and  this
part should be left long, in order to admit afterwards of a very gradual and easy
twist.  In order to facilitate this, it is also desirable to make the incision on the
right side  a little  lower than  that on the  left.   After the flap has been raised
throughout the whole of its extent, a piece  of wet lint should  be applied to the
forehead, with a view of  arresting the bleeding, before the next step is taken.
This  consists in paring the surface and edges  of the stump  of the nose,  and
removing the integuments from it in such a  way as to leave  a triangular  raw
surface.   In doing this care must be taken, whilst a good base of attachment is
left, not to remove the parts  too widely, lest  the  cheeks, by separating, have a
tendency to gape too much, and the nose to become flattened out.  The integu-
ments also should be dissected away in such a manner as to form a deep groove
shelving inwards,  so as to receive and hold the flap more securely and with less
overlapping of the edges.  The operation must now be discontinued  for a few
minutes until all bleeding has ceased, and the cut surfaces have become glazed;
this point is of great importance in securing direct adhesion, and must be care-
fully attended to.  The bleeding having been arrested by exposure to the air,
and by the torsion rather than the  ligature  of any spouting branch, the flap from
the forehead should  be brought down by a twist from left to right, and attached
by a few points of fine suture on either side to the edge of the incision  around
the  nasal aperture.  A pledget of soft lint, moderately greased, should now be
gently insinuated  under the flap, the lower part of the incision in the forehead
drawn together by a point of  suture, but not  so as  to  constrict the root in any
way, and  the rest of the exposed surface covered with water-dressing.   The
parts will then present the appearance of fig.  265, taken from  a patient of mine
the day after  the  operation.   Fig. 264 represents the deformity for which the
operation was performed.  The patient  should be put to bed with a piece of
soft lint laid over  the whole of the face, so as to maintain  its  temperature, and
if it be winter, placed in a room that is kept well warmed day and night.   The
diet for the first few days should be simple, but abundant,  consisting chiefly of
nutritious slops.
   The dressings must not be  disturbed for three days; by this time, if all goes
well, the flap will be found somewhat tumid, warm, and sensitive, but pale in
 
FORMATION OF A NEW  NOSE.               697
color.  The plug in the nose will now require changing, lest it be rendered
offensive by the discharges; its withdrawal and  the  substitution of another
Fig. 264.                           Fig.  265.
must be done with  the greatest gentleness, the surgeon bearing in mind that
any undue pressure or traction  may destroy adhesions and prove fatal to the
vitality of the flap.   If the sutures produce no irritation, they may be left in
till the fifth  or sixth day, by which time the adhesions will be tolerably perfect,
and they may with safety be cut and withdrawn.  As the  adhesions strengthen
and the vitality of the flap improves, it must be elevated by putting underneath
it a larger plug of lint, for which, after a time may be substituted a small gutta-
percha tube  moulded to the figure of the inside  of the nose.  QMema of a some-
what solid character is apt to come on in the  flap, giving it a white appearance,
but this  is  of  little  moment, and will gradually  subside as  the circulation
through  it  becomes  more actively  established.  The flap gradually becomes
thicker and  firmer, throwing  out  granulations from  its under surface, which
eventually becomes  clothed with mucous  membrane.  The wound in the  fore-
head must be dressed like an ordinary ulcer, and be well touched with nitrate
of silver from time to time, to insure its contraction.  It usually cicatrizes with
great readiness, and leaves remarkably little deformity.
  2d.  The next  step in the  operation is the division of the root  of the flap,
which may be done about a month after it has been fashioned,  when its vascu-
larity, through its lateral adhesions, will be perfected; the division  of  the root
is best done by passing  a  narrow-bladed bistoury under the twist, and cutting
upwards  towards the  eyebrows,  removing a wedge-shaped portion  of  the soft
parts so as to make a smooth and proper bridge.
  3d. The addition of the columna is now all that is wanted to make the nose
complete.   This  must be made from  the upper lip at the same time perhaps
that the bridge is fashioned, and may be cut and fixed in the way that has been
already described in speaking  of the restoration of this feature, the interior of
the apex of the  new nose having been well  pared  to receive it.  The  columna
requires to be well supported by means  of a narrow  strip of plaster passing from
one cheek to the  other, and usually requires a good deal of fashioning before it
is perfect; indeed this is the part of the operation  that I have found always
most troublesome, and requiring most  attention.   The new nose must be con-
tinued to be supported from  beneath, for some months after its formation, by
plugs of lint, or  small gutta-percha tubes, as it will evince a great tendency to
contract and to alter in its general outline and shape, becoming, if the surgeon 
698
PLASTIC SURGERY OF  THE  FACE.
is not careful, either depressed or dumpy.  The sensibility of the new nose is
entirely  destroyed  for a  time after  the  division of the bridge, but it slowly
returns from  all sides, appearing  first in the  neighborhood of the adhesions
between  it and the cheeks, then near the columna, next in the bridge, and thus

                 Fig. 266.                                Fig. 267.
the organ at last has  its sensations restored; for this, however, several months
will usually be required, and the part in which it returns last of all is its central
portion.   The annexed cuts give a very faithful representation of a patient on
whom  I operated, before and after the restoration of the lost organ  (figs. 266
and 267).
   The success of the case will depend very greatly upon  the  minute attention
that the surgeon bestows on the details of the operation, and on the  care  that
he takes in  the after-treatment.   During  the operation the chief points to be
attended to are, that the flap is  made of sufficient size, and that  all oozing has
ceased before the cut  edges are brought into contact, and  that no tension or
constriction be  exercised.  The  principal  causes of failure  in the operation or in
the result, so far as concerns the  after-appearance of the patient, are in  con-
sequence  of gangrene of the flap, in whole or in part, taking place from  the
root being  too narrow, too tightly twisted, or the  flap too roughly handled in
its dissection.  So also if it be cut too small and not properly supported after-
wards, the result will not be very satisfactory.   Other  accidents  occasionally
happen;  thus erysipelas may occur, destroying at once the vitality of the flap,
or, coming on  at a  later  period,  when  the new nose will slough under the
attack of inflammation, which it has not sufficient vitality to resist,  as happened
in one of Mr. Liston's earlier cases; or it may be  destroyed by a return of the
lupus which proved destructive to the old one.   Hemorrhage  may also  occur
from underneath the flap.   In the  last case  operated on by Mr. Liston before
his death, and  which was  completed by Mr. Morton at University College  Hos-
pital, hemorrhage to the extent of  more than a pint took place on the ninth day
without any evident cause, from under the flap, and could only be arrested by
plugging.  Lastly, the  operation is not without its  dangers.  Dieffenbach  lost
two  patients out  of six on whom he operated in Paris; their constitutions, pro-
bably, being in an unfavorable state.
   When  the nose is depressed and flattened, in consequence of the loss of the
cartilages,  vomer,  and septum,  though  the  external  parts  remain  entire,
Dieffenbach has proposed a plan  for raising it, by slitting it longitudinally 
FORMATION  OF A  NEW LIP.
699
into  three  pieces;  dissecting the lateral slips from the osseous attachments,
then paring the edges to such an extent that they overlap, and  stitching them
together, to bring  the whole  organ forwards by  pushing long hare-lip pins
across its base, so as to elevate and narrow its attachments, which are brought
more into the mesial line.   Fergusson has improved this procedure by not slit-
ting the nose down, but by dissecting it away from the bones from within  the
nostril, and then pushing long steel-pointed silver needles across from cheek to
cheek, and twisting  their ends over perforated pieces of sole leather, through
which they had previously been  passed, thus bringing the whole organ bodily
forwards.   The  columna is  next fashioned in the way that has already been
described, and the nose thus completed.

                   CHEILOPLASTIC  OPERATIONS.

   The restoration of  a  portion  of the  lip, that has  been lost  by accident or
 disease, is not so readily effected as that of the nose, but yet, a good  deal may
 be done to restore the deformity.   The plan originally introduced by Chopart
 consists, when it is the lower lip that is deformed, in  carrying an incision from
 behind the lower jaw,  down  to the os hyoides, so that a square flap may result,
 which is detached from above downwards.   This flap is  then  brought  up  and
 fixed to the  pared  edges  of the remaining portion of the lip by  points of
 suture, the head being  kept .properly inclined, in  order to  prevent undue
 tension.   After sufficient union has taken place  to preserve  the vitality of
 the flap, its lower attachment may be divided.  The flap should, if possible, not
 be twisted, though it is not always practicable to avoid this.  This operation is
 not usually very  satisfactory in its  results, as the new flap is apt  to  become
 cedematous and inverted at the  edge, or the flow of saliva may interfere with
 proper union.   In those cases in which the
 greater portion of the lower lip has been ex-            Fig. 268.
 cised for cancerous disease affecting its upper
 margin,  the  most successful  procedure for
 the restoration  of the deformity, consists in
 a modification of the  plan recommended by
 Serres, and from this I have  derived excel-
 lent results, as in the case  which is here re-
 presented   (fig. 268).  The  object  of the
 operation is to raise the lower lip on a level
 with the incisor teeth.   This is effected in
 the following manner:  an incision,  about
 three quarters of an inch in length, is made
 directly outwards from the  angle of  the
 mouth, on either side, into  the  cheek;  from
 the extremity of this, a  cut is  carried ob-
 liquely downwards  on to the upper margin
 of the lower lip, so as to excise the included
 triangular  piece; the lower lip  is then dis-
 sected away from the  jaw, from  the inside of
 the mouth, and a V  shaped piece taken out
 of its centre.  By means of a hare-lip pin on
 either side, and a point of suture, the incisions in the angle of the  mouth are
 brought accurately  together, and in the same way the  vertical one, in the centre,
 united (fio-. 269).  In this way the whole of the  lower lip is raised, and brought
 more  forwards.   If care has been taken, in removing the cancer from the edge
 of the lip, to leave the mucous membrane rather long, which may always  be
 done, as the  skin is affected to a greater extent than it, a  good prolabium may
 be  formed, and the restoration effected with but little deformity.  Care must be
 
700
PLASTIC  SURGERY  OF THE  FACE.
taken to prevent union  occurring between the inside of the lower lip and jaw
by the interposition of a strip of oiled lint.
  Mr. Syme has introduced an operation  by which the cancerous ulcer of the
lower lip having been removed in a triangular form, by two incisions extending
from the angles of the mouth to the chin, the cuts are carried obliquely down-
wards  and  outwards, on each side, under the  body of the jaw, and made  to
terminate in a slight curve outwards and  upwards (fig. 270).   The flaps thus
Fig. 269.
Fig. 270.
formed  are  detached from  their  subjacent connections, and the whole raised
upwards, so that  the original triangular incision  comes into a horizontal line,
and is made to constitute the margin of the  new lip; the secondary incisions
under the jaw coming  together in  a vertical direction, in which they are re-
tained by twisted and interrupted  sutures.
Fig. 271.
                BLEPHAROPLASTIC  OPERATIONS.

  Blepharoplasty, or the operation by which the eyelids are repaired, is occa-
sionally required for loss of substance,—the result of wounds, cicatrices, or ope-
rations.  It is less satisfactory in its results than most of the other plastic pro-
cedures about the face; but yet may, in some cases, improve materially the
patient's appearance.
  When the upper eyelid  requires repair, the flap is taken from the forehead;
                              when it is  the  lower  lid,  from the cheek or
                              temple.   This   operation  may be performed
                              either by the gliding method, or  by twisting a
                              flap into its new situation.  When by the gliding
                              method, a triangular flap is cut  and partially
                              detached  (fig. 271 a),  and then drawn gently
                              forwards until it corresponds to and fills up the
                              gap that requires repair, when  it  is there fixed
                              by a few points of suture.  When the twisting
                              method is employed, an oval  flap is  detached
                              (fig. 271 b), except its pedicle, and twisted
                              down, to be planted on the raw surface.
                                 Occasionally neither of these methods (fig.
272) is applicable, and then the procedure, that was successfully adopted in a
case of which the annexed  cut is  a representation, may be adopted.   Here there
was a deep and hard cicatrix across the lower  eyelid, causing eversion of its
outer portion, and adhesion  of  the inner part to the ball  of'the eye.   After
dividing the adhesions  and  removing the cicatrix, I made a semilunar incision
so as to dissect up the  eyelid, and then fixed it  by points of suture in its new
situation, where it became  firmly adherent (fig. 273).
  Operations of various kinds are frequently performed on the eyelids that are
truly of a plastic character.
^^mnroggS^^
 
BLEPH AROPL ASTIC OPERATIONS.
701
  Thus in Symblepharon, or adhesion between  the lid and the eye-ball, the
adherent portion of lid may be included between V shaped incisions removed
and the edges of the cuts brought together (fig. 274 a).

                   Fig. 272.                        Fig. 273.
  In Epicanthis, or the projection of the nasal fold of the eyelids, an elliptical
portion may be removed parallel
to the  nose, and the  edges of                   Fig. 274.
the incision  brought  together
with sutures.
  In Ptosis, or drooping of the
upper eyelid,  an oval portion of
the lid may be raised horizon-
tally,  and  removed  so  as  to
leave an oval gap  (fig. 274 b),
the  edges  of  which  being
brought together  will  lessen the depth of the lid, and thus  diminish the
deformity.
  In Entropium, or inversion of the eyelid, the same operation may be prac-
tised on it,  and thus, by the contraction of the  cicatrix, the tendency to its
turning inwards lessened.   But various other procedures are at times required
                                in order to remedy this deformity.   Thus a
            Fig. 275.            vertical instead of a  transverse flap may be
                                removed; or Crampton's plan may be followed,
                                which consists in making a vertical  incision
                                through the whole thickness of the lid, near
                                either angle (fig. 275 a), and then removing
                                a  transverse  fold of  tbe  skin,  bringing the
                                edges  of  that wound  together  in the usual
                                way.    This  operation  is  chiefly applicable
                                when  the  tarsal  cartilage  is contracted and
                                shortened  as  it  were; or  lastly, when the
                                tarsal  cartilage is much contracted  and in-
                                verted, the whole edge of the lid  may be
removed  by passing a Beer's spatula between it and the ball, and then cutting
upon it.
  In Ectropium, or eversion, the lid may be well everted and a portion of the
conjunctiva  raised with a pair of forceps and snipped off.   This  operation sel-
dom succeeds however; and it is usually better to remove a wedge-shaped por-
tion of the lid, of  size proportioned to the amount of eversion; or  Dieffenbach's
method may be tried, which consists in making a transverse incision  through
the lid down to the conjunctiva, seizing this, drawing it forwards until  the lid
is restored to its proper shape, then  removing the projecting fold  and  bringing
the edges of the incision together in tbe usual way (fig. 275 b).
  Besides these more regular plastic operations, various other procedures may
be required  for the restoration of deformities of the face, in which the surgeon
 
702             PLASTIC  SURGERY OF THE  FACE.

may display much ingenuity and benefit his patient greatly.  The annexed cuts
(figs. 276, 277) represent a case lately under my care, before and the day after

                   Fig. 276.                            Fig. 277.
operation, in which there was a large aperture by the side of the nose, with
loss of the bones  of the nasal fossae,  that was  successfully  closed by a flap  of
skin taken from the forehead.

                    DISEASES OF  THE  TONGUE.

   Infants and even adults are said to be tongue-tied, when the frenum linguaa
is shorter than  usual, causing the  end  of the tongue to be depressed and fixed,
so that it cannot be protruded beyond  the incisors.   If this  malformation be
considerable, suckling  and distinct articulation  may be interfered with, and
then  division of the fold becomes necessary, which may readily  be  done  by
snipping it across with  a pair of round-ended scissors.   In this little operation,
the risk of wounding  the  ranine arteries that is sometimes spoken of, may be
avoided by keeping tbe point of the scissors downwards towards the floor of the
mouth.
   Prolapsus of the tongue has occasionally been met with, either as  a congenital
or an acquired condition;  it  has  been  described by Lassus and Crosse as con-
sisting either in a want of power in the  retractor muscles or in  hypertrophy
of that organ.  In this condition, the tongue lolls out of the mouth, is greatly
swollen,  of a  purplish color, but somewhat dry, with constant dribbling of
saliva.   If the  swelling  have  existed  for a long time, it may give rise to  de-
formity of the teeth,  and of the  alveolus of the lower jaw, which is pushed
forwards.  In  the treatment of this  affection, little can be done  unless it be
excessive and  of a permanent character,  when excision of a portion of  the
tongue by knife or ligature may be required.  In children, the ligature would
certainly be  the safest, as excision might be followed by abundant  hemorrhage,
not very easy to arrest.
   Glossitis is a rare affection, more particularly when  occurring  idiopathically;
most commonly it results from profuse  and injudicious salivation.  In this  dis-
ease the tongue is greatly infiltrated with serum and blood, becoming immensely
swollen,  so as  to  hang out of the mouth, with profuse salivation  and inability
on the part of the  patient  to swallow or speak, with perhaps a  threatening of
suffocation.   The treatment is as simple as it is efficient; it consists in making
 
DISEASES  OF  THE TONGUE.
703
a long and free incision along the dorsum of the tongue on either side of the
raphe, which gives free and immediate relief by the escape  of the blood and
infiltrated fluids.  I have seen a patient, who was nearly suffocated by the im-
mense size of his tongue, relieved at once, and get nearly well in the course of
a few hours  by such incisions.   Purgatives, especially of a saline character, are
also useful, but  these  cannot be administered until after the swelling has been
relieved in the way just mentioned.
   Abscess of the tongue, though rare, occasionally occurs.   A boy was brought
to me  some time ago with  an elastic fluctuating tumor of  slow growth, and
about the size of a small  plum, situated deeply in the centre of the tongue; on
puncturing it, about half an ounce  of healthy pus was let out, after which the
cyst speedily closed.
   The epidermic covering of the tongue may become the seat of various morbid
 changes; amongst the most remarkable of which is psoriasis.   In this affection
 the  tongue  is  indurated, shrivelled and  dry,  having cracks  upon its surface,
 with patches of a  dead-white color, and irregular shape, varying in size from
 that of a split-pea to an inch  in diameter; this  condition exactly resembling
 psoriasis of  the palms of the hands, may occur with  or without scaly disease of
 the  general integument.  I have  seen it in  both conditions, and have always
 found  it  a  most difficult affection  to  treat.   The preparations of arsenic with
 Plummer's  pill and  sarsaparilla, have, however,  appeared to afford the best
 results.   In  some instances, it is  evidently  of syphilitic  origin, and  then it
 requires to  be treated on the general  principles  that guide  us in the manage-
 ment of the constitutional forms of that disease.
   The  surface of the tongue occasionally assumes a glazed and warty character,
 as if covered with a layer of boiled sago, the mucous membrane being cedema-
 tous, elevated, and papillated, but at the same time glassy and semi-transparent,
 and without induration.  This condition, which is usually of syphilitic origin,
 requires the constitutional treatment for that disease.
   Fissures  or cracks not uncommonly appear upon the  side of the  tongue,
 usually opposite the molar teeth, sometimes  dependent on irritation of stumps,
 but not unfrequently on dyspepsia.   These cracks may  in some depraved  states
 of the  constitution extend  rapidly, eroding  away a  considerable portion of the
 side of the organ in a  short time, so as to leave  a large  and deep sloughy
 cavity with much dusky inflammation  around it, with great fetor of  the breath,
 and a copious discharge of saliva which trickles out of the corners of the mouth;
 the patient being  usually destroyed in from three  to  six months, by the irri-
 tation  of the  discharges, the inability to take  food, and the supervention  of
 hemorrhage.  This disease, which is a combination of sloughing and ulceration,
 is best treated in the early stages by the application  of leeches beneath the jaw,
 and the  use of chlorinated gargles, with a moderately antiphlogistic regimen;
 as it advances, the  internal administration  of arsenic is useful in some  cases,
 with the application of the balsam of Peru, either pure  or diluted with the yelk
 of egg, and the employment of gargles composed of the chlorides and the tinc-
  ture of myrrh.
    Syphilitic tubercle is not unfrequently met with in the tongue, as  one of the
  advanced symptoms of constitutional  syphilis, forming an indurated irregularly
  circumscribed  mass, of a round shape, situated deeply in the substance of the
  organ, or toward the centre of the tip.   The surface covering the  tubercle is
  of a dusky red or coppery color; it rarely runs on to ulceration, though rhagades
  and fissures occasionally form  around it;  there  is no fetid discharge and no
  destruction of the organ in these cases.  The treatment consists in the adminis-
  tration  of  small  doses  of bichloride of mercury in sarsaparilla, under which it
  will rapidly disappear.
    Various cancerous and  cancroid diseases may occur in the tongue.   These
  affections usually commence with  tubercles, or  fissures, or  as  a  solid mass  in 
704
DISEASES  OF  THE TONGUE.
the body of the organ; most  commonly the disease is situated at the sides, but
occasionally the tip  is affected.  If as a tubercle or warty growth, it is usually
flat, indurated, and of a purplish-red color, gradually running  into ulceration;
if with a fissure, this from  the commencement  has  an  indurated base, a foul
surface, and an everted edge.   As the ulceration extends, a chasm with ragged
sides, a sloughy surface  that  cannot be cleansed, and a widely indurated base,
gradually forms; there is great  fetor of  the breath, profuse salivation, and as
the disease  progresses, implication  of the mucous membrane and of the struc-
tures  of the floor of the mouth,  and of the submaxillary or sublingual glands,
takes  place.  The lymphatic glands under the jaw  usually  become involved at
an early period, but  I have  known  the disease exist for a year or two without
their  becoming implicated.   Cachexy at  last supervenes, and  the patient dies
from  the conjoined effects of exhaustion, irritation, and poisoning of the system.
In  the majority of instances, the disease assumes  a cancroid form, but tumors
of the tongue may occasionally occur, presenting all the characters of scirrhus.
In  one instance I have seen  cancer of the tongue assume  a truly encephaloid
character; it was a case in which the disease had twice been removed, and recur-
ring a third time,  assumed the character of a large, soft, fungating growth, with
rapid  implication of the floor of the mouth and maxillary glands, death  speedily
occurring from exhaustion.
   The diagnosis of these various forms of disease of the tongue is important.
The  foul and  sloughing ulcer  may  be  distinguished  from all  others by the
rapidity of its progress, its  eroding action, and the  absence of all induration at
its  base.   Syphilitic ulceration, with an  indurated base, commonly closely
resembles cancer  of  the tongue; so closely indeed, that  it is  only with great
difficulty that the  diagnosis can  be  effected.   This, however, may generally be
accomplished after a time, by observing that the syphilitic  ulcer is elongated,
irregular, and does not rapidly extend; the cancerous ulcer on the other hand
is of a circular shape, has eroded edges, and spreads with considerable rapidity.
The influence  also of treatment  will  after a time throw light upon the nature
of the disease, and the scrapings of the cancerous ulcer when examined under
the microscope, will  always  reveal its true character.
   The diagnosis between the  syphilitic and cancerous tubercle is most impor-
tant;  here  the  duration of the  disease and the co-existence  of constitutional
syphilis must be taken into account.  It is also of much moment to attend to
the situation of the  tumor,  the syphilitic tubercle being almost invariably met
with  deeply in the substance of the organ, whilst the cancerous growth is com-
monly seated at its edges or tip.
   In  the treatment of cancer of  the  tongue therapeutic means are utterly use-
less ;  and no measures hold out  any chance of recovery to  the patient except
the removal of the  diseased  structure.  This may be effected either by the
ligature or the knife, and should be  done as early as possible, before glandular
or constitutional infection has  come on.   When  the free portion of .the tongue
only  is diseased the  morbid structure may readily and safely be excised; any
hemorrhage that ensues being arrested by the ligature of the  bleeding points,
or by the introduction of ice into the mouth.  When the organ is more exten-
sively diseased it  has been proposed to divide  the  lower jaw, and thus to get a
view  of the whole of the  tongue, and to remove  as much as proper, treating
afterwards  the  section in  the bone as a fracture of it.  When, however, the
tongue is very deeply diseased excision is objectionable, as the hemorrhage that
follows may be so considerable as  to be stopped with difficulty, and, indeed, to
require the application of the  actual  cautery for its arrest.  In these deep can-
cerous affections of  the tongue  also,  there is usually great  enlargement of the
submaxillary  glands, with  infiltration of the floor  of  the mouth and of the
neighboring soft  parts to such an extent as to render it impossible with safety
or advantage to excise the diseased mass. 
OPERATIONS FOR CANCER OF THE  TONGUE.      705
  The ligature is the plan usually had recourse to, and which, indeed, I think,
is in  all cases, except where the tip is alone involved, preferable to excision;
but though there is no risk of hemorrhage when this means is used, yet it is
not without objection on account of the  painful nature of the  process  and its
tediousness.  Mr. Hilton has removed the first objection by proposing and prac-
tising the section of the gustatory nerve prior to the application of the ligatures.
This operation may be done by drawing the tongue forwards and dividing the
mucous membrane and submucous tissue vertically for three quarters of an inch,
opposite the molar teeth, over the hyoglossus muscle, and across the upper por-
tion of the  sublingual gland; much venous bleeding usually occurs, which
embarrasses  the  search for the nerve, yet with a little dissection this  may be
exposed and  divided,  when sensation will cease in the whole of  that portion of
the tongue which is anterior to the line of incision.   By means  of the  ligature
any portion of the tongue,  however deeply seated, may be securely strangled.
For the purposes of this  operation  strong thick  saddler's  whipcord is the best,
as it does not readily cut through  the soft and brittle tissue of the organ, as
would be the case if the small  compressed cord usually sold by the instrument-
makers is used.
   In removing cancer of the tongue by ligature, the  patient should  be conve-
niently seated opposite a strong light.  The  surgeon then passes a strong silk
               thread doubled, through the tip  of  the  tongue, by which an
    Fig. 278.    assistant  draws the  organ  out of the mouth; a wooden wedge is
               next placed between the  teeth of the upper and lower jaws, on
               the side  opposite to that on which  the  operation is to be per-
               formed, and the ligature  is then passed by means of an ordinary
               nevus needle, or what is often  more  convenient, a  corkscrew
               needle curved on the side as well as to the point (fig. 278).  In
               many cases  the plan described  for ligaturing fiat nevi will be
               found the most convenient mode of passing the whipcord round
               the cancer  of  the  tongue  (fig. 279).  In whatever way  the
               ligatures are applied, care should always be taken to pass them
               through  the healthy tissue of the organ  wide  of the  disease,
               and they should then be tied very tightly, so as to strangle the

                                         Fig.  279.
8
mass effectually.  Great swelling of the  tongue, followed by profuse  salivation
and some  fetor of the breath attend this operation, but the  mass, if properly
constricted, will slough away in a few days, leaving a large gap that readily fills
by granulation.   When the  disease exists so  far  back  in the tongue that it
cannot readily be reached from  the  mouth, Cloquet, Arnott, and others have
successfully strangled it by making an incision in the hyoid region, between
the genio-hyoid muscles, forcing the ligatures by means of long needles through
the base of the tongue, and then drawing them tight through the  aperture  in
the neck, so as effectually  to  constrict the diseased mass.
       45 
706
DISEASES OF  THE  TONGUE.
  Regnoli has successfully extirpated large portions of the tongue for cancerous
disease of the back of the organ, by making an incision of a semi-lunar shape,
along the line of the  lower jaw from one angle of the bone to the other, thus
opening into the cavity of the mouth through its floor, then making a vertical
cut through the centre of this, from the os hyoides forwards, clearing the parts
by a little dissection,  and drawing the tongue through the opening down upon
the anterior  part of the  neck, where the diseased structures may be ligatured
or excised (fig. 280).  The wound is then closed and united in the usual way.
By this means the surgeon can reach portions of the organ that  cannot be got
at in any other way.
   The ecraseur has been successfully used by Chassaignac in removing tumors
of the tongue that could not otherwise be extirpated.  In such operations  two

                Fig. 280.                              Fig. 281.
or more instruments  are  commonly required, which, as Chassaignac represents
(fig. 281), must be passed through the substance of the tongue  in opposite
directions, so as to isolate and detach the diseased portion of the organ.
  When, however, the floor  of the mouth is implicated in the morbid action,
nothing should, I think,  be attempted, as it is impossible to extirpate the whole
of the disease, and partial removal of it will only be followed by  rapid recur-
rence and increased  activity of development.   I do not think that  the enlarge-
ment  of the submaxillary glands  merely should be any bar to the operation,
provided the  disease be limited,  and  the constitution  good,  as  under these
circumstances the glands may be excised, as well  as the disease  of the tongue
removed; or,  if they be not of any very considerable size, they may be left,
when they  will perhaps subside  without  the necessity of operation, as their
enlargement may probably be dependent upon simple irritation; or should they
continue indurated, they may readily be removed at a subsequent period.
   Tumors of various kinds, encysted, fatty, and erectile, are met  with  in the
tongue, and underneath it in the floor  of the mouth.   They require extirpation
by  the ligature, or enucleation with the handle of the scalpel or fingers, accord-
ing to their situation and size, and for  these  irregular operations no  special
directions can be  given.  In  removing such tumors as these, when situated
under or by the side of the tongue, the  knife  must  necessarily be used with
much caution.  It  must,  however, be borne in mind, that if these growths cannot
be  reached from the inside of the  mouth, they may be got at by incision through 
OPERATIONS FOR CANCER OF  THE  TONGUE.      707
Fig. 282.
the mylo-hyoid region, where there is but a slight thickness of soft parts between
the surface and floor of the mouth.
  Ranula is perhaps the most remarkable of these
buccal tumors. This disease occurs under two forms;
1st,  as a globular swelling, semi-transparent, evi-
dently containing fluid, and often attaining the size
of a walnut  or  pigeon's  egg, situated under  the
tono-ue, pushing this organ upwards and backwards,
and  consequently interfering with deglutition  and
speech (fig. 282).   The walls  of  the cyst  are
usually thin, with small vessels ramifying on them;
its contents are  glairy and  serous.  This form of
ranula is usually said to be a dilatation of Wharton's
 duct; but it certainly appears to me that there is no
 proof of the disease being of this nature, and, in-
 deed, it is not very easy to understand how so small
 a duct can be dilated  to  so large a size as is occa-
 sionally attained by these tumors, which  seem, in
 some cases at least, rather to consist of distinct cystic
 formations such as commonly occur in  connection
 with  other secreting  glands.   The treatment  of
 this form of ranula consists either in passing a seton through its walls, so that
 contraction may take place on this, or else in the excision of a large portion of
 the anterior wall of the cyst, the remainder contracting, until it at last becomes
 obliterated.
   2d, Besides the ordinary form of ranula, an encysted  tumor, partaking ot  tnis
 character, is occasionally met with, lying above the mylo-hyoid muscle, between
 it and  the buccal mucous membrane, projecting, however, more distinctly  into
 the neck than into the  mouth;  occupying, perhaps, all the space between  the
 lower jaw and the os hyoides on one side, and attaining the size of an orange.
 In  a  case of this kind  in  a lad  of  twenty, lately under my care, the contents of
 the tumor, which  closely resembled cream cheese in character, were found to be
 composed of well-formed epithelial scales and much fatty matter.  Such tumors
 are, I think, best  treated by having  a free opening made into them from the
 mouth, their contents squeezed or spooned out, and  the  cavity being stuffed with
 lint allowed to granulate and contract.   If an attempt be made to extirpate them
 from without, the profuse and perhaps dangerous hemorrhage, the firmness with
 which the cyst wall is incorporated with surrounding parts, the danger attendant
 on the free use  of the knife in the neighborhood of such important parts as lie
 between the mylo-hyoid muscle and the base of the tongue, will render such an
  operation not only an unsatisfactory, but a hazardous procedure. 
708
DISEASES  OF  THE  JAWS.
                           CHAPTER  L.

                     DISEASES  OF  THE JAWS.

                       DISEASES OF THE  GUMS.

  Abscess of the gums is of very frequent  occurrence, from the inflammation
of decayed  teeth.  Here a free and early incision should be made, which, by
giving exit to the pus, will afford immediate relief.
  Spongy and sloughy ulceration of the gums will occur as the result of consti-
                        tutional  cachexy in anyway induced — by mercury,
        Fig. 283.         malaria, syphilis, &c.  They are best treated by tonics,
                        in conjunction with the chlorate of potass and mineral
                        acids internally.    If spreading  actively, escharotics,
                        such as the muriatic acid or creosote, may be advan-
                        tageously applied.  If not making  much progress, a
                        solution  of the  nitrate of silver, with  chlorinated or
                        tannin gargles, will be useful.
                          Epulis is a tumor of a fibrous character, springing
                        from the periosteum and edge of the alveolus, and im-
                        plicating the osseous walls, growing up between, and
                        loosening the neigboring teeth, which it displaces and
                        envelopes in its structure.   It  is most frequently met
                        with in the lower jaw. and commonly about the molar
teeth (fig. 283).  This  tumor is red, smooth, and  lobulated, at  first hard and
semi-elastic, like the ordinary  structure  of the gum, but after a time softening
by disintegration, and ulcerating on the surface, with a purulent  or sanious dis-
charge;  it appears simply to be a circumscribed hypertrophy of the gum.
  Tbe treatment  of epulis consists in the  removal of the whole of the mass and
of that portion of the alveolus  from which it springs.   As  it evinces a  great
tendency to reproduction, it must  not  simply be shaved  off the bones, but a
portion of the osseous structure must be removed as well; unless this point be
attended to, the growth will to a certainty be reproduced.  In performing the
operation, the first thing to be done is to extract a tooth contiguous to and on
either side  of the  tumor; a cut must  then be made with  a saw through the
alveoli of the teeth that have  been removed, down to a level with the base of
the growth.  In  doing this care must be taken not to cut too near the remain-
ing teeth, lest the alveoli be opened and  their  support  lost.  If the  tumor is
large it may be necessary to saw deeply, but the base of the lower jaw should in
all cases be left intact, the whole of its substance  not being sawn through, so
that, though a considerable portion of bone be removed, yet the   length of the
jaw may be preserved.   For this purpose Hey's saw should not  be used, it is a
higgling instrument, difficult  to manage  in this  situation;  but  a straight and
stiff-backed saw, with as deep a blade as the mouth will conveniently admit, will
be found most useful (fig. 209).  The epulis, included  between two vertical
cuts, may now be removed with cross-cutting forceps, and the bleeding stopped
by placing a plug in  the wound and compressing  it against the teeth of the
upper jaw by means  of a bandage passed under the chin.  Should there be a
spouting dental artery, it may be necessary to apply a red-hot wire in order to
arrest its bleeding.   The cut surface will speedily granulate, and  the cavity fills
up with fibrous tissue.
  Cancerous ulcers and fungous growths from the alveolar processes, malignant
epulis, as they are called, occur in the same way as the  last; but they are soft,
 
DISEASES OF THE  ANTRUM AND  UPPER  JAW.     709
purplish, very vascular, grow rapidly, and are speedily reproduced after removal;
they principally, I think, occur in males advanced in life.  The same operation
requires to be practised for these diseases as for the simple epulis, and  as  there
is usually much hemorrhage  following their removal, a red-hot iron  must be
applied to the bleeding surface.

         DISEASES OF  THE  ANTRUM  AND  UPPER  JAW.

   Our present knowledge of diseases of the jaws, and of the operative procedures
 necessary for their removal, is  chiefly due to the labors of Gensoul and of Liston.
 Mr. O'Shaughnessy also, who appears  to  have had many opportunities of wit-
 nessing these affections amongst the natives  of India, has added much to  our
 acquaintance with their pathology and treatment.
   The antrum  may  be  the seat  of fluid accumulations or of solid  tumors.
 Dropsy of the antrum from accumulation of mucus within this cavity occasion-
 ally occurs.  As the  aperture leading  from this  cavity into  the nose is a little
 above its floor, there  may be a natural  tendency for the fluid  secreted here to
 accumulate to some extent before it is discharged.  If, however, this  aperture
 be from any cause blocked  up, the secretion may increase to so great  a degree
 as to occasion serious inconvenience by its outward pressure.   In cases such as
 these, the accumulation of fluid  has   been  known after a time to expand  the
 walls of the cavity;  and in this way the  floor of  the  orbit  or  the  roof of the
 mouth may be caused to bulge, the nasal  cavity  may be  encroached upon, and
 the cheek rendered  round and  prominent — an indolent  semi-elastic  tumor
 forming in it and protruding it outwards, and giving rise to the  egg-shell or
 parchment crackling on pressure.  The  treatment in  these  cases consists in
 making an opening into the cavity of the antrum with a strong perforator through
 its most expanded and thinnest part, and leaving a plug of lint in the  aperture,
  so as to allow the discharge to escape  freely.   The shape  of the cheek may be
  restored by the gradual  pressure of a  spring pad or double-headed roller.
    Suppuration  may  take  place  in the  antrum, being usually excited by the
  irritation of a carious molar tooth, or by some injury of the face, and occasioning
  perhaps much pain, with throbbing or lancinating sensations.   The  pus, as  it
  forms, will sometimes overflow, as it were, into the nose through  the aperture
  between these  cavities, and  then may keep up  constant irritation, with much
  fetor in the nostrils; in other cases, it drains through the socket of a tooth into
  the mouth; and in other instances again, its exit being prevented, it gives rise
  to enlargement of the cheek, the soft parts of which become brawny
  and inflamed,  and the bones expanded, so that at last they are
  thinned to  such  an  extent, that, as  in dropsy of the cavity, they
  crackle when pressed upon.  Any portion of the  wall of the cavity
  —the orbital, buccal, palatal, or nasal—may thus be expanded and
  fluctuation be felt through it, and the lachrymal duct being com-
  monly obstructed, the eye  on the affected side becomes watery.
    The treatment of  this condition consists in the extraction of any
  carious tooth seated in the neighborhood of the antrum, or if they be
  all sound, in the removal of the second molar, the fangs of which
  come in close relation to, and frequently perforate the bottom of
  the cavity.   In this way an  exit should  be given to the matter;
  but as it will  not discharge itself sufficiently freely, the antrum
  must be opened through the  alveolus, or through the canine  fossa
  under the cheek, provided it be much expanded  in  this situation,
  so that  its cavity is easily reached.  The  perforation into the
  antrum may readily be made, or the socket of the tooth enlarged,
  by means of a triangular antrum-perforator, such as here repre-
  sented (fi°\  284).   As the  matter  draws away, the  cavity will
  gradually contract, and the deformity thus be removed. It is well not to attempt 
710
DISEASES  OF  THE JAWS.
to perforate in the site of teeth that have been  extracted for some  length of
time, as here the bone becomes unduly consolidated, and I have  consequently
seen failures in reaching the cavity occur.  The matter that is discharged  is
often very offensive, or it may be thick and  pasty from the absorption of its
watery parts.  After the aperture has been made, the cavity should be syringed
out with tepid water, and its shape gradually restored by pressure.
   Tumors of various kinds spring from the upper jaw, taking their origin either
from its surface, from the interior of the antrum, or  from the pterygo-axillary
fossa.  Those that grow  from the surface of the bone, are either some  of the
various forms of epulis that spring from its alveolar border, and must be treated
as already described, or they are exostoses growing from the outer surface of the
bone, projecting perhaps up into the orbit, and requiring removal with the saw,
bone-nippers, or gouge.   In doing this, care must  be taken not to destroy the
nasal process of the bone, lest the  lachrymal sac be opened.
   The tumors that spring from the cavity of the antrum or from the posterior
part of the upper jaw are of very various kinds;—fibrous, cartilaginous, osseous,
fatty, fibro-plastic, erectile,  and encephaloid growths  may all be met with  in
this situation.  In  the  Museum  of University  College, which is very rich  in
specimens of these tumors, most of the above  varieties will  be found.  The
fibrous tumor is  perhaps the most common;  it principally occurs  in  elderly
people, and may attain a very considerable bulk.  The encephaloid comes next
in order of frequency, and the osseous and enchondromatous occur, but  are ex-
tremely rare.   The  osseous  tumors are remarkable as occasionally appearing
to  set  up a  spontaneous attempt  at  elimination, by  necrosis  taking place  in
 them.  These various  growths are most commonly connected with, or spring
 from, the mucous membrane of the antrum, and in  growing gradually expand
 and dilate the walls of this cavity,  pressing the bone  outwards, thinning
 them, and giving rise to a considerable outward projection  of one  side of the
 face.  The tumor thus formed is  usually smooth, round, or oval, slightly lobed
 perhaps, more especially if of a fibrous character, and has in many cases a ten-
 dency to hang downwards so as to overlap the lower jaw to a certain extent; at
 the same time it encroaches more  or less upon the other  cavities lying in the
 vicinity of the  antrum.   Thus, it  pushes down the palate, causing considerable
 swelling in the roof of  the  mouth; displaces the alveolar processes and teeth,
 giving rise  to  irregularity in their outline; and when encroaching upon the
 orbit, occasioning stillicidium lachrymarum, or even impairment of vision.   As
 the tumor enlarges, it obstructs the nasal cavity, and  stretching back into the
 pharynx, interferes with respiration and deglutition.   When  it is  of an  ence-
 phaloid character, obstruction of  the nasal fossa will be found to be one of its
 earliest signs;  and  the integuments will be observed speedily to become  in-
 volved, the gums implicated, and the submaxillary absorbent glands enlarged.
    In the diagnosis of  these  tumors  there  are  three  principal points to be at-
 tended to: — 1st, to distinguish  them from fluid accumulations;  2d, to deter-
 mine whether the growth is simple or malignant; and, 3d,  to ascertain  its seat.
 In  making the diagnosis from fluid accumulations in the antrum, the history of
 the case, and the uniform enlargement of the cavity without the tumor project-
 ing externally beyond  any part  of its walls, may enable the surgeon to deter-
 mine that it is not of a solid character.  But in many cases this is not sufficient,
  and it becomes necessary to  have recourse to an exploratory puncture by means
  of  the perforator, through  one or other of the more thinned and expanded parts
  already indicated.   This should  never be omitted in  cases of doubt, for it has
  happened even to so  good a surgeon as Gensoul, that after making incisions
  through  the cheek with the view of extirpating the tumor, the  bones were
  found to be expanded  by an  antral abscess, and that, consequently, the  opera-
  tion had been undertaken  unnecessarily.
    In determining whether the growth be of a simple or malignant character, 
TUMORS OF  THE  ANTRUM.
711
the surgeon will experience much difficulty, so long as it is confined to the cavity
of the antrum; but when once it has perforated and got  beyond its walls, this
point is  easily solved.  Whilst the  tumor is still confined within the antrum,
much light may however be thrown upon its nature by attention to the rapidity
of its growth; the greater this is, the more  reason there is to suspect its malig-
nant character.  But though  attention  to  this sign is of value, yet too much
importance must not be attached to it; for though as a general rule, the fibrous
and cartilaginous tumors  may increase  less  rapidly than  the  malignant, yet it
may happen that these attain a very great bulk in a short  space of time.  With
regard to the age of the patient, that is of  comparatively little value in a diag-
nostic point of view.   I think, however, that as a general rule, simple tumors
most frequently occur in the young, whilst the malignant  forms of the affection
are commonly met with at  the  middle or advanced periods of life.   It is of
much importance, even in a diagnostic point of view,  to examine the condition
of the submaxillary glands.   When the disease is  malignant, they become en-
larged and indurated, at  a very early period.  In a case  lately under my care,
the malignant character of a tumor whilst still in the antrum, was determined
by the fact of there  being a long chain of indurated lymphatic glands, lying
under the angle of  the lower jaw, where they had  become secondarily affected
by absorption, before the bones had been  perforated  by  the growth.   When
once a malignant tumor has got beyond  the cavity of the antrum, and is  thus
relieved from the pressure of its walls, it grows with great rapidity, insinuating
itself extensively amongst the bones of the face and skull, by creeping through
the foramina and fissures, encroaching greatly on the nasal cavity and  orbit; im-
plicating the integuments of  the cheek and soft structures within the mouth;
and throwing out sprouting masses in these  several situations, which present all
the characters of the true malignant fungus.
   A point of very great importance in relation to  operative interference is to
determine  whether  the tumor springs from  the cavity of  the antrum, or takes
its origin behind the superior maxilla in the pterygo-maxillary fossa.   In  the
former  case, the nasal  or palatal  walls  of  the antrum are expanded, and  the
line of teeth rendered irregular.  In the latter, the maxillary bone will be found
to be simply pushed  bodily forwards, there being little if any deformity in its
outline, the line of teeth not being displaced, or the walls of the antrum, —
palatal, nasal, or orbital, expanded.  Yet it must be  borne in mind that the
difficulty of the diagnosis is greatly increased by the fact that a tumor, though
not originating  in  the antrum, may pass into the  orbit, through  the spheno-
maxillary fissure, and may  make  its way forwards  amongst the bones  of the
face, partly by creeping through, and partly by displacing them.
   In the treatment of tumors of the antrum,  nothing can be done  except to
 extirpate the growth; and it is consequently of great  importance to  distin-
guish those forms of  the disease  in which an operation can be undertaken
with safety, and with a fair chance of success, from those in which none should
be performed.  When the tumor, springing from  the antrum, is of a simple
character,  the disease should be removed, together with the whole of the supe-
rior maxilla, the tumor, whatever size it has attained, being generally encysted,
and the bones expanded around it;  so that it is well bounded, and does not im-
plicate neighboring parts.  Here, as Liston justly observes, no nibbling or grub-
bing operations should  be done, but free excision of the whole mass  practised.
When the tumor springs from the  pterygo-maxillary  fossa pushing  the bones
of the  side  of the  face  forwards, I think  it  is  doubtful whether the surgeon
ou°-ht to interfere, as the  base of the skull may be implicated to such an extent
that the patient may die a few hours after  the operation,  as I saw happen in a
case of Listen's.   When once a malignant growth  of  this part has  passed
beyond the osseous boundaries of the antrum, it should not be interfered with.
So Ion"- as it is contained within this cavity, where  indeed it is often impossible 
712
DISEASES  OF  THE JAWS.
to ascertain, until after removal, the true nature of the affection, it may be
excised, provided the glands in the neck  be not greatly enlarged.  If they are
much  implicated,  even though the  walls of the antrum  be not perforated, I
think it is safer not  to interfere, as a cure by operative procedure must be hope-
less.   Whenever the soft structures of the cheek are involved so as to require
partial excision with the tumor, no operation should be performed, as the dis-
ease will probably have become constitutional, cannot be completely extirpated,
and will speedily recur in the cicatrix.
   The operation of  the excision of the upper jaw together with the malar bone
for tumor of the antrum, was first proposed  by Lizars in 1826, though Gensoul
of Lyons was the first surgeon by whom the operation was actually performed,
in May, 1829.  It may conveniently be done in the following way: The central
incisor on the diseased side having been extracted, the point of a bistoury
should be entered opposite the external angular process of the frontal bone, and
carried with a semi-circular sweep into  the angle of the mouth.   From the
upper end of this incision, a cut  about one inch  in length  may be carried along
the zygoma.  Another incision is made from the nasal process of the superior
maxillary bone, down to the side  of  the nose, round the ala,  which it detaches,
and through the centre of the upper lip into the mouth.   The flap thus  formed
is dissected upwards until the margin of  the orbit is reached, the soft parts are
then  carefully separated from the  floor of this cavity, and the  infra-orbital nerve
dissected and drawn upwards with a curved copper spatula, which protects them
and  the  globe of  the eye.  The next  step  in  the operation consists in the
division  of the bones.  This may best be done with strong cutting pliers; the
zygoma should be first cut across, the external orbital angle next divided, and
then the internal angle cut  through by putting  one  blade of the  forceps into
the  nostril and the other into the orbit.   The  palatal arch must next be cut
across by notching  it deeply with a  Hey's, or a narrow-bladed saw, and then
passing the  pliers into the  mouth  and nose, cutting through the line of the
groove and the alveolus of the  incisor that had been extracted.   The whole
mass having thus had its osseous connections separated, is depressed,  drawn
forwards, and readily removed by breaking down adhesions  with the finger, or
with the bistoury by the  division of a few remaining soft parts.   In the early
stage of the operation, during the incisions through the cheek, there is often a
good deal of hemorrhage; this may be arrested by pressure,  or by the ligature
of any vessels, such as the  facial, or transverse fascial, that bleed with great
activity, and if necessary by the  application of the actual cautery to the bones.
However much the  soft parts may be stretched no skin should ever be removed,
as it will all eventually contract.   In the later stage  of the operation after the
removal  of the tumor  there is not so much hemorrhage as might be expected,
though some branches of the internal maxillary will require ligature.   By an
operation  such  as  this, the  whole of the superior maxillary and  malar bones
may, if necessary, be removed, and the large cavity that is left between  the eye
and mouth, having some lint introduced into the bottom so as to support the parts
in  the orbit and  the cheek, may be  allowed to  granulate;  the  cheek being
replaced and retained in situ by a  few points of twisted suture evenly introduced
through the line of incision in it, and in the upper lip.   After cicatrization is
complete, the deformity resulting from such  a  procedure will be far less than
might at first be anticipated.
   In some cases the malar bone and floor of the orbit will be found to be sound.
When this is  the  case they should both be left, and with this view, after the
cheek has been turned up, as just  described, a deep groove should be made
with a narrow, straight-backed saw,  below the  orbit directly across from the
nasal  process of the maxillary, and  the  outer edge of the malar bones.   The
removal  of the growth may now be effected by cutting through the  nasal process 
DISEASES OF  THE  LOWER  JAW.
713
with the forceps, and then applying them to the horizontal groove made below
the orbit, after which the palatal arch may be divided as already directed.
   Mr. Fergusson has in some cases succeeded in removing tumors of considerable
magnitude by a single incision through the cheek, from the angle of the mouth
upwards and  outwards;  and in other cases by slitting open the upper lip in the
mesial line, and  then carrying  the knife along  the side of  the base of the
columna into the nostrils, by which simple incision this distinguished surgeon
has shown, that sufficient relaxation of  parts can be obtained to  excise the
greater portion of the superior maxillary bone.

                  DISEASES  OF THE LOWER JAW.

   The  lower jaw is  not  unfrequently the seat  of necrosis,  which may arise
either from  some constitutional cause, from local  injury or irritation, or from
the specific action of the fumes of phosphorus.   In this disease we must wait
until the bone has become loosened, and then by incisions through the gum, or
through the  structures of the lower part of  the  cheek, or under and along the
lower angle of the jaw, reach the diseased bone and extract  this; separating, if
necessary, any part that may still be adherent by means of cutting pliers.
    Tumors not  unfrequently spring from the lower jaw.  Like  those  in  the
superior maxilla they may either be simple or malignant.  Amongst  the simple,
we most commonly find the fibro-cystic.  Fibrous tumors are also occasionally
met with, and more rarely osseous and enchondromatous growths.   The malig-
nant tumors  are principally of an encephaloid character. These various growths
frequently occur in early and middle life, and  usually spring from the diploe,
between the  two tables of which the bone is composed.  They project into the
mouth  and on to the  side of the neck, forming large rounded uniform,  or
imperfectly lobed masses.  Occasionally  malignant diseases  spring from  the
neighborhood of the bone, and, without invading  its  structure, envelope it so
as to give rise to an appearance of morbid implication of it.
   Epulis not unfrequently springs  from the alveoli of  the lower jaw; however
large this  may  be, it is always  a disease  of  the  alveoli, and can implicate  the
bone only by extension to it.   It  is  usually sufficient to remove the mass with
the alveoli from which it grows, the base of the  bone being left,  which is  a
great advantage, as it prevents shortening of the jaw.
    Operation. — Extract the tooth on either side  of the growth, cut  with Hey's
saw down the alveolus on  either side, then make  a cross-cut  under the tumor
into the bone with the saw, and next apply cross-cutting forceps so as to remove it.
   In the cystic and fibro-cystic  tumor of the jaw the  growth is expanded into
cysts having more or less solid matter intermixed, partaking of the character of
epulis.   These cysts are of various degrees of thickness; some being thin and
membranous, others  having the walls partly composed of  fibrous  tissue, and
others  again having expanded bony lamellae largely entering into their compo-
sition,  so that on pressure they occasionally communicate  the semi-crepitant
sensations peculiar to the cystic  expansions of the osseous structure.   The fluid
contained in these cysts is a viscid liquid, usually semi-transparent, yellowish,
or bloody.
   In the lower, as  in the upper jaw, it is of great importance to diagnose the
simple  from the malignant affections, as in the latter form of disease an opera-
tion is rarely justifiable, the soft  tissues  around the bone being usually impli-
cated to such an extent as not to admit of removal, and consequently of the
full and  complete  extirpation  of the  disease.   The malignant tumors may
generally be  readily detected by the rapidity of their growth, their pulpy or
elastic character and infiltration of neighboring parts, with implication of the
sub-maxillary glands.
   The  treatment of tumors of the  lower jaw depends in a great  measure upon 
714                  DISEASES  OF  THE  JAWS.
the character of the growth.  In cystic tumors of moderate size, with thin walla
and but little deposit of fibrous tissue around the cysts, the best mode of treat-
ment consists in cutting down on the expanded portion of bone, opening the
cyst by means of the antrum-perforator, small trephine, or cutting-pliers, accord-
ing to  its size  and the thickness of its walls;  letting out the fluid  contained
within, and then by introducing a plug of lint get it to granulate from the bottom,
and gradually to contract.  When the cysts are so large that they have destroyed
the integrity of the bone, or when they are associated with a large quantity of
fibrous tissue, so as to constitute true fibro-cystic tumors, excision of the diseased
bone must be practised.   This, also, is the only plan of treatment  that can  be
had recourse to in other affections of this bone.
   The operation of excision of a portion of the lower jaw for tumor of that bone
was first performed by  Dupuytren.   As the growths for which this operation is
performed are usually situated between the symphysis and  angle  of  the  bone,
seldom extending beyond the middle line, the operation is generally  limited to
one side of  the face.   In some instances, however, the  tumor may encroach so
far that it may be necessary to remove more than the half of  the bone;  and in
other cases, again, though of very rare occurrence, the  whole of the  bone has
been disarticulated.
   When the tumor is of small size, and  is situated  about midway between the
symphysis and  angle of the jaw, it may be reached by making a semi-lunar
incision of sufficient length under the lower edge of the bone, dissecting up the
flap thus formed, then  carrying the knife cautiously along the inner side  of the
jaw, so as to detach  the mucous membrane of the mouth  and the mylo-hyoid
muscle to a sufficient  extent.  One of the teeth  on either side of the tumor
having been previously drawn, the  jaw  must now be deeply notched through
their alveoli into  its base with  a  narrow strong-backed saw, and  cut through
with pliers.  After the fragment of diseased bone, with the attached tumor, has
been removed,  the teeth  should  be tied together with strong silver wire, or a
silver cap should be fitted upon the teeth of the two portions  of bone that are
left, and attached by an elastic spring to another silver cap put on those  of the
upper jaw, so as to prevent the displacement that would otherwise occur  in the
smaller fragment.   Union takes place after a time  by fibrous  tissue, which be-
comes  sufficiently dense to make  the jaw strong and useful.  In those cases in
which  the tumor encroaches upon the angle and ramus  of the jaw, it is, better
to remove the bone at the articulation  on the affected side, for if the articular
end including the coronoid process be left, it will be  displaced forwards and
upwards by the action of the temporal and external pterygoid muscles, and be
a source of much inconvenience and irritation to the patient, unattended by any
corresponding utility.  In these cases the removal of one lateral half of the jaw
will consequently be required, and the operation may be performed in the fol-
lowing way: — The point of a strong bistoury  or scalpel should be entered im-
mediately behind  the  articulation,  carried down the posterior margin  of the
ramus  behind the angle, and under the body of the bone beyond the anterior
limits of the tumor, where it must slope gradually upwards, terminating at some
distance from the lips,  which should not be encroached  upon; the  convex flap
thus formed is dissected up, and  the  facial  artery and any other branches
requiring  ligature tied.   The knife  is then carried behind the jaw in front of
the tumor, and one of  the incisor teeth having  been extracted before the opera-
tion  commenced, a saw should be applied to the bone in this  situation, and  its
section finished by means  of the cutting-pliers; the surgeon then dissects under
and around it;  in this situation a scalpel, curved on the flat, will be found useful,
keeping the edge of  the knife  close to  the  bone  and  tumor.  When he has
cleared the tumor and ramus, he  depresses the  body of the bone  forcibly with
his left hand, in order more  readily to  divide the  attachment of the temporal
muscle to  the coronoid process.   This  having been done, the only part left is 
CLEFT  PALATE.
715
the disarticulation, which is best effected by opening the joint from the front,
whilst the bone is well depressed and twisted somewhat outwards, the  edge of
the knife being kept close to its neck, scraping  the bone so  as, if possible, to
avoid wounding the internal maxillary artery, when any remaining attachments
having been cut through, the disarticulation is effected.  In depressing  the bone
to get at the temporal muscle and the joint, care must be taken  not  to use too
much force, lest it happen that the ramus gives way, having been weakened by
the disease; a good deal of trouble being consequently experienced in removing
the fragment left behind, which can only be done by seizing it with  necrosis
forceps, thus  dragging it forwards, and then dividing the muscle  and  capsule.
Should the internal maxillary artery have been divided, it must be ligatured, or
the termination of the external carotid, where the vessel divides into  the  tem-
poral and  internal maxillary,  tied : any other branches that bleed will necessarily
also require the  ligature; and  then the  cavity having  been  lightly filled with
lint, should be left to granulate; the cheek being laid down and attached along
the line of incision by hare-lip pins and twisted sutures.  A  kind of fibrous
tissue forms in place of the jaw that has been removed, and comparatively  little
deformity results.  When the disease of the bone extends beyond the symphysis,
a thick ligature should be passed through the end of the  tongue, which  must
be drawn  forwards by an assistant, lest  on the division of the  insertion of its
muscles into the lower jaw it be forcibly retracted into the pharynx,  and thus
occasion suffocation.
                          CHAPTER  LI.

                    DISEASES OF THE  THROAT.

                           CLEFT PALATE.

  Various degrees of congenital deformity may occur in the palate and uvula;
thus the uvula alone may be bifid, or the cleft may extend through the greater
part or the whole of the soft palate; or, the hard palate may be divided as well;
and, lastly, the separation may extend forwards to the integuments of the face,
giving rise to the complication of hare-lip.  The soft palate and uvula are most
frequently cleft without the hard palate being divided; but, in some,  though
rare cases  the lip and the hard palate are fissured without the  soft one being
cleft.   These malformations  necessarily give rise  to great  inconvenience, by
interfering with deglutition, and rendering  the speech  nasal  and  imperfect.
Durino- the swallowing of fluids, especially, there is a tendency to regurgitation
through the nose, though this is occasionally prevented by the  approximation
of the edges of the fissure.
  In the treatment  of these malformations, the first question to be determined
is the age at which  the operation should be performed.   As the  success of the
operation  depends in a great measure  upon  the  patient remaining perfectly
tranquil and steady during the necessary procedures, which are of a  tedious
and protracted character,—upon his assisting the surgeon by opening his mouth,
and not stru°-°-ling on  the  introduction of the instruments, — and, after the
operation  in^making as little movement as possible in speech or deglutition for
some day's • it is usually considered  expedient not to interfere with this malfor-
mation until the patient has attained the age to understand the  necessity of re-
maining quiet, and  to be able  to control his movements; but yet some recent 
716
DISEASES  OF  THE THROAT.
observations by Fergusson and Sedillot have shown that the necessary operation
may be done  successfully on  young  children.  It need scarcely be remarked,
that the general health  ought to be  in the best possible state, before any pro-
cedure requiring immediate union of parts  be attempted.
  The operation  for the cure of a cleft in  the soft palate  may be said to have
been introduced  by Roux; for  although several attempts  at the  cure of this
deformity had been made by surgeons before his time, yet he was the first to
establish staphyloraphy as a distinct  operation.   Many modifications of Roux's
plan have  been  practised by Graefe, Warren, and others,  in order to render it
more easy of execution and  certain  in its results; but to Fergusson is due the
great merit of introducing a new principle  of treatment in  the operation—viz.,
the application of myotomy to it, and  thus paralyzing the movements  of the
muscles of the palate.   Fergusson found that the great cause of failure in these
cases was the  mobility of the parts, and the traction exercised by the muscles,
principally the levator palati, and the palato-pharyngeus on the  line of union;
in order to obviate  this, he conceived the happy idea of dividing these muscles.
Before Fergusson laid  down the principles of this operation, various cuts had
been made in the  palate by different  surgeons, with a view of taking off the
tension after the sutures were tied, more  especially two parallel incisions, one
on  either side of the  line of union; these, however, were done almost at hap-
hazard, and in an empirical way, without the recognition of any  distinct princi-
ple being involved.
   In the  operation, as performed by Mr. Fergusson,  there are four distinct
stages.   1st. The muscles of the palate are  divided, by passing a curved lancet-
ended  knife  through  the fissure behind the velum, midway between its attach-
ment to the bones  and the posterior margin, and about half-way between the
velum and the end of the Eustachian tube; by cutting deeply with the point
of  the knife in this situation the levator  palati is divided.  The uvula is then
seized and drawn forwards, so as to put the posterior pillar  of the fauces on the
stretch, which is to be snipped across, so as to divide the palato-pharyngeus.
2d.  The  next step  in  the operation  consists in paring the edges of the  fissure
from above downwards by means of a sharp-pointed bistoury.  This is best done
by seizing the lower  end of the uvula, putting it on the stretch, and cutting
first on one side  and then on the other, leaving the angle  of union to be after-
wards  removed.   The  patient should  then be allowed to  remain quiet,  and to
gargle the mouth  with cold water or to suck ice, so as to stop the bleeding.
3d. When this is arrested, the surgeon proceeds to the next step, that of intro-
 ducing the sutures; this  may be done by means of a nevus needle, armed with
 a moderate-sized thread, being passed from below upwards on the left side of the
 fissure, about a quarter of an inch from the margin ; the thread should now be
 seized with forceps, and one end of it pulled forwards through the fissure.  This
 may again be threaded in the  needle and  passed through the opposite side of
 the fissure from behind  forwards, through  the right side; as the point of the
 needle appears, the thread should again be seized and the  needle at the same
 time withdrawn;  the  suture is then tied by  means of the  surgeon's knot,
 and in this way from two to four sutures may be passed, according to the extent
 of the fissure, tied lightly, and the  knots  cut close.   In  tying the knots great
 care should be  taken  that  no undue traction  be exercised upon the parts; in
 fact, the  use of the  sutures  is not to draw, but simply to hold, the parts to-
 gether ;  the division of the muscles has caused these to be relaxed, so that they
 hang  down loosely and  merely require to  be held in apposition by the sutures.
 The patient must next be put  to bed, and every care taken to avoid any move-
 ment  of  the palate.  He should be  restricted to fluid  but  nourishing food for a
 few days,  and should be  directed to  swallow this with as little effort as possible,
 and indeed should not be allowed anything solid until complete union has taken
 place.  All coughing,  spitting, or swallowing of the saliva should be  interdicted. 
DISEASES  OF  THE  HARD PALATE AND  UVULA.    717
4th. The stiches should be left in for several days, and indeed need not be dis-
turbed so long as they produce no irritation.   They usually require removal by
the eighth or tenth day, but  occasionally may be left with advantage for some
time longer, until they excite irritation, or until union is perfect;  they should
then be cut across with  scissors and drawn out, the upper one first, the middle
next, and the lower one last.   Should there be any aperture left in the palate,
where union has not taken place, this may be closed by touching it with a point
of nitrate of silver.
   The voice  in these cases does not usually at once recover its natural tone
after the operation, although in some cases it may; but at the end of a month
or six weeks the patient may be put through a course of instruction with a view
 of regulating the movements of the tongue and the actions of the soft palate.
   Fissures of the hard palate are usually closed by means of " obturators" made
 of gold, vulcanized India-rubber, or ivory.   Dr. Warren,  of Boston, has pro-
 posed to close the fissures here by dissecting the soft tissues from the palatal
 arch between the  margin  of the cleft and the edge of the gum, and then uni-
 ting them in the middle line by means of stiches, in the same way as in fissured
 soft palate.
   This operation  has lately been brought before the  profession in this country
 by  Mr. Pollock, who has  invented  some ingenious instruments for its proper
 performance.
   Mr. Pollock's operation is as follows: — An incision having been made along
 the edge of  the cleft, at the junction of the nasal and palatal mucous  mem-
 branes, the soft covering of the hard palate is carefully  dissected or scraped
 down off the bones by  means  of curved knives,  great care being taken that the
 mucous membrane and its subjacent fibro-cellular tissue,  which varies  greatly
 in thickness  in  different cases, are not perforated;  when this has been well
 loosened on either side, it will be found  to  hang down as a curtain from the
 vault of the mouth, — the two parts coming into apposition along the  mesial
 line, or possibly overlapping.
    The edges being then smoothly pared, are brought into apposition by means
 of  a few points  of  suture introduced in the ordinary way and without any
 dragging.   On this point great care is necessary.  The knots having been tied,
 the°patient is confined  to bed for several days, and  on an abundant, but fluid or
 pulpy diet.   Union  will usually be found to be perfect at the end of  a week.
  At a later period,  the fissure in the soft palate, which always accompanies that
  in  the hard, should be cleared;  but it is  of  the greatest consequence that
  this be not attempted  at  the same time that the operation is done on the hard
  palate.
    In dividing the levator palati, Mr. Pollock adopts  a different practice to that
  of Mr. Fergusson.  Instead of cutting from behind, he passes a ligature through
  the curtainof the soft palate,  so as to contract and draw it forwards; and then
  pushing a narrow-bladed knife through the soft palate to the inner side  of the
  hamular  process,  by raising  the  handle and depressing  its point, he  divides
  readily the muscular fibres.   This method of dividing the levator palati, which
  is  analogous to the plan employed and depicted by M. Sedillot (figs. 285 to
  288) appears to be more simple and easy of execution  than the division  of the
  muscles  of the   velum  from  behind.   The gap that is left  closes  without
  difficulty by granulation, and seems still  more  to  take  off tension from the

  PaThe uvula occasionally  becoming  elongated, and  hanging  down into the
  pharynx  so as to  touch  the  epiglottis and  sensitive  mucous membranes in its
  neighborhood, gives rise to a tickling or spasmodic cough which  can  only be
  cured by removing the pendulous body.  This little opeijation  may be readily
  done by seizing the end  of the uvula, with a pair of polypus forceps, and snip-
  ping across its root.   Of late I have been in the habit of using a pair of "vul- 
718
DISEASES OF THE  THROAT.
sellum scissors " (fig. 289), which I have  had constructed  for the purpose, by
which the uvula is cut off at the same moment that it is seized, thus rendering
the operation easier and less irritating to the patient.
Fig. 285.                          Fig. 286.
Fig. 287.                         Fio. 288.
  The tonsils are not  unfrequently the seat of disease, becoming inflamed or
permanently  enlarged.  When inflamed  they  become swollen and red,  with
much pain in the side of the neck and ear, increased by any attempt at swallow-
ing ; there is usually rather a profuse secretion of saliva,  and a good deal of
swelling under the  angles of  the jaws; the tongue is much coated with thick

                                 Fig. 289.
pasty mucus, and the voice is  thick  and nasal.  The treatment consists in the
application of leeches under the jaw, of fomentations, the inhalation of the
steam of hot water, and  low diet, which need scarcely be enforced, on account
of the difficulty and pain in swallowing.   If the mouth can be opened, much 
AFFECTIONS  OF  THE TONSILS.
719
relief may be given by scarifying the tonsils with a probe-pointed bistoury, and
if abscess form, it should be opened early, which may most readily be done with
a gum-lancet.
  The tonsils often become  chronically indurated and enlarged, sometimes as
the result of repeated attacks  of inflammation of these parts, but in the majority
of instances independent of any inflammatory mischief, though when once en-
larged these organs are constantly liable to  inflammatory attacks.  Hypertrophy
of the tonsils most commonly  occurs as a strumous disease in scrofulous children,
who have a tendency to  congestion of the  mucous membrane of the nose, and
to enlargement of the lymphatic glands of the neck.   In such cases as these
the enlargement of the tonsils may gradually subside as  the  child grows older
and stronger, and  the  treatment should be directed to the improvement of the
general health and strength, by means  that  are  ordinarily had recourse to in
the management of strumous affections; the internal use of  iron and the local
 application of the tincture of iodine or of nitrate of silver being occasionally
 serviceable.  In  the majority of instances,  however, the  disease  will  not  be
 influenced  by any therapeutic means that may be  adopted;  and as the enlarge-
 ment, continuing  or increasing, gives rise to difficulty in respiration, and  thus
 interferes with the due arterialization  of  the blood  in  the lungs, and impairs
 the child's speech, it becomes necessary  to  remove the projecting portions of
 the enlarged growths.   This may most conveniently be done by means of the
 ordinary tonsil-guillotine; the  ring  of the instrument  being passed over the
 tumor, the cutting blade is pushed forwards, and  thus a slice of the projecting
 part of the growth is removed.  In some cases not a little difficulty is experi-
 enced in getting the tonsil fairly into the ring of the instrument, more particu-
 larly if the child is unruly;  this may be obviated by drawing it through with a
 vulsellum  or double hook, and indeed in some of the machines sold for the pur-
 pose a kind  of prong is attached, which  being fixed into, draws  forwards the
 tonsils before it is sliced off  (fig. 290).  In performing this  operation, especially

                                  Fig. 290.
in children, it  is most  convenient for the surgeon to stand behind the patient,
as he can thus  look better into  his mouth  and has more  command over the
head.  Should a guillotine  not be at hand, the tonsil may be removed by seiz-
ing it with a vulsellum, drawing it forwards, and then taking off a slice with a
probe-pointed bistoury, the base of the blade of which should be wrapped round
with a piece  of  plaster, to prevent its wounding the tongue.  In excising the
tonsil in  this way, care must  be  taken to cut downwards and inwards towards
the mesial line, and on no account to turn the edge  of the  knife outwards lest
the internal carotid artery be  endangered.   The hemorrhage that follows this
operation is usually very trifling, but I have known it to  be sufficiently abun-
dant to  endanger  the  patient's life.   In such  cases ice  and gallic  acid will
usually arrest  the bleeding.  In one case to which I was called I  found a gargle
of spirits of turpentine suspended  in  mucilage effectual  after all other means
had failed. 
720
DISEASES  OF THE  THROAT.
                   DISEASES  OF  THE  PHARYNX.

  Inflammation of the pharynx of a diffuse erysipeloid character, with low fever,
not unfrequently occurs;  it is best treated by tbe application of a strong solu-
tion of nitrate  of silver, the use of  emollient gargles, and the internal adminis-
tration of ammonia, with bark, stimulants, and support.  If it have a tendency
to run into sloughing action, the internal administration of the  mineral acids,
with bark and  stimulants, the nitrate of silver lotion and chlorinated gargles are
useful.   Sometimes abscess forms  in  the  substance of the  velum,  and then
requires to be opened with the knife that is delineated at page 346.
  Abscess occasionally forms in the cellular tissue behind the  pharynx, the pos-
terior wall of which is consequently pushed forwards so as to occlude  the poste-
rior nares, giving rise to a peculiar nasal intonation of voice;  it also may inter-
fere with breathing by pressing upon the upper part of the larynx.   This kind
of abscess is  often connected with disease of the bones at the  base of the skull,
or  of the upper cervical vertebrae.  In many cases, if left  to itself, it would
burst through the mucous membrane into the mouth, but in others it comes for-
wards under  the sterno-mastoid muscles into the forepart of the neck.  By ex-
ploring the pharynx with the finger, which  may readily be  done, tension and
fluctuation through its posterior wall may easily  be made out.  In these cases,
the treatment simply consists in letting out the matter by puncturing the tense
membrane covering it.  This may be done by means of a sharp-pointed bistoury
properly protected, or the ordinary  abscess knife.   The  pus  let  out  is usually
offensive, even though the bones be not affected.
  Tumors are occasionally met with  in the post-pharyngeal cellular tissue, giving
rise to  the same swelling, difficulty in respiration, and deglutition, and lateral
projection, as occurs in abscess of this region.   These growths are mostly can-
cerous, and speedily prove fatal.  Polypi  in the pharynx usually come down
from the nasal cavities, but sometimes  spring from the inside of this canal on
one or  other of its margins.   They are usually,  when truly  pharyngeal,  of a
malignant character, and grow with great rapidity.   The uses of the part are
necessarily interfered with, and death may  eventually result from obstruction to
deglutition and respiration.   Cancer of the pharynx  of  an epithelial character
has occasionally been met with.   This form of  the disease, which  is of rare
occurrence, does not differ from similar growths elsewhere.

                  DISEASES OF THE 03 S O P H A G U S .

  All diseases of this mucous  canal have a tendency to occlude its passage, and
hence are commonly described as strictures of it.  In some  instances the con-
striction of the oesophagus may be of a purely nervous or  spasmodic  character;
but in the majority of instances it  is  the  result  either of fibrous  or cancerous
degeneration of the walls of the canal, or of the  projection  of malignant growths
into its interior.
   The  spasmodic stricture usually occurs  in hysterical women, and not unfre-
quently results from local irritation occurring after the removal of a fish-bone or
some such body from the canal.  It is often chiefly seated in the constrictors of
the pharynx.  In it the symptoms are usually intermittent, the patient expe-
riencing difficulty in swallowing certain articles  of food, or at particular periods
of  the day,  whilst at  other times deglutition is perfect.  In  many instances it
appears  simply to be  a variety of the  hysterical  globus.  In the  treatment of
this affection, the patient must be put  upon an  anti-hysterical plan, with cold
douches and electricity to the neck, and the occasional introduction of the bougie
to blunt the  sensibility of the  part.
    Organic stricture of  the oesophagus usually  occurs either at the commence- 
INFLAMMATION OF  THE  LARYNX.
721
ment or end of the canal, most frequently at the former, opposite the cricoid car-
tilage.   The  patient first complains of difficulty in deglutition, he finds that  a
portion  of the food that he has apparently swallowed, returns into his mouth
after a time, and that he is obliged at last to confine himself to slops.  On ex-
amining the oesophagus by means  of a bougie, the surgeon will find a part that
appears to be constricted, and at which the point of the  instrument  is either
arrested altogether or passes with  difficulty.  After a time  the patient gradually
becomes cachectic, and a painful  and distressing death will  at  last occur from
low  starvation, or from  the  irritation  occasioned by the  formation of abscess
around  the seat of disease.
   In the  treatment of organic stricture of the oesophagus, care should be taken
that the patient is principally kept upon nutritious slops, or upon meat that has
been well chopped up, as larger fragments are apt to become impacted at  the
seat of constriction.   Means should at  the  same  time be taken  to dilate  the
stricture.   If it be of a fibrous character, such a plan of treatment will be of use ;
if cancerous, it is useless to attempt its dilatation, and upon the whole, I think it
better not to irritate the disease by pushing instruments through it.   In intro-
ducing bougies into the strictured part of the oesophagus, there is often a good
deal of difficulty in getting the point of the instrument into the narrowed por-
 tion of the canal.  This is more particularly the case when the constriction com-
 mences suddenly; the  oesophagus, as is frequently the case, being dilated  into
 a pouch-like sac above it, in which the food is apt to lodge and the end of the
 instrument to be arrested, and at the bottom of which a  narrow orifice exists,
 leading into the lower portion  of  the canal.   In these cases much patience and
 care may be required  in  overcoming the difficulty.   In a  patient who had a
 strictured oesophagus  of this kind, who had not swallowed food for nine days,
 and who was consequently nearly exhausted  by starvation, I  succeeded, after
 much difficulty, in getting a No.  5 gum elastic catheter  into  the  stricture,
 through which nutriment was  injected  into the  stomach.  In this case much
 benefit was afterwards derived by gradually dilating the stricture, which  was
 done on  the same principle that has been introduced by  Mr. Wakley in the
 treatment of urethral strictures, — by getting a narrow instrument through the
 constriction, and then slipping a  larger one over it.   I first introduced a long
 narrow bougie through the stricture as a guide, and then slid a gum-elastic tube,
 well rounded at the end over this; and  although the patient eventually died of
 cancerous degeneration of the oesophagus, with abscess, he was by these means
 kept alive for many months, enabled to swallow food, and  put in a state of com-
 parative comfort.   It is needless to observe  that, in the treatment of stricture
 of the oesophagus by bougies, no force should  be employed, lest by any accident
 the walls of the canal be perforated, or the  constriction be dependent on the
 pressure of a tumor or of an intra-thoracic aneurism.   Indeed, it is well, in all
 cases of difficulty of deglutition dependent on lesion of the oesophagus, that the
 thorax should be examined, with a view  of ascertaining  whether such disease
 may exist, before any  treatment by dilatation is undertaken.   In cases in which
 the stricture has become impermeable, the  patient must necessarily speedily
 sink, exhausted by starvation.  Sedillot seems to think, that, under such circum-
 stances, it would be justifiable to  lay open the stomach, with the view of intro-
 ducing food directly into that organ.  This plan, however, appears to be some-
 what too  heroic to be  adopted  in  practice.   The consequence of such an opera-
 tion would probably be to save the patient the horror of a lingering death from
 starvation, by more speedily terminating his existence.

                     DISEASES  OF  THE  LARYNX.

   Inflammation of the larynx principally occurs in adults,  from exposure to cold,
 to the infection of erysipelas, or  to the general occasioning causes of the low
        46 
722                DISEASES  OF  THE THROAT.
forms of inflammation; it differs essentially from  the croup  of children, which
is attended by an albuminous exudation, and spreads downwards into  the bron-
chi; whilst in laryngitis, there is no effusion of plastic matter, and the disease
is  confined to  the  larynx itself.   Laryngitis  may not only be of an acute or
chronic kind, but it  likewise presents two  distinct varieties,  according to the
parts affected, the cause from which it arises, and the  condition of constitution
in which it occurs; in one, the true acute laryngitis,  the inflammation is chiefly
seated in the mucous membrane and cartilages;  in  the other, the cedematous
laryngitis, the affection chiefly occurs  in the submucous cellular tissue, within
and around the larynx.
   In all inflammatory affections  of the larynx, whether acute or chronic, there
is great danger to life; the rima glottidis, that narrow chink through which all
the air  destined  for  respiration must enter,  becomes readily occluded,  and
asphyxia consequently results.   This may happen either by the swelling of the
lips of the glottis, from the effusion of plastic matter  within  or upon them, or
by the occurrence of spasm in the larynx; indeed, there is  always more or less
spasm conjoined with all the inflammatory affections  of this part of the air-tube,
and this spasm being superadded  to already existing  mechanical occlusion, com-
monly proves fatal.  These laryngeal  spasms do not at first recur oftener than
at intervals of half an hour or an hour, but as the disease advances they become
more frequent, and in any one of them the patient may be carried off. It is of
importance to bear in mind that death may occur in these cases, although a con-
siderable portion of  the cavity of the  larynx continue free.   Thus Dr. Cheyne
 states that there is always in croup at least  three-eighths of the cavity of the
 larynx open  for the transmission of air, and  that death must consequently result
 from some other cause than mere mechanical obstruction.  This freedom from
 permanent occlusion commonly occurs in cases of laryngitis, and the immediate
 cause of death in the majority of instances appears to be spasm, conjoined with
 defective arterialization  of the  blood,  which becoming dark and  poisonous,
 causes congestion of the lungs  or brain, and thus  low pneumonia and con-
 vulsions.
    In acute  laryngitis  the  symptoms are  those of local inflammatory action of
 an acute kind, conjoined with those  indicative of interference with.the  proper
 admission of  air to  the lungs.    The cartilages and the mucous  membrane are
 the  parts principally  inflamed, and  but little effusion takes place  under the
 mucous membrane;  hence the symptoms are not  always indicative of such early
 or intense interference with respiration, as  is met with in the cedematous form
 of the disease.  In  acute laryngitis  there is pain and tenderness on pressing
 upon the larynx, more especially about the pomum adami.   The voice at first
 is harsh and rough, then stridulous  or sonorous, with difficulty in  deglutition.
 The difficulty in swallowing is often at first the most  prominent symptom, and
 continues throughout; dyspnoea, often of a spasmodic character, then comes on,
 the  lips becoming livid, the features  pale,  and bedewed with perspiration, the
 eyes watery and bloodshot, and  the respiratory muscles being called into violent
 action,  the  nostrils are dilated, gasping  efforts at breathing, and sudden  fits of
 increased difficulty in inspiring come on; at the same time  the pulse becomes
 feeble, though it continues rapid, and unless efficiently relieved,  the  patient
 will speedily sink.   When it proves  fatal, the acute usually runs into the cede-
 matous form of laryngitis.
    The treatment in this  disease should be actively antiphlogistic.  No time
 must be lost, otherwise  the patient will fall into a hopeless state of asphyxia.
 Free blood-letting,  the  application of an  abundant  supply  of leeches to the
 larynx, and the administration of calomel in large doses, with antimonials, must
 be had  recourse to.  If notwithstanding the administration  of  these remedies,
 the difficulty in respiration continue to increase, the  windpipe must be opened
 before the lungs and brain  become irretrievably engorged.  It is no easy matter 
                    (EDEMATOUS LARYNGITIS.                 723

to determine when it is no longer prudent to trust to active antiphlogistic treat-
ment, and when operation should he had recourse to; indeed the determination
of this point may be considered as one of  the nicest questions in surgery.  As
a general rule  it may be stated, that if notwithstanding the antiphlogistic means
above indicated, the  dyspnoea get gradually more urgent, and paroxysms  of
spasmodic difficulty of breathing become more frequent and severe, then no time
should be lost in the  performance of the  operation, for however short a period
the  disease may have  existed.   I can  truly say that I have seen several cases
lost  by delaying the performance of this  operation, but  never one  by opening
the windpipe  too early.   Indeed if the opening  be even made somewhat early,
I do not think that much, if any, harm results, as the larynx is thereby set at
rest; and on the laryngitis being subdued by the continuance of proper treat-
ment, the aperture which simply served as a breathing-hole may be allowed to
 close by granulation.
   In cedematous laryngitis, the disease is seated chiefly, if not entirely, in the
 submucous cellular tissue,  and frequently comes  on  in  the  course of  chronic
 affections of the larynx.  It may, however, be of a distinctly erysipelatous cha-
 racter, occurring as the result of  exposure to infection, or to  atmospheric vicis-
 situdes.  In  fact, in many cases  it appears to be at times epidemic, and in its
 pathological conditions  resembles closely phlegmonous erysipelas  of the part;
 the mucous membrane becoming red, pulpy, and swollen, and the cellular tissue
 lying beneath it infiltrated with  semi-puriform plastic matter.   In this form of
 the disease, the fauces  are  reddened,  dusky, and swollen; there is much and
 early dyspnoea, the voice becomes hoarse, rough, and speedily extinct, with much
 difficulty in deglutition, and  on passing the finger over the back of  the tongue,
  the epiglottis will be felt rigid and turgid.   There may be some degree  of ten-
  derness about the larynx, but the  local  symptoms, which are less acute,  are
  attended by a greater amount of dyspnoea than in the active  form of laryngitis.
  In  cedematous  laryngitis there is also  a good deal of spasm associated with  the
  local turgescence.  These spasms  sometimes come  on early, and carry off the
  patient at once, and are very apt to be brought on by speaking or swallowing;
  but as  the disease advances, more continuous dyspnoea may supervene, with
  great restlessness, a quick, small pulse, and convulsive breathing,  the  counte-
  nance being  pale, sunk, and clammy, and the eye dull.   Stupor at length super-
  venes, which speedily terminates in  death.
    The  cedematous infiltration in this form of laryngitis is principally confined
  to  the submucous cellular tissue around  the  epiglottis, at the margins of the
  glottis, and  to that which lies at the  back of the  thyroid          ggi
  cartilage.  In  these  situations  the  tissue is distended with
  sero-plastic  fluid, of  an opalescent  character,  so as  almost
  completely to occlude the  rima glottidis (fig. 291).   It is a
  pathological  fact of much importance  that  this  effusion
  never extends  below  the true vocal  cords;  being limited at
  this point by the direct adhesion of the mucous  membrane
  to  the subjacent fibrous tissue, without the intervention of
  any cellular  membrane.
    It is of great importance to make the  diagnosis between
  the two  forms of laryngitis.   In  the acute variety of the
  disease, antiphlogistic treatment is of great moment; in the
  cedematous form it is comparatively useless, for here effusion
  sets in early, and nothing is left for the surgeon but to open
  the air-passages, so as  to  give  the patient breathing-room,
  whilst the disease is  being subdued.  In  making the diag-
  nosis, the epidemic character of the  affection, the  absence
  of much pain  in the larynx, and the dusky-red and swollen
  fauces point to the cedematous variety. Then also the effect     f^.
  of antiphlogistic treatment should be taken into account.  If, after its active
 
724
DISEASES  OF  THE  THROAT.
employment, no alleviation of the symptoms  occurs, it  is only reasonable  to
suppose that the obstruction to breathing is owing rather to a purely mechanical
obstacle than to simple inflammation.                      ...
  The treatment of oedematous laryngitis must be antiphlogistic, though the
constitution will not usually bear any very active measures of this description.
Leeching under the jaws and  over the larynx, the administration of antimonials
and  salines, will be especially serviceable.   In many cases, scarification with a
hernia knife or probe-pointed  bistoury about the root of the epiglottis, the sides
of the olottis, and the back  of the thyroid cartilage, will be found  the most
ready means of unloading  the infiltrated mucous  membrane.   In these cases it
is, however, especially necessary to open the windpipe before it is too late, and
the luncrs become engorged.  After the proper  employment of the means that
have been indicated and their failure, the less delay there is in opening the air-
passap-es through the crico-thyroid membrane the better.   The  surgeon should
not wait until extreme and  continuous dyspnoea has set in; this may never occur,
the difficulty in breathing being rather of a spasmodic than continuous character,
and in one of these spasms life may suddenly become extinct.  The lungs also
may become fatally congested if the difficulty in  breathing be allowed to con-
tinue too long.   The operation adds but little  to  the  patient's danger, but the
increased risk is immense  if it be delayed to an advanced period.  Not unfre-
quently this operation is delayed until too late; there is, I think, more risk of
doing this than of opening the windpipe too early.  When once  dyspnoea with
 laryngeal  spasm has fairly set in, every moment is precious, and the patient
 may at any time  be carried  off by the recurrence of the spasmodic seizures.
 The  patient does  not die  gradually asphyxiated, but is  suddenly seized with a
 spasm that terminates his  existence.
   If the  oedematous  laryngitis become chronic, sloughing and  putrid suppu-
 ration of the submucous cellular tissue may occur, as in phlegmonous  erysipelas
 of other parts of the body, and the patient  may die  partly from asphyxia and
 partly  from typhoid symptoms, with putridity of the breath and mouth.   In
 these cases the administration of  stimulants and tonics, more particularly port
 wine and bark, with free sponging of the part with a strong  solution  of nitrate
 of silver, will be urgently required.
   The larynx is liable to  various  chronic  diseases of a serious character, some
 of which are incurable, leaving a permanent impairment of voice, or alteration
 in the  use of the larynx.   These affections present great variety, and as many
 of them are attended by loss of voice, they are included under the general
 term of aphonia.  In many cases this affection results simply from cold in
 relaxed and debilitated  subjects,  or after long  exercise of the voice in persons
 not accustomed to public  speaking.   This affection commonly occurs amongst
 clergymen, and hence is familiarly known as the clergyman's sore throat; it is
 also of frequent occurrence  amongst singers, but may be met with among all
 classes of the community.  Aphonia commonly appears to depend upon chronic
 inflammation of the mucous  membrane of the rima glottidis, but is more espe-
 cially dependent on disease  of that extensive mucous surface which stretches
 from  the base of the epiglottis  over the  back of the thyroid cartilage.  In
 many instances it may also extend into the interior of the  larynx, and at  last
 may implicate  the vocal  cords.   In all these situations the membrane is red-
 dened and inflamed, ulcerated at points, and secreting a thin and acrid mucus.
 In other instances again,  the disease implicates the soft  palate, the back of the
 nares,  and the neighboring  parts; and  in these cases  the  morbidly inflamed
 surfaces will be seen to secrete a thick puriform fluid, which  usually hangs in
 a broad streak down one side of the posterior wall of the pharynx.
    The symptoms of this  chronic irritation  of the mucous membrane in these
 situations  consist of habitual tickling or spasmodic  cough, a veiled  or hoarse
 character of voice, with  perhaps, at last, complete  extinction  of it, so that it 
            TREATMENT  OF CHRONIC  LARYNGITIS.         725

cannot be raised above a whisper; at the same time there is usually a feeling
as if there was some  constant  cause of irritation in the  throat, attended  by a
desire to cough up and expectorate.  As the disease advances, the expectoration
becomes more and more puriform, the cough increases, the patient emaciates, is
affected  with  night-sweats, and  at  last sinks from  what  is  called  laryngeal
phthisis.   When the posterior  nares and the neighboring parts of the pharynx
are affected, the  symptoms are not so severe, though they may eventually be-
come so by the extension  of the disease  downwards.
   These  affections are very  frequently mistaken  for  chronic bronchitic,  or
catarrhal attacks.   From  the first they may be distinguished by the absence of
all auscultatory signs in the chest, and examination of the pharynx will prevent
the  disease being confounded with an ordinary catarrh.   This examination,
however, requires to be properly  done, so that a full view may be gained of all
the parts engaged in the morbid action.  This is best obtained by seating the
patient opposite a good light, and then, depressing the root of the tongue at the
same time that it  is drawn forwards  by means of a proper  tongue-depressor or
spatula, directing  the patient to inspire.  In  order to examine the mucous mem-
brane at the  back of the pharynx, and in the neighborhood of the posterior
nares, the velum may be raised by any convenient instrument.
   The treatment  of these various chronic inflammations of the mucous mem-
brane of the pharynx and larynx requires to be conducted by the topical appli-
cation of a solution of the nitrate of silver, which may almost be looked  upon
as specific in these diseases.
   The practice of treating chronic disease of the larynx by the application of a
 strong solution of the nitrate of  silver is by no means of recent origin.   Many
years ago it was employed by Sir C. Bell, and before him M. Bretonneau  applied
the  solution in these cases by  means of a sponge attached to a piece of whale-
bone.   Of late years this practice has been brought very prominently before the
profession by Trosseau, and by  the American surgeons, especially by  Horace
Green and J.  Warren.
   Of the great value of this  treatment in  laryngeal  disease  there  can be no
doubt.  I believe it to be almost impossible to bring  deeply-seated and very
 chronic inflammatory or ulcerative affections of this part of the  air-passages to a
 satisfactory termination by any other means.   The mode of application that is
 the  simplest and most effectual, consists in depressing the tongue with a proper
 spatula, and then passing a throat-sponge,  consisting  of a small piece of this
material firmly attached to a curved whalebone stick, and saturated with a solu-

                                  Fig. 292.

           --------------------------------_=




tion of nitrate of silver, down  to the parts that are diseased, so that the liquid
may be applied to the whole of the affected surfaces.   This solution should vary
in strength from half a drachm to a drachm of the salt to an ounce of distilled
water; most commonly, the latter strength will be most  useful.  This  plan of
treatment has been much practised of late years in this country, and with con-
siderable success in a large number  of cases.   Some of its  advocates, however,
not  content with  curing in this way disease  that is visibly seated in the throat,
state that the  morbid action extends down the trachea into the bronchi, and that
it is necessary to follow it in these situations.  They accordingly speak of pass-
ing  the proband  between and beyond the  vocal cords, and  of sponging and
mopping out the interior  of the larynx and the lower parts of  the air-tube, and
of applying the caustic solution to them, as if this were a proceeding that could 
726
DISEASES  OF  THE THROAT.
be adopted with as little difficulty as passing the sponge into the nares.  I can-
not believe, however,  that this practice, though  commonly spoken about and
professedly employed,  is ever in reality carried out.   Any one acquainted with
the physiology of the larynx knows how acutely sensitive it is, and how it resists
the introduction of any foreign body by the  most violently spasmodic fits of
coughing, in its normal state; and any surgeon who has seen the effects resulting
from  the fair  and complete inhalation of a drop  or two of the solution of the
nitrate of silver in a morbid and irritable condition  of this tube, must feel sure
that  no sponge saturated with a solution of this  caustic could ever have been
thrust down beyond and between the vocal cords.
   On inquiring  into  the  evidence on which is founded  the  doctrine of the
passage of the  sponge probang through  and  beyond  the vocal cords, I have
failed to  discover that any of a positive character exists, and so far  as I can
gather  from the writings of its supporters, it would appear that the reasons
from which  it  is  inferred to  do  so may be arranged  under the  following
heads: —
   1st. The sensations of the patient.
   2d. The sensations  of the surgeon.
   3d. The  analogy offered by the  introduction  of tubes for the purposes of
 artificial respiration, and by the inhalation of foreign bodies.
   These different conditions we must, examine somewhat in detail.
   1st.  The sensations of the patient. — The exquisite  degree of sensibility pos-
 sessed by the larynx need not be dwelt upon here.  Mr. Porter in his admirable
 work " On the  Surgical  Pathology  of the Larynx and Trachea," very justly
 says, " It (the  larynx) is placed as an outwork  to protect the important organ
 of respiration, and  rejects vehemently and with  spasmodic violence, every sub-
 stance  that can  by possibility prove  offensive or injurious."   Many years ago
 Magendie shows that this was the most  sensitive part of the respiratory tube;
 and in the year 1843  I published in the  " Medical  Gazette" a series of experi-
 ments, which demonstrated  the same fact.  Since then  I have had  repeated
 opportunities of verifying the  correctness of these observations in  the human
 subject in cases of cut-throat  and aerial fistula, in which, by means of probes
 introduced through the artificial opening, I have tested the extreme sensibility
 of the larynx as compared with other parts of the air-passages, and  have often
 observed the  spasmodic irritation and great distress suffered by the patient when
 its mucous membrane is touched from within, and this, even though the part is
 no longer subservient  to the purposes of respiration, and the sensation of asphyxia
 not experienced, which" would  otherwise  be induced, and which would greatly
 aggravate the distress.
    If a long, bent probe, or a  gum-elastic  catheter, be passed over the back of
 the tongue, two classes of sensations will be elicited, according to the part that
 is touched.   If the instrument be  directed down the  pharynx, and altogether
 behind the larynx,  into the  oesophagus,  as in  the introduction  of the  stomach-
 pump  tube,  the patient  will experience  some  little  distress, which  is easily
 quieted.   The face will become slightly  congested, and the eyes, perhaps, some-
 what suffused, with a disposition to cough, a slight feeling of choking, and some
 constriction about  the chest.  All  these sensations,  however, are transitory.
 These symptoms may be termed pharyngeal.
    If, on the  other hand, the probe or tube be bent forwards, so as to touch the
 lips  of the glottis, and more particularly if an  attempt be made to push  it  on
 into the larynx, then a widely different  train  of symptoms will be induced.
 The patient  suffers extreme distress and anxiety; there is great sensation  of
 constriction about the chest and throat, spasmodic difficulty in breathing, and
 an inability to speak; the countenance becomes much congested  and livid, the
 eyes protrude and stream with tears, he stands up", gropes wildly with his hands,
 and  is pacified with great difficulty.  As the attack  goes off,  there are deep, 
TREATMENT OF  CHRONIC  LARYNGITIS.         727
sobbing inspirations, and catches in the breathing.  These symptoms, which are
analogous to those induced by the irritation of the inside of the larynx through
an aerial fistula, may be termed laryngeal.
  The first class of symptoms is produced by the application of an irritant to
the mucous membrane of the pharynx;  the second, to irritation of the larynx.
Their severity will, in a great measure, depend upon the nature of the irritant
applied.   They will necessarily be far more severe when a sponge soaked in a
caustic solution is thrust down the throat, than when a smooth and unirritating
gum elastic tube  is passed.
   Both these classes of symptoms are commonly met with after the application
of the throat probang.  When the pharyngeal  symptoms  occur, there can  be
little doubt that  no sponge saturated with  a strong solution of nitrate of silver
has penetrated  into the glottis. But is not the case different when the laryngeal
 symptoms are  fully developed ?   Must  these not, when  existing in  their full
 intensity, be taken as evidence  of the introduction  of the  sponge  probang
 through the glottis ?  To  this I have no hesitation in answering in the negative.
 I have  repeatedly brought  on  these symptoms,  in the  most marked degree,
 without the use of a sponge at all, or the introduction of any solid body into the
 larynx.   In fact, if a drop of a strong solution  of the nitrate of silver is fairly
 inspired into the larynx, the most intense distress, and appearance of impending
 asphyxia will be induced.   I saw this well exemplified some time since at the
 hospital, whilst applying  a strong solution  of nitrate of silver by means of lint
 wrapped round a probe to a syphilitic ulcer on the soft palate, altogether away
 from  the  larynx;  a drop was accidentally inhaled, when the patient was sud-
 denly seized with one of the most intense attacks of laryngeal spasm that I have
 ever seen;  for a few moments she appeared to be about to die asphyxiated, and
 had all the laryngeal symptoms above described fully marked.
   In many cases I am in the habit of applying the solution of the nitrate of
 silver by means of a strong glass tube bent nearly at right angles about an inch
 from one extremity.   A few drops of the solution are introduced into the bent
 end of the tube,  and this being passed over the back of the patient's tongue, so
 as to overhang the glottis, the other end is closed by the pressure of the finger.
 The patient having previously emptied his chest,  is then told to take a deep
 breath,  and, at the moment of doing this, the finger being removed from  the
 tube, the solution contained at its bent end is inhaled  fairly into the larynx;
 and, when so applied, will produce the symptoms already described.
    Thus, then, we may  conclude, that when  the pharyngeal symptoms exist
 alone, the sponge cannot have passed into the true air-passages; and that  the
 laryngeal symptoms, however intense they may be, afford no evidence of more
 than the inhalation of a  drop or two of the caustic solution into the  glottis.
    2d.  Sensations of the  Surgeon. — The  little reliance  that can be  placed on
 the mere sense  of touch in many  explorations  of the  mucous canals is well
 known  to surgeons.  It often  happens, for instance, that in the  attempt to
 relieve retention of urine from enlarged prostate, the catheter is supposed to be
 lodged  in the bladder, when it has only reached the  dilated  sinus of  the
 urethra:  so also in passing bougies up the rectum, that the instrument  has
 entered the sigmoid  flexure, when, in  reality, it has curled back upon itself.
 Those practitioners, however, who  believe in  the  possibility of passing  the
 sponge  probang  beyond the vocal cords, rely much  on  the sensations communi-
 cated by its passage through this narrowed portion of the larynx.   They  say
 that in  passing the instrument to the proper depth, a certain sense of obstruction
 is felt; against  this,  which is believed to be the vocal cords, the_ sponge is
 firmly pressed for a  moment,  when the  obstacle yields, and the  instrument
 passes onwards into the air-tubes.  On  the withdrawal of the probang, the same
 feeling of constriction is experienced by the sponge being drawn up against  the
 cords.  These sensations are  undoubtedly experienced.  I  have many times 
728
DISEASES  OF  THE  THROAT.
felt them myself, and, had I judged  by them alone, could have been almost
certain  that I had  passed  the  instrument between and below the vocal cords,
and this belief would have been strengthened by the circumstance that in many
of the instances in which this constriction was felt the laryngeal symptoms were
manifested.   I soon found, however, that  this was by no means uniformly the
case,  but that it not unfrequently happened that the pharyngeal symptoms only
were  induced; and that consequently,  in accordance with what I believed to be
the proper state of sensibility of the larynx, the interior of that tube could not
have  been traversed by the caustic sponge.   Finding also the same sensation
often experienced in the introduction  of bougies and tubes into the oesophagus
and  stomach, it was  clear that it could have  nothing to do with their progress
through the larynx; and I was led to conclude that it was occasioned by the
passage of the instrument  through that narrowed portion of  the  end of' the
pharynx,  or the  beginning  of  the oesophagus,  where  the  cartilages of the
larynx, projecting backwards, give rise to a  certain amount  of constriction,
compressing the  gullet, as it were, against the spine.   Here  the  instrument
meets with a certain degree of obstruction,  which is partly  mechanical and
partly occasioned by spasm  of constrictors of the  pharynx, and, on this being
overcome, passes on with  a sudden  slip, again  to meet with  a  degree  of
constriction on being withdrawn.
   In numerous  experiments on the dead body that  I have made on this point,
I have very frequently found that the instrument had  passed into the oesophagus,
when, from the  sensation it gave, those who had introduced  it felt confident
that  it had  entered the air-passages.   In fact, the shape of the sponge probang,
as it is always sold (fig. 292), is such that  it cannot be made to enter the larynx,
 and  to pass beyond the vocal cords in the dead body,  without the employment
 of a considerable  degree of force, and by means of  those manipulations which
 are alone admissible in the  living patient.   A probang, with a short curve, such
 as those that  are uniformly employed,  has a natural tendency to take the direct
 passage, as it were, down the oesophagus, instead of turning forwards  to enter
 the  larynx.   When the  curve is  much increased, as  in an ordinary catheter,
 the  sponge may, during  life, be passed between the lips of the glottis, but it
 cannot even  then be made to pass between  and below the vocal cords, in con-
 sequence of the  curve being too large to be admitted  into the diameter of the
 trachea.  The evidence of the New York Academy Commission fully warrants
 this  statement;  for the reporters  remark, that notwithstanding the most perse-
 vering efforts with the whalebone slightly bent, as used by Dr. Green, and with
 patients  who quietly submitted to the  test of experiment,  the results were
 entirely negative.   In  no instance did  it enter the trachea.   In two instances,
 with the whalebone curved like a common catheter,  the sponge was thought to
 have entered the larynx, but with repeated  attempts  it could  not be forced
 between  the  vocal cords, and  the  suffocation was so great that it was necessary
 to withdraw the  instrument.
   The fallacy of the sensations of the  surgeon is well illustrated in the following
 extract from  the report of the Commission of the New York Academy: — " We
 witnessed in  cases 11 and 21 the fallacy of Dr. Green's opinion as to the success
 of his  experiment, though based on so large an experience.  In both instances,
 whilst  positive that he had successfully  passed the instrument  (an elastic tube)
 into the  trachea, the patient vomited through the tube, and  thus demonstrated
 his  error."
   From  these observations, then,  I would conclude that the sensations  of the
 surgeon afford no reliable evidence as to the course taken by the instrument.
   3d.  In asserting that the sponge probang can be passed  into the  air-passages,
 much  reliance  has been placed on the  analogy afforded by the introduction of
 tubes for the purpose  of artificial respiration, and in the occasional inhalation
 of  foreign bodies.  Does  any such  analogy really exist?   I think  not.   It 
TREATMENT OF  CHRONIC LARYNGITIS.         729
seems to me that so very different a degree of irritation would be set up by the
introduction of a smooth, well-oiled tube of small calibre, through which the
patient can breathe, and from which consequently there is no risk of suffocation,
and  the passage of a caustic sponge, which not only would stimulate the part
violently,  but would necessarily induce temporary asphyxia by blocking up
mechanically the  air-passage, that no  analogy can  be drawn from the one case
to the other.   To  do so, seems about as reasonable as  to infer, that  because
a gum-elastic or  silver catheter may  be passed  along the urethra, therefore a
whalebone rod, tipped with a  sponge soaked in a caustic liquid, might also be
introduced into the bladder.
   With regard to the introduction of foreign bodies into the larynx, it appears
 to me that there is no analogy whatever between this accident and the passage
 of the caustic sponge.  In  the one case, the parts' are  taken by surprise, the
 foreign body being accidentally sucked into the chest by a rush  of air, during
 inspiration, through an open glottis.   In the other case, the patient is prepared
 for  what is about to take place, involuntarily and instinctively resists, and, hold-
 ing his breath, keeps the glottis closed.
   But setting aside this question  of analogy, which  is of little  moment,  is the
 introduction of tubes, even into the larynx so very easy and simple and certain
 a procedure as some writers seem  to suppose  it  to  be ?  On  the dead  body,
 undoubtedly nothing is easier than to pass a catheter into the larynx, and  down
  into either bronchus; but is it so in the living?   That excellent surgeon, Mr.
  Porter, of Dublin, when speaking of the introduction of Desault's tubes through
  the rima glottidis, in cases of cut-throat, says : "Awkward and reiterated attempts
  produce  inconceivable  distress,  and even when performed  with the utmost
  dexterity,  it must unavoidably excite  cough and restlessness."   And again :
  " Every time the instrument touches the  larynx,  the patient becomes anxious
  and restless; he tosses himself about, and coughs convulsively; and each motion,
  whilst it increases his own distress, renders the  performance of the operation
  more difficult.....Can such a patient  endure the irritation  that a few mo-
  ments' unsuccessful poking at the rima glottidis will inevitably occasion ?" The
  truth of these remarks must be acquiesced in by every surgeon who  has ever
  attempted the operation there described.
     On this point, the evidence of the New York Academy Commission is pecu-
  liarly valuable.   That Commission, in its inquiry, employed two tubes, the size
  of a No. 10 catheter: one, selected by Dr. Green, was slightly bent at its ex-
  tremity, and was one of the kind employed by him in his practice.  The other
   consisted of a catheter with a wire stilette, bent with a curve, the segment of a
   circle six inches in diameter.  This tube does not appear to be used in practice,
   but was employed for the purpose of comparison.  The result of the experiments
   with these tubes was, that Dr. Green (who was the only one that  employed it)
   failed in passing the tube with the small curve in thirty-five out of thirty-eight
   trials, or in about ninety-two per cent, of the cases;  and that the tube with the
   large curve was passed in eight cases out of thirteen;  whilst the sponge pro-
   bang failed in every case (eighteen) in which it was tried.
     "From these experiments it would appear that the instrument best adapted
   to succeed in cathetcrism of  the air-passages is the tube having a large  curve;
   whilst the least adapted to enter the trachea is the sponge probang.
     In the  course of these experiments a point  of much  interest was elicited by
   the Commission, —viz., that a patient might blow out a lighted candle  or col-
   lapse and inflate a bladder attached to its free extremity, through the tube  even
   though it had never entered the  trachea, but had  been purposely passed into the
   oesonhasus.                                         , .  ,,       i  •   ,i  .
     On this third point, then, I think we  are warranted in the  conclusion that
   there is not sufficient analogy between the introduction of the sponge probang
   and that of a catheter tube into  the  larynx, to lead us to suppose the passage of 
730                DISEASES  OF THE  THROAT.

the former instrument possible, because that of the latter is occasionally prac-
ticable ; and that the introduction  even of a tube of the  same shape  as the
sponge probang is an operation of extreme difficulty, failing  in  far the greater
proportion of cases in  which it has been attempted; and that the  introduction
of foreign bodies into  the larynx is effected under totally different conditions to
that in which the sponge is attempted to be passed.
   Finally, I think that we are fully justified in adopting the conclusion  of the
Commission of the New York Academy, that there is no reliable evidence that
the sponge probang has ever been passed through and  beyond the vocal cords.
   The inhalation of the nitrate of silver  in  powder is most conveniently done
by mixing it, in  proper  proportions, with  some  innocuous, impalpable powder,
such as ground and dried sugar.  The strength may vary from  one part  of the
nitrate of silver to twelve, sixteen, or twenty of the sugar.   A small quantity
of the powder  so prepared should be  put  into the end of a thick glass tube,
which has been bent nearly at right angles, about  one inch from its extremity.
The surgeon, placing his finger  over the orifice of the straight part of the tube,
carries the bent end behind the tongue, over the epiglottis; he  then directs the
patient to make a sudden inspiration, and  at the moment of his doing so takes
away his  thumb, so as to allow the  powder to be  drawn out of the tube and
into the  air-passages  along with the current of inspired air.   In this way the
nitrate of silver  may, in some cases, be very conveniently applied to the whole
of the affected mucous surfaces without the  irritation produced by the friction
of the sponge.
   The injection  of  the  solution of the nitrate of silver may easily be done  by
means of the instrument that  is here delineated  (fig. 293), and which I have
had constructed  for this purpose. It consists of a silver tube, perforated at the

                                  Fig. 293.
end, and having a small piston moving in it with a sponge attached to its lower
surface.  The instrument is charged by dipping  the  end  in  the  solution, and
then drawing back the piston-rod.  It is then passed into the pharynx, or be-
tween the lips of the glottis, and the fluid injected into the air-passages or upon
the inflamed surfaces in a number of fine streams, by pushing down the piston
and compressing the sponge.  By means  of this laryngeal syringe the nitrate
of silver can be applied to any part of the pharynx, without irritating the tender
mucous membrane  by the contact of a rough body, and by applying its nozzle
to or between the lips of the glottis, the  fluid may be readily thrown down into
the interior of the larynx with the greatest certainty and  ease.   In those cases
in which it is wished to apply the solution of the nitrate of silver into the air-
passages, I far prefer using this simple instrument to the ordinary sponge, the
mere pressure of which upon a tender mucous surface may be a source of irrita-
tion.  When the mucous membrane behind the velum, or of the posterior nares
is affected, the solution may readily be injected  against these parts by turning
the end of the instrument upwards, and then injecting it directly on to the
affected surfaces.  In whatever way the  caustic is used, its application should
be repeated about every second or third day, in  order to insure its full effects
In some instances, however, advantages may be obtained by using it every day;
in others, again,  a longer interval is required than that just stated.
   In the  more  advanced forms  of chronic disease of the larynx, the mucous
membrane becomes infiltrated with plastic deposits, which also  form upon its
surface in  the shape of vegetations, and at last  run into ulceration, with  much 
SPASMODIC  CROUP.
731
narrowing of the rima and  muco-puriform discharge.  These  diseases are  often
of a syphilitic origin, and after continuing for some length of time give rise  to
hoarseness, cough, shortness of breath, a pale, pasty and cedematous  look  about
the face, with suffused eyes and constant difficulty in  breathing.   Under these
circumstances  there is a constant  tendency to acute inflammation supervening
on the chronic laryngeal disease, and the affection commonly proves fatal by the
induction of oedema glottidis, often coming on with  great rapidity.
  Necrosis of the cartilages of the larynx not unfrequently happens in the more
advanced forms of  this affection, attended with all-the signs, constitutional and
local, of the so-called laryngeal phthisis, and by the  expectoration of large quan-
tities of fetid puriform sputa, often streaked with  blood, and occasionally con-
taining masses of  the  necrosed and  disintegrated  cartilage.  In many cases
abscesses form outside the tube,  and after  much irritation  and distress open
externally, and not unfrequently they are  met with  to such an extent as to
undermine and disorganize the greater portion of the tissues of the anterior part
of the neck.  Where  they correspond to the necrosed patches of cartilage they
give rise to aerial fistula, through which bubbles of air escape during  respiration.
   In the treatment of these more severe diseases of the larynx, the  daily appli-
 cation of nitrate of silver  will be found of great benefit.  It should be  freely
 applied to, or injected upon the mucous membrane about  the epiglottis, within
 the lips  of the glottis, and  more  especially that loose and  filamentous tissue
 which is extended over the back of the thyroid  cartilage, and which is commonly
 the seat of  much chronic  irritation, and the chief source of  the  muco-puriform
 discharge.  At  the same time the  internal  administration of the bichloride  of
 mercury with sarsaparilla will often be found of great service, more  particularly
 in those cases in which the disease is of a syphilitic character;  the  patient
 being kept in a regulated  temperature, not allowed to  exert his voice, and avoid-
 ing all laborious exertion.  Whenever acute inflammation supervenes in these
 cases, with a tendency to  oedema about  the glottis, the patient should be nar-
 rowly watched, as  he may readily be carried off by the sudden swelling  of the
 lips of the rima, or the supervention of spasm.  In such  cases as these, the air-
 passages may require  to be opened to allow of respiration to be carried on, and
 this  operation must not be delayed until such time as the patient falls into an
 asphyxial condition.
   Nervous affections  of the  larynx  occur both in  children and  adults.   In
 children this affection, commonly called spasmodic croup, comes on suddenly
 and runs its course with great rapidity.  The child is seized, often without pre-
 vious warning, with  difficulty in  breathing,  uses violent efforts  to  inspire,  be-
 comes black in the face and convulsed, and may die before anything  can be done
 for his relief.  In other  instances again he gapes and gasps a few times, and
 eventually  recovers himself  with a long deep-drawn
 whooping inspiration.  In such  cases as these, the
 treatment at the time of the fits consists  in dashing
 cold water  in the face, in exposing the body to a cur-
 rent of cold air, and  in using friction to the extremi-
 ties.  If asphyxia occur,  artificial respiration must be
 kept up either through an opening made in the wind-
 pipe or by  the mouth.
   In the  adult,  these  spasmodic affections  of the
 larynx may come on either from pure hysteria,  or from
 irritation of the laryngeal nerves by the pressure of
 tumors  or aneurisms  upon them.   In other instances
 again they appear to arise from the presence of some
 local  inflammatory mischief about  the glottis.   In
 the hysterical form of the affection the ordinary reme-
 dies  for hysteria, together  with  cold  douches, will
Fig. 294.
be of  essential  service. 
732
DISEASES  OF THE THROAT.
In some cases, however, the obstruction  to respiration is so great, that the sur-
geon  may almost think it necessary to have recourse to operation.  When the
disease arises from irritation to the trunks of the nerves, such a procedure is
seldom justifiable, as the occasioning cause is usually in itself of a fatal character.
   Tumors or polypi occasionally form in the larynx.   They are commonly gra-
nular, or small cauliflower-looking bodies, though they occasionally attain the
size of a hazel-nut (fig. 294).   They necessarily interfere with respiration, and
at last may give rise to asphyxia by obstructing the cavity of the larynx.

                 OPERATIONS  ON  THE  WINDPIPE.

   The windpipe may require  to be opened  either to  allow of the formation of
a temporary breathing aperture, in consequence of the obstruction of the larynx
from  causes that are speedily removable; or, the air-passages  may require to
have  a permanent aperture established in them in  those forms of chronic laryn-
geal disease, in which the obstruction depends upon such organic alterations of
structure as are not remediable.  Amongst the conditions that require the tem-
porary opening of these passages may  be  mentioned,  all  acute inflammatory
affections of the larynx,  together with the various nervous or spasmodic diseases
of  this organ; so also certain traumatic conditions may require  this operation,
as  the impaction of masses  of food in  the gullet inducing asphyxia and not
admitting of immediate removal, the presence of foreign bodies in the air-pas-
sages, and oedema of the glottis from wounds of the thyro-hyoid membrane.
   The establishment  of a permanent aperture in  the air-passages  is especially
required in chronic diseases of the larynx, attended by thickening of the mucous
membrane, abscess, or necrosis of  the cartilages, and  in fact such conditions as
do not admit of removal; so also in polypi of the larynx a permanent opening
below the obstructed point may be required.
   It is a question whether the windpipe should be  opened in cases of croup.
 Were croup merely a disease of the larynx it would doubtless be proper to per-
 form the operation;  but it has been incontestably shown that in this affection
 when it is severe, the inflammation is not confined to  the  larynx,  but usually
 extends down the bronchi even  to the lungs,  which  become engorged and
 affected, so that death very commonly results from this cause, as much or more
 than from the laryngeal  disease.   Hence opening  the trachea alone will  not
 suffice in saving life  in the  majority of instances, as the child will ultimately
 die of broncho-pneumonia.   In this respect, the result of tracheotomy in  croup
 differs remarkably from  that of the same operation for acute laryngitis in  the
 adult.   A serious  objection also to  the  performance  of this operation in  croup
 is  the difficulty attending it;  the struggles  and screams  of the  child, by in-
■creasing the tendency to spasm, interfere materially with  the surgeon's attempt
 to open the windpipe.  Indeed I have known more than one case in which the
 bleeding was so profuse as to  prove fatal.   But  although, as a general rule, I
 fully agree with Porter in strongly reprobating this practice in croup, yet cases
 are doubtless occasionally met with, in which the disease is so clearly limited to
 the larynx—the respiration being free throughout the lungs and bronchi—that
 the surgeon may feel himself justified in endeavoring to save the little patient,
 struggling against overpowering asphyxia, by opening his windpipe.  In several
 such cases,.to which I have been called by other practitioners, and which were
 apparently most favorable to the operation, I have considered myself justified in
 doing  this, though in no instance have I as yet succeeded  in eventually saving
 a child by this operation;  and I think that the general experience of surgeons
 in this country is unfavorable to its performance.   Trousseau, who strongly
 advocates tracheotomy  in  croup,  has, however,  published a large number of
 successful cases in favor of this proceeding.   But even in Paris it is not  a very
 successful procedure; thus it appears that at the  Hospital for Sick Children  in 
OPERATIONS  ON THE  WINDPIPE.
733
that city, the operation has been performed 215 times in the last five years, and
that of these only 47 were cured.  Unless we assume that the disease, as occur-
ring in Paris, is different from the form of croup we  meet with here, I think it
may fairly be doubted whether an operation could be necessary in many of these
instances, and whether a large proportion of the children might not have reco-
vered under ordinary medical treatment.
  When it has been determined to open the windpipe for acute disease, more
especially supervening on chronic laryngitis, the less delay there is in having
recourse to operation the better, as the patient may at any moment be seized
with laryngeal spasm, and be carried off.  The operation ought always, however,
to be completed, even though the patient has apparently expired before  the
windpipe has been opened, for resuscitation may, even in these extreme  cases,
be effected by artificial respiration.  When life hangs on so slender a thread as
it does in urgent cases of laryngeal obstruction, the first touch of the knife may
cause a spasmodic seizure that  may give  rise to apparent  death.   It has twice
happened to me to operate under  such circumstances, and in  both cases to be
fortunate enough to save the patient's life.   In one  case to which I was called
about five years ago by my friend Mr. E. Baker, the patient,  an elderly  woman,
was apparently dying from  the  supervention of acute upon chronic  laryngeal
disease.   I lost no time in making an incision into the crico-thyroid membrane,
but at the  first touch of  the knife she sunk back apparently dead.  I immedi-
ately completed the operation, and introduced a large silver tube, through which
the lungs were inflated, when, in the course of a few minutes, the  action of the
heart recommenced,  and the patient eventually  recovered.   She has never,
however, been able to breathe without the silver tube, which  she wears in her
windpipe up to the present  time.  In another case to which  I was  hastily sum-
moned  by my friend Mr. Tweed, I found the  patient, a  young woman, in  the
last  stage  of asphyxia  from acute disease of the larynx.  I immediately pro-
ceeded  to  operate, with the assistance of my then house-surgeon, Mr. Lister.
As the  patient's neck  was short and thick, and  the veins  excessively turgid,
there was profuse hemorrhage on the first incisions being  made; whilst waiting
a minute or two until this would cease before opening the windpipe, the patient
fell back and apparently expired.  I lost no time in plunging  the scalpel into
the crico-thyroid membrane, and cutting down through the cricoid cartilage, so
as to make a free aperture into the  air-passages.  On endeavoring to set up
artificial respiration, 1 found the chest clogged with  inspissated  mucus, which
prevented  the  entrance of air into  the  lungs; the life of a fellow-creature
being at stake, and dependent on the immediate and  full  establishment of arti-
ficial respiration, I felt  there was  only one thing to  be  done,  and that was to
empty the chest of the matters that  loaded it, and that this must  be done
instantaneously.  I accordingly applied my lips to  the wound  and sucked  out
three or more mouthfuls of blood and mucus, when I  had the satisfaction to see
that air could be got  to enter the lungs.   By keeping up artificial respiration
for some time, the heart began feebly to act,  the face to become less  livid,  and
the circulation to be re-established; the patient eventually did  well, and is now
alive and in good health.
   In opening the  windpipe, the  surgeon has the choice of two situations, in
which he may make the aperture, — either in  the  crico-thyroid  membrane by
laryngotomy, or in some part of the  trachea  by tracheotomy. _ Besides these
two  established  operations, some  surgeons have performed a, third, — laryngo-
tracheotomy, by opening the membrane and dividing the  cricoid  cartilage with
the upper rings of the trachea.
   Whichever operation  is  performed, so soon as  the windpipe is opened, the
patient is seized with an attack  of spasm  and convulsive cough, often attended
by much struggling and distress, during which the whistling occasioned by the
passage of the  air  through the new  passage is very loud and marked.  The 
734
DISEASES  OF  THE THROAT.
patient, however, soon reoovers himself, and then breathes naturally and easily
the signs of asphyxia disappearing.
   Laryngotomy is an  easy  operation, the crico-thyroid membrane is  almost
superficial, and may readily  be reached by making a vertical incision  in the
mesial line, between the sterno-thyroid muscles, about an inch in length, and
then a cross cut  through  the  membrane  with an  ordinary scalpel.   The air-
passage  having thus been opened, a silver tube,  curved  on the flat, may be
readily introduced  and retained by tapes  round the  neck.   The only trouble-
some result that can  occur in this  operation is the wound of a small arterial
branch, the inferior laryngeal, that crosses the membrane.   I have  never seen
any trouble arise from this, but should it occur  the hemorrhage would readily
be arrested  by pressure or ligature.
   Tracheotomy consists in making an opening into some part of the trachea, by
exposing the tube and cutting  across one or more of its rings.
   In performing tracheotomy the patient's  shoulders  should be supported with
pillows, and  his head be  thrown as much  back as practicable.  An incision
about an inch and a half in length should then be made with a scalpel directly
in the mesial line  from the cricoid  cartilage downwards.   After dividing the
integuments, any veins that present themselves should be  avoided  as  carefully
as possible, being held aside with a blunt hook.   By using the point  of the
scalpel to a  limited extent, and  dilating the deeper portions of the incision with
its handle or with a director, the trachea may  be reached with safety; it must
then be opened by pushing the point of the knife, with its back turned towards
the sternum,  between two of  the rings, and  cutting upwards, through about
three of  them (fig. 295).   The tube must then be introduced and  retained  by
tapes round the neck.
   This operation is often attended by extreme difficulty, and not unfrequently
with  a considerable amount of danger.   The difficulty in exposing the tube
increases greatly as the incisions  approach the sternum, and are far greater in
stout short-necked persons than in those of a different development.
   There are three situations in  which the trachea may be opened, either  above,
underneath, or below the isthmus of the  thyroid body, which usually crosses the
air-tube opposite its third or fourth ring.  Above  the isthmus, the trachea is
comparatively superficial, and is not  covered by any venous  plexus, nor does
any other source of difficulty present itself to the surgeon.   Where the isthmus
crosses the trachea, this tube is overlaid by a venous plexus as well as by the
glandular structure. Below the thyroid gland, the air-tube is overlapped  by the
sterno-hyoid and sterno-thyroid  muscles and by the inferior thyroid veins, which
are of large  size, together with some tracheal branches from the inferior thyroid
artery; and not unfrequently an irregular arterial branch ascends in this situa-
tion in front of the trachea  to  supply the thyroid body.   The carotid arteries
also are in close relation to the  vessel on  either side, and opposite the episternal
notch it is crossed by the left  carotid and by the innominata, which vessel has
been seen by Mr. Macilwain to cross the tube at the very point where tracheo-
tomy is usually performed.  A glance at these important  relations will  suffice
to indicate the difficulty that must, in many cases,  occur in exposing and open-
ing the trachea.  This difficulty is greatly increased when the veins of the neck
have become turgid in consequence of the pulmonic obstruction.  It will also be
seen that the  trachea is  less  covered, and  may consequently be  much more
readily reached above, than below the  isthmus of the thyroid gland; and though
some  surgeons, as  Velpeau for instance,  have recommended the opening to be
made in the lower part of the tube, the greater number advise  that it should be
entered in its upper part, though the incision may, if necessary, be carried down-
wards as  low as, or  even through the isthmus.
   The difficulties occurring in tracheotomy are chiefly referable to three causes; 
DIFFICULTIES IN TRACHEOTOMY.
735
1st, the risk of profuse hemorrhage; 2d, the difficulty in  opening the air-pas-
sage ;  and 3d, trouble in introducing the trachea-tube.
  1st.  The hemorrhage in this operation may occur either from arteries, veins,
or the thyroid gland.   Arterial hemorrhage is less frequent and troublesome
than the bleeding from other sources.   When it occurs it chiefly happens from
the wound of some anomalous branch, or from that of the small  tracheal vessels.
Desault has however mentioned a fatal case in which death arose from a wound
of the carotid.   The arterial anastomosis of the isthmus  of the thyroid body
may, if this part be enlarged, occasion some difficuly in the performance  of the
operation, but  the main  source of danger unquestionably proceeds  from the
venous bleeding.  Not only are the plexuses of veins of large size, more particu-
larly where they cover the lower part of the  trachea,  but as has already been
observed they become immensely gorged by  the  asphyxia that necessitates the
operation.  Hence, when wounded, the bleeding may be so abundant as scarcely
to be controllable, and may retard very greatly the after-steps of the  operation.
Many surgeons of authority in  these  matters, advise that the windpipe  should
 not be opened so long as the bleeding is abundant, lest the blood entering the
bronchi and lungs through the aperture, asphyxiate the patient.  I think, how-
ever, that in many cases the best way to arrest this hemorrhage is by opening
the trachea, and thus  enabling  respiration to go on,  for as the lungs  unload
themselves the bleeding will cease.
   2d. Another difficulty in tracheotomy sometimes consists in opening the tube
after it is exposed.   In consequence of the convulsive  breathing of the patient,
 the sterno-mastoids are put upon the stretch, thus increasing  considerably the
 depth of the wound in the neck, and at each short and gasping respiration, the
 air-tube is rapidly pumped or jerked to and fro, approaching to and receding
 from the surface in such a way that  the scalpel  cannot  be thrust into  it with
 safety.  In order to do this with the least risk, a sharp pointed hook should be
 passed between two  of the rings, and the tube being thus fixed, opened by cut-
 ting upwards (fig. 295).   Or the hook being grooved along its convexity, as
Fig. 295.
Chassaignac recommends, is to be introduced under the cricoid cartilage, the air-
tube pulled up and opened by sliding the scalpel along the groove of this hook-
Fig. 296.
director   I have found it advantageous in some cases to open the trachea with
a cutting-hook, such as is here represented (fig. 296).  By means of an instru- 
736
DISEASES  OF  THE  THROAT.
ment of this kind, the trachea is first fixed and then divided without danger to
the patient.  The danger from hemorrhage, and the  difficulty in  opening  the
trachea, are much greater in children than in adults.  Before the age of puberty,
                           this tube is deeply seated, covered with a quantity of
          Fig. 297.         loose granular fat, containing many veins, and is of
                           small size, so that a slight deviation of the incision
                           to  one side  or the other may readily lead the sur-
                           geon astray,  and into dangerous proximity with the
                           carotid artery.
                              3d. After the trachea has been opened, the next
                           point is  to introduce, in cases requiring it, a proper
                           tube.   In  the first instance, one of a conical shape
                           should be employed, as  it is  not only introduced
                           more  readily than a  cylindrical one,  but fills up
                           completely the  aperture in the trachea, so as to
                           prevent the  draining of blood into the lungs.   In
                           passing  the  tube, some  little difficulty may occa-
                           sionally be experienced,  owing to  the elasticity of
                            the sides of  the incision  in the windpipe, in conse-
                            quence  of which one of them is apt to get doubled
                            under the end  of the instrument.   This  may he
 avoided by the use  of  Dr. Fuller's  bivalve tube introduced  closed, and then
 expanded by slipping a  canula into it;  or one side of the cut in the trachea may
 be held aside with the forceps or a blunt hook, whilst the tube is slipt under the
 other.   If the rings of the trachea are very rigid  and unyielding, the silver
 tube may most conveniently be introduced by expanding the incision by means
 of the trachea-forceps (fig. 297), and  then  passing the tube  between or under
 their blades.
    My  friend and colleague, Mr. H.  Thompson, has recommended  a very simple
 and most ingenious  mode  of opening  the trachea, by which   the  dangers and
 difficulties of the old operation, such as have just been described,  are in a great
 measure avoided.   This operation consists in making the puncture at once into
 the windpipe by means of the tracheotome as  here depicted  (fig. 298), which

                                   Fig.  298.
serves at the same time as a guide to the tube into the opening.  By means of
this instrument a puncture is made transversely through the skin and  cellular
tissue, and between the first and second rings of the trachea, so that the carti-
lages are not injured.  When the  blades have been introduced they should be
held there by the left hand, and the screw in  the handle gradually turned, so
that the separation of the blades may dilate the contiguous structures until the
aperture is sufficiently large to allow a tube to be introduced.
   Mr. Thompson  states that the  proper point for introducing the instrument
may always be determined by feeling for the projection of the cricoid cartilage,
and defining its lower border clearly with the finger.  The point of the instru-
ment should then  be introduced transversely in the mesial line a quarter of an
inch below this cartilage, when  it will enter  the  space  between the first and
second rings.  The screw is then  to be  turned, the blades expanded,  and the
tube introduced, as above described.   This operation is certainly one of the
 
DIFFICULTIES IN  TRACHEOTOMY.
737
safest, easiest, and most speedy modes of opening the trachea, and appears to
be a very great improvement upon the ordinary methods of performing trache-
otomy.  It is not, however, applicable  to children, nor  would it,  I  think, be
desirable to have  recourse to it in those cases in which  the trachea requires to
be opened for the extraction of foreign bodies from the windpipe, as the vertical
incision tends to facilitate their escape.
   On comparing tracheotomy as ordinarily performed, with laryngotomy, I think
there can be little doubt that the surgeon should  give the preference, in all
cases where it is practicable, to  the  latter operation,  on  account of its greater
simplicity, safety, and rapidity, though in these respects it appears to be equalled
by the method introduced by  Mr. Thompson.  In all those cases in  which the
obstruction to respiration is dependent upon inflammatory effusions into the sub-
mucous cellular tissue, whether it be dependent upon  idiopathic or erysipelatous
laryngitis, or upon the irritation and inflammation excited by swallowing boiling
water or the stronger acids, the swelling, for reasons  that have already been
mentioned, never extends below the true vocal cords;  hence  an opening into
the crico-thyroid  membrane will  always be below the seat of obstruction.  An
objection it is true has been urged to laryngotomy in these cases, that it does
not allow of the patient  wearing a tube without much irritation being induced.
This, however, I  have not found to be the case in my practice.  I have at pre-
sent two patients  under observation, in both of whom I introduced a silver tube
in this situation a considerable time back, and in whom no special irritation has
been occasioned by it.   In one case  the  tube has been worn for eight, and in
the other for nearly five  years; the larynx in both instances having been  nearly
completely occluded by  chronic  disease.  When  the windpipe requires  to be
opened for the extraction of a foreign  body, tracheotomy should be  performed
in preference to laryngotomy, as the latter operation does not admit of sufficient
 space for its expulsion or extraction.
   In children, tracheotomy is almost always a tedious  and  often a dangerous
 operation,  the  exposure  of the  trachea requiring very careful  dissection, and
 much time being often lost  before it can be punctured, owing to the free hemor-
 rhage which usually occurs.
    In my opinion, laryngotomy is the operation that should, as a general rule, be
 preferred, and this opinion is  based on  the following reasons: —
    1st. That as in laryngotomy the air-tube is always opened  below the seat of
 obstruction, there can  be no necessity to make an aperture further from the seat
 of disease.  In laryngitis, whether that affection  assume the  acute  or chronic
 character, the obstruction in breathing is in  a great measure mechanical, and
 dependent upon  the infiltration of the  submucous cellular tissue of the larynx,
 and partly of the large plane  of this tissue, which lies behind the box  of the
 larynx, and which, by expanding, as it were, into  the pharynx, obstructs deglu-
 tition, and afterwards, by the extension of this swelling and  infiltration  to the
 lips of  the glottis and the interior of the larynx,  causing an impediment to the
 entrance of air into the  bronchi.  But, as has been pointed out by Mr. Prescott
 Hewett, this submucous cellular tissue terminates at the true vocal cords, where
 the mucous membrane becomes directly applied to the subjacent fibrous struc-
 tures, the swelling and consequent  mechanical impediment  is confined  to the
 limits of the thyroid cartilage, and any opening made below this will clear the
 lowest limit of the disease, which is always accurately and almost mathematically
 bounded below by the  vocal  cords.  Hence an  aperture in  the  crico-thyroid
 membrane is quite as  effectual as one in the trachea.
    2d. Laryngotomy is a far safer operation than tracheotomy.   On this point I
 need scarcely dwell;  a glance  at the  anatomy of the  parts  concerned will be
sufficient to establish it.  The crico-thyroid  membrane  is nearly subcutaneous,
and no  parts of  importance can  be wounded  in  opening it, if we  except the
small inferior laryngeal artery, which crosses it, and which might be  cut  across,
       47 
738
DISEASES  OF  THE  THROAT.
but from which I have never seen any trouble arise.  The trachea, on the con-
trary, is not only deeply seated, but covered by a large plexus  of blood-vessels,
which, when rendered  turgid  by the asphyxiated condition  that exists  when
these operations are required, pours out a large quantity of dark blood, and thus
seriously embarrasses and  delays the surgeon at a time when the  life of the
patient depends on the  speedy admission of air to his lungs.
   3d.  Laryngotomy can be much  more quickly performed than tracheotomy.
This I look upon as an  inestimable  advantage  in  many of the cases requiring
operation; a few seconds, more or less, being sufficient to turn the balance either
in favor of life or of death.  The rapidity with which laryngeal obstruction —
partly mechanical and partly from spasm — sets in, is sometimes so great, more
particularly when an acute inflammation supervenes  on  chronic disease of the
larynx, that life may be extinguished before the surgeon has time to open the
windpipe, if he endeavors to do so by tracheotomy.   In extreme cases, such  as
where the lungs have become slowly engorged, the action of the heart is already
enfeebled, and a sudden spasm occurring at the  glottis, will at once place the
patient beyond recovery.  But  even  though life appears for the moment extinct,
it is the  imperative duty of the surgeon to open the  air-passages as  speedily as
possible, and to endeavor, by means of artificial respiration, to recall the flicker-
ing spark;  and it is impossible to experience a greater satisfaction in the exer-
cise of our profession, or to  witness a greater triumph of art,  than  in thus
snatching a patient out of  the very  jaws of death.
   It is a practice with some  surgeons not to open  the windpipe until  all, or
nearly all, the bleeding has  ceased.  But in this way much valuable time may
be consumed, and the  patient  may be fatally exhausted  by a tedious  and pro-
longed operation, and by the  loss  of an unnecessarily large quantity of blood.
The hemorrhage in these  operations is almost entirely of a venous character,
and is, in a great measure, dependent on the distension  of the veins of the neck
that occurs in asphyxia, as the result of the accumulation of blood in the right
cavities of the heart, consequent upon the obstructed  circulation through the
lungs; and the bleeding will continue so long as that obstruction remains unre-
moved.   But as  the respiratory process is re-established, this obstruction  to the
pulmonic  circulation  diminishes,  the cardiac  cavities  become unloaded, the
venous turgescence of the  neck subsides, and the hemorrhage proportionately
lessens.   This I  have repeatedly found in asphyxia artificially induced in ani-
mals, and have more than once seen in the human subject in cases in  which it
has become necessary  to open the windpipe at once, without waiting to arrest
hemorrhage.   Hence, except  in those  instances  in  which an arterial twig or
large venous trunk has been wounded, and which must, of course, be  secured,
the occurrence of bleeding, though tolerably smart, need  not deter the surgeon
from opening the windpipe;  as the relief afforded to  respiration will  induce a
 corresponding and rapid dimunition in the venous turgescence of the neck, and
in the consequent flow of blood from the wound.
   Trachea-tubes should be  of such a calibre throughout as to admit  of respira-
 tion being carried on through  them without any effort on the part of the patient.
 Many of those that are to be met with  in the instrument-makers' shops, though
 very wide at  the mouth, are far too narrow and contracted at the lower aperture
 to allow a  free and  unimpeded passage for the  air of respiration, being made
 very conical in order to admit of easy introduction, and  to occlude completely
 the opening in the windpipe, so as to prevent the entry of any blood by the side
 of the tube.   The disadvantage attending  this mode of construction  may in a
 great degree be  remedied,  by having a longitudinal  opening like the large
 eye of a catheter cut  in the  side  of  the  tube, immediately above the inferior
 aperture.
   One great  difficulty  that the surgeon has to meet in  cases of tracheotomy or
 laryngotomy is to keep the tube from being clogged and obstructed by mucus. 
TRACHEOTOMY — TRACHEA-TUBES.           739
It is usually stated that the tube may be  kept clear by the occasional introduc-
tion of a feather, of a piece of sponge fixed to a stick, or a bit of lint wrapped
round a probe.  In this way it is  true that  the frothy or spumous mucus that
collects in the tube may be readily enough cleared away; but this simple means
will in very many  cases be found  to be  quite ineffectual in removing another
kind of mucus that in certain  conditions rapidly accumulates to a considerable
extent within the  tube.   On  examining a trachea-tube that has been worn for
but a few hours, it will be found that its interior becomes gradually lined by a
coating of dry, gummy, and very  tenacious mucus, which is so firmly adherent
to the metal as to render it necessary,  before the tube can be properly cleaned,
to detach this lining by means of a penknife or pointed probe; or, what is better,
by pouring  boiling water through  the  tube.   This tenacious mucus, collecting,
as it does, in largest quantity  at the inferior aperture, and at the curve of the
trachea-tube, may block  up its calibre  to a very great  and dangerous extent,
whilst the  mouth of the tube  appears  to  be perfectly pervious and free, and
though feathers and pieces of stick, armed with sponge or lint, have been intro-
 duced from time  to time; but these, passing over  this dry mucus, are quite
 unable to detach it from the side  of the tube, and merely bring away the sputa
 and more frothy mucus.
   Mr. Obre has devised a very simple  means to remedy this inconvenience.   It
 consists in  the  trachea-tube being  made  of uniform calibre throughout,  and
 having an interior tube accurately fitted  to it, and projecting about one-eighth
 of an inch beyond the lower extremity of the outer tube.   It is in the projection
 of the  internal  tube beyond the  lower  end of the  external one that the great
 utility of this contrivance consists.  If the two tubes are of the same length, or
 still more, if the innermost tube be the shorter, a plug of mucus may be left at
 the end of  the outer canula, on the withdrawal of the inner tube.   But if this
 be the  longer of the two,  the end  of the outer tube  will be  effectually cleared
  every time  it is withdrawn, which may be done  as often as any mucus collects,
 without in the slightest  degree  disturbing the patient.   The two tubes are
Fig. 299.
Fig. 300.
Fig. 301.
fixed by means of a button, attached to the  edge of the outer one (figs. 299,
300).   I have found it convenient to have the  ordinary set of three trachea-
tubes made  in this way, the internal tube being the largest,  the middle the
next in length, and the external the shortest.   By this arrangement the smaller
trachea-tube is made to serve the purpose of the internal canula.  When used for
laryngotomy, these may conveniently be curved on the flat (fig. 301), their longest
diameter being lateral instead of antero-posterior, thus adapting  themselves to
the form of  the aperture in the  crico-thyroid  membrane. 
740
DISEASES  OF  THE THROAT.
                   DISEASES OF  THE PAROTID.

   Parotitis or mumps is  a common  affection, especially in  children, though it
not unfrequently occurs in adults.   It usually arises  from cold and wet,  and
is  frequently infectious.   Both sides of the neck  are  usually affected, and the
swelling, stiffness, and pain are often  considerable, though it very rarely happens
that suppuration occurs unless it be in the lymphatic glands of the neighbor-
hood.  Metastasis, though of rare occurrence, has been  described as occasionally
happening to the testicle  or breast.   The  treatment  for this  affection is of a
simple character, the application of hot fomentations and  leeches if it be severe;
the administration  of saline purgatives, and, as the affection is on the decline,
frictions with camphorated oil will hasten its resolution.
   Tumors of the parotid itself are not so frequent as morbid growths situated
upon or in the vicinity of this gland, yet occasionally they occur either upon it,
or consist in an actual transformation of its structure.   The tumors usually met
with  here are of a fibrous nature and often encysted; they are hard, deeply
attached, but yet movable  on careful  manipulation; round, and often attain a
                                      very great size, up to that of, a cocoa-nut
                                      even (fig. 302); the skin covering them
                                      is thin but not  adherent, and not unfre-
                                      quently a  net-work of veins  covers the
                                      mass.  These  growths  frequently send
                                      prolongations under the lower jaw, and
                                      then  occupy the whole  of  the space
                                      between its angle and the mastoid  pro-
                                      cess; when firmly  bound down, they
                                      involve the blood-vessels and nerves in
                                      this  important  region, coming into rela-
                                      tion with the  styloid  process and  its
                                      muscles, and  even  pressing upon the
                                      pharynx.   In consequence of the large
                                      size  that  these tumors may  attain they
                                      have a tendency to  produce  atrophy of
                                      the  parotid, and often by  interfering
                                      with the  cerebral  circulation  occasion
                                      various congestive symptoms about the
 brain.  In some cases the parotid may undergo cancerous infiltration, the tumor
 then presenting the characters and running the course of the ordinary forms of
 malignant disease.
   It is of importance to effect the  diagnosis in their  early stages between the
 non-malignant  and the malignant varieties of  this affection.  In  the  fibrous
 tumor there is always mobility, and  although the attachment may be deep, the
 skin is not involved, and the outline of the mass  is usually well defined, square,
 and somewhat lobulated.   In the scirrhous  growth there is  no mobility, but the
 mass is solidly fixed, its outline is  ill-defined, the skin soon assumes a reddish-
 purple color, brawny, and presents the usual characters  indicative of subjacent
 malignant action.  When these  tumors are  medullary, they grow with consider-
 able  rapidity, feel soft, pulpy, and  are  ill-defined in their outline, especially
 under the ear and  by the  ramus of the jaw.
   In the treatment of these tumors, extirpation is necessarily the  only course
 that can be adopted; and  this should  not be attempted  if  the disease be malig-
 nant in its  characters; for as it would  be impossible to  get away its deeper
 attachments, the growth to a certainty would easily return. Even if the disease
 be of a simple character, care must be taken that every  lobule and prolongation
 be extirpated, for  if any is left, however small,  it will,  without doubt, become
 
TUMORS OF THE  NECK.
741
the nucleus of a new tumor.   In removing tumors in this situation, the super-
ficial incisions should be made free, and either longitudinal or crucial, so  that
the whole mass may be fairly exposed.  The edge  of the  knife must then be
directed  against  it, and the dissection  carried on from below upwards, so that
one division  of the  blood-vessels  supplying it may  be sufficient.  After the
tumor has been well loosened by the division of investing fasciae and structures,
and it is surprising  how movable it often  becomes after  this has been done,
though  it may previously appear to have been  incorporated solidly with the
subjacent tissues, it should be taken hold of by the hand or a large double hook,
and drawn well forwards whilst the deep dissection is being carried on.  In
prosecuting this,  the surgeon must  particularly guard against wounding the
external carotid artery and the portio dura nerve, which are especially exposed
to injury.  In some cases the division  of these structures cannot be prevented,
as they are incorporated in the mass that  is undergoing removal.   The hemor-
rhage under  these circumstances would of course be abundant, but may imme-
diately be arrested by the ligature of the divided artery;  indeed, in most cases
the bleeding is profuse, owing to the unavoidable section of nutrient vessels and
of large subcutaneous veins, but may generally be  readily arrested by ligature
and  pressure.  In other instances, however, by keeping the edge  of the knife
carefully against the tumor and by drawing it well forward, so as to loosen it in
its cellular bed at each stroke of the scalpel,  removal of the morbid mass may
be effected without  the  division of any important vessel  or nerve.  After the
extirpation of some small tumors of a fibrous or encysted character lodged  in
the substance of the parotid, there is often a great tendency to copious secondary
hemorrhage,  requiring pressure, or even  the application of the actual cautery
for its arrest.  Excision  of the parotid  itself is occasionally spoken of, but is
Very rarely if ever done.  I believe that in most, if not all, the cases in which
it is stated that complete removal of this gland has been accomplished, tumors
overlaying and compressing it, have been mistaken for it.  It is evident that a
 diseased parotid could  not  be removed without the division  of the  external
 carotid and the portio dura.
   Tumors of the  neck.  Besides tumors in  the parotid  region, fatty, fibrous,
 and encysted growths are not unfrequently  met with  in the submaxillary space,
 and in the posterior triangles  of the neck.  In these situations they may occa-
 sionally attain a  considerable  size,  though they seldom  extend very deeply,
 being superficial to the deep fascia.  Hence when the integuments and superfi-
 cial structures covering them  are  divided, the  growth may be  insulated with
 sufficient facility,  its fixity being in a great  measure  due to  its being bound
 down by the investing fascia rather than to its having contracted deep adhesions.
 Before determining upon the removal of a tumor situated  in one of the triangles
 of the neck, it is necessary that a diagnosis be effected of its nature, and that
 some opinion be formed of the probable extent of its deep attachments.
   The first point to ascertain is, whether it be simple or malignant.  If simple,
 it will usually have been many years in growing; it will be hard but not stony,
 lobulated or  somewhat square-shaped; the  patient's  general health being good.
 It will  generally  be found to be  movable, though  not  perhaps to any  great
 extent, and will present no sign of incorporation with neighboring structures;
 the  fibres of the platysma will  not appear to spread  over it, and the sterno-
 mastoid may be traced  to  one side  of or below it.  Under such circumstances
 the removal  of the tumor  may be undertaken by any surgeon possessing  a fair
 share of anatomical knowledge and manual skill, with every prospect^ of success.
 But if the tumor be of stony hardness, have implicated the skin, be immovable,
 the whole head moved  on any  attempt  at drawing it aside; if it be defined
 under the jaw and  ear, or rapidly growing, soft and pulpy to the feel, deeply
 seated under the angle of the jaw, evidently below the platysma and deep fascia
 of the  neck, and possibly beneath the  sterno-mastoid, then  no attempt  at 
742     NATURE AND  TREATMENT OF  BRONCHOCELE.

extirpation should  be undertaken, as the  mass could either  not be removed
with safety, or  if it were by any possibility extirpated, then necessary contami-
nation of the neighboring parts would certainly lead to a speedy recurrence of
the disease.
  A peculiar cystic tumor, the hydrocele  of the  neck, has been  described by
Maunoir and Phillips.   The disease  usually appears in  the posterior inferior
triangle, forms  a largish  bladder-like tumor, unilocular in some cases, multilocu-
lar in others; filled with  a yellow or chocolate-colored sero-albuminous fluid, and
may attain so large a size as to interfere with deglutition and respiration; the
skin covering these growths is not discolored, but thin and expanded.  The treat-
ment consists in the introduction of a seton after  the tumor has been tapped.
  Enlargement of the lymphatic glands of the neck either terminating in chronic
induration or abscess, is  of such common  occurrence as to constitute perhaps
the most frequent form of glandular enlargement.   The tumors  thus formed,
present nothing peculiar in their progress  or treatment when occurring in this
situation, except that when abscess forms it should be  opened early by a small
incision, and in such a direction, corresponding to the natural folds of the skin,
as to leave as little scarring as possible.

                            BRONCHOCELE.

   The thyroid  gland is subject to various chronic enlargements which commonly
go by the name of bronchocele.  It may be simply hypertrophied,  and may then
attain a very considerable size;  in some cases  forming an immense  lobulated
tumor on the forepart of the neck, such as  is met with in various districts of this
country and of the continent, in which the disease is endemic.  In the majority
of instances these tumors are, however, of but very moderate size, commencing at
first as a mere  fulness and uniform or rounded  enlargement of the isthmus, or
of one of the lateral lobes of the thyroid gland, and gradually increasing, until
perhaps  by the pressure of the growth confined between the sterno-mastoid
muscle and the deep structures of the neck, respiration and deglutition become
seriously  affected.  There is a remarkable connection between tumors of the
thyroid gland of  this kind, and a general anemic  condition of the system.   In
London nothing is more common than to find a certain degree of bronchocele in
pale and bloodless women and girls;  indeed so frequent is  the coincidence that
it is impossible not to regard it in the light of cause  and effect. Mr. W. Cooper
has  pointed  out  the  fact, that great prominence of the eyeballs is frequently
associated with these  conditions.
   In some cases cystic tumors are met with in this gland, either associated with
general hypertrophy  of it, or occurring independently of this.   These cysts,
which may be single or numerous, usually contain a dark bloody-looking fluid,
and have often cauliflower-like excrescences projecting into their interior.   In
some instances pulsation has been observed in a bronchocele.  This may either
be communicated by the artery lying beneath it, or be owing to the very vascular
character of  the tumor itself.  In either case, when  confined to one  lobe only,
care must be taken not to confound  the beatings with carotid aneurism, a mis-
take that I have known  to occur, and the diagnosis of  which has  been adverted
to at page 539.
   The treatment of bronchocele must vary according  to the size and character
of the tumor; when small, and associated with  anemia, and  of comparatively
recent formation, it is best treated by improving  the general  condition of the
patient by the  administration of iron internally,  especially the iodide, with  the
external application of  the iodine or iodide of  lead ointment.  When of large
size, its absorption cannot, I think,  be expected  to take  place by these or any
other means, and the question then arises  as to the propriety of having recourse
to operative interference. The excision of  the tumor  is seldom to be thought of; 
DISEASES  OF  THE  BREAST.                743
its vascularity is so great, and the arterial supply that it receives from both sets
of thyroid arteries so abundant, that any attempt at extirpation must generally
be attended by such profuse hemorrhage as necessarily to prevent the completion
of the operation.   Cases have, it is true, occurred to Roux and others, in which
laro-e bronchoceles have been successfully extirpated; but these operations must
be looked upon as altogether the exception in the treatment of the disease; and
cases are certainly not often met with in which a surgeon would think it proper
to undertake  so serious a  procedure for  an affection that is not necessarily
mortal.   In the event of its being thought desirable to operate, the better plan
would be, after exposing the tumor, to enucleate  it as much as  possible with
the  handle of the scalpel, ligaturing carefully all  the vessels  divided  as  they
 were cut.
   The ligature of the thyroid arteries has been practised by some  surgeons, and
 it is stated, with a certain degree of success.  The  difficulties and  danger of the
 operation, the uncertainty  of its  results,  and the  readiness with which the
 arterial supply would be forwarded to the tumor from other sources, have caused
 it to be but little resorted to by surgeons of the present day.   The introduction
 of a seton across the tumor is occasionally attended by beneficial results.  This
 operation, however, is not unaccompanied by danger; a patient on whom it was
 being performed in the neighborhood  of London a few years ago, having lost
 his life by the puncture of a  vein  at the  root of  the neck, into which air was
 spontaneously admitted.
   In some instances  the employment of pressure has been of use, especially in
 conjunction with the  iodine inunctions; though  it is not easy to apply this
 means, and any considerable degree  of  it can necessarily not be_ borne,  on
 account of the increased  difficulty of respiration  that is thus occasioned.   In
 fact, the compression exercised upon the tumor by the sterno-mastoid muscle in
 some of these  cases is occasionally so  considerable, that it becomes necessary
 to divide its tendon  subcutaneously, in order to relieve  the  trachea from the
 constriction to which  it is thus  subjected.   When the tumor is chiefly of a
 cystic  character, the  fluid contents may be  drawn  off by tapping, and  an
 endeavor may be made to get the  cysts to close  by inducing inflammation in
  them by the injection  of tincture of iodine.
     CHAPTER  LII.

DISEASES OF THE BREAST.
  These affections when occurring in the female, are of great interest to the
surgeon, not only on account  of their great variety, but from the difficulty of
diagnosis attending them and  the  importance of determining the question of
operative interference in connection with them.
  The mammary gland is subject to certain  anomalies as to development;  thus,
in some instances, it has been found  to  be altogether wanting.  Sir A. Cooper
and Froriep both relate instances in which this structure was not developed, and
in which the  ovaries were also deficient.   A  more remarkable  anomaly  con-
sists in the development  of  a number of supernumerary breasts    Birkett has
collected 14 reported cases, in which there were more than  two breasts;  more
frequently there is but one supernumerary gland, sometimes two  and occasion-
ally  though  very rarely, three have been  met with,  constituting quintuple 
744                DISEASES  OF THE BREAST.
mammae.   Supernumerary nipples have likewise been found  to  occur;  two to
each breast have been met with, each communicating with the gland, and passing
milk.  Most frequently the supernumerary breast is situated somewhere in the
neighborhood of the normal gland, as on the anterior  part of the thorax;  and
where four are  developed they have been found placed in two parallel rows  one
above the other.   Occasionally they have been met with in very strange situa-
tions ; thus they have been seen on the outer part of the thigh, in the groin and
on the back ; and children have even  been  known to have been suckled by these
abnormal breasts.
  Diseases of the breast seldom occur before  puberty, being most  frequently
met with either during lactation, when the functions of  the gland are in a high
degree of development, or towards the  termination of menstrual life, when the
actions of  the organ are necessarily influenced by the changes that  are taking
place in the uterine  system.  Before  puberty,  the breast occasionally,  but
rarely, becomes the seat of inflammation  and abscess,  in  all probability acci-
dentally so, these changes  taking  place in it in the same way that they might
in any other part of the  body.  More  serious  disease has, however, been  met
with in the mammary gland, even  at this very early age;  thus, Mr.  Lyford has
recorded a case of cancer of the breast in a girl of  eight.   As the period of
puberty approaches, the breasts often swell, become hard, knotty, and somewhat
painful, indicative of some commencing change in the generative system.   In
other cases again  a precocious hypertrophy may take place, frequently attended
with severe neuralgia in the part.  When puberty occurs  the  breasts naturally
enlarge, and often  become tender,  and occasionally one undergoes a certain
degree of hypertrophy, increasing greatly in bulk beyond the other.   These
various changes, though exciting  alarm in  females, cannot be  regarded as of
any serious importance, and  seldom  require more  than the simplest surgical
treatment.
   Neuralgia of the  breast occasionally occurs to so severe a degree as to  con-
stitute a positive  disease, either in girls or at a more advanced period of life,
when it not unfrequently complicates other more serious affections of this organ.
It is especially apt to occur in young, delicate, unmarried females of the hyste-
rical temperament, though it is often met  with in strong, ruddy-looking women,
who are perhaps subject to neuralgic pains in the back, and in other situations.
 Most commonly the catamenia will be found  to be irregular, and uterine  con-
gestion,  inflammation, or ulceration, will be discovered on examination;  indeed,
 of  late, since the attention of the profession has been drawn to these affections,
I have scarcely ever failed to detect one  or  other of these conditions in the
uterus in cases of irritable breast.
   In neuralgia of the breast  the mammary gland may be of its normal size and
consistence, but in some instances  the whole of it is more or less indurated and
hypertrophied.   There is always much general  pain and aching deeply in its
substance, with cutaneous tenderness of its surface, and  lancinating or radiating
sensations that extend into the axilla and  down the arm.  These painful sensa-
tions are commonly increased before  the menstrual period, and not unfrequently
alternate in  opposite breasts.   The  diagnosis  of this affection  from the more
serious mammary disease may usually be effected by attending to the superficial
and radiating character of the pain,  to the temperament of the woman in whom
it occurs, its shifting seat,  and the absence of any positive signs of disease in
 the breast.
   The treatment consists  especially  in attention to the condition of  the uterine
 organs;  unless this be  done in a  proper way,  the disease will prove to be ex-
 cessively rebellious and  troublesome  to manage.  By using the  speculum,  how-
ever, when necessary, and removing any uterine irritation that may be found
by proper remedies, this affection will yield with far greater readiness than by
 any other  plan of treatment.   At  the  same  time, anti-hysterical constitutional 
HYPERTROPHY  OF  THE  BREAST.
745
Fig. 303.
remedies may be employed;  the preparations of iron administered, when neces-
sary ;  and the local pain relieved by the application of belladonna and opiate
plasters, or inunctions with atrophine ointment.
   Simple hypertrophy  of the breast  not  unfrequently occurs, associated with
very severe neuralgia of the organ.   An increase  of size,  such as naturally
takes  place during pregnancy, between the fourth and the ninth months, will
occasionally commence  at puberty, and go on  until the  organ attains an  enor-
mous bulk, as in fig. 303, which represents the breast of a girl of fifteen.  In
some  cases the  breast has been found to
weigh as much as twenty  pounds after
death;  and after removal, a breast of this
kind, taken from  a young woman  under
thirty, has weighed no less than twelve
 pounds, being entirely composed  of its
 normal tissues, greatly hypertrophied.  In
 these cases of  hypertrophy, both  breasts
 are usually affected, though one is com-
 monly  more so than  the  other.   When
 first this morbid condition commences, the
 breast  preserves its usual shape, though
 it is increased  in bulk; but as it enlarges
 it gradually projects  forwards,  drawing
 down the skin of the shoulders,  of the
 sides of the chest, and even of the back,
 and  hanging  downwards, until, as in a
 case  mentioned by Berard, it has been
 known to reach to the knees.  The treat-
 ment of this  affection is very unsatis-
 factory.   The general health must be
 attended to,  and an  endeavor may be
 made to excite lactation, and  thus to un-
 load the vessels of the breast by the em-
 ployment of  galactogogue  remedies.   I
 do not think that  amputation of the organ
 should be performed in these cases, unless
 the  growth attain so great a size as to
 render life a burden.   The lobular hyper-
 trophy of the breast, described by Sir A.
  Cooper, as occurring chiefly in unmarried
 women between  thirty and forty years of age, and which appears on manipula-
  tion to be composed of several solid  but movable masses, that after a time begin
  to diminish in size, until the breast  at last atrophies, and is in a great measure
  absorbed, seems to me to  be rather a species  of the chronic  mammary tumor
  than of pure  hypertrophy.
    The lacteal secretion is occasionally the cause of abnormal  conditions in the
  breast;  thus  the  milk may appear at  unusual times,  a twelvemonth, tor
  instance, after weaning; it has  occasionally  been known to be secreted in chil-
  dren, and  in  some remarkable  instances in men.  In  other  instances, again,
  after parturition, there  is  a total absence of milk, either owing to want of
  development  in the gland, or to debility on the part of the  mother,   I he oppo-
  site condition will occasionally occur, and an  excessive  flow of milk may con-
  tinue in hysterical females after the child has been weaned.  In such cases as
  these, the galactorrhea  may be checked by  the  employment of tonics, the
  administration of acids, &c.                                            ___
    It may happen during  lactation  that  one of the lactiferous  ducts becomes
  obstructed, either by its becoming  obliterated by inflammation or occluded by
 
746
DISEASES  OF  THE  BREAST.
the deposit in it of a small concretion — a lacteal calculus.  In either case the
walls of the  duct may be expanded, so that at last it  constitutes a moderate-
sized cyst, fluctuating on pressure, and evidently containing fluid.   In some
cases the  lacteal tumor  has  been known  to attain  an  enormous  size.   A
M. Walpy has related a case in which he drew off ten pounds of milk by tapping
a  collection  of this kind.  These tumors may exist for  a considerable time.
Dupuytren records  an instance in which it had  existed  for  ten months, and
Cooper one of a year's duration.  In these chronic cases the milk usually under-
goes  changes; becoming  creamy, thick, and oily, and  in some instances would
appear by the absorption  of  its watery parts to leave a solid residue.   In other
instances, again,  the  milk appears as if diffused through the  substance of the
glands and  its ducts, constituting a spongy semi-fluctuating tumor.   Velpeau
has pointed out that these lacteal deposits undergo a series of changes, somewhat
similar to those  that take place in blood that has been extravasated, becoming
absorbed in whole or part in  some  instances, in others  left fluid, and in others
becoming encysted.
   In these cases the readiest mode of getting rid of the tumor is, as Sir A.
Cooper advises, to make  an oblique puncture  from the nipple  towards it, by
means of a  trochar  and  canula, so that a fistulous track may be left, along
which the milk is discharged, and thus got rid of, the  child being at the same
time weaned, so  that the secretion may cease.   In  some cases  after  weaning,
the  milk may be  diffused into  the substance of the  gland  or collected into
masses of curd, forming hard  nodules, which give a good deal of trouble, and
may  eventually go on to ^ome of the forms of inflammation that will imme-
diately be described; these swellings are usually best got rid of by frictions with
somewhat stimulating embrocations, such as camphorated oil, &c, by which their
absorption is promoted.
   Infiammation of the breast may take place at any period of life, but is usually
associated with that change in the  function of the gland  which occurs during
lactation.  It is  commonly met with during  the  first  month or two  after  the
birth of the child, and seldom occurs during weaning.   The inflammation may
affect any one of the constituents of which the breast  is composed, and may be
limited to this;  thus it may take place in the nipple—in  the subcutaneous  cel-
lular tissue lying between the skin and the gland—in the gland itself, or in that
 extensive plane of cellular membrane upon which  the gland rests, and which
intervenes between it and the pectoral muscle.  But although the inflammation
commonly affects  these  different  parts, yet  in many cases  the whole of the
breast appears to  be affected, and no  distinct implication of any special tissue
 can be made out.
   Infiammation of the nipple and areola usually occurs at an  early  period of
 lactation in delicate  women, and  especially  during their  first  pregnancy.   It
 commences  in the follicles  of the part, accompanied  by  superficial ulceration,
 abrasion, fissure, and cracks, with oozing of a small  quantity of  thin, sero-puri-
 form fluid, great pain during suckling, so  much so indeed  as  to prevent the
 proper continuance of this act; and is usually accompanied  by  a great deal of
 constitutional irritation.   In some instances  the fissured state of the nipple
 would appear to precede  the setting in of inflammation;  in  other cases again,
 the  inflammation is the  primary condition.  When the  areola and nipple  are
 inflamed, these  parts become  conical, red, and swollen, with much pain, owing
 to the density of the subcutaneous tissue in this situation.  When this disease,
 commonly called cracked nipple, has set in, most relief is afforded by the appli-
 cation of the nitrate of silver to the bottom of the fissures, and over the inflamed
 surface.  This  application, though painful at the  time, gives the patient after-
 wards more complete ease  than any other with which  I am acquainted.   In
 some instances the application of the citrine ointment, and in other and slighter
 ca^es that of collodion is useful.   When inflammation  exists,  with  superficial 
TREATMENT OF  INFLAMMATION  OF THE BREAST.  747
abrasion, but without any distinct crack, the employment of astringent applica-
tions, such as the tincture of myrrh and of catechu, borax and honey, or spirit
and water, may be useful.  In these cases also, a leaden nipple shield may be
employed with advantage, and the state of the infant's secretions should be
carefully attended to;  the  occurrence  of aphthous ulcers  in  the mouth being
followed with especial frequency by the disease in question.
   Abscess  of the areola not unfrequently occurs  in  suckling women, with the
ordinary signs of local inflammation, terminating in circumscribed suppuration.
The treatment consists in the application  of warm  poultices  made  with lead
lotion, and lancing the part early.   In  doing this,  care should be taken that the
cut be made from the centre of the  nipple towards the circumference of the
areola, so as not to cut the lacteal  ducts.
   The infiammation of the breast,  which, as it generally terminates in suppura-
tion, is usually called milk abscess, may occur in three situations;  1st, in the
subcutaneous cellular  tissue; 2d,  in  the bed of cellular tissue in which the
mammary gland is lodged; and 3d, in the gland itself.
   1st. Inflammation, followed by abscess of the subcutaneous cellular tissue of
 the breast, though  commonly occurring during  lactation, is  more frequently
 met with than any other form of inflammation in this region at other periods of
 life, more particularly about the age  of  puberty.  Its symptoms are those of
 simple phlegmonous inflammation of these structures, differing in no way from
 abscesses  of this kind in other situations, except that it is always  distinctly
 circumscribed.
   2d. When  inflammation occurs  in  the cellular plane which lies between the
 mamma and the pectoral muscle, it diffuses itself over the whole of  the  cellular
 layer, and almost invariably runs into abscess with considerable rapidity, giving
 rise to great pain in this  situation of a  deep, heavy, and throbbing  character,
 much increased by moving the arm and shoulder, attended by swelling, oedema,
 and a slight red blush upon the skin.  The breast becomes prominent, is conical
 and projecting, the whole organ being pushed  forwards by the pressure from
 behind;  the subcutaneous veins become engorged, and at last abscess forms.  It
 is not always easy in these cases  to  determine whether suppuration has_ taken
 place or not, the depth  at which  matter forms  rendering it  impossible in the
 early stages to detect fluctuation until it approaches the surface;  its presence
 may, however, be suspected by the occurrence of  deep-seated throbbing pain,
 oedema, and some superficial redness.   The abscess  at last  points at some part
 of the margin of the gland, usually at  its lower and outer side, where the matter
 seems to gravitate; after a time, however, it  will  commonly appear at other
 points of the circumference of the  gland,  beyond  which it always  extends,
 though it seldom, if ever, perforates  the structure.   I  have, in more than one
 instance, seen a series of four or five apertures, forming a large circle round the
 margin of the gland.  It very commonly happens  that  the  aperture  through
 which the pus  discharges itself  in  these situations, degenerates into  fistulous
 canals, by no means easily closed.
    3d. Inflammation of the gland itself is not  of such frequent occurrence as
 either of the other  forms  of abscess;  when the  whole of the organ is affected, it
 gives rise to  great swelling of the  breast, with severe aching and lancinating
 pain, and  much constitutional  disturbance, usually of an irritative  type.  JNot
 unfrequently one lobule only of the gland becomes inflamed  and then  the local
 signs are proportionately limited, and occasionally cease. As Velpeau has pointed
 out, one  lobule after  another  may become  inflamed, so that a succession  of
 abscesses forms in different parts  of  the gland.  As the inflammation advances
 to suppuration, the skin is reddened, assumes a dusky  hue, becomes glazed, has
 a peculiar greasy appearance, and pits on pressure.  When matter has formed,
 the tension of the superficial parts with oedema and perhaps deep-seated fluctua-
 tion determine its presence. 
748                DISEASES  OF THE BREAST.
  In the treatment of inflammation and abscess of the breast occurring during
lactation, it must be borne in mind that we have not a sthenic inflammatory con-
dition to deal with, but that the disease almost invariably happens in pale deli-
cate women, commonly of a strumous habit, and weakened by recent parturition ;
indeed the affection appears to be rather an inflammation  of  an irritative and
congestive, than  of a sthenic character.  It is therefore obvious that antiphlo-
gistic means of an active nature are not admissible;  and the best plan of treat-
ment appears to consist in keeping up the strength of the patient by proper con-
stitutional  support, at the same  time that the  local inflammation is checked by
topical antiphlogistic measures.   The  first  thing  to  be done is to prevent the
occurrence of suppuration; if this  can  be accomplished, which is, however,
rarely the case, much will be gained.   In order to effect this,  the breast  should
be supported in a sling, so as to lessen congestion  in it, and the arm at the same
time should be fixed to one side  in  order to prevent  traction of  the pectorals
and movement of the submammary cellular tissue.  If the patient's strength is
good, leeches may be applied; in the majority of cases, however, they will not
be  required, but warm evaporating lead lotions or the assiduous application of
chamomile or poppy fomentations may be  substituted in their stead ; at the same
time the milk should  be drawn  off by means  of a  breast-pump or sucker, the
child being put to the unaffected breast or weaned, and  an  occasional saline
purgative administered.  When suppuration is impending, the application of
fomentations may be continued, the patient being allowed a more liberal supply
 of nourishment, with a moderate quantity of malt liquor; and so soon as matter
 can be felt, it should be cut down upon and let out by an aperture in the most
 dependent position.  It is of great importance  that the matter should be let out
 early, and  by an opening into  the  lowest part of the abscess; if it is not, it
 burrows deeply, diffusing  itself through  the  cellular tissue under, beyond, and
 around the gland, and opening at several points, leaves long fistulous  tracks per-
 forating the breast in various directions.  When suppuration is  going on, the
 patient's strength  must be supported with tonics, the mineral acids, bark and
 quinine.   Porter must be  liberally allowed, and  plenty of nourishment given.
 The sinuses that are left may usually be got to close by attention to the state of
 the general health: should they not do  so, however, the employment of pres-
 sure and the  use of stimulating injections may, in time,  accomplish this.   In
 the event of their proving rebellious, it has been proposed to slit them up, but
 this is an unnecessarily severe practice, and may, I believe, in all cases be dis-
 pensed with.
    Chronic or encysted abscess of the breast, is a disease  of great importance,
 inasmuch as it  simulates closely various tumors  in this situation; so much so,
 indeed, that it is only with extreme difficulty that  the diagnosis is  effected  in
 some cases.  It may commence either as  the result of acute lacteal inflammation,
 but  more commonly without any distinct cause; as the consequence, probably,
 of a very chronic and gradual engorgement of the cellular tissue in  this region.
 An  indurated indolent  swelling forms, and  this may gradually soften in  the
 centre, but fluctuation may for a long time be very indistinct, and even absent,
 being obscured by the thick wall of plastic matter that is thrown out around the
 collection of pus.  It is owing to the deposition of this dense mass of limiting fibrine
 that the encysted abscess is commonly developed as a hard and apparently solid
 lump.  It is in general not very distinctly circumscribed, and of but moderate
 magnitude, after a time remains stationary,  or but slowly increases with but
 little pain during a space of many months; and  is not unfrequently attended
 with retraction of the nipple.
    The diagnosis of this form of abscess is of great importance, inasmuch as it
  has not unfrequently been excised for tumor of the breast.   I  am acquainted
  with many instances in which this mistake has been committed.   Such an error
  may, however, commonly be avoided by observing that the abscess commences 
CHRONIC  MAMMARY  TUMORS.
749
during lactation;  that although it is of slow formation and without pain it is not
distinctly  circumscribed, but gradually fuses in an  irregular manner  into the
neighboring tissues; that it is not freely movable, but rather incorporated with
adjacent parts; and that elasticity, or even fluctuation may be commonly felt at
one part of it.  Should there be much doubt in the case, the introduction of a
grooved needle by giving issue to the pus, will always determine its true nature;
indeed this simple means of diagnosis should never be neglected in all cases in
which there is reason to suspect the possibility of the apparent tumor of the breast
being in reality an abscess.   The cure of these encysted abscesses of the breast
may most conveniently be effected by making a puncture into them, and then
passing a  seton across them  in a perpendicular direction ;  the inflammation thus
excited in the tumor will speedily lead to its being softened down, and even-
tually disappearing.

                      TUMORS  OF  THE BREAST.

   The study of the various tumors of the breast, more especially in a diagnostic
point of view, is of the first importance to the practical surgeon; for though it
might be  supposed that it would be easy, if not to recognize the minuter shades
of pathological- difference between morbid growths so superficially situated as
those of the mammary gland; at all events to diagnose the malignant  from the
non-malignant affections of this  organ; yet in practice nothing is more difficult
in many cases; and it not only  requires great experience, but also an intimate
acquaintance with the special course and symptoms of each particular disease, to
come to a correct conclusion as to its nature.  Even with all the light that expe-
rience and a careful examination of the characters of the tumor may throw upon
 the nature of the disease, it will be impossible for the surgeon to avoid occasional
 errors in their diagnosis.

                      NON-MALIGNANT TUMORS.

   Mammary tumors may be of a simple or a malignant character.  The recogni-
 tion  of the different varieties  of simple tumor that affect the breast gland, is
 principally due to Sir A. Cooper; and this department of surgical pathology has
 of late years been  much extended  by the researches of M. Velpeau and  Mr.
 Birkett.  The non-malignant tumors of the breast comprise the chronic mammary
 tumor, the  different varieties of cystic growth, the painful tubercle, hydatid
 cysts, and various forms of fibrous, cartilaginous, and osseous growths.
   The chronic mammary or adenoid tumor is perhaps the most common variety
 of these benign structures.  It usually occurs as the result  of blows,  squeezes,
 or lacteal irritation, and  is almost invariably met with in young women  under
 thirty years of age; seldom if ever occurring at a later period than forty; usually
 in persons  otherwise  hearty; and  most frequently in those of a sanguineous
 nervous temperament.   This tumor is generally of small size, though occasion-
 ally it may attain the bulk of the fist.  On examination after removal, it appears
 irregularly lobulated, and its cut surface will  be found  to  present a bluish or
 greyish-white color, which  after exposure to the air assumes a rosy tint, and on
 pressure,  drops of a thick creamy fluid will often be seen to exude.  Under the
 microscope it has been found, by Mr. Birkett, to consist of imperfectly developed
 hypertrophy of the glandular tissue; the terminal cells of which are filled with
 epithelial scales.
   This tumor usually commences as a small, movable, finely nodulated growth,
 attached  by a pedicle  to one side of the  mammary gland; it is hard and incom-
 pressible, often appears isolated, and not generally  painful; it increases slowly,
 and without discoloring  the skin or becoming attached to it, and is often many
 years in attaining a moderate size.  It is often floating  as  it were in the sub- 
750
DISEASES  OF  THE  BREAST.
stance of the gland, into which it can be pushed back.   These tumors are fre-
quently mistaken for cancerous  growths, and the diagnosis  is often as difficult
as it  is important; though, in  many cases, the  otherwise good health of the
patient, the mobility of the mass, the absence  of all implication of the skin or
glands,  the want of hardness and of a circumscribed character will usually  indi-
cate its  true nature.
   The  treatment consists  in  attention to the general health, and the employ-
ment  of local  absorbent remedies.    In this  way  tumors of this  description
have  occasionally disappeared;  in  some instances they have  been known to
become spontaneously absorbed after marriage or during pregnancy.   If obsti-
nate,  their dispersion may  be facilitated  by the occasional application of two or
three leeches, followed by inunction  of the iodide of lead  ointment; and the
internal administration of Plummer's pill, and the compound decoction of aloes.
In addition to these means, the  employment of compression will be found espe-
cially serviceable;  this may be  applied  either by means of  Arnott's  slack air-
cushion, or by using a pad to which  a spiral spring is attached, and which being
compressed by a proper arrangement of bandages across the chest will keep up
steady and continued pressure upon the tumor.  I have employed this kind of
apparatus,  which is far less expensive and cumbersome than  the air-compressor,
in several cases of mammary  tumor with  great advantage.   The  advantage
attending it  is  that it can be  used in conjunction with absorbent ointments,
which cannot be used with the air-bag, as the grease entering into their compo-
sition destroys the macintosh cloth of which it  is made.   In  this way absorption
may not unfrequently be secured ; and I am disposed to think that not a few
of the so-called  cases of cancer of the breast that have been reported as having
been  cured by  pressure, were,  in reality,  instances of the  chronic mammary
tumor in which absorption had been brought about in this way.   Should the
growth  attain too great a magnitude  to admit  of absorption by the means that
have  just  been recommended, its excision  must be practised.   In doing this it
is not necessary to remove the whole of the breast, but it will be quite sufficient
to extirpate the tumor itself.  If  the growths implicate the edge of the mam-
mary gland, this may be done by two incisions  that radiate from the nipple as
from  a centre, thus inclosing a triangular portion of the breast.   If it be movable
and be  in the substance of the gland itself, it may often be enucleated through
a simple incision.
   It  occasionally happens that  the   chronic mammary tumor becomes the seat
of intense  neuralgic pains  of a very severe  and paroxysmal  character, attended
with  very considerable cutaneous sensibility, constituting the  form of disease
that goes by the name of the painful mammary tumor.  This condition  most
frequently occurs in early life, and in women of an irritable and delicate consti-
tution ; it is  commonly associated with disorder of the uterine functions, the
pain increasing  at the catamenial periods, and  appearing to be essentially owing
to the implication of some of the twigs  of  the intercosto-humeral nerves in the
disease.  The treatment of this affection  must have special  reference to the
removal of the neuralgic condition.  This is commonly best effected by the
internal administration of alteratives and tonics, more particularly of the pre-
parations  of iron and  zinc, with cod-liver oil if necessary, and by the inunction
of the  iodide of lead ointment, conjoined  with  belladonna  or aconite into the
affected breast.   In many cases the application  of a few leeches, from time to
time, more particularly in the vicinity of the  axilla, will lessen the  neuralgia
more  effectually than any other  plan of treatment; and, in  others, again,  pres-
sure will be  found serviceable.   If all  other means fail, excision of the tumor
may in  this, as in the last case,  ultimately be found necessary.
   Cystic tumors of the breast are amongst the most common of the non-malig-
nant affections of this  organ.  They may occur in three distinct forms: 1st. As
a single unilocular cyst; 2d. As several of these cysts occurring together; and 
CYSTIC  TUMORS.
751
3d. As the cysto-sarcomatous tumor, in which  the cystic development appears
to be superadded to a structure  analogous to that of the chronic mammary
tumor.  Besides  these  forms of non-malignant cystic tumor, we  occasionally
meet with cystic  cancer of the breast.
   The single or unilocular cyst of the female breast, described by Sir B. Brodie
as the sero-cystic tumor, and  by Sir A. Cooper as a variety of hyatid tumor
usually occurs in  the form of a small thin sac, about the size of a filbert, con-
taining a clear serous fluid, imbedded  in  the granular substance of the breast,
and  movable under the skin; most commonly more than one cyst of this kind is
present in the breast, though  as  one attains  a greater development than the
others, the smaller ones may readily escape detection.  These cysts, when single
and  small, always contain  a clear serous  fluid, but as  they increase in size, or
become multiple, their  contents  may  assume  a greenish,  brown, or  blackish
tinge.   They  may continue for a great length of time of small size, but in other
cases, again, they gradually increase until they contain several ounces of serum.
Sir B. Brodie  is of opinion that they are originally formed by a dilatation of the
lactiferous tubes, and refers to a  preparation  in  which this  position  can  be
demonstrated.  The diagnosis  of the  affection  may usually be  readily effected
by feeling the globular elastic cyst or cysts under the skin;  the mammary gland
being movable, and not adherent  to any of the adjacent structures.  In those
cases, however, in which the tumor lies deeply, the diagnosis may not so readily
be made, more especially from some of the cystic forms of cancer to which I
shall by and by have occasion to advert.  Whenever the surgeon has any doubt
about the  existence  of  fluid in a tumor of the breast, he should introduce
an exploring trochar, when, if the disease be cystic, the  fluid will be discharged.
If the tumor  prove to  be  solid, no ill consequences will result from the simple
puncture.   Two  instances  have lately occurred to me, in which, from want of
this simple precaution, very excellent surgeons had condemned as  cancerous,
tumors of the breast that proved to be cystic.
   Unilocular cysts of the breast occasionally attain an immense size, at the same
time that their walls continue thin and supple.    In some of these instances, the
fluid continues to the last of a truly serous character; in other  cases, however,
it becomes more or less glairy or mucilaginous, and hence Velpeau has described
this variety  as the sero-mucous cyst.  In other cases, the walls of the cysts have
been known to undergo calcareous  degeneration.   When  these cysts attain a
very large  size, their walls being thin, and the skin covering them tense, they
may become translucent, and  thus constitute a true hydrocele  of the breast,
resembling in  many respects similar serous tumors that form in the neck.
   In the majority of instances,  as has already been observed, no material change
takes place in  the cyst, except, perhaps, its gradual increase in size; but in other
instances, peculiar changes occur in them, in consequence of which  they become
filled up by a dense solid growth springing from their interior, at last under-
going ulceration,  and  giving rise to a series of destructive changes.   The patho-
logical phenomena that accompany these  changes have been ably investigated
by Sir B. Brodie.    He finds that, in the first instance, one or more membranous
cysts, containing  serum, are formed in the  breast; the  fluid gradually becomes
darker in color, and opaque; after a time, a  fibrinous excrescence, of a lobulated
or foliated form,  springs up into the interior of the cyst, gradually  displacing
and  occasioning  absorption of the contained fluid, and, at  last, filling  up the
whole of its interior; and then coming in contact with  the  capsule by which it
is compressed,  or  with which it may be firmly incorporated,  the whole tumor is
converted  into a solid mass, in  which the remains of the cysts still continue to
be perceptible.  Sir B. Brodie thinks there  is reason for believing that a growth
of a fibrinous substance takes place from the outer side of the cyst as well, thus
adding to the general size of the breast.  If one of the larger cysts be laid open,
or if the pressure of the intra-cystic growth cause inflammation and ulceration 
752
DISEASES  OF  THE  BREAST.
of its capsule,  this may at last be perforated, and a fungous mass will sprout
through  it, presenting many of the ordinary symptoms of a malignant  growth,
being irregular, dark-colored, bleeding readily, and increasing  rapidly in  size.
When such changes as these have taken place, the tumor assumes a formidable
character, and will rapidly prove fatal by the induction of exhaustion and hectic.
Tumors of this  description, composed of cysts having intra-cystic growths sprout-
ing from  their interior, may attain an immense magnitude and weight.  They
have been met with of six, eight, or even twelve pounds weight, but the largest
is one described by Velpeau, which weighed forty pounds.
   The various  forms of cystic tumor  that have just been described, when  asso-
ciated with the development of fibrinous intra-cystic matter, constitute forms of
the so-called  cystic sarcoma.   Another variety of  this disease, however, is not
unfrequently met with, in which the  sarcomatous or solid element of the tumor
preponderates  over the  cystic part  of the growth.   In these cases the tumor
will be found to be composed of a dense, white, lobulated, or foliated structure,
closely resembling that of the chronic mammary tumor, and consisting either of
imperfect hypertrophy of  the breast-gland, or of the  deposit of a fibrinous ma-
terial.  This mass is studded throughout with a number of small  cysts, varying
in size from a  pin's head to a hazel-nut, and usually containing clear fluid.  If
some of these cysts increase out of proportion to the rest, the tumor will assume
more of the true cystic character.
   This form of cystic sarcoma usually occurs in women from thirty to thirty-five
years of age, as the result of injury or as the remote consequence of some inflam-
matory action during lactation.   On examining a breast affected in this way, it
will be found  that the tumor, which may either be confined to one lobe, or im-
plicate the whole of the gland, is hard, heavy, and solid to the feel; on careful
examination, however, its surface may be felt to be finely nodulated; and, occa-
sionally, a larger cyst than usual may be found projecting, which  is recognized
by its elastic feel and  globular shape.  The  disease is  slow in its  growth, and
does  not implicate the adjacent cutaneous  or cellular structures; hence, the
tumor is movable  on the pectoral  muscles,  and  the skin is unattached to  it.
The  axillary glands, also,  are not enlarged, at least not to any material extent.
The nipple will always be found to be normal in its shape, and not depressed.
   The treatment of these various forms of cystic and sarcomatous growths varies,
according to the  size of the cysts, and  the  quantity of solid matter deposited
inside and around them.  When the  cysts are small,  the fluid  contents may be
let out by puncturing with a small trochar; but a cure cannot usually be effected
in this way, as the fluid readily re-accumulates.  In such cases as these, Sir B.
 Brodie has found  considerable advantage in  the application of stimulating em-
 brocations, more particularly of one  composed of equal  parts of camphorated
 spirit and weak spirit, with one-eighth part  of liquor plumbi.   In other cases,
 blistering and the application of the tincture of iodine, may be serviceable.
 Under these plans of treatment I have  several times  seen the tumor  disappear,
 occasionally it will suppurate and is thus got rid of.   Should, however, these
 plans of treatment produce no good  effect, it may be  necessary to remove the
 whole  of the  breast  affected by the disease.  It is better either to leave the
 tumor and treat it by palliatives, or to remove the  whole breast; partial removal
 of the breast,  extirpation  of the tumor, with its lobe  of the mammary gland, is
 not usually a very successful operation.   Often very severe inflammation of the
 glands and of the succeeding textures  is set up.   This I have seen  on several
 occasions, and therefore think it  better that the breast should  either be left, or
 removed in toto.   Such an  operation, however, should not be undertaken in the
 early stages,  as  the tumor may continue  for many  years  without seriously
 troubling or  endangering the  patient,  and may perhaps eventually  undergo
 atrophy or absorption.   If, however, it show  a disposition to increase, to become
 troublesome by its bulk, or painful,  it should then certainly be extirpated, and 
MALIGNANT TUMORS  OF THE BREAST.         753
this operation may always  be performed with a good prospect of success, inas-
much as the disease is not malignant, and does  not tend to  contaminate  the
constitution.   It  is a remarkable fact, however, which has  been  adverted to by
Lawrence and Brodie,  that even though the whole of the breast be extirpated,
a similar affection  occasionally recurs in the cicatrix, requiring subsequent ope-
ration ;  and then, perhaps, being permanently eradicated.   This  must either be
owing to some portion  of the cystic structure having been left in  the first opera-
tion, or to the development of new cysts in the site of the former; but to which
cause it is  referable is still uncertain.   A still more remarkable circumstance
connected with these  tumors  is, that after their removal a recurrence of  cancer
will occasionally  take  place in the cicatrix.  The repeated recurrence of these
cystic tumors is very remarkable.   Mr. Caesar Hawkins relates a case in which
 the growths had  to be removed eight times for as many recurrences.
   Besides these tumors, the breast is occasionally the seat of other morbid
 orowths; as for instance, fibrous, osseous, and  cartilaginous masses have been
 met with in this  situation.  All these affections, however, are of extremely rare
 occurrence, and when  they form it is almost impossible to determine their true
 nature  until after removal.  Their  extirpation  is  usually practised on account
 of the  obscurity  attending the diagnosis, and the fact of their commonly being
 mistaken for cancerous growths.
   Sir A. Cooper describes a scrofulous tumor of the breast, the  precise  nature
 of which is not  very  apparent from the account given  by that  surgeon.   It is
 not improbable,  however, that it is of a tuberculous character; and Velpeau
 states that he has found tubercles occurring in the breast in two forms.   In the
 first, principally deposited in  the skin and  subcutaneous cellular tissue;  and in
 the other, of a fibro-tuberculous character, affecting the gland itself.
   Hydatids of the breast are of rare occurrence, and  have been principally
 described by Sir A. Cooper, and cases  have been related by Graefe and  others.
 These hydatid tumors are so  excessively rare and obscure that their true nature
 would  not in  all probability be suspected until after removal.  They present
 the ordinary characters of a deeply-seated cyst, with fluctuation  and some indu-
 ration round the globular swelling,  and an absence of pain.   In such a  case as
 this, an incision  into the tumor will cause  the escape of the acephalocysts, and
 the ultimate suppuration of  the cavity in which they lodged, which will gradu-
 ally cicatrize.  In some rare  cases,  tumors containing foetal remains have  been
 met with  in the breast;  these cases,  however, are rather matters of surgical
 curiosity than of practical importance.

              MALIGNANT  TUMORS  OF  THE BREAST.

    All the various forms of cancer have been met with in  the breast;  scirrhus,
 however, occurs  with far greater frequency than any of the  other  varieties.
 Occasionally the  encephaloid form of  the disease is met with, but colloid very
 rarely  occurs; indeed, the  only case  of colloid  of  the  mammary  gland,  with
 which  I am acquainted, is  that  in  a preparation  in  the University College
 Museum.   Cancer of the breast, whatever form it assume, is  invariably pri-
 mary :  it may affect one  lobe only, or be  infiltrated  into the whole gland;  and
 it may commence in the  nipple or in the skin covering the  breast.   Most fre-
 quently only one side is affected, but in some cases both  mammary glands are
 implicated.                                                 .
    Scirrhus is that form of cancer that is commonly met with in the  breast;  it
 may occur in several  ways, either as affecting the nipple, as being deposited in
 the form of an intra-mammary tumor, or  as infiltrating the whole substance of
 the oroan.  It most  commonly commences as a circumscribed  tumor of small
 size, at°first perhaps smooth  and round, hard and indolent in its character, with
 little or  no pain; it  is readily movable, may be situated  in  one lobe, and  at-
        48 
754
DISEASES  OF  THE BREAST.
tached perhaps to the rest of the gland by a distinct  pedicle.  As it increases
in size, it becomes hard, knobbed, and irregular, perhaps  presenting a finely-
granular feel, and becoming fixed to the gland and subjacent parts.  When the
disease begins as scirrhous infiltration of the breast, the gland is from the  first,
hard, rugged, irregular, nodulated, and heavy; often somewhat square in shape,
and early accompanied by adhesions to subjacent parts.   In other cases again,
the development of  the  scirrhous  mass is accompanied by a corresponding
atrophy of the mammary gland,  which becomes shrivelled and disappears en-
tirely.  In some instances rather large cysts may form in connection with these
scirrhous masses.   In a woman, whose breast  I lately removed, for what was
supposed to be cystic sarcoma, but proved after the operation to be a scirrhous
tumor, the mass contained several cysts as large as cherries, filled with dark or
greenish fluid, and  projecting from its surface;  and  in a lady who is at present
under my care  for scirrhus of the  breast, a tumor  as large as a pigeon's  egg,
containing sanguinolent fluid, formed on the surface of the tumor.
   As the swelling increases  in size,  it has a  tendency to become more fixed to
the subjacent parts, becoming adherent to the pectoral muscles, and incorporated
with the cellular tissue at the border of the  axilla.  The tumor also begins to
form a distinct external projection, becomes  more irregular in shape, is the seat
of severe pain,  more particularly at night,  and is usually covered by a plexus
of blue and dilated veins.   The  ordinary symptoms of cancerous cachexy now
begin to set in, and the disease then makes still more rapid progress.
   The tumor may in  some cases  remain for  a great  length of time without im-
plicating the skin, but most commonly after it has existed for a few months this
tissue becomes more or less  involved in the morbid action.   Instead of being
loose and movable over the surface of the tumor, it will  be found, on being
pinched up between the fingers,  to dimple at one  part, where it may be felt to
be attached by a kind of cord-like  process  to the tumor beneath it.  After a
time, that portion of the skin which first became fixed in  this way, acquires a
reddish or purplish color,  and is covered with thin, scaly, epidermic desquama-
tions, and becomes permeated by a number of small ramifying vessels.  A crack
or fissure eventually forms in this; a small  exudation of a mucous fluid takes
place, which dries into a scab; under this, ulcerative action sets in, which spee-
dily assumes the ordinary characters of a scirrhous ulcer, having hard, elevated,
and everted edges, a  greyish-green  or foul surface, and discharging a quantity
of very fetid pus.   In  some  cases ulceration may take place at several  points,
and thus the whole surface of the breast become  converted into one immense
chasm, which may even extend up into the axilla.
   The skin, when  affected, often  assumes a red, glazed, hard, and brawny cha-
racter, being shining, and as if greasy upon the surface, having its pores en-
larged, and enveloping the  side of the chest in  a kind of stiff, solid  casing,
attended usually by much pain, considerable oedema of the  arm, and an aggra-
vated form of constitutional cachexy; ulceration at last takes place in this har-
dened mass, and then speedily destroys the patient.  In other cases, the integu-
ments covering the breast become early contaminated  by the  cancerous matter
assuming a hard,  leathery character,  or feeling brawny and  infiltrated; often
without discoloration,  but presenting  a hypertrophied  appearance, the pores
being enlarged, and  the  interspaces between them increased.  In other  cases
the infiltrated skin assumes a brownish or purplish color.
   The pain is in many cases but trifling in the early stages of the affection, so
much so indeed,  that it  is  the  tumor, often  accidentally noticed,  that first
excites alarm; as  it increases, however, the suffering becomes severe, more par-
ticularly at night,  is  greatly aggravated by handling the diseased mass, and
chiefly extends  up to the shoulder and down the  arm.  The pain usually be-
comes most severe  about the time when the skin is first implicated; but as the 
CANCER  OF THE  BREAST.
755
cutaneous infiltration goes  on,  it  gradually lessens, owing probably  to  the
destruction of the cutaneous nerves.
  Retraction of the nipple commonly commences about the same time that the
skin is implicated; it appears to be owing to the glandular substance becoming
involved in the mass of the tumor, and thus giving rise to shortening of the lac-
teal ducts, in consequence of which, by the  projection forwards  of the  general
mass of the breast, the nipple appears to become completely buried   This sign
has, I think, received more importance than it deserves in connexion with can-
cer, as it does not occur in all cases of malignant disease, and is occasionally met
with in simple mammary tumors.
   The  axillary glands  usually become enlarged early in the disease, and may
 attain a greater size than that of the original tumor, and on close examination
 a kind of indurated cord may be felt extending in the course of the  absorbents,
 from the edge of the  pectoral muscle to the axilla.   After a time the supra or
 sub-clavicular glands may likewise become complicated.   In fact, the whole  of
 the glandular structures in the vicinity of the shoulder undergo  cancerous infil-
 tration.   When this is the case, the pressure that is exercised upon the axillary
 vein may occasion oedema of the  arm and  hand.  The glandular  infiltration
 usually increases rapidly after the skin has become implicated.
    As the scirrhus extends, it gradually affects the subjacent muscles, cellular
 tissue, the ribs, and at last the pleura, commonly giving rise eventually to hydro-
 thorax or secondary visceral deposits.  In many instances, however,  the disease
  proves fatal by the induction of exhaustion.  The constitutional cachexy is in
 many cases not very distinctly marked, until  after the skin has become involved;
 but then it rapidly increases, more especially when ulceration takes  place.   In-
 deed the cancerous degeneration of the skin may be looked upon as an epoch of
 peculiar importance in scirrhus of the breast, as it  is at this period that the pain
 increases, that the lymphatic system becomes infected, and that the constitution
 becomes distinctly poisoned.
    The duration of life after the  occurrence of scirrhus of  the breast, varies
 greatly, so  much so that the disease  may be considered as assuming an acute
 and a chronic form.  The acute variety principally  occurs in ruddy and plethoric
 women, and commonly proves fatal in a few months.  In  those who are of a
 more  feeble and delicate constitution, the  disease, as  a general rule, takes a
 slower course.  Sir A. Cooper states that the disease, on an  average,  is from  two
  to three years in growing, and from six months to two years in  destroying life,
  after being fully formed.   In this estimate, which is probably correct, Dr. Walshe
 agrees, so that the average duration of life in cancer of the breast would probably
 be about three years.   As  a general rule, the progress  of scirrhus  is slower in
  old people, in whom it occasionally gives rise to a kind of atrophy of the breast,
 with shrinking and induration  of the  tumor.   There  are many instances  on
 record,  however, in which cancer of the breast  has existed for a far longer
 period than has just been mentioned, for ten, twelve, or even as in a case related
 by Sir B. Brodie, for twenty-five years.
    After removal, scirrhus of the mamma presents considerable variety in appear-
 ance.   In the majority of  instances it occurs as a peculiarly hard knobbed  and
 irregular mass,  creaking under the knife when cut, and presenting on section a
 greyish or bluish-grey, semi-transparent surface, traversed in various directions
 by bands  of a  more opaque character, and exuding on pressure a thin reddish
  juice.   In many instances masses of an opaque character, and yellowish tint,
 may be seen in the midst  of the  tumor.   These, which look like  tuberculous
 deposits, consist in reality of fatty  degeneration of the  scirrhous structure.   In
 other cases again, on  pressing  the tumor, small drops  of a thick creamy fluid
 will appear to exude at various points.  This appears to  be the inspissated  and
 altered secretion  of the  gland retained in  the ducts.    Cysts are occasionally,
 though rarely, met with  in scirrhus of the breast; these are usually small, and 
756
DISEASES  OF  THE BREAST.
contain clear fluid, being deeply imbedded  in  the  substance  of the  tumor; in
other cases again, they may be large and globular, and filled with a bloody or
dark-green liquid.  The microscopical characters of scirrhus  of the  breast, are
such as are represented in  fig. 148.
   Encephaloid of the mammary gland  is by no means  of such common occur-
rence as scirrhus, but yet all the varieties of this form of cancer have been  met
with  in  the  breast;  and fungus  haematodes has been seen to spring from the
bottom of cystoid growths  previously developed in  this region.  Encephaloid of
the breast may sometimes  acquire a considerable size; thus, Cruveilhier relates
a  case in which the  tumor weighed nearly twelve pounds.   The  structure of
this disease does not  differ from that of the same  affection in other situations;
both the hard and the  soft varieties may be  met  with, and  in some advanced
cases  the true fungous growths  occur.  Encephaloid usually begins deeply in
the substance of the breast, as a soft globular tumor, which rapidly increases in
bulk; the integuments covering it  are  not at first adherent,  but are  usually
pushed before it, and speedily become permeated by a largely ramified net-work
of veins.  The mass  feels  as if cdmposed  of several soft and  rounded  tumors,
which communicate an obscurely fluctuating sensation, causing  perhaps the sur-
geon to mistake the growth for a cystic formation, or an abscess.   The breast
now rapidly assumes a very prominent and conical form;  the skin covering it at
its most projecting part  becomes thinned and  reddened, and at last gives way,
leaving a large circular ulcer, from which a fungous mass of greyish or reddish-
brown color speedily  sprouts up, with a good deal of discharge of' a foul, bloody,
and offensive  character.   From this,  disintegrated  masses  are  occasionally
detached by a kind of sloughing action, and cases may even occur in which the
whole of the fungous protrusion sloughs away, and cicatrization taking  place, a
tolerably perfect cure may  result.  These cases, however, are so rare, as scarcely
to influence our prognosis of the necessarily fatal character of the affection.
Implication of the glandular structures in the vicinity of the tumor, followed by
constitutional cachexy, occurs in this as in true scirrhus of the  breast.   The
progress of the disease is always extremely rapid, more particularly in young and
otherwise bealthy subjects.
   Colloid cancer and melanosis of the  breast occur so rarely,  and only in  con-
nection with the other varieties of the disease, that they can merely be looked
upon as presenting points  of pathological interest.
   The causes of cancer of the breast are usually  of an extremely obscure character.
The most marked circumstance that influences its occurrence is certainly sex, it
being, as is  well  known, almost  entirely confined  to  women;  yet instances in
which this affection is met with in the male breast  occasionally occur.  Its pecu-
liar  frequency in the female may possibly be  owing to the great and sudden
alternations  of the functional activity of the breast in women.  The changes
that are impressed upon this organ at puberty  and  during pregnancy, the various
alternations  it undergoes, and  inflammatory  affections to  which  it is  subject
during lactation, the  frequent irritation to which it is exposed  by sympathizing
with uterine derangement, and the  diminution in its vital activity that takes
place  at the change  of life, are sufficient  to  explain the great liability of this
organ to disease  generally; and  may not  improbably give a clue to the reason
why it is so peculiarly the seat of cancer in women.  The age at which cancer
of the breast most frequently occurs is  between the thirtieth and fiftieth year.
According to Birkett, it is most commonly  met with between the ages of forty-
five and fifty;  a period of life that is  popularly  looked upon as specially ob-
noxious to this malady.   At these ages, cancer of  the breast usually affects the
form of scirrhus.  When occurring, as it very rarely  does, in early life,  it more
frequently assumes the encephaloid character.  I have, however,  removed a
scirrhous breast from an unmarried woman of twenty-three  years of age.   In
elderly women, scirrhus also is the prevalent form, though  I have seen two  or 
DIAGNOSIS OF  CANCER  OF THE  BREAST.       757
three instances of encephaloid at an  advanced period  of life;  one case, in  a
woman upwards of seventy years of age.  Indeed, cancer, in either form, may
affect this organ up to  the latest periods to which life is prolonged.  Married
women are said to be more liable than single ones to cancer of  the  breast; it
may, however, fairly be doubted whether they are proportionately so, and it is a
common belief, founded, I believe, in  some degree on truth, that the disease is
most common in those women who have not borne children.
   Injuries inflicted upon the breast, such as blows, squeezes, &c, are commonly
referred to, and are greatly dreaded  by women, as the causes of cancer.   That
they might be so in constitutions otherwise  predisposed to the affection, does
not  appear improbable, and that they are so in reality, I have not the least
doubt.  The number  of instances that have  fallen under  my  observation, in
which a blow or squeeze of the breast has speedily been followed by the  appear-
ance of a cancerous tumor  in  it, leave no doubt whatever on my mind of the
truth of the popular  belief that associates the injury with the disease, in the
relation of cause and effect.   Lacteal inflammations are  likewise frequently
supposed  to tend to  the production of cancer of the breast.   Of this doctrine I
think that we do not possess at  present sufficient proof, though it appears to me
highly probable that disturbances of the functions of the organ during lactation
 may predispose to the occurrence of this disease.
   The diagnosis of cancer of the breast from  other diseases affecting this organ,
 is of the  first importance, and  is attended by corresponding difficulties.   The
 great point is to determine whether the tumor of the breast is of a cancerous
 character or not; beyond this it matters little in practice that the  surgeon should
 go — and, indeed, except in some of  the forms of cystic disease of this organ,
 few practitioners would  feel disposed to endeavor  to carry their  diagnosis
 beyond this point.   The great and essential difficulty in determining the nature
 of a tumor of  the breast consists in the fact  of the  same signs being  more  or
 less common to many growths in this region; a hard, circumscribed, indolent
 mass, chronic in its progress, with  a certain  amount  of pain, being the usual
 characteristics presented by all solid mammary  tumors; and  though  in  nine
 cases  out of ten, a tumor  presenting these characters, which has  existed for a
 year or  more, in an elderly woman,  and has resisted ordinary absorbent and
 alterative  treatment, is of a scirrhous  character,  yet instances of the  reverse
 occasionally occur.  Nothing can  better  exemplify the difficulty of diagnosis
 in tumors of  the  breast,  than the  circumstance, which  is not  unfrequently
 witnessed, that after the removal of the diseased mass, its section, and careful
 examination, surgeons of equal experience will differ as to whether it is malig-
 nant or not, and to what  class  of affections  to refer it; and, indeed, in many
 of these  cases  it is impossible to  ascertain  its  precise nature  without having
 recourse to microscopical observation.
   It is extremely difficult to lay down any definite rules of  diagnosis, by which
 the question as to the  malignancy of a tumor of the breast can be solved.  In
 the majority of cases  of cystic  growth in this region there is  little difficulty;
 the existence  of cysts of sufficient size to be readily felt or seen through the
 skin, being  generally characteristic of  the malignant cystic growths.   It must
 be borne in mind, however, that cases, such as one to which allusion has already
 been made, may occur in which cysts are conjoined with cancerous development.
   The diagnosis between cystic sarcoma and some forms of cystic cancer of the
 breast is  not always easy, indeed may be impracticable, and can only be deter-
 mined after removal by microscopical examination.  I have lately had a patient
 in the hospital fifty-nine years of age, in whose  breast a hard tumor,  as large
 as half an orange, had existed for five years;  it was perfectly and freely movable,
 unconnected in any way with  the  skin, there was no retraction of the nipple,
 and no  lancinating pains.  On its upper side, several large cysts could be felt,
 and seen  through the skin.  On examination  after removal, it was found to be 
758
DISEASES OF  THE  BREAST.
encysted scirrhus, with large cysts, the size of cherries, containing bloody and
yellow fluid.   The only very suspicious circumstances here were the age of the
patient, and the existence of one small indurated gland in the axilla.
  In  these  cases of  doubt,  the  safer  plan  is always to make an exploratory
puncture, and, if necessary, to examine under the microscope the contents with-
drawn by the groove in the  needle or by the trochar;  indeed, if there is the
slightest doubt as to the nature of the tumor, this exploratory puncture should
never be omitted before its  removal is determined upon.  I have more than
once  seen tumors pronounced positively to be scirrhous, and  for which ampu-
tation of the breast had been recommended, turn out to be cystic, and disappear
entirely as their contents were withdrawn.
KON-MALIGNANT tumors.	SCIRRHOUS TUMORS.
Feel. — Moderately hard, nodulated, irre-gular in shape, occasionally more or less lobed, not very distinctly circumscribed, sometimes elastic in parts. Mobility is considerable, though occa-sionally there is a deep pedunculated attachment. Skin of the natural color throughout, though thinned and expanded, with the tumor lying close beneath it. Only implicated in the advanced stage of cystic sarcoma. Nipple usually not retracted. Veins of the skin not much dilated. Pain often moderate, if severe, continuous or of a neuralgic character, much in-creased by handling. Axillary glands of usual size, or but slightly enlarged and movable. Lymphatics not affected; supra-clavicular glands not affected. No constitutional infection.	Feel of a stony hardness, knobby and distinctly circumscribed, or else some-what square, and occupying the whole of the substance of the gland. Mobility at first considerable, but soon becomes fixed to the deeper structures by a broad attachment. Skin becomes early implicated — at first dimpled, then red or purple, and in other cases brawny and leather-like, so that it does not admit of being pinched up into folds, or nodulated, purpled-red masses form in it. Nipple usually retracted. Veins of the skin very greatly dilated. Pain severe and lancinating, especially at night after handling, and when the skin is implicated, but not continuous. Axillary glands enlarged, indurated, and fixed. Indurated mass of lymphatics under and parallel to edge of the pec-toral, stretching into the axilla; supra-clavicular glands enlarged. Constitutional cachexy as disease advances.
  Between  cancer and the ordinary solid tumors of the breast, the diagnosis is
often extremely difficult, but we may arrange  the chief signs of the two forms
of disease in distinct groups, when, by comparing them together, the differences
may be more clearly seen.   (See Table, above.)
  Treatment of cancer of the breast.—In  cases of cancer of the breast, the first
question  that presents itself to the  surgeon, is whether any plan of treatment
short of the removal of the tumor holds out a prospect  of cure, or even of
relief;  and  if not,  whether the  extirpation  of the cancerous breast can  be
undertaken  with the prospect of ridding  the  patient of an  otherwise fatal dis-
ease; or at least of prolonging her existence.   To these questions the remarks
made at page 406 et seq., on the general treatment of cancer, may be considered
applicable.  The management  of cancer of the breast, however, involves so
many special considerations  of importance that it becomes necessary to consider
its bearings  somewhat in detail.
  No constitutional means  appear to be  of the  slightest service  in arresting,
and  still less  in removing,  cancerous tumors  of the breast.  The  advantages
stated to have been derived from the use of arsenic, conium, iron, and various
preparations of mercury, have not been borne out by experience; and indeed it 
           TREATMENT OF  CANCER  OF  THE BREAST.       759

may be stated  generally that these and all other known remedies  are perfectly
valueless in the curative treatment of this disease.
   Compression by various  means, whether by plasters, as employed by Young;
by agaric, as used by Recamier; by the spring-pads of Tanchou, or  the  slack
air-cushion of  Dr. Arnott, has been  much praised, not only as a palliative, but
as a curative  means  of treatment  in this  disease; and  cases  are  recorded,
which, however, even  the warmest advocates of this plan of treatment are forced
to admit to be altogether  exceptional, in which the employment of this means
has been stated   to have effected  a complete   removal  of the  tumor.   But
although I am not prepared to deny that hard and  chronic tumors of the breast
may have  become absorbed during the employment  of this  treatment; and
indeed I have had occasion to observe this in  my own  practice, in cases  of
chronic mammary growth;  I think that evidence is altogether  wanting to show
that an undoubted case of cancer of the breast has ever been cured by this
means.   And  notwithstanding the high  authority  with  which some of  these
alleged cases of cancer have  been brought  before the  profession, no  positive
proof has been adduced to show that the tumor that was observed was  really
and truly of a cancerous  character, and that it may  not have been either  a
chronic mammary tumor,  or an encysted abscess of the breast.   Every practical
surgeon well  knows that it is utterly impossible  in  the present state of science
to diagnose in many  cases with complete  certainty the true nature of  a tumor
of the breast,  and must frequently have witnessed cases  in which, after  extir-
pation, the morbid growth has been  found to be of a different character to what
had originally been supposed.   I am acquainted with at least eight or ten cases
in which  some of the most experienced  surgeons, both in this country and in
Paris, have amputated the breast, for supposed scirrhus, when  after removal, it
was found simply to  have been the seat  of a chronic  abscess, with very  dense
walls.   And with regard  to hard, chronic, and  indolent  tumors of the breast,
few surgeons will hazard  a positive diagnosis, as  to whether it is of a scirrhous
character or not,  until they have actually seen a section of it; and even then
how often does it not happen  that  men of equal experience will differ in the
 judgment  they pronounce as to its nature.   For these reasons it is impossible
not to receive  with the  utmost hesitation the cases of supposed cancer of the
breast reported as cured  by the  advocates of compression, and  not  to suspect
that the  cases recorded  by these  gentlemen as  instances of the  successful
employment of this plan of treatment, may have been other chronic  tumors of
the breast, than those of a cancerous character.
   But though I think that there is no evidence  before the profession to  prove
the utility of  compression as a curative agent in cancer of  the breast, I  think
that when practised  with Dr. Arnott's slack air-cushion, or Tanchou's spring-
pad, it  is of considerable  value  as a palliative in some of the  earlier stages of
this disease;  when it may undoubtedly  occasionally  arrest its progress  for  a
time, diminish the size  of the swelling, and lessen  the violence of those attacks
of lancinating pain  which are  so distressing to the  patient.   In conjunction
with the pressure, much relief to suffering may  be afforded by the use of bella-
donna plasters, or of atropine or aconite inunctions, together with the  internal
exhibition of  conium.  In  the  advanced  stages  of the disease, however,  when
the skin is involved,  the pressure is often unbearable, increasing  the pain, and
acting as a source of  irritation to the patient.  In some  cases of this kind, in
which the slack  air-cushion could not be borne, I have  seen relief afforded by
moderate pressure with  thick layers of amadou, supported  by an elastic bandage,
belladonna or conium in powder being dusted on the innermost layer of amadou.
A very thin gutta-percha  shield, moulded to the  part, may sometimes be advan-
tageously applied over this, and kept on by turns of an elastic roller.   AVhen
the skin is implicated and very tender, the application of bread poultices  made
with belladonna and  lead lotion is of use.   When the disease has run into an 
760
DISEASES  OF  THE BREAST.
ulcerated stage, the internal administration of conium, so as to blunt the sensi-
bility, and the local application of chlorinated lotions to lessen the fetor, together
with the application of the watery extract of opium  or of belladonna  are of
much use.   In such cases as these, the  application of  caustics has been greatly
vaunted, and portions of the diseased surface may be cleansed or removed by
these means.
   Caustics employed in accordance with the principles laid down at  p. 407 may
occasionally  be advantageously  employed in the  treatment  of cancer  of the
breast, when excision is not practicable.
   The constitutional and ordinary  local  treatment of cancer of the breast being
thus, at  the  most, of a palliative  character, the question of operation  always
presents itself at last.   The objects proposed  by an operation are  in the fir^t
place, by the extirpation of  the diseased breast, to prevent constitutional infec-
tion, and thus  permanently  to free the patient from her  necessarily fatal affec-
tion ; or, failing in this, to retard  the progress of  the constitutional infection,
and thus at least to prolong  existence.  How far these objects  are  attained by
amputation  of the cancerous  breast is  a subject of important  inquiry to the
surgeon.  The  operation has of late  been discountenanced  by many excellent
pathologists; not so much from any intrinsic danger it  may possess, for although
occasionally fatal from  erysipelas or some  similar accidental complication, there
is nothing specially hazardous about  it;  nor from its being  now, as formerly,
open to the objection of subjecting the patient to unnecessary pain, all suffering
during its performance being prevented by anesthetics, and  little inconvenience
being experienced at subsequent dressings, which are  usually of a nearly pain-
less character;  but the great objection  lies in the fact of the disease, in many
cases, returning with equal, and in others perhaps with  greater rapidity after
the operation, than if none had been performed.
   The principal points in connection with the operation appear to resolve them-
selves into two questions:—1st. Whether, in any cases of cancer of the breast,
constitutional infection may be prevented by amputation of that organ; and if
so, under what  circumstances this will  most probably happen ?   And, 2d.
Although the disease may eventually return in the part or elsewhere, whether
excision may not  arrest the  rapidity of  the fatal termination ?
   In answer to the first  question, it is  not easy to give a very definite reply.
Nothing shows more clearly the  worthlessness of so-called  surgical statistics
than the discrepancy that  exists between those that have been published as
exhibiting the liability to relapse of cancer after operation.   Thus,  Hill states,
that out of 88 cancers on which he had operated at least two years before the
return was made, there were only 10 relapses, and 2 deaths; whilst Alexander
Munro  states, that out of 60  cancers which  he had  seen  removed, in  only 4
patients was there no relapse at the end of the second year.   Boyer only saved
1 in 25, and Macfarlane gives  a still more unfavorable account  of his practice;
for he says, that out of 32 cases of cancer operated upon by himself, there was
not one instance of radical cure; and of  80 other cases that he was acquainted
with, the result was in  every instance unfavorable.  Warren, on the  other hand,
saved  one in 3;  and  Cooper  1 in 4.   Amidst  such conflicting statements  as
these, it is  clearly impossible  to eliminate more  than  the general fact which is
well known to  every surgeon, that  in a large number of the cases of cancer that
are operated upon, there is a tolerably speedy return of  the disease.  In these
cases there are, however, many points to be taken into  account, that  gross statis-
tics can  take no cognizance of; much  being  necessarily dependent upon the
skill with which the operation is performed, as well as upon the care employed
by the  surgeon to cut widely of the disease, and to  extirpate  completely not
only the whole  of the morbid mass, but those tissues in its neighborhood that
might be supposed to be implicated.
   In many of  the cases, also, it is  by no means improbable that the  practice, at 
           OPERATION IN CANCER  OF THE  BREAST.       761

one time pretty generally followed, may have been adopted, of merely extir-
pating the tumor without removing the whole  of the breast.   I am, therefore,
disposed to look upon any deductions based upon the statistics of such  men as
Hill,  Macfarlane,  and Benedict as of very little value when  applied to the
surgery of the present day.
   It would, however, appear from the result of those inquiries, that in a certain
proportion of cases, whatever the precise ratio be, and this is still undetermined,
the disease may be effectually removed by extirpation of the breast.
   As the second  question, — whether as a general rule  life  may not be pro-
longed by the performance  of the  operation,—it would appear,  if the statistics
collected by Leroy D'Etiolles are accurate, that hitherto it has not.  Dr. Walshe
comes to the conclusion that the operation cannot as a general rule be regarded
as a means of prolonging life,  but that in  the majority of cases death is hastened
by such interference.   Sir A. Cooper and Sir  B. Brodie both agree that in the
majority of cases,  the disease  returns in  two or three years after the operation,
and then kills the patient.
   But though the general result of a statistical inquiry into this subject, based
upon  the imperfect  materials and probably very incorrect figures  at  present
before the profession, leads to the conclusion  that operations for cancer of the
breast, when  indiscriminately performed, have hitherto not only failed to cure
the disease, but actually in a great number of  cases  hastened its fatal termina-
tion, yet it must be borne in mind that instances do occur in which life is cer-
tainly prolonged by  this  means considerably beyond  its  average duration in
cancer  of the breast.  Thus, Callaway operated on a  case in which no return
took place for twenty-two years.   Velpeau states that he has removed encepha-
loid tumors  of the breast, and that the patient has  remained free from the dis-
ease for eight or ten years.   Sir B. Brodie and other surgeons relate similar
instances in  which the patient's life has been prolonged after the performance
of the operation;  and the experience of the most eminent practical surgeons is
decidedly in  favor of having  recourse to  it under certain circumstances.
   The only reliable statistics that  we possess on the relative duration of life in
cases of cancer of the breast, with or without operation, are those collected by
Mr. Paget.   He states that of 139 cases, 75  were  not submitted  to operation;
of these the average duration of life was 48  months.   Of  64 operated on
the corresponding average has been a little  more than  52 months.   In the
first two years of the  disease  the   proportion  of deaths was much less in
those operated on than in those who were left, — being in the former less than
11 per  cent., in the latter more than 30 per cent.   The longest duration of life
in a  case not  operated on was 18 years; in  those operated on,  a  little more
than  12 years.
   There is, however, another point of view from which  these operations may be
considered;  for even if they do not  prolong life, they  may greatly improve the
patient's condition, and place her in  a state of comparative comfort during the
remainder of her existence.   Thus she may be suffering so much pain from the
local  affection, or  if it be ulcerated, be so much affected by the fetor of the dis-
charges, that she may be placed in a position  of far greater comfort by having
the local source of disease and irritation removed; and though she die eventually
of cancer, it  may be with much less  suffering  to herself  and others for her to
be carried  off by  secondary deposits  in  the lungs or liver, than to be worn out
by the  external affection.
   In considering  the propriety of  operating in cancer of the breast, it is of the
utmost  importance to determine those cases in which the operation may possibly
be the means of preserving or prolonging life, from those in which there is no
prospect of its being of any service, or in which indeed  it must inevitably hasten
the patient's death.   Whatever the  value of  statistics  may be  in  determining
the question as to whether in cases of cancer of the breast generally, the opera- 
762
DISEASES  OF  THE BREAST.
tion will effect a cure  or prolong  life,  they are not  equally valuable  in their
application to individual  cases.   When  a surgeon is  called for his opinion re-
specting the propriety of amputating the breast of the patient before him, it is
not sufficient  for him to  be able to state what the general result of the opera-
tion  may be, but he must be able to satisfy himself whether the particular in-
stance under consideration may not be one  of those cases, exceptional  perhaps,
in which there is a fair  probability of the operation extirpating the disease
entirely from the system, or at all events  prolonging the patient's existence.  In
order to  do this  it  is necessary to endeavor to lay down some  rules that may
guide us in selecting those cases in which the operation  may be advantageously
done, and in setting aside others in which  we know that it will almost to a cer-
tainty hasten the patient's death.   And  indeed  it is the  absence of all such con-
siderations in general statistical  investigations into the results of operation for
cancer, that deprives them  of much of  their value as guides in actual  practice.
   Though  nothing can be more unsurgical or improper  than the indiscriminate
extirpation of all cancerous tumors of  the  breast from every patient who may
present herself, in whatever stage of the disease; and though such  a practice
would doubtless be followed by fully as disastrous results as  those that  occurred
to Macfarlane, Benedict,  and others;  yet there can be  little doubt  that a sur-
geon who would  employ a  certain  principle of selection, would  obtain a very
different and far more successful result in his practice.   Sir B. Brodie  has very
clearly and  succinctly pointed  out the  most important circumstances by which
the question  as  to  the propriety of operating in these cases should be deter-
mined.   Before doing  so, he very justly dwells on the  fact that in many cases
the operation may fail, and the disease speedily recur  through the  negligence
of the surgeon in leaving behind portions of the gland, slices of the tumor, or
contaminated tissues, and  that thus  the operation may receive discredit, for
what is in reality the fault of the surgeon who  performed it.
   With  reference to operations, cancerous diseases of the breast may  be divided
into three classes: — 1st. Those in which it is the duty of the surgeon to dis-
countenance excision; 2d. Those in which  operation is of doubtful expediency;
and 3d.  Those in which it is the duty of the surgeon to recommend it.
   1st. Cases unfit for operation. — In this  class we may include the following
conditions: (1) Those  cases in which there is strongly-marked constitutional
cachexy; (2) When both breasts are involved;  (3) When there are secondary
deposits  in internal organs;  (4) When  the glands under, and  especially above
the clavicle are much enlarged;  (5) If  the tumor be adherent to the  ribs and
intercostal  muscles; (6) When  the skin is hard,  brawny,  and infiltrated, of a
reddish-brown color, having a hard, leathery feel, or a greasy, glazed appearance;
(7) If the  tumor is rapidly growing in a patient with  a strong hereditary taint;
(8) If extensively ulcerated and fungating.
   2d. Doubtful  cases. — (1) If the patient is aged, weak, or  anemic, and the
tumor large, it is seldom  expedient to operate, as  the shock may destroy life;
(2) When  the skin is merely dimpled in by a kind of pedicle passing from the
tumor to its under surface,  an operation  may be performed  unless other circum-
stances should contra-indicate it, but in such cases it is  necessary widely to ex-
cise the  integument surrounding the attached point.  The cancer cells, as I have
more than  once had occasion to observe, will be found to have diffused them-
selves extensively through the neighboring skin, which, to  the naked eye and
to the touch, has a  perfectly healthy appearance, the tumor being  surrounded
by a kind of  halo or atmosphere of cancer infiltration;  (3)  When there is but
moderate enlargement of the axillary glands, which are  so  situated  as to admit
of removal, the operation may be performed; (4) When  the cancer is ulcerated,
it is seldom proper to operate, but if all  other conditions are favorable,  this even
need not in some special  cases be a bar.   As Sir B. Brodie has pointed out,  the 
           OPERATION  IN CANCER  OF  THE BREAST.        763

patient's existence may sometimes  in these cases  be prolonged, and her comfort
materially increased, by the removal of the diseased and ulcerated mass.
  3d. Cases admitting of operation. — The exclusion of all  the cases that fall
under the  preceding categories will necessarily limit very materially those in
which  an operation may be  undertaken; it can, however, be performed with
every prospect  of its being advantageous to the patient, if the  tumor  be of
moderate size, slow or nearly stationary in its  growth, unconnected with  or at
least merely attached by a pedicle to  the  skin, pretty distinctly circumscribed,
movable on the subjacent parts, and not complicated by enlarged glands in the
axilla or elsewhere.   The patient  has  an  especially good prospect of recovery,
according to Brodie, if the disease be seated in the nipple.  In all cases when
an operation is  undertaken, the whole of the breast should be removed, and the
contiguous tissues pretty widely excised.   The integuments being loose in this
situation, readily come together even after considerable loss of substance.  When
the tumor is pediculated, only being attached to the gland  at one  point, some
surgeons have recommended that it alone should be extirpated, the breast being
left.  This practice, however, is not a safe one; I have  seen it  followed by  a
speedy relapse, and should certainly always be disposed to extirpate  the  whole
of the organ in this, as in every case of cancer of the breast.
   When once a tumor of the breast has  been ascertained to be of a cancerous
character, the sooner it is removed the better, unless one of  the  special reasons
adverse to operation that have  just  been  adverted to should  exist.   I cannot
conceive that any good can come  of delay in these cases.   The  disease (for
reasons stated at  p. 410) appears in the early stages  often to be entirely  local;
there is no evidence of constitutional  infection, but if the operation be delayed
the skin speedily becomes implicated,  the axillary glands enlarge, and cancerous
cachexy sets in.  When the operation is performed, the whole of the breast and
the surrounding cellulo-adipose structures should be freely removed, as there  is
often a halo of cancer  deposit around the morbid mass, in  tissues  apparently
healthy.
   Relapse of cancer after operation may  take  place  in two ways;  either in the
vicinity of the part operated upon, or in some  internal organ.  When recurring
in the neighborhood of the previously affected part,  it is probably owing  to the
cancer-cells having diffused themselves so widely into the skin, the subcutaneous
cellular tissue  and  muscles, or neighboring lymphatic glands,  that after the
removal of the tumor these  cells become the germs of new growths.   Under
these circumstances it may recur  in the cicatrix and then implicate the glands;
or, in the glands, without the cicatrix having been previously affected. In local
relapse of this  kind, it often happens that the disease so reproduced, runs its
course more rapidly than if no operation  had  been done; the increased  action
set up in  the part during the healing process appearing to give augmented force
to the reproductive  energy of  the cancerous growths.  In some cases it even
returns in the cicatrix  before  cicatrization  is  completed, the ulcerated surface
then assuming the ordinary character of the cancerous ulcer.  In other cases
some weeks or  months after the cicatrix is fully formed, it assumes a  dusky red
or purplish tinge, becoming hard, stony, and nodulated at points; these nodules
being round or oval, often very numerous, and varying in size from a pin's head
to a pigeon's egg, studding the whole length  and breadth of the cicatrix, and
at last running into true cancerous ulceration.   Under such circumstances  as
these the only  hope of prolonging the patient's life lies in the speedy excision
of the whole of  the diseased structures, provided there be no deep affection of
the glands, or evidence of internal secondary deposit.  But if the axillary glands
be much enlarged, either alone or together, with recurrent disease in the cicatrix,
or if there be any sign of internal cancer, further operations will  be improper. 
764
DISEASES  OF  THE  BREAST.
                  AMPUTATION  OF THE BREAST.

  The operation for the removal of a breast, whether affected with cancer or
other disease, may be performed in the following way:—The patient should lie
upon  a table, with the  arm hanging over the side, and held by an assistant.
If the tumor be  large, and the  loss of blood a matter of much consequence,
another assistant should compressJlie subclavian artery on the first rib.  If the
veins about the part be much  dilated, measures  should  be taken to  arrest tho
flow of blood from them, as it may sometimes be  dangerously profuse; indeed,
South relates the case of a patient who died from  this  cause, during the opera-
tion.   An  oblique elliptical incision, of sufficient length, should then be made,
first below, and next above the nipple, so as  to include a sufficient quantity of
integument.   The  dissection  should then be  rapidly  carried down, by a few
strokes of  the scalpel, to the pectoral muscle, and the breast removed from the
cellular bed in which it lies.  Some surgeons  extirpate the breast by a perpen-
dicular, others by a transverse incision.  I think  that  an  oblique  incision fol-
lowing the course of the fibres of the great  pectoral is most  convenient,  as it
enables the surgeon, if necessary, to  extend the  cut  into  the axilla for the
removal of enlarged glands, and  after cicatrization, allows of the movements of
the arm without undue traction.   After the removal of the diseased breast, it
and the tumor, as well as the whole interior  of the wound, must be carefully
examined, in order to ascertain that no slices  of morbid tissue have been left
behind; if so, they  must be freely cut out, and if, as  sometimes happens, the
growth is rather firmly adherent  to the pectoral muscle, or subjacent structures,
portions of these must also be removed.   Should it be  found that there are any
enlarged glands in  the axilla, they may be extirpated, either by extending the
wound upwards  in this region, or by making a separate  incision into the axilla,
and carefully dissecting them out.  In  doing  this, the edge and  point of the
scalpel should be very carefully used, and the glands rather teased out with the
handle of  the knife and fingers, so as to  avoid the risk  of hemorrhage, which is
apt to be  troublesome  in  this situation.   The  extirpation of enlarged axillary
glands is the most troublesome part of  operations on the breast, as they  often
extend much  higher into the  axilla, and under the edge  of the pectoral  than
would at  first appear.  When exposed,  they may be seized with a double  hook
or artery-forceps well drawn down, and then enucleated  as far as practicable with
the fingers, aided by a few cautious touches with  the edge of the knife.  The
less the point is used deep in the axilla, the better for  the patient.  Should the
glandular  mass  extend high  up, coming into  close relation with  the axillary
vessels, it would not be prudent to attempt its complete extirpation with the
knife, but having been separated as  far as practicable in  the way already men-
tioned, it should be well drawn down, and then tied tightly as high as possible
with a piece of  whipcord, all  that portion below the noose  being then cut off.
In this way the two great dangers that attend  the  extirpation of tumors in this
locality, that  are deeply situated and  out of sight, viz., hemorrhage and the
entry of air into dilated veins, may be avoided, and the ligature being applied
beyond the diseased mass, that which remains of it will slough away when the
thread separates.  During the operation itself all hemorrhage may  be controlled
by pressure on the subclavian above the clavicle.
   It occasionally happens that  tumors  are  met with in the axilla as a primary
disease, unconnected with any malignant or other  morbid action, either in the
upper extremity or  the breast.   Such masses  may either be  of a  strumous or
 cancerous nature, and  require extirpation.  When strumous, they  are readily
 enough enucleated; but when  cancerous, they become so  widely and deeply
 adherent  that their removal cannot  be undertaken without much danger.  In 
TAPPING THE  CHEST.
765
such dissections as  these, I have  had occasion to expose the axillary and sub-
scapular vessels to some extent.
  After any bleeding vessels  have been  ligatured, the incision through which
the breast was taken out may be brought together by a few points of suture, and
supported by a bandage, so as to prevent bagging of matter.  In many cases it
will unite by the first intention, for, owing  to the yielding  nature  of the parts
in this  situation, the lips  of  the cut come into very  good apposition, even
though a considerable mass has been removed.   By some it has been supposed
that relapse of cancer is less liable to take  place  if the wound unite by granu-
lation, than if it come together by more speedy union; of this, however, there
is at present no proof with which I am acquainted, though it is by no means
improbable  that the suppurative action  may eliminate  cancer-cells from  the
neighboring tissues.
  The  male breast, though very rarely the seat of disease, may occasionally
become  affected in  a somewhat  similar manner to the mammary gland in the
female;  being in some instances  hypertrophied, in others, the seat  of an abnor-
mal secretion of milk, and, in other cases, affected by the formation of cysts,
encysted, and scirrhous tumors.   These  growths require removal  by the same
kind of  operative procedure that is adopted when they affect the female breast,
though of a less extensive character.
                       TAPPING  THE  CHEST.

  Paracentesis thoracis may best be done with an ordinary trochar of moderate
size, and  the  most convenient spot for the puncture is usually the side of the
chest in  the fifth intercostal space, at the line of insertion of the  serratus
magnus.  The skin having  been  punctured with a scalpel, the trochar should
be pushed over the upper margin of the sixth rib into the middle of the space,
so as to avoid the intercostal artery, and must then be thrust sharply and boldly

                                 Fig. 304.
into the pleural sac, so as to make sure of perforating any false membranes that
may line its interior, and which, if the instrument he pushed slowly on, might
be carried before it, and thus prevent the escape of the fluid.  Air may in this
operation  gain entrance  into the  pleura, and, decomposing the pus, become a
source of irritation.   In order to obviate this inconvenience, the instrument
figured in the accompanying sketch (fig.  304) will be found useful; the trochar
having been introduced, and the stop-cock shut, as the piston-stylet is withdrawn
a bladder is attached to the end of the canula, and when this has been filled the
stop-cock is again closed, the bladder emptied and reapplied (fig. 305).  In this
way as much of the fluid as is desired may be removed.   After  the withdrawal
of the canula, the puncture is closed by a pad of lint, strapping, and bandage.
After  tapping, the  lung will either  expand, and fill up the  cavity previously
occupied by the  fluid, or if adhesions prevent this, the  thoracic parietes will
gradually collapse.
  In hydrops pericardii, the pericardium may be tapped  by making an incision 
766
HERNIA.
Fig. 305.
through the  skin  and cellular tissue in the fifth intercostal  space, and then
puncturing the membrane with a fine trochar at that point where palpation and
auscultation have  indicated the greatest amount of fluid.   The trochar should
be passed obliquely.
DISEASES  OF  THE   ABDOMEN.
                         CHAPTER  LIII.

                               HERNIA.

  By hernia, in its widest  sense, is meant the displacement of any organ from
the cavity in which it is naturally contained, by  being  protruded through an
abnormal or accidental opening in its walls; when, however, it escapes  through
one of the  natural outlets  of the part, it is not considered hernial.  Thus, the
protrusion of the brain through an  aperture in  the cranium, or of the lung
through one in  the thoracic walls, or of a portion of  intestine through the
abdominal parietes, is termed a hernia  of these organs;  but the descent of the
bowel through the anus does not come under this designation.  Here, however,
we have only to  consider the  hernial protrusions that occur in the abdomen —
the common situation  of this disease.
  A hernia  may occur at  almost any part of the abdominal  wall, though it is
far more liable to do so in some situations than in others, being commonly met
with at those points where the muscular and tendinous structures are weakened
to allow the passage of the spermatic cord in the male,  and of the round liga-
ment in the female; or for the transmission of the large vessels  to the lower
extremity;  hence the  inguinal and crural canals  are the common situations of
this disease.  It may, however, occur in various other situations, as at the um-
bilicus, the  thyroid foramen, the sciatic notch, in  the  vagina, the  perineum,
through the muscular portions of the abdominal wall, the diaphragm, etc.
  In whatever situation it occurs, a hernia is composed of a sac and its  contents.
The sac is the prolongation of that portion of the perineum which overlies and
corresponds  to the  aperture  through which the  hernia  protrudes, and is in all 
CONTENTS OF  SAC.
767
cases composed of a neck and body.  The neck is usually narrowed, though in
some old herniae it becomes wide and expanded: it is commonly short, consfstino-
indeed of a sudden constriction of the sac in this situation, as happens in many
forms of femoral hernia; but in other cases it is  elongated, narrowed, and thick-
ened, and even vascular in its structure.  The neck of the hernial sac  usually
becomes greatly thickened, and of an opaque color, in consequence of the depo-
sition of plastic matter in or upon it, from the irritation to which it has been
subjected by the  pressure of the  hernial tumor or the truss, from the incorpo-
ration of the subserous  cellular tissue that lies external to it, or by the pucker-
ing together of its folds, which have been compressed by  the aperture in which
it lies.  The body of the sac varies greatly in shape and size, being usually glo-
bular or pyriform, sometimes elongated and  cylindrical;  it may vary from the
size of a cherry to a tumor  as large as the head.    When recent, it is  usually
thin and transparent, though in some cases it becomes greatly thickened, having
arborescent vessels ramifying on it, and being  almost laminated in structure;
this is especially the case in old femoral herniae.  In other instances, however,
it becomes thinned  and atrophied as the tumor expands, so that the contents
become visible through it.   This is especially the case in old umbilical herniae,
in which I have seen it as thin as the finest gold-beater's skin.  In some  cases
the hernial  sac undergoes degeneration, becoming  converted  into a fibrous or
even calcareous layer.
   The sac, though usually forming a perfect inclosure to the hernial  contents,
occasionally constitutes but a partial  investment to them, more particularly in
such  organs  as the  ccecum or bladder, which are naturally partially uncovered
by the peritoneum.  In other instances, again, it may be ruptured, or altogether
absent; more rarely a double hernial sac is met with, one being protruded into
or placed behind  the other.   There are instances of three sacs occurring toge-
ther, and Sir A. Cooper even relates a case  in which six were met with in the
same person.
   The abdominal parietes outside the sac undergo important changes.  The  aper-
ture through which the hernia protrudes usually becomes  circular; after a  time,
indurated and rounded  at the edge, and considerably enlarged;  when  situated
in the movable portions of the  abdominal wall, as  in the inguinal  regions, it
becomes displaced in old herniae, being dragged down by  the weight of the pro-
trusion, usually towards the mesial line.  The subserous  cellular tissue always
becomes greatly thickened,  often indurated and fatty, so  as to constitute one of
the densest  investments of the sac, and, in some old cases of hernia, closely to
resemble omentum.  The more superficial structures, such as the integument
and fascia, become  much elongated and stretched;  often tense, but not unfre-
quently hanging  in folds; they are usually thinned, but if a truss has been long
worn, they become  thickened and condensed by the pressure of the pad.
   The contents of  the  sac vary greatly, every viscus except the  pancreas and
stomach  having been  found  in hernial tumors.  Most frequently a portion of
the small intestine, more particularly  of the ileum, is protruded, constituting
the form of hernia  called enterocele.  The quantity  of intestine within  the sac
may vary from a  small section of the calibre  of the gut, the whole diameter not
being  included, to  a coil several feet in  length, with its attached mesentery.
After a portion of the intestine has once descended, the protruded part tends to
increase in quantity, until, as in some large and old herniae, the greater  portion
has been known to lie in the  sac.   The large intestine is rarely found in a her-
nia, though  the ccecum is occasionally met with.  When intestine has been long
protruded, it usually becomes thickened in its  coats, and narrowed, greyish on
the surface, and  more or less deranged in  its  functions.  The corresponding
mesentery becomes  thickened, hypertrophied, and vascular.
   Omentum is often found in hernial  sacs, together with intestine, but is not
unfrequently met with alone, constituting the disease called epiplocele.   After 
768
HERNIA.
having been protruded  for some time  it  becomes thickened, brawny, and
laminated, losing its  ordinary cellulo-adipose  texture, and becoming indurated.
Its veins usually assume  a somewhat varicose  condition, and the  mass of
omentum acquires  a  triangular shape, the apex being upwards at the abdo-
minal aperture, and the base below broad and expanded.   In some  cases it can
be unfolded, in others it is matted together into a cylindrical mass.  Occasion-
ally apertures form in it, through  which a coil of intestine may protrude, thus
becoming secondarily strangulated within the  sac.  In other instances cysts are
met with  in it containing fluid;  or  into which  the intestine may even slip.
When intestine and  omentum together are  found in a hernia, the disease  is
termed an entero-epiplocele, and under these circumstances the omentum usually
descends before, and occasionally envelops  the intestine.  Besides these the
ordinary contents of  herniae, the  stomach, liver, spleen, sigmoid flexure of the
colon, bladder, uterus, and ovaries, have all been found in them.
   Adhesions commonly form within the sac in old standing cases.   These may
take place between the  contained  viscera merely, as between two coils of intes-
tine,  or between  these and the  omentum; or they may form between the wall
of  the sac  and its contents, either by broad  bands, or else by bridging  across
from  one  side to the other, and  enclosing a  portion of the viscera.  In recent
cases these adhesions are soft, and may readily be broken down; but when of
longer duration they are often very dense, and are especially firm about the neck
of  the sac.
   Besides the viscera,  the hernial sac always  contains a certain quantity of
fluid  secreted by and lubricating its interior.  In most cases this is in but small
                         quantity, but in some instances, when the sac is in-
         Fig. 306.         flamed, or the hernia strangulated, a very considerable
                         bulk of liquid  has  been  met with;  I have seen as
                         much as a  pint escape from a large  hernia in an old
                         man.  When abundant, it is generally of a brownish
                         color, though clear and transparent, and is met with in
                         largest  quantities in  inguinal herniae.   In some in-
                         stances  this fluid becomes  collected in a kind  of cyst
                         within the  sac formed  by the  omentum contracting
                         adhesions to its upper part, and leaving  space  below
                         for the fluid to collect, in which this  accumulates be-
                         tween the  omentum  above and the  wall of the sac
                         below;  this condition, represented in the annexed
                         figure (306), has been called hydrocele of the hernial
                         sac, and constitutes a somewhat rare  form of disease.
                         The fluid is often in considerable quantity; in a case
                         which I tapped some years ago, nearly three pints of
 dark brown liquid had thus accumulated, and were drawn off.
   If we limit the term hydrocele of the hernial sac to those cases in which there
 is a slow and gradual accumulation of fluid at the bottom  of an old hernial sac,
 which has been  cut off  from all  communication with the peritoneum either by
 the radical cure of the  hernia, or by the adhesion of intestine  or  omentum to
 the upper part and neck of the sac, it must be  considered a disease of unfrequent
 occurrence, and but few cases are recorded by surgical writers.   Mr. Curling, in
 his work on the Testis, states that during his connection with the London Hos-
 pital, he has seen only one case; and the only others with which I am acquainted,
 besides  one that occurred in my own practice, are two related by Pott, two by
 Pelletan, one by Boyer, and one by Lawrence.   This disease  must not be con-
 founded with the  accumulation of fluid, in whatever quantity, in  strangulated
 hernia, or in hernial sacs  that communicate with  the  peritoneal  cavity.  Its
 distinguishing feature is the accumulation of  fluid in a sac that has been cut off
 from all communication with the  cavity of the peritoneum.
 
CAUSES  OF  HERNIA.
769
  The symptoms of hernia, though varying considerably according to the con-
tents of the sac and  the condition in which  it  is placed, present in all cases
many points in common.  Thus there is an elongated or rounded tumor at one
of the usual abdominal  apertures, broader below than  above, where it is often
narrowed into a kind of neck; usually increasing in size if the patient stands,
holds his breath, coughs, or makes much muscular exertion.  It can be pushed
back into the abdomen on pressure, or goes back readily if the patient lies down,
but reappears when he stands up.   On coughing, a strong and distinct impulse
may be felt in it.
   When the hernia is altogether  intestinal, it is  usually smooth, gurgling when
pressed upon, and sometimes  tympanitic and rumbling.   It may be  returned into
the cavity  of the abdomen with a  distinct  slip and gurgle; it has a well-marked
impulse on coughing, and is usually accompanied  by various dyspeptic symptoms,
and often with a good deal of dragging uneasiness.
   The omental hernia is usually  soft and doughy, returning slowly on pressure
 into  the abdomen, feeling irregular on the surface, and having an ill-defined
 outline.  It occurs most  frequently on the left side, and is rare  in infants, in
 whom the  omentum is short. In  entero-epiplocele there is a combination of the
 two  conditions and their signs;  but these are usually so  uncertain, that  few
 surgeons care to predict before  opening the sac what the probable nature of the
 contents may be.
    Cecal hernia necessarily  only occurs on the right side.  It is a large, knobby,
 and  irregular tumor, irreducible, owing  to  the adhesions contracted by that
 portion of ccecum which is uncovered by peritoneum.   The peculiarity of these
 hernise consists in the sac being absent, or only  partial in the majority of cases,
 owin°- to the peritoneum stripping off as the gut descends.  When these herniae
 are  Large, and partially invested  by serous membrane,  a sac usually exists  at
 their  upper aspect, into which  a  portion  of  small  intestine  may fall, and
  which may in some  cases constitute  a second hernia lying above or before the
  coecal  one, which will be found situated at the posterior wall when  this hernial
  pouch is  opened.   Occasionally  the vermiform  appendix and the caput-coli
  are  found in  the  sac, but can rarely be  returned.  The rule of ccecal herniae
  only having a partial peritoneal investment, does not hold good in all cases; and
  instances  have occasionally  been  met in which this portion of intestine lay in a
  distinct sac.
    Hernia of the bladder or cystocele is of very  rare occurrence;  and, like that
  of the ccecum, is usually enclosed  in a partial peritoneal investment, though
  it is not necessarily so.  South states that there is a preparation at St. Thomas's
  Hospital, in which the fundus of the bladder, with its peritoneal covering, has
  passed into a distinct sac.  In some instances the cystocele is  accompanied  by
  an enterocele. These herniae are always  irreducible, and are attended by a good
  deal of difficulty in urinating, with varying tension, according to the quantity
  of fluid they contain; by  squeezing them,  urine may be forced out through
  the urethra, and fluctuation has been felt in them.  Urinary calculi have been
  formed in these tumors, and have been removed by incision through the scrotum,
  or have ulcerated out.
    The causes of hernia are  usually sufficiently well marked.   In some instances,
  the disease is congenital, arising from  preternatural patency of the abdominal
  apertures; in other cases, again, it occurs at a later period of life, in consequence
  of some forcible effort, as in lifting a heavy weight, jumping, coughing, strain-
  ing at stool, or in passing water through a tight stricture.  It is especially apt
  to occur from such causes as these in tall and delicate  people, more particularly
  in  those  who have  got a  natural  disposition  to weakness,  or  bulging of the
  groins   The displacement of the abdominal viscera by a gravid uterus, will also
  occasionally give  rise to the disease.  Hernia  is especially apt to occur from a
  combination of causes: thus,  if an aged person, one with a feeble organization,
           49 
770
HERNIA.
or whose abdominal apertures have been patent in consequence of rather sudden
emaciation, makes a violent effort, a hernial protrusion is very apt to occur.
  Amongst the most frequent predisposing causes of hernia are certainly sex,
age, and occupation.   Men  are  far more liable  to  this disease than women.
Thus, according to Malgaigne, in France one man in thirteen and one woman
in fifty-two, are the subjects of  hernia.  But, though  men are  more generally
liable to hernia than women, they are less so to certain forms  of the disease,
especially to the femoral and umbilical.   It is to the inguinal that  they are par-
ticularly subject,  although  old  women  very commonly suffer from  this form.
According to Mr.  Lawrence, out of 83,584 patients who applied to the City of
London  Truss Society, 67,798 were males, and  15,786 females;  for the inte-
resting statistical account of the  relative frequency of the different  kinds of rup-
ture, deduced from the foregoing figures, I would refer to Mr. Lawrence's most
excellent Treatise on Hernia, 5th ed. p. 11.
   Age  exercises  a  very material  influence upon the frequency  of hernia.
Malgaigne, who has carefully investigated this subject, finds that in infancy the
disease is sufficiently common, owing to the  prevalence of congenital hernia at
this period of life; and, that in the first year after birth hernia occurs in the
proportion of 1 in every 21  children.   It then goes on decreasing in frequency,
there being 1 in 29 at the second year; 1 in  37  at the third year; until, at the
thirteenth year, it has fallen to  1 in 77.  Shortly after this, its frequency
begins  to rise  again, and  then goes on progressively increasing until the close
of life; thus, at the 21st year,  there is  one case in 32; at the 28th year, 1 in
21; at the 35th, 1 in 17; at the 40th, 1 in 9; at 50, 1 in 6; from 60 to 70,1
in 4; and from 70 to 75,1 in 3.   In women,  hernia most frequently occurs from
the 20th to the 50th years.   Those occupations in which  the individual is  ex-
posed to violent muscular efforts, more particularly of an intermitting character,
predispose strongly to  the occurrence of hernia, and in these employments  the
 tendency to the  disease is  often greatly increased by the injurious  habit of
 wearing tight  girths or belts round the waist, which, by constricting the abdo-
 men, throw  the whole pressure of the abdominal contents upon the inguinal
 regions.
   The conditions in which  a hernia may be found, are very various, and entail
 corresponding differences in the result  and treatment of the affection.  When
 first formed, most herniae may be said to  be incomplete, being for a time retained
 within the orifice of the canal through which they eventually protrude;  when
 they have got altogether beyond  the  abdominal walls,  they are said to be
 complete, and this is the condition in which they are usually presented to the
 surgeon.
   A hernia is commonly at first  reducible, that is to say, it may readily be pushed
 back into the cavity of the  abdomen, protruding again when  the patient stands
 up, holds  his breath, or makes any exertion, and  having a distinct and forcible
 impulse on coughing.   Though  the hernial contents, in these cases, are reduced
 into the abdomen, the sac is not;  it almost  immediately contracts adhesions to
 the cellular tissue, by which it  is  firmly fixed in  its  new situation, though in
 some particular cases, as we shall hereafter see,  it may be pushed  back.
    In the  treatment of a reducible  hernia, our object is by the  application of a
 proper truss, to retain the  protrusion within the cavity of the abdomen.  In
 order to do  this, the  patient must be  provided with a proper kind of truss,
 adapted to the particular nature of the hernia.   Amongst  the best are, I think,
 Salmon and  Odys',  or Tod's,  for  inguinal  hernia, and the Mocmain for the
 femoral.   In umbilical  and ventral ruptures, an elastic pad and belt  may most
 conveniently be used.   In selecting these trusses, care should be taken that the
 spring is of proper strength, adapted  to the size and power of the individual,
 and that it be  properly shaped, so that it does not  touch  any part of the abdo-
 minal wall, but merely bears upon  the points of pressure and counter-pressure. 
RADICAL CURE  OF HERNIA.
771
The pad should be convex, and firmly stuffed, and of sufficient size to press not
only upon the external aperture, but upon the whole length of the canal.  Be-
fore applying the truss, the hernia must be reduced, by placing the patient in
the recumbent position, relaxing the muscles by bending the thigh upon the
abdomen, and pressing the tumor back in the proper direction; the truss should
then be put on, and be worn during the whole of the day; indeed, the patient
should never be allowed to stand without wearing it.  At night,  it may either
be left off altogether, or a lighter one applied.   In some cases the  skin becomes
irritated  by the pressure of the pad; under these  circumstances, an elastic air-
cushion may be  used, or  the  parts subjected to pressure may be well washed
with spirit lotion.   The truss may be known to fit  by testing it in  the following
way.   The patient should be made to sit down on the edge of a chair, and then
extending his legs, opening them widely, and bending the body forwards, cough
several times.   If the hernia do not slip down behind the pad on  this trial, we
may be sure that the truss is an efficient one, and will keep the rupture up under
all ordinary circumstances.
  Radical cure of Hernia.—Various means have been devised in order to effect
the radical cure of a reducible hernia.   The only plan that is at the same time
perfectly safe and permanently successful is by the compression of a well-made
truss.  In this way it not  unfrequently happens that the hernias of infants be-
come radically cured; the  same result however seldom occurs at a more advanced
period of life.  In  order  that compression should succeed  in this way, it  is
necessary that it should not only  be applied to the external aperture through
which the rupture escapes, but to  the whole of the canal.   It must also be con-
tinued for a very considerable time, for at  least a year or two, and care should
be taken that during the treatment the rupture is not allowed to descend; every
time it comes down, any good that may have been derived is necessarily done
away with, and the treatment has to begin, as it were, anew.   After the cure is
supposed to have been effected in  this way,  the application of the truss must be
continued for a very considerable length of  time, lest by any unfortunate move-
ment the rupture descend again.
  The operations that have been devised  for the  radical  cure of hernia are all
founded  on one of two principles, viz.,  the excitation of such an amount of
peritonitis in the sac, or its neck,  as to secure its  obliteration, or the plugging
of the hernial aperture by invagination of the integumental tissues.
  If the accomplishment of these conditions would  always prevent the recur-
rence of the rupture, the  radical  cure  might frequently be undertaken.  But
it is impossible to look upon the  agglutination  of the walls of the sac, or the
closure of the abdominal aperture, as the sole  conditions required.  To accom-
plish the radical cure, it would be necessary in many cases to effect changes in
the shape  and  connections of the abdominal  contents, to alter the size of the
abdominal cavity, and  indeed to modify in  various ways many conditions inde-
pendently of those immediately connected with the hernial protrusion.   Many
of the means of radical cure, by which  obliteration of the interior of the sac
or its neck is sought to be effected by the application of sutures or  ligatures, the
introduction of caustics,  its excision,  scarification, puncture, or injection with
tincture of iodine, are attended with so much  danger from  peritonitis, and so
seldom by any good results, that their  consideration need  not detain us here.
The same remark applies  to the attempt to obliterate the  canal through which
the hernia  protrudes, by invaginating and stitching into it a portion of the
neighboring integument, which operation, though much cried up,  especially by
some  of the continental surgeons, who have extensively practised it, has been
found  very seldom  to  be attended by any  permanently beneficial  results; the
invaginated portion of tissue speedily yielding to  the outward pressure of the
viscera, allowing recurrence of the hernia to take place.   Of late years, how-
ever, Wiitzer, of Bonn, has adopted a plan of radically curing reducible inguinal 
772
HERNIA.
herniae, which  combines the two principles on which the older operations were
founded, viz., the  agglutination of the  neck of the hernial sac  by the exci-
tation of inflammation in it, and the closure of the inguinal canal by the inva-
gination of the scrotum; and he carries  out these objects in a safer  and more
successful manner than by any of the methods previously employed.   This plan
of treatment consists in introducing a plug of the scrotum  into the inguinal
canal, and fixing it there by exciting adhesive  inflammation in the neck of the
sac.   The details of the operation are as follow:  The patient lying on his back,
and the hernia being reduced, the surgeon pushes  his  index-finger  up the  in-
guinal canal as high as the internal ring, carrying before it a cone of the scrotal
tissues; a box-wood  hollow cylinder, about four inches long (fig. 307 C), well

                                  Fig. 307.


           /A        B
G
c
oiled, is then pushed up as the finger is withdrawn, so as to occupy its place in
the inguinal canal.  Along  the interior of this  cylinder a flexible gilt-steel
needle (A), fixed in a movable handle, is then pushed, so as to traverse the inva-
ginated scrotum, the  hernial sac, and the  anterior abdominal  wall, through
which its point is caused to protrude.   A concave  box-wood case (B) is then
passed over  the projecting point of the needle, and fixed by the other end by a
screw apparatus to the cylinder (C), so as to compress the inclosed tissues. The
apparatus  so fixed is left in situ for  six or eight days, when some discharge
being established, it is withdrawn, and the invaginated scrotal plug  supported
by lint introduced up its interior, and by a spica bandage.  The patient is kept
quiet for a fortnight longer, when he is allowed to move about, wearing a light
truss for three or four months.
  This method of treatment is easy of execution, and  appears to be more suc-
cessful than any that has preceded it.   And yet it is open to the objections that
attend all plans for the radical cure of hernia, viz., the possible excitation  of
a dangerous amount of peritonitis, and the want of adhesion between the lower
part of the scrotal plug and the corresponding part of  the inguinal canal and
ring.   It should of course not be employed indiscriminately, but only in those
cases in which, from the laborious nature  of the employment and the otherwise
good health of the patient, the radical cure may fairly be attempted.
  Irreducible herniae  are usually of old date, and  large size.   They generally
contain a considerable  quantity of thickened omentum, as well as intestine and
mesentery.   In many instances, a rupture of this  kind is partly reducible, the
greater portion remaining behind.  It is usually  the gut which slips up, and
the omentum that  cannot be returned.   The  irreducibility of  a rupture may
either be owing to its shape, to the existencejof adhesions, or be dependent on
its very nature.   If the sac  become  the  seat  of  an hour-glass  contraction, ot
its  neck become elongated and  narrowed, the hernial contents may continue
permanently protruding.  So also the  expanded condition of the lower part of
the omentum, and the narrowing of its neck  may prevent a return of the rup-
ture.   The  existence of adhesions, either between  the  sac and  its  contents, or
between protruded intestine and  omentum, will commonly render a hernia irre-
ducible; and  most frequently these are associated with changes in  the shape 
INFLAMED AND INCARCERATED IRREDUCIBLE HERNIA.       773
of the sac or the omentum.   Herniae of the ccecum and  bladder can never be
returned, on account of the  anatomical conditions, to which  reference has
already been made.
   An irreducible hernia is usually a source of great  inconvenience;  it has a
tendency to increase if left to itself, until at last it may contain, as in some ex-
treme cases it has been found to do, the greater portion of the abdominal viscera,
forming an enormous tumor, inconvenient by its size and weight, in which the
penis and scrotum are buried.  Even when the irreducible hernia is of small
size, it gives rise to a sensation of weakness  in  the part, with dragging pains,
and is very frequently accompanied by colicky sensations and dyspeptic derange-
ments.  The patient also, under these circumstances, is  in a state of considerable
danger, lest the rupture becomes strangulated by violent efforts, or injured and
inflamed by blows.   For  these reasons, it is  necessary not  only to protect a
rupture of this  kind from  external  violence,  but to  endeavor  to prevent its
increase in size.  This may best be  done by letting the patient wear a truss
with  a large concave pad, which supports and  protects it provided  the rupture
be not of too  great a size  for the application  of such an  instrument.   If its
magnitude be very considerable, it must be supported by means of a suspensory
bandage.   Mr. Bransby Cooper has  recommended  that an  attempt should be
made to convert the irreducible into a reducible hernia, by keeping the  patient
in bed for several weeks, on low diet,, with  the continued application  of ice to
 the tumor; and if it contain  much  omentum, giving small  doses of  blue pill
and tartar emetic, so as to promote the absorption of the fat.   This plan, which
 appears to have answered well in some cases, certainly deserves a further trial.
   The occurrence of inflammation in an irreducible hernia is a  serious compli-
 cation, and one that simulates strangulation very closely.   When this complica-
 tion occurs the part becomes swollen, hot, tender, and painful; there is not much
 tension in  the tumor which  is seldom  increased  beyond its usual magnitude;
 there is a good deal of pyrexia, and symptoms of peritonitis spreading from the
 vicinity of the inflamed rupture set in.  In  some cases there is vomiting, but it
 is not constant, and never feculent, occurring generally early in the disease, and
 consisting principally of the contents of the stomach, being apparently an  effort
 of nature to get rid of an indigestible meal.   If there is constipation, as usually
 happens in all cases of peritonitis, it is not complete, flatus occasionally passing
 per anum, together with a small quantity of fluid faeces.  It is of importance in
 these cases to observe that the inflammation commences in  the body of the sac,
 and  extends  into those parts of the abdomen that are contiguous to its neck;
 the stomach  and intestinal derangements  being  secondary to  this condition.
 The  treatment of  an irreducible  hernia  must be directed  to  the  peritonitis
 which  attends it; the application of leeches  to the sac and its neck, the free
 administration of calomel  and opium, the employment of enemata, with  strict
 antiphlogistic  regimen and rest, will usually speedily subdue all inflammatory
 action.
    An irreducible hernia occasionally becomes obstructed, then constituting the
 condition  termed incarcerated hernia.  This condition principally occurs in old
 people, by the accumulation of flatus, or of undigested matters, such as cherry
 stones or mustard seeds, in an angle of the gut.   In these cases there is con-
 stipation,  with eructation, and  perhaps occasional vomiting.   There  may be
 some degree of pain, weight, or  uneasiness about the  tumor,  but there is no
 tension in  it or its neck, and the symptoms  altogether are  of a chronic and
 subacute character.  The treatment  of such  a case  as  this  should  consist in
 the administration  of a good purgative  injection;  the compound  colocynth
 enema  is the best, thrown up as high as possible by means of a long tube.  Ice
 may then be applied to the tumor for about half an hour, and then the taxis, as
 will  immediately be described, may be used  under chloroform.  The ice may
 be omitted in those cases in which, on handling the tumor, gurgling can readily 
774
STRANGULATED HERNIA.
be felt; but  the  taxis should always be used, as by it the incarcerated gut may
be partially emptied of its contents; or if any additional protrusion should have
happened to have slipped down, this maybe returned.  After these means have
been  employed, an active purgative, either of calomel or croton  oil and colo-
cynth  should be administered, and if any inflammation ensue,  this must  be
treated as already described.

                      STRANGULATED HERNIA.

   A hernia is said to be  strangulated when a portion of gut or omentum that
is protruded is so tightly constricted that it cannot be returned into the abdo-
men ; having its functions arrested, and if not relieved speedily, running into
gangrene.  This  condition  may occur  at all periods of life, being met with in
infants a few days old, and in centenarians.  It commonly arises from a sudden
violent  effort by which a fresh  portion of intestine is forcibly protruded  into a
previously existing hernia, which it distends to such a degree  as to produce
this strangulation.   But  though old herniae are more subject to this condition
than recent ones, it may occur at the very first formation of a hernial swelling,
the gut becoming strangled as it is protruded.  There are, therefore, two dis-
tinct kinds of strangulation.   One which  may be  said to be of a passive kind,
chiefly occurring in elderly people, the subjects  of old and perhaps irreducible
hernias, which in  consequence of some accidental circumstance become distended
by the descent of a larger portion  of intestine than usual, and this, undergoing
constriction and compression at  the neck of the sac, gradually becomes strangu-
lated.   The other kind of strangulation is most frequent in younger individuals;
in it the symptoms are  of a more active character, the bowel becoming pro-
truded in consequence of violent exertion, and undergoing rapid strangulation,
the tension of the parts  not  having been lessened by the previous long exist-
ence  of an irreducible hernia.
   The  mechanism of strangulation has  been attributed either to a spasmodic
action of  the walls of the aperture through which the hernia protrudes, or else
may be  considered as  dependent  on changes  taking place  in the protruded
parts, subsequent to and occasioned by their constriction by the tissues  exter-
nal to them.   The strangulation cannot, I think, with justice, ever be regarded
as of a spasmodic character, the aperture in the abdominal wall, through  which
the  hernia escapes, being tendinous, or fibrous, and certainly not in any way
contractile, though the action of the abdominal muscles may  undoubtedly in-
crease the tension of its sides;  the continued and permanent character of this
strangulation, when once it has taken place, would also  discountenance this
opinion ;  those forms  of hernia, indeed, as the ventral,  which occur in purely
muscular structures, being very rarely  strangulated, and when they are so, the
constriction being generally occasioned by the formation of dense adventitious
bands upon or within the sac, and not by any muscular agency.
   Strangulation  certainly appears in all cases to be the result  of  congestion of
the protruded  parts, induced by the constriction to which they are subjected;
the mechanism being as follows: — A knuckle  of  intestine, or bit of omentum
is suddenly protruded during an  effort of some kind.  This  immediately be-
comes compressed  by  the sides of the  narrow aperture  through which  it has
escaped;  the return of its venous  blood is consequently interfered with, and
swelling and oedema rapidly ensue, together with stagnation of the blood in it.
If the constriction be excessively tight, the walls  of the ring being very hard
and sharp, the part that is so strangulated maybe deprived of its vitality  in the
course of a few hours.   If the  strangulation be less severe, the congestion will
run  into  inflammation,  the  changes characteristic of this condition speedily
supervening.   In proportion as the congestion augments, and the inflammation 
STRANGULATION. — SEAT  OF STRICTURE.       775
comes on, the  return  of the protruded  parts is necessarily rendered more diffi-
cult by the increase of their swelling.
  The stricture is most  commonly situated outside the neck  of the sac in  the
tendinous or ligamentous  structures surround-
ing it;  not unfrequently in  the  altered  and           Fig. 308.
thickened subserous  cellular tissue.   In other
cases  again, and indeed with great frequency, it
is met with in the neck of the  sac itself  (fig.
308), which is narrowed, elongated, and tubular,
or constricted  by bands that  are  incorporated
with  it.  More  rarely it exists in the body of the
 sac, which may  have  assumed an hour-glass
 shape.   In some cases it would appear as if this
 particular shape were  owing to an old hernia
 having been pushed down by a recent one above
 it.  The stricture is sometimes, though by no
 means  frequently met with  inside the sac, con-
 sisting of bands of adhesions stretching across
 this, or of the indurated edge  of an aperture of
 the omentum through which a portion of the gut
 has slipped.
    The changes induced in the strangulated parts result from the pressure of the
 stricture and  the consequent interference with the circulation through them.
 If the strangulation is acute, that portion of intestine which lies immediately
 under  the stricture will be seen to be nipped or marked by a deep sulcus, which
 is occasioned  partly by the  pressure to which it has been subjected, and partly
 by the swelling up of the congested tissues beyond it.   The changes that take
  place in the protruded  intestine  rapidly increase in proportion to the length of
  the continuance of the strangulation.   The tightness of the stricture  and the
  acuteness of the strangulation  have, however, more to  do with these  changes
  than even the time that it has lasted.   I have seen the bowel so tightly nipped
  that, though  the strangulation had only existed eight hours when  the ope-
  ration was performed,  the vitality was lost in the part  constricted (fig. 307);
  and in other cases I have known the strangulation to have lasted for five or six
  days before the operation was performed, and yet the part recover itself.
    The first change  that takes place in  the protruded parts in a case of strangu-
  lated  hernia  is their congestion; this rapidly  ruus  on to inflammation, and
  speedily terminates in gangrene.   The protruded bowel becomes, at first, of a
  claret, maroon, or purplish-brown color, sometimes ecchymosed on the surface,
  with  thickening  and  stiffening of its coats, owing to  effusion into  their sub-
  stance ; some liquid is also usually poured out into its interior.  In this stage,
  that of congestion,  the omentum will  also be found with its veins  a  good deal
  congested.   When  inflammation has set in, the  bowel preserves the same color
  as in  the congested condition, but usually becomes coated here and there with
  flakes of lymph, which give  it a rough and villous look; the omentum  has a
  somewhat rosy tinge, and there is usually a good deal of reddish fluid poured
  out into the sac.   When gangrene occurs, the bowel loses its  lustre and polish,
  becoming of an ashy grey, or dull black  color, soft and somewhat lacerable, so
  that its coats readily separate  from one  another; the  serous membrane espe-
  cially peeling off.  The omentum is dark purplish, or of a kind of dull yellowish-
  grey, and there is usually a considerable quantity of dark, turbid  serum m the
  sac, the whole contents of which are extremely offensive.   Most usually when
  gangrene occurs in a strangulated rupture,  inflammation  of the  sac and  its
  coverings takes place, accompanied, after a time, by a reddish-blue or congested
  appearance  and some  tenderness on pressure, and if the part is left unreduced,
  eventually emphysematous crackling.  If the case is left without being relieved, 
776
STRANGULATED HERNIA.
gangrene of the skin will at last take place, the sac  giving way and the  fa?cal
matters being discharged through the softened and disintegrated tissues.  Under
such circumstances  as  these, which, however, are very rarely met with at  the
present day, the patient usually eventually dies of low peritonitis by extension
of the  inflammation to the serous membrane.  No effusion, however, of  feculent
matter will take place into the  peritoneal cavity even under  such unfavorable
conditions;  the portion of  bowel immediately within the stricture becoming
adherent by plastic matter to this on its internal surface, and thus the escape of
any extravasation into the cavity of the abdomen being prevented.  It  does not
always follow that there is any external evidence of the occurrence of gangrene
within the sac; and the bowel is frequently nipped to such an extent as to pre-
vent its regaining its vitality without any unusual condition being presented
until the sac is actually laid open and the intestine examined.
   In  the more advanced cases of  strangulated hernia, the peritoneum always
becomes inflamed, usually to a considerable extent, the disease affecting  a diffuse
form, accompanied by the effusion of turbid serum,  often of a very acrid and
irritating character,  and mixed with flakes  of lymph, sometimes  to  such  an
extent as to give it a truly  puriform  appearance.  This glutinous lymph mats
together contiguous coils of intestine, often appearing to be smeared over them
like so much melted butter.
   The symptoms  of strangulation  are  of two  kinds: 1st, as they affect  the
tumor; and  2d, as they influence the constitution generally.
   1st. The tumor, if the hernia be an old one, will be found  increased in size,
or it  may appear for the  first time when strangulated.   It  will  generally be
found  to  be hard, tense, and rounded, more  particularly if it be an entrocele.
When  the  hernia is  in a  great  measure omental, it is,  however, not unfre-
quently soft  and doughy,  though  strangulated.  It seldom  increases in size
after strangulation  has occurred, as no fresh protrusion can  take  place below
the stricture, but I have known it to be greatly augmented  in bulk after  the
strangulation had existed for  some hours, by the effusion of serum into the  sac.
If the hernia have previously been reducible, it can no longer be put back,  and
there is no impulse in it, or increase in its  size on coughing, the stricture pre-
venting the transmission of  the shock  to the contents of the tumor; and in
this way, as pointed out by Mr. Luke,  the  situation of the  constriction may
sometimes be ascertained by observing at what point the impulse ceases.
   2d.  So soon as the strangulation has  occurred,  the patient becomes uneasy
and restless.   If the  constriction be of an active character, he will be  seized
with acute  pain  in the part, which speedily  extends  to the contiguous portion
of the abdomen, assuming the characters of peritoneal inflammation.   The first
thing  that happens when intestine is strangulated, whether a large coil be con-
stricted, or a small portion  only of the  diameter of the gut  be nipped, is an
arrest of the  peristaltic  movement  of the  part implicated, the occurrence of
obstruction to  the onward course of  the intestinal  contents, followed by consti-
pation, vomiting, and colicky pains.  The constipation is always complete, nei-
ther feces nor flatus passing  through; the bowels may sometimes act once after
the strangulation has occurred from that portion which lies  below the seat of
constriction, but they cannot, of course,  empty themselves thoroughly, or from
above the strangled part.  Vomiting usually sets in early, and is often  of a very
severe and continuous character, with much retching and straining; at  first  con-
sisting of the contents of the stomach, with some bilious matters, but afterwards
becoming feculent, or stercoraceous,  owing to inverted peristaltic action extend-
 ing as far down as the constricted part of  the gut. These symptoms are attended
by colicky and dragging pains about the  navel.  They are more severe in their
 character when the strangulation is acute and the hernia is intestinal, than when
it is passive, and the rupture omental.   They occur  equally in the incomplete
as in  the complete forms of the disease; indeed, it  not  unfrequently happens 
DIAGNOSIS  OF  STRANGULATED HERNIA.        777
that  the hernial  tumor may be so small as to have  escaped  observation; the
occurrence of the above symptoms being  the  first indication of the  probable
nature of  the mischief.  Hence, it is well always to  examine for hernia when
called  to  a patient suddenly seized  with constipation, vomiting, and colicky
pains, even if told that no tumor exists.
   After the strangulation  has existed for some  time, the inflammation that
occurs in the  sac extends to the contiguous peritoneum, accompanied by the
ordinary signs of peritonitis, such as  tension of the abdominal muscles, tender-
ness, with lancinating pains  about the abdomen, and tympanitis.   The patient
lies  on  his back with the  knees drawn up, has a small,  hard,  quick,  and
perhaps intermittent  pulse, a dry tongue, which  speedily becomes  brown, and
a pale, anxious, and dragged countenance, with a good deal of heat of skin, and
inflammatory fever.  In  some  cases, this is  of a  sthenic  type, but, in the
majority  of instances,  especially in  feeble subjects,  it assumes the  irritative
form.   When gangrene of the rupture takes place, hiccup  usually comes on,
with sudden cessation  of pain in the tumor, an intermittent pulse, cold sweats,
 pallor, anxiety, rapid sinking of the vital powers, usually with slight delirium,
 and speedy death.
   The symptoms just given are those that we usually meet with in strangulated
 hernia.   They may, however, be modified in some important  respects.
   1st.  There  may  be little  or  no tension in a strangulated  hernia, the  tumor
 continuing soft and  lax; this is especially the  case when the hernia contains
 omentum, and  in congenital  herniae when strangulated.   It may also occur in
 the case of double herniae  on  the same side, in consequence of the  outer sac
 being empty, or merely filled with serum, and the posterior one being protruded
 against this and strangulated; but its tension being masked by the  lax state of
 the outer one.
   2d. Vomiting sometimes does not take place from  first to last, there being at
 most a little retching;  at other times the patient vomits once  or twice, and then
 there is no recurrence of this symptom  so long as he remains quiet.
   3d.  Extensive peritonitis with  copious effusion of a  puriform liquid  may
 occur without any  pain, and with but little tenderness; the  anxiety of counte-
 nance and sharpness  of pulse being the only symptoms that  lead to a  suspicion
 of its existence.
   4th. Death  may result from  exhaustion consequent on vomiting  and peri-
 tonitis, without any sign of gangrene in the constricted portion of intestine.
    Strangulated hernia requires to be diagnosed —
    1st. From  an obstructed  irreducible  hernia.  In  this there are  no acute
 symptoms, and  the rupture will generally be  found to be a large one  of old
 standing.  It  may become  somewhat tense and swollen, but is not  tender to
 the touch, and always presents  a certain degree of impulse on coughing.  There
 is no  sign of peritonitis.   There may be constipation,  but there is no vomiting,
 or if  there be any, it is simply  of a mucous and  bilious character, consisting of
 the contents of the stomach.   The  speedy restoration of the intestinal action,
 by the treatment already indicated as  proper in these cases, will  remove any
 doubt as to the nature of the affection.
    2d. From an inflamed irreducible hernia.  Here there is great tenderness and
 pain  in  the tumor, with pyrexia, and some general  peritonitis, but there is no
 vomiting; or if the patient have vomited once or twice, he does not continue to
  do so with that degree of violence, or in the same quantity,  as he would if the
 peritonitis were the result of strangulation.  Then, again, the constipation is not
 absolute and entire, but flatus and liquid faeces will usually pass.    _  ^
    3d. From  general peritonitis conjoined with  hernia,  the  diagnosis is often
 extremely difficult, more  especially  if  the hernia be an irreducible  one.  In
 these cases, however, it will be observed that  the peritonitis may be most  intense
 at a  distance from the sac; that there  will be little or no vomiting, or if there 
778
STRANGULATED HERNIA.
be, that it is simply of mucus, and the contents  of the stomach;  and that the
constipation is by no means obstinate or insurmountable by ordinary means.
   4th. In  the  case  of double hernia, one tumor may be strangulated and the
other not, though  irreducible.   Under these  circumstances it may at first be a
little difficult to determine which  one is the  seat of constriction.  This, how-
ever, may be ascertained, as in a case that was lately under  my care at the
Hospital, by observing  greater tension and tenderness about the neck of the
strangulated, than of the unconstricted one.   Besides these various conditions
of hernia, which may be confounded with strangulation, there are other tumors
which may likewise be mistaken  for this disease, but these we shall have to
consider when  speaking of  the special forms of hernia.
   The  treatment of strangulated hernia, is one of  the most important subjects
in surgery   The object sought to be accomplished is the removal of the con-
striction  from  the  strangled hernial tumor.  This is  effected  either by the
reduction of its contents or the division of the stricture.  The reduction of the
hernia is effected by the employment of the taxis, by which is meant the various
manual  procedures employed in  putting the rupture back.  The taxis, when
properly performed, is seldom  attended by any serious consequences to the
patient.  I have never known  it followed by death, and out  of  293 cases of
hernia  reported by Mr.  Luke, as  having  been reduced by the  taxis in the
London Hospital, none died.  It  is not unfrequently  followed, however, by
rather a sharp  attack  of peritonitis, which  might  probably, in some  instances,
prove fatal; in one instance I have seen it followed  by very abundant hemor-
rhage from the bowel, probably owing to the  rupture of  some of the congested
 vessels  of  the  strangled  portion  of the  gut.  In using the taxis, great care
 should in all cases be employed, and no undue force should ever be had recourse
 to.  No good can ever be effected by violence, the  resistance of the ring cannot
 be  overcome  by forcible pressure, and a vast deal  of harm may be done by
 squeezing the tender and inflamed gut up against its edge, causing it to overlap,
 and thus  to be bruised or even  perhaps torn.  The taxis should not be pro-
 longed beyond  half an hour; if properly employed for this time,  the hernia, if
 reducible, will  probably go back.    If it be employed, as it is often very impro-
 perly, for  a lengthened period, and by several surgeons in succession, the pro-
 truded  part becomes  ecchymosed,  irritated, and disposed to inflammation, and
 the chances of recovery after a subsequent operation are much lessened.  When
 the parts are much  inflamed, the  taxis should be employed with great caution;
 and if it  have been fairly and fully used by another surgeon it is better not to
 repeat it.  When gangrene has  occured, it  should never be employed, as the
 putting back   of the  mortified  gut  into the abdomen  would be followed  by
 extravasation of faeces and fatal peritonitis.
    In  using the taxis, it should  be borne in mind that  there are two obstacles
 to  overcome;   the resistance of  the  parts around  the  ring, and the bulk  of
 the tumor. The first may be somewhat lessened by relaxing  the  abdominal
 muscles, and consequently diminishing the tension exercised upon the tendinous
 apertures  and  fasciae of the groin.  In  order to effect this, the patient should
 be placed in a proper position, the body being bent forwards, the thigh adducted,
 and semi-flexed upon the  abdomen; the  surgeon  may then,  by  employing
 steady pressure on the tumor, endeavor to squeeze out some of the flatus from
 the strangled  portion  of intestine, and thus  to effect its reduction.  In doing
 this, the neck  of the sac  should be steadied by  the fingers of the left hand;
 whilst,  with the right spread over the tumor, the surgeon endeavors to  push it
 backwards, using a kind of kneading motion, and sometimes in the first instance
 drawing it slightly downwards, so as to disentangle it from the neck of the sac.
 The direction  of the pressure is important;  it  should always be in the line of
 the descent of the tumor.  These  means may be employed as soon as the patient
 is  seen by the surgeon, when,  by steadily carrying on the taxis for a few 
           THE TAXIS IN  STRANGULATED  HERNIA.        779

minutes, he will  perhaps hear and feel a gurgling in the tumor, which will be
followed by its immediate reduction.   If the patient is thin, and the outline of
the aperture  through which  the hernia escapes, tolerably defined, I have suc-
ceeded in reducing the protrusion, after failure of the taxis in the ordinary way,
by passing the tip of my finger or the nail under the edge of the ring, and
pulling this firmly and forcibly on one side so as to steady and at the same time
dilate  it, pressure being kept up on the tumor  with the other  hand.  This
manoeuvre can  be practised with more facility and success  in  femoral hernia,
where  the upper edge of the saphenous opening is sharply defined, but may also
successfully be  had recourse to in inguinal and umbilical protrusions; should,
however, reduction  not ensue, it will  be  desirable to have recourse at once to
further means, the object of which is by relaxing the muscles and  lessening the
bulk of the tumor to enable the hernia to be reduced.
   The means to be employed must be modified according to the condition of the
strangulation, whether it be of the active or passive kind. If  it be very acute,
occurring in a young, robust, and  otherwise healthy subject, the  patient may
have about twelve or sixteen ounces  of blood taken  away from  the arm;  he
should then be put  into a hot bath, where he may remain for twenty minutes or
half an hour, or until he feels faint, and whilst in  the bath in this  condition the
 taxis  should be  employed.   If it  do not  succeed, he  should be taken out,
 wrapped up in  blankets, and have chloroform administered.  When fully under
 the influence of this agent, which is certainly the most efficient that we possess
 for relaxing muscular contraction, the taxis may be tried once again.   Should it
 still fail, the operation should be immediately proceeded with.
   No  good can possibly  come of delay in these cases, and repeated attempts  at
 the taxis should  be carefully avoided.  If the hernia does not admit  of  reduc-
 tion in the  early stage of the strangulation, it  will  necessarily be  much  less
 likely to do so when tbe parts, by being squeezed  and  bruised by much manipu-
 lation, will have their congestive  condition greatly increased.  The  frequent
 employment  of the operation without  opening the  sac, of late years, very pro-
 perly  renders surgeons much less averse to early division  of the stricture than
 was formerly the case.
   When the strangulation is less acute, or occurs in a more  aged  or less robust
 subject, it is well to omit the  bleeding, and to trust  to the  warm-bath and the
 chloroform.
   When  the strangulation is of a passive character, and occurs in feeble or
 elderly people, other measures may be adopted with the view  of lessening the
 bulk of the  tumor, which, rather than the tension of the parts, offers the chief
 obstacle to reduction in these cases.   Under such circumstances, especially when
 the tumor is large,  and not very tense, I  think it  is well to dispense with the
 hot-bath,  which has sometimes a tendency to increase  any congestion that may
 already exist in the hernia;  I have in more than  one  case seen a strangulated
 rupture enlarge considerably after the employment of the bath.  In such cases
 as these, more time may safely be spent in  attempts  at reduction than in very
 acutely strangulated herniae.   It is, I think, a useful practice to commence the
 treatment by the administration of a large enema, which, by emptying the lower
 bowel, will alter the relations  of the  abdominal contents, and may materially
 facilitate the reduction of the tumor.   The best enema is one  of gruel and cas-
 tor-oil, with some spirits of turpentine added  to it; it should be injected through
 a full-sized tube, and passed high up into the gut, and with  a moderate degree
 of force.  In administering it, care must be taken that no injury be done to the
 bowel. It would scarcely be necessary to  give such  a caution as this, were it
 not that I was summoned, some years ago, by two very excellent  practitioners
 to see  a woman with strangulated femoral hernia, to whom an enema  of about
two quarts of tepid water had been administered;  and as this had not returned,
and did not appear  to have gone up the bowel, they suspected that  it must have 
780
STRANGULATED  HERNIA.
passed out of the rectum into the surrounding cellular tissue.   As the patient,
however, did not seem to be suffering from this cause, and as the symptoms of
strangulation were urgent, I operated on the hernia.  Death suddenly occurred,
apparently from exhaustion, in about  eight hours, and on examining the body
it was found that the rectum had been perforated, the fluid  injected into the
meso-rectum, separating the gut from the sacrum, and had thence extended into
the general sub-peritoneal  cellular  tissue, which contained a  quantity of the
liquid;  some of the water also appeared to have got into the peritoneal cavity.
  In  the large herniae of old people in which there is a good deal of flatus, after
the enema has  been administered, a bladder of ice may be applied for three or
four hours with excellent effect.   Chloroform may then be given, and the taxis
employed under its influence.  Of late years, indeed, I have been in most cases
in the habit of trusting almost  solely to chloroform as a relaxing agent, and
have  often dispensed with-the use of the warm-bath, and the other means just
detailed.   I put a patient with strangulated hernia at once under chloroform,
and then try the taxis for a few minutes, not exceeding half an hour;  if this
fail, I then at  once proceed to the operation without  any further attempts at
reduction, which are not only useless, but injurious, by bruising the protruded
parts.
   After the reduction of a strangulated hernia, constipation and retching, with
nausea, may occasionally  continue;  and the tumor, if the hernia have been
small and deep-seated (more particularly if femoral), may continue to be  felt,
though less tense than before; consisting  simply of the sac thickened and in-
flamed, with serous fluid in it.  Under these circumstances we  must be  careful
not to operate.   I  have, on two  or  three occasions, seen an  empty sac operated
on, to the annoyance of  the surgeon and danger  of the patient.   The mistake
may  be avoided by observing that the symptoms gradually lessen in severity by
waiting, and that the tympanitis subsides, the abdomen becoming more  supple.
   The length  of time that the congestive condition  of the bowel will continue
after a strangulated portion of intestine has been reduced is very considerable.
In a  case  of strangulated femoral hernia which was some time ago  under my
care, reduction was effected, but strangulation recurring at the end  of twelve
 days an operation  became necessary; this was performed, and the patient died
on the eighth  day  after  it, or the twenty-first from the first strangulation.   On
examination, the small intestine was found congested in  two distinct portions,
each of which  was  about eight inches in length, and had several feet of  healthy
gut intervening.   One of these congested portions lay  opposite  the wound, and
was  evidently the  intestine that was last strangulated.   The  other was  alto-
gether away from the seat of operation, but was equally darkly congested, being
almost of a black color, and was clearly that portion which had  been constricted
some time previously; and which, although twenty days  had  elapsed,  had not
as yet recovered itself.
   After the taxis has  been  fairly employed for a sufficient time, and has not
succeeded in reducing the hernia, the operation must be proceeded with.  It is
impossible to lay down any definite rule as to the time that it is prudent to con-
tinue efforts at reduction, but it may be stated generally that after the different
 adjuvants of the taxis the surgeon may think it  desirable to apply, have been
fairly tried and have failed, the operation should be undertaken without further
 delay.   There are  few surgeons who will not at  once acknowledge the truth of
the remark of the late Mr. Hey of Leeds, — that  he had  often regretted  per-
 forming this operation too late, but never having done it too early.  It is true
 that  cases are occasionally recorded, in which after four or five days of treatment
 the hernia has gone up; but how rare it is to meet with such cases in practice;
 and in all probability in delaying the operation in the hope  of  finding one such
 case, the lives of dozens of patients would be sacrificed.   Mr. Luke has shown
 as the result of the experience at the London Hospital, that the ratio  of mor- 
OPERATION  FOR  STRANGULATED  HERNIA.      781
tality increases greatly in proportion to the length of time that the strangulation
is allowed to continue.  Of 69 cases of strangulated hernia operated upon within
the first  48 hours  of  strangulation, 12 died, or 1  in 5-7; whilst of 38  cases
operated on after more  than 48 hours had elapsed, 15 died, or 1 in 2-5.  Indeed,
one chief reason of the greater mortality from operations for hernia in hospital
than in private practice, probably arises from the fact that much valuable time
is frequently consumed before assistance is sought, or in fruitless efforts to reduce
the swelling before the patient's admission.  Not  only is time lost in this way,
but the bowel is often bruised and  injuriously squeezed, so that inflammation
already existing in it is considerably increased.
Fig. 309.
          OPERATION  FOR  STRANGULATED  HERNIA.

  The operation for strangulated  hernia may be performed in two ways;  either
by opening the sac, exposing its  contents, and dividing the stricture wherever
it is situated, from within ;
or, it may be done by divid-
ing the stricture outside.
without opening the  sac.
In either case  the  great
object  of the  operation,
the division  of the stric-
ture by the  knife, is the
same;  but  the  mode in
which it is effected  is dif-
ferent.   We shall first de-
scribe  the  operation in
which the  sac  is  opened
—afterwards that in which
it is not; and then briefly
compare   the   two   pro-
cedures.
   Operation. The patient
having been brought to
the edge of the bed, or placed  on  a table of convenient height, the bladder
should  be emptied, and the  parts that  are the seat of operation  shaved.  An
incision of sufficient length is then made over
the neck of the sac; this may be best done by a
fold of skin being pinched up,  transfixed by
pushing  the scalpel across its base  with the
back of  the instrument  turned towards the
hernia, and  then cutting upwards (fig. 309); a
linear  incision is thus  made which may be
extended at  either  end if necessary; the dis-
section is then  carried through the  superficial
fascia and fat with the scalpel and forceps.  If
any small artery spout freely, it  had better be
tied at once, lest the bleeding obstruct the view
of the  part in the  subsequent  steps  of the
operation.   As  the  surgeon approaches the
sac, more caution is required,  more particu-
larly if the  sub-serous cellular tissue is dense,
opaque  and  laminated.    The surgeon  must
pinch this up with the  forceps,  make  a small
incision into it, introduce a director, and lay it open  upon this, or on the nnger
(fig. 310).   If it is thin  and not opaque, so as to admit a view of the subjacent
Fig. 310.
 
782
STRANGULATED HERNIA.
parts, he may dissect it through with the unsupported hand.  In  this way he
proceeds  until the  sac is  reached,  which is  usually known  by  its  rounded
and tense appearance, its filamentous character, and by the arborescent arrange-
ment of vessels upon  its surface.   In some  cases the surgeon thinks that he
has reached  the sac, when in  reality he has only got upon a deeper layer of
condensed cellular tissue in close contact with it; here the absence of all appear-
ance of vessels, the  dull and opaque character of the tissue and  its more solid
feel, together with the  absence  of the peculiar tension  that is characteristic of
the sac, will enable  him to recognize the real state of things.   In other  cases
again it may happen that the sac  is so thin, and the superficial structures so
little condensed, that the  surgeon lays it open in the earlier incisions before
he thinks he has reached it.  Under these circumstances a portion of the intes-
tine protruding  might be  mistaken for the sac.  This  dangerous error may
be avoided by observing the peculiar  smooth and highly polished appearance
presented by the dark and congested gut; the  absence of arborescent vessels
and the non-existence of any adhesions between its deeper portions  and the
tissues  upon which  it  lies.  If the  sac  is prematurely  opened  and omentum
protrudes, the granular appearance and peculiar feel  of this  tissue will at once
cause its recognition.
   The sac having been exposed, must be carefully opened; this should be done
towards its anterior aspect; and if it be a small one,  at its lower part.   It may
best be done, if the  sac be not very tense, by  seizing a portion of it between the
finger and thumb, and thus feeling that no intestine is included; a small portion
of it is then pinched up by the forceps, and an opening is made into it by cutting
upon their points with the edge of the scalpel laid horizontally.   If the sac be
very tense, it cannot be pinched up in this way, and then it may best be opened
by introducing the point of a fine hook very cautiously into its substance, raising
up a portion  of  it in this way, and then making an aperture  into it.  There is
little risk of wounding the gut in doing this, for, as the tension of the sac arises
from the effusion of fluid into it, a layer of this will  be interposed  between it
and the gut.   In these cases, the fluid sometimes squirts out in a  full jet, and
occasionally exists in a very considerable  quantity.  I have seen  at least a pint
of slightly bloody serum escape  on  opening the  sac of an old strangulated ingui-
nal hernia.   Most frequently, however, there is not more than half an ounce to
an ounce, and sometimes the quantity is considerably less than this.  In  some
instances, scarcely any exists, and  then it becomes necessary to proceed with
extreme caution in opening the  sac, as the gut, or omentum, is applied closely
to its inner wall.  In such  cases as these the  sac is not unfrequently sufficiently
translucent to enable the surgeon to see its contents through  it, and he should
then open it opposite to the omentum or to any small  mass of fat that he  may
observe shining through it.  The opening once having been made into the sac,

                                  Fig. 311.
may be extended by the introduction of a broad director (fig. 311), upon which
it  is to be  slit up  to  a sufficient extent to admit  of the  examination of its
contents.
   The next point  in  the operation is the  division of the  stricture; and this
requires considerable care, lest injury be done to the neighboring parts of im-
portance, or the gut be wounded.   Vessels and structures in the vicinity of the
stricture are avoided by dividing it in a proper direction,  in accordance with
ordinary anatomical considerations,  which will be  described when we come to
speak of the special forms of rupture.  All  injury to the intestine is prevented
by introducing the  index-finger of the left hand up to the scat of stricture, 
          OPERATION  FOR  STRANGULATED HERNIA.      783

insinuating the  finger-nail underneath it,  and  dividing  the constriction  by
means  of a hernia knife, having a very limited  cutting edge (fig. 312).  If  a

                                  Fig. 312.
director be used to guide the knife, the intestine will be in considerable danger,
as the instrument may be slid  under that  portion of it which lies beneath "the
stricture, or  the  tense gut, curling over the side of the groove, may come in
contact with the edge of the  knife.   These accidents are prevented by usin<j
the finger  as a  director, and
slipping the hernia-knife (which                  Fig. 313.
should not have quite so long
a probe-point  as  those usually
made) along the palmar surface
of the finger, upon its flat side:
the finger serving to keep the
bowel out of the way, and  de-
tecting  any part that may be
interposed between the edge of
the knife and the stricture (fig.
313).
  During the  division of the stricture, the protruding portion of intestine must
be protected from injury by the knife, either by the operator spreading his  left
hand over them, in such a way that they may not be touched by the edge of
the instrument, or  they may be protected by an attentive and careful assistant.
  In some cases the  stricture  is so tight that it is at first almost impossible to
get the edge of the nail  underneath it.  The surgeon will, however, generally
succeed in doing so, by directing his assistant  to draw down the coil  of intes-
tine, so as  to  loosen it, as it were, from underneath the stricture; he will then
usually succeed in  passing his  finger up in  the  middle of the coil, where the
mesentery lies.  So soon  as  the blunt end  of  the  hernia-knife has been  got
under  the  stricture, its sharp  edge must  be turned  up,  and the  constriction
divided in  a proper direction, to a very limited extent, from the one-eighth to
the quarter of an inch.  The  intestine and  omentum must then be examined,
and dealt with according to the condition in which they  are found.   If these
structures are sufficiently healthy to admit  of reduction,  the  intestine should
first of all be replaced.   This  must be done by pushing it back with as much
gentleness  as  possible, and  chiefly by using the  index fingers.  When it has
slipped up into the abdomen, the omentum must be returned in the same  way.
In  reducing the hernial  protrusion, after the sac  has  been,  laid  open,  care
should be  taken that the margins of this are firmly held down by means of  a
pair of forceps, lest  it, together with its  contents, be returned en masse, the
stricture being undivided.   After reduction, the surgeon should pass his finger
up  into the  canal  through which the hernia has  descended, and see that all is
clear.  A suture or two should next be applied through the lips of the wound,
with a few cross strips of plaster between them, a long pad  of lint laid  over
it, and a spica bandage to retain it all in  proper position.  About the third or
fourth day  the sutures  may  be removed,  and  water-dressing applied.   If
inflammation  or suppuration  should set  in, the part must  be well  poulticed,
and care should be taken to leave the most  dependent  aperture free, as other-
wise the pus formed in the external incisions may flow back through the  inter-
 
784
STRANGULATED HERNIA.
nal aperture into the peritoneal cavity, and occasion fatal inflammation.   In-
deed I think it desirable that union of the lips of the wound after the operation
for hernia should not take place by the first intention, as it not unfrequently
happens, when this occurs, that the pus and other discharges not finding a ready
outlet, may either be diffused between  the  muscular planes of the abdominal
wall, occasioning sloughing and abscess, or either finding its way back into the
peritoneal  cavity, may excite  inflammation of it — a  result that I have more
than once seen occur.
   The patient should be kept quiet in bed, and,  if there be no  sign of  perito-
nitis, have an opiate given him.  The bowels will probably act in the course of
the first twenty-four hours; should they not do so,  a castor-oil and gruel  enema
may be thrown up.  It is, I think, of very great importance not to administer
any purgatives in these  cases, and to take little  heed  of the bowels not acting,
even for three or four days after the operation. If the mechanical obstacle have
been removed, they will be sure to recover their proper action, though in con-
sequence of the gut having been severely constricted and almost wounded by
the pressure of the stricture, it may require to be  left quiet for a few days
before it can recover its  peristaltic  action.  The administration of purgatives,
by still further irritating it, will increase the risk of inflammation in it, and will
probably do much  harm.  The patient, of course, must be kept upon the sim-
plest  and most  unirritating diet; indeed, should only be allowed  barley-water
and ice for the first day or two, afterwards some  beef-tea; but no solid food till
the bowels have acted, and all risk of peritonitis has  passed.
   The great danger to  be apprehended after operation for hernia  is the super-
vention of peritonitis.   This  may have existed  before  the operation,  may be
impending at the time, and may be occasioned, or at all events greatly increased
by the necessary wound of the peritoneum.   Two distinct kinds of peritonitis
commonly  follow operations for hernia; one, the active  or acute, the other, the
passive or latent.
   The acute peritonitis is the variety commonly met with in strong and  robust
people, otherwise healthy, who are the subjects of this operation.  It presents
the ordinary symptoms of acute idiopathic inflammation of the abdomen; there
is tenderness of a diffused character, with lancinating pains.  The patient  lies
on his back, with  his knees  drawn up, has an  anxious countenance, a quick,
hard pulse, a dry tongue, and much inflammatory fever; the respiration is prin-
cipally thoracic, and tympanitis soon comes on.   The bowels are usually consti-
pated, though sometimes irritated.  The treatment  of this form of herniary peri-
tonitis is best conducted upon ordinary antiphlogistic principles; the disease is
a purely inflammatory one, and proper means must  be taken to subdue it.   This
may be best done  by free venesection and the application, perhaps repeated, of
two or three dozen leeches to the abdomen;  calomel and opium in pill must be
administered  every fourth or sixth hour, and the patient confined  to  barley-
water and ice.   As the inflammatory action is subdued, the constipation which
is occasioned by it will  be relieved without the  necessity of administering any
purgatives.   The tympanitis may best be  removed by turpentine enemata, and
any lurking tenderness by the application of blisters.
   Latent or passive peritonitis is a form  of disease  that appears to be of the
diffused or erysipelatous character, chiefly occurring in old people, or in  weakly
subjects, and is especially apt to follow upon  inflammation of the omentum and
its consequent suppuration, or it may  occur in consequence of the extension of
diseased action  from the cutaneous wound, and  in other cases from the morbid
condition induced  by the strangulated gut.   In hospital patients especially, in
whom all disease  is apt  to assume a low character, this inflammation is pecu-
liarly liable to occur.   In some instances it sets in without the appearance of
any marked local symptoms of inflammation, no pain  or uneasiness in the abdo-
men; but two or three days after the operation  the patient becomes depressed, 
HERNIARY  PERITONITIS.
785
with a quick and weak pulse, an anxious  countenance, a tumid and tympanitic
abdomen, and  rapid  sinking of strength.   In the majority of cases, however
some of the ordinary local  signs of peritonitis are present.   After  death, the
abdominal cavity will be found to contain a quantity of turbid serous fluid, mixed
with flakes of lymph, in many instances  in such quantity as to give it a puri-
form appearance, and not unfrequently matting  together the coils of intestine.
In the  treatment of this affection it is  necessary to support the  patient, and in
some instances even  to administer stimulants, such as ammonia, the brandy-and-
egg mixture, &c.   Depleting measures of all kinds are quite inadmissible;  and
indeed, the remedy that offers most prospect of benefit to the patient is opium,
in full  doses, one grain  being given every third or fourth hour until some effect
is produced  upon the constitution.  Opium not  only acts  as a useful stimulant
in these cases, but has a tendency to  allay the  increased vascular action.   At
the same time a blister to the abdomen, to  be dressed with mercurial ointment,
may be advantageously employed, and turpentine enemata administered, with
the view of  removing the tympanitis, which is a source of much distress to the
patient.
   Treatment of intestine.—The condition in which the contents of  the sac are
found in a case of hernia determines greatly the course that the  surgeon should
pursue after the division  of the stricture.  Most frequently the  intestine is
deeply congested, being of a  reddish-purple, a claret, or chocolate color.  This
 congested state must not be confounded with gangrene of the part, which might
 happen if the surgeon were to content himself simply with judging of its con-
 dition  by the color.  However dark this may be, the gut cannot be said to be
 gangrenous  so long as  it is polished and firm, free from putrescent odor, and
 without a greenish tinge.   In  cases in which there is much doubt as to whether
 its vitality continues or not, it has been  proposed to scarify its  surface lightly
 with the point of a lancet.   If blood flows from the punctures, this may be taken
 as a proof of  the continuance  of the vitality of the part.   Such a procedure as
 this, however, is  certainly attended by some degree of danger, and  can seldom
 be required.
   When the intestine is merely congested,  however deeply this may be, the rule
 is, that it should be returned into the cavity of the abdomen in the hope of its
 ultimately recovering itself;  this it will generally do if  it have not been too
 much  handled after the sac has  been opened; but in some cases it  will slough
 a few days after it has  been reduced, and  the faeces  being discharged through
 the wound,  a feculent fistula will be formed, which  may  happen as late as the
 eighth or tenth day after the operation.  In those cases, however, in which the
 intestine has been very tightly nipped by a sharp-edged stricture, so  that a  deep
 sulcus, or depression, is left upon it, it seldom, I think, recovers itself, whether
 the whole of the coil of gut has been thus  affected, or the constriction has  been
 limited to a small portion  of  the diameter of the intestine.  It is  remarkable
 how very quickly changes which are incompatible with life may ensue in a por-
 tion of gut that has been very tightly strangulated.  I have known a coil of
 intestine, that had been but eight hours strangulated before the operation was
 performed, so tightly constricted as not to  regain its vitality after its reduction
 (fig. 314).  In such cases as these the patient usually dies of peritonitis in the
 course of a few days, without the bowels having acted, all peristaltic motion hav-
 ing necessarily been annihilated at the injured point. On examination after death,
 the constricted intestine will be found to present all the appearances of gangrene,
 being  of a black or  ashy-grey  color, without having any flocculi  or lymph depo-
 sited upon its surface,  though these  may  be in abundance in the neighboring
 parts.   From the very unfavorable result of those cases in which there has been
 very tight nipping of the protruded bowel, a very cautious prognosis should be
 given, and in  reducing  the  gut after the division of the stricture, care should be
 taken  not to push it far back  into the abdomen, but to leave it near the inner
       50 
786
STRANGULATED  HERNIA.
ring, so that  in the event of its ultimately giving way, there may be less risk of
                                     feculent extravasation.  In those cases in
              Fig. 314.               which the  nipping has  been very severe,
                                     the sulcus being distinctly marked,  and
                                     the intestine excessively dark  and con-
                                     gested, though not actually gangrenous, it
                                     would, I  think, be  better after dividing
                                     the stricture  to  leave the gut outside the
                                     ring rather than to return it; the reduc-
                                     tion of intestine  in this  state  being almost
                                     invariably followed by fatal peritonitis.
                                       It is important to observe that although
                                     intestine  which  has  been  so severely
                                     nipped as  this,  may not  be able  to re-
                                     cover its vitality, and will fall into a state
                                     of gangrene after being reduced, yet that
                                     it  does not at  the  time of its exposure
                                     present the  characters  of putrescence;
                                     there is   no  fetor,  no  green   or  pulpy
 appearance,  or loss of polish or separation  of peritoneum;  it  is simply of a
 dark  purple or maroon color, and that  it has been  tightly  nipped  is evident
 by the sulcus upon it.   There are  no signs of gangrene,  simply because suffi-
 cient time has not elapsed for putrefaction to set in.  It is just as when a  pile
 or nevus has been tied, though vitality is extinct in the part, which is swollen
 ana purple, some time must elapse before signs of putresence manifest  them-
 selves ; so it may be with a strictured gut which may have lost its vitality;  and
 it should  be treated as mortified intestine, though there  be no sign of putridity
 about it.
   When the intestine is actually gangrenous, the integuments covering the tumor
 will be infiltrated, brawny, and duskily  congested, the  structures immediately
 overlying  the sac  matted  together; the sac will contain  fetid  dark-colored
 serum or  pus, and the softened, lacerable, or pulpy look of tbe protruded part,
 its loss of lustre and peculiar greenish-black, or  dark-grey color, will  cause the
 nature of the mischief to be readily recognised.  In the majority of cases there
 will be much constitutional depression, a clammy skin,  tympanitic  abdomen,
 and brown  or black  tongue, but in some  instances I have known all these
 symptoms to be  absent,  and  the condition  of the  patient to present no very
 unfavorable  state.  Some  difference of opinion  exists as to the proper line of
 practice to be adopted in  such cases.   Travers and  Lawrence seem to think
 that  the  division of the  stricture  is unnecessary, or may even be  injurious;
 whilst Dupuytren, A. Cooper, and Key (with  whom  I  concur), advise that it
 should be  done;  that the  stricture should be divided in the usual way, that a free
 incision should then be made into the protruded portion of bowel, which must
 be left unreduced, so as to allow the  escape of fasces, and the wound left open,
 and covered by a poultice.   In this way an artificial anus will necessarily be
 formed, through which the feculent matter finds exit.   The gut in the vicinity
 of the stricture  is retained in situ by masses  of plastic matter, which prevent
 the peritoneal cavity being opened.   If the intestine should already have given
 way before the  operation is performed, the  stricture  must be divided and the
 part then  left unreduced, care being taken to interfere as  little as  possible with
 any adhesions or connections lying inside the  neck of  the sac, though I fully
 agree with Aston Key, in thinking that the danger of  disturbing them has been
 exaggerated.
   When  a  small portion of the bowel  only is gangrenous, the better  plan is
 to return it into  the cavity of the abdomen, without laying it open,  but it should
 not be pushed any distance into this cavity; the pressure of the surrounding
 
TREATMENT OF  OMENTUM.                787
parts will prevent extravasation.  When the slough  separates it will probably
be discharged into the  cavity of the intestine, and the aperture resulting will
be closed by the adhesions that extend between its margin and the abdominal
wall.
   The management of adhesions varies according to the condition of the bowel
and  the  nature and situation  of the bands.  As has just been remarked, if
gangrene is present, especial care must be taken not to disturb any connections
that have been formed about the neck of the sac, and which constitute the most
effectual barrier against feculent extravasation.  When the adhesions are recent,
consisting merely of plastic matter, in whatever situation they exist, they may
readily be  broken down with the finger or  the handle of the scalpel,  and the
parts then returned.   When of old standing, and dense,  they must be dealt
with according to their connections.   Most frequently these adhesions occur in
the shape of thickened bands situated within and stretching across the  neck of
the sac.   In other cases again, they may be found either as filamentous bands,
or as broad attachments connecting the  sac with  its  contents, and tying these,
perhaps, together.  When of a narrow  and constricted form, and more  parti-
 cularly when  seated in the neck of the sac, or stretching  like bridles across
 its interior, they may  readily be divided with  a probe-pointed bistoury, or the
 hernia-knife.   If consisting  of broad  attachments, they  may be dissected
 away by a little careful manipulation from the parts  in the inside of the sac;
 though if the adhesions be very extensive and of old standing, it may sometimes
 be more prudent to dissect away that portion of the  sac which is in connection
 with them, or even to leave them untouched, and  the adherent intestine or
 omentum  unreduced,  rather than  to endeavor to separate  them.  They may,
 however, attach themselves in such situations that it becomes necessary to divide
 them; thus I have, in a case of congenital hernia, found it necessary to dissect
 away some very extensive and wide-spread adhesions that  had formed between
 the omentum and the testicle, and which indeed had almost completely enveloped
 that organ.
   Internal adhesions between  the omentum  and intestine or mesentery occa-
 sionally exist, consisting usually of  pretty firm  bands stretching  across from
 one part to the other, sometimes connected  with  the inner wall of the sac, but
 in other cases confined to its contents;  as these bands may constitute  the real
 stricture, continuing to strangulate the  gut after the division of the structures
 outside  and in the  neck  of  the sac, they must  necessarily  be  divided.   This
 operation  requires  great care, lest  the  neighboring  intestine be wounded,
 and is best done by  passing a director underneath, and cutting them through
 with a probe-pointed bistoury;  or, if this cannot be done  on account of their
 connections, they must be seized with the forceps and carefully dissected off the
 gut.  In  a  case of large inguinal hernia, containing  both gut and omentum,
 on which I operated  some years ago, I found after dividing the stricture, and
 taking hold of the omentum  in  order to  push back the intestine,  that this
 could not be reduced.  On searching for the cause of difficulty, and drawing
 the mass well down, I found high up,  in the part  corresponding to the neck
 of  the sac, a narrow band, like a piece of whipcord, stretching across from the
 omentum to the mesentery and  firmly tying down  the  gut.   On dissecting
 this  carefully through,  the  constricted portion of intestine subjacent  to it
 sprung up to its full diameter, all constriction  being  removed, and was then very
 readily reduced.                                       .           ,  , ,   .
    Treatment  of omentum. —If the  omentum is small  in quantity, healthy in
 character, though congested  and  apparently recently protruded, not haying
 undergone those changes  that occur in it  when it  has been a long time in a
 hernial  sac, it should be reduced after the intestine  has  been put back   It,
 however, its mass be very large, or if it be hypertrophied or otherwise altered
 in  structure, at the  same time that it  is congested, I think the best  surgeons 
788
STRANGULATED  HERNIA.
are agreed that it should not be returned into the abdominal cavity, as inflam-
mation of it, epiploitis, will probably set in and  terminate fatally with effusion
into the peritoneal sac.   So also, if the  omentum is in large quantity, and  has
become inflamed in the sac, it should not be returned, as the inflammation in it
is very apt to run on to a kind of sloughy condition  of the whole  mass.  If
gangrenous, it should certainly not be reduced.   In all  these  cases of hyper-
trophied, inflamed, or gangrenous omentum, the best practice consists in cutting
off the mass, as  recommended by Sir A. Cooper and Lawrence.   If it be  left
in the sac, inflammation or  sloughing of it may occur, and the patient can derive
no corresponding advantage to the danger he will consequently run.  The exci-
sion of the  mass may readily be  performed by seizing and cutting  it off at a
level with the external ring.  As the  arteries of the stump, which are some-
times pretty numerous, are  apt to bleed freely, they must be tied  singly by fine
ligatures, which should be  left  hanging  out  of  the wound.   There  is often a
tendency to the  retraction  of the stump of the  omentum into the  abdominal
cavity, in which case the ligatures, dropping into the peritoneum, may become
sources of great irritation; in order to prevent this, the better plan is, I think,
to knot them together, and to fix their  ends by a piece  of plaster upon the fore-
part of the  abdomen.  Surgeons formerly were in the habit of including  the
constricted neck of the omentum in a tight ligature, cutting off the mass below
this, and leaving  the stump in  the inguinal  canal or ring.   This practice  has
been generally abandoned, from dread of peritonitis being induced by the con-
striction of the ligature.  It may, however, be safely followed in some instances,
in those particularly in which the protruded mass is very much indurated, hav-
ing a narrow neck.  In some  cases of this  kind, occurring  at the  hospital, I
have employed this practice with excellent effect.   The quantity of omentum
that is cut off varies considerably; the  mass removed usually weighs  from four
to six ounces, but in some instances it may amount to a pound or  more.
  Sacs or apertures are occasionally formed in the omentum, in which a knuckle
of intestine may have become enveloped, or by the margins of which it may be
strangulated.  These envelopes of omentum  around the gut, which have been
especially described by P. Hewett, may occur in all kinds of hernia, at least in
the inguinal, the femoral,  and the umbilical, and sometimes  acquire a large
size, completely shutting in the gut.  It is of importance to bear their existence
in mind, and in all cases to unravel the omentum before removing it, lest it
contain a knuckle of intestine, which might be wounded in the operation.
   Wounds of the intestine may accidentally occur at  two periods  of the opera-
tion, either by the surgeon  cutting too  freely down upon the sac, and opening
this before he is aware of what he is about;  or else, at the time of the division
of the  stricture, a portion of the gut which  lies beneath it getting in the way
of the  edge of the knife, and being  nicked by it.  The first kind of accident
can only happen  from a certain  degree of carelessness;  but it is not always so
easy to avoid wounding the  gut when the  stricture is so tight that the finger-nail
cannot be  slipped under it as a guide  to the  hernia-knife.   In such  cases as
these, a very narrow director must be  used; and this is a most  dangerous in-
strument, as in passing it deeply out of sight under the tight stricture, a small
portion of the gut may curl up over its side into the groove, and thus become
notched by the knife as this is slid along it.  This accident has  happened to
the best and most careful surgeons.  Lawrence relates two cases  that  occurred
to him, and Sir A. Cooper, Cloquet, Jobert,  and Liston  have all met with it.
It may be known to have  occurred by the  bubbling up of a small quantity of
flatus and liquid  faeces from the bottom of  the  incision.  The treatment of  a
wound of the gut must depend upon its size.  When very small,  rather resem-
bling a puncture  than a cut, the  practice recommended by Sir A. Cooper should
be adopted, viz., to seize the margins of the  incision with a pair of forceps, and
to tie a fine silk thread tightly round them, the ends of which should then be 
             ARTIFICIAL ANUS. — FAECAL  FISTULA.          789

cut off, and the gut returned into the abdominal  cavity.  Such a proceeding as
this does  not appear to give rise to much, if to  any increase of danger.   In a
case that occurred to me at the Hospital, in which, owing to the excessive tight-
ness of the stricture, a very narrow director  could only be got under it, the gut
immediately above it was  notched and opened by a kind of punctured wound;
this was tied up in the way mentioned, and after  the death of the patient, which
took place on the fourth day after the operation, from gangrene of the strangu-
lated  portion of bowel, the silk  ligature was found to be completely enveloped
in a plug of  plastic matter.  If the wound be of larger size, it must be closed
by the glover's stitch.
   Wound of one of the  arteries in  the neighborhood of  the sac  may  occur
during the division of the stricture, either in consequence of some  anomaly in
the distribution of the vessel, or from  the surgeon dividing the parts in a wrong
direction.  This accident  usually happens to the epigastric or obturator arteries,
and  Lawrence has collected 14 recorded cases in which it has occurred:  the
result in these has been very various.  In  some  the patients have  died; in
others, after much loss of blood, and consequent faintness, the bleeding  ceased
spontaneously.  The proper treatment would certainly consist in cutting down
upon and securing the bleeding vessel.   In the event of the surgeon operating
on a case of hernia, without having been able  previously to  satisfy himself as
 to its precise character; or if from  any cause in dividing the  stricture he  has
 reason to dread  the proximity of an artery, he may safely and  readily divide
 the  constriction with a knife  that would not easily cut an artery,  and he will
 find, if he blunt the edge of his hernia-knife, by drawing it over the back of
 the  scalpel, that it will still be keen enough to relieve the strangulation, whilst
 it would push before it any artery that might happen to be in the way.
   Sloughing of the sac is of rare occurrence, and when it happens is commonly
 attended by fatal  results; it is not, however, necessarily so.   It has twice hap-
 pened in my practice, and in  both  cases the  patient  recovered.  In  an old
 woman on whom I recently  operated  for femoral hernia of very large size, the
 sac sloughed away, exposing nearly the whole of Scarpa's triangle with almost
 as much  distinctness as if it had been dissected; but although in much  danger
 for a time from an acute  attack of peritonitis, she ultimately recovered.
   Artificial anus and faecal fistula.—When an aperture exists in the bowel by
 which the whole of the intestinal contents escape externally, the disease is said
 to be an  artificial anus.  When but a small portion so escapes, the greater part
 finding  its  way out  through the anus, a faecal fistula  is said to  exist.  The
 quantity of  feculent discharge  necessarily depends upon  the extent of the de-
 struction of the  intestinal  coats, and its character, on the part of the gut that
 is injured.   The escape takes  place involuntarily,  and usually  continuously.
 This condition may occur in several ways.   Thus, the gut may be accidentally
 wounded during the operation, and  the faeces afterwards continue to  be dis-
 charged  through the aperture so made; or it may have  been gangrenous, and
 have given way into the  sac before the operation; or the surgeon may have
 intentionally laid open a gangrenous portion of intestine, so as to facilitate the
 escape of the faeces.   In  some cases in which the  bowel has been severely
 nipped, and is dark and congested, though it  have  not fallen into a state of
 gangrene, it may not be able to recover itself after its return into the abdominal
 cavity, but  will give way in  the  course of three, four, six, or  even ten days
 after the operation.   In  these cases,  a small quantity of feculant matter is first
 observed in the  dressings, and gradually a greater discharge appears, until  at
 last the fistulous opening is completely established.   In such cases, it is of im-
 portance to observe, that although the  bowel  gives  way within the peritoneal
 cavity, the faeces do not become extravasated  into this, but  escape externally.
 This important  circumstance  is owing to the fact of the portion of the bowel
 that is nipped losing its  peristaltic action, and consequently remaining where it 
790
STRANGULATED HERNIA.
is put back ;  the parts in the neighborhood inflaming, throwing out lymph, and
becoming consolidated  to each  other  and to the parietal peritoneum, so as to
include the gangrenous portion of the gut, and completely to circumscribe it.
It is consequently of great  importance, in such cases as these, not in any way
to disturb the adhesions that have formed between the sides of the aperture in
the gut and the neck of the sac.
   The pathology of artificial anus is commonly as follows; — The edges of the
aperture in the gut  are  glued by plastic  matter  to the abdominal wall, and
whether the whole or a portion  only of the calibre of the intestine is destroyed,
the aperture  of the upper and lower end, though at first lying almost in a con-
tinuous line, soon come to unite at a more or less acute angle.  These are at first
similar in  size, and present no material differences in shape or appearance; as
the disease becomes more chronic, they gradually alter in their characters, the
lower  aperture being  no  longer used for the transmission of faeces, gradually
becoming narrower (fig. 316, b), until at last it may be almost completely oblite-
rated,  whilst the upper portion  of intestine becomes dilated (316, a), in conse-
quence of there being usually some  slight  obstruction to the  outward passage
of the  faeces.  The mesenteric portion, opposite the aperture, becomes drawn out
into a  kind  of prolongation or spur, the  full  importance of  which  was first
pointed  out by Dupuytren.  This  spur-like process projects between  the  two
apertures, and being deflected by the passage of the faeces, has at last a tendency
to act  as a kind of valve,  and  thus to occlude the orifice into the lower portion
of the  gut.  The integuments in the neighborhood of such an aperture as this
usually become irritated, inflamed, and excoriated, from  the constant passage of
the faeces over them.  In some cases, the mucous membrane lining the  edges
becomes everted, and pouting;  and, in others, a true prolapse  takes place, large
portions of the membrane protruding.  An artificial anus fully formed in this
way never undergoes spontaneous cure.  Besides  this, which  is the ordinary
form of artificial anus, we must, I think, recognize at least two other varieties,
both of which I have met in practice.  In  one  of these the angle formed  by
the gut is adherent to the upper extremity  of the sac which has been returned,
and thus lying at some distance from the surface, the faecal matter traverses a
long canal before  it reaches the external aperture.  In the  other variety the
angle  of the gut  is fixed at a higher point within  the abdomen,  and the faeces
find their way out through a channel bounded by agglutinated coils of intestine
and layers of lymph.   In both of these  forms there is a considerable distance
between the external opening and the aperture  in  the gut.   Thus, then, there
are three forms of artificial anus, differing from one another  according to the
situation of the angle of the  gut in relation to the external opening, and to its
connections.
   When a fecal fistula has formed, the condition of parts is somewhat different.
In these cases, the aperture in the intestine consists of  merely a  small perfora-
tion in its coats, unattended by any considerable loss  of substance, through which
a quantity of thin fluid and feculent matter exudes, giving rise  to a good  deal
of irritation  of neighboring structures.   In some cases, there are several aper-
tures communicating with the gut, and extending through the skin.   Fistulous
openings of this kind not unfrequently undergo spontaneous cure after existing
for a few weeks or months.
   Treatment of artificial anus.—As the existence of an artificial anus, by inter-
fering with nutrition, commonly gives rise to considerable emaciation, it becomes
necessary to support the patient's strength, by a sufficient quantity of good and
nourishing food;  this is of greater consequence the higher the fistula is, as the
interference with  the earlier stages of the digestive process, and the loss of
nutritive material by the discharge  of the  chyme, is proportionately great.  If
the aperture be merely of a fistulous kind, the pressure of a pad, to prevent the
escape of feculent matter, may  enable a spontaneous closure of it to take place. 
             ARTIFICIAL ANUS. — FiECAL  FISTULA.         791

Spontaneous cure will occasionally take place, even  though a perfect artificial
anus exist.  In  a recent case under my care at the hospital, a whole knuckle
of intestine was gangrenous, and sloughed away, leaving an artificial anus, which
discharged the greater part of intestinal contents, but gradually contracted and
closed without any local application or treatment beyond attention to cleanliness.
If the aperture become a permanent  artificial anus, surgical means must, if pos-
sible, be adopted in order to  effect a cure.  In accomplishing this, two impor-
tant indications have to be  fulfilled :  the first is to diminish or destroy the pro-
jecting valvular or spur-like process, and thus  to  re-establish the continuity of
the canal; and after this has been done, the external wound may be closed, by
paring its edges, and bringing them  together with harelip pins.
  The first  object is best accomplished by Dupuytren's enterotome (fig. 315);
this consists of  an instrument something like a pair of scissors, with blunt but
Fig. 315.                                 Fig. 316.
serrated blades, which may be brought together by acting upon a screw that
traverses its handle.  One blade of the instrument (a) is passed into the upper,
the other (b) into  the lower portion of intestine, they are then approximated
slowly and fixed by means  of the screw in such a way as to compress on either
side the spur-like process (fig. 316).  Very gradually, day by day, this screw is
tightened so as to induce sloughing of this projection, and cohesion of its serous
surfaces.  As this  action goes on, the irritation caused by the instrument will
occasion plastic matter to be thrown out in the angle formed by the intestine,
so that the  peritoneum and mesentery become consolidated, and all opening into
the peritoneal cavity avoided.  Should the spur-like process be accidentally cut
through before the lymph is thrown out in sufficient quantity, the peritoneum
would be opened, and death probably ensue; hence the necessity for caution in
this procedure.  So soon as the blades of  the  instrument  have come into con-
tact, and the spur-like process has consequently sloughed away, the great obstacle
to the closure  of  the artificial anus will be removed, and the continuity of the 
792
STRANGULATED HERNIA.
canal being thus re-established, its lips may be pared and brought together by
harelip pins and sutures.
  [The late Dr. Physick devised and executed an operation by which he effected
the destruction of the eperon or spur, and tbe re-establishment of the continuity
of the intestinal canal, more easily than by the employment of the cumbersome
and inconvenient enterotome of Dupuytren.   He passed a curved needle armed
with a ligature  completely  through the  spur-like ridge, the needle entering
through  the orifice of one gut and emerging by the other.   The extremities of
the ligature being then loosely tied, in order to approximate the peritoneal sur-
faces, were fastened  at the  external  opening; and the thread  was allowed to
remain thus  for several days, until by its  action as a seton, sufficient effusion of
plasma had taken place to effect  the consolidation desired.  The ridge of gut
was then divided by a bistoury.]

   OPERATION  FOR  HERNIA  WITHOUT   OPENING  THE  SAC.

   The possibility of removing the stricture in strangulated hernia without laying
 the sac open, naturally suggested  itself when it was known that in many cases
the stricture was seated in the tendinous and cellular tissues outside the neck of
 the sac,  and that when these were divided the protrusion was readily reduced.
 This operation was performed by Petit as long  ago  as 1718, but was  seldom
 practised until it was revived of late years by Aston Key and Luke.  The great
 advantage sought to be gained by this operation is, that as the peritoneum is not
 interfered with or its cavity opened, the risk from  peritonitis will be proportion-
 ately lessened.   The wound made by the operation being altogether superficial,
 and the  sac not opened, its risk has been compared to  that of the taxis, with the
 addition of that which would result from a superficial wound.  This argument
 would be conclusive  in  favor of the operation without opening the sac, if it
 could be shown  that in all cases of strangulated  hernia that peritonitis is occa-
 sioned by interfering with the peritoneal cavity;  it must, however, be admitted
 even by the keenest advocates of  Petit's operation that this is not the case. In
 many instances the inflammation exists before any operation is performed, being
 evidently produced by the stricture  of and consequent injury to the  gut.   But
 it  cannot with fairness be argued, that  though the peritonitis may exist before
 the operation, the incision of the peritoneal cavity does not increase it;  even in
 healthy persons, laying open the  abdomen, handling the gut and omentum, and
 pushing the fingers into the peritoneal sac, would  always be followed by intense,
 perhaps even fatal, peritonitis.  It is only reasonable to believe that the same
 procedures in an already inflamed peritoneum would be followed by equally dis-
 astrous  results.
    That the  opening made into the cavity of the abdomen  in reality adds to the
 frequency of the peritonitis, cannot I think be doubted by any  practitioner. It
 not unfrequently  happens in  strangulated  hernia, that no  sign  of peritoneal
 inflammation sets in until  two or three days after the operation is performed,
 and then occurs evidently as the result of this procedure.  That the fatality of
 the peritonitis,  even if existing before  any  operation be  practised,  must be
 greatly  increased  by interference with the serous sac, is evident from  the fact
 that has been already mentioned that death very rarely occurs  (not more  than
 once  in many hundred  cases) after  the  reduction of a strangulated hernia by
 the taxis.   Fully admitting, therefore, that in many cases the peritonitis exists
 before the operation, and is occasioned by causes independent of it; it is I think
 impossible to deny that the inflammation is frequently directly occasioned by
 opening the peritoneal cavity, and handling  the viscera, and  that when already
 existing, its fatality must be greatly increased by this procedure.  In fact there
 are two causes  for  peritonitis in cases of operated  strangulated hernia—viz.,
 the constriction of the stricture, and the wound of the peritoneum.  That peri- 
     OPERATION FOR HERNIA  WITHOUT  OPENING SAC.  793

tonitis which arises from the pressure of the stricture is equally liable to happen,
whether Petit's operation or that by opening the sac is practised, and often pre-
cedes the operation; whilst  the peritonitis  which arises from  wound  of the
serous  membrane does  not occur in Petit's operation, but is necessarily confined
to that in which the sac is opened.
   There are, however, two objections  that may be urged against Petit's opera-
tion with more justice than  that it  does  not tend  to prevent the occurrence of
peritonitis.  The first is, that if the intestine be not seen, it may sometimes be
returned in a gangrenous condition; and  the second, that the gut may possibly
be returned still  strangled by bands of adhesion, or by inclusion in an omental
aperture. With regard to the first objection, it may be stated, that if the intes-
tine is in a gangrenous state there will usually be some  evidence of  this condi-
 tion, either in the change that has taken place in the general symptoms of the
 patient,  or in the condition of the sac and its coverings, which will enable the
 surgeon to guess at the condition  of the enclosed parts, and would of course
 induce him to expose  them  fully and examine them  thoroughly.   This objec-
 tion, however, cannot  apply to those cases in  which the strangulation has only
 existed for a time that would be insufficient to allow of the occurrence  of gan-
 grene, and does  not therefore  apply to the performance of Petit's operation in
 recent cases of strangulation.  With regard to the occurrence of internal stran-
 gulation, it is excessively rare, and when it does ocemvit still more  rarely hap-
 pens,  whether the strangulation is affected by  bands of adhesion, or by an aper-
 ture in the  omentum, that the  parts can be returned without opening the sac,
 adhesions usually existing  also between  this  structure and  its contents.   But
 the best answer  to the objections against the operation without opening  the sac,
 are the  results that have followed this practice.   Mr. Luke, who has had great
 experience on this  subject, states that he has operated  in 84 cases of hernia.
 In 25 of these the  sac was opened; in 59 the sac remained unopened.  Of the
 25 in which it was opened, 8 died, whilst of  the  59 in which Petit's operation
 was performed, only 7 died.  If  to Mr. Luke's cases we add those reported by
 Mr. N.  Ward, we shall find 36 deaths in 153 cases of Petit's operation.   That
 the ordinary operation indeed of opening the sac  is an exceedingly  fatal one, is
 well known to all hospital surgeons, and is fully proved by surgical statistics.
 Of 77 operations for hernia, reported by Sir A.  Cooper, 36 proved fatal; and
i of 545  cases recorded in the  journals,  and  collected  by Dr. Turner, 260 are
 reported to have died.  The result, therefore, of  Mr. Luke's operations is most
 favorable, when contrasted with those in which the sac was opened.
    The  operation, without  opening the  sac, may be practised  in all forms of
 hernia  but is much more readily done in some varieties of the disease than in
 others.   It is especially applicable in cases  of  femoral hernia, in which the
 stricture is  commonly outside  the sac, as will be mentioned when  speaking of
 that  form of the disease.   Of 31  cases of  femoral hernia operated on by Mr.
 Luke, the sac only required to be opened in 7.   In inguinal hernia it is  not so
 easy to perform Petit's operation; indeed, in  the  majority of cases the  surgeon
 will fail to remove  the stricture in this way.   This is owing to the  constriction
  being usually seated in the neck of the sac, and is especially observable in con-
 genital hernia.   Of  20 inguinal herniae  operated on  by Mr. Luke, the  sac
 required to be opened in 13 instances.                                   .  .
    For the various reasons that have been mentioned, I am decidedly of opinion
 that  this operation should always be attempted in preference to the ordinary
 one of opening  the  sac, in those  cases in which the hernia has not been long
 strangulated, presents no sign of the occurrence of gangrene in  it, and more
 especially when  it is femoral  or umbilical.  Even if the surgeon fail in com-
 pleting Petit's  operation, in consequence of  the  incorporation of the stricture
 in the  neck  of the  sac, or the constriction of this part,  no harm can have
 resulted; for the sac, after being exposed, may  at any time be opened  in  the 
794                  STRANGULATED HERNIA.
ordinary way,  and the  operation  completed  by dividing  the  stricture from
within.
  When the hernia is of large size and irreducible, it is of especial importance
to avoid opening the sac.  If this  be done, the contents will inflame, and fatal
peritonitis commonly ensues.  In  these cases, as  Mr. Luke  has  pointed  out, it
rarely happens that the adherent parts are seriously strangulated, but the whole
mischief seems to be occasioned and to be received by the new  protrusion that
has taken place, and gives rise to the tension; and  if this can be liberated and
reduced, the surgeon has done all that need be accomplished.  The evidence of
the  reduction  of the  recent protrusion, although the old adherent and irredu-
cible hernia be left, is usually sufficiently obvious, the portion of gut returning
with a slip and a gurgle, with considerable  diminution in the general tension
of the tumor.
   With regard to the mode  of performing Petit's operation, little need be said
here, as it is precisely identical with the steps of the other operation up to the
period of the exposure of the sac, except that, when it is not intended to open
this, the incisions should be carried more directly over its neck.   The stricture,
if situated outside the sac, will then be found either in some of the tendinous
structures surrounding it, or else in the  subserous cellular tissue lying upon it.
After the division of the constricting bands in this situation, by means of a
probe-pointed knife carried underneath them, or by dissecting down upon them,
an attempt at  the taxis may be made  by compressing  the tumor in the usual
way, at the same time that its neck is  steadied by the fingers of the left hand.
If the  contents can be  reduced,  the  incision in the superficial structures is
brought together by a few strips of plaster, over  which a pad and bandage may
be applied.  Should peritonitis  come  on, as  the result  of  the strangulation, it
 must be  treated  in the usual way.  If, after the surgeon has fairly divided all
 the structures  outside  the  sac, he finds still that the  return of the  hernia is
 prevented by some constriction in  its neck, it will be necessary to lay  this open
 and divide the constriction in the usual way.

              REDUCTION OF  THE HERNIA  IN  MASS.

   The reduction of the hernia in  mass consists in the return of the sac and its
 contents  into  the abdomen, still in a state  of strangulation.   When it is said
 that the  parts are returned into  the  abdomen,  it must not be  understood that
 they are  pushed back into its cavity, but that the external  protrusion  is caused
 to disappear by being  pushed into the subserous  cellular tissue, behind and
 underneath  the parietal  peritoneum  between it and the  abdominal muscles.
 This remarkable accident, which was first described by the French surgeons of
 the last century, received little  notice from practitioners in this country, until
 attention was drawn to  it by Mr. Luke.
   Reduction in mass has only been observed in cases of inguinal  hernia,  and
 has chiefly occurred  from the patient's  own  efforts  in reducing a strangulated
 rupture.   It is a remarkable fact,  that in most of the instances in which it has
 occurred, only a very slight degree of force  appears  to  have been employed in
 the reduction  of the tumor, and the accident would seem to have resulted from
 the  adhesions  between the  sac and the neighboring parts being much weaker
 than natural, so that a moderate degree of force caused the whole to slip through
 the canal.   It may, however, occur from the surgeon's  efforts,  if these are too
 forcible or long continued.
   The symptoms  indicative of this accident are constitutional  and  local.  The
 constitutional  symptoms consist in a continuance of those that are indicative of
 the existence  of strangulation, notwithstanding the disappearance of the tumor.
 The vomiting and constipation persisting, the  patient  speedily becomes much 
REDUCTION  OF  THE HERNIA  IN  MASS.         795
depressed in strength, being seized with hiccup and prostration of all vital power;
signs of gangrene then evince themselves within the sac.
  An examination  of the parts of hernia will  usually enable the surgeon  to
recognize  the  nature of the  accident; he will  ascertain that a tumor had
previously existed, and will  learn, from a description of its general characters
and the symptoms occasioned by it, that it was in  all probability a strangulated
rupture.  He will then find, on examining the part, that there is a total absence
of all that fulness which is occasioned by  the  presence of the sac, even after
its contents only have been  reduced; the sac, in such cases, always giving rise
to a feeling of fulness and roundness in the  part.  He will, on the  contrary" find
that the abdominal  ring is peculiarly and  very distinctly opened; it is  much
larger  than usual,  and  somewhat rounded.  On  pushing the  finger into  the
canal, this will be felt quite  empty, but in some  cases on deep pressure with the
finger, especially when the  patient stands  up or coughs,  a rounded tumor may
be indistinctly felt behind the ordinary seat of the hernia.  In many cases, how-
ever, the most careful manual examination will fail to detect any prominence
of this kind.
   If, after careful  examination of such a case  as this, in which the  symptoms
of strangulation continue, the surgeon learns by the  previous history that a
tumor has existed, that  it has suddenly gone up, and, further,  if he finds that
the seat of the  supposed hernia  presents  the  negative evidence that has just
been described, it will then be necessary for him to push his  inquiries  a step
further by an  exploratory incision.  Such an incision as this may first be used
as a simple means  of diagnosis, and, as  it does  not  penetrate the  peritoneal
cavity, there  is no  danger  attending  it; and if  the  hernia  be found, it will
serve the purpose  of the ordinary incision required in the operation, and may
be used for the relief of the  strangulation.   The first incision should be made
so as to expose the  abdominal ring; if this be found peculiarly round and open,
it would increase the probability of the  existence of the condition sought for.
The inguinal  canal must next be laid open, and the parts contained within it
carefully examined.  If no appearance of  hernial sac is found,  but the cord
distinctly and clearly seen, still further presumptive evidence will be afforded
of the reduction having  been effected in mass;  for if the hernia have been put
back  in  the  usual  way,  the sac will necessarily be left in the canal, and will
preserve its usual relations to  the  cord.  This supposition will be strengthened
almost to a certainty if it be found that the "condensed cellular capsule imme-
diately investing  the sac," as it  is termed by  Mr. Luke — in other words, the
condensed and laminated subserous cellular tissue — has been left in the canal.
An opening made into this will, as that surgeon observes, allow the finger to be
brought into contact with the hernial tumor itself.  Should,  however, this con-
densed cellular tissue not be found, it must not  be concluded  that no hernia is
present, inasmuch as this investment may have been accidentally absent.  The
finger should then be passed into the internal ring, which will probably be found
open, and being carried from side  to side, the  tumor, if present, will be detected
lying external to the peritoneum,  behind the abdominal wall.  When found, it
must  be brought down  into the  canal by  enlarging the ring; it must then be
opened, its contents examined, and the stricture in its neck divided. The intes-
tine that has been so strangled must be dealt with in accordance with the rules
already laid down.  If the tumor cannot be  readily brought down so as to admit
of an examination of it and its contents, the patient should be desired to make
some  propulsive efforts,  so as to cause it to  protrude.  If it still do not come
down, it must be opened, and the stricture cautiously divided within the abdo-
men with a sheathed bistoury.
  Hydrocele of the hernial sac is a rare condition, the pathology  of which has
already been  adverted  to.   In the treatment, two lines of practice  are  open,
the palliative  and curative.   The first consists in  merely tapping,  and thus 
796
INGUINAL  HERNIA.
withdrawing the fluid, and the other in freely laying open the lower portion of
the sac, and endeavoring to secure its closure by granulation.  This operation,
which, however, is not devoid  of danger, has  been performed with success by
Pott and others.
                         INGUINAL  HERNIA.

   By inguinal hernia is  meant that protrusion which occupies the whole or a
portion of the inguinal canal, and when fully formed passes out of the external
abdominal ring into the scrotum.   Many varieties of this hernia are recognized
by surgeons.   Thus it is said to be complete when it passes  out of the external
ring;  incomplete or interstitial,  so  long as  it  is contained within  the  canal;
oblique,  when it occupies the whole course of the canal;  direct, when it passes
through a limited extent of it;  congenital, when it lies in the sac of the tunica
vaginalis; and encysted or infantile, when it  lies behind this.  Inguinal herniae
constitute the commonest species of rupture,  and would be much more frequent
than they are, were  it not for the  obliquity of the canal,  and  the manner in
which its sides  are  applied to one another, and  closely overlap the spermatic
cord.  They occur with most readiness in those  cases in which the canal is short
and the apertures wide.   Although these herniae are commonly incomplete in
their early stages, it is seldom that they come under the  observation  of the
surgeon, until the protrusion has  passed beyond the external abdominal ring.
   The oblique  inguinal hernia, often called external, on account  of its relation
to the epigastric artery, passes through the whole length of the canal, from one
ring to the other; and usually protrudes through the external one, constituting
one of the forms of scrotal hernia.   As it passes along the  canal, it necessarily
receives the same investments that the spermatic cord does, although these are
often  greatly modified  in character by being elongated,  hypertrophied, and
otherwise altered in appearance.   If we regard the inguinal canal as consisting
 of a series  of invaginations of the different layers of the abdominal parietes,
 the outermost  being the  skin, and the  innermost the fascia transversalis, with
 the peritoneum applied to  this,  it is easy to understand  how the hernia in its
 descent  has these  prolongations  drawn  over it, thus becoming successively
 invested with  the same coverings as the spermatic cord.   Thus it first  pushes
 before it  that portion  of  the peritoneum which lies in a fossa, just external to
 the epigastric  vessels; it next receives an  investment from the  fascia trans-
 versalis, which often becomes thickened and laminated, constituting the fascia
 propria of the sac; as it passes  under the internal oblique, it receives some of
 the fibres  of this muscle, in the  shape of  the cremasteric fascia, and  lastly,
 when it reaches the external  abdominal  ring,  which it greatly distends  and
 renders  round  and open, it becomes  covered by the  inter-columnar fascia,
 receiving also a partial investment around its neck from  some of the expanded
 and thickened fibrous bands that lie near the  ring, and which are always most
 marked upon its outer side.
    The  relations of the spermatic cord  and  testes, and of  the epigastric artery
 to an inguinal hernia are  necessarily of great importance.   The spermatic cord
 will almost invariably be  found to be situated behind, or rather underneath the
 oblique inguinal hernia, and the  testis will be found to lie at its lower and back
 part,  where it may always be distinctly felt.  In some cases the elements of the
 spermatic  cord become separated, the vas deferens lying on one side, and the
 spermatic vessels on the other.   In other rare  cases again, an instance of which
 there is in a preparation in the University College  Museum, the hernia lies
 behind the cord, and has  the testis in front.   In other  cases again, it  may
 happen, as was observed during an operation in which I assisted my friend, the
 late Mr. Morton, that the elements of the cord are all separately spread out on
 the forepart of the hernial tumor.
    The  epigastric artery has the  same  relations to the oblique inguinal hernia
 that it has to the spermatic cord, lying to the inner side of and behind its neck. 
INGUINAL HERNIA.
797
The pressure of large and  old  inguinal herniae has,  however, a tendency  to
modify somewhat the relations of this  vessel.   By distending the  rin°s  and
dragging the posterior wall of the canal downwards and inwards, they shorten
the canal, and cause a great  deflection of the  artery from its natural course,
which  is changed from an  oblique  direction to being curved downwards and
inwards, under the outer edge of the rectus muscle.
   The direct  inguinal hernia does  not pass out  like the oblique through the
internal abdominal ring, but pushes forwards through  a triangular space, which
is bounded by the epigastric artery on the outer side, the edge of the rectus  on
the inner,  and the crural arch at its  base;  through this the  hernial tumor
protrudes,  pushing before it, or rupturing the posterior  wall of the inguinal
canal.   The coverings that this form of hernia receives, vary according to the
length  of the canal that it traverses,  and the portion of  the posterior wall
through which it  protrudes.  In  fact,  there are at least two distinct forms of
direct inguinal  hernia, which differ according as they are situated  above or
below the obliterated remains of the umbilical artery.   One, the most common
 variety, is  situated below the cord-like remains of this vessel, between it and
 the outer edge of the rectus.   The  other, which is of less frequent  occurrence,
 is situated  above this vessel, between it  and  the epigastric artery.   In that
 form of direct inguinal  hernia, which  lies below the  umbilical artery, the pro-
 trusion takes place through that part of the posterior wall of the inguinal  canal
 which  is situated almost behind  and  opposite to the external  ring.  In this
 situation, the investments  successively received  by the hernia, are,  first, the
 peritoneum and the fascia transversalis; it then comes in contact with the con-
 joined tendons  of the internal  oblique and transversalis muscles, which it may
 either rupture or push before it, thinned out and expanded.  Most frequently
 these  are ruptured, constituting a partial investment to the protrusion, which is
 most evident  on the innermost part of the sac, that which is nearest the mesial
 line.  As  the hernia passes  through the  external abdominal ring, it receives
 from it the inter-columnar fascia and fibres, and lastly is invested by  the common
 fascia and  integuments.   In that  form  of direct inguinal  hernia which lies
 above the  umbilical artery, but which is of rare occurrence, the protrusion may
 pass under the lower edge  of the transversalis muscle, and then receives a
 partial investment of cremasteric fascia, especially on its iliac side, as it comes
 into  relation with  the internal oblique.  This form  of direct inguinal hernia,
 therefore,  receives very  nearly the same covering that the oblique does, though
 its investment by the cremaster is not so perfect.  It does  not come  into relation
 with the conjoined tendons.
   In  the direct inguinal hernia, the spermatic cord lies to the outer side of  the
 sac (fig. 318), and its elements are  never separated from one another, as occa-
 sionally happens in the oblique.  The epigastric artery also is on the outer side,
 but usually arches very  distinctly over the neck  of the sac, sometimes indeed
 completely encircling the upper as well as the outer margin (fig. 318).
   The incomplete or interstitial hernia is usually  of the oblique kind, but Law-
 rence  has  observed that it  may be of the  direct variety. ^ It often  escapes
 notice, but may not unfrequently be observed on the opposite  side to an ordi-
 nary inguinal hernia.   Double inguinal  hernia on opposite sides  are of very
 common occurrence, and they  may be of  the  same, or  assume different  forms.
 In  some  instances,  as  in the annexed drawing, from  a preparation in  the
 University College Museum, the  two forms may be observed on the  same side
 (fig. 317).                                                          .
   In  females, inguinal herniae are not common, except at advanced periods of
 life;  they  will then be seen to have the same relations as in the  male, except
 that the round  ligament is substituted for the spermatic cord.
   The symptoms  of inguinal hernia vary  somewhat  according to its character,
 whether interstitial, complete or scrotal, oblique or direct.   In the interstitial 
798
INGUINAL HERNIA.
hernia, a degree  of fulness will be  perceived  in the canal when the patient
stands or coughs, and on pressing the finger on the  internal ring, or passing it

          Fig.  317.                             Fia. 318.
  Double inguinal hernia on the same side—      Double direct inguinal hernia — neck of
oblique above, direct below — separated by    sac crossed by epigastric artery.
epigastric vessels.
up into the external ring, and directing the patient to cough, a distinct impulse,
together with tumor, may be felt.  In  the ordinary oblique inguinal hernia, a
tumor of an  oblong or oval shape, oblique in its direction, taking the course of
the canal downwards and forwards, will be felt protruding through the external
abdominal ring, and presenting all the usual signs of a hernia.   So long as it is
confined  to  the neighborhood of the pubes, it is of moderate size; but when
once it gets into the scrotum, where it meets with less resistance, it may gradu-
ally enlarge  until  it attains  an  enormous bulk.   The testicle, however, may
always be felt pretty distinctly at its posterior inferior part.   In women this
form of hernia descends into the labium, but never attains the same magnitude
as in men.    When of  large size, these  ruptures usually contain both  intestine
and omentum, most frequently a portion of the ileum, though the various  other
viscera, such as the ccecum, bladder, &c, have been found in  them.  In the
direct inguinal hernia, the symptoms pretty closely resemble those of the oblique,
except that  the tumor  is more rounded, and  usually not so large; the  neck
wider, and situated near the root of the penis, with the cord on  its outer side.
   The different forms  of inguinal hernia are not unfrequently complicated with
various other affections; either with different kinds of rupture, or with diseases
of the cord or testis, such as  hydrocele of the cord, of the tunica vaginalis, or
varicocele; these various complications necessarily make the diagnosis somewhat
more  obscure, but with care and practice it may generally easily be made  out.
   The diagnosis of inguinal hernia is usually readily effected, the characters
and position  of the tumor enabling  the surgeon to determine its true nature.
In  most cases it  is useless  to  endeavor  to  ascertain whether the hernia is
oblique or direct,  all old oblique herniae having a tendency to  drag the  inner
ring downwards and inwards, approximating it and bringing it nearly opposite
to the outer  one, shortening and destroying the obliquity of the canal.  Hence
the direction of the neck and of the axis of the tumor in these cases so nearly
resembles what is met  with in the direct form  of hernia,  that the surgeon 
DIAGNOSIS  OF INGUINAL  HERNIA.
799
should not attempt to undertake  the  operation, more particularly the division
of the stricture, on any imaginary diagnosis.   Some forms of femoral hernia
may occasionally be confounded with the inguinal; the distinguishing points
between these two forms of the  disease will  be considered in the section on
femoral hernia.
   The diagnosis of inguinal  hernia from other diseases in this vicinity has to
be considered under the  two conditions in which the rupture is found, in  the
canal, and in the scrotum.   Whilst in the canal, the inguinal hernia requires
to be diagnosed, — 1st. From abscess, descending from the interior of the abdo-
men or pelvis through the canal,  and  passing  out through  the abdominal ring.
The diagnosis may here be effected by recognising the soft fluctuating feel of
the abscess, which though  reducible on pressure, and descending on coughing
with  a distinct  impulse, does not present the  more solid  characters and  the
gurgling sensation of a hernia.   2d.  From encysted or diffused hydrocele of the
cord.  In the encysted  hydrocele there is a smooth  oval swelling situated on
the cord, which  can be apparently reduced, being pushed up into the  canal, and
descends again  on coughing or straining; but it maybe distinguished from
hernia by being always of the same size, by not being reducible into  the cavity
of the abdomen, by the  absence of all gurgle, and by its very defined outline.
 In the diffused hydrocele of the cord, the absence of distinct impulse  on cough-
 ing, the impossibility of returning the swelling completely within the  abdominal
 cavity, and  of feeling the  cord  in a free and natural state, will prevent the
 disease being confounded with hernia.   3d.  Fatty or other tumors occasionally
 form on the cord, but the circumscribed character and limited size of these
 swellings, the absence of impulse on  coughing, and of reducibility into the
 cavity of the abdomen, will point out that  they are not herniae.  4th. The
 lodgement of the testis in the  inguinal canal will give rise to a tumor, which
 closely resembles incomplete inguinal hernia, and if it should happen  to become
 inflamed in  this  situation,  the  difficulty of the diagnosis from strangulated
 hernia may  be very  considerable.   In the  ordinary undescended  testis, the
 absence of that  organ in the scrotum  on the affected side, the peculiar sickening
 pain occasioned by the pressure of the tumor, the absence of gurgling, and of
 all possibility of reduction,  will  enable the  diagnosis to be effected.  A very
 remarkable case of inflamed testis in the inguinal  canal simulating a strangu-
 lated inguinal hernia, occurred  some time ago at the hospital.   A  man about
 forty, said  to be  laboring  under strangulated hernia, was sent up  from the
 country for operation.   On  being called to  him, I found the house-surgeon
 attempting the reduction of the tumor in the hot bath;  but as soon as I felt
 the swelling, I  was convinced from  its hard, solid, and  irregular feel, that  it
 was not a hernia.   On inquiring into the history of the case it appears that the
 patient had, for the last two days, suffered from  occasional vomiting, and  had
 been constipated; that  the tumor in  the  groin  had not appeared suddenly,
 though it had enlarged with great rapidity, and that it was excessively painful;
 and that he had always worn a truss  for a supposed rupture on  that side, until
 the last few weeks, when, in consequence of the instrument breaking, he  had
 discontinued it.   On  examining  the groin carefully, a tumor about  as large as
 the fist was found in the right inguinal canal; it was tender to the touch, hard,
 and irregular at the upper  and outer part, but somewhat  soft  and  fluctuating
 below; when the  finger was passed into  the external ring, the  outline of the
 tumor could be very  distinctly felt in  the canal.   There was no impulse  in  it
 on coughing, but  some  abdominal tenderness on  that side.  The right testis
 was not in the scrotum.   I ordered the man to be bled, the tumor to be leeched,
 and salines administered; under this treatment the case did well.
   When the hernia has descended into the scrotum, it may be confounded, 1st.
 With hydrocele  of the tunica vaginalis.  In this disease, there is an oval or pyri-
form tumor, usually translucent,  unchangeable in size or shape by pressure, and 
800
INGUINAL HERNIA.
having the cord clear and distinct above it, with an absence of impulse on cough-
ing, or of gurgling in attempts at reduction.   In cases of congenital hydrocele
in children, in which there is still an opening communicating with the perito-
neal cavity, the tumor may be diminished in size, by steady pressure, but gradu-
ally returns again, fluctuates, and  is translucent.  In these cases its translucency,
the gradual manner in which the sac is emptied, and is refilled, so different from
the sudden slip up and protrusion  of a hernia, enable the surgeon to establish
the diagnosis.  It  not unfrequently  happens  that  hernia  is complicated with
hydrocele of the tunica vaginalis.  In these cases, the two separate tumors can
usually be distinguished, there being some degree of constriction, or of consoli-
dation, between them.   The hydrocele will  present its ordinary characters of
translucency, irreducibility, and  circumscribed outline, and is commonly placed
anterior to the hernia, which lies towards the back of the scrotum, and may be
distinguished  by its  reducibility and  impulse  on  coughing.   It  sometimes
happens, as in a case which recently fell under my observation, that a hydrocele
of the cord is associated  with one  of the tunica vaginalis, and a hernia;  under
such circumstances, the diagnosis requires a little  care,  but may be effected
readily enough by separately  determining the  characters of the  different swell-
ings.  2d. From varicocele, the diagnosis may be  effected in the way pointed out
by Sir A. Cooper.  The patient should be placed in the recumbent position, and
 the swelling reduced;  the surgeon then presses upon  the external ring with his
 fingers, taking care to cover the  whole of it, and desires the patient to stand up.
 If it be a hernia, the tumor cannot descend, but if a  varicocele, it will speedily
 reappear, whilst the pressure  is  being kept up, the blood being conveyed into it
 through the spermatic arteries.  3d. Tumors  of the testis may be distinguished
 from hernia by their solid feel, rounded shape, by the absence of all impulse on
 coughing, and, especially, by the cord being felt free  and clear above them, and
 the inguinal  canal unoccupied.   4th.  In hematocele,  the cause of the swelling,
 its  pyriform shape, opacity,  solid feel,  the absence of impulse on  coughing,
 and  the defined characters of the cord, will  enable  the surgeon to make the
 diagnosis.
    Treatment of inguinal hernia. — When reducible, the rupture must be kept
 up by a well-made truss, the pad of which, of an  oval  shape, should press not
 only upon the external ring, but upon the whole  length of the canal.  When
 irreducible, and of large size, nothing can be done  beyond supporting it in a
 bag-truss.
    When  strangulated, if the taxis  properly  employed  in the direction of the
  canal has failed, the operation must be proceeded with  in the following way: —
  The bladder having been emptied, and the pubes shaved,  the patient should be
  brought to the edge of the bed, and the surgeon, standing between his legs, and
  having the skin covering the external ring well pinched up, divides the fold in
  the usual way, by an incision three inches in  length,  commencing about an inch
  above the external abdominal ring.   Should  any spouting vessels, as the super-
  ficial external pudic, be divided in  this incision, they  had better be ligatured.
  The  surgeon then proceeds with  the section through  the subcutaneous struc-
  tures; he will find in many cases the superficial  fascia considerably thickened,
  more particularly if the  patient has long worn  a truss.   He  divides this  struc-
  ture  in  the line  of the  external incision, and  then  exposes the inter-columnar
  fascia, which will also generally be found thickened and  incorporated with the
  superficial fascia.   In many cases, the  inter-columnar  fibres will  be found con-
  densed into a thick and broad fillet, which limits  the  further extension of the
  ring, and  produces an  evident constriction  upon the neck of large inguinal
  herniae. An opening should be carefully made into this fascia, a grooved director
  passed under the  edge of the ring, and this slit up.  In some cases, though but
  very rarely, it will now  be found  that the hernia may be reduced, its  strangula-
  tion depending on the constriction of the margins of  this aperture; most com- 
TREATMENT  OF  INGUINAL  HERNIA.           801
monly, however, the stricture is situated  deeper than this.   The  cremasteric
fascia, which is generally  considerably  thickened,  is  now exposed,  when its
fibres will be found to form a kind  of  reticulated mesh over the hernial tumor.
This stricture must be carefully divided upon a  director, when the  subserous
cellular tissue, or fascia propria, will be laid bare.   This structure is  usually
thickened and vascular, and not unfrequently the stricture appears to be situated
in it, or in a kind of condensed  ring formed by the  incorporation of it with the
meshes of the  cremaster.  If it be found, after the division of these fasciae, that
the  stricture has been removed, and  the  hernia can be  reduced,  it would of
course be unnecessary to lay  open the  sac, and the safety of the patient will be
considerably enhanced, more  particularly if the operation is performed for an old
scrotal hernia  of large size, by not doing so.   If, however, as will happen in the
majority of instances, in inguinal hernia, it will be found that the stricture is in
the neck of the sac itself, occasioned by a condensation, constriction, and  puck-
ering of it, the sac must be carefully opened at its anterior part, the  finger intro-
duced, and the stricture divided from  within, by pressing  the finger-nail under
it, and cautiously sliding the hernia-knife  along  this.  It is an established rule
in surgery,  that this division should be  effected  in  a direction immediately
upwards, so that it may lie  parallel with  the epigastric vessels, whether it be
situated upon  the inner or outer side of  these.   It  is true that if  the surgeon
could be sure  that he had to do with an oblique inguinal hernia, he might safely
divide the stricture outwards, or, if he was certain  that the  protrusion was of
the  direct kind, he might  make  the section  inwards;  but,  as it commonly
happens that  he cannot determine with absolute certainty which hernia  he is
operating upon, he adopts the  safer plan recommended by Sir A. Cooper and
Lawrence, of cutting upwards from the middle of the ring parallel to the epigas-
tric  vessels.
   The seat  of stricture in inguinal hernia  will thus  be seen to differ in different
cases, and in some instances it  exists  in two situations.   I  think it most com-
monly occurs in the neck of the sac, owing to contraction and elongation of it
with condensation  of  the subserous cellular tissue   lying immediately upon it.
In other cases, though much more  rarely,  it seems to be formed by a thickening
of the transversalis fascia at the inner  ring, but altogether  outside the sac; occa-
sionally it is met with in some part of the canal, at  the lower edge  of the inter-
nal  oblique, but much more frequently at the external  abdominal  ring.  In
many cases there is very tight constriction in this  situation, as well  as  in the
deeper portions of the canal, or  at the inner ring;  hence  after the division of
any  stricture at the external abdominal  ring, the deeper  portions  of the canal
should always be  carefully examined before any attempt is made to put the
hernia back.
   The operation for an incomplete inguinal hernia  requires  to  be conducted in
the same way  as that which  has just  been described, except that  the incision
need not be quite so  long, and  should not  extend beyond the  external ring.
After this has been laid open, and the tendon of the external oblique slit up, a
flat  director must  be passed under the  lower edge  of the internal  oblique and
transversalis muscles, which  must be carefully divided; should  the stricture not
be relieved  in this way, and the sac require to be   laid open, the deep section
must be made in  the same way and in  the same direction as has already been
described.
   Inguinal herniae, which contain either the  cecum, the sigmoid flexure of the
colon, or the urinary bladder.—In these  cases  the protruded  viscera axe only
partially covered by peritoneum, hence  in operating upon such herniae, when
strangulated, care  must be  taken  that the intestine be not wounded, which is
apt to occur,  in consequence of the  surgeon dividing the  parts without due
caution, not suspecting himself  to  be in the neighborhood of the gut, in conse-
quence  of his not having reached a  sac, which  does  not exist.   As the pro-
         51 
802
INGUINAL HERNIA.
truded  parts are generally adherent in these cases, the surgeon  must content
himself with leaving them unreduced after the division of the stricture; under
such circumstances, it has happened that the protrusion is ultimately drawn back
into the abdomen by some natural action of the parts.
  Operations  for strangulated  inguinal hernia  are required during a greater
range of ages than those for any other kind of protrusion.   I have operated suc-
cessfully for congenital  hernia  in infants less than six weeks old, and for an
ordinary oblique inguinal hernia in one four months of age, and it has been done
on centenarians. When small and recent, the protrusion usually consists of in-
testine  only;  when  large  it commonly contains omentum as well.  The treat-
ment of these contents, and the  after management of the case, must be conducted
in accordance with the rules laid down at page 785, et seq.
  Hernia of the tunica vaginalis or congenital hernia.—In this case the hernia
descends  inside the  tunica vaginalis, which  constitutes its  sac.   It is  always
oblique, and takes the course of the spermatic cord; most commonly descending
into the scrotum, but sometimes lying within the  canal, out of which, perhaps,
the testis has imperfectly  passed.  This hernia differs from an ordinary oblique
hernia in  the absence of a true peritoneal sac, and in the protruded parts lying
in the tunica vaginalis and in  contact with the testicle (fig. 319).  The great
peculiarity, indeed, of this hernia consists in its  descending  along the canal,
left open  by the descent of the testis.  It is well  known that in the foetus the
testis originally lies below the kidney, and as it descends in the later months
of foetal life into the inguinal canal and scrotum, it pushes before it a prolonga-
tion of the peritoneum, exactly  resembling a hernial sac.
   That prolongation of  the peritoneum which is carried down around the testis
in its descent, may be divided into two portions, the funicular and the testicular.
The funicular  being  that which corresponds to the cord, extending  from the
internal ring to  the scrotum; the testicular being that which becomes the tunica
vaginalis.   A congenital  hernia  occurs in  consequence  of the funicular  pro-
longation not becoming,  as in the  normal condition, converted into a filamentous
fibro-cellular tissue, but remaining pervious,  and thus serving as a medium of
communication  between the general  cavity of the peritoneum and the tunica
vaginalis, and along the  open channel thus left the congenital  hernia descends.
The reason  why in many cases  the hernia is not truly congenital, but occurs in
after-life, is that the funicular portion is only partially closed or contracted, and
that under a sudden effort this septum is broken through, and thus the gut falls
into the tunica vaginalis.
Fig. 319.
Fig. 320.
Congenital hernia.
Infantile hernia.
  Hernia of the  tunica vaginalis, though usually called " congenital" is rarely
so in reality; the tendency is congenital, but the disease is not.   It not unfre- 
        SYMPTOMS OF, AND  OPERATION FOR CONGENITAL HERNIA.     803

quently happens, it is true, that these herniae show themselves early in life, in
infants a few weeks or months old; though  at these  ages even the funicular
prolongation of the peritoneum may be so completely occluded, that the hernia
which occurs is of an ordinary oblique character.   Not unfrequently, however,
the hernia does not take place until a considerably later period of life than this,
and may suddenly happen in the adult; thus, Velpeau relates instances in which
it occurred for the first time between the ages of  eighteen and twenty-five.   I
lately operated in a case on a man  thirty-five years of age, in whom this  kind of
hernia occurred for the first time when he was twelve years old; and some years
ago, in a case at the  Hospital, on a man about fifty, in whom, on  the most care-
ful inquiry, it would appear  that  the protrusion had  not shown itself  until he
was about thirty years of age.
   The symptoms of  hernia in the tunica vaginalis closely resemble those of the
 ordinary oblique;  most commonly, however, the scrotal tumor is much rounded,
 and the neck feels narrow and constricted.   The testis, also, cannot be felt dis-
 tinct and separate from the tumor, but is surrounded by, and, as it were, buried
 in the substance of  the hernia,  through which  it may sometimes be felt at the
 lower and back part of  the scrotum.
   When  an undescended testis  is complicated with  congenital hernia in the
 inguinal canal, much difficulty may occur in effecting  the diagnosis.  In a case
 of this kind to which I was  lately called by my friend Dr. Pretty, there could
 be felt behind and  above  an inflamed and swollen  testicle, which lay at the
 external abdominal ring,  a small,  hard, round tumor in the upper portion of the
 canal; as symptoms of strangulation were urgent, this was cut down upon, the
 anterior wall of the canal incised,  and the tunica vaginalis, much distended with
 fluid laid open, when a small knuckle of intestine was found lying at its upper
 part, very tightly constricted by the inner ring.
   The treatment of congenital hernia consists in the reduction of the tumor and
 the application of a proper truss,  the pad of which should compress the whole
 length of the inguinal canal.  In  some cases, in children, a radical cure may be
 effected in this way; but in order to accomplish this  desirable result, the truss
 must be worn  for at least a couple of years.   The application of a truss with an
 air-pad will in many instances  be found especially useful, more particularly in
 children, in whom  it  applies itself with greater exactness than an  ordinary
 incompressible one.
    When strangulated, the congenital hernia does  not  commonly admit of reduc-
 tion, and thus necessarily renders an operation imperative.  This procedure is
 more  commonly  required for this kind of hernia in  adults than in infants.
 During the last five years I have operated  on 12 cases of congenital hernia;
 of these 7 were  on adults from twenty-two  to fifty years of age; 1 on a lad of
 fifteen; 1 on a child of four months; and 3 on infants under six weeks of age.
 The operation is the same as that for oblique inguinal hernia, but the parts  con-
 cerned are usually thinner, the tunica vaginalis serving  for a sac;  hence more
 caution than usual is  required in these cases.  The sac commonly contains a
 large quantity of clear dark-colored fluid, there being, in fact, a hydrocele  con-
 joined with the  hernia.   The  stricture will, I believe,  always be found in the
 neck of the sac, which  appears to be condensed, elongated, and narrowed; hence
 it is useless in these cases to endeavor to relieve the strangulation, without lay-
 ing open the sac, and dividing its neck from within.  As the congenital hernia
 is always external to the  epigastric vessels, the section of the stricture  may be
 done with perfect safety in  a direction upwards and  outwards; though, if the
 surgeon should have any doubt  as to the exact nature of the case, it will be
 better to divide the stricture directly upwards.  The  reduction of the  contents
 of the hernia will often  be  prevented  by adhesions  in the neck of the sac, or
 between them and the testes.   I  have found both the gut and omentum closely
 incorporated with this  organ, and requiring some nice dissection to  separate 
804
INFANTILE  AND  FEMORAL  HERNIA.
them.  In operating upon infants  of a very tender age, much caution will ne-
cessarily  be required, on account of the density of the coverings, their tension,
and the small size of the apertures.   The testes, as well as the spermatic cord,
the veins of which are excessively turgid, will usually be found much congested,
and of a black or bluish-black color.
   A species of congenital hernia has  been met with  in the female, especially
in children, in which the protrusion takes place into the canal of Nuck, which
invests the round  ligament.   In one instance I have seen a double inguinal
hernia in  a girl of five years old.   It is of extremely  rare occurrence,  and
requires  the same treatment as the corresponding disease in the male.
   The encysted hernia  of the  tunica  vaginalis, or infantile hernia, as it has
been  somewhat absurdly termed, occurs in those  cases in which the funicular
portion of the tunica vaginalis is partly obstructed by a  septum, or  by being
converted  into filamentous  tissue, but in such a way as to leave  a pouch above,
which is protruded down behind  or into  the  tunica vaginalis, so  that it lies
behind this cavity (fig. 320).   There are  no characters by which the encysted
can be distinguished from the ordinary congenital hernia.   If it should become
strangulated, it must be borne in mind  that, during  the operation, the tunica
vaginalis will first be opened; no hernia will be seen here, but the tumor lies
behind this sac, and requires to be dissected into through the double serous
layer of  which it is composed.   The stricture would  probably be in the neck,
and requires to be divided in the usual way.
                         FEMORAL  HERNIA.

  By femoral hernia is usually meant a protrusion that escapes under Poupart's
ligament, and enters the sheath of the vessels internal to the femoral vein.  This
hernia passes down into the  innermost compartment of the sheath, which is
occupied by fat and lymphatics, and usually contains a gland or two.  It passes
first of all through the crural ring, where it has Gimbernat's ligament to its
inner side;  the  septum, which separates the femoral vein from the inner com-
                                  partment of the sheath of the vessels to its
                                  outer aspect;  Poupart's  ligament in front,
                                  and  the bone behind  (fig.  321).   After
                                  passing through  the crural ring, it enters
                                  the  crural canal, which  extends for about
                                  an inch and a half  down the thigh on the
                                  pectineus muscle, and is covered by the
                                  iliac prolongation of the fascia lata.   As it
                                  approaches the lower corner of the saphe-
                                  nous opening, where the canal terminates,
                                  it passes under the falciform process of the
                                  fascia lata, and out upon the thigh through
                                  the  saphenous aperture; here it expands,
                                  becomes rounded, and has often a tendency
                                  to turn  upwards  over Poupart's ligament
                                  (fig. 323), lying in  this  way upon the iliac
                                  region, and sometimes even  ascending  to
                                  some distance upon  the  anterior abdominal
                                  wall. In the descent of the hernia through
                                  this course, it first  of all pushes before it
                                  the  peritoneal sac, and  then receives an
                                  investment of the subserous  cellular tissue.
It next  comes into relation with the  septum  crurale, a mass of dense cellular
tissue, containing fat and lymphatics, occupying the crural ring.   This septum
often becomes  incorporated and matted with the contiguous portion  of  the
  1, Femoral  artery; 2, femoral vein;
3, innermost compartment of the sheaths
of the vessels into which a small hernia
is protruding; 4, saphena vein. 
RELATIONS AND  SYMPTOMS OF FEMORAL HERNIA.  805
sheath, thus constituting the fascia propria of this hernia, which is commonly
thickened, laminated, and of an opaque fatty structure, like omentum.  As the
hernia continues  to  descend, it comes into relation with the cribriform fascia,
which occupies the saphenous opening, and, lastly, pushes before it the integu-
mental structures.
  As the tumor descends through this course, it necessarily comes into relation
with very important parts (fig. 322).   Thus it is separated from the femoral vein
solely by the septum of  the                     FlG  322
sheath of the vessels.  It  has
the  epigastric  artery above
and to its outer side,  and the
spermatic cord in the male,
or round  ligament   in   the
female,  almost  immediately
above it.  The  obturator ar-
tery, when arising in the nor-
mal  manner from the internal
iliac, does not come into rela-
tion  with  the neck of  the
 sac;  but when  it takes its
 origin, as it not unfrequently
 does, from the external iliac,
 the  common femoral, or the
 epigastric, it may have  im-
 portant relations to  this  part
 of the hernia.    Most  com-
 monly, under these  circum-
 stances, it passes  to  the  iliac
 or outer side of the neck, but
 occasionally it  winds  round
 its inner or pubic side, coming
 into  pretty close  relation with
 it, and then, as will immediately be  mentioned, may be in considerable danger
 during the operation.  The combination, however, of this particular variety of
 the  obturator artery and  femoral  hernia, is  a  very uncommon _ occurrence
 because, in the first place, this internal distribution of the artery is  rare;  and
 when it does occur, as it passes  directly over  that portion of the crural ring
 through which the sac would protrude, it necessarily strengthens this, and so
 diminishes the chance of rupture.                    #                  __,
   The contents of a femoral hernia are usually intestinal, and most commonly
 consist of a portion of the ileum.  Occasionally omentum is contained within the
 sac,  but seldom in large  quantity.  I have, however  several times had occasion
 to operate in cases of Sid femoral hernia, in which it became necessary to remove
 large portions of adherent omentum, in one, ten and a half °»"ce^nd  ».the
 other, about seven.   In each case there was  a sma knuckle of intestine^stran-
 gulated behind  the omentum.   The ovaries,  Fallopian  tubes, &c,  have been
 known to be strangulated in this variety of hernia.
   The symptoms of femoral hernia are usually well marked, they consis of a
 tolerably firm, tense, and unyielding tumor, of a rounded  ^^'^f^1™
 groin, to the inner  side  of the femoral vessels, having its neck ™da Prap£ s
 ligament, though as it increases in size its base may be turned above this struc-
 ture; sometimes, though rarely, it  passes downwards upon the ^gh    Its size
 varies considerably, most  commonly it is not larger t^n a walnu  or a P^eonJ
 egg, and then is deeply  seated in the angle between the body ofthP^V^
 thTfemoral vessels,  out  occasionally it may  attain a cons.de* *   g
 as the fist or a French roll; when large,this hernia usually rises up above fou
  1. Femoral hernia; 2, femoral vein; 3, femoral artery,
giving off, 4, common  trunk of epigastric and obturator
arteries; 5, epigastric artery; 6, spermatic cord. 
806
FEMORAL  HERNIA.
part's ligament, and extends  outwards in a direction parallel to it, so that it
                                 assumes an  elongated  shape; it  is then
             Fig. 323.             usually  somewhat doughy and soft, even
                                 when strangulated; very different from  the
                                 excessively tense feel that it has when small.
                                    In some rare cases the femoral hernia has
                                 been found lying external to the vessels, the
                                 mouth  of the sac being between them  and
                                 the iliac spine.  Under these circumstances
                                 strangulation cannot well occur, inasmuch as
                                 the mouth will be the widest part of the sac;
                                 but, as  Hesselbach has observed, if the fascia
                                 iliaca be torn  by the pressure of the tumor,
                                 the rupture may  be  strangled in the aper-
                                 ture  thus  formed.   Should an operation
                                 ever be required under such  circumstances,
                                 it must be borne in mind that the circum-
 flex ilii artery may be in some danger.
   The diagnosis of femoral  hernia is  not always easy.   When the hernia is
 large, and more particularly when it rises up above Poupart's ligament, which
 some herniae, even of very moderate size are apt to do, it  might at first be mis-
 taken for an inguinal rupture.  The diagnosis, however, may always be effected
 by ascertaining the relation that the neck  of the sac has to Poupart's ligament,
 the inguinal hernia being situated above, the femoral below this cord.  When a
 small femoral hernia in a fat subject rises upwards, so as to overlay Poupart's
 ligament, it resembles very closely an incomplete inguinal hernia, but its charac-
 ters may be determined by the passage of the finger up the canal, which will be
 found to be free, and the hernia can only  be felt through its posterior and infe-
 rior wall.  After reducing a femoral hernia, the finger also can usually be pushed
 into the inferior aperture of the crural canal, when the situation and sharp  out-
 line of the falciform process will determine the nature of the opening through
 which the protrusion has  occurred.
   The  diseases occurring in  the groin, with which femoral  hernia may most
 readily be confounded, are — 1st. Enlarged lymphatic glands in this  situation.
 From these  it may be distinguished by the absence of impulse in the glandular
 tumor,  and by the simultaneous  enlargement of several glands.  A small stran-
 gulated hernia may however co-exist with these, being subjacent to, and covered
 in by them.  When this is the case, and  the local signs  of hernia are obscure,
 whilst the symptoms of strangulation continue, an incision should be made into
 the part, and the dissection carefully carried through and underneath the glands,
 with the view of determining whether the hernia exists  or not.  2d. A small
 fatty growth has been met with in the crural canal, simulating closely a hernia;
 the want of impulse on coughing, together with its limited and doughy charac-
 ter, and the absence of circumscription in the tumor, will enable the surgeon to
 distinguish  it from hernia.   3d. Psoas abscess  not unfrequently points very
 nearly  in the situation of femoral hernia: from  this it may however be distin-
 guished by its fluctuating feel, soft yet semi-elastic character, and by the general
 history of the  case.   The  impulse on  coughing, which is very distinct in the
 abscess,  is  commonly more  forcible and  direct  than  that of  a hernia; and
 although the purulent collection may in many cases be squeezed back into the
 abdomen when the patient lies down, yet  it returns without a gurgle,  and with-
 out that distinct slip which accompanies the reduction of a hernia.  5th. Varix
 of the saphena vein is in some danger of being confounded with hernia.   It may,
 however, be distinguished from this by the impulse in it being less distinct, and
 by the enlargement of the lower part of the vein being marked in the varix, but
 not existing in the rupture.
 
    TREATMENT  AND  OPERATION  FOR  FEMORAL  HERNIA. 807

  Femoral hernia most commonly occurs in women, and very seldom under the
age of twenty; differing in both these respects from the inguinal rupture.  Sir
A. Cooper states that he had only seen three cases under the above ao-e.  It
very seldom becomes  strangulated at an early period of life, even when existing.
I have lately had a girl of nineteen under my care with femoral hernia, in whom
strangulation had already occurred on four occasions, reduction, however havin°-
been happily effected each time.
   The  treatment of  femoral hernia when reducible must be conducted in the
ordinary way by the  application of a proper truss.   A cure, however, is never
I believe effected by  the pressure of  the pad, as sometimes happens in inguinal
hernia, owing probably to the  rigidity and  incompressibility  of the tendinous
and aponeurotic structures through which this rupture protrudes. It is difficult
to keep this form of hernia up by means of a truss.  The best instrument for
this purpose is, I think, the " mocmain truss," which I have found succeed when
all others  have  failed.  When the hernia is irreducible it should be supported
by means of a truss with a concave pad.
   When a femoral rupture is strangulated, reduction should be effected either by
taxis or operation as  speedily as possible, gangrene more rapidly ensuing in this
than in any other form of hernia.   In  attempting the taxis  the structures in
the groin should be well  relaxed by bending the body forwards and flexing the
thigh upon the  abdomen; if it do not succeed with the assistance of the means
recommended at page 778, the operation should be proceeded with at once. The
operation for strangulated femoral hernia may be undertaken earlier and with a
better prospect of success than  that for any other form of rupture; this  is
owing to the  stricture being so commonly seated outside the  sac, that the ope-
ration usually admits of  being  completed without implicating the peritoneum.
The advantage of this mode  of procedure in femoral hernia has been fully
pointed  out by A. Key,  Luke, and Gay, and  is  now, I think, pretty  generally
recognised and practised.   Mr. Gay more particularly, in his Work on Femoral
Hernia, has pointed  out that  the stricture  may  commonly be divided without
opening the sac, by making a very limited incision on the inner side of the neck
of the tumor;  and  he justly observes  that the  operation undertaken  in this
manner  is little more than the taxis with the addition of a superficial  incision.
   The stricture in femoral hernia is often found to be occasioned by the pressure
of the crural arch.   Lawrence states  that  it may  be most effectually relieved
by dividing the thin posterior border of this arch  near the pubes.  Other sur-
geons recommend that  the sharp edge of Gimbernat's  ligament  should be
divided, and  others  again  that the division should be made at the junction of
Gimbernat's and Poupart's  ligament through those ligamentous bands  that go
by the name of Hey's, or the ilio-femoral ligament, or, at the  inner edge of the
falciform  process; and indeed  it is  in  this situation that both Lawrence and
Hey direct the division to be  made.   In operating for femoral hernia, I have
certainly most frequently found the stricture still to continue  after the division
of these ligamentous structures, and to be occasioned by fibrous bands  often
very distinct, narrow, and glistening, lying  across the neck of the sac in the
fascia propria of the hernia; and I agree with the opinion expressed  by Sir A.
Cooper, that  the neck of the  sheath is  the common  seat  of strangulation in
femoral  hernia;  these transverse fibres which sometimes  appear to be partially
reticulated, consisting probably of a condensation of the  tendinous fibres that
are normally found in  the sheath of the vessels.   In order to  expose them it is
commonly necessary  to draw the neck of the sac well down, when they will be
seen deeply to indent and constrict it.
   The operation without opening  the sac may most conveniently be performed,
when the  tumor is of small size,  by  making an incision along the inner side of
its neck and then dissecting through the superficial structures until the fascia
propria is exposed and carefully opened, the finger nail  or a flat director may 
808
FEMORAL HERNIA.
then be insinuated under the sharp edge of Gimbernat's ligament, which at the
point of junction with Poupart's, may be divided upwards  and inwards to the
extent of a line or two by means  of a hernia knife.  The  reduction  may now
be attempted, and often  effected;  should any obstacle exist, the neck of the sac
must be well drawn down and exposed, and any transverse bands situated upon
it dissected through with the scalpel and forceps.   I have on many occasions
found it necessary to do this before reduction could be  effected.
  The  operation performed in  this  way is certainly a very simple procedure,
and  adds  little to the danger of the patient.  If it be thought desirable to open
the sac, the operation must be performed in a different manner, the parts requir-
ing to be pretty fully exposed;  and indeed, if the tumor be of any considerable
magnitude, even though the sac be not opened, it will be better to expose  the
part  somewhat more freely in the way to be described.   An incision snould be
made parallel to Poupart's ligament,  by  pinching up the skin, and then a trans-
verse cut from  the centre of this carried over the  tumor so as to present the
following shape    I  I ; the dissection must then be carried through the super-

ficial fascia, when the septum crurale or fascia propria will be exposed; in some
cases, especially if the  hernia  be a large one, this is  thin, and requires to be
carefully slit  up on a  director.   In many instances, however, it  is so dense,
laminated, and changed in structure, as scarcely to  be recognised for what it is.
It not unfrequently happens that after  the superficial fascia has been divided,
an oval, smooth, and firm body is exposed, which at first looks like the hernial
sac, or a lump of omentum; this  is  in reality the fascia propria, thickened by
the  long-continued pressure of the truss, and congested perhaps by the attempts
at reduction; and in the midst of this, the sac will at last be found after the
dissection has been carried through several layers of this tissue. In it occasion-
 ally  cysts containing bloody serum may be found, and  then the difficulty in the
recognition of the structure is greatly increased.  Though the mobility of this
 mass, the facility of tracing its neck, and the roundness of its general  outline,
 often cause it to be mistaken for sac or  omentum, it may be distinguished from
 the first by the absence of the  characteristic vessels upon its surface, and from
 the second by its more rounded, solid feel, and uniform appearance.  When the
 sac  has been reached, it must be very carefully opened, there being usually very
 little, if  any fluid between  it and  its  contents; the  finger-nail must  then be
 passed under the sharp edge of the stricture, which should  be divided in a
 direction upwards and inwards.   The reason why this  line  of incision is univer-
 sally chosen by surgeons in this country at the present day is, that it is the only
 direction in which the stricture can  be  divided without risk of inflicting serious
 injury upon  neighboring parts.   If the section be made outwards, the femoral
 vein would be in danger; if upwards  and outwards, the  epigastric  artery; if
 directly upwards, the spermatic cord : hence the only direction is either inwards,
 or upwards and inwards.  If the" cut be made  inwards, the sharp edge  of Gim-
 bernat's ligament alone will be  divided, and the crural arch not sufficiently libe-
 rated.  But if the division be made upwards and inwards, the ilio-femoral liga-
 ment will be divided, and thus the  tension of  the whole of the arch lessened;
  the  only danger that can occur from the division of the stricture in  this direc-
 tion is the very remote  one of the division of the obturator artery, when it takes
  the anomalous course  round the inside of the neck of the sac.   Mr. Guthrie
  states that he has known some of the best surgeons in London lose patients by
  hemorrhage after  the  operation for femoral hernia.   This accident, however,
  must be of extremely rare occurrence, and might in a  great measure be guarded
  against by slightly blunting the edge of the hernia-knife  before dividing the
  stricture, so that the  tense fibrous bands  constituting the constriction  would
  yield, but the artery probably escape,  being  pushed  before the blunted  edge.
  I have however more than once seen blood well up pretty freely on the division 
UMBILICAL  HERNIA.                    809
of the  stricture, but it has ceased spontaneously, and I have never known  it
give any trouble.   If the division of the stricture is  limited to a line or two,
there will be but little danger of wounding the vessel, even when it takes the
abnormal course.
   It will generally be found that the intestine contained in the sac of a femoral
hernia  is dark colored and tightly nipped; it requires to be treated in accord-
ance with the general principles that guide us in the management of hernia.

                        UMBILICAL HERNIA.

   By umbilical hernia or exomphalus is meant a protrusion through the um-
bilical  aperture.  This is sometimes  congenital, and when  so, it has happened
that the protrusion has been included in and accidentally strangulated by, the
ligature  applied to the  umbilical  cord.  More  frequently, however, it occurs a
few months after birth  in consequence  of the  child  straining or crying.   In
these  cases it  is readily recognised  by a smooth, rounded, and  tense tumor,
starting forwards at the umbilicus, readily reducible on pressure.  The treat-
 ment  should consist in keeping  the  tumor reduced by the application of  an
 elastic India-rubber belt with an air-pad  that presses firmly upon the  aperture;
 or should  such a contrivance as this not be at hand, the  reduction may readily
 enough be effected by applying a piece of soap-plaster  spread  on  amadou, over
 the aperture, upon which a well-padded slice of cork  may be  tightly strapped.
 It most commonly happens that after pressure has in this way  been kept up  for
 some months, a radical  cure results.
    Umbilical hernia in adults most frequently occurs in women, especially those
 who have  borne many  children,  or who are loaded  with  internal fat.   It is
 by no means unlikely that the tendency to this disease is  often  established in
 childhood, but does not become developed  until  the  abdominal muscles have
 been weakened and the umbilical aperture relaxed by the pressure of the gravid
 uterus.
    The umbilical rupture usually attains  a considerable bulk, and often acquires
 an enormous size;  when large it is commonly irregular  or  semilunar in shape,
 sometimes appearing to be composed of several  distinct tumors.   It  is usually
 partly doughy and partly tympanitic to the  feel, has  a  distinct impulse  on
 coughing, and is readily reducible;  not unfrequently it happens, however, that
  a portion of the rupture continues irreducible,  owing to the existence of adhe-
 rent omentum.  The coverings of an umbilical rupture are usually extremely
 thin,  consisting merely of the peritoneum, a layer of  condensed fascia which is
 often  perforated at several points by circular openings  through  which the hernia
  protrudes, and the  integuments containing the umbilical cicatrix, which is
  expanded  over the part.
    The treatment consists, if reducible, in wearing a properly constructed truss;
  if irreducible, in  applying a hollow cup-shaped pad supported by a bandage
  over the part.   It not  unfrequently happens that an irreducible  umbilical rup-
  ture in old women becomes  obstructed,  being attended with tension of the pro-
  trusion, with nausea and constipation.   In these cases much discrimination will
  be required  to avoid confounding this condition of the tumor with strangulation
  of it.  This may be done by attention to the rules laid down (page 777), when
  by local blood-letting, fomentations, and  aperients, relief may usually be afforded.
  Should, however, the bowels not speedily act, and should the tumor continue
  irreducible, it will, I think,  be better to cut down upon it, and  treat it as a
  strangulated hernia, dividing adhesions and reducing the swelling; for if it be
  left obstructed and unreduced, the whole tumor may run into  a state of gangre-
  nous inflammation, under which circumstances operative interference  will be of
  little  use.                                                 .            „,.
    The stricture should, if possible, be divided without opening the sac.  lhis 
810
VARIETIES OF HERNIA.
may usually be accomplished by drawing the tumor well down and then making
an  incision  about two inches in length over the neck and its upper part in the
mesial line.  If the tumor overlaps  here it may be more convenient to make
the incision by the side or even between, but as a general rule the upper part
is the best.  After the  division of the integumental structures and often of a
deep layer of fat, the end  of the  nail may be slipped under the edge of the
sharp  circular  margin  through which the  protrusion has  occurred, and the
stricture being divided away from the sac, and  if possible in the mesial line,
reduction may  be readily and safely accomplished.  Should  the  strangulation
not be thus relieved, the sac  must be opened, and any stricture divided from
within.  But the  surgeon should exhaust every means before he opens the sac
of  an  umbilical hernia, especially of large size,  the patient I believe rarely
recovering when this is done, — much less frequently, so far as my experience
goes, than in other forms of hernia.   Sometimes after the external division of
the stricture it will  be found that there is an internal strangulation in these
herniae, the gut having slipped through an aperture formed I  believe in the
condensed fascia covering the sac;  if so, the edge of this sharply-defined open-
ing may require division.  Sir A. Cooper mentions an umbilical hernia forming
two tumors, having a communication between  them; and South relates a case
in which the tumor resembled a figure of 8, a dense cellular band binding down
the middle of the sac.  In such cases as these, which are by no means uncom-
mon, central constriction may require to  be divided as well as the stricture at
the neck of the sac.   Adherent omentum  had,  I think, better be left in the
sac in  cases of umbilical hernia, and gangrenous intestine or omentum must be
treated upon general principles.   It is not often that  strangulation of an umbi-
lical hernia occurs  during pregnancy, but should this happen, the  operation
must be performed as usual; that condition not complicating the case much; and
instances are recorded by Sir  A. Cooper, Lawrence and others, of its successful
performance at this period.   After the division of the strictures and the reduc-
tion of parts, a large and very thick compress must be  laid over the loose folds
of integument in the site of the hernia, and be retained  in position by a broad
and firmly applied flannel roller.

                  OTHER VARIETIES OF HERNIA.

   Ventral hernia. — By ventral herniae, are meant those  protrusions that occur
through any part  of the abdominal wall,  except  the inguinal, the femoral or
umbilical apertures; they most  commonly occur in the  mid-line between the
recti muscles,  the linea alba appearing  to have  given  way in  this  situation
during parturition, and here  they may attain  an  immense  size.   A case was
lately sent to me from  the country in which there was  a long triangular gap
through the upper part  of  the abdominal  wall,  extending from the umbilicus to
the ensiform cartilage, through which a  protrusion  had  taken place that was
nearly as large as an adult's  head.   These ruptures have also been met with
in  the  lineae semi-lunares, the hypochondriac  and iliac  regions; and  Cloquet
describes a  case occurring in  the lumbar region.    When these herniae happen
in the vicinity of the  stomach, they are apt to occasion dyspeptic  symptoms
and much gastric  irritation; but Lawrence is doubtless right in  thinking  that
these symptoms do not arise  from the implication of  the stomach, but simply
from irritation  of it.   These  different protrusions have  occasionally been met
with as the result of injuries, by which  the anterior abdominal wall has been
lacerated; indeed they seldom, if ever, take place below the umbilicus, unless
arising from a directly traumatic cause.
   The  treatment of ventral hernia must  consist  in  supporting  the  tumor by
means  of a broad belt and  properly constructed  pad.   Should  they become
strangulated, which  I  believe very rarely happens, owing to the width of  the 
OBTURATOR HERNIA.
811
neck of the sac, the operation must be performed in the same way as for umbi-
lical rupture, care being  taken to divide cautiously the integuments, any apo-
neurotic investments, and the  peritoneal  sac:  the  stricture  should always be
divided upwards in the mesial line.
  A rare kind  of ventral rupture  has been described, principally by the Ger-
man surgeons, in which the abdominal wall has yielded to a considerable extent,
forming a broad and  expanded tumor, without any distinct neck or pedicle.
Sometimes these tumors may  attain an immense size, stretching perhaps down
to the knees,  and containing even the gravid uterus.
   Obturator  hernia.—The occurrence of this form of hernia is extremely rare,
and its  existence has  still more rarely been determined until after death; in
fact Lawrence  seems  to  doubt the possibility  of the  recognition of this com-
plaint during life, in  consequence  of the small size which  the  tumor attains,
and its  being covered in  by and  compressed under the pectineus muscle.
Two instances have, however, lately been  recorded,  one by Mr. Obre, the other
by  Bransby Cooper, in which a strangulated hernia  of  this kind was recognized
during life.   And these  are probably the only  instances on record in which an
operation has been successfully performed; almost all the other cases mentioned
by  writers having been accidentally discovered  after death, which had occurred
from internal strangulation, the precise seat of which could not be detected.
In  Mr. ObrS's case, the patient was seized with  symptoms of strangulation, but
no  tumor could be detected in any of the ordinary seats of hernia.  " On un-
covering the  upper part  of both thighs  at the  same time, the  eye detected a
slight degree of fulness in Scarpa's triangle on  the  right side; this triangle of
the  opposite  limb was well marked with  a hollow, or depression passing down
its  centre, but this was lost on the affected  side, and the whole contour of this
part of the limb was visibly fuller than that of the corresponding one.   There
was no tumor or circumscribed swelling, but on standing over the patient, and
using firm pressure with  the ends of  the  fingers over the neighborhood  of the
femoral artery,  and a little below the saphenous opening, a distinct hardness
could be felt  (slight in its extent), giving  an impression as if the  sheaths of the
vessels were being pressed on."  Taking the dangerous state  of the patient into
consideration, Mr. Obre acting in  accordance with  the best rules of surgery,
and thinking that there might be a hernia deeply strangulated  in the femoral
canal, made  an incision  downwards in this situation, but was disappointed on
finding, when the saphenous opening was exposed, that there was no intestine
confined there; but as a hardened structure  could be deeply felt at the inner
border of the opening, the fascia lata was exposed, and the pectineus divided to
the extent of about two  inches, when a hernial sac  about the size of a pigeon's
egg, and containing intestine came  into view.    In  this operation the saphena
vein gave  some trouble,  lying as it did in the course of  the incision.  The sac
having been  laid open, the stricture  was divided upwards, during which  part
of the procedure the vein was accidentally cut,  and  required ligature; no other
vessel was tied.   The operation, which reflects the greatest credit  on  Mr.  Obre's
diagnostic skill and dexterity, was perfectly successful, the  patient making an
excellent recovery.
  Besides the  obturator, various other pelvic herniae may take place, such as a
protrusion into  the perineum,  the vagina, or through the sciatic notch.   These
various forms of rupture are of extreme rarity, and present many difficulties
in their diagnosis.
  Perineal hernia commonly  occurs  in  the middle line, between the  rectum
and the bladder in men, or the rectum and vagina in women,  but  sometimes the
protrusion has been known to take  place  by the side  of the anus, or even in
front of this.  Of these various forms of rupture many instances have been col-
lected by Lawrence from different writers.   The treatment  of such a hernia
would consist in supporting the protrusion by means of a pad and bandage; as 
812
VARIETIES OF  HERNIA.
the mouth of the sac is very large in these cases, it  is not probable that any
strangulation would occur.
   Vaginal hernia has occasionally been met with, the tumor protruding through
the posterior or upper wall  of the vagina, and presenting the ordinary characters
of this disease, such as impulse on  coughing  and reducibility.  It may most
conveniently be kept up by means of a sponge pessary.
   Pudendal hernia has been described by Sir A. Cooper as very closely resem-
bling vaginal rupture.  The situation of the tumor may cause it to be mistaken
for an inguinal hernia, but from this it may be recognized by the upper part of
the  labium  and the  ring  being  completely free, whilst a tumor presenting the
ordinary characters of a rupture is situated  in the  lower part of the labium,
and forms a prominence extending along the  side of the vagina.
   Sciatic hernia. — This rare form of  hernia has been described by Sir A.
Cooper as passing  through  the  sciatic notch, where it  lies between the lower
border of the pyriform muscle and the spine of  the  ischium.  It lies in close
relation with the sciatic nerve, and with the internal iliac vessels.   In the case
related by Cooper, the obturator artery passed above, and the vein below the
neck of the sac.   From the depth at which such  a hernia would be seated, and
its small size, it would probably escape observation during life, but if detected
it might readily be retained  by means of proper bandages and a pad.   Should
operation ever be required in case of strangulation, the deep incisions must be
carefully  conducted, on account of the great  importance of the parts surround-
ing the sac.
   Diaphragmatic hernia.—This form of  hernia is of unfrequent  occurrence,
and I believe always results in  consequence of a wound or laceration of the
diaphragm.  It usually attains a large size, and commonly contains the stomach
or the transverse colon, with a portion  of the omentum, which form a tumor in
the thoracic cavity, encroaching upon the lungs,  and pushing the heart to one
side.  These herniae are not enclosed in a peritoneal sac, but  have been found
                                       partially enveloped  by the pleura, and
                                       have, I believe, only been met with in
                                       the left side of the chest; the situation
                                       of the liver on the  right side prevent-
                                       ing  their formation  there.  The fol-
                                       lowing case,  which  occurred  at the
                                       University College  Hospital, affords  a
                                       very good instance of this very rare
                                       affection.
                                          A man seventy-four years of age was
                                       admitted into University College Hos-
                                       pital.   About twelve months before,
                                       he fell into an area about ten feet deep,
                                       and believes that he  injured his chest
                                        and head, as from that time he has suf-
                                       fered  much  from shortness  of breath
                                        and occasional sensation of suffocation,
                                        has  a hacking cough, and cannot  lie
                                        down  without feeling some difficulty
                                       in breathing.   At the time of the acci-
                                        dent he  coughed up about three spoon-
fuls of blood.   Ever since the accident he suffered much from dyspeptic symp-
toms and constipation, though before he met with the injury  he had experienced
no inconvenience in this respect.   About a month ago the difficulty in breathing
increased;  and  four days ago violent  pain in the abdomen came  on, and his
bowels ceased to act, although he took a variety of aperient medicines and had
enemata  containing croton oil administered.
Fig. 324.
 
INTESTINAL  OBSTRUCTION.                813
  On admission the abdomen was found much distended, tense, and tympanitic,
with pain  around the umbilicus; the tongue was coated with whitish-brown,
moist fur-  the pulse was small, quick, and somewhat resisting; there was nausea,
but no vomiting.   The skin was cool and the countenance anxious;  the bowels
had not acted for seven  days, but he  had  frequent desire to go  to  stool.
Ordered an aperient draught every third hour.  As this had no effect, he was
directed to take  calomel and elaterium pills, and to have turpentine  enemata,
which afforded him some relief,  though they brought away no faeces.   The
patient became more restless, the  skin cold  and flabby, the countenance more
anxious the breathing shorter, and the abdomen more tympanitic, and he died
two days after admission, and nine from the commencement of the obstruction.
   Examination  of the body twenty-four hours after death.—The abdomen was
 distended and tympanitic, and the peritoneal sac contained about six ounces of
 fluid  with here and there patches of recently-effused lymph.  The small intes-
 tines' were not distended: the large were  greatly  distended with flatus, the
 ccecum  extending into the  cavity of the pelvis;  the ascending and  the trans-
 verse colon were much distended, and  it was found  that a large loop of the
 transverse and of the descending colon  had passed  through an opening in the
 cordiform tendon of  the diaphragm into the pleural sac, and was there stran-
 gulated (fig. 324).  The colon  below the stricture was contracted, and entirely
 empty.   On opening  the thorax, the loop of intestine, fourteen inches  in length,
 of a pale slate color,  and distended with gas, was found  in the left pleural sac.
 It reached as  high as the fifth rib, touched the pericardium, and was overlapped
 by the free margin of the  left lung.   Where strangulated, it was of a darker
 color than elsewhere.  The opening in the  diaphragm, through which  it had
 passed, admitted little  more than  the point  of the forefinger, and  had a thin
 tendinous margin.  The tenth and eleventh ribs, on the  left side, were found
 to have been  fractured; the latter was united  by  osseous matter, but the tenth
 rib, at the seat  of fracture, had formed a false joint.  Connected with this and
 with the intercostal  space  below it, was a firm adhesion about an inch broad,
  and an inch and a half  long, united by its  other  extremity in the  protruded
  meso-colon and  the diaphragm.   The protruded meso-colon was firmly adherent
  to the upper surface  of the diaphragm; close to the opening in it the  lungs were
  tolerably healthy.  The right  pleura contained three ounces, and the left eight
  ounces of serum.
                         CHAPTER  LIV.

                   INTESTINAL OBSTRUCTION.

  Intestinal obstructions maybe of two distinct kinds, tlie■ ««*« andfte
chronic, which should not be confounded with one another, asthey are^usually
dependent upon very different  conditions, and require  ^^^fj^
ment to be adopted for their relief.  The acute intest^^1 ^truction may an e
in various ways.  When of a mechanical origin, it m0^ ^^^^Vsudden y
consequence of the  formation  of an internal hernia, ^^J^ or
strangulated, a portion of gut slipping through an "f^J? *« "^^^
omentum (fig. 325),  or becoming  constricted by bands adLhesions,  « J^rta
cula, stretching across from one side of the abdomen to ^n°^ Jj"^^
again, it may occur  from invagination, the  upper portion of the intestine  slip 
814
INTESTINAL  OBSTRUCTION.
ping into the lower, or by a portion of gut becoming twisted upon itself, and
                                          thus forming a volvulus,  owing to
                 Fig. 325.                  the mesentery or meso-colon  being
                                          unusually long, and allowing a half-
                                          twist to take place, in consequence
                                          of which  complete obstruction oc-
                                          curs.   In other instances, again, as
                                          Mr.  Phillips  has  pointed out, the
                                          same train of symptoms  may arise
                                          in consequence of a malignant stric-
                                          ture gradually closing and then at
                                          last  becoming suddenly  occluded.
                                          When the obstruction occurs by the
                                          formation of an internal hernia, the
                                          same changes take place in the con-
                                          stricted  intestine that happen  in
                                          ordinary ruptures, peritonitis super-
                                          vening, and gangrene rapidly result-
ing.  It is of much importance, however, in practice, to bear in mind that severe,
and even fatal intestinal obstruction may occur, simply from spasmodic causes,
or as the result of inflammatory affections of the  abdomen, without  the exist-
ence of any mechanical lesion.
   The  symptoms of acute intestinal obstruction, when  arising from a mechanical
cause,  such  as  the formation of  an internal hernia, or volvulus, are always
characterized by a very marked vital depression.  There is  constipation, it is
true, from the very first, but this symptom is not the  most prominent one, and
those that result are evidently, as in an ordinary case of strangulated hernia,
the consequence of the injury inflicted upon the intestine, rather than of the
mere mechanical obstacle to the onward passage of the faeces.  At the moment
of  the  occurrence of the  attack, the  patient is usually  seized with  a sudden
feeling of something wrong having taken place in the abdomen; or he is struck
with intense  pain at one point.   There may be sudden  syncope, though most
usually the depression of vital power does not amount to this.  Vomiting speedily
occurs; at first of the contents of the stomach, but after a time of a stercoraceous
character; sometimes it assumes this form almost from the very first.   The ab-
domen becomes swollen and tender, the intestines being  blown up with  flatus,
so  as to give rise to immense tympanitic distension, rolling over one another, and
 occasioning loud  rumbling and gurgling noises.   If the abdominal walls are
 thin, the rolling of the intestines may be distinctly felt, and in many cases seen
 through them; and may sometimes be observed to be continued up to one spot,
 where  they cease.  At this point an intumescence may sometimes be indistinctly
 felt, corresponding to the  seat of strangulation.   If relief be not afforded, the
 sufferings of the  patient  become  very considerable, and his  mental  distress
 agonizing; the vomiting,  perhaps, becomes less  frequent, but  the  depression
 increases, and at last death results, usually about  the sixth  to  the tenth day,
 though sometimes sooner from exhaustion, peritonitis, and gangrene  conjoined,
 the mind being clear  to the last, and the patient's attention  being intently and
 distressingly rivetted  upon the possibility of getting relief from the bowels.
    Chronic intestinal obstruction usually arises from the gradual obliteration of
 the inferior portion of the  large  intestine, in consequence  of the  malignant
 degeneration of its walls,—from the compression of the gut by a tumor growing
 near it, — or  from the obstruction of its  cavity by the accumulation of large
 masses of hardened, feculent matters.   The symptoms, in the earlier stages of
 these cases, are commonly those that will be described  as indicating stricture
 of the large intestine; but when  once complete obstruction  has come on, the
 constipation becomes the  most prominent symptom.  There may be compara-
 
DIAGNOSIS OF INTESTINAL OBSTRUCTION.       815
tively little constitutional  disturbance at first, but the bowels cannot be made
to act, and  any attempt  at forcing their operation  by the  administration of
purgatives, gives rise to sickness and much distress. During the progress of the
attack, eructations, retchings, and vomitings  are  of frequent occurrence, but it
seldom happens that this is stercoraceous till the  very last; there may be much
tympanitis, with rumbling and gurgling  of the intestines, but most frequently
the abdomen fills slowly and gradually, and the  symptoms do not occur until
after some days have elapsed.   In many instances life is prolonged for several
weeks, for five or six, even after complete obstruction has set in; and  in some
cases recovery may take place even though a considerable time have elapsed from
 the  occurrence of the obstruction.   In a lady whom I attended some time ago,
 with Mr. Powell, recovery took place, although there had been complete obstruc-
 tion for upwards of  five weeks.
   The diagnosis of the causes of the  obstruction is of great importance; atten-
 tion as to whether it assumes the acute or  chronic form will throw some light
 upon the conditions that  occasion it.  It is often difficult to  determine whether
 the obstruction is of a mechanical nature, or whether it depends upon a spas-
  modic or inflammatory affection of the intestine.  The practice to be adopted in
  any particular case must  at last be determined by a history of the symptoms, by
  a careful exploration of the abdomen and rectum, and by the light that can thus
  be  thrown  upon the question, as to whether the obstruction in that particular
  case be dependent on causes  that  are removable or not by medical means.   In
  many instances,  the  history of the  case, the assemblage of  strongly-marked
  symptoms, and the  result of abdominal and rectal exploration, enable the sur-
  geon to determine, without  much difficulty, that the  obstruction is dependent
  on causes that are not removable by any means  short  of operative interference.
  But, in other cases, no means that we  possess enable us to arrive at a correct,
  or even  an approximate  diagnosis.  Cases are recorded that have ended fatally
  from obstruction in forty-eight hours, without  sickness, fixed pain in the abdo-
  men, or tympanitis.  These  cases, however,  are certainly exceptional, and do
  not bear upon the question as to the propriety of performing  gastrotomy in those
  instances in which it can be satisfactorily determined that a mechanical obstacle,
  not removable  by medical means, exists.  That the  diagnosis may so far be
  effected with tolerable certainty is evident, from the fact that in all those cases
   of gastrotomy that have been of late  years  practised in  this country, by Mr.
   Luke, Mr. Hilton, Mr. Avery, and myself, mechanical obstruction, irremovable
   by any but operative interference, was found.
     1st.  The  most prominent  symptoms, and  those that will chiefly engage  the
   surgeon's  attention, are —a, the duration of the constipation; p, the occurrence
   of fixed local pain  in the abdomen; and, y, the  character of the vomited matters.
     a. The  duration of the constipation does not  throw much light upon the cause.
   Indeed if patients be naturally costive, constipation may last for a considerable
   number of days,  or even weeks, without producing  any very serious  or  tatal
   consequences.   Most practitioners must have seen cases in which  the constipa-
   tion has continued for three or four  weeks, without destroying the patient.  Vr.
   Johnson mentions a case in which it lasted for forty-five days.   In these cases,
   however, constipation has usually come on gradually, being, as it were, an aggra-
   vation of the patient's  natural condition.  In cases  of acute internal strangula-
   tion, the constipation is always sudden, and is  accompanied or speedily toiiowea
   by other symptoms indicating intestinal obstruction.       _
     p. The  occurrence affixed pain is  common to many conditions of the abdomen;
   though, when taken in  conjunction  with the sudden supervention of obstruction
   to the onward passage of the faeces,  with more  or less tumefaction corresponding
   to the seat of pain, and more especially with the next symptom to which i sball
   advert, it is not without considerable value in  the diagnosis of these cases.
     7. The Character of the  Vomiting.—When the obstruction is not dependent 
816
INTESTINAL  OBSTRUCTION.
on complete mechanical occlusion of the bowel, there may be incessant vomiting,
and the stomach may reject its contents as often as  anything is introduced into
it;  but the vomiting will not  be  feculent  in  the majority of cases, however
obstinate the constipation may be, and  however long it may last.  If, however,
there be complete mechanical occlusion, feculent vomiting  most commonly sets
in early, frequently by the third day, or even  sooner;  and will continue until
the cause of occlusion be removed.   The vomiting, however, is not continuous,
but will usually only  occur after food has been  taken  into  the stomach.   It is
true that feculent vomiting is not sufficient, by itself, to determine the diagnosis;
and that it may occur in cases of pure spasmodic ileus, in which the obstruction
is removable by medical means.   A remarkable  case of this kind occurred a few
years ago at the Westminster Hospital, under Dr. Basham, in the person of a
black woman, who was admitted for haematemesis, with catamenial suppression.
The stomach was very irritable, with occasional colicky pains  in the abdomen
for the  first two  weeks.  The bowels, although torpid, were not completely
occluded till within forty-eight hours of the stercoraceous vomiting.  This latter
condition continued  for five weeks  altogether,  with an interval, in which  the
bowels acted;  indeed, towards the latter period of the case, feculent vomiting
occurred on the  same day that a small alvine evacuation was obtained.  She
suffered during the greater part of  this period from dysuria.   There was also
frequent spasmodic constriction of the rectum; and altogether much hysteria
was mixed up with the symptoms. The stercoraceous vomiting gradually abated,
the natural order of things returned, and she left the hospital sufficiently well to
walk to Portsmouth in three days.   It is therefore as necessary to bear in mind
the occasional  dependence of feculent vomiting on  pure spasmodic ileus, or on
other  conditions that are removable  by medical aid  alone, as that it may be
absent in cases in which the obstruction, whether seated  in the small or in the
large intestine, is not under the influence of medical treatment, and can only be
relieved by surgical assistance.  But I believe that a careful exploration of the
abdomen and rectum, and a proper inquiry into the history  of the case, will most
generally prevent the surgeon from  being led into any serious error by trusting
too implicitly to the  presence or absence of this one symptom.
   2d. After determining whether the obstruction be dependent on causes that
are removable or not, the next most  important point is doubtless to ascertain
whether  the obstruction is seated  in the large or in the  small intestine.  In
 general, there may be no great difficulty in  coming to an  accurate opinion on
this point, if it be borne in  mind that obstructions of the large intestines are
 most generally chronic, whilst those of the small are, in by far the majority of
 cases, acute in their character.   The  earlier occurrence of feculent vomiting
 when the obstruction is in the small intestine, the greater tympanitic distension
 and bulging in the course of the ccecum  and  colon when  seated in the large
 intestine, — the amount of urinary secretion being, as was pointed out by Mr.
 Hilton and Dr. Bird, less in the former than in the latter case,—and the result
 of careful exploration of the rectum, will most commonly enable the surgeon
to decide this question with sufficient precision  to guide him in the choice of an
 operation.  Yet, cases do occur, in which, though the obstruction be seated in
 the large intestine, — the symptoms are acute,  and evidently not dependent on
 chronic obstructive disease, the vomiting of early occurrence, the distension of
 the abdomen slight,  and in which exploration by the  rectum yields no result;
and it is in cases of this  description, presenting a train of  symptoms of  mixed
and uncertain  character, that the diagnosis of the precise seat of the obstruction
 cannot be made.
   The question as to whether the cavity of the peritoneum should  be  opened
or not, will altogether turn, in any given case of intestinal obstruction, depen-
dent on causes that cannot be  removed without  operative  interference, on the 
TREATMENT  OF  INTESTINAL  OBSTRUCTION.      817
point, whether such obstructing  cause implicates the bowel above or below the
lower end of the descending colon.
  o.  When the obstruction is situated below the descending colon, exploration
of the  rectum will usually determine to  what  cause  it is more immediately
referable.   Thus it may be owing to strangulation of internal  piles, to com-
pression of  the rectum by an over-distended bladder,  or to an enlarged uterus,
engorged and tilted backwards so as to compress and constrict the rectum, and
thus to  lead to the supposition  of  the  existence of tumor.  If the  intestinal
obstruction be owing to one or the other  of these causes,  it may readily be re-
lieved  by appropriate treatment.  It, however,  more  commonly  proceeds from
other conditions in this  situation, that do not admit of relief except by opera-
tive  interference; as from constriction, simple or malignant, of the upper portion
of the rectum, or of the lower part of the sigmoid flexure of the colon, in con-
sequence of the  pressure of a pelvic tumor,  or of a  stricture from fibrous  or
cancerous degeneration  of this part of the wall of the gut.  Under  these cir-
cumstances, the obstruction may be as complete as in a case of internal strangu-
lation, and  the patient will inevitably perish unless relieved by operation.   But
there is this important difference between the  operative interference that may
be called for by these obstructions that are situated below the descending colon,
and  those at a higher point in the intestinal canal:—that  in the latter case the
peritoneum must be opened; whilst in the former, relief may be given without
 interfering with the cavity of the peritoneum, by the  operation of opening the
 descending colon in the left, or  the ccecum in the right lumbar region, between
 the  reflexions of the peritoneum at  the  part where the gut is not covered  by
 that membrane.
   (3. When the obstruction is  situated above  the descending colon, it almost
 always occurs  in the small  intestine,  rarely in the ccecum, or transverse  colon,
 and may be dependent on  various causes, some of which are removable, and
 others not, and of which preparations may be found in all the large pathological
 collections in  London.   Thus,  it may be the  result  of internal strangulation,
 either occasioned by the small intestine  falling into a pouch,  formed by the
 meso-colon, or by the constriction of the gut by the passage across it of adven-
 titious  bands  of  fibres.  It  may  be occasioned by  intus-susception, by the
 lodgment of biliary or  other similar concretions, or by mere spasm of the small
 intestine, which may be  so persistent  as to  prove fatal.   This is, doubtless, a
 rare occurrence;  but cases of the  kind are on record, in  which the only post-
 mortem appearance that  could be  discovered  has been a spasmodically con-
 tracted ileum.  The great practical difficulty in all these cases  of obstruction,
 above the sigmoid flexure of the colon, is to determine  the cause of the  ob-
 struction, whether it is of such  a nature as may be removed by operation or not.
 In some of the cases mentioned, there may be special symptoms, which lead to
 a tolerably correct diagnosis.  Thus,  in intus-susception, bloody or mucous
 stools may give a clue; in malignant or  fibrous degeneration of the colon,  the
 chronic nature of the disease, the history of the case,  and the appearance of the
 patient, may indicate the nature of the obstructing cause.

           TREATMENT  OF  INTESTINAL OBSTRUCTION.

   1st  The treatment of acute obstruction must necessarily be in  a great measure
 determined by the diagnosis that is made as to its cause.   Before proceeding to
 the employment  of any measures, whether medical or surgica, in  these  cases,
 the surgeon should, however, never  omit to institute a careful  examinaUon of
 the varfous abdominal  and  pelvic apertures for some of the more obscure forms
 of external hernia;  for in cases of supposed  internal strangulation it has occa-
 sionally turned  out, after death, that  the patient had been laboring under a
 small femoral, obturator, or sciatic hernia.   If such  a condition be detected, it
         52 
818
INTESTINAL  OBSTRUCTION.
must, of course, be relieved  by proper operative  means.  In  the event of no
such protrusion being detected, and from the general obscurity of the symptoms
in these cases rendering an exact diagnosis in the  earlier  stages almost impos-
sible, it is generally expedient to try the  effect of proper medical  treatment,
which will  sometimes,  even in apparently hopeless cases, afford relief.  The
only plan of treatment that appears to me of any value is an antiphlogistic one;
the continued administration  of calomel and opium, with the free  application of
leeches to the abdomen, followed by fomentations, will be of  considerable  ser-
vice, and in  some cases, even  the most hopeless  and complicated, will afford
satisfactory  results.  In a very complicated case of intestinal obstruction which
I attended with Dr. Garrod, this plan was eminently successful.   A patient was
admitted  into the hospital  under Dr. Garrod, having symptoms of internal
strangulation; he had at the same time double  inguinal hernia, and a small
umbilical rupture, as well as  the remains of a fatty tumor  which had  been
partially removed from the abdominal wall  many years previously.  There was
peritonitis with tympanitis,  stercoraceous vomiting, and  much  depression  of
power, but  as there was no strangulation  existing about any of the  external
apertures, and as there was no evidence as to the precise locality of the internal
mischief,  it  was  not thought  advisable to have  recourse to operation.  The
patient was  accordingly treated with calomel and opium, together with other
antiphlogistic means, when, on the tenth day, the obstruction gave way and the
bowels acted, the case ultimately doing well.
   The inflation of the obstructed intestine, by  the injection of air into the rec-
tum, has been recommended  in cases of intus-susception,  and  occasionally been
practised with success.   In the case of a young lady about ten years of age, to
whom I was  called  into consultation with Drs. Murphy,  Watson, and West, it
was determined to do this on the fifth day after the setting in  of symptoms of
acute intestinal obstruction, apparently dependent on intus-susception. The infla-
tion was followed by perfect success,  the child feeling " as if a bone broke " in
the abdomen, the obstruction  being  removed, and motions following  in three
hours, though all  the previous treatment had been unavailing.   For the conve-
nient performance of this operation I have had an apparatus  constructed, con-
sisting of a circular double action bellows, with a long vulcanized India-rubber
tube, furnished with a stop-cock and rectum tubes of different  sizes for children
and adults.   When  the air is thus pumped in,  it  is doubtful  whether it passes
beyond the  ilio-caecal valve, but this is of little consequence, in children  espe-
cially, in whom the inflation of the large intestine  alone may be quite sufficient,
the obstruction often consisting of the slipping of a portion of the small intes-
tine through this aperture.
   If, however, for any of the various reasons that have already been mentioned,
an internal  strangulation of some kind be diagnosed, attended by urgent symp-
toms, and threatening the life of the patient, the great question to be determined
is, whether it is advisable to have recourse  to operative  interference, and if so,
when it is proper to undertake it ?  The solution of these questions is fraught
with  difficulty, and must always be a matter of the most anxious consideration
to  the surgeon.   It is not only that he knows that if the patient is left unre-
lieved, he must necessarily die;  but that he is  aware that the only means of
relief, gastrotomy, is probably  nearly as fatal  as the disease for which  it is
undertaken;  no case in which this operation has  hitherto been  performed for
internal  strangulation having recovered.   But the difficulties that present them-
selves in the solution of the question are much increased  by the great obscurity
in diagnosing the cause  of the obstruction; for in many cases it is absolutely
impossible to determine with certainty whether  it be dependent on ileus, or arise
from mechanical  causes.   If, however, by attention to any of the points that
have been pretty fully adverted to, it can be satisfactorily made out that there
is an internal strangulation, and more especially if the intumescence occasioned 
TREATMENT  OF  CHRONIC INTESTINAL  OBSTRUCTION. 819
by it can be felt, it would evidently be  the duty of the surgeon to give the
patient his only chance by the division of the stricture.   With regard to the
time at which this should be done, the only general  rule that can be laid  down
is probably the conclusion arrived at by Mr. Phillips, that operation is justifiable
when three or four days have passed, without any relief from ordinary means,
constipation being complete, and vomiting of faecal matters continuing.
   Gastrotomy may be  performed in the  following way:—The room being well
warmed, the patient should be laid  on a high table, his legs being allowed  to
hang ever the end of it, so as to afford a  full view of the abdomen.  The bladder
having then been emptied, chloroform should be administered j and the surgeon,
taking his stand between the legs  of the patient, proceeds to  make the incision
through the abdominal wall.   If a tumor can be felt, or the seat of obstruction
in any way diagnosed, this must be made in a longitudinal manner directly ovei
the seat of mischief; if there is no evidence to show where it  is situated, it had
best be made in the  mesial line.   It must be carried through the abdominal
wall until the peritoneum is reached; this must then  be slit up by means of a
probe-pointed bistoury guided by the fore-finger of the left hand.  The coils of
intestine will now probably protrude through the wound, curling over its edges;
they must be drawn to  one side,  and be  carefully  supported by  an  assistant,
 who should press upon them with a soft towel, whilst the surgeon goes in search
 of the obstruction.  This he does by very carefully and gently tracing upwards
 the contracted and empty coils, which must necessarily be below the seat  of ob-
 struction, or following downwards the distended intestine.   If there be a hernial
 constriction,  he  may divide the band that  constitutes the stricture by means  of
 the scalpel, or break it  through with  the finger, or withdraw from the aperture
 in the omentum or mesentery into which it had slipped, the constricted coil of
 intestine.  If it be  a  case  of volvulus, the gut may be untwisted, as in  a case
 on which I operated.  The intestines having been  returned, the wound should
 be closed  by the interrupted suture, and the  application of some  transverse
 strips  of  plaster; the patient must then have his knees bent over a pillow, and
 should be kept  principally upon  ice  and  barley-water.  Opium  must also be
 administered, and the  case generally treated on  the ordinary principles of abdo-
 minal wound.
    2d. The treatment  of chronic intestinal obstruction must be conducted upon
 different principles.  Here the great point is to remove the constipation.  With
 this view the rectum should be explored, and if found to be blocked up  by im-
 pacted faeces, as may  sometimes happen, these must  be removed, and copious
 enemata administered.  At  the same time purgatives may have a trial given them,
 and a drop or two of croton-oil may be exhibited.   If  the constipation, however,
 arise from mechanical causes,  this means  will usually considerably increase  the
 patient's distress, and  then  it should not be repeated; but the patient should be
 kept quiet in  bed,  have a nourishing diet, but one  that leaves  little residue,
 administered, and the passage opened by enemata, and the introduction of  the
 tube of a stomach-pump.  If these means  do not succeed, and if the obstruction,
 as is almost  always the  case in these chronic instances, be seated in or below the
 sigmoid flexure  of the  colon, the intestine must be opened at a point above the
 seat of disease.   This may be required  for acute as well as chronic obstruction;
 for it may be observed, that, although in the acute form, the obstacle is usually
 situated in the  small intestine, yet it is  occasionally met with in the colon.  But
 in chronic obstruction it is  always the large  intestine  that is affected,  lhe
 operation  required  to give exit to the  intestinal contents  is  of two kinds; in
 one the intestine is opened in the left iliac fossa, by  cutting through the peri-
  toneum covering it.   In the other it is opened in the left loin by cutting between
  the layers of the meso-colon, and thus opening it where it is uncovered by peri-
  toneum.                                                               , ,
    The first  operation —or Littre's, as it  has been called —was proposed by a 
820
INTESTINAL  OBSTRUCTION.
surgeon of that name, in 1710, who advised that in these cases the sigmoid
flexure of the colon should be opened from the left iliac region; but it was not
until the year 1776 that  any operation of the  kind  was performed; when Pil-
lore, a surgeon of Rouen, was the first to make an artificial anus on the adult,
for relief of retention of  faeces: this he did, not according  to Littre's method,
but by opening the ccecum from the right  iliac region.  Fine, of Geneva, in
1797, opened the transverse colon from the umbilical region, in a case of reten-
tion of faeces produced by scirrhus of the upper part of the rectum.
   Although these operations serve to fulfil the indication of relieving the
retention of the faeces, they are all defective in  one most important respect, for,
as the peritoneum must in all of them of necessity be wounded, an intense and
frequently fatal peritonitis is the inevitable  consequence.   It was to avoid this
serious complication  that  Callisen, in 1796, proposed opening  the  colon  from
behind, in the left lumbar region, where it is not covered  by peritoneum.  He
once attempted this  operation on the dead  body of  a  child, but failing in his
endeavor to reach the intestine without wounding  the serous membrane, he
seems to have relinquished all further idea of it; and it was subsequently re-
jected as impracticable by all those writers on surgery who have treated of this
subject.
   Amussat, at the time that he was attending the celebrated Broussais for that
scirrhous affection of the  rectum of which he ultimately died, was led to reflect
on the resources which surgery offers  in similar cases; and, after making some
experiments on the dead body, with  the view  of contrasting the merit of the
different operations that have been proposed for the  formation of artificial anus
in cases  of obstruction of the  large  intestines, he  became convinced that the
operation proposed by Callisen, if somewhat  modified, was not only practicable,
but safe.  He soon had an opportunity of  putting  this opinion to the test of
experiment in 1839,  and  since this the operation has been performed forty-four
times.
   The following is the way in which Amussat's operation may be performed:
A transverse  incision  is to be made  two fingers' breadth above and parallel to
the crista ilii of the left side, or  rather in the  middle of that space which is
bounded by the false  ribs  above and by the crista ilii  below; the incision should
commence at the external margin of the erector spinae, and extend outwards for
about four inches.  The  spinous processes  of the lumbar vertebrae, the crista
                                              of the ilium, and the last false
                   Fig. 326.                   rib,  are the principal guides.
   z                                          The  superior margin  of the
                                              crista ilii is, however, the safest
                                              of these, and the transverse in-
                                              cision may be said to correspond
                                              to the middle third of this part
                                              of the ilium.   After having di-
                                              vided the skin  and  the  more
                                              superficial tissues, the muscular
                                              layers are next to be incised as
                                              they  present themselves; if ne-
                                              cessary, the  external border of
                                              the quadratus  lumborum may
                                              also  be  cut  across.   The dis-
                                              section  is then very carefully to
                                              be carried through  the dense
                                              layers of cellulo-adipose tissue,
                                              which lie immediately upon the
intestine and the colon sought for; this will, in general, readily present itself, and
may at once be recognized by its greenish color and distended appearance (fig. 326).
t*j
is)
\ 
       OPERATION FOR  ARTIFICIAL ANUS IN THE LUMBAR REGION.    821

The operation may then be completed by passing a tenaculum, or needle armed
with a strong waxed thread, into the most projecting part of the gut; and, by
this means,  drawing it to the surface  of the wound, in order to prevent it
shrinking or sinking back when  opened.   It is  now to be punctured with  a
large trochar or bistoury, and  its contents  having been  evacuated, the sides of
the opening in the intestine are to be fixed to those of the  incision in the skin
by four or five points of suture, so  as to prevent the contents of the bowel being
effused into  the cellular tissue of the wound  (fig. 327).   It is of importance to
draw the colon well forwards  before opening it, in
order to prevent its contents  from being effused          Fig. 327.
into the loose cellular tissue of the wound,  where
they may set up considerable  irritation  and  retard
the union of the parts.   If the patient be  very fat,
the operation is proportionately difficult, on account
of  the  depth of cellulo-adipose tissues  lying in
front of the quadratus, and which requires  to be very carefully dissected through
before the gut Can be reached.  This step of the operation will be much facili-
tated by dividing the deeper-seated tissues  in a crucial manner, so as to give
 the operator more space.  When the operation is practised  on the dead body, it
 will be found on dissection that the following are the parts cut through: After
 the  skin and cellular tissue,  the  latissimus  dorsi will be seen divided towards
 the  posterior third of the incision, and  the obliquus externus in the anterior
 two-thirds  of it; the  obliquus internus  and the transversalis, sometimes the
 quadratus lumborum, the cellulo-adipose  tissue  which  immediately covers the
 intestine, and finally the  colon itself.  The colon will usually be found a little
 in front of  a point that lies  midway between the anterior and posterior spines
 of the ilium.   After the more superficial incisions have been made,  the surest
 guide to it  will  be the line of condensed fascia which  forms the anterior edge
 of the sheath of the quadratus, and which  lies  between that muscle and the
 transversalis.   This line  may always readily be distinguished by its  buff color
 from the surrounding muscular  structures.  Very  few vessels or nerves are
 wounded, as they for the most part run parallel to the line of incision; whereas
 if the vertical incision of Callisen were adopted,  they would necessarily be cut
 across.
   Amussat's operation  may also be called for in cases of cancer of the rectum,
 when there is perhaps but little or no distension of the  gut, the object being to
 prevent the faeces  passing over and irritating the ulcerated surface;  in such
 cases as these the operation is very difficult  in execution; for on account of the
 contracted state of the colon, that intestine  recedes behind the quadratus lum-
 borum, and the  folds of peritoneum nearly surround or invest it, and  it is  so
 covered in  by fat and cellular tissue that a  very cautious dissection is required
 to expose it without wounding the peritoneum.
   When we compare  the different  operations that have been proposed for the
 formation of an  artificial anus, it will be  found  that Callisen's, as modified by
 Amussat, is the one to which the preference must be given, for by it alone the
 peritoneum is not wounded, and thus the inflammation of that membrane, which
 is a necessary and so often a fatal consequence of the other operations, is avoided.
 Beside this advantage,  which is of the  very greatest importance, Amussat's
 operation presents several other claims to our notice.   As only one side of the
 colon can be drawn forwards, and  not a knuckle of it, as would  be the case if
 the small intestines were operated upon, it is evident that the spar-like process
 which has been described by  Dupuytren, must exist to a very small extent; and
 consequently, if  the  artificial  anus should ever become  useless,  the  natural
 passage for the faeces having been  re-established, it could  readily be  closed up.
 If, however, the peritoneum  should be accidentally wounded  in the attempt to
 reach the  colon from behind, even then  this operation would be preferable to
 
822
INTESTINAL  OBSTRUCTION.
that of Littre; for the  cavity of the* abdomen having  been opened at its most
depending part (in the recumbent position), the faecal matters would have much
less tendency to be effused into it, than if it were opened in front.  In respect
of not wounding the peritoneum, this operation closely resembles that of punc-
turing the bladder above the pubes, and below the reflection of that membrane.
There is, however, one  important difference between the two operations, which
may influence the result; for in the one case  as the patient lies upon his back
the urine has a tendency to stagnate in the wound, being obliged, in order to
escape, to mount  against  its own gravity; whilst  in the other case, the faecal
matters find a ready exit from a wound situated in a depending part.
   Mr. Caesar Hawkins, in a most interesting  and valuable  paper, published in
the 25th volume of the " Medico-Chirurgical Transactions," has collected  and
analyzed 44 cases, in which an artificial anus  has been formed by opening  the
intestine; in 17 of these the artificial anus was  made through the peritoneum,
and in 27 behind that membrane;  but  for various reasons, which are stated at
length in the paper, Mr. Hawkins excludes 5 of the cases of peritoneal section,
leaving only 12  to compare with  the 26 cases of operation behind this mem-
brane.   Of the former, he  finds that 7 died  and  5 recovered;  the recoveries
amounting therefore  to only forty-one  per cent.- in the cases of this category,
whilst of the 26 cases where  the peritoneum was uninjured, 10 died and 16
recovered; the proportion of recoveries in the cases of this category amounting
to sixty-one per cent.  Though the large intestine was opened in all these cases,
the operation was performed on the right side in 10 instances;  in 4 cases  the
right colon  and ccecum were opened through the peritoneum, and of these all
died; whilst in the remaining 6, in which the right colon  was opened behind
the peritoneum, 4 recovered.  The preference,  therefore,  as  Mr. Hawkins
observes, on  the right  side, is certainly due  to  the  lumbar operation.  It is
remarkable, however, that in the operation on the left  colon, the results  are
somewhat different; for of  8 cases in which this  intestine was opened through
the peritoneum, 5 recovered and 3  died; whilst of 20 cases in which the lumbar
operation was performed,  11 recovered and 9 died.  Mr. Hawkins observes, that
the inequalities of the numbers appear, however, to leave the question as to the
mode of operating on  the descending colon, still undecided, and that  an ope-
rator is justified in selecting whichever situation he thinks best  for the forma-
tion of an artificial anus on the left side of the body; though, for the reasons
that have already been given, I should prefer Amussat's to Littre's operation.
In those cases in which death has resulted from Amussat's operation, peritonitis
does not appear to have exercised any material  influence, and  the fatal result
seems rather to have depended on the influence of previous disease on the con-
stitution of the patient, or  on changes  taking place in the bowels, than on the
operation itself, which  appears  occasionally to have been uselessly done at the
last extremity.   We  should, therefore, have  less hesitation in performing  the
extra-peritoneal operation in an early stage of those cases  in which it is called
for, than we  should if the section itself were  attended with any serious risk to
the patient's life. 
DISEASES  OF  THE LARGE  INTESTINE  AND ANUS.  823
                         CHAPTER  LV.

    DISEASES  OF  THE  LARGE  INTESTINE AND  ANUS.

                  CONGENITAL  MALFORMATIONS

  Of the anus and rectum are by no means of unfrequent occurrence, and are
of considerable  importance; for,  if unrelieved,  they must  necessarily  be the
cause  of speedily  fatal  intestinal  obstruction.   They may  exist in  various
decrees, which I think may most  conveniently be arranged under the following
heads:—
  1st. Narrowing  of the anus so as partially to close  it, the  canal continuing
pervious, but not sufficiently so as to allow of the bowels being completely emp-
tied, the contraction  usually merely admitting a  full-sized probe;  in some cases
appearing to depend upon constriction of the anal orifice, in others upon an
imperfect septum stretching across it.  The treatment of this variety consists in
notching the contracted  anus with a probe-pointed  bistoury, and  then introdu-
cing a sponge tent, so as to dilate it to the proper size,  to which it must  be kept
by the occasional introduction of  a bougie.
   2d. The anus may be completely closed by a membranous septum stretching
across it, usually having  a raphe along the central line, and a  slight depression,
through which  the dark  meconium  can be seen, and on which an impulse can
be felt.  In  this variety an incision  must be made through the  septum  along
the middle line, and this again cut across on either side, when the meconium
will freely escape.  The four angles that are left must  now be  removed,  and the
aperture kept open by the introduction of a  well-oiled plug.  ^ This constitutes
perhaps the most common form of malformation that is met with.
   3d.  The  anus may remain open, but, at a distance of about half an inch or
 an inch from its aperture, the rectum will be found occluded by a perfect mem-
 branous septum, stretching across it.  This is  a rare and somewhat puzzling
 kind of malformation, as in it the infant will be found to labor under intestinal
 obstruction,  and yet, on  examination, the anal  orifice will be found  perfectly
 formed, and thus  the surgeon might be misled as to the seat of the obstacle.
 He will, however, detect it by introducing a  probe  or the end of his little finger
 into the anus.  In two  cases of this kind which  have  been brought  to me, I
 have opened the  septum by puncturing it with a  large trochar, and, after the
 lapse of a few  days, dilated the  aperture by means of a sheathed bistoury, the
 cases ultimately doing well.
   4th.  The  anus  may be completely absent,  being blocked up by a dense mass
 of fibro-cellular structure, from half-an-inch to an inch in thickness, above which
 the rectum terminates in a kind of cul-de-sac.  In such a case as this, an inci-
 sion about an inch  in length should be carefully  made, from the point of the
 coccyx forwards, and  the dissection carried down until the gut is reached; this
 must then be punctured, and the meconium allowed to escape.   If thecut sur-
by a mucous membrane, the probability is that the irritation set  up along it by
the intestinal matters will ultimately prove fatal to the child   Indeed, it com-
monly happens  in  these  cases that death results in a few days  from irritation
occasioned by the  absorption of the excreted fluids.   In order to  obviate this
source of danger, Amussat thought of bringing down the mucous membrane of 
824  DISEASES  OF THE  LARGE  INTESTINE AND  ANUS.

the bowel  to the anal orifice, and of fixing it there by sutures, so as to afford
the meconium a mucous canal to pass through, and thus to prevent the diffuse
inflammation which  is apt to take place in the cellular tissue of the pelvis, by
the contact and absorption of the effused  matters.  In many cases it is by no
means easy to do this, but yet it should always be attempted, as I believe the
whole safety of the  child depends upon this being carried out.   For some con-
siderable time after the operation, the aperture should be kept dilated by means
of bougies; a gum-elastic or pewter tube, through which the faeces are allowed
to escape, may be fixed in  the part.
   5th.  The anus may be closed, and the whole of the rectum absent, the intes-
tine (colon) terminating in an  expanded  pouch,  situated high up at the brim
of the pelvis.   Such cases as these only differ from the last  in the extent of
the occlusion, and cannot indeed be distinguished from it until the surgeon has
made an incision in the site of  the anus, and has failed to reach the gut at the
usual distance  from the surface.  In these cases the  dissection requires to be
carried with caution to a considerable depth along the mesial line, the surgeon
taking  the curve of the sacrum and coccyx for his guide, and bearing in mind
the  relations of the bladder and  large vessels in the neighborhood, carefully
proceeding in search of the gut, which may be  found at a considerable depth
from the surface.   In three  instances of this kind on which I have operated, it
was  necessary to proceed to a  depth of at least one  and a half or two inches
before  the bowel was reached, which, on account of the narrowness of the
wound  and  the small size and  important relations of  the parts, is not an easy
matter.  An attempt  may be made to bring down and fix the  gut  at the exter-
nal orifice, as in the last case, but, on account of the distance that  it  is from the
surface, this can rarely be  expected to succeed.  As the perineal section seldom
succeeds in saving  life in  these  cases, it might be  a question  whether the
 descending colon should not be opened in the iliac or lumbar regions.
   In these cases  three courses  present themselves to  the surgeon.  1st. The
 colon may be opened in the left iliac region;  2d.  It may be reached in the left
 lumbar region; and, 3d. An opening may be made into it through the perineum.
   The only advantage that the iliac incision, or Littre's operation  presents, is
 that it is an operation easy of performance, and that whether the surgeon reaches
 the colon  or not, he is certain to hit upon some part of the intestinal tube which
 may be drawn forwards and opened.
   The objections to this operation are, the inconvenient situation of the artificial
 anus; the great danger that must necessarily result from wounding the perito-
 neum ; the  chance  of not finding  the  sigmoid flexure; and, as has often hap-
 pened, of being obliged to open that portion of the small intestine which first
 presents itself.
   The mortality  after this operation  is very  great.   Amussat states, that of
 twenty-one  children thus operated on, only four ultimately recovered; and it
 is worthy of remark, that all the successful cases occurred in the town of Brest.
   The lumbar incision, or Amussat's operation, has not as yet, to my knowledge,
 been successfully practised on an imperforate  child.
   The advantages of this operation consist not only in the artificial anus being
 situated at a more convenient spot than in Littre's operation, but-more especially
 in the possibility of opening the colon in this situation without wounding  the
 peritoneum.
   The objections to this operation, as applied to imperforate children, lie  in the
 frequent co-existence of malformation  or  malposition of the colon, with absence
 of the rectum, and in the  impossibility in  many cases of determining,  before
 proceeding to operate, whether  the anus is only occluded by a membranous sep-
 tum, or  whether  the rectum  is  absent  as  well.   If it could be  ascertained
 beforehand that, though the rectum be absent, the descending colon occupies its
 normal position in  the left  lumbar region, I  think it  probable that the lumbar 
            STRICTURE  OF THE LARGE  INTESTINE.         825

incision would be attended with less danger than any other operation that could
be practised; but in the absence of this knowledge, it would scarcely appear to
be justifiable to have recourse to it, as the colon might not be found,  and the
anus might merely be covered by a dense membranous septum.
  The perineal  incision has the advantage of being in the natural situation of
the anus, and of being easily practised and perfectly successful in all those cases
in which the anus only is imperforate, the rectum being present.  It is in  those
cases only in which there is congenital absence of the rectum that this operation
is difficult of performance, and uncertain  in its results.   If it could be ascer-
tained, before proceeding to operate, that  the rectum be absent it might be
wiser to search for the  bowel in the lumbar region.   But as the surgeon has no
means of ascertaining,  before making his  incision, whether  the rectum be one
inch or three inches from the surface, he  must cut into the perineum in order
to obtain the necessary information;  and  if once he has penetrated to such a
depth as to  get beyond the levator ani muscle, or into the  deep fasciae in this
situation, a great portion of the immediate danger of the  operation will have
been incurred, and few would think it advisable to  leave the perineal operation
unfinished, and expose the child to the additional risk of opening the colon in
the lumbar region.
   There is one point in connection with the perineal operation to which it is of
much importance especially to attend, not only as respects the immediate result
of the operation, but as regards the ultimate success of the procedure, I mean
the bringing down of the mucous membrane of the  gut, and fixing it to the lips
of the external wound.  Unless this  be done, the  line of incision between  the
termination  of the  gut  and the aperture in  the integuments  will degenerate into
a fistulous canal, which, like all  fistulae, will have a tendency  to contract, and
will be  a source of endless embarrassment  to the  surgeon  and to  the patient.
If the mucous membrane can be brought down and fixed  to the opening in the
integument, this source of inconvenience will be removed,  and the patient will
be saved all that danger which results from the passage of the meconium over
a surface of recently incised cellular tissue.   This, however, can only be done
when the intestine terminates at a short distance from the surface.  If the peri-
neal incision be  two or three inches in depth, there would  be little  probability
of the surgeon being able to bring the  intestine down to such an  extent.  In
the case that I have related I attempted to do so,  but found  that  the gut was
too firmly fixed  to be moved by any traction that it would have been  safe to
have  employed.
   6th.  The  anal orifice may be absent, and the  gut may  open into  one  of the
neighboring mucous canals, as the vagina, the urethra, or into the bladder.  In such
anomalous cases as these there is usually, I believe, but little to be done, except
to restore the anal orifice, and then to take the chance of the other preternatural
communication closing.  This it will sometimes do, and cases have occurred in
which, although the whole of the meconium with flatus  had  escaped per ure-
thram, yet on opening the rectum the abnormal communication seemed gradu-
ally to close, the faeces being directed into their proper channel.  In a case in
which I was recently  consulted, there was  imperforate anus and rectum, and
the bowel protruded as a red, fleshy tube, about four inches in  length, from the
end of which in the anterior abdominal wall, just below the umbilicus, and im-
mediately above an  extroverted bladder, the meconium  escaped.   In such a
complicated malformation surgery could evidently do nothing.

            STRICTURE  OF THE  LARGE  INTESTINE.

  Stricture may occur  in any part of the rectum or colon, and is of two kinds,
the simple, consisting of mere thickening of the bowel, with  fibrous degenera- 
826    DISEASES  OF  THE LARGE  INTESTINE AND ANUS.

tion of its coats and contraction of its canal;  and the malignant,  dependent on
cancerous degeneration of, or formations in the bowel.
   The simple or fibrous  stricture, though occasionally occurring in the trans-
verse or descending colon, is most  frequently met with  at the junction of the
sigmoid flexure and the rectum, or at the upper part of this gut, from four to
six inches  from  the anus.  Not unfrequently a very tight annular stricture is
found in otherwise healthy subjects, chiefly in young women, at the lower part
of the rectum, about an inch and a half from the anal orifice, appearing almost
as if it were the remains of a septum, or a thickened annular fold of the mucous
membrane in  this situation.
   Stricture of the large intestine commonly occurs in elderly people, and with
special frequency in women;  that form which occurs low down  I  have however
frequently seen in young women, otherwise perfectly healthy.
   The symptoms of stricture of the rectum consist at first of some difficulty in
defecation, the  patient being  obliged  to  strain  at stool.   The faeces will also
appear to be  flattened or  narrowed, and  in many cases, more especially as the
stricture advances, are passed in the  form of small scybala, with  occasionally a
kind of spurious diarrhea,  consisting of the passage of the more fluid intestinal
contents, whilst  the solid  matters are left behind.  At the same time there is
very commonly pain in defecation and  the occasional passage of some mucus or
blood, and dyspeptic  symptoms, with  flatulent distension of the abdomen are
apt to come  on.   If  the  stricture  is within  four or five inches of the anus, it
may be reached with  the  finger, and its precise  situation  and diameter ascer-
tained.  If above this point, it must be examined by the introduction of a well-
greased bougie, attention being paid to the curve which the rectum makes from
side to side, as well as from before backwards.  In introducing bougies in order
to ascertain the presence of a stricture above  the upper end of the rectum, but
little  information can be  gained in many cases, as the point of the instrument
is apt to hitch in folds of the mucous membrane, or opposite the promontory of
the sacrum, and  thus its onward passage being  prevented, an  appearance of
constriction may present itself, which in  reality does not occur, and unless care
be taken the mucous membrane may actually be  lacerated, and the instrument
forced through it into the  peritoneal cavity.  In other cases again  the bougie
will appear to pass, when in reality its point meeting with an obstruction  curves
downwards into the rectum.
   The progress and  termination of a simple stricture vary in different cases.
In some the contraction of the stricture may go on increasing, until at last com-
plete  occlusion takes  place, with  retention of faeces and all the symptoms of
obstructed  bowels.  This  condition usually  comes  on slowly,  and  after the
obstruction is complete, life  may  continue  for  several weeks; but in some
instances the  obstruction  appears  to  take place  rather suddenly, and with all
the symptoms  of acute intestinal  strangulation, with death  in a few days.
Abscess occasionally  forms in the neighborhood  of  the stricture, and passing
down into  the pelvis may either burst into the ischio-rectal space, into the
vagina, or present upon the nates.   The  discharge of pus  from  this source, as
well as from the mucous membrane lining the stricture which falls into an ulce-
rated state, may induce extreme emaciation and hectic, to which the impairment
of nutrition consequent upon the disturbance  of digestion adds materially.  In
some  cases peritonitis will  at least ensue, either in consequence of ulcer or
abscess communicating with the serous cavity, or  else from the  extension of the
irritation outwards.
   The treatment of simple stricture  of  the  rectum  must be conducted on the
principle of dilating the canal at its constricted point.  If this be within reach
of the finger,  the dilatation can be readily carried out.  If it is above the upper
part of the rectum, and the stricture  be tight, it is extremely difficult to intro-
duce the proper instruments with  certainty.   When the stricture is low down, 
   CANCER  AND MALIGNANT STRICTURE OF THE RECTUM.  827

bo that the end of the finger can be introduced into it, it may readily be dilated
by introducing a rectum bougie every second day, and gradually increasing the
size of the instrument.  If the stricture yields  but slowly, and is very tight
and indurated,  I have found it  a convenient plan  to  introduce  a sheathed
probe-pointed bistoury into it and to notch it towards its posterior aspect, where
this may be done without danger to the peritoneum.   A tent of compressed
sponge should then  be introduced and  left in for twelve hours.   On its with-
drawal bougies may more readily be passed,  or the dilatation may be carried on
by means of  tents of compressed sponge.  When the  stricture is above the
reach of the finger  a good  deal  of management will be  required to get the
bougie into it.  This  is best done by laying  the patient on  his  left side and
using a moderate-sized wax or elastic bougie, which must be passed without the
employment of any force.  When once the surgeon has got one through, others
can readily be got to  follow in the same track.   The great danger in introducing
the bougies high up is to mistake the obstruction offered by their point coming
in contact with one of the valvular folds of  mucous  membrane, that occur in
this situation, for that  of the stricture, and pushing on  the instrument to per-
forate it — an accident that would probably occasion fatal peritonitis.   During
the introduction of bougies,  the bowels must be kept regular by means of leni-
tive electuary and  the occasional use of emollient enemata.  If much pain or
irritation should be occasioned by their presence,  opium should be administered
internally or  in the form of  suppositories.  Though a simple  stricture of the
rectum may be much relieved by the use of bougies, it is seldom I think cured
by this means, there  being  a great tendency for it to contract so soon as the
treatment is discontinued.
   If  complete obstruction occur, an endeavor should be made to relieve  the
patient by the use of enemata of gruel and  linseed-oil, and the strength should
be supported by a diet that is nourishing, at the  same time that it leaves little
or no solid residue; the bowels may eventually act after  a considerable lapse of
time, the  stricture apparently giving way.  In a case which I attended with
Mr. Powell, and to which reference has  already been made, the stricture gave
way after obstruction had  lasted for about five  weeks,  some  hardened  faeces
with  bloody mucus being discharged, which  were speedily followed  by abun-
dant  feculent motions.  Should the obstruction, however, continue, and  the
patient consequently be in imminent danger of death from this cause, the intes-
tine should be opened if possible by Amussat's operation, performed in the way
already described (p. 820).   This may require to be  done either  on the right
or  left side,  according to the seat of stricture.   In the majority of instances
this will be situated below the descending colon, so that relief may be given by
opening this intestine in the left loin;  but  if it is impossible, or even very
difficult to  determine the precise seat of the obstruction, the operation may as
readily be performed in the right lumbar region.   In those rare cases in which
the stricture is seated in the transverse colon, there would probably be consi-
derable distension  of the right loin, without any  corresponding enlargement of
the left;  under these circumstances, the  proper plan  would be  to open  the
ccecum.

   CANCER AND  MALIGNANT STRICTURE  OF THE RECTUM.

   Cancer of the rectum usually occurs in the form of degeneration or infiltration
of the substance of the wall of the gut, giving rise to considerable induration
and contraction of the bowel.  In other cases a flat cauliflower growth springs
from  the inner surface of the intestine, being hard, nodulated, and presenting
all the ordinary characters of scirrhus.   And  sometimes even this is somewhat
pedunculated, so as  to resemble a hemorrhoidal protrusion:  and  lastly a scir- 
828    DISEASES  OF  THE  LARGE  INTESTINE AND ANUS.

rhous tumor may form in the cellular tissue external to the  rectum, and at last
press upon and implicate the gut.
  Most usually cancerous disease is seated from three to five inches  above the
anus, and may implicate a considerable portion of the bowel, extending upwards
rather  than downwards, and  giving rise  to  considerable induration and con-
traction, with complete occlusion of the interior  of the gut.
  The symptoms of cancer of the rectum  are  pain and weight in the gut, with
a sensation as  if the  bowels  had  not been completely relieved, together with
the discharge of mucus, blood, or pus, and some flattening  of the faeces.  On
exploring the parts with the finger, the lower portion of the  rectum will usually
be found considerably expanded, whilst the tip of the finger will come in con-
tact with the  contracted, hardened, and rugged scirrhous  mass.  The patient
experiences most suffering during defecation, in  consequence of  the passage of
faeces over the raw and ulcerated surface.   This  pain is not  confined  merely to
the  diseased part, where  the sensation is of a hot and burning character, but
usually radiates round the  loins and down the thighs, and is so severe, that the
patient looks forward to each action of the bowels with the greatest possible
dread, and restrains it as  long as possible.   The whole nervous system  at last
participates in this continually recurring  suffering, the countenance becomes
anxious, the spirits depressed,  sleep  and  digestion  destroyed.   The patient's
condition is indeed truly miserable between the dread  of excessive suffering
when the bowels act, on the  one hand, and the  fear of impending obstruction
on  the other, and  in  many instances  he is worn out by this suffering, together
with the constitutional cachexy induced  by the contamination of the  system
with the cancerous matters.  Not unfrequently the misery is much increased by
the  formation of  fistulous openings  in the  neighborhood  of  the  bowel,  and
communications between it and  neighboring parts, such as the vagina, bladder,
or urethra, with cancerous implication of them.  In  other instances, though
more rarely, death occurs from  faecal  obstruction, as in  the  case  of simple
stricture.
   The treatment must necessarily be of a palliative kind; large  doses of opium
being  required  after each action of the bowels to lessen  the patient's distress.
Little  good can be expected from more active measures; dilatation only irritates
the  disease, and would tend to increase the mischief.   The application of caus-
tics, such as potassa fusa, does not offer much prospect of advantage, as  only a
superficial slough  could in this way be formed, without very serious risk to the
patient, and it is  an  excessively  painful  remedy.  Amussat  has proposed to
crush and break down the morbid mass by means of the finger and forceps; but
from such treatment as this little good can be anticipated.  The recommendation
to excise the cancerous mass,  as made by Lisfranc  and other French surgeons,
is contrary to every principle of good surgery,  as it is impossible to extirpate
the  whole of the disease, without either  laying  open the peritoneal  cavity, or
destroying the patient by the profuse hemorrhage which could scarcely be ar-
rested.  If palliative means fail in affording the  requisite relief,  and the patient
suffers much  local pain and constitutional irritation during defecation, the pro-
priety of establishing an artificial anus in the left  lumbar region might be dis-
cussed, not with a view of saving life, but rather in  the  hope of  prolonging
existence, and lessening suffering by preventing  the exhaustion and  agonizing
pain that attend the passage of  the feculent  matter over the ulcerated  surface
(p. 821).  In several instances much relief of  suffering and considerable pro-
longation of life has been  effected  by this procedure.
   Polypi  sometimes form in the rectum,  constituting large pendulous  tumors
of a flbro-mucous character;  they may most conveniently and safely be removed
by the application of a ligature to their neck. 
ULCER AND  FISSURE  OF THE ANUS.
829
                     DISEASES OF  THE  ANUS.

  Cancer of the anus is  not a very common affection,  and when met with
usually occurs in consequence of scirrhus of the  rectum spreading  to  and
involving the margin of the anus.  When it occurs as a primary disease it  is
usually of an epithelial character, and may then form about the anus just as it
does at other muco-cutaneous apertures.   If limited and  detected in the early
stage it might advantageously be excised, but at a more advanced period of the
disease, such a practice could scarcely be adopted with any prospect of success,
in consequence of the impossibility of removing  the  whole of the structures
implicated.
   Ulcer and fissure of the anus. — This disease, though trivial in point of size
and in its pathological relations, is of great practical importance on  account of
the excessive local  pain, and  great  constitutional irritation to which a patient
laboring under it is  often subject.  Ulcer and fissure commonly exist  together
in this situation, though  it by no means  unfrequently happens that the two
conditions occur separately; the ulcer  is usually of small size,  seldom larger
than a silver threepence, of a circular or a longitudinal shape, situated between
the folds of the mucous membrane in the upper part of the anus, or rather the
lower part of the rectum, just above the ring  formed  by the sphincter, and is
usually met with towards the posterior  part of the gut on one side of, or oppo-
site to, the point of  the coccyx.  Occasionally more than one ulcer exists in this
situation.  If a fissure accompanies the ulcer, it commonly leads from this across
the face of the sphincter  to the verge of the anus;  but in many cases one  or
two fissures, sometimes even three or four exist, without any ulcer. The fissures
are usually slightly indurated and cord-like, and not  unfrequently their external
termination is concealed by a small pile or flap of integument.
   The existence of the ulcer may usually be determined by exploring the rectum
with the finger, which if  practised in these examinations, will detect a small,
soft, and velvety patch at the diseased spot; on touching which the patient will
usually complain of acute and burning pain.  In  some cases  the ulcer may be
brought into view by examining the rectum with the speculum ani, such as here
delineated (figs. 328 a and 329).  The fissures may always readily be detected

                 Fig. 328.                                 Fig. 329.
by everting the mucous membrane of the anus, and by lifting up  or  turning
aside the pile that covers the lower end of the crack.  During this examination
 
830   DISEASES OF  THE  LARGE  INTESTINE  AND  ANUS.

it will usually be found that the sphincter ani is in a more or less spasmodically
contracted state, admitting the finger and instrument with difficulty.
  The symptoms of ulcer or fissure in the anus  are very characteristic.  The
patient complains of pain usually of a severe burning character on the passage
of a motion, especially if a hard one, especially at the time of  defecation, but
more frequently commencing a few minutes afterwards and continuing for from
half an hour to several hours.   This pain is very severe and peculiarly wearing
and burning; it is  generally most felt, opposite the  sacro-iliac articulation, but
not unfrequently radiates round the pelvis or down the thighs.   In many cases
it produces  a good  deal of continued irritation about the genito-urinary organs,
giving rise to symptoms of spasmodic  stricture;  a frequent desire to urinate,
tenderness about the prostate, and seminal emissions.  Very commonly in women,
the pains produced by the rectal disease  simulate those  occasioned  by uterine
irritation; and, in both sexes, they may after a time become continuous, and be
attended by a good deal of constant uneasiness in sitting, so that the patient is
obliged to raise the affected hip.  There is often a discharge of  a streak of pus
or blood on the faeces, and  commonly a good deal  of mucous  exudation, with
some tenesmus on defecation; but in  some  instances  these  symptoms are
altogether absent, and the patient never suffers any local inconvenience except
from the pain.
   The constitutional irritation is often very great, the nervous system generally
sympathizing with the local mischief.  The countenance becomes pale, anxious,
careworn, and the expression is indicative of constant suffering.
   This  affection most commonly occurs  in women, especially  in  those  of an
hysterical temperament and weakly constitution.   When met with in men, it is
most frequently seen in enfeebled, cachectic, and debilitated subjects, and appears
to be the result of a broken state of health.
   The  treatment of fissures or ulcers of the anus, when the disease is met with
in  the early stages, may sometimes be successfully conducted by the application
of nitrate of  silver  to  the fissure, and  the  use of an  anodyne or  astringent
suppository   I have found a very excellent and useful  suppository in this and
many other painful affections of the anus to be composed of 2 grains of extract
 of belladonna, 2 grains of the acetate of lead, and 4 of tannin, made up to  a
 proper consistence with a little suet.   This may be  introduced  into the rectum
 every night and allowed to dissolve there; the bowels should at the  same time
 be kept gently open with castor-oil, or the lenitive electuary.  In those cases in
 which the disease has been of some standing these means will not suffice, and it
 becomes necessary to have recourse to a'very  simple operation  to effect a cure.
 This consists in dividing the affected mucous membrane through the ulcer or
 fissure, with possibly some of  the subjacent fibres of the sphincter muscle, by
 which the part is set at rest and cicatrization speedily takes place.   The relief
 after the operation is usually immediate.  Indeed after this simple operation a
 patient  who has been suffering severely for months or years will often get com-
 plete and almost instantaneous relief.  The merit of introducing this plan of
 treatment for the cure of ulcer and fissure of  the anus into surgical practice  is
 due to Sir  B. Brodie.   Boyer had  previously recommended that the sphincter
 should be cut completely across in order that  its  action might be paralyzed, but
 Sir B. Brodie found that the  ulcer  could be made to heal as readily by the
 limited incision above mentioned.  The operation is  readily done by introducing
 the left fore-finger into the rectum, guiding  along  it a probe-pointed bistoury,
 and then cutting downwards and outwards, carrying the knife  about the eighth
 of an inch in depth.   The section  may either be made through the ulcer and
 fissure, or on either side of the coccyx.  It is  doubtless better, when practicable,
 to cut through the diseased structures, though it is  not necessary to do so; and
 it  is always better to make an incision on both sides of the sphincter, so as to be
 sure that the muscle is set at rest.  No dressing is required after this operation, 
ABSCESS OF  THE  RECTUM  AND  ANUS.         831
but if the incision do not readily heal at the end of a fortnight or three weeks,
it should be touched from the bottom with the nitrate of silver.   The patient's
bowels should be well opened before the operation, and a dose of castor-oil may
be oiven on the second or third day after it.   During the  process of cicatriza-
tion it will often be  advantageous to give iron, and to put the patient on a very
nourishing diet.
   Spasmodic contraction of the sphincter ani is usually associated with fissure
or ulcer of the  anus, but occasionally it occurs without this complication, and
in  all cases  it may be  connected with a  neuralgic  condition of the part.  In
hysterical women this neuralgia and spasm  are especially apt to occur, though
it is  not improbable that in many of the so-called cases  of neuralgia of the
 anus  some positive disease,  such as a small ulcer or fissure, may be detected on
 close examination, as I have had several occasions to verify.  The treatment
 of spasm of the sphincter, whether associated with neuralgia or not,  consists in
 the employment of local  sedatives,  enemata, and laxatives, with, if necessary,
 the  division of a few of  the  muscular fibres,  together with  the mucous
 membrane.
    Abscess not unfrequently occurs in the vicinity of the rectum and anus.  It
 may either be  superficial, being confined to  the muco-cutaneous structures, and
 presenting the  ordinary characters of acute subcutaneous abscess, or it may be
 deeply seated, forming  in the ischio-rectal  fossa.   It is these rectal abscesses
 that are of most practical importance.  The may be of two kinds — acute and
 chronic.                                         #
    The  acute ischio-rectal abscess forms deeply  in the  fossa,  with  throbbing,
 shooting, and  stabbing pains through the  anus, rectum,  and perineum; on
 examination, a  hard brawny substance may be felt in  the cellular tissues by
 the  side  of the gut,  either  by examination from  without, or by  exploration
  through the rectum, which speedily softens, and  will, unless an outlet be made
  for it,°either burst externally, or into the cavity of the gut, or both ways.  This
  acute form of abscess usually occurs  in persons  of otherwise strong and healthy
  constitutions.
    The chronic ischio-rectal abscess, on  the other hand,  occurs insidiously in
  persons  of cachectic, broken,  or phthisical constitutions, and without  much
  pain or local inconvenience will form a large collection, denuding the gut to a
  considerable extent, in fact, almost surrounding the rectum, and then spreading
  widely on the  nates or hip, presenting all the  ordinary characters of a chronic
  abscess.  This  kind of purulent collection may form in  this  as in any other
  situation in the body, as the result of congestion, or some  local irritation.   But
  there is reason to believe that in some instances  at least, it occurs as the result
  of perforation  of the gut,  either by ulceration  from within, or by some foreign
  body, as a fish-bone, for instance, transfixing it, and thus inducing inflammatory
  action in the cellular tissue outside the rectum.
    In the treatment of these abscesses the principal point to be attended to is
  to prevent the extensive  denudation of the  gut.  In order to do this they must
  be opened, so soon as  the  formation of pus can be ascertained  to  have taken
  place, by making  a free, and if necessary,  a deep incision into the  ischio-rectal
  space by the side of the  bowel.   Unless  this be done, they may  either burst
  into the interior  of the gut, or spread widely upon the  nates, and then  give
  way.   The pus that is let out of these collections is always extremely offensive,
  even though not  mixed with any feculent matter, the near neighborhood of the
  bowel appearing to determine some change in it that renders its smell peculiarly
  stercoraceous.   After the  evacuation of the abscess the patient feels easy, and
  thinks that all is well, the  discharge gradually lessening and the cavity-con-
  tracting;  but  it  does not  close, and a  fistula will be left, which  cut,
  exude a thin watery pus, in which  feculent matter, perhaps  accumulates from
  time to time, giving rise to fresh outbreaks and extensions of  the disease. 
832    DISEASES OF THE LARGE  INTESTINE AND  ANUS.
                           FISTULA  IN  ANO.

  The sinus left by the contraction  of the cavity of an ischio-rectal abscess
constitutes a fistula  in ano;  an affection that has attracted  a good deal of
attention  from the frequency of its  occurrence, and the difficulty of curing it
without having recourse to operation.
  Fistula in ano may vary as to extent and kind.  Some fistulae are very limited,
being  merely the sinus left in the submucous cellular tissue of the anus after
the  bursting  of a  superficial abscess in this  situation, extending  to a short
distance up the gut inside the sphincter.  This form of fistula constitutes, however,
a kind of spurious variety of the disease, for the true fistula in ano is outside the
sphincter in the surrounding cellular tissue, extending always as high as the upper
margin of that muscle, and frequently stretching to a considerable distance up
the side  of the gut.  Most frequently the lower aperture of the fistula is some-
where in the perineum or ischio-rectal fossa, just beyond  the sphincter; but
not unfrequently sinuses  extend  from this outwards to a considerable distance,
undermining the integuments  about the buttocks, stretching away towards the
trochanters, and opening at a great distance  from the bowel.   These  extensive
fistulae and sinuses are frequently connected  with stricture of the gut.
  Fistula in ano varies also as to kind.   It is said to be complete when it com-
municates by one end with the interior  of the  rectum, and opens by the other
upon the external surface.  It is  said  to be incomplete  when it  has only one
aperture, whether that is external or internal.
  The complete fistula is the most common, and probably arises in the majority
of cases  from some source of irritation  seated within the bowel, by which the
mucous membrane of the rectum has been perforated, and an  abscess has formed
in the cellular tissue outside the  gut.   The external opening in  this form of
fistula is  usually from half an inch  to  an inch from the margin  of the anus,
though it may be seated at a greater distance than this, as upon the hip.   It is
commonly of  small size, and  has  a vascular granulation projecting from, or
occluding it; and a thin purulent discharge usually drains  away from  it in small
quantities, moistening the surrounding integuments.  The internal  opening is
usually situated  just  above the sphincter, where the rectum begins to expand.
But the fistula does not terminate  at this internal  aperture,  for in the majority
of cases it runs up into a kind  of cul-de-sac, to a considerable  distance further.
The internal aperture may readily be detected by introducing a blunt curved
probe  into the fistula, when by a little management it may be  carried through
the inner  opening.   In some  cases the existence of this may be ascertained
by examining the interior of the  bowel with  a speculum ani.
  The incomplete or blind fistula may be of two kinds,  and commonly  arises
from  constitutional causes.   When there is no internal perforation, a mere
sinus having been left by the bursting of an abscess, the fistula is termed blind
external.   When there  is only an  internal aperture  it is called blind internal.
The blind external  fistula is readily recognized  by its being  found that the
probe does not penetrate  the interior of the gut.  The blind internal is not so
readily detected,  but  in this case  it will generally be found  that the patient
suffers from an  occasional and tolerably abundant discharge of pus  from the
interior of the bowel;  that  there is a good  deal  of tenderness, with some
brawny induration on one side  of the anus; and that the pus may be made to
well out in some quantity by pressing upon this part.   On passing the  finger
into the  rectum  the  ragged internal  aperture  in the  gut may readily be felt
through which the pus exudes.
  In the treatment of fistula in ano, operative interference is usually necessary.
It is  true  that in some rare instances the canal may be got to close under the
influence  of constitutional management, aided perhaps by stimulating its  inte- 
OPERATION  FOR FISTULA  IN  ANO.
833
nor with the nitrate of silver, or by touching it with a probe dipped in nitric
acid.  This kind of treatment is however only successful in the blind external
fistula, several instances of which I have  seen get well  in this way, but it can
never be  expected to answer in  any other variety of the disease.  When the
fistula is complete, the only plan  of treatment that offers any chance of success,
is the division of the sphincter, so that this muscle which tends to prevent the
closure of the sinus,, may be paralyzed, and the fistula being laid open from the
bottom, made to heal by granulation.  Various plans have been devised for the
division of the sphincter,  and much ingenuity has been  expended in attempts
to discover simpler and less painful modes  of effecting this than by  the knife,
but hitherto without success, and the only plan of treatment that deserves any
 attention is the division of the sphincter with a curved bistoury.
   The operation for fistula in ano should not be  performed indiscriminately in
 all cases and  at all periods  of the disease.   If the fistula be dependent upon stric-
 ture of the gut, and more especially if this be of a malignant character, it is evi-
 dent that no operation can be attended by a chance of success, and none should
 be attempted.  So also if the  patient be cachectic and broken in health, it is
 well to improve his constitutional powers before undertaking an  operation, lest
 the wound that results may not readily cicatrize.   It is  also well to  wait until
 the disease has assumed a  somewhat chronic form before  proceeding to the divi-
 sion of the sphincter; if this be done early  after  the bursting of the abscess, or
 at any time if there be much inflammatory action going  on, the wound is apt to
 assume a somewhat  sloughy condition, and to heal with great difficulty. ^ The
 most important question usually connected  with  the operation for fistula, is the
 propriety of performing it in phthisical subjects.  It is a well-known fact that
 fistula in ano is especially apt to  occur in  consumptive individuals, and it is often
 a nice point to determine whether an  operation should be per-
  formed or not in them; — how  far the drain from the  fistula may
  keep up or even generate the tendency  to  phthisis, or how far it
  may be  salutary in acting as a  counter-irritant, and in preventing
  the morbid condition of the lung developing itself.  Dr. Theophilus
  Thompson states that the  co-existence of fistula  with phthisis  ap-
  pears to retard the progress of the latter disease, acting  as a deri-
  vative, and doubtless in  some  instances this may be so.  I have,
  however, in several cases found considerable advantage  result by
  operating for fistula in the early stages of phthisis, or in suspected
  cases of that disease, the patient's health having considerably im-
  proved after the healing  of  the fistula.   In such cases it may be
  of use to put an issue  in the arm or  side of the chest.  But  in
  confirmed,  and still less in advanced phthisis, no operation should
  ever be practised, as  the wound will not heal, and the patient must
  be weakened by the  additional discharge.
    The operation should be performed in the following way: —The
  bowels having been well cleared out the day before with a dose of
  castor-oil, and an enema administered on the morning of the ope-
  ration, the patient should be laid  on  his left side, with the nates
  projecting over the edge of the bed; a probe must then be passed
  through the fistulous  track into the rectum,  and the surgeon in-
  troducing the forefinger into the gut, feels for the end  of the in-
  strument, he then passes a short strong-bladed  probe-pointed bis-
Fig. 330.
figure (330), through the fistula, using the probe as a guide, though
in some  cases  this  may conveniently be dispensed with.  \V hen
he feels the end  of the knife projecting into the rectum, through  the  internal
aperture of the fistula, he withdraws the probe, hooks his forefinger over it(ng
331), and by a sweeping and pressing cut, raising the handle of the instrument
      53 
834  DISEASES OF THE  LARGE INTESTINE  AND ANUS.

at the same time that he pushes down its point, brings both finger  and blade
                                    out at the anal aperture,  cutting through
               Fig. 331.              the whole thickness of parts between this
                                    and the fistula, so as to lay the two cavi-
                                    ties into one.  In performing this opera-
                                    tion,  the  surgeon must cut with  his  left
                                    hand if the fistula be upon  the left side;
                                    and in either case should be careful  not
                                    to  wound his own  finger, as such cuts
                                    often prove  troublesome  in healing.   If
                                    sinuses stretch from the  fistula along the
                                    nates or  hip, he  may, if he  pleases, slit
                                    these up with a  probe-pointed bistoury,
                                    before  dividing the sphincter.   But if
                                    they be extensive, such an operation may
                                    be of a somewhat serious character, and
                                    it will then be better to make a puncture
                                    into  the  sinus near the  external margin
                                    of the anus, and divide this structure in
                                    the usual way.   If  the fistula be a blind
                                    external  one, it must at  the time of the
                                    operation be made  complete, by scratch-
 ing with the end of the knife  through  the thinned  structures that intervene
 between its extremity and the interior of the gut; and  the operation must then
 be completed in the way described.  If it be a blind internal fistula, a puncture
 must be made through the integuments into the canal, with a sharp-pointed bis-
 toury, and the operation then concluded in the ordinary way.
   When there is an internal aperture  into the gut, this  will  usually be found
 just above the sphincter; but  the fistula  does not  terminate  here, frequently
 extending up by the side  of the gut for an inch or two.   Under these circum-
 stances, what should be done with the cul-de-sac above the inner aperture ?  If
 it be laid open, an extensive and deep wound will be inflicted, which  may im-
 plicate some of the hemorrhoidal vessels, and thus give rise to a dangerous
 degree of bleeding.  Hence, surgeons  generally  content themselves with the
 division of the sphincter and all  the parts intervening between the inner aper-
 ture of the fistula and the verge  of the anus;  the sinus  which is  left usually
 contracting and closing without difficulty when this has  been done.   In some
 cases  it happens, however, that  this cul-de-sac is not readily obliterated, but
 gives rise to a good deal of trouble, in consequence of the occasional accumula-
 tion of pus in it, and the thickening of its  aperture into the bowel giving rise to
 spasmodic  contraction of the  sphincter and a kind  of rectal stricture.  This
 inconvenience gradually subsides in most cases; should it  continue, it may be
 obviated by introducing a sheathed bistoury into the track and dividing it.
   The after-treatment should be as simple  as possible, consistently with securing
 closure of the wound by granulation from the bottom.   A narrow slip of oiled
 lint should be introduced between the lips of  the wound, and this must be left
 in for forty-eight hours, during which  time the bowels are kept confined by the
 administration of  a grain or two of opium immediately after the operation.  On
 the second  day a dose of castor-oil may be administered, which will not only
 act upon the bowels, but bring away the piece of lint.   The wound must then
 be lightly dressed  from the  bottom, a  poultice applied, and care taken at the
 daily dressing, by the  introduction of a probe, to prevent the bridging over of
 granulations.   After the wound  has completely united, a notch will usually be
 left by the side of the anus, which gives rise to some inconvenience for a time
 by the occasional involuntary  discharge of a  little intestinal  mucus, and some
 flatus.  This especially happens  in those  cases in which the  incision  has been
 
HEMORRHOIDS,  OR PILES.
835
made anterior to the  anus into the perineum, and when  incontinence of faeces
may  for  a time,  be  left.  Should  the operation be  followed  by abundant
hemorrhage 0f a dangerous character, the rectum must be  securely plugged,
either with compressed sponge or with a bougie surrounded by lint.
HEMORRHOIDS,  OR PILES.
  By hemorrhoids  or piles, is meant a morbid condition of the blood-vessels
of the anus and lower part of the rectum, more especially of the veins of the
submucous  and subcutaneous cellular tissue, giving rise to more or less intu-
mescence of the part, which  may or  may not be attended with a discharge of
blood.  Surgeons are commonly in the  habit of classifying piles, according as
they bleed or not, into open or blind;  or according  as  they are situated above
or below the verge of the anus, into internal or  external;  the  internal being
always within the gut, the external habitually protruding out of  or around the
anal aperture.   The  first may either bleed or not;  the latter are always blind.
To  this division into external  and internal, Mr. B. Cooper has added an inter-
mediate variety, the  intero-external,  which is  partly within and partly without
the anus.  These divisions are of much practical moment, as the treatment is
very materially modified according as the hemorrhoid is situated above or below
the anal verge.
   We must look  to the  peculiar arrangement of  the veins of the rectum  as
 directly predisposing to the occurrence of piles.  The lower part of the rectum
 and the  verge of the anus are  composed  of a plane of muscular  fibre and  a
 muco-cutaneous surface, with an intervening stratum of dense  cellular tissue.
 In this cellular membrane is situated a close  interlacement of net-work of tor-
 tuous veins.   The blood  from this plexus of hemorrhoidal veins, finds its way
 into the general system  through two distinct channels.  By far the  greatest
 portion of  it is carried  into the  inferior mesenteric vein and thence  into the
 vena porta through the medium of the superior  hemorrhoidal vein, which may
 be looked  upon as the extreme  radicle of  the portal system; and secondly, a
 certain quantity passes into the internal iliac vein through branches that accom-
 pany the middle hemorrhoidal artery. We  may therefore look upon the hemor-
 rhoidal plexus as  being placed  midway between the portal and general venous
 systems, being the  point indeed at which they touch; but as belonging rather
 to the portal than  to  the systemic veins.   In  these arrangements we see  all
 the elements  that would  predispose to congestion,  and consequent dilatation  oi
 the vessels of a part.   There is a large and intricate  plexus of veins in which,
  as in all similar net-works, there is a tendency for  the blood to circulate slowly
  at times;  the natural tendency to stasis of the blood  being much  increased by
  the dependent position of the  part, and by the anatomical  fact that in conse-
  quence of the absence of valves in the superior hemorrhoidal vein and in the
  vessels  into which  it pours its  contents, the whole pressure of the column ot
  blood in the portal system may be brought to bear upon the hemorrhoidal plexus.
  The  circulation  through the portal system is likewise subject to much inter-
  ference  in consequence  of  hepatic and  intestinal obstruction, and  in  these
  changes the blood in the hemorrhoidal plexus also participates; and were it not
  for the  provision  that exists by which this plexus may free itself to  a certain
  extent from over-distension by its communication with the internal iliac through
  the medium of the middle  hemorrhoidal vein, piles would be much more ire-
  quent than they even now are, as a consequence of obstructed poptal circu at on
  Another great cause of hemorrhoidal enlargement is to be found in the want of
  support that the veins of this plexus experience on their mucous aspect dun, g
  defecation.   Situated as they are in cellular tissue, between a p hue of muscu-
  lar fibres on one side, and yielding mucous membrane on  the other, Jhen  dis-
  tended  by the constriction which they undergo  during and after the expulsion 
836    DISEASES  OF  THE  LARGE INTESTINE AND  ANUS.

of the contents of the rectum, they necessarily give way on that side on which
they have the least support, being forced down and elongated, together with the
mucous membrane under which they ramify, and which has a natural tendency
to become slightly everted during the act of defecation.   It will be found that
all the more  immediate or exciting causes of piles act by unduly increasing one
or other of those  natural tendencies that  exist in the  system, by favoring the
local congestion or determination of blood at the  same time that they produce
a lax state of fibre.
   Age  exercises considerable influence in predisposing to piles.   This disease
is not unfrequently met with  in young men of eighteen or twenty years of age,
more especially if they be of a relaxed  and phlegmatic temperament with lan-
guid circulation, and are obliged to lead a more sedentary  life than is natural or
proper  at that age.  After this  period the  liability to the disease  diminishes
until middle age  is  reached, when the tendency to hemorrhoidal affections is
again  increased, and becomes more  marked than at any former period of life,
owing to the more  active operation of those causes  that tend to impede the
return of the portal blood.
   Sex  appears to exercise more influence on the occurrence of hemorrhoids at
particular periods of life, than on the general liability to the disease.   It cer-
tainly appears to  be  more frequently met with amongst men at an early age,
than in young women; but at  a later period of  life, so far as my observation
goes, the disease  occurs with nearly equal frequency in both sexes.  The com-
parative  exemption of young women  is readily accounted  for by the  periodic
discharges from the  uterus  preventing the  congestions  that might otherwise
occur in the parts in its  vicinity.  The greater frequency at a later period of
life is  attributable  not only to the  tendency induced during pregnancy by the
pressure of the gravid uterus, but also, after the cessation  of the menses, to the
determination that is apt to be set up in certain organs of the female economy,
and to the retardation of the portal circulation by the  accumulation of fat and
other causes; these conditions chiefly occur in women of a sanguine and plethoric
habit of body.
   A sedentary life with indolent habits constitutes, perhaps, the most powerful
predisposing cause of the disease; more  especially if habitual high living is
conjoined with want of proper and sufficient exercise.  Indeed the artificial and
luxurious habits of the more opulent classes, by diminishing tone at the same
time that they occasion plethora and  a tendency to  abdominal engorgement,
 exercise  a considerable influence on the occurrence  of  this disease, which is
 much more  frequent amongst  them  than in persons  in  the  humbler walks in
 life.
   There  are a number of minor conditions which are commonly looked upon as
 predisposing causes of this disease, though it is extremely difficult to determine
 the precise share  that each has in its occurrence.  Amongst these may be men-
 tioned intemperance in food and drink; residence in warm, moist, and relaxing
 climates; the use of soft and warm beds;  or, the opposite  condition of sitting
 on a cold stone or damp cushion.   Over-exeitement of  the generative organs
 will also  occasion it.
   Amongst the exciting causes may be mentioned  local irritation of any kind.
 Thus  in some people hard riding will bring on an attack of piles.  The habitual
 use of drastic purgatives, more  especially of aloes, rhubarb, &c, is  well known
 to occasion the disease;  though it must be  observed that individuals who make
 habitual  use of these remedies,  often labor  under some of those obstructions of
 the abdominal viscera that have already been noticed as conducing to piles. The
 existence of other diseases about the rectum and anus, such as fistula, ulcer or
 stricture, by inducing local congestion and irritation, may excite the disease; so
 also uterine affections and various diseases of the genito-urinary organs may give
 rise to this affection. 
STRUCTURE  OF  PILES.                    837
  The most direct exciting cause of piles is certainly a retardation to the return
of the portal  blood.   Any impediment to  the  onward  current of the blood
through the hemorrhoidal or mesenteric veins, the trunk  or ramifications of the
vena porta, exercises a marked influence on the  tendency to congestion of the
hemorrhoidal  plexus.   Habitual constipation; the  accumulation of hardened
feculent masses in the large intestine; the want of  due secretion from the
mucous surface;  obstruction to the proper action of the liver, and  consequent
congestion of that organ;  the pressure  of abdominal tumors, or of the gravid
uterus are  all active  exciting  causes, interfering as they do with  the proper
return of the portal blood.   In some cases even  the  existence  of  an  obstacle
in the systemic  veins may occasion  this disease; thus it will arise from  the
pressure of an aneurismal  tumor  on some of the larger venous trunks within
the chest.
   Structure of piles.—A pile, whether external or internal, consists essentially,
 in the first instance, of a varicose condition of a portion of the hemorrhoidal
 plexus, or, rather, of  the small veins of the submucous tissue  that pour their
 contents into this;  this varicose  condition  becoming  prominently developed at
 certain points, gives rise to small knots or tumors.  A pile, in this state, is quite
 soft and compressible, and  can readily be  emptied by  pressure, and when  cut
 into, will be found to be composed of one or more cells filled  with blood, and
 surrounded by areolar tissue.  The appearance of cells is, however, deceptive,
 and is occasioned by a section of the sacculated  and dilated veins that enter into
 the composition of the tumor.  After the piles have existed for  some little time,
  or after they have once become inflamed, the tissues that enter into their com-
  position undergo modifications that induce  corresponding  alterations in  the
  character of the tumor.  The coats of the veins  become thickened, their cellular
  dilatations are filled with coagulated blood, the  investing areolar tissue  is hyper-
  trophied or thickened by plastic deposit, and on being cut into, the pile  is seen
  to be composed of a spongy kind  of tissue  filled with blood.   External piles,
  when examined after removal, often resemble in structure a mass  of hypertro-
  phied cellular tissue, infiltrated with plastic matter, in which a number of small
  vessels  of uniform  character  ramify,  but without  any appearance  of cells.
  Internal piles,  on the contrary, contain  more of the  venous, and less of the
  cellular element.  They are also commonly furnished with a small central artery,
  which is apt to bleed freely, or  even dangerously, if the tumor is cut  across;
  hence, provided they are  not  clogged with coagulated  blood, they may readily
  be injected from the inferior mesenteric  artery.
    In studying the structure of hemorrhoids, it is of importance to observe  that
  they occur under two different forms: one in which there are distinct tumors,
  within or external to the anus, and the other in which there is  merely a varicose
  condition of the veins of this region, without distinct intumescence.
    In those cases in which there is merely a  general varicose state  of  the veins
  of the  submucous  cellular tissue  of the  anus,  without  any distinct  tumor
  springing above the  level of the membrane, it will be  found  that the  smaller
  branches of the hemorrhoidal plexus, and the  small twigs that enter these from
  the submucous  cellular tissue, have undergone varicose dilatation, being appa-
  rently greatly increased in number, as well as  in size.  The mucous membrane
  is of a deep mulberry, or port-wine color, and becomes everted after each motion
  There is usually some  mucous secretion about the anus, rendering the  part
  moist:  and the patient  complains at times of weight  and of bearing down,  with
  pains either in the  part  itself, the sacro-lumbar region, or the  thighs,   ine
  motions, more especially if hard, are streaked  with blood and more or leas of
  this fluid drops in a rapid manner after  the  passage  of the  faeces   Ihere is
  seldom much blood lost, but at times there is an exacerbation of all these symp-
  toms, and the hemorrhage, as will more particularly be mentioned hereafter, may
  become very abundant.  This condition of the mucous membrane  may precede, 
838    DISEASES OF THE LARGE  INTESTINE  AND  ANUS.

and is frequently found to accompany the true pile, whether external or internal,
and may be looked upon as constituting the first stage of this disease.  If this
state of things is allowed to continue unrelieved, the tendency to congestion
increases;  more and more of the mucous  membrane becomes  everted  and pro-
truded after defecation;  the submucous cellular  tissue becomes stretched and
lax, and the case is apt to become one of  prolapsus ani.
   External hemorrhoids are those that are situated below the verge of the anus,
and  that are  invested  by cutaneous, or,  at  most,  by muco-cutaneous tissue.
Before  appearing as defined tumors, they usually constitute longitudinal folds
that surround the anal aperture, or radiate from it  as from a centre.   In color,
they vary from  that of the natural structures to a pink or purplish  hue, and
their tegumentary covering consisting of the thin skin of the part, they resemble
folds of this tissue  rather than of mucous membrane.  Their size varies, accord-
ing to the state of congestion, and, hence, the same  tumor may at one time be
soft, flaccid, and loose, apparently nothing more than a fold of integument, and
at another may become tense, tumid, and  ready to burst.   When  of small size
and recent formation, they do not in  general  give rise to much distress, merely
some local heat, pricking, and itching, with a sense of fulness  after defecation;
but when of large size, and inflamed or irritated, they may occasion very acute
suffering.  There  is not only deep-seated, dull, aching and throbbing pain  in
the pile itself, but this shoots up the side of the rectum, through the perineum,
and into the nates, and  is much  increased when the patient  stands  or walks.
After a few days these symptoms  subside; suppuration  either taking  place  in
the pile, or the blood contained in it coagulating.   The  parts are, however, left
in a thickened and indurated state, and do not readily resume  their former soft
and flaccid condition, effusion of plastic matter taking place into the cellular
tissue,  and the contained blood perhaps coagulating, so that the tumor can no
longer  be emptied by pressure, assuming the form of a broad, rounded  or indu-
rated mass.
   Internal piles. — When the pile is situated altogether within the verge of the
anus it is called internal; of these there are two principal varieties, the  longi-
tudinal and the globular.
   The longitudinal, or as it  is sometimes called, the fleshy pile, is  generally
met with  about an  inch or two up the rectum.  It  is  spongy, elastic, firm, or
tough,  of  a dark reddish, or dusky brown tint, tapering  upwards from a broad
base.   It seldom bleeds or varies  much in  size; between these piles are  found
small curtains, valves, or folds of mucous membrane, forming sacculi, or  pouches,
with their convexities looking upwards.   These sacculi  are apt to become dis-
tended and pressed downwards by the faeces,  more especially if the motions are
hard and  the bowels have been  constipated, thus giving rise to a tendency to
prolapsus.
   When the  hemorrhoid assumes a globular form  it constitutes the  ordinary
bleeding pile.  It  may be situated  on  a broad base, or, as  not unfrequently
happens, its point of attachment  to the  mucous membrane becoming elongated
it assumes a pedunculated shape, hanging downwards into  the cavity of the
rectum.   It is of a dark bluish color, and numerous small vessels of a brighter
hue than the body  of  the pile may be seen ramifying on  the mucous membrane
investing it.  Its surface is at first smooth  and shining, and may continue so
throughout, being covered with a thin and  delicate prolongation of the  lining
membrane of the gut.   Not unfrequently, however, superficial ulceration takes
place, and then it has  a granulated strawberry-like appearance.
   Internal piles are usually attended by a sensation of  heat, itching,  pricking,
or smarting about the  anus, and a feeling as if there  were a foreign body within
the gut.   After defecation these  sensations are increased and are  often accom-
panied by a bearing down, as if the bowel was not emptied  of its contents, that
is peculiarly  distressing and  sickening.  This is occasioned by the piles or tho 
INTERNAL PILES.                      g39
elongated  and condensed  mucous membrane to which  they are attached, pro-
truded during the expulsion of the faeces, and not returning sufficiently quickly,
being grasped by the sphincter ani and constricted by it.   This feeling of dis-
comfort and bearing down is much increased if the patient stand or walk much
after having had a stool, or by a confined state of the bowels.  If this state of
things is not properly attended to, the symptoms become increased in severity,
the bearing down sensation amounts to true tenesmus, and the act of defecation
becomes so painful that the patient defers it as long as possible, and then  when
it does take place, in  consequence  of the accumulated  excreta  and  their
indurated   character,  the  suffering  is  much increased.   Internal piles now
usually make their appearance  if they have not existed before, the  mucous
membrane of the rectum becomes prolapsed, and an increase secretion  of thin
mucus takes place from the orifice of the gut,  moistening the part and soiling
the patient's linen.   Irritation  in neighboring organs is frequently set  up, and
occasionally to so great an extent as to mask the original complaint, the patient
referring his principal pain and  discomfort  to these sympathetic disturbances.
There is often a dull aching fixed pain  at the lower part of the lumbar spine,
and more frequently opposite the sacrum or the sacro-iliac articulations  on
either side; this is  sometimes very severe, perhaps down the thigh, or round
the groins; irritability of the testicles may come on, or irritation about the neck
of the  bladder, causing  the frequent desire to  micturate, and increasing the
patient's  sufferings by the straining that takes place.   The general health now
suffers, the patient may become emaciated, and the countenance often presents
a peculiarly anxious, drawn, and  care-worn look.
   The  symptom,  however,  that first of  all, and most prominently fixes the
patient's  attention is hemorrhage.  This varies  greatly in quantity; at first it
may merely consist of a few drops falling after the passage of a motion, or the
cylinder of faeces may be stained on one side by a streak or spots of blood, or it
may amount to several ounces or even pints.
   When  moderate in quantity it often affords  relief to the other local symp-
toms, and  seldom proves  injurious from the quantity  lost  at one time, but if
profuse and occurring at  short intervals, its effects  on the constitution may be
alarming.
   The hemorrhoidal flux is connected  with, and in  the great majority of cases
dependent upon, the existence  of distinct hemorrhoidal tumors.  Occasionally,
however,  it appears  to  occur when there is no distinct separate tumor project-
ing  above the  surface  of the  membrane;  but  in  these cases there is general
intumescence and congestion of the whole of the mucous membrane of the  lower
part of the rectum, from which the blood exudes in drops.
   It is frequently ushered in by an exacerbation of those symptoms that com-
monly accompany piles, such as a sensation of fulness, weight and tension  about
the  parts.  But the symptoms  that  precede  its occurrence are  often  much
more imperfectly marked than  is usually stated, and are  frequently absent
altogether.
   The flux may be periodical,  occurring every month, or at intervals of two,
three, or  six months,  remittent or intermittent;  when once it has set in, it
usually continues from three to six days, increasing in  quantity up to the third
or fourth  day, and then lessening.
   When  moderate in quantity and  short in duration, it is  often a  source of
relief to the patient;  but if a very large quantity be  lost at one time, or if it
continue for too long a period,  more harm  is usually done to the patient  by its
long  continuance than by its  excessive quantity at any one time.   The patient
may become much debilitated;  nervous headaches, pallor, palpitations,  syncope
may result.  In some cases, it has been said, that this  discharge is of service,
actino- as  a derivative, and preventing diseases falling on more important parts;
it has especially been looked  upon, and, doubtless is in many cases a safeguard 
840  DISEASES  OF THE  LARGE INTESTINE AND  ANUS.

from apoplexy and visceral congestions and obstructions, more particularly when
occurring in plethoric and corpulent persons who habitually live too high.  In
other cases it  may be  considered  as  critical,  more especially when occurring
about the cessation of the menstrual period.
  The color of the blood most generally is  florid, as if it came from the small
arteries or capillaries of the part rather than the veins.   It would appear, as
if in consequence of  the over-distended and varicose condition of the veins of
the part, the onward flow through the arteries and capillaries leading to them
was obstructed, and that in consequence of the  accumulated pressure on these
vessels  their parietes gave way, allowing the florid blood to escape from  the
veins.
  Very commonly the  internal piles when  brought down, present a somewhat
granular surface, in  consequence of ulceration  having taken place,  and  the
whole surface will be seen to exude blood in drops.  In other instances again,
the blood appears to come from a cavity in one side of the hemorrhoid, as if
rupture had occurred  from over-distension at that part.   Occasionally, how-
ever, the flow of blood  is so rapid and copious  that it  could not be supposed to
come from exudation, but would appear to depend on rupture of the vessels of
the part.
  The  hemorrhoidal flux may be  accompanied  by, or alternate with a thin
glairy mucous discharge from the rectum and diseased structures; this would
appear  to be  nothing more  than  hyper-secretion  of the membrane, in conse-
quence of the irritation set up by the  pressure of the piles; it is seldom in
sufficient quantity to  produce much annoyance, or to be of much moment to the
patient.
  Piles are not uncommonly complicated with other diseases of the rectum, such
as fissures,  fistula, or prolapsus; when  connected with fissure, the  hemorrhoid
often,  as  Mr. Syme  has remarked, assumes a peculiar form and  appearance,
presenting itself as a small red-colored body, like a pea in size, firm, and seated
at the  base  of the fissure, which it often  conceals; to a practised eye,  however,
the presence of a pile  of this  peculiar  color and shape is sufficient to indicate
the existence of the fissure.
   In that form of fistula in which the aperture is near the  anus, one or more
external piles of small  size are often found  situated at  the orifice of the fistula,
and  prolapsus  rarely, if ever, is met with in  adults, without the simultaneous
occurrence  of piles.
   Terminations. — Hemorrhoidal tumors may terminate by subsidence, coagu-
lation, suppuration, and sphacelus.   Complete subsidence  of the pile can only
take place when the disease is of recent occurrence.   When of long standing,
and after it has been exposed to successive  attacks of inflammation  and turges-
cence, it never subsides completely, and the cellular tissue and muco-cutaneous
structures becoming hypertrophied, form elongated pendulous flaps around the
margin of the anus.
   Coagulation of the contents of the  pile is the result of inflammation having
taken  place in it, and probably terminating in plastic effusion, by which the
vessels leading from it  are obstructed.   When it takes place, the tumor, after
more or less active  inflammation, becomes  hard, incompressible, and  indolent,
permanent  in size, and  of a purplish or plum-color.  The coagulum thus formed
may remain persistent,  may excite  suppuration, or may be absorbed, the hyper-
trophied tissues forming one of the usual anal folds.   In  some rare  instances
the coagula may become converted into structures resembling phlebolites.
   Coagulation more  frequently takes place in external than in internal piles,
owing to the great impediment in the return  of  the blood  from  them, and to
their greater liability to inflammation, their exposed situation leading  them to
be bruised or otherwise injured; when it occurs in internal piles, it most com- 
TREATMENT  OF  PILES.
841
monly affects those that are of a columnar or longitudinal shape, and least fre-
quently the globular variety.
  Suppuration is not an uncommon  termination, if acute inflammation have
been set up in  external piles, more especially in those that have previously been
coagulated; when the abscess is discharged, small coagula escape with its con-
tents, the cavity  granulates, and becoming obliterated,  the pile is cured.
  In some rare cases, when there is much elongation of the mucous membrane
from which the pile  springs, prolapsus of that membrane and of the piles may
take place, which being grasped after  it has  descended  by the contraction of the
sphincter, the  same  effect  may be produced as if a ligature were applied; the
tumor becomes much  swollen, hard,  livid,  and tense, there is  much constitu-
tional disturbance and  restlessness, but after a few days all the symptoms are
relieved by the part that is constricted sloughing and dropping  off.
   The diagnosis must  be regarded in two points of view :—1st,  as concerns the
hemorrhoidal tumors;  and, 2d, with reference to the hemorrhoidal  flux.
   Hemorrhoidal tumors must be diagnosed  from prolapsus ani, polypus of the
rectum, and condylomata about the anus.
   From prolapsus, the diagnosis is not always easy; indeed, the  two diseases
are so generally  associated, that it is of little moment to attempt it.
   In true prolapsus, ocular  examination will suffice to distinguish the membra-
nous wall  of the intestine, forming a smooth, rounded, and somewhat lobulated
annular protuberance, from the isolated tumors of piles.  In  polypus, the history
of the case, the  pedunculated and solitary character of the tumor, its large size,
and comparatively slight tendency to periodical hemorrhage,  will enable the
surgeon to make the diagnosis.   From condylomata the diagnosis  is easy; the
soft, flat, mucous, and  wart-like character  of these  growths, their  history, and
their occurrence at other points, as the perineum, scrotum, vulva, and buttocks,
will enable the surgeon to distinguish them without any difficulty.
   The hemorrhoidal flux must be distinguished from other  intestinal hemor-
rhages.   This may be  done by attention to the  character of the  blood, which
will enable us in many cases  to determine  its source.  When  from piles it is
liquid, of a more or less florid color, and not unfrequently is quite bright, stain-
ing or coating the faeces  rather than being mixed up with them. When, on the
contrary, the blood is poured out at some higher point in  the  intestinal canal
than  the  usual  seat of hemorrhoids, it is of a dark sooty character, mixed up
with  liquid faeces either in a  diffused form, or in small black  coagula, and no
fresh or bright blood will be visible.  Digital exploration of the  rectum in cases
of piles, and the presence of symptoms indicating the existence of mischief at
a higher part of the intestine than the anus in cases of melaena, will also serve
to point to the seat of  the flux.
   Treatment of Piles. — In conducting the treatment of a case of piles, that
surgeon will succeed best who looks  upon  the  disease not as a local affection,
merely requiring manual interference, but as a symptom, or rather an effect, of
remote  visceral  obstruction and disease, the removal  of which may alone be
sufficient to accomplish its  cure, without the necessity  of any local interference;
or should it be thought necessary to have recourse to  operative  procedure, that
this must be made secondary to the removal of those  conditions that have pri-
marily occasioned the congestion and dilatation of the hemorrhoidal vessels.
The treatment of piles, therefore, must be considered, 1st, as  regards the re-
moval of those constitutional conditions or visceral obstructions that occasion the
disease, together with any topical applications that may be considered necessary;
and, 2d, with  reference  to  the operative procedures  that  may be required for
the removal of the affection.
   1st. The constitutional management of  piles necessarily varies considerably,
according to the condition  of  the patient in which  they occur,  and the visceral
obstruction to which they  may be referable.  Thus, when  occurring in debih- 
842    DISEASES  OF  THE  LARGE  INTESTINE AND ANUS.

fated  persons, apparently from  relaxation of the vessels, most benefit will  be
derived by a mild tonic and nutritious plan, at the same  time that the  bowels
are kept regular by some of  the aperients that will immediately be mentioned.
In these cases, also, much advantage is often  obtained by the administration of
the confection of black pepper, which acts as a useful local stimulant to the
vessels of the rectum.  In tbe great majority of instances, however, more par-
ticularly when occurring  about  the middle period of life, piles  are connected
with  a  plethoric  state of system, and  obstruction of the abdominal viscera.
Under these circumstances,  our efforts should be directed to the  reduction of
the plethoric condition, by putting  the  patient  upon a proper regimen, prohi-
biting the use of stimulants, and lessening the quantity of animal  food that he
is in the habit of taking.  When the piles arise from the pressure of a gravid
uterus, or other abdominal tumor, little can be done, except, by local palliatives
and mild aperients, to moderate the inconvenience  attending them.
  In  all cases of piles, but  more  particularly in those  arising from hepatic ob-
struction, mild aperients are of essential service; by removing feculent accumu-
lations,  and establishing a free  secretion  from the intestinal surface, they tend
materially to prevent congestion of the portal system.  At the same time, drastic
purgatives of all kinds should carefully be avoided.  The most useful aperients
are the  electuary of senna, sulphur, and castor-oil, one or other of which should
be taken regularly, twice  or thrice a-week at bed-time, in as small a quantity as
will  be sufficient to  keep the bowels free.   In many cases  the  confection of
senna may advantageously be given  in  combination with precipitated sulphur
and the bitartrate of potass, equal parts of each of these being made into a mass
with twice their quantity of  the confection and  a little syrup; of  this electuary
a dessert-spoonful may be taken every night  or every second night.  If  there
be a relaxed condition of the rectum and anus  conjoined with the piles, as not
unfrequently happens, in  old as well as in young people, the administration of
an electuary composed  of equal parts of  the confections  of senna and of  black
pepper, or of cubebs, will be found very useful.  In fact, in all  cases in which
the black pepper is administered, an aperient should be given from time to time
to prevent its accumulation  in  the large intestine.  When  the  liver is  much
obstructed, the treatment should be specially directed to the relief of this organ;
with  this view,  a course of Plummer's pill, followed by taraxacum, and, in
relaxed  constitutions, the mineral acids, will be found especially  servicable, at
the same time that the bowels are kept free by gentle aperients.
   The  habitual use  of lavements, consisting either of soap and water or thin
gruel, will be  found  advantageous in many cases of piles, though  in some they
appear to irritate, and rather to increase  the disease.  "When the piles occur in
relaxed  constitutions, the lavement should be used cold; but when the patient
is of full habit of body, a tepid one will usually be  found  to agree best.  In the
general management of piles it need  scarcely  be observed that any habits which
favor the disease should be sedulously avoided.
   The local treatment of  piles is of considerable importance.  The parts should
be regularly sponged  with cold water, morning and evening.   If there be  much
relaxation, and the piles  are internal, benefit may result from the employment
of some astringent injection, such as a very weak solution  of the sulphate of
iron,  or of the tincture of the sesqui-ehloride, a grain of the first, or ten  drops
of the second to an ounce of water; of this about two ounces may be injected
every night, and left in the rectum.  The application of an astringent ointment,
such  as  the unguentum gallae comp., will be attended  by much benefit, or the
employment of the anodyne  and astringent suppository  already recommended.
   If  the piles become inflamed, the patient snould  keep his bed, and  leeches
should  be  freely applied around, but  not  upon  the  tumors.   Tepid  lotions,
poultices, and poppy fomentations, must be assiduously used, a very spare diet
enjoined, and the bowels opened  by mild saline aperients.  If a coagulum form 
OPERATIONS FOR PILES.                  843
in an external pile, as the result of inflammation, the tumor should be laid open
with a lancet, and its contents either squeezed, or turned out with the flat end
of a director.  If abscess form, it  must be punctured in the usual way, and the
part afterwards poulticed.  Should strangulation of the piles take place, the pro-
truded swelling must be returned by gentle steady pressure and the part after-
wards well poulticed.
  2d.  Operation.—The means above indicated are usually sufficient in ordinary
cases of piles; but if in  consequence of the inconvenient  size that  the disease
attains, the general irritation  and  local uneasiness to which it gives  rise, or the
abundance of the hemorrhage being such as seriously to interfere with  the
 health of the patient, it will  become necessary at  last to  have recourse  to ope-
 rative interference,  with a view of removing the diseased  structures.  No ope-
 ration should ever be  undertaken whilst the  pile is in an inflamed state, lest
 unhealthy inflammatory action to an undue extent be  set up in the part; it is
 also well to get the patient's  health in a good state, as  erysipelas may otherwise
 follow these operations, and  before proceeding to  them, care should always be
 taken that the bowels  have  been well opened.  There are three plans of treat-
 ment adopted  by surgeons for the  removal of piles, viz., the excision of the
 tumor, its strangulation by ligature, or destruction by caustics.  These methods
 of treatment should not be employed indiscriminately.  The first is  alone appli-
 cable to external piles, the two last  may be adopted in the internal  form of the
 disease.
    The removal of external piles is readily effected.   The tumor should be seized
 with a vulsellum, or hook, drawn forwards, and snipped off with  a pair of knife-
 ed°-ed scissors, curved upon  the  flat.  At the same time that the external piles
 are removed in this way, any pendulous flaps  of skin in their vicinity should be
 excised,  lest they become irritated, and  constitute the  basis of a fresh  pile.
  After the excision  of external piles there is usually  but trifling hemorrhage,
  which may readily be arrested by the application  of cold lint, or a pad and  "|"
  bandage; should any small artery bleed, it may be pinched and thus stopped.^
    Internal piles should only be removed by the ligature;  in fact it may be laid
  down as a rule in surgery, that all external piles should be cut off, and all inter-
  nal  piles tied.   The  reason of  this difference in  the practice  to  be adopted,
  according as the pile  is situated above or below the margin of the anus, is the
  liability to hemorrhage in the one case, but not in the other.  The bleeding that
  follows the excision of an external pile is not only small  in quantity, but may
  readily be arrested by cold or pressure.   With internal piles, however, it is dif-
  ferent; these tumors are not only more vascular, being often fed by a large cen-
  tral arterial twig, but are deeply seated, and do not readily admit of the appli-
  cation of means for the arrest of the flow of blood from them.   So  difficult is it
  to stop  the bleeding from  an  internal pile  in some cases, that patients have
  actually lost their lives from this cause after  its excision, even in the hands of
  some of the most  distinguished  surgeons.   The excision of internal piles has
  consequently been very properly abandoned.                          #
    The operation for the ligature  of internal piles may most  conveniently be
  conducted in the following manner:—The patient having had his bowels cleared
  out by a dose of castor-oil  on the  day preceding  that fixed  for the operation,
  should have an abundant lavement of warm water administered about  an  hour
  before the surgeon arrives, and he should  then be directed to sit for half an hour
  on a bidet, or  over a  pan containing hot  water, bearing down at the same time
  so as to cause the piles to  protrude.  When all  is ready he should be laid on
  the bed  on his  left side, with the nates well  projecting, the surgeon then seizes
  the most prominent  pile with a hook, vulsellum, or  broad-ended  forceps  (fig.
  332), draws it well forwards, and ties its base as tightly  as possible with a thin
  whin-cord ligature.   He does the same to one pile after the other,  until all that
  can be met with have been  strangulated in this way.  In  some  cases the pile is 
844  DISEASES  OF  THE  LARGE  INTESTINE  AND  ANUS.
so broad at the base that the ligature will  not  include  it without transfixion;
when this is required, it may usually be done  readily enough by means  of a
                   nevus needle, or by the instrument
      Fig. 332.      represented  in the  annexed  figure       Fio. 333.
                   (333), Bushe's needle, which consists
                   of  a steel  shank, fixed in an  ivory
                   handle, and having its  free  end per-
                   forated for the reception of  a needle
                   eye near its point.   The advantage
                   of this instrument is that not only is
                   the angle  formed by  the needle and
                   the shank a very convenient one for
                   passing a ligature through a pile in-
                   side  the  anus, but more particularly
                   that as the  needle can be detached,
                   it may, as soon as it is carried across
                   the base of the tumor, be separated
                   and so withdrawn more readily than
                   it  otherwise could.   If the pile is
                   longitudinal it may be deeply notched
                   in a  direction upwards at its  lower
                   attachment, and  the  ligature tied in
                   the groove  thus formed.  In  what-
                   ever  way the ligatures are applied, care should be taken
                   that they are tied as tightly as possible, so that the piles may
                   be  effectually strangled at  once, as in this way they sepa-
                   rate much more readily, and with far less pain to the patient
 than if loosely tied.   When all the tumors requiring ligature have been tied,
 the ends of the threads must be cut off close, and the strangulated mass pushed
 back into the bowel.   If there be any external  piles, these must now be cut off,
 for unless this be done they become irritated, swollen, and inflamed by the pre-
 sence of the  ligatures, and constitute a source  of much distress.  The patient
 must now return to bed, and should keep the recumbent  posture until the liga
 tures separate, which usually happens from the sixth  to  the eighth day,  when
 an ulcerated  surface will be left, which, however speedily closes and  contracts.
 In some cases this process may be facilitated by the application of  the nitrate
 of silver through a speculum ani.  On  the second day after the operation, the
 bowels may be opened with a dose of castor-oil.  In the  after-treatment of the
 case, care must be taken to prevent the recurrence of those causes that gave
 rise to the affection in  the first instance.  After piles have been tied, more par-
 ticularly if they are seated towards the anterior part of the rectum, there is fre-
 quently great irritation set up about the neck of the bladder, so that  the patient
 experiences difficulty  in  passing his urine, and  sometimes suffers from complete
 retention;  a  warm hip-bath,  and a full dose of hyoscyamus and nitric  ether
 will usually relieve this, and enable the urine to pass.   In some cases when the
 external piles are  very large and vascular, and  the patient debilitated, the ordi-
 nary rule of cutting them off may advantageously  be deviated from,  and a com-
 bination of the treatment by excision and  ligature be adopted.   In  such  cases,
 an incision may be made through the integuments merely,  and then the piles
 tied in  the course of the groove thus formed.  By these means the  pain and
 constitutional disturbance consequent on the inclusion  of a portion of the inte-
 gument in the ligature is avoided, at the same time that the  risk of hemorrhage
 is not incurred.
    Treatment by caustics.—In certain kinds of internal piles, the application of
 nitric acid  has been recommended by Mr. Houston of Dublin, and Mr. H. Lee,
 and may certainly advantageously be adopted.  It must not, however, be applied 
PROLAPSUS ANI.
845
to the external or the intero-external pile, as it will  produce extreme irritation,
nor can it be looked upon as a substitute for the ligature in internal piles gene-
rally.  It is  especially in the granular pile, having an  ulcerated surface,  that
this mode of treatment is  useful, as in these  cases it appears, by destroying a
portion of the mucous  membrane, not only to cure  the  pile
to which  it is  applied,  but by producing an ulcer, to  give     Fig. 334.
rise to a  cicatrix,  which by contracting, consolidates  the
parts in  its vicinity, and so lessens the relaxed state of the
rectum, which favors the hemorrhoidal tendency. The  acid
may most conveniently be  applied through  a speculum ani,
having a circular  aperture  on  one side  (fig.  334).   This
 should be introduced well oiled, until the pile project in the
 opening in it, when it  must be freely rubbed with a piece
 of stick,  or  a  glass rod or brush, dipped  in  the acid;  the
 surface is then immediately wiped with a piece of lint satu-
 rated with prepared chalk  and water, and the instrument
 removed.   A thin slough separates, leaving a  raw surface,
 which gradually cicatrizes  and contracts.   The application
 of the acid occasions but little pain when made fairly within
 the rectum, but if a drop of it accidentally come in contact
 with  the muco-cutaneous surface, a vast deal  of  irritation
 and inflammation  are  excited.   This plan  of treatment,
 though useful in particular forms of pile, as when  the  tumor is granular or flat,
 so as not to admit of ready removal by the  ligature, should not  I think be prac-
 tised when  the ligature can be employed, as it is by no means so certain a mode
 of treatment.  It cannot  be  considered  altogether devoid  of risk, for 1 have
 known one  instance in  which fatal erysipelas followed the cauterization ot piles
  with nitric  acid.                                        .           , .      ,
     Pruritus ani is often an  extremely troublesome affection,  the  itching  ana
  general  irritation about the anus being almost unbearable.   In many instances
  it appears to be a true prurigo of this part; in other cases it appears to be con-
  nected with the irritation of external piles, worms, or some  similar affection.
  The treatment must in a great measure have reference to the  cause.  11 there
  be an  external pile,  the  removal of it, or if worms, their expulsion, will  pro-
  bably cure the disease.   If it arise from prurigo, it  will require  some special
  treatment.   In  some  cases the  arsenical  preparations will be found  uselui,
  together with the local application  of chlorinated lotions, or  those  containing
  hydrocyanic acid.
                             PROLAPSUS  ANI.

     Prolapsus ani consists  in a protrusion of the mucous membrane of the rectum
  through the anal orifice;  the  cellular  tissue that lies  underneath it being jalso
  in the majority of instances  much thickened  and elongated   In the o  dinary
  prolapsus the muscular structures of the  gut are not protruded; but yet it ha
  occasionally happened that the  muscular coat has ^nded with the mucous
  membrane, an  invagination  of the bowel  taking place,  which constitutes a
  different and far more serious condition than the ordinary FolaPsu^       ,,
    ' Prolapsus not unfrequently occurs in children, especially  those who ^feeble
   or who suffer from much irritation of the digestive or binary organs  J" J^ioJ
   persons generally there is a natural tendency to prolapsus, *° W J^H£
  of the mucous membrane that takes place during d efecatiom ^S™*^J
  any constitutional condition  that gives rise  to atony of the  muscular sjs em
  more especially if irritation  of the intestinal  mucous ^™£.^™£
  with this,  as in dysentery, chronic diarrhea,  &c   So agam  the  ^™ "™£
  pation often occurring in  persons of a  relaxed ^V^LTrS™-
   ceeding from want of power in  the rectum to expel its contents, and requiring 
846    DISEASES OF  THE  LARGE INTESTINE AND  ANUS.

constant straining at stool, predisposes to  this affection. It is especially common
in those who labor under stricture, stone, or any other disease about the urinary
organs that requires a considerable effort  to be made in expelling  the  contents
of the bladder.   In persons whose constitution has  been  relaxed by a long resi-
dence in India,  this disease also  frequently occurs.   In other cases again, and
indeed  most usually, the prolapsus is associated with piles, the weight and drag-
ging  of the hemorrhoid drawing down the mucous membrane with it.  This  is
especially apt to happen when there is a general  hemorrhoidal tendency about
the anus.  In fact  the  causes  of prolapsus  may be  summed up under three
heads.   1st. As dependent  on  simple relaxation of tissue, such as is met with
in children and weakly  persons.   2d. As owing to sympathetic irritation, as in
chronic tenesmus, stone  in the bladder, &c.  And 3d. As being associated with
a hemorrhoidal  condition of the  vessels of the part.
   Prolapsus is readily recognized.   It consists in the  protrusion  of a ring of
mucous  membrane  of a red or  purplish color, and having a somewhat  turgid
look, rather lobulated in shape and varying in size from half a walnut to a small
                                             orange (fig. 335).   The mucous
                  Fia. 335.                   membrane covering this ring will
                                             be found to be continuous with
                                             that investing the sphincter, and
                                              this  constitutes the mark  of dis-
                                             tinction between  the  ordinary
                                             prolapsus and  the invagination
                                             that has  occasionally been  met
                                             with of the whole  thickness of
                                              the  gut; for  in this affection,
                                             which is extremely rare, there  is
                                             a deep and  distinct sulcus be-
                                             tween  the protrusion  and  the
                                             margin of  the sphincter.   In
                                             prolapsus  there is, when the  pro-
trusion is down, a dragging and smarting sensation, often attended with a good
deal of spasm about the neck of the bladder, and not unfrequently with  symp-
toms  of stricture.  In chronic cases, the anal aperture will appear to be perma-
nently relaxed,  and on  introducing the  finger into it, it will be  found  to be
widened and weakened.   The folds of skin in its neighborhood will be seen to
be relaxed and elongated, radiating from it as from a centre; they are commonly
bluish, soft, somewhat swollen, and pendulous, and often the seat of a good deal
of  irritation.   The protrusion at  first occurs only after defecation and then
readily goes back  of itself, or is reduced by the exercise  of steady  pressure
upon it; after a time, however, it will come down at other periods; thus it may
protrude after  riding, walking, or  even standing, and is returned with  much
difficulty.
   Strangulation of the prolapsus may occasionally occur  if it is allowed to  pro-
trude for a considerable  length  of time without a proper attempt being made
to push it back.  It then becomes swollen and livid with great pain and  tenes-
mus,  discharges  a fetid ill-conditioned pus, and  may eventually fall into  a
sloughy state.
   Tbe treatment of prolapsus may be said to  be palliative and curative.    The
palliative treatment consists in the first place in reducing the tumor when  pro-
truded.  This, under ordinary circumstances, the patient does for himself, but
if it becomes congested it requires the help of the surgeon to put it back.  This
may occasionally be readily done by laying the patient on his side, or making
him lean over the back of a chair,  and then  greasing  the mass with  some oil,
seizing it with a soft towel, and  by gradually  compressing it, work it back.   It
may be kept up  by the patient wearing a  belt with a  pad and elastic  support.
 
PROLAPSUS  ANI.
847
Olive-shaped pewter pessaries are occasionally employed, with the view of pre-
venting the protrusion, but I have never seen them of any service, the sphincter
being usually too relaxed to keep  them  up, and their  pressure  appearing  to
excite irritation.
  The regulation of the bowels is as important in  cases of prolapsus as in piles.
It is usually best done by the administration  of those laxatives that have been
recommended for the  latter disease.   It is a  good  plan in prolapsus  to  get the
patient to have his daily motion  at bed-time instead of at the usual hour in the
morning, the recumbent position and the uniform  temperature of  the bed pre-
venting that irritation of the sphincter and spasm  of  the  anal  muscles that
commonly continues for some time after the reduction of the prolapsus, and which
is a source of great discomfort when occurring in  the early part of the  day.
  The relaxation of the mucous membrane of the rectum that essentially con-
stitutes prolapsus may often be obviated by astringent injections or  suppositories.
The best injections are those of the sulphate  of iron in the strength of from one
to three grains in an ounce of water thrown up in small quantities sufficient for
the bowel to retain.   In  children, injections  of this kind, conjoined with regu-
lation of the bowels by mild aperients, the administration  of a moderate quantity
of unstimulating food, and afterwards the employment of tonics, will commonly
remove the disease, unless it arise  from stone in the bladder, or  some other
affection  inducing much and  continued straining.   In mild  cases of prolapsus
in adults, conjoined with  a relaxed state of the mucous membrane of the rectum
and relaxation of the sphincter, the  use  of  the  iron injections will be  found
particularly beneficial, at the same time that  the action of the bowels  is regu-
lated by means  of an electuary taken  in  the morning  or at night.   By thus
giving tone to the bowel, at the same time  that  constipation is prevented, the
disease will occasionally undergo a cure, provided it be not associated with any
affection  in other organs.
  In those cases in which the prolapsus is hemorrhoidal, the protrusion being
dragged  down by the weight and strain of the pile, the same treatment  must be
adopted as  has  been recommended  for the latter  disease, and usually after the
ligature  and removal  of  the  pile, the prolapsus will be cured.  In  slight cases
of prolapsus, in which the  disease appears rather to be owing to the relaxation
of the sphincter and of the tissues external to it, the muco-cutaneous integument
hanging  in loose and  pendulous  folds around the anus, considerable benefit will
commonly result by snipping off these pendulous flaps of skin; the cut surface
that is left cicatrizing, and by its contraction  bracing up the  part,  and thus pre-
venting  its further protrusion.  These pendulous flaps are best removed in a
radiating manner from the anal  orifice, with  curved knife-edged scissors.
   When the prolapsus is considerable, and if the ordinary palliative treatment
has, after a proper trial being given it, failed  in effecting  a cure, it  will be neces-
sary  to remove  the  protruded  mucous membrane by operation.   This should
always be done by the application of the ligature; excision,  though easy, being
objectionable in this as  in the case of piles, on account of the danger from
hemorrhage.  The ligature should  be applied in the  following way: — The
patient having had the bowels freely opened on the preceding day, and an enema
of tepid  water on the morning of operation, should be directed to  sit over a pan
of hot water, in  order to  make  the  prolapsus descend;  it may then be  seized
with a pair of broad-ended forceps, such as are represented, fig. 332, and  drawn
well forwards.   The base must next be firmly tied with a strong piece  of whip-
cord, and a similar process repeated  on  the opposite side of the anus.   Should
there be any difficulty on account of the shape of the protrusion in ligaturing
the  base firmly, this may be obviated  by transfixing it with a  hemorrhoidal
needle, and tying it on either side.   I  think, however, that it is better, if pos-
sible, to  avoid doing this.  The  ends of the ligature must then be cut short, the
whole protrusion returned into the bowel, the external flaps of skin  cut off, and 
348  DISEASES  OF THE LARGE INTESTINE  AND  ANUS.

an opiate pill administered, so as to arrest all peristaltic  action  for a few days.
Should the ulcerated surface show any difficulty in healing, it should be touched
with the nitrate of silver.  This operation always leaves a permanent cure.
  The ligature of prolapsus, like that of internal piles, is not very painful, and
for  it chloroform need not be administered; indeed, it is, perhaps, better that
it should not be given in these cases, as the protrusion is apt to slip up under
its influence, the patient not being able to exercise the proper expulsive efforts.
But as  the excision of the  external flaps  and piles is attended by very sharp
suffering, it is  as well  to administer the anaesthetic at  the time that they are
being removed.
  Should a prolapsus become strangulated, it would be necessary to try to reduce
it through the sphincter by the employment of the taxis; if this cannot readily
be  accomplished, free  incisions  may be made  into it; if it be not reduced, it
will slough away, and thus undergo permanent cure.  In  some rare cases, a por-
tion of invaginated  intestine descending through the anus has become strangu-
lated ; in such cases as these, reduction must be effected if possible without, but
if necessary with, division of the sphincter.

                          RECTAL FISTULA.

  Fistulous openings occasionally occur between  the rectum and the bladder in
men; or between this gut and tbe vagina in women.
  The recto-vesical fistule are of very rare occurrence, and usually result either
from  organic  disease  of a  cancerous character, establishing  a  communication
between  the rectum  and the  bladder or by a wound of the gut during the opera-
tion of lithotomy.  In these cases the urine escapes per anum in greater or less
quantity, occasioning constant irritation or excoriation of these parts, with a sort
of liquid diarrhea, and the wet state in which the patient is kept by the drib-
bling of urine gives rise to an offensive ammoniacal  odor about him.   If the
communication between the  rectum and bladder be a free one,  feculent matter
and flatus get admission into the urinary organ, and escape from  time to time by
the urethra; perhaps even more abundantly  than the urine does per anum. This
is especially the case when the fistula is carcinomatous, and it is remarkable how
little irritation is often set  up by this admixture of faeces with urine in the
bladder.  The fistulous aperture in the rectum can always  readily be detected by
passing the finger into the gut, or  examining its interior with the speculum ani.
  If the disease be of a cancerous character, nothing can  be done in the way of
treatment beyond keeping  the parts clean; but if traumatic in its origin, of
small size,  and  more especially if it be recent, its closure  may not unfrequently
be  accomplished by touching it with the  nitrate of silver, or a red-hot wire
through  a speculum ani.  In these  cases,  the platinum  loop made  red-hot by
the galvanic current, according to Mr. Marshall's plan, might advantageously be
employed.   If, however, the fistula be of old standing, and the aperture large,
cauterization would probably not  succeed, and then perhaps the only mode of
treatment that could be adopted would be to introduce a  grooved staff into the
urethra, and cut through the sphincter upon this, thus laying the parts  into one,
and converting the anal into a perineal fistula;  then by keeping the catheter in
the bladder, and  emptying this, granulations will spring up, and deep  union be
accomplished.
  Entero-vaginal fistula. — It has happened that a communication has been set
up  between the small intestine and the vagina, an artificial anus in fact forming
in this cavity.  These  cases, however, are very rare, and  may indeed be looked
upon as incurable; for though some of the French surgeons, as Roux and Casa-
mayor, have endeavored to establish by a deep and  difficult dissection a commu-
nication between  the small and large intestine, the operation, as might have been
expected, has proved fatal to the patient. 
TAPPING  THE  ABDOMEN.
849
  Recto-vaginal fistule are usually the result of sloughing of the posterior wall
of the va<rina, in consequence of some undue pressure exercised upon it during
parturition.  The size of these fistulous openings varies greatly ;  sometimes there
is merely a small perforation, at others there may be loss of the greater portion
of the posterior wall of the vagina.   Whatever their size, they are necessarily
sources  of very great  discomfort and annoyance, both  physical and mental, to
the patient.   The  recognition of the disease  is  of course at  once made;  the
escape of faeces and flatus into the vagina being obvious, and  digital or ocular
examination through the two-bladed speculum  at once  detecting the  seat  and
extent of the aperture.   As there is just the possibility of the communication
existing- between the vagina and the small intestine, it may be  useful to bear in
mind that when this has been the case, the feculent  matter that  escapes  has been
found to be yellower and less stercoraceous that when the rectum is opened.
   If the  fistula be small and recent, it may occasionally be closed by  attention
to  cleanliness, at the same time that its edges are touched with the nitrate of
 silver, a hot iron wire, or the  platinum loop.   If  it be very large, the greater
part of the posterior wall of the vagina having been destroyed, it will probably
 be incurable;  but even here the patient should not be left to her fate, and some
 operation should be attempted which might lessen its size, even if it do not com-
 pletely close it.  The operation for the  closure  of a recto-vaginal fistula consists,
 after emptying the patient's bowels by  purgatives and an enema, in introducing
 a bivalve speculum into the vagina and through the opening in it, freely paring
 tbe ed°-es of the aperture.   The next point is to  bring its edges into apposition,
 and in doing this, the recommendation made by Copeland and Brown of dividing
 the sphincter ani should always be acted on, as it is a most important  auxiliary
  to the  success  of  the  operative procedures that  are required; for as there is
  always loss  of substance in these fistulae, there is necessarily a  great tendency to
  tension on their sides when any attempt is made to draw them together;  and it
  is also of importance that any muscular movement  about the parts  in the neigh-
  borhood  of the fistula should  be arrested, as this might otherwise break down
  union after it had taken place between the edges.  The sides of the fistula must
  then be drawn into apposition by sutures introduced by means of the corkscrew
  needle, and knotted as in the operation for cleft palate, or by means of the bead
  suture.   The success  of the operation depends not only on the proper comple-
  tion of the steps  of  the  operation, but greatly on the  after-treatment   This
  should consist in the administration of opium, to prevent the  bowels acting for
  several days; indeed,  until union  has  taken  place between the edges.   They
  may then be moved by means of laxatives and oleaginous enemata carefully
  given.   During the treatment, the parts should be  disturbed as little as possible,
  and the urine drawn  off  every sixth hour.   The patient must be  kept  upon
  a very moderate diet, and  the stitches may be left in  for six or eight  days,
  when they must  be  cut out and carefully removed.   Should any point of the
  fistula not be closed, the application of the nitrate of  silver may induce proper
  union of it.

                       TAPPING THE ABDOMEN.

    The  abdomen  often requires tapping, either for ascites or encysted  dropsy.
  The operation, which is perhaps the  simplest in  surgery, may be  performed as
  follows: —The bladder having been emptied, the patient is seated on the edge
  of the bed or of a large chair, or if very  weak lies on  the side, and has  a broad
  flannel roller, split at either  end  to  within  six  inches of the middle, passed
  round the body  in such a way that  the untorn  part covers the front ot  the
  abdomen, whilst the ends which are crossed behind are given to an assistant on
  either side, who must draw tightly upon them as  the water flows,  lhe surgeon
  then seating  himself before the  patient, makes  a small incision with a scalpel
      54 
850
DISEASES OF THE BLADDER.
into  the  mesial line about two inches below the umbilicus, and  through  the
opening  thus made, he  thrusts the trochar;  as  the fluid  escapes, the patient
often becomes faint, but this may commonly be guarded against by continuing
to draw upon  the  bandage so as to keep  up good pressure  in the abdomen.
After all the fluid  has  escaped, the aperture must be closed with a strip or  two
of plaster supported by a pad and bandage.
   The incision through which the trochar is thrust  need not enter the peri-
toneum,  though  if it  does it matters little.   The trochar itself must be of  full
size  with a well-fitting canula.  Sometimes it is convenient to have one fitted
with a stop-cock, to the end of which a vulcanized india-rubber tube may be
adapted,  by which the fluid is carried quietly and without splashing into  the
pail  destined  to receive it.   Should the particular character of the accumulation
of fluid in encysted dropsy not admit of its withdrawal by an aperture  below
the  umbilicus, the  abdomen may be tapped in any other convenient situation,
except in the course of the epigastric vessels.
DISEASES  OF  THE  GENITO-URINARY  ORGANS.
                         CHAPTER  LVI.

        DISEASES  OF  THE  BLADDER  AND PROSTATE.

                              CYSTITIS.

  Idiopathic inflammation of the bladder is of rare occurrence; this disease
most commonly originating either from traumatic causes, as from the passage
of instruments, the irritation of broken fragments of calculus, &c, or it  may
arise from irritation produced by the application of blisters, the administration
of diuretics, or directly from the extension of gonorrhea to the interior of the
organ.
  The symptoms of cystitis consist not only in the local pain and weight about
the hypogastric and iliac regions, with tenderness on pressure in these situations,
and a  good  deal  of constitutional  irritation; but in  the  existence  of extreme
irritability about  the bladder.   So soon as a few drops of urine collect  they
excite  so much irritation  in this viscus that they cannot be retained, and are
expelled by a kind of spasmodic or convulsive effort, often  accompanied  by a
good deal of tenesmus and great suffering.   The urine will be found to be  high
colored, mixed with more or less mucus or pus, and often tinged with blood.
   An  acute  attack of cystitis usually terminates in the chronic form of the
disease, and  thus  gradually undergoes  resolution;  occasionally,  however, it
terminates fatally, and when this is the case the patient's symptoms commonly
assume an ataxic character, the tongue becoming brown and dry, the pulse
rapid and weak, and the  urine very offensive.  On examination after death, it
will commonly be found that the inflammation  of the bladder has gone on  to
gangrene of the mucous membrane, to diffuse peritonitis, or to the formation  of
abscess either in   the  substance  of the wall  of  the bladder or between the
bladder and  the  rectum, with perhaps infiltration of urine in the deep cellular
tissue of the pelvis or the perineum. 
TREATMENT OF CYSTITIS AND  VESICAL CATARRH.   851
  The treatment of cystitis is of a very simple character, the disease admitting
of little being done in the way of medicines.  The free application  of leeches
to the  neighborhood of the  inflamed  organ,  long-continued soaking in  warm
hip-baths, the application  of poppy fomentations  or  of laudanum and linseed-
meal poultices,  the injection  of emollient enemata, and the  copious administra-
tion  of  barley-water or mucilaginous drinks, will subdue the inflammation and
afford the patient great comfort; to these means may be added the administra-
tion  of antimonials with henbane or opiates.  The only salines that are of much
use are  the citrate and nitrate of potass, and these must be given largely diluted.
   The acute  cystitis commonly degenerates into the chronic form of the disease,
or, as it is frequently called, the  irritable  bladder, though  this  may set in
originally in  a  subacute form as the  result of gonorrhea,  in connection  with
gout, or from the presence of calculi.  The symptoms in this affection are much
the same as in the  acute variety, though necessarily in a minor degree; there
is pain and a sensation of weight  on holding the water,  a very frequent desire
to pass it, with pains about the pelvic region.  This disease not unfrequently
lasts almost  an  indefinite time, eventually degenerating into vesical catarrh.
This form of irritation of the bladder, though inflammatory, is usually asthenic,
and is  principally characterized by an abundant muco-puriform discharge from
its interior.
   It may arise  from a great variety of causes,—generally, an acrid state of the
urine, or disease in the bladder, such as  tumors, stone, or a fasciculated  condi-
tion of that  organ, occasion  it.   In enlarged  prostate and stricture it is  also
 commonly met  with.   In  some cases it would appear to arise from sympathetic
 causes; thus, the irritation of a pile or fissure of the anus  may give rise  to it,
 or it may be  dependent on renal disease.
   In vesical  catarrh the symptoms  are  made up of  local irritation  and consti-
 tutional debility.  There is frequent desire to make water, which is  usually
 ammoniacal and fetid, and is mixed with a
 large quantity of glutinous, stringy mucus,
 which gives  it a turbid appearance.   The
 urine, on standing, separates into two parts,
 the  upper being clear, but the lower con-
 sisting  of a thick, viscid, slimy or  gummy
 mucus, often semi-opaque and purulent in
 appearance;  it  sticks  tenaciously to  the
 bottom of the  pot, and when  poured  out
 hangs  from the  edge in  long,  stringy
 masses (fig. 336).  It is often mixed with
 urinary  deposits,  more  especially  of  a
 phosphatic kind.
   This chronic  form of  inflammation  of
 the  bladder is not unfrequently fatal, death
 resulting eventually  with symptoms of  a
 typhoid character;  the tongue becoming
 brown  and the pulse feeble, and these are
 usually associated  with urinary poisoning
 of the blood,  the  mental  manifestations
 becoming dull and obscured, and the body
 emitting a strongly urinous  odor, and  the
skin a dense, clammy sweat.                                       .
   On examining the bladder after death in such cases, great thickening ot the
muscular coat of the mucous membrane will usually be  found, together with a
dilated  and  tortuous condition of the veins ramifying upon it, the blood con-
tained within which is peculiarly black.  Abscesses  may be found  m the walls
or outside  them, circumscribed  and bounded  by plastic  matter,
Fig. 336.
 1. 1. Mucus.  2. Epithelium.  3. Pus.
4. " Organic Globules," met with in the
The  mucous 
852
DISEASES  OF  THE  BLADDER.
membrane is thrown into folds and ridges, which become thickened and hard-
ened, having irregular depressions between them, so as to cause the interior of
the bladder to resemble somewhat the inside of one of the cavities of the heart
with its projecting  columnae carneae.  This fasciculated condition is almost an
invariable  accompaniment of long-continued chronic inflammatory irritation of
the bladder.  As the organ becomes hypertrophied, in consequence  of the con-
tinuance of the disease, it usually becomes sacculated, the cysts forming at its
posterior  or lateral  parts.  The  sacculi  are of two  kinds,  both of which
are formed by projections between  the  fasciculi  of the  wall of the bladder.
In the first and least common kind, the  muscular as well as the mucous coat
is pushed outwards.  In the second  form of cyst, the mucous coat alone  forms
                      a  kind  of hernial protrusion (fig.  337).  In the cysts
        Fig. 337.       thus formed, accumulations of various kinds may take
                      place: mucus, pus, sabulous matters, and even calculous
                      concretions not unfrequently being  met with in these
                      situations.   It is the  retention  of  urine,  mixed with
                      mucus or pus in these  cysts, where it undergoes decom-
                      position, that is a common cause of the great  fetor of
                      the urine in such  cases.
                         The treatment of chronic cystitis must be of a mode-
                      rately antiphlogistic character, so long as inflammatory
                      action keeps  up;  when once this  subsides and the  dis-
 ease  falls  into an  asthenic condition, or degenerates into vesical  catarrh, the
 management of the disease must to a considerable extent be modified.   In the
 early stages, whilst there is tenderness and inflammatory action, leeches, warm
 hip-baths, poppy fomentations, mucilaginous  drinks with henbane, and some
 alkaline remedies,  especially the  liquor  potassae largely diluted, will be  found
 most useful, the bowels  at the same time  being  kept open with castor-oil and
 enemata.
   WThen vesical catarrh has come on, and the disease has lost its inflammatory
 character, appearing rather to consist of  atonic  exudation from  the mucous
 membrane, a different plan of treatment  will require  to be  adopted.   In such
 cases as these the administration of vegetable astringents, as the uva  ursi, buchu,
 or the pareira brava, with henbane and nitric acid, will often be of service.  In
 many cases, however, most benefit is derived from the administration of the
 balsams, more particularly of  copaiba.   It may either be given with the liquor
 potassae,  or may advantageously be administered  in combination  with  a  few
 drops of spirits of  turpentine; in the more advanced forms of the disease, when
 typhoid symptoms  come  on, bark and  ammonia will  be found most useful,
 together with the  administration of the  brandy-and-egg mixture.  In these
 cases also it is of great importance to empty the bladder, by  means of the cathe-
 ter, of the viscid mucus  that accumulates in  it, and the putrefaction of which
 tends to engender  the depressed state into which the  patient sinks.  In some
 cases this may advantageously be done by washing it out with warm  water injec-
 tions through a double-current  catheter.  In this stage of the disease benefit
 may occasionally be  derived from the employment of  very slightly astringent
 injections. Amongst the most useful of these will be found the nitrate of silver,
 in the proportion  of one  grain  to four or six ounces of tepid distilled water.
 Sir B.  Brodie has  advantageously employed water very  slightly acidulated  with
 nitric acid.
   A peculiar  form of chronic  inflammation of the mucous membrane  of the
 bladder is occasionally met with in strumous children, and appears to be an
 affection closely allied to the congestive  and  subacute  inflammatory conditions
 of the different mucous membranes, as of the eyes, nose, and throat, that  com-
 monly  occur in such subjects.  In  this disease the child makes water with great
 frequency and with much pain,  the urine  is  offensive,  and usually phosphatic,
 
TUMORS OF  THE  BLADDER.
853
and not unfrequently there  is a good deal of uneasiness  complained of about
the groins and along the penis.  On sounding the bladder it will  be found
roughened, fasciculated,  and often containing  sabulous  matters  mixed with
mucus; occasionally there is a good deal of gastro-intestinal  irritation, and not
unfrequently worms are present.   The treatment should consist in attention to
the general improvement of the health of the patient, in the removal of intes-
tinal irritation, the regulation of the digestive functions, and in the administra-
tion of copaiba in  small doses, either alone or conjoined with a few minims  of
liquor  potassae, at the same time that general anti-strumous  treatment must be
properly carried out.
   Irritability  of the bladder in women not unfrequently occurs, and simulates
stone so closely that it is only after very careful sounding that the surgeon is
satisfied that no calculus exists.   This condition appears to be dependent on a
morbidly sensitive state of the  mucous membrane  of the urethra  and bladder,
that may arise from a variety of causes; in some cases it is a truly neurotic or
 hysterical condition.  In other instances it is  sympathetic, being connected with
 some local disease of the  genito-urinary organs, with a vascular tumor at the
 meatus of the urethra, or some affection of the  uterus, which will require to be
 cured  before the bladder can be got into a sound state.   Prolapsus of the ante-
 rior wall of the vagina, drawing down the corresponding portion of the bladder,
 will keep up this condition; if so, the prolapsus must be cured by some plastic
 operative procedure.   Under all  circumstances, however, when this state has
 once been set up, it is very difficult to remove.  In  many cases it is undoubtedly
 due to the irritation produced by a morbid state of the urine dependent on mal-
 assimilation, and usually connected with  an excess of  lithates.  In  such cases
 as these, careful regulation of diet, and  the  administration  of potass with hen-
 bane or copaiba, will afford much relief;  but the complaint  is of a very chronic
 and intractable nature, and under the most careful treatment will often continue
 for years.
                     TUMORS  OF  THE  BLADDER.

    Fungous growths or polypi are  occasionally met with  in the  bladder, flat,
 pedunculated', or  pyriform in  shape; they may occur  at all  ages, and usually
 give  rise  to  a  certain degree  of irritation  in this organ,  which is especially
 marked when they occur in the vicinity of its neck, where they may even cause
 retention of urine and some of the symptoms of stone.   These fungous growths
 occasionally are of a malignant character, and then give rise to bloody urine, m
 which cancer-cells and debris  may be found on microscopic  examination, thus
 serving as a  diagnostic mark of the nature of the disease.   Malignant  fungus
 or cancer of  the3 bladder is usually associated with similar diseases of the  pros-
  tate or neighboring structures, and in women may be secondary to cancer of the
  uterus.  According  to Walshe  it does  not appear before  the  fortieth year.
  These tumors, whether simple or malignant, occasionally become incrusted with
  calculous matter deposited upon them by the urine; and then they will resemble
  still  more closely a  calculus when the bladder is  sounded; from it, however
  they  may be distinguished by their fixed character, and by the impossibility ot
  getting a sound around them.  Some difficulty  is often experienced in ex-
  amining the  bladder in these cases, for as the fungous  mass pushes  back the
  posterior wall of the viscus, it has a tendency  to elongate  the prostatic  portion
  of the urethra and the neck of the bladder, so that a very long  instrument is
  required to reach it.   Little can in general be done in the way of treatment in
  this disease,  though the example of Civiale  might,  in  some cases, be advantage-
  ously followed, who removed a small growth seated at the neck of  the  bladder
  by seizing and  twisting it off with a lithotrite.  And Warner has recorded a
  case in which a tumor of this  kind, the size of an egg, was tied  in the  bladder
  of a woman after dilating her urethra. 
854
DISEASES  OF  THE BLADDER.
  Hematuria, or bloody urine, is a common consequence  of the ulceration  of
malignant  disease of the  bladder  or prostate.  It may,  however, arise  from
various other causes, as from congestion of  the kidneys, from  the  irritation  of
calculi, or it may be of a passive nature.  Usually the blood passes away mixed
with urine, but  sometimes it accumulates in large quantity, filling up the  blad-
der with a soft fibrinous coagulum, and causing it to reach to the umbilicus and
to feel like a gravid uterus.
  In  most cases the hemorrhage  may be checked by the administration  of
gallic acid, or the  sesquichloride of iron.   The bladder may be emptied by  an
ordinary catheter, but when distended  by coagulum, it may be  necessary  to
wash  it  out  by injecting warm water through  a double-current catheter.   If
decomposition occur in the coagulum giving rise to the  formation of flatus  in
the bladder,  a weak tepid saline solution,  to which  a little creosote has  been
added, may advantageously be used.

                  PARALYSIS  OF  THE  BLADDER.

  Paralysis of the bladder may occur with the opposite conditions of retention
and incontinence of urine, according to the part of  the organ that has lost  its
contractile power.  When the body of the bladder is paralyzed, whilst the neck
preserves its  contractility, retention of urine will ensue in consequence of simple
inability on the part of the organ to  expel its contents, and not from the exist-
ence of any mechanical  obstacle to the  outward flow of the urine.  When,  on
the other hand, it is the neck  of the bladder that is paralyzed, whilst the body
of the viscus retains its contractility, the urine cannot be retained, but dribbles
away involuntarily, thus constituting incontinence.
  Loss of tone  in the body of the bladder, leading  eventually to its paralysis,
not unfrequently occurs in old age as the result of simple diminution of mus-
cular power; or it  may happen as  a  consequence of fever,  or as one of the
symptoms of paraplegia, from whatever cause arising.   It may occur suddenly
in cases  of injury in which the lower part of the spinal cord is paralyzed.
   When coming  on slowly as the result of disease, the patient  usually finds
that the water escapes in  a dribbling manner; that there is some difficulty in
emptying the bladder  completely;  and  that there is not that forcible  ejection
of the last drops of urine that is characteristic of  a healthy tone in the organ;
at the same time there is not unfrequently  a tendency to the dribbling away of
a few drops  towards  the  end of the emission of urine, and after its apparent
cessation.  There is also an occasional  escape of urine at night.  When com-
plete retention occurs, whether fliis take place gradually or suddenly, the bladder
slowly enlarges, rising at last out of  the pelvis  into the abdomen, stretching  up
into the hypogastric region, reaching even as high as the umbilicus.   On ex-
amining the  lower  part of the abdomen,  the  organ will be  felt  hard, elastic,
rounded, and pyriform in shape, projecting above the pubes, and feeling much
like an  enlarged  uterus.   In  this  situation, also, percussion  will elicit  a dull
sound, and on exploring the part through the  rectum the  bladder will be found
to  project in this direction also, and on  tapping with  the fingers above the
pubes, fluctuation may be  felt through the  wall of  the gut.  After the bladder
has once become distend'ed, it commonly happens  that a quantity  of urine con-
tinues to dribble out of it; in fact the amount that escapes  in this manner may
be  very  considerable, though the retention  continue unrelieved.  This  retention
with dribbling  is a condition  of much practical  importance, as the continued
escape of  urine may lead  the patient, and  even the surgeon to  overlook  the
true nature of the disease; the more so as in elderly people retention  slowly
induced often  occasions but little inconvenience.   I have drawn off nearly a
gallon of urine  from a patient  in whom it had not been suspected that retention
existed, in consequence of the continuance  of this dribbling.  In women, re- 
RETENTION  OF  URINE—PARALYSIS OF BLADDER.  855
tention is not by any means so common as in men, but  the  bladder will some-
times attain an enormous size, rising as high  as the  umbilicus; and  such en-
larged bladders have been tapped under the supposition of the tumor being an
ovarian cyst or some similar growth.   I once witnessed such a case, in which
the surgeon, to his surprise, on tapping the tumor drew off a quantity of clear
and healthy urine instead of ovarian fluid; fortunately no bad effects followed.
This retention  with  dribbling occurs in consequence  of the  bladder,  as it rises
out of the pelvis, elongating its neck; and  as the body becomes bent  forward
over the  pubes, a sharp curve or angle is formed  at  the  junction of the neck
 and body of the viscus, through which a small quantity of urine continues to
 dribble away,  and escapes rather by its own gravity than by any expulsive effort
 on the part of the patient.
   The retention from paralysis  can readily be diagnosed from retention from
 obstruction, for on  introducing the catheter, when the patient is  lying on his
 back, the instrument will not only readily enter, but  the urine will simply flow
 out in a uniform stream, not being projected in a jet by  the  contraction of the
 walls  of the organ, but rising and falling in obedience to the respiratory move-
 ments.  The urine that escapes in a case of retention will always be found to be
 high-colored  and  very ammoniacal,  its specific  gravity is also  considerably
 increased in  consequence  probably of the absorption  of its more watery  con-
 stituents.                                         .        ,    ,     ...
    The continuance of  retention of urine from paralysis of the bladder, will pro-
 bably o-ive rise to fatal consequences;  a sub-acute inflammation taking place in
  the mucous membrane of the organ which falls into  a  sloughy condition, accom-
  panied by symptoms of a typhoid type.  In some instances coma comes on, owing
  to the poisoning of the system by the absorption of  the  urinary constituents
  Even though the retention be relieved, this condition is apt to come  on; vesical
  catarrh with  fetid  urine supervening, the tongue becoming brown, and low ieyer
  setting in.   It is very seldom that  the  bladder ulcerates  or bursts when the
  retention arises from  paralysis of that organ independent of any mechanical
  obstacle, the continued dribbling preventing this consequence.
    The treatment of this form of retention must have  reference to the cause  ot
  the paralysis  of the bladder;  but under all circumstances  the urine must be
  drawn  off regularly, as the  over-distension of the organ not only keeps up  its
  paralytic state, but may occasion serious consequences  by inducing chronic
  inflammation of it.   A large catheter must accordingly be introduced "W^J
  toioe a day,  even  though retention be not complete, and in doing this  care must
  be taken that the beak of the instrument properly enters the body of the blad-
  der, which is further  removed from the pubes than  usual; for it will BometameB
  happen that  it may get into the dilated prostatic part of the urethra or elon-
  gated neck  of the bladder,  when an ounce  or two  of urine escaping, it may be
  supposed that there  is  no  more left behind, though  in  reality the visus is
  immensely distended.   In order  to get the catheter well in its poisblouW be
   closely hooked round  the pubes and  raised by dep™B8ing *e Wle bet^
   the  thighs.   In cases of paralysis, the catheter should not be allowed to, remain
   in the bladder, lest its point pressing against the mucous membrane increase
   the  tendency to low cystitis, or give rise to sloughing.
     If the retention arise from paralysis dependent ^ ^ry^d^^J^
   spine, it will occasionally be found  that strychnine  either administered  inter-
   nally or applied endermically will tend to lessen it.  If from old age, the admin-
   istration oFcantharides, or the application of  a blister to the »e™m^may be of
   use.   In some cases  the application of cold to the  inside of the  hghs or• abdo
   men, will facilitate the contraction of the organ  hence * * *he cus tomof Borne
   old  men laboring under this affection to press the^chamber utensil■ ^»st *Jj
   inside of the thighs, and I have known a patient find more relief by sitting on
   the marble  top of his commode, than in any other  way. 
856
DISEASES  OF  THE BLADDER.
  Incontinence of urine arises from weakness of the neck of the bladder, in con-
sequence of which there is not sufficient power to hold the contents of the organ,
and the water dribbles out.  In  most cases the sphincter-like action of the neck
is not perhaps quite lost, so  that a small quantity is ejected from time to time,
the urine in fact escaping so soon as enough has accumulated to overcome the
slight resistance offered by the  partial  contractility of this part of the bladder.
When there  is paralysis of the body of the bladder as well as of the neck, the
urine dribbles out as fast as  it is poured in by the ureters.
  Incontinence of urine,  consequent upon weakness of the neck of the bladder,
may arise from a variety  of  causes; it is most frequent in children, in whom it
occurs during sleep, the patient losing  the command  over the  sphincter so soon
as a small quantity of urine has  accumulated behind it.  In  old people it may
arise from simple debility, and is commonly associated with a tendency to reten-
tion.   In many cases it is sympathetic,  dependent on  the irritation of piles, stric-
ture of the urethra, or stone in the bladder, and occasionally results from nervous
causes, more particularly  in  women of an hysterical temperament.  Over-disten-
sion of the bladder  will occasion incontinence of urine, not from paralysis, but
from a  kind of strain of the  muscular structures of  the part; in this way a
patient, who from circumstances has been unable to empty his bladder for a con-
siderable time, may  suffer from incontinence.   In children of a strumous habit,
incontinence of urine is  very apt to occur, the child wetting its bed an hour or
two after it goes to sleep.  In such cases the urine will  generally be found to  be
loaded with lithic acid crystals.
   The treatment  must depend  upon the cause.  When arising in weakly chil-
dren, if it be not connected with worms  or gastro-intestinal irritation, which
should then be removed,  the administration of tonics will be found useful,—
either quinine or the tincture of the sesquichloride of iron, alone or conjoined
 with tincture  of lytta.   If  there be irritation of the mucous membrane of the
bladder,  the administration of alkalies,  in conjunction with  a tonic, as  the
 potassio-tartrate of  iron, or  a little  copaiba  mixed with honey, will be found a
 very serviceable  remedy; cold sponging,  light  clothing  at  night, and means
 calculated to break  the habit,  such  as waking the child at the time at which it
 generally occurs, changing his position  in  bed, &c, should not be  omitted.
 When occurring  at  a more  advanced period of life, if there be any source  of
 sympathetic irritation, this must be removed ; if none can be discovered, tonics,
 especially iron and  lytta,  with strychnine and  galvanism, must be had recourse
 to, together with cold douching or shower-baths.
   Hysterical retention and  incontinence not unfrequently occur in nervous girls,
 and require to be treated by anti-hysterical remedies, amongst which the prepa-
 rations of the sesquichloride of iron, either alone or with valerian, will be found
 most  useful.  Cold  douches are also  of great service.  In cases of hysterical
 retention, it may sometimes be necessary  to use the  catheter;  but under such
 circumstances it is  well  not to employ this instrument too  frequently, as  the
 patients  are apt to get into  the habit of having it introduced, and will, with  that
 morbid propensity that characterizes hysteria, continue for a length  of time to
 require its introduction.   If left to themselves, though the bladder may become
 much distended, it will not burst, but will probably empty itself without further
 trouble,  more particularly if the patient is put into a tub and well douched over
 the hips and loins with cold water.   In some  cases these morbid conditions in
 women appear to be connected with some local irritation about the urethra or
 uterus, and then proper treatment must be  directed to these organs before the
 disease can  be cured.
    The bladder is often the seat of severe pain, either continuous or remittent,
 without  any disease being discernible  in it on  the closest examination ; the pain
 being either a kind of neuralgic condition, especially occurring in hysterical or
 hypochondriacal patients, or else being sympathetic with and dependent on dis- 
DISEASES  OF  THE  PROSTATE.               857
ease at a distance, as in the kidneys, uterus, rectum, &c.   At the same time it
must be borne in mind, that the secretion of acid or irritating urine will, in some
individuals, be a source of much and constant suffering; and that any disease seated
about or  coming in contact with, the neck  of the bladder, as tumor, stone, &c,'
is  especially apt  to give rise to  severe  suffering, and will in many cases  be
accompanied by frequent desire to micturate, with much spasm about the part.
   Extroversion of the bladder, consisting in an absence of the anterior wall of
that organ, with deficiency  in the corresponding part of the abdominal parietes,
is occasionally met with as a  somewhat rare congenital malformation.   In these
cases the posterior wall  of  the bladder  being pushed forwards by the pressure
of the abdominal viscera behind, forms a  rounded  tumor about the size of a
 small orange just above the pubes.  The surface of this tumor is red, vascular,
 and papillated, evidently composed of mucous membrane; at  its lower  aspect
 the orifices  of the ureters will be observed to open and to discharge the urine
 in drops or in a stream.  For a full description of the mechanism of the passage
 of the urine in these  malformations, I would refer  to a case that fell under my
 notice, and in which I made a number of experiments on the rapidity of the
 passage of foreign matter through the kidneys, reported in the Medical Gazette
 for 1845.  This" malformation is incurable.   Operations have been planned and
 performed with the view of closing in the exposed bladder by plastic procedures,
 but they have never proved  successful, and  have terminated in  some instances
 in the patient's  death; they do  not therefore afford much encouragement for
 repetition.   The  patient should,  however, wear a  properly constructed  instru-
 ment to receive  and  collect the urine; consisting of a hollow shield strapped
 over the part, communicating by means of a tube with an India-rubber bottle
 that may be attached along the inside of his thigh.

                   DISEASES  OF  THE PROSTATE.

    The prostate  is subject to acute  and  chronic inflammation, to hypertrophy,
  scirrhus, and the formation of calculi.
    Inflammation of the prostate or prostatitis very rarely occurs as an idiopathic
  affection, but is  most commonly met with  as the result of gonorrhea, more espe-
  cially in middle-aged men, rarely in those under twenty-five or thirty. _  lhe
  symptoms of prostatitis are deep-seated  pain, heat  and weight in the perineum
  with a frequent  desire to  make water, and very great and spasmodic  pain accom-
  panying the emission of urine;  in  fact the irritability that is set up about the
  neck of the bladder is perhaps the most marked and distressing feature in the
  disease.  These symptoms are, however, common to various inflammatory affec-
  tions of the urinary organs, and they can only be distinctly referred  to the
  inflamed prostate by rectal  exploration.   On  introducing the  finger into  he
  gut, the prostate will  be found  much enlarged and  exquisitely tender to the
  touch; and the patient  often  suffers considerably  from the pressure  of the
  inflamed organ upon the  rectum during defecation.
     The  treatment of acute inflammation of the prostate, should be  of an active
  antiphlogistic character, so as to prevent, if possible, the formation of abscess in
  it   The  perineum must be cupped or well leeched, warm hip-baths  and poppy
  fomentations  assiduously employed,  and salines -^antimony administered.
  In this way the formation of abscess within or around the prostate may m many

   strati may happen  either as a consequence of acute inflammation
   running into the suppurative" stage, and  in this way it is not very unfrequent y
   met with  as a  complication of  gonorrhea; or it may occur with comparatively
   kte antecedent inflammation_as sometimes happens in pyemia, or if the organ
     accidentally  bruised during  lithotrity.  In these  cases,  abscess perhaps"
   frequently f rms in the cellular envelope as in the organ  itself.   Idiopathic 
858
DISEASES  OF  THE PROSTATE.
suppuration of the prostate, irrespective of any of the above causes, is, however
of rare occurrence, but a case happened to me some time ago in which, without
any  apparent  reason, after the operation for  strangulated hernia, a purulent
collection formed in this situation.
  When inflammation of the prostate terminates in abscess, rigors with throb-
bing and perhaps retention of urine occur.   In all cases the perineum becomes
brawny, or, tenderness of the  gland, and deep fluctuation may be felt through
the rectum.  When left to  itself, this abscess  most usually gives way into the
urethra, but it may, especially when  occurring  in  the prostatic capsule, open
externally into the perineum or into the rectum.   In many cases the abscess pre-
senting on  the urethral surface of the prostate is burst during the introduction
of the catheter, used for the relief of the  retention  of urine induced by the
pressure of the tumefaction; the matter escaping along the side of and through
the instrument.
  So soon as it  can be ascertained that abscess has formed in the prostate, the
pus  should be let out  by a deep  incision into any brawny or indurated mass
that can be felt in  the  perineum.  The surgeon must not wait for fluctuation,
but must cut  deeply in  the direction  of the matter, keeping, however, in the
mesial line.  Even  if none escape at first it may do so if the part is well  poul-
ticed for a few hours, and  thus communication with the urethra or rectum be
prevented.
  In prostatitis, retention may occur from the swelling of the organ, the infil-
tration of exudative matters around it, or the formation of pus in it.  In these
cases the neck of the bladder will be carried to a considerable distance from
the  surface, and may very probably  not be reached  by an ordinary catheter,
which  may be buried up  to the rings and'yet not enter the cavity of that organ;
under  these circumstances a silver prostate  catheter should be employed, and
this must be carefully introduced, lest by getting into the cavity of an abscess
which  has  already burst per urethram, it might be  supposed to have entered
the bladder itself.   In introducing the instrument under these circumstances,
care should be taken to keep its point constantly in  contact with the upper sur-
face of the urethra, and to hook it round the pubes.   The upper surface of the
urethra is a sure  guide to the bladder; for any abscess, false passage, or irregu-
larity of direction will always first affect the lower aspect of this  canal, as being
surrounded by yielding structures, whilst  the upper part being firmly supported
by bone and ligament cannot so readily alter its direction.
   Chronic sub-acute inflammation  of the prostate  not unfrequently occurs in
cachectic and debilitated individuals as an idiopathic affection; but, in other cases,
it is connected with  gonorrhea, or some local irritation. In this form of the dis-
ease, there is not only heat, weight, and pain in the region of the gland, with
tenderness on rectal exploration,  but there is usually a considerable  discharge
from time to time of a viscid, ropy mucus, the morbid secretion  of the follicles
of the gland, which is frequently mistaken for spermatorrhea.   This discharge
is occasionally ejected by the acceleratores urinae muscles, which are irritated by
extension of morbid action to them, and is at other times squeezed out when the
patient goes to stool, by the pressure  of  the faeces  and the action of the anal
muscles.   In most cases its continuance is  accompanied by a good deal of irri-
tability about the neck of the bladder, and debility of the generative organs.
Its existence is a source of much distress to the  patient, whose mind usually
becomes  harassed by the dread of impotence.   The discharge, however, is not
seminal, and may always be distinguished from true spermatorrhea by the absence
of the  characteristic spermatozoa.
   The treatment of these cases must consist in the gradual removal of the local
inflammatory action  by the application of leeches to the perineum, by warm hip-
baths,  and if some chronic enlargement of the prostate has taken place, by the
administration of small doses of the bichloride of mercury in compound tincture 
HYPERTROPHY  OF  THE  PROSTATE.
859
of bark.  Should the patient suffer much in making water, liquor potassae, with
a small quantity of copaiba and tincture of henbane will be  useful.  In some
cases much advantage will be derived from the repeated application of blisters
to the perineum.
  Hypertrophy and tumors of the prostate. — Chronic enlargement of the pros-
tate may be looked  upon  as a senile disease, seldom occurring before the age
of fifty, and being commonly met with after this; at that period of life, as Sir
B. Brodie  observes, when the hair becomes  grey and  scanty, when  atheroma
begins to be deposited in the coats of the arteries, and  when the arcus senilis
forms on the cornea, the prostate often becomes increased in size. At the same
time, however, other changes take place in  the genito-urinary system; thus the
urethra becomes dilated and the bladder thickened, and unless the enlargement
of the prostate advances in too great a proportion to the other changes, so as to
interfere with the free escape of the urine, no disease can properly be said to be
established.   If  we look upon the diseased enlargement of tbe prostate as such
an amount of hypertrophy of the gland as interferes seriously with the discharge
of the urine, we shall probably not  find  it so frequent  even  in old men, as is
generally supposed.   Guthrie states that it is not commonly found in the pen-
sioners  at Greenwich Hospital.  Mr. Henry Thompson  has found  that an en-
largement appreciable after death existed in 30 per cent, of men above the age
of 50; but that such a degree of enlargement as to give rise to symptoms during
life was only met with in 12 per cent, of the cases he examined.   Though age
must be looked upon as the primary cause  of this particular hypertrophy of the
prostate, there can  be little doubt that it may be predisposed to  by any con-
tinued source of irritation of the urinary organs, such as  gonorrhea, strictures, or
hard living.
   Enlargement of the prostate is principally due to fatty degeneration of, with
phosphatic deposits in, that organ, the texture of  which is  usually indurated,
though sometimes it has been found to be looser and softer than natural.
   The enlargement may occupy the whole  of the organ, causing its size to in-
crease to that of a large egg or small orange; or it may be confined principally
to the  lateral  lobes, which may either both or singly  become hypertrophied.
When this is the case, the urethra becomes greatly elongated  and tortuous,
winding round the promontories formed by these lobes, and sometimes assuming
the form of a sinus, being irregularly dilated;  or a complete change may take
place,  not only in the direction, but in the shape of the canal, which becomes
elongated from above  downwards into a kind of  chink, or, is  else flattened out
laterally.  In  all cases of enlarged prostate, whatever be its shape, the corre-
sponding portion of the  urethra becomes larger and wider than  natural.  The
elongation of this canal is owing to the general enlargement of the prostate, in
which the canal that  traverses  it must necessarily partake, and its expansion to
the outward growth of the organ.  So capacious does this portion of the urethra
sometimes become, that it may hold two or three ounces of urine, and in conse-
quence of its elongation will carry the neck of the bladder upwards, and behind
the pubes to a considerable distance from the surface.
   The  urethral  portion of the prostate may become greatly enlarged in size,
with or without accompanying hypertrophy of the lateral lobes.  It then usually
assumes a  nipple-like  appearance,  but  sometimes becomes  constricted  at the
base and expanded above, so as to be truly pedunculated (fig. 339),  constituting
at last a round  and solid tumor overlapping the urethro-vesical orifice.  Occa-
sionally the verumontanum alone  appears to  be affected, forming a kind of
thickened valvular projection, which interferes  materially with the flow of the
urine.                                                                . ,  .
   Mr. Thompson has carefully studied the nature  of the tumors met with in
the prostate.  The following remarks embody his observations : " The existence
of solid tumors of different kinds is by no means rare  in  the  prostate.   They 
860               DISEASES OF  THE  PROSTATE.

were pointed  out by  Sir E. Home, and  by him supposed to be of the nature
of apoplectic clots.  Subsequently they  have been regarded  as  fibrous tumors,
and more lately it  has been  shown  that some possess a structure approaching
very nearly to that of the secreting tissue contained in  the prostatic substance
around.  It is shown that enlargement  of the prostate is very frequently asso-
ciated with the development, more or less marked, of such growths in some one
of three forms; in short, that the production" of defined tumor is more fre-
quently than otherwise the essential element of the pathological condition known
as hypertrophy of the prostate.  Of 14 enlarged prostates  6 exhibited numerous
fibrous tumors in the substance of the lateral lobes; the others show polypoid
enlargements, single, binary, or multiple, springing from the ' posterior median
portion.'  The varieties may be briefly noticed as follows : —
   " 1.  A simple fibrous tumor, small, nearly isolated, made up of closely packed
organic muscular fibres, with areolar tissue, intimately resembling those found
imbedded in the walls of the uterus.
   "2.  A tumor composed of the same elements as the preceding, but contain-
ing, in addition, some of the glandular  substance of the prostate, more or less
imperfectly developed.   This also  may  be  imbedded, with or without a cyst,
seeming sometimes to partake  more of  the  character of a local enlargement,
limited to a small  portion  or lobule of the prostate tissue,  and only partially
isolated.  Although separating this  class from the previous one for facility of
reference, it is more  than probable that the two nearly  merge into each other
at their adjacent limits, the latter approximating to the former by insensible
                                    gradations :  so that some tumors which
                                    appear to be purely fibrous at first may be
                                    found to exhibit slight traces, in parts of
                                    its structure, of  the glandular element.
                                    In all, however, the basis is  the organic
                                    muscular fibre.
                                       " 3.  A tumor composed entirely of the
                                    ordinary structures of the prostate fully
                                    developed, and enjoying activity of func-
                                    tion  in common with  the rest of the
                                    organ.  It assumes a pyriform  shape even
                                    in  its earliest stage, and springs from the
                                    posterior median  portion.   It may vary
                                    in  size from that of a pea to that of a
                                    middle-sized pear.  The analogies between
                                    these and  the polypoid  tumors of the
                                    uterus are considerable; pointed out by
                                    Velpeau and  others, modern  researches
                                    seem to indicate them more plainly."
                                       These enlargements are productive of
                                    various inconveniences with regard to the
                                    passage of the water, giving rise either to
                                    retention or to incontinence, or to a kind
                                    of mixture of both conditions.  When the
                                    lateral  enlargements cause the urethra to
                                    assume a  somewhat tortuous  course, the
                                    middle lobe, if hypertrophied, may readily
                                    occasion retention,  by projecting against
                                    the entrance  to  this  winding  channel.
Then  again, if the middle lobe continues small whilst  the enlargement of the
lateral  lobes takes a direction up towards the bladder, widening as they go, the
vesical neck  may be so dilated that incontinence and a  continuous dribbling
will occur through a kind of fissure that  extends between  the lateral lobes.
 
RETENTION  OF URINE.
861
  The  obstacle offered to the passage of the urine by an enlarged prostate will
usually eventually give rise to  a chronically thickened, fasciculated, and sac-
culated bladder, the fundus of which descends below and behind the enlarged
gland, forming a kind of pouch that cannot empty itself, and  in which mucus
and morbid  concretions are apt to collect.   The ureters often become dilated
and the kidneys chronically diseased;  a  series  of changes well illustrated by
the preceding cut (fig. 338).
  The symptoms of enlarged  prostate all arise primarily from  the mechanical
obstacle offered to the passage of the urine.   The first symptoms usually consist
in the feeling  of a  necessity to  strain slightly before the urine will flow; and
then after the  bladder has  been apparently emptied, the involuntary escape of
a small quantity of  water.  The patient also finds that he is much  longer  than
usual in emptying  the bladder, for though the  stream flows freely enough  so
soon as it has once begun to escape, yet  it cannot be properly projected, the
viscus having, to a  certain extent, lost its  tonicity.  About this time  changes
begin to take place  in the urine, which  usually becomes somewhat fetid, though
it continues acid, and  is often intermixed with more or less viscid, stringy
mucus; though in  many cases it  is clear, pale, and not in any way altered  in
character.   The symptoms often come on in a very gradual manner, the patient
straining and  experiencing much difficulty in the extrusion  of the urine for
months or even years before retention will occur.  As the disease advances and
the bladder becomes less  capable of emptying itself, two or  three ounces  or
more of residual urine are left,  which  becomes dark, mixed with adhesive,
sticky mucus;  and, at last, if the mucous membrane of the bladder falls  into a
chronic state of inflammation, assumes a  milky appearance from an admixture
of pus, and  becomes horribly offensive, blackening the silver catheter.
   The exact condition of the enlarged prostate can  only be ascertained by
examination through the rectum and urethra.  By rectal exploration with the
finger, the degree  of enlargement of the lateral lobes can best be ascertained,
though as  in many cases the  end of the finger cannot reach the further
extremity of the gland, it will be impossible to say to what extent the hyper-
trophy has  extended.   The urethral exploration must be conducted by means
of a long gum elastic or a silver prostatic catheter, and will afford information
that rectal  exploration cannot give; as  by it is ascertained approximately the
size of the  middle lobe, and the  condition  of the urethra as to elongation and
curve.
   Retention of urine constitutes the great danger in advanced  cases of enlarged
prostate.  It  commonly comes on gradually, the patient having for some time
before experienced  considerable difficulty in passing his urine,  and he will often
find that  the  more he strains in  his efforts to  do this the less readily will  it
come away; whereas, when  he remains  quiet,  it will  usually flow with  more
freedom.  The retention from prostatic enlargement is of the mixed kind, there
being  always  more or less incontinence conjoined with  it.  When  the bladder
has become  tense, and the prostatic portion  of the urethra put  upon the stretch,
the escape of  a certain quantity of urine will take place, until, by the relief of
the  tension  of  the over-distended bladder, the parts  about its neck  and the
enlarged prostate become relaxed, so  that they again fall together, and thus, the
urethra resuming its tortuous condition, the outlet is occluded.   In these cases,
error may always be guarded against  by the surgeon feeling the enlarged bladder
rising up above the pubes, and  reaching perhaps as high as the umbilicus.
This condition is an extremely dangerous one, not so much from any riskm)1 the
bladder or  urethra giving way in consequence  of over-distension, which very
rarely happens  in  retention from enlarged prostate, as from the occurrence  of
paralysis of the bladder, or the  probability of the early setting in of chronic
inflammation  of its mucous membrane,  which  is specially apt to take  place.
The bladder has usually not emptied itself completely for a considerable length 
862
DISEASES  OF  THE PROSTATE.
of time before the retention is complete, and a quantity of ropy mucus having
collected in  the fundus  behind the prostate, whence it cannot be expelled,
becomes putrid, and thus disposes to the supervention of that  form of chronic
inflammation of the vesical mucous membrane, which, occurring in a depressed
state of the system, is especially apt to give rise to a brown tongue with quick
pulse,  and typhoid symptoms.  Indeed,  when  death  occurs from  prostatic
disease, it usually takes place in this way.
   In  the treatment of enlarged prostate  little can be done by medical means,
though the patient's  condition  may be  somewhat  ameliorated  by treatment
calculated  to  lessen irritation  about  the urinary organs, and to improve  the
condition of the urine.  With this view, if it be very acid, alkalies with henbane
should  be  given; if neutral or alkaline, the dilute nitric acid with henbane or
opium; if mixed with ropy mucus, the infusions of uva ursi or of buchu,  and
if containing muco-pus, the pareira brava may be administered.  If hemorrhage
occur, the  tincture  of the sesquichloride  of iron or gallic acid will be useful.
Counter-irritation, the application  of iodine, and other measures calculated to
promote absorption of the  enlarged  gland, will  be found of little service,  and
are usually productive of serious annoyance to the patient.
   In the treatment of enlarged prostate, it  is of great importance to use  the
catheter regularly,  in order to empty the pouch that  forms in the bas-fond of
the bladder behind  the prostate; and which being below the level of the urethra,
tends to collect an  accumulation of viscid mucus and fetid urine which cannot
be expelled by the patient's unaided  efforts, partly from  their gravitating  into
this pouch, and partly by  the  muscular power of the organ being impaired.
The removal of these matters is of great  importance, as,  independently of  any
retention, they may, by undergoing putrefaction, give rise to typhoid infection.
The bladder should be effectually emptied every day.  This may best  be done
by the introduction of a gum catheter  of full size, which should be passed
without the stylet,  at first once, and then, if necessary, twice in the twenty-four
hours.  This the patient should be taught to do  himself;  and  thus the habitual
distension of the bladder, or retention in it of a quantity of urine, will be  pre-
vented, and all the accompanying constitutional  disturbance averted.  Some-
times  in  order to  empty the bladder thoroughly, a prostatic  catheter must be
used.   This instrument should be  made of silver, and be of large size, equal to
 about No. 12.  In order to enter the bladder properly, which is carried away
 from the surface by the elongated  urethra, the  prostatic  should  be  about  four
                            inches longer than an ordinary catheter; and as the
           Fig. 339.           neck of the viscus is usually pushed up high behind
                            the pubes by the projection  upwards of the lateral
                            lobes, the curve of the instrument should be greater
                            and longer than usual.  I find the best-shaped pro-
                            static catheter to  be one,  the curve of which is
                            exactly the third  of the circumference of a circle
                            five-and-half inches in diameter.   The eyes should
                            be  large  and rounded, and I  have found it of
                            use  to  have  the  lower  end  of the  stylet  pro-
                            vided with a piston plate, so that by withdrawing
                            this, the mucus may be  sucked in through the  eyes
                            of the  instrument.  In some  cases, however, a
                            moderately curved gum elastic catheter of full  size,
                            enters the bladder most  easily;  in fact, no   one
                            curve or one kind of instrument will answer in all
                            cases.  In introducing the catheter, care should be
                            taken when the point enters the prostatic portion
                            of the urethra, to depress the handle well between
 the thighs, lest the end hitch  against the enlarged middle lobe (fig. 339), or do
 
TREATMENT OF  RETENTION  FROM ENLARGED PROSTATE.      863
not sweep sufficiently round the pubes.   So also that it fairly enters the body
of the bladder; in enlarged prostate the corresponding portion of the urethra is
often elongated and dilated, forming a bend or pouch, containing perhaps  half
an ounce  to  one ounce of urine; this the catheter may enter and  empty, and
the surgeon then erroneously supposing that he has passed the instrument into
the bladder, may rest content; but this is a grievous error, as the bladder is left
distended beyond this pouch.
   When retention has occurred, relief can only be afforded by the proper use of
the catheter, and this should never be delayed, as typhoid symptoms in elderly
people rapidly set in.  Three questions present themselves in connection with
the treatment of this form of retention.
   1st. As to the kind of catheter  that  should be used  for its  relief.  Sir B.
Brodie recommends a gum-elastic instrument, long, of large size, and kept on a
well-curved iron stylet, so as to preserve its curve when that is withdrawn.  This
 must be introduced  either with or without the  stylet; if possible, without it.
 Other surgeons of  great authority in these matters  prefer the silver  prostatic
 catheter, and I certainly think that for the relief of retention a silver instrument
 is safer, and more easily managed than the gum-elastic one.   It  might be sup-
 posed that a less chance of mischief would  result from  the gum-elastic than
 from the metallic catheter, as  being the softer and  more yielding  instrument;
 but this is, I think, erroneous, if the stylet is allowed to remain in,  as it is then
 as rigid at the point, as hard, and as likely to penetrate soft structures as a  silver
 one would be.   If the stylet be withdrawn, it is often a very unmanageable in-
 strument; it is impossible to know how to direct its point, and  if  the  obstacle
 be a  difficult  one  to surmount, it is not easy to guide  it over it. With  the
 metallic instrument, on the other hand, the surgeon  can feel his way as it were,
 and will, if he depress the handle well, as soon as the point enters  the prostatic
 portion of the urethra, find little difficulty in guiding it into the  bladder.   It
 is the first introduction of the instrument that  especially requires care, and as
 much gentleness as  possible ; after it has  once  been introduced, it will almost
 invariably readily  find its own way.
    2d. The  next question  in connection with the relief of retention in these
  cases is whether the catheter should be left in the bladder, or be withdrawn after
  the viscus is emptied.  As a general rule, it is certainly far better  not to leave
  the catheter in; its presence in the diseased bladder setting up a low form of
  inflammation, or giving rise to sloughing of the mucous membrane.   The in-
  strument should be introduced twice in the twenty-four hours, and care should
  be taken if possible to  empty the pouch behind the prostate by depressing its
  point. When the instrument is used habitually in  this way, the gum catheter
  may  be employed.  Should the mucus be very viscid and offensive the bladder
  may  be washed out with tepid water through a double current catheter   After
  the bladder has been emptied for the first time, it will be found to refill in the
  course of a very few hours, usually in six or eight,  the secretion of the kidneys
  appearing to be  set free on  the removal of the pressure   Should any great
  difficulty be experienced  in introducing the catheter, it may be thought desirable
  to leave it in for two or three days, and then a gum-elastic one is always to  be pre-
  ferred, as under these circumstances it presents a great advantage over the silver
  catheter, becoming soft, accommodating itself to the shape of the parts after the
  stylet has been taken out, and not being so liable to irritate the mucousi mem-
  b/ane with its point, which,  dipping down into  the pouch behind  the.pro s ate
   acts  as  a syphon, emptying this  part  of the  bladder  far better than a silver

   catheter could d*        ^ connection with  the  relief of retention from en-
   larged prostate, is as to the course that should  be pursued, if no instrument can
   be got into the bladder in the ordinary way.   In  these cases which, however
   very rarely occur, two lines of practice may be  adopted: either the puncture of 
864
DISEASES  OF  THE  PROSTATE.
Fig. 340.
the bladder above the pubes, or forcible  catheterism.  The puncture above the
pubes can very seldom be required.  Since the University College Hospital was
opened, twenty-one years ago, only one case has presented itself in which it was
thought proper to adopt such a procedure.  The operation consists in making an
incision, about an  inch and a half in length, in the mesial line, immediately
above the  pubes, and  then passing a long curved  trochar,  with  its concavity
                                             downwards,  into  the  bladder
                                             behind that bone,  and conse-
                                             quently underneath the reflexion
                                             of the peritoneum (fig.  340, a).
                                             The canula must  be left in for
                                             the  escape of the urine, whilst
                                             the  continuity  of the  natural
                                             passage is being restored. When
                                             the bladder is greatly distended,
                                             in consequence of retention from
                                             enlargement  of the prostate, the
                                             peritoneal  reflection  is  carried
                                             up with it,  and a considerable
                                             portion of the  anterior wall of
                                             the  organ uncovered  by  peri-
                                             toneum is left above the pubes.
                                             In a case of unrelieved retention
                                             which I had an opportunity of
                                              dissecting,  I  found that  the
                                              fundus of the bladder reached
                                              to five inches above the  sym-
 physis pubes, and two below the umbilicus; that the line of reflection of the
 peritoneum was 3^ inches  above the bone, and  that the space  uncovered by
 serous membrane was 2\ inches wide.  The bladder contained nearly 40 ounces
 of urine.
   Puncture  through the  rectum is not generally a safe procedure in retention
 from enlarged prostate, in  consequence of this  structure encroaching  on  that
 part of the inferior fundus of the bladder which is uncovered by peritoneum.
 When, however, the retention arises  from enlargement of the  urethral portion
 rather than of the  lateral lobes, it may be safely done, and indeed I have known
 it put in practice with advantage in such cases.
   A far safer procedure  than  this,  and  one  that  is  recommended by Sir B.
 Brodie,  Mr.  Liston, and most surgeons of authority in these matters, is forcible
 catheterism.   As the retention  is generally owing to an enlargement of the
 urethral portion  of the prostate, relief may be  afforded by pushing the point of
 a silver catheter  through this obstacle into the bladder.   A  false passage is thus
 formed, in which  the instrument  should be  left for about forty-eight hours,
 when  it will generally enter it with sufficient  readiness on  being introduced
 again.
   After the retention has been relieved the bladder will often be paralyzed for
 a time, the urine flowing out, but with  no power of expulsion for some weeks.
 Under these circumstances the catheter should be used twice in the twenty-four
 hours; good diet, with wine, quinine and  extract of nux vomica may be given,
 and blisters applied to the  sacrum;  afterwards the patient  should be taught to
 pass the catheter for himself once or twice daily.
   The radical cure of the  impediment to the  flow of the urine  has been pro-
 posed to be  effected by removing  the enlarged middle lobe of the prostate by
 ligature, by excision with  a lithotrite, or  by lateral or median incision of the
 perineum.   Such  operations, however, from  their difficulty and danger, should
a. Puncture above pubes.  b. Puncture through rectum.
          c. Reflexions of peritoneum. 
DISEASES  OF  THE  URETHRA.                 865
not be lightly undertaken;  perhaps the least dangerous mode of removal would
be by median urethrotomy.
  The  existence of malignant disease of the prostate is of very rare occurrence,
and  may  commonly be  ascertained  by exploration through the rectum  and
urethra.   The passage, also, of bloody urine, or of clear urine followed by a dis-
charge of blood, mixed, perhaps, with the debris of a cancerous growth will like-
wise tend to establish  the nature of the  affection, which is necessarily fatal.
The consideration of prostatic calculi  will  be deferred till we come to speak of
urinary concretions generally.
      CHAPTER  LVII.

DISEASES  OF  THE  URETHRA.

          URETHRITIS.
  Simple inflammation of the urethra is especially apt to occur in  strumous,
rheumatic, or gouty individuals, from slight  sources of irritation, either direct
or sympathetic, that would not excite it in more healthy  constitutions.   In
strumous children, it may arise  from worms  in the intestines, or from  gastric
irritation; and in  gouty or  rheumatic subjects, it appears often to occur  in con-
nection with an acid or loaded state of the  urine.   In other cases,  again, the
irritation of a stricture, the  passage of instruments, or ordinary sexual inter-
course, may occasion the disease, without there being anything of a  specific or
venereal  character about it.  Women who are out of health, pregnant,  or  suf-
fering from leucorrhea, may, and often do, give rise  to local irritation  of  this
kind.  Urethritis, especially when arising from sexual intercourse, is  frequently
mistaken for gonorrhoea, but from this it may be distinguished  by the  less in-
tense degree of inflammation,  and  by  the absence of those secondary conse-
quences  that so  frequently follow true  gonorrhoea; but yet, in many instances,
the diagnosis is extremely difficult, especially from the subacute forms of gonor-
rhoea that are so common in London.
   The symptoms of urethritis  consist of heat, pricking, tension about the  ure-
thra for a day or two,  followed  by muco-purulent discharge, often rather  pro-
fuse, and accompanied  by some ardor urinae.   The symptoms altogether are not
severe, and the disease usually subsides  at the end of a week or ten days, but
sometimes  it becomes chronic, especially if conjoined with stricture, and then
constitutes an extremely troublesome affection, more  particularly in gouty indi-
viduals.                                                          „.  ,    ,
   The treatment of urethritis is of a mild, antiphlogistic character.   1 he bowels
should be kept open, and salines freely administered; in many cases small doses
of colchicum, in  combination with alkalies,  will be found of especial service  in
cutting the disease short.   The use of emollient, or slightly astringent injec-
tions, such as opiate lotions, or a very weak solution of acetate of lead, with bel-
ladonna, will be found serviceable as the disease is on the dechne, but not until
then; and when the affection has got into a chronic stage, small doses of copaiba
may be advantageously administered.  The  diet, in all cases, should be ot the
blandest character, stimulants of all kinds being interdicted.                ,
   If the disease be conjoined with  slight stricture, it may not unfrequently give
rise  to  temporary retention  of urine.  This may, however, most commonly  be
       55 
866
DISEASES  OF  THE  URETHRA.
readily relieved by antiphlogistic treatment, cupping, or leeches to the perineum,
the warm hip-bath, and salines, with, perhaps, opiate suppositories, and plenty
of demulcent drinks.   The catheter should not be used in these cases, if it is
possible to give relief without it.
   Urethral abscess occasionally forms  as  the result of urethritis, a soft fluctu-
ating point  being perceived in the neighborhood of the canal.   So soon  as this
is detected, it should  be opened, when the  aperture  that  results will readily
close.  If left, it will  probably burst into the urethra instead of externally, the
tissues in that direction being less resistant; and  then, if it should be opened
externally as well, a troublesome urinary fistula will result.
   Perineal abscess may form, as the result of urethritis, in whatever way excited,
the patient  complaining of a sensation of weight, with pain and throbbing, deep
in the perineum.  On  examination, a hard, tense  swelling will be found, situ-
ated a little anterior to the anus, and extending along the side  of the urethra.
It presents  no sign of fluctuation until it comes forwards into the scrotum.  The
treatment consists in the application of leeches, followed by fomentations, and
an early incision through the perineum into the swelling.  In some cases, the
abscess is situated altogether external to the  urethra, and then the aperture
closes readily enough, like that of any other ordinary abscess.   In other cases,
again, it communicates with the  canal,  and  then fistulous openings are left
through which a certain quantity of urine escapes.  These apertures gradually
tend  to close if they be not  complicated with stricture or other urethral disease;
should they be so, they will require special treatment, of a kind that will be
mentioned at a later period.

                              GONORRHEA.

   Gonorrhea is a specific disease accompanied by inflammation, and an abundant
muco-purulent discharge, affecting the urethra most  commonly, but also the
other mucous membranes of the genital organs, as  of the prepuce and the glans
in the male, and of  the vulva and vagina  in the female.
   The urethra is the usual  seat of gonorrhea in the male, and the disease may
be looked on as a specific urethritis, which is  usually fixed with greatest inten-
sity in the fossa navicularis; but it may extend itself over a much wider surface,
affecting  the entire length  of the canal, and extending over the whole mucous
lining of the bladder.  In  the female it  commonly spreads over the extensive
mucous surface of the  internal organs of generation, and sometimes even invades
the uterus.
   Gonorrhea is a truly specific and a highly contagious affection, arising in all
cases from the application of a peculiar animal poison, generated by  impure or
indiscriminate sexual intercourse, to the parts which it attacks, and must not be
confounded with the various  non-specific  inflammatory diseases that may affect
the parts commonly the seat of gonorrhea, and which  are all characterized by
muco-purulent discharges.
   The  poison of  gonorrhea differs entirely from  that of syphilis, as has been
fully proved by the unerring test of inoculation;  these diseases not being capa-
ble of reproducing one another under any circumstances.
   Gonorrhea is usually looked  upon  as a purely local affection of  the  genital
organs.   Some surgeons, however, amongst whom may be especially mentioned
Mr. Travers, seem  to consider it as  occasionally assuming a  constitutional
character;  in this opinion  I entirely agree.  Although the gonorrhea  in the
early stages is doubtless a  strictly local affection,  yet there is a particular train
of phenomena occasionally following it of a very characteristic nature, that can
scarcely be looked upon in  any other light than as being the result of constitu-
tional infection, the more so as they are very apt to occur in  some individuals
who never have gonorrhea without the disease being followed by these sequences, 
GONORRHEA.                          867
whilst others are altogether exempt from them.   The parts that are secondarily
affected are chiefly the  fibrous tissues, the mucous and the cutaneous surfaces
The affections  of the fibrous tissues give rise to rheumatism, and the peculiar
forms of inflammation of the testicle and of the sclerotic.   The affection of the
mucous membrane displays itself in specific inflammations of the throat, and of
the eyes;  and the skin becomes the seat of certain eruptions.   The occurrence
of these various  affections, assuming  as  they do a specific type so distinctly
marked  that they can at once be characterized as gonorrheal, certainly tends to
show that the disease impresses the constitution in some peculiar manner some-
thin"- analogous to, though in a far minor degree, and with much less certainty,
than syphilis.
   The symptoms of gonorrhea in the male may be divided into three stages:—
1st. The incubative stage,  or the period  of irritation; 2d. The acute; and 3d.
 The chronic inflammatory stage.
   The first stage, that of irritation, usually comes on  from three to  five days
 after connection, when the patient begins  to  experience some degree of heat,
 itching, and  general irritation about the penis.   The lips of the  urethra are
 somewhat  red  and  swollen, its orifice gaping, and on squeezing it some muco-
 pus exudes.   This stage  usually commences  about the time mentioned, but
 sometimes sets  in immediately after  connection;  and in other instances does
 not occur for eight or ten  days;  after lasting for twenty-four or  forty-eight
 hours it terminates in the second stage, which is one of active inflammation.
 The discharge now becomes abundant, thick, and of a greenish-yellow color;
 there is great pain  in  making water, with  considerable  heat and smarting, and
 the urine flows in a diminished  stream, but is passed with increased frequency.
 The urethra is swollen, firm and cord-like to the touch ; the whole penis, indeed,
 looks generally red and turgescent.  As the disease advances, and the bulbous
 portion of the urethra becomes affected, tension in the perineum will be com-
 plained of.  If the prostatic portion  is the seat of disease, there will be heat
 and weight about the  anus.   During the whole of this period there is generally
 a good deal of constitutional disturbance, restlessness, and fever.
    One of the most troublesome symptoms in this stage  of the complaint is the
 occurrence of chordee, which consists in painful erections at night, with a twist
 in the body of the penis, which is usually curved down  towards the scrotum.
    These  symptoms usually continue for about a fortnight, when the third stage,
 that of subacute or  chronic inflammation,  sets in; during this period of the
 affection the inflammatory symptoms gradually subside, but a thin muco-puru-
 lent discharge keeps  up, with some degree  of  heat and irritation about the ure-
 thra, and occasional  smarting in  making water; under proper treatment this
 usually subsides in  the  course  of another fortnight or  three weeks; but it
 neglected, or in certain constitutions, it may last for many months, or even years,
 then degenerating into a gleet.   In proportion to the  continuance  ot the auc-
  tion the inflammatory symptoms subside, though the  specific and  contagious
  character does not disappear, and the infection may continue so long as the dis-
  charge keeps up.  Hunter mentions the case of a girl who had been two years
  in  the Magdalen Hospital,  and who infected a person with whom she had con-
  nection immediately after she left that institution.  The persistence of the con-
  tagion of gleet is, it is  true, more marked in women than in men.   So long
  however, as any discharge continues from the male urethra the patient must be
  looked upon as infectious.                                         , ,
    The severity and  the  continuance of gonorrhea  are often opposed to   one
  another.  Thus the disease is most severe in young and Pleth0"c persons   and
  in first attacks; but it is  most difficult of cure in brumous and phegmahc con-
  stitutions, more especially if there be a gouty or rheumatic tendency co-exu*.
  ing, and is very troublesome to remove after repeated attacks.  I have obsen ed 
868
DISEASES  OF  THE  URETHRA.
repeatedly that it is very apt to degenerate into a gleet in those people who are
subject to chronic diseases of the skin.
  The length of time that the infection of gleet will continue in both sexes, but
especially in  the female, makes it somewhat difficult to say whether the poison
of gonorrhea can be generated de novo, as it is not improbable that many indi-
viduals communicate the  disease, believing themselves to be perfectly cured,
though still suffering from slight gleet.
  The treatment of gonorrhea must be conducted with reference to the stage to
which the disease has attained, but  especially with regard to the amount of
inflammatory action accompanying it.  It is of two kinds, rational, and specific
or empirical.  Both plans are useful, and, indeed, usually necessary for a proper
cure, but they cannot be adopted indiscriminately.  Thus, if specific means are
employed during the  acute inflammatory stage of the complaint, much mischief
may ensue; whilst if antiphlogistic treatment is persevered in  for too long a
time, the disease may be kept up indefinitely.
  It has been proposed to adopt what has been termed the abortive or revulsive
treatment, during the  earliest stages of gonorrhea;  indeed, during the incu-
bative period.  This  method consists  either in the injection of a very strong
solution  of the nitrate  of silver  into  the urethra, or the application to the in-
flamed mucous membrane of a strong ointment of that salt by means of a bougie
smeared  with it; other surgeons, again, have  recommended  the administration
of very large doses of  copaiba at this period.  These various plans have, how-
ever, I think, deservedly fallen  into  disrepute.   I have on several  occasions
seen most intense inflammation excited by these modes of treatment, and never,
in any case,  any good result.  Independently of this, it is impossible to  know
whether the  case, in  the earliest stage, will prove to be one of simple urethritis
or a specific gonorrhea.
  In the acute inflammatory  stage, attended by heat, swelling of the organ,
great ardor urinae, and  abundant  muco-purulent discharge, the treatment must
be  entirely antiphlogistic, the activity of the  measures being proportioned to
the intensity of the inflammation.  If this be of a very severe character, leeches
may be applied to the perineum,  or to any very tender point along the urethra.
If not so intense, warm  hip-baths, poppy fomentations, or the envelopment of
the penis in warm-water  dressing, will be of  essential service.   At  the same
time the urine must be diluted, and its acidity lessened by the patient drinking
large quantities of alkaline diluents,— barley-water or linseed  tea  containing a
little nitre or carbonate of potass in  solution, or soda-water; and the skin and
bowels may be kept in  action by  tbe administration, every fourth or sixth hour,
of a powder  composed  of 3j of sulphate magnesia, 5 grains of nitre, and T1^th
of a grain of tartar emetic, dissolved  in a wine-glass of water.  All stimulants
must be  avoided, the diet  being  restricted to light slops, and perfect rest en-
joined.   By such means  as  these, the activity  of the inflammation will  be
gradually lessened, the discharge becoming thinner,  the smarting in making
water not so  severe, and the erections less painful.  The patient should also be
desired to pass his water frequently, so that it may not be too concentrated.
  When this the second stage of the  disease has  been reached, specific  treat-
ment may be employed with great advantage, which, if it were had recourse to
at an earlier  period, would certainly have increased the inflammatory action and
given the patient much distress.   At  the same time the specific remedies, such
as copaiba and cubebs, must be cautiously given, even in this stage; the surgeon
feeling his way with them, and being  prepared to discontinue  them and to
return to strictly antiphlogistic measures, if he finds that they increase the irri-
tation.   Should the disease, however,  from the commencement, have  assumed a
subacute character, the  specific treatment may with safety be adopted  at a much
earlier period.
  Copaiba and cubebs are the remedies that are almost universally had recourse 
TREATMENT  OF  GONORRHEA.
869
to in this stage of gonorrhea.  Of these copaiba is the least irritating, and con-
sequently most generally to be preferred.   It may be administered  in a variety
of ways, in capsule, pill, draught, or extract.  In  capsule it is  generally to be
preferred, on account of the nauseous taste being thus more readily disguised;
but in many cases it acts with more certainty, and with better  effect, if  given
in either of the other forms.  When the  capsules are given, the patient may
take from six to eight or ten in the day, and should at the same time have an
alkaline mixture, which increases materially the effect of the  drug.   A very
excellent  mode of administering copaiba  is  to  rub it  down into a  mass with
burnt magnesia, and to let the patient  take about jj of this paste  three  times
in a day, in  a bolus wrapped in wafer-paper;  or, if the taste is not  much ob-
jected to, he may take it most advantageously in mucilage,  with liquor potassae
and tincture of henbane.
   In some relaxed constitutions, and more  particularly after  frequent  claps,
cubebs will be found  to cure the  patient more readily than copaiba, or rather
most successfully, if given  in combination with it.   An excellent plan  is  to
put about half an ounce of the powdered  cubebs into a mortar, and to rub it up
with as much copaiba  as will form a stiff paste, of which  the  patient should
take 3j as a bolus thrice  daily.   The effects of this electuary are often  most
striking, but it can only be used  in the  constitutions indicated, and after the
more active inflammatory symptoms have  subsided.
   It is during  the second stage of gonorrhea  that  injections  may advantage-
ously be used.  Much and very unfounded prejudice exists against their  use in
the minds of many;  but  surely it is as safe to apply proper local applications
to an inflamed urethra as it is to an inflamed conjunctiva;  and  the bad  conse-
quences, such as a stricture and inflamed  testicle, which have  sometimes been
referred to their use,  have rather been due, either to the long continuance and
to the severity of the disease  itself, than to the remedies employed,  or to their
application at too early a stage,  or of too  great a strength.  It is in long  stand-
 ing cases of gonorrhea, in which  the  discharge continues for months or years,
 that stricture results, not in  cases of ordinary duration; and in these it is the
 result of  the chronic inflammatory thickening  of the mucous  membrane, and
 has no more to do with the  injections  than with  the copaiba or salines the
 patient may have taken.  As the ardor urinae subsides, emollient  and slightly
 astringent injections may be used.  The best are perhaps the acetate of lead in
 tepid water, of the strength of  two grains to the ounce.  If this induce irrita-
 tion, a few grains of the watery extract of opium may advantageously be added.
 As the disease subsides, a stronger astringent is required, and  then  one  or two
 grains of the acetate  of zinc may be added to each ounce of the injection; or
 a very weak solution  of the sulphate or chloride of  zinc  may be employed, gr.
 ij-of the first, and gr. £ of  the  second to each ounce of water;  or an injection
 of gr. i of the  nitrate of silver to the ounce may be used.  During the whole
 of this stage the diet  and  habits of life must be  carefully regulated, and all
 stimulants interdicted.  The injections  should be discontinued as soon  as the
 discharge has ceased; unless  this be done they may re-induce it.
    The mode of injection is of  importance.   A glass syringe should always be
 used, with a smooth, rounded nozzle.  The patient sitting on  the edge of the
 chair and holding up the  penis, should carefully insert the end of the syringe
 between  the lips of the urethra,  and then slowly throw in the injection as far
 as it will go.  Although the inflammation is usually confined to the anterior
 portion of the urethra, yet it may extend to the bulb, and the  injection  should
 be  applied to the whole length  of the  inflamed mucous  membrane.   If any
 enter the bladder it cannot signify, as it will immediately be  decomposed by
 the salts and mucus of the urine.
    In  the third stage of gonorrhea, that of gleet, much  difficulty will often be
 experienced in curing the patient of his discharge.   Here much depends  not 
870
DISEASES  OF  THE  URETHRA.
only on the administration of proper remedies, but in care being taken atten-
tively to regulate his habits of life.   It will constantly be found that after the
disease  has apparently been cured,  excesses at table, and more especially the
drinking of beer, effervescing or acid wines, will bring back the discharge.   So
also it will return  after connection,  though it had previously  ceased entirely
This is especially the case in those constitutions that are either  strumous, gouty
or rheumatic, and in which all urethral inflammations are with difficulty removed.
In these cases, then, abstinence from all stimulants, dietetic as well as alcoholic,
and improvement of the tone of the system by change of air, sea-bathing, &e.,
will often be of essential service.  At the  same time, the electuary of cubebs
and copaiba, or one composed of cubebs and the sesquioxide of iron, may be
administered with advantage.  In other cases again, especially in  relaxed con-
stitutions,  the  tincture of the  sesquichloride of iron, alone or conjoined with a
few drops  of spirits of  turpentine or tincture of lytta, will be found productive
of much advantage.
   In chronic gleets, local applications will be found to be necessary for the cure
of the disease.  Amongst these I have found none more useful than one com-
posed of ten grains of the chloride of zinc  and  one scruple  of gallic acid to
eight  ounces of water.   In some cases the nitrate of silver injections, of the
strength of half a grain, or the bichloride of mercury, in the proportion of a
quarter of a  grain to  the  ounce, will be  serviceable.  And  indeed in  most
instances it is beneficial to vary the injections, the mucous membrane appearing
to get  accustomed  to the  same stimulants  after a time, and thus not being
impressed  by it in  a proper manner,
   After the gleet has continued for some months, more benefit will often be
derived from the  introduction of a full-sized metallic bougie  every second or
third day  than by  any other local means, even where no stricture  exists.   The
instrument should  be left in for about ten minutes, and should be of the largest
size that the urethra will admit.

                 COMPLICATIONS OF  GONORRHEA.

    Gonorrhea when acute or virulent seldom runs its course without local com-
 plications  of some  kind, the result of  the  propagation of the inflammation to
 neighboring parts, often of  considerable severity, and occasionally even hazardous
 to life;—such as chordee, phymosis, sympathetic bubo, abscess in perineo, irri-
 tability of the bladder, retention of urine, hemorrhage from  the  urethra, &c.
 Many of these complications present no special features, but require to be treated
 on general principles,  without reference to their specific cause.  Others, again,
 demand more special management, and these we  may briefly consider here.
    The chordee, or painful  erection of the penis, with twist of the organ, coming
 on at night, is often a most distressing and troublesome symptom.  It is usually
 best relieved by the application of cold to the part, but more  especially by the
 administration at bed-time of  a pill  composed of  gr. j  of opium to gr. v of cam-
 phor, the camphor acting as a direct sedative to the generative organs.  Ricord
 recommends a suppository of camphor and opium, gr. x of camphor, and gr. j
 of the watery extract of opium, to be introduced into the rectum an hour before
 bed-time, as the best means of removing the tendency to chordee.
    The irritability of  the bladder with  spasm of the neck and dysuria may be
 of two kinds, either inflammatory, — coming on  in the earlier stages of the dis-
 ease with pain in  the  perineum, and  all the symptoms of active  inflammation
 about the part strongly marked; or atonic, — supervening at a more advanced
 period, without any special signs of inflammation.  In  the first case leeches to
 the perineum, hot poppy  fomentations, the warm bidet, with full doses of Do-
  ver's  powder, or  of henbane and  carbonate of potass or nitre, will probably
  afford much relief.  When the disease is atonic, the administration of the tine- 
SEQUENCES  OF  GONORRHEA—IMPOTENCE.       871
ture of the sesquichloride  of iron, conjoined with  local soothing remedies, as
the poppy fomentations or bidet, and an opiate suppository will be beneficial.
  In retention of unne from gonorrhea the obstruction is usually dependent on
a congested and inflammatory condition of the mucous  membrane of the ure-
thra.  In these  cases, leeches to the  perineum, the warm hip-bath, and opiate
suppositories will probably  afford relief.   It  is  always desirable to avoid using
the catheter, as it is apt to  lacerate the swollen  and softened mucous membrane
and thus to occasion  troublesome bleeding; and will always be productive of
much pain,  and of increased irritation  of the canal.   Should, however, the
retention  have  continued twenty-four hours, or longer, it may most probably
not give  way by the means above indicated, and then it will be necessary to use
the instrument, when  a full-sized silver one should be very carefully introduced ;
a large instrument entering the  bladder as easily and with less risk of injury to
the tender walls of the canal, than a  smaller one.
   When once the catheter has been introduced, it is often a somewhat  difficult
matter to determine whether it should be left in or taken  out.  If it is left in,
inflammatory action is increased.  If it is taken out, it may not be got in again.
 The solution to this question is to be found in the facility with which the instru-
 ment is passed.   If it has been introduced without much difficulty, it is better
 to withdraw it after the bladder has been emptied, and to continue the antiphlo-
 gistic treatment, when a second  introduction may not be required.  If, on  the
 other hand, the catheter has been passed with great difficulty, and is firmly
 grasped either by  spasm or stricture,  it should  be left in;  but very active treat-
 ment must be employed to prevent its exciting too much inflammation.
   It  must, however,  be  remembered  that the  retention may be due  to more
 serious  conditions than  this; to prostatitis, to abscess  in that gland, or in the
 perineum, or to inflammatory exudation  in  the tissues  about the neck of the
 bladder.  Under these circumstances, more active antiphlogistic measures will
 be required, with the use  of  the catheter twice in the  twenty-four hours, and
 probably free incisions into the perineum, if there be pus or  urine extravasated
 into that region.
   In many cases  also of gonorrheal retention, there is an old stricture as well
 as the clap.  Here the employment of energetic  antiphlogistic measures, with
 the use  of the catheter are indicated, but as the stricture is the chief  cause of
 obstruction the treatment must be directed to  it.
   Hemorrhage from  the urethra may occur either as the result of chordee, and
 consequent rupture of some blood-vessels of the mucous membrane, as  the con-
 sequence of attempts at passing the  catheter, or as  a kind  of exudation  from
 the mucous  membrane.   Most  commonly it may be arrested by the application
 of cold,  and the employment of moderate local antiphlogistic treatment.  Should
 it be abundant, pressure by means of a bandage to the penis or perineum, and
 the introduction of a large gum-elastic catheter will arrest it.

                     SEQUENCES  OF GONORRHEA.

   The sequences, or more remote complications  of gonorrhea, are partly local
 and partly constitutional.  Amongst the local, we find  more particularly warts
 about the prepuce and glans  or within the urethal  orifice, which require to be
 treated by excision or caustics;  and  stricture,  the management of which is fully
 described elsewhere.   In  some cases, also, in  consequence of extravasation of
 blood, or the effusion of plastic matter into tbe corpus spongiosum or the corpora
 cavernosa, limited and localized  induration and  thickening of the penis  may
 result,  attended by  chordee, painful erections, and a permanent twist in^the
 organ   In such  conditions as  these absorption  of  the effused mass may be
 attempted by the administration of small doses of the  bichloride of mercury;
 with the inunction of the iodide of lead ointment. 
872
DISEASES  OF  THE URETHRA.
  After the cure of a clap that has  been  of long continuance, the generative
organs are often left in a weak and irritable state; the penis, scrotum, and sper-
matic cords  being lax and elongated,  with an apparent want* of power, and often
painful and  dragging sensations about the cords and groins.  In some  of  these
cases the patient loses the power of erection, emission taking place before erec-
tion, and thus preventing proper connection.  In other instances, again, erection
of the penis takes place, but is immediately followed by emission;  and in some
cases, although erection occur, the expulsive power  seems to be  lost, and the
semen, though escaping through the  ejaculatory ducts, is  not  properly ejected,
but either flows back into the bladder,  or slowly escapes after the  erection has
gone down.   Besides these various morbid  states, nocturnal emissions are com-
mon, especially after slight derangement  of the digestive organs and of the
nervous system; and viscid prostatic fluid is not uncommonly squeezed out after
the escape of  the urine, or during defecation.   These various morbid conditions
are commonly confounded with spermatorrhea, which they closely resemble, and
constitute different forms of impotence.   They require  careful  consideration on
the part of  the surgeon, as  their existence is a source  of the greatest mental
depression and distress to the sufferer;  certainly one cause of conjugal infidelity,
and occasionally, I believe, of  suicide.   These affections, which are of extreme
frequency amongst  all  classes of the community, have scarcely as yet received
that  attention on  the  part  of the profession  generally that  their importance
deserves, and the unfortunate sufferers  from them are too often driven into the
hands of those pestilent quacks that  flourish  in the  metropolis, and now infest
almost every town in the country, and by whom they are not unfrequently ruined
in health as well as in purse.
   These various forms  of impotence, of spermatorrhea, of debility of the genera-
tive organs, or by whatever  other name  the  condition  may go, are frequently
difficult of  cure, on account of the ready way in which  they are influenced by
moral causes; and the hypochondriacal  state into which a patient laboring under
them usually falls,  makes it of much  importance to speak cheerfully, to hold out
hopes of a  speedy recovery, and to endeavor to divert the  patient's mind from
dwelling constantly on his infirmity.  He should also be cautioned not to attempt
to  have connection during treatment,  lest  the occurrence of  failure should
dispirit and depress him still more.
   The curative treatment of these cases should consist in giving tone to, and in
lessening the irritability of the genito-urinary  organs.   The first object  is  ob-
tained by the administration of tbe tincture of the  sesquichloride of iron, but
more especially by the  habitual daily use of the cold hip-bath.  This the patient
should use  every night and  morning, remaining in  it,  at first, for about three
minutes, but gradually increasing the  time of immersion to ten or fifteen.   In
 some cases, the cold shower-bath appears to give more tone, and then should  be
 preferred.  These means, useful as adjuncts, will not however cure the patient.
 For this purpose, the local irritability must be  removed, by the application  of
 the nitrate  of  silver to the prostatic  and bulbous portions of  the  urethra.   It
 will usually be found that there is a  good deal of tenderness in these situations,
 felt by pressing upon the perineum, or bypassing an instrument into the urethra,
 when, as the point enters the bulb, the patient will usually suffer much pain.
 The continuance of this irritation certainly keeps up  the nocturnal emissions,
 and thus maintains the debility of the  genital organs, and the  nervous  irrita-
 tability that  is so characteristic of these cases.  It may most  effectually  be
 remedied by the application of the nitrate  of silver, as originally recommended
 by Lallemand; and if this  is done  in a proper manner, a cure will  usually be
 accomplished.   Of late years I have employed, with much advantage in such
 cases, the instrument here figured (fig. 341).   It consists of a silver catheter,
 having about a dozen minute  apertures  near the end.   In  the interior is con-
 tained a slender piece of sponge, about two inches long, fixed  to the  expanded 
SEQUENCES  OF  GONORRHEA.               873
end of a firm stylet that moves within the catheter.  The. instrument is charged
by filling the sponge with some solution of the nitrate of silver by withdrawing
the stylet.   It may then  be well oiled, and being passed down to the spot to be
Fig. 341.
cauterized, the solution is forced out of the aperture, by pushing down the rod,
which compresses the sponge.   I have found this syringe-catheter far safer and
more manageable than Lallemand's or any other porte-caustics that  act by pro-
truding a spoon or sponge, which is apt to be grasped by the spasmodic action
of the muscles of the part, often being returned with difficulty into the shaft,
and not without  risk of lacerating  the  mucous membrane.  I generally use a
solution of the strength of 3j  of the nitrate to  an ounce  of  water, though
sometimes only a half,  or a third of this strength can be borne.   The applica-
tion  usually occasions  a good  deal of irritation  for a time, sometimes even a
muco-purulent discharge, and can only be repeated at intervals of from ten days
to a fortnight.  Any undue amount of irritation  must be  subdued by ordinary
antiphlogistic treatment.
   Besides  these  strictly  local  complications  of gonorrhea,  a certain  set of
sequences to which some constitutions are especially liable, occasionally occurs
as the result of  this disease, viz., inflammation of  the testes and of the eyes,
rheumatism, cutaneous eruptions, and sore throat.  Some of these, as the affec-
tions of the eyes  and testes, may either be local or constitutional; the others are
clearly constitutional.
   Gonorrheal infiammation of the testis, is certainly the most common of these
sequences.  It almost invariably affects only one testis, and commences in the
epididymis, whence it extends to the body of the organ.  It usually occurs in
those individuals who have a lax and long scrotum, with very pendulous testes.
It seldom sets in before the third  week after the occurrence of the gonorrhea,
but may occur at any period during the continuance of the discharge, though it
is more frequent between the fifth  and sixth weeks than at any other time.   In
 cases  of gleet, also, it not uncommonly odours at a  later period.  In many
 instances it is referred to  some slight  injury— a blow,  or squeeze,  received
 during the continuance of the gonorrhea;  but, in other cases, it would appear
 to arise from extension of the inflammation along the ejaculatory duct; and in
 others, again, to  a kind  of  metastasis of the morbid action from the urethra to
 the  testis.   The  fact  of  the disease commencing in the epididymis  may be
 advanced  in support  of the  first  opinion;  whilst the fact that the discharge
 usually ceases when the inflammation of the testicle  comes on, and returns as
 it subsides, may be adduced in support of the doctrine of its metastatic origin.
 As the symptoms and treatment of gonorrheal inflammation of the testicle pre-
 sent nothing peculiar, I shall reserve their consideration until we come to speaK
 of diseases of this organ.                                          ___«„„,„.
   Gonorrheal infiammation of the eyes is fortunately not of very common occur-
 rence.  It may affect either the conjunctiva or the sclerotic.
   Gonorrheal conjunctivitis is one of the most destructive forms of ophthalmia,
 givin- rise, not  unfrequently in  the course of forty-eight hours,  to  the most
 fntense chemosis, with opacity and softening of thecornea,followedhj■Btaphy-
 loma and a discharge of the humors.  In the majority  of instances only one 
874
DISEASES OF  THE  URETHRA.
        eye is affected, but in some, both are involved to an equal extent.  The disease
        commences with the ordinary symptoms of conjunctival  inflammation;  itching
        and swelling of the eyelids, velvetty redness of the conjunctiva, muco-purulent
        discharge, with much lachrymation.  The chemosis sets in early, and  is of a
        very  severe  character, and  unless treatment affords speedy relief, the conse-
        quences are most disastrous  to vision.  Lawrence  states, that  of 14 cases that
        fell under his observation, 9  had only one eye affected, and 5 both.  Of the 9 in
        whom one eye only was diseased, the organ was lost in 6 cases;  of the 5 in whom
        both  eyes were affected, both organs were destroyed in one  case; in 2 one eye
        only  was lost; one patient recovered imperfectly,  and in only one did complete
i        recovery ensue.
           It has been a question with surgeons whether gonorrheal ophthalmia is the
         result of the direct application of the specific pus to the conjunctiva, or occurs
         as a  constitutional disorder.   There  can  be little doubt that the  application of
         the pus to the surface of the conjunctiva might occasion the disease, but at the
         same time it is perfectly  certain that in many instances there is no evidence of
         contact; the inflammation occurring in both  eyes without the patient having
         apparently communicated it;  and though it is necessarily difficult to adduce
         positive proof on this point, it is but reasonable to presume that such cases may
 ;        be constitutional.
            The  treatment of this dangerous affection must be  of an  active character;
         blood should be taken freely from the temples  by  cupping, or if the  patient is
         sufficiently robust, from  the arm, as strongly recommended by Lawrence, who
         places great reliance on it;  he must of course be kept in a dark  room, and on a
         strict antiphlogistic regimen.   The disease must,  however, be met, and the eye
         can  alone be  saved  by active  local treatment.   The most active topical agent
         that we possess is the nitrate of  silver.   The use of this  astringent, originally
         introduced  by Littell, has been much insisted  on by Guthrie, Walker, and
         others, and is generally  adopted  at the  present day, being certainly the  most
         useful  agent that we possess.   Surgeons differ somewhat  in opinion as to the
         strength  of the application ;  some, the Germans especially, advise that the solid
          stick should be used, whilst others employ it  in solution, of  the strength of a
          drachm to the ounce of  distilled water;  Mr. Wharton Jones employs a weaker
          solution, one of four or five grains to the ounce, and I have seen cases very suc-
          cessfully treated by this  plan; so much  so, indeed, that I should be disposed in
          future to adopt it in preference to the stronger solution.  A  few drops must be
          introduced  about twice  in the twenty-four hours, into the inner canthus of the
i          eye; the lids  between times being kept covered  by compresses  dipped in weak
          alum  lotion, and  the purulent discharge carefully washed away as  it accumu-
          lates,  by the employment of tepid alum injections.   In doing this, great care
          must be  taken that none of the discharges come in contact with the eyes of the
          surgeon or nurses, as it  is of a  highly contagious character, and will  almost to
          a certainty reproduce the same  disease; and  instances are recorded in which,
          in  this way, the  attendant's vision has been  destroyed.   If the chemosis be
          considerable, it must be incised, and  as the inflammation subsides, belladonna
          lotions may be employed with advantage, and the use  of the  nitrate of silver
          gradually discontinued.
             Gonorrheal sclerotitis is by  no means of such frequent occurrence as  the
          conjunctival  inflammation; when it happens it  will commonly be found  to be
          associated  with  gonorrheal rheumatism, and  not unfrequently with inflamma-
          tion of the testicle, occurring apparently in those individuals in whom there is
          a tendency to affection of the fibrous tissues.   This disease is evidently of con-
          stitutional  origin, as it cannot possibly arise from local contagion;  it is attended
          by  the ordinary signs of sclerotic inflammation, and is usually accompanied by
          some  degree of iritis.   In the  treatment there is nothing very  peculiar, cup-
          ping  or leeches to the  temples, with  belladonna  fomentations, are the principal 
GONORRHEA  IN  WOMEN.
875
local means, and calomel and opium, continued until the gums are affected, con-
stitute the chief elements of the practice to be pursued, and must be persevered
in until  the anterior chamber clears, and  any effused lymph is  absorbed.  As
the disease declines, and especially if the  patient is somewhat debilitated, soda,
rhubarb and bark in powder may be given internally, and blisters kept open on
the temples.
   Inflammation of the nose, attended by profuse suppuration, is a complication
that I have more than once had occasion to observe in gonorrhea.  The swel-
ling of the organ is_ considerable,  the tenderness great, and the discharge abun-
dant; a condition, indeed, of  the Schneiderian membrane that seems analogous
to the inflammation of the conjunctiva just described.   The treatment that I
have found succeed best consists in fomentations followed  by astringent lotions
or injections.
   Gonorrheal  rheumatism principally  occurs  in young, florid, and  otherwise
healthy men.   It is of two  kinds; in one, the most common, and indeed the
typical variety, the fibrous and muscular structures are affected; in the other,
the  joints are implicated.  The fibrous or muscular form of rheumatism is not
infrequently associated with inflammation  of  the testicle or the sclerotic.  It
commonly affects the fleshy parts of the body, as the hips, the shoulders, and
the  thighs, and not infrequently occurs in the soles  of the feet.  It is  always
 painful at night, but is not commonly attended by any very severe constitutional
 disturbance.  The synovial form presents the ordinary characters of rheumatism
 of the joints, the knees and ankles being those chiefly involved.  In the treat-
 ment of these affections, calomel and opium, or Dover's powder with colchicum,
 must constitute the most  important elements  until the acute stage  is passed,
 when the iodide of potass may be advantageously given.
   Cutaneous eruptions  chiefly consisting of roseola,  with slight pityriasis, and
 perhaps a few patches of psoriasis with very flimsy scales, occasionally occur in
 rather severe cases  of gonorrhea,  usually appearing from six  weeks to three
 months after the commencement of the attack.  They are chiefly diffused about
 the chest and  belly, and present no sign  of coppery redness.   At the time of
 their occurrence, the fauces  commonly become similarly involved, presenting,
 as was first pointed out by Travers, a diffused  superficial redness on  the velum
 palati and pillars, with perhaps superficial ulceration on these, the tonsils or the
 uvula.  The occurrence of these affections is usually preceded by slight febrile
 action, which, however, subsides on their full evolution.   Those roseolar erup-
 tions, occurring  during  gonorrhea, have  occasionally been attributed  to some
peculiar influence exercised  by the copaiba, but I think not on  sufficient evi-
 dence.   I am not aware that copaiba, when administered for other diseases than
 gonorrhea, ever produces such eruptions,  and  they will occur, as I have seen in
 several instances, when  no copaiba is being given.  The treatment of these
 affections should consist in the administration of salines, followed by the iodide
 of potass  in small doses.   Mercurials are never required.
   Gonorrhea in the female differs from the same affection in the male in not
 being so  severe, though it is usually more extensive, and of longer duration.
 The severity is less, on account of the shortness of the female urethra preventing
 the occurrence of the retention of urine as in the male, and also from the absence
 of such parts as  the prostate, testes, &c, the implication  of which constitutes
 the principal source of difficulty in men.   Gonorrhea in  the female  may affect
 the part  to very different degrees; thus the vulva alone may be implicated, or,
 as most commonly happens, the  inflammation  may spread to the whole of the
 mucous membrane of the vagina.   The  urethra is less commonly the  seat of
 disease, though occasionally implicated  with other parts; and, lastly, the  interior
 of the uterus may become affected by this specific inflammation.  In some cases
even, it will spread along the Fallopian tubes to the  ovaries, and I have known 
876
DISEASES OF THE URETHRA.
one or two cases in which  rather acute attacks of peritonitis, probably induced
in this way, have complicated this disease.
   The symptoms  of gonorrhea in women are sufficiently well  marked  in the
early stages, where there is an abundant muco-purulent discharge from the parts
affected, with  a good deal of inflammatory irritation about them, accompanied
with pain in micturition, and a frequent  desire to  pass water.  As the disease
becomes chronic, however, it is more difficult to determine its true character; it
being apt to be confounded with some of those accidental and  leucorrheal dis-
charges to which females of all ages are subject.
   In the majority of cases, gonorrhea may be distinguished from all other muco-
purulent discharges  of the female organs by the presence of inflammation about
the external parts, the mucous membrane of the vagina and urethra.   In these
cases  it  will be found, on introducing a speculum, which, however, occasions
considerable pain, and is firmly grasped by the contraction of the vagina, that
the discharge  comes from the wall of  this canal, and that the uterine orifice is
free or nearly so from it;  whereas, in  leucorrhea  the discharge proceeds in a
great  measure from the interior of the  uterus, the os and cervix  of which would
probably also present signs of diseased action.   It must, however, be borne in
mind  that the discharge in gonorrhea may occasionally be  in a great  degree
uterine;  and that that of leucorrhea  may be  an exudation  from the  mucous
membrane  of  the vagina.   Under such circumstances, when  the  disease  is
chronic, it is almost  impossible to arrive at a correct conclusion as  to the nature
of the case from simple inspection;  and in these cases of doubt, the surgeon had
better give a very guarded opinion, lest he be led into the error of inculpating
an innocent woman.   The difficulty is  increased, and a good  deal of obscurity
thrown over the  case by the fact  that leucorrheal discharges will occasionally
give rise to  urethritis in the male, which closely simulates gonorrhea.  Children
also are occasionally  subject to an acute inflammation of the vagina and nymphae
as the result of simple irritation, of constitutional  disturbance,  or of teething;
these  cases require to be recognized, as they have frequently  been the cause of
unfounded accusations.
   The treatment of  gonorrhea in the female  must vary according as  the disease
is acute or chronic.  In the acute stages,  general and local antiphlogistic means
must  be had recourse to—salines,  low diet, rest  in bed, and  emollient sedative
fomentations.   As the disease subsides into a chronic condition, astringent injec-
tions must  be  employed; a weak solution of the acetate of  lead,  or the liquor
aluminis comp. largely diluted with tepid water,  being  especially useful.  In
other cases again, a weak solution of the nitrate  of silver  may be  used with
much  advantage.  These injections should be employed three or four times a
day, and in large  quantity.   After they  have  been thrown  up, a piece of lint
well soaked in the lotion should be introduced between the opposed mucous sur-
faces, so as to  prevent  their coming into apposition, the discharge  being in a
great measure kept up by their friction against one another.   In order that the
injection be properly given, the woman should lie flat upon her back, and pump
in the fluid by means of one  of  Kennedy's elastic bottles.  In the treatment of
gonorrhea in women, specifics are of no use unless the urethra be affected, when
copaiba may be given, as in the male.   The disease is apt to degenerate into a
chronic,  gleety condition, leaving a thin, muco-puriform discharge, which will
continue to  be infectious for a great length of time.

                  STRICTURE  OF  THE  URETHRA.

   Much discrepancy of opinion has for a long time existed as to the structure
of  the urethra,  some  surgeons admitting, others  denying its muscularity.
Though  the presence of muscular fibres in the urethra had been  suspected by
many in consequence of the phenomena  presented by some  forms of stricture 
STRICTURE.
877
bein"- solely explicable in this way, it is only very recently that their existence
has been  demonstrated; Kblliker and Hancock  having shown that the tube is
surrounded through its entire length with an organic muscular coat.   Hancock
has demonstrated the course of these  fibres.  He has pointed out that the fibres
of the inner layer of the muscular coat of the bladder pass forwards underneath
the mucous membrane of  the prostatic  portion of  the urethra, and those from
the outer layer of the muscular  coat of the bladder outside the prostate.   These
two layers join at the membranous portion of the urethra, forming the muscular
covering of this portion  of the canal.   At the bulb these two layers divide again,
the inner, lying underneath the mucous membrane, separated from it merely by
cellular tissue; the external, lying outside  the corpus spongiosum,  between it
and its fibrous investment; at  the anterior  extremity of the urethra they unite
ao-ain  and form its lips.   Thus  the  urethra is surrounded through its whole
 leno-th by muscular fibres, a double layer of which invests it at the membranous
 portion, and again at the external meatus.   The prostate and corpus spongiosum
 are included between planes of these fibres.   The vesicles and ducts of the pros-
 tate are  surrounded by layers  of organic fibre; those of the ejaculatory ducts
 combo- from  the organic  layer  of the vas deferens.   These fibres are totally
 distinct from  the common muscular apparatus of the perineum, and their exist-
 ence proves the urethra to be, what had often been suspected, a musculo-mem-
 branous canal.
    By stricture of the urethra  is  meant a narrowing of the canal at one or more
 points.  This  may proceed from three distinct conditions; viz: — 1st, spasmodic
 action of the  layer of the organic  muscular fibres situated  outside the mucous
 membrane; 2d,  congestion of the  mucous membrane  of the  canal; or,  3d,
 oro-anic changes in the mucous and submucous tissues, consisting of thickening,
 induration, or the deposit of plastic matter within them.  According as  the
 disease arises from one or other  of these causes it may be termed a spasmodic, a
 congestive, or an organic stricture.   These  different forms of the disease having
 the one condition, narrowing of the  urethra, and  its  consequences  in  common,
 and in practice being often associated together, present so much variety in their
 symptoms, in the treatment they require, and in the constitutions in which they
 occur, as to require separate description.
    1st.  Spasmodic  stricture. —The  existence of this form of the disease has
 been  much cavilled at; surgeons disregarding the evidence of their own senses,
  and being led away  by an imperfect  anatomical examination of  the urethra,
  denied  the possibility  of spasm of this canal, not being able to demonstrate the
  existence of  any muscular fibres in sufficiently close proximity to the mucous
  membrane to influence it by their action.  The possession of muscular contrac-
  tility by the  urethra is, however, obvious from the facts that a bougie may occa-
  sionally be introduced with sufficient ease, but that the  surgeon  on attempting
  to withdraw  it, will find it tightly grasped :  so also occasionally on inking
  the instrument he will feel it  meet with an obstruction which on steady pressure
  will yield with that species of quivering that is  peculiar to spasm of muscular
  fibre   Then again, the fact that a patient would at one time pass his urine with
  the most perfect freedom, whilst if it  were rendered acrid or acid by drinking
  spirits  effervescent wines, or other similar beverages, almost complete obstruo-
  Znl^ZZe, tends to prove the ^"g"™^*?^*™
  striction of the canal.  These facts, though sufficiently convincngto many sur-
  geons had failed to carry proof of the existence of spasmodic stricture to others
  until Me recent  researches of Kblliker and Hancock, which  have above been
  referred to,  set the question of the  muscularity of the urethra fina ly^ at rest
     In spasmodic stricture we  find evidence of narrowing ^^^^/^
   sequel impediment  to  the  ^ ^^™^y ^^U^n^
   influence of certain causes, and as  speedily subsidy,  a p     ,           »
   in his ordinary health, and  passing water freely, may, if he take such loou 
878               DISEASES  OF  THE URETHRA.
drink as will give rise to a very acid condition of his urine, if he be exposed to
cold, or get out of health in any way, suddenly find himself able only to pass his
water in a small stream by drops  with much straining, or may even be seized
with complete retention.  Under appropriate treatment these symptoms rapidly
subside, recurring, however, on the application of any exciting cause.  At  the
time of the occurrence of this spasm there is often a sensation of weight and  un-
easiness in the perineum, with  evident irritation of the urethral  mucous mem-
brane, as  shown by reddening  of the lips of the orifice: in fact, a tendency to
a combination of the congestive  with the  spasmodic form of stricture.   The
causes of spasmodic stricture are usually such conditions as occasion a relaxed
and  irritable  state of system, as long residence in hot climates, more especially
if conjoined with habitual excesses in drinking, high living, and venereal indul-
gences. The more immediate causes are usually any circumstances that occasion
irritation  of the urethral mucous membrane, which,  being propagated to  the
organic muscular fibres  beneath, calls them into activity and thus gives rise to
the spasmodic affection.  The  most usual of these are those conditions of  the
system in which the lithates are largely eliminated, as exposure to cold and wet,
by which  the action of the skin is suspended, too free an indulgence in spirituous
and  acid  liquors, — such as red or effervescent wines, beer, or punch, — which
are well known to give  rise to an attack in many constitutions.
   Treatment of spasmodic stricture. — If the patient is suffering from spasmodic
difficulty in making water, a  suppository,  consisting of 3j of laudanum in  a
little starch, should  be  thrown up the rectum,  the warm hip-bath used, and a
full  dose  of Dover's  powder administered.   As the opium begins to take effect,
the urine will usually be passed  without much difficulty.   The bowels should
then be made to act, when the patient will usually be relieved.   If  the spasm
continue, as it often does,  for some days  or  weeks after this, a full-sized wax
bougie should be introduced every second or third day, in order to  lessen  the
irritability of the urethra.  In some  cases this is more effectually done by the
use of a plated bougie,  well warmed and oiled.   Whatever  instrument is used
should be of large size,  from No.  8 to 10. A small bougie will often be arrested
and will create much irritation when a large one will pass readily.  If the  use
of the instrument causes irritation and increase of spasm, it is better  to omit  it
entirely, and to trust to constitutional treatment.  But  the surgeon must  not
be  discouraged  if the  first few introductions of the bougie appear to increase
the irritation; as the urethra becomes accustomed to the use of the instrument,
relaxation of the spasm  will take place.   At the  same  time  the  patient's
general health should be carefully attended to;  the bowels must be  kept open,
and  the  diet regulated;  all  acids,  stimulants  and  sweets,  being  carefully
avoided.  During the time that the bougie is being used, he should take, three
times a day, a draught, composed of twenty minims of liquor potassae, with the
same quantity of tincture of henbane and sweet spirits of nitre in camphor julep.
   As a preventive  treatment of  these  attacks, a careful regulation of the diet,
warm clothing, with the use of flannel, and keeping the skin in action by means
of horsehair gloves and tepid baths, will be found serviceable.
   2d.  Congestive  stricture---Many surgeons look upon spasmodic strictures  as
essentially dependent on congestion of the mucous membrane of the urethra,
overlooking altogether  the existence  of spasm, or considering it as the result
 of irritation of the perineal muscles, and not of the true organic muscles of the
 canal.  That the two conditions of congestion  and spasm are frequently asso-
 ciated in the urethra, in the relation of cause and effect, there can be no doubt;
and this is  the most frequent condition in which spasmodic strictures  are found.
 Indeed, congestion plays an important part in all forms of stricture;  it may, as
 we have just seen, be connected with the spasmodic variety, it may occur alone,
or it may be associated  with organic stricture. Some parts of the urethra appear
 to be more  subject to congestion  than others;  thus, for instance, the membra- 
CONGESTIVE  AND ORGANIC  STRICTURES.       879
nous and prostatic  portions, especially the folds of mucous membrane consti-
tuting the verumontanum, are peculiarly liable to become congested.
  Congestive  strictures frequently occur  as  the  result of chronic and long-
continued inflammation of the urethra, or of the passage of urine that has been
rendered irritating by being too concentrated., or by an  admixture of an undue
proportion  of lithates.  It is especially in gouty or rheumatic subjects who
suffer from irritability of the skin and mucous membranes that this condition
occurs.   In these cases there is no true or permanent obstruction, but the
disease is transitory, and solely due to a swollen state of the membrane of the
part.
   In congestive stricture we  not only find the common symptoms occasioned
by an impediment to the free passage of the urine; but some swelling of the
lips of the urethra with reddening and eversion of them.   There is also_ slight
gleety exudation, and not unfrequently an abundant puriform discharge, in fact
 urethritis of a marked kind, with a sense of weight  or fulness in the perineum,
 pain in micturition, and sometimes uneasiness in defecation.  This state of things
 constitutes a very troublesome affection, intimately connected with the various
 forms of urethritis, and exceedingly  apt to relapse from apparently very trivial
 circumstances, slight errors of diet, dyspeptic derangements, or any local sources
 of irritation.
    The treatment in these cases should consist in  careful regulation of the diet
 and habits of life, and  especially in the administration  of the alkaline  and seda-
 tive mixture above  indicated in combination with small doses of  copaiba.   In
 many cases a course of Plummer's pill, in conjunction with the compound de-
 coction of aloes, will be found of essential service.  If there is much tenderness
 or weight about the perineum, the  application of leeches to this part, together
 with the use of the warm hip-bath, will be serviceable.
    Con»-estive  strictures, though more  influenced by  constitutional than local
 means"in many  cases,  yet require  the  introduction  of bougies  in  order  to
 prevent the constriction becoming  permanent.  In some instances  a wax, in
 other a silver or pewter instrument, will be found  to  answer best.   Whatever
 is used, care should be taken  to introduce it slowly and  with every possible
 gentleness.   With all  care some hemorrhage usually follows the passage of  the
  instrument, not from laceration, but simply as the result of compression of  the
  mucous membrane, and  the discharge of which appears rather to be beneficial
  than otherwise.                                .   ,       ,,  „,       ,.    i
    3d. Organic stricture.-This form of stricture is the result of long-continued
  inflammation of the urethra, or of some injury to the  canal from blows or kicks
  in the perineum  by  which a portion of it is destroyed or  sloughs  away
  Repeated gonorrheas and long-continued gleets  are the most fertile causes of
  this disease.   In  the  urethra as elsewhere, plastic matter is deposited in  and
  around the mucous membrane, as the result of inflammation; consolidation of
  this takes place, followed by contraction of the canal.   The long continuance of
  inflammation is more to be dreaded than its  intensity in occasioning thisjns-
  chief; hence it is of great importance, not to allow gleets to run on indefinitely
  as they will almost to  a certainty be followed by constriction of some portion of

  thThelL" of organic stricture varies  considerably, indeed  any portion of the
  urethra may be  affected by it,  except the prostatic  ^P™£^^
  mon belief amongst surgeons, that the membranous poruou u
  most  frequently affected by ** ^'J^^S^ 9   spti   en
  doubt, is an erroneous opinion.  Mr. Henry Smith has exaniinea »   P
  of stricture contained in the different London muse™;f^hese he foun  on y
  21 seated in the membranous portion of the urethra,  whilst , / were anterio^o
  the triangular ligament; the  majority of  these  being either inr*e bulbous
  portion of the urethra, or a little in advance of  this.  Mr. Henry lhompson, 
880
DISEASES  OF  THE  URETHRA.
in his excellent work on Stricture, states  as  the  result of his numerous obser-
vations, that stricture is more frequently met with at the junction of the spongy
and membranous  portions of the urethra, next, about one inch anterior to this,
and most rarely, so far back as the membranous portion itself; lastly, he states,
" I can confidently assert that there is not a single case of stricture in the pros-
tatic portion of the urethra to be found in  any one of the public  museums of
London, Edinburgh, or Paris."   Not unfrequently strictures are met with at
the mouth of the  urethra, and occasionally they are multiple, two very frequently
occurring, and  sometimes  as  many as four  or five.  When  there  are several
strictures, one will always  be found at the bulb or in the membranous portion
of the urethra.
   The characters of organic stricture vary greatly;  in some cases it is annular,
encircling the  whole of the  canal, and  occasionally  for  some little  distance.
These elongated annular strictures usually arise from consolidation of the corpus
spongiosum by plastic matter compressing the urethra, as in fig.  343.  In other
cases  again, annular strictures may be  narrow and  sharp-edged, and  are then
called  pack-thread or bridle  strictures;  consisting  of  bands stretching across
the urethra (fig. 312).  Sometimes there are several of  these in  close proximity
Fig. 342.                 Fia. 343.               Fig. 344.
to one another, leaving merely narrow passages between or under them.  These
bands occasionally stretch directly across the canal, but at other times and more
commonly they take a somewhat oblique direction  (fig. 344).   It is  not very
clear how these bridles or frena  stretching across the urethra are formed.   It
can scarcely be by the effusion of plastic matter; it is more probable that they
are occasioned by a valvular projection of the mucous membrane  which has
been perforated, perhaps by the  point of .the catheter, and thus apertures pro-
duced in it.   These various kinds  of  organic stricture  are  hard and elastic,
sometimes, when old, almost cartilaginous in their density, feeling  gristly and
rough to the instrument that passes over them.
   The amount of constriction varies greatly in  organic stricture, from merely
slight narrowing of the channel to almost complete obstruction of it.  A question
has arisen whether the canal of the urethra is  ever rendered completely imper-
meable by a stricture.  In answering this, it is necessary to be agreed  upon the
meaning of the term " impermeable."   If by it is meant impenetrable to the 
SYMPTOMS  OF  ORGANIC  STRICTURE.           881
passage of a catheter, there can be no doubt that such strictures may occasionally,
though very rarely, occur, the  channel being so narrow, oblique, or tortuous,
that the instrument cannot be  passed through it.   Strictures, however, of this
description, may usually be ultimately made  permeable to instruments by proper
and careful treatment.   If by " impermeable" is meant generally impervious to
the passage of urine, there can  be no doubt that such a condition does not exist.
It would clearly be  incompatible with life, unless a fistulous opening existed
behind the stricture, through which the urine might pass out; and, even with
such an  aperture existing, I have  never heard of, or seen a case in which  no
urine whatever  escaped  by the meatus,  unless in  consequence  of injury or
 disease a portion of the  whole calibre  of the urethra had sloughed away; and
 it is clear that so long as any passes out in this way, a stricture cannot be looked
 upon as truly  impermeable.
   When  an  organic stricture  is once  formed, it will continue unless removed
 by surgical means, and  as it usually becomes more  closely contracted, it will
 offer an increasing  obstacle to the free flow of  the urine, and thus eventually
 tend to give rise to important  structural changes in the urinary apparatus.
   The urethra behind it becomes increased in diameter, sometimes dilated into
 a true  pouch, in which  sabulous masses, and even small calculous concretions
 occasionally  collect.   The bladder,  subjected to increased pressure by the
 necessity of  overcoming the  obstacle  to the passage of the urine,  becomes
 thickened and fasciculated, the ureters are  often found dilated, from a tendency
 to a reflux of the urine, or  to  compression  of  their vesical orifices, in  conse-
 quence of the altered structure of  the bladder.  The kidneys become irritated,
 congested, and at last the seat of some of those various structural changes that,
 by impairing their functions, and interfering with the  proper depuration of the
 blood, may eventually destroy the patient.
    Symptoms of organic stricture. — It is  surprising how much constitutional
 irritation is  set up in some  systems by a  stricture, even  though it be not very
 tio-ht.  The interference with the free flow of the urine causes irritation of the
 bladder and  kidneys, the secretion  from  which becomes less abundant  than
 usual; in consequence  of this, the actions of the  skin,  and other depurative
 organs, are deranged, and thus the system  at large is influenced and suffers.
    The local signs of stricture  are always well marked, and are very unequivocal.
 The disease usually commences with the retention of a few drops of urine after
 evacuation of the contents of the bladder.   The patient finds that he has to
 make water  more  frequently  than usual, particularly  at  night;  there is some
 straining, perhaps a slight gleety discharge, and a  feeling  of weakness about
 the genital organs.   The stream of urine has changes impressed upon it during
 its passage through the  stricture, by which  its shape and direction are modified ;
 thus,  it may become  forked,  scattered, twisted,  fan-like, or be discharged m a
 double  current —one projecting directly forwards, the other dropping perpen-
 dicularly downwards.   As the  disease  advances, these  symptoms necessarily
 become  more marked,  until they may terminate in  complete retention; they,
 however, often come on in a very insidious manner, and when the patient seeks
  advice he is found to  be already the subject of a very tight fnd intractable
  stricture; indeed, in some cases, the first circumstance that directs the attention
  of the patient to his complaint is  the  sudden occurrence of retention of urine
    The  existence of stricture can, however, only be  determined with certa nty
  by the introduction of an instrument down the urethra.  In  exploringth  canal
  in a suspected case, two points have to oe  ascertained-the exl^«e,5pram^neC-
  ture, and its  degree of tightness. The existence of a stricture is best determmed
  by passing a plated steel sound, or a silver catheter of medium size about No 8,
  wellTueJ anPd warmed.  This'will  readily pass so far as the ^str^d ^
  but then be  arrested.   In this exploration  too small an instrumen tmust^ ot be
  used, lest it hitch in the fossae of the urethra or against the verumontanum, and
         56 
882
DISEASES  OF TnE URETHRA.
this accidental arrest be mistaken for the obstruction produced by the stricture;
or it  might pass through the stricture, and thus mislead  the surgeon.   The
existence of a stricture having been ascertained, the next point is to determine
its degree  of tightness.   This is best done by  withdrawing  the  instrument
previously  used, and then introducing a  smaller  one  about the size of the
stream of water that the patient  makes.   If this fail to enter the  stricture, a
smaller one still must be used, until  that size is  reached, which  can be intro-
duced with but  a moderate degree  of force.   In this way the existence, the seat
and degree of tightness of the stricture, are ascertained.  The  tact of an expe-
rienced surgeon will also lead him to judge to a  certain extent of  the length,
degree of induration, &c, of the constriction.
   The employment of soft wax bougies has been recommended with the view
of taking a mould  of the size, shape, and direction of the stricture, by pressing
the end of the instrument into it; but no  possible advantage can be derived
from  this proceeding, and a surgeon accustomed to  the use of metallic instru-
ments can obtain  all this  information with  more certainty by the  finer touch
afforded by them.
   The treatment of strictures of the urethra may be conducted by three methods
— 1st, mechanical dilatation; 2d, by  caustics;  and 3d, by the division of the
contraction.   Whatever  plan of treatment be  adopted, the surgeon must bear
in mind that his operations have to be conducted  upon a tender canal endowed
with  exquisite  sensibility, that sympathizes  closely  with the conditions of the
general system, and in which improper violence or too  active measures may set
up a degree  of irritation that readily extends to neighboring structures, and
thus jeopardizes the life of the patient.  But though it is necessary to recollect
all this,  he  must not run into the opposite  and  equally dangerous  extreme of
adopting inefficient measures for the removal of the obstruction.  A bad stric-
ture  is one of the most serious diseases that the  human frame is liable to, and
will almost inevitably, if left to  itself, terminate fatally by the  induction of
renal disease; and we must therefore not hesitate  to adopt sufficiently energetic
measures for its removal; and if these are  properly conducted, there is scarcely
any affection  in which tbe surgeon can afford his  patient greater relief than in
this.   At  the  same  time, however,  that  local  means are  being used, consti-
tutional treatment  should not be neglected.   Organic  stricture is often more or
less associated  with spasmodic or congestive stricture, and requires the same
constitutional treatment, modified  according to circumstances that are necessary
in these affections — proper regulation of diet, avoidance of all articles of food
that  generate lithates, care not to allow the urine to become too  concentrated,
and attention  to the maintenance of the healthy action of the liver and skin, will
tend  much to  increase the patient's  comfort, and to ward  off  the more serious
consequences of stricture.
   1st.  Mechanical dilatation, as it is erroneously termed, is the usual and cer-
tainly the most successful mode of treating ordinary strictures; but it is not the
mere  stretching, or forcible  dilatation of the stricture, cures it.   The means
 employed to produce dilatation tend to promote the absorption of those plastic
 matters  effused in  and  underneath  the mucous  membrane,  which especially
 constitute the stricture, and thus to occasion a permanent cure.
   The instruments that  are used for dilatation are either metallic, such as silver
 catheters, steel sounds, plated  or  pewter bougies;  or  made of some soft and
 yielding material,  as  gum-elastic  catheters, catgut,  wax,  or elastic  bougies.
 Though most surgeons will prefer one kind  of instrument  to another, it is well
 not to be too  exclusive in the use  of any one; for it will be found in particular
 strictures  and  certain constitutions advantageous to  depart from the ordinary
 practice, and that the surgeon may modify with great benefit to his patient the
 mechanical means that  he adopts.   As a general  rule, I  think that metallic
 instruments are decidedly preferable, more especially when the  stricture is tight, 
TREATMENT OF  STRICTURE — CATHETERS.       883
cartilaginous, and of old standing; nothing will pass such a stricture as this so
readily as a well-made steel sound or silver catheter.
  The shape and curve of catheters and sounds is of much importance;  the best
curve for these instruments, I think, consists of the one-fourth of the circum-
ference of a circle 4£ inches in diameter.   If sounds are used, they should be
made slightly conical, so that the thickest part corresponds to the bend of the
instrument, and be well  rounded at the point.   Sounds  are particularly useful
when the stricture will admit a moderate-sized instrument.   The sound should
have a broad metallic handle, which transmits any sensation communicated to
the point more accurately than a wooden one.  If a catheter be used,—and this
instrument is most applicable in small strictures, in which, if the  difficulty of
introduction be great, it  may advantageously be left, — it should be made very
solid and stiff.   The  rings should be large, so as to serve for a handle, and the
eyes well rounded off and somewhat depressed, so that they may not scrape the
urethra.   These instruments should  be used with every possible care  and gen-
tleness ;  but though no one more strongly recognizes than I do the necessity of
not employing unnecessary violence  in their introduction, yet it is useless to
think of getting through a tight hard stricture without the  employment of some
degree of force.  The catheter or sound will not " find its own way" here, as it
may in a healthy urethra;  but  it must be guided and directed by the hand of
the surgeon, and there is  scarcely an operation in surgery that requires more
tact and  delicacy of manipulation than that of passing  an  instrument through
a tight, or, as it is termed, an impermeable stricture.  Here some degree of force
must be  used, but the skill is shown in proportioning this to the amount of re-
sistance, and in using it in a  proper direction.   The  appearance of force is
indeed often greater than in reality;  for though the point of the catheter have
 got through a tight stricture, it may still  require considerable pressure to push
 the rest  of the instrument through it.
   Catheters  and metallic sounds are best introduced by laying the patient flat
upon his back, with the pelvis  somewhat raised, and the head and shoulders
low.  The surgeon, standing on his left side, inserts the instrument well warmed
and oiled into the urethra, with its concavity turned towards the left groin, and
 passes it down the canal, at the same time drawing the  penis upwards with his
 left hand, so as to put the mucous membrane on the stretch..  As the instru-
 ment approaches the triangular ligament, the handle is carried to the mesial
 line, and at the same time raised perpendicularly; and, as its point passes under
 the pubes, it should be kept well against  the upper surface  of the urethra, and
 made to  enter the bladder by depressing  the  handle  towards and  between the
 thio-hs.  The surest  guide to the bladder is the upper surface of the urethra,
 which is more fixed than the lower, and less liable to the existence  of fistulous
 openings or false passages.   Should  difficulty be experienced, the introduction
 may be  facilitated by injecting and slightly distending the urethra with oil
 before passing the instrument.
   If the stricture be not only very tight,  but twisted, it  may be somewhat dim-
 cult to get a metallic instrument through; and then the plan recom-
 mended  by Sir B.  Brodie may be advantageously employed.   This con-
 sists in  taking a fine catgut bougie,  and  bending it in this  shape, about
 an inch  from the point,  so as to follow the track of the stricture more
closely.   In this way strictures that are otherwise impassable may be got
throu-h  with comparative ease.   Under the influence of chloroform, how-
ever, many strictures maybe  readily passed with  metallic inrtruments
that are  not pervious in any other way.  I have repeatedly succeeded by
its use in passing catheters  through very  tight strictures which had been
impenetrable for months or years without this agent.
   Gum-elastic bougies and catheters  and  wax bougies are not nearly so manage-
able as  metallic instruments, usually bending back  against  tight strictures; 
884
DISEASES  OF  THE  URETHRA.
in fact, it is only in those of a spasmodic and congestive kind, in which a large
instrument will readily pass, that they are of much service.  They are usually
best introduced whilst the  patient  is standing, and they generally glide most
readily into the bladder  if  they have been slightly curved before being passed.
When they are of wax, it is useful  to  smooth them down between the fingers
before introducing them.  In  using the  elastic catheter, a  stylet is usually
required; but in some cases the instrument  appears to enter more easily with-
out this.  In  others again, it may be passed with  the  stylet  down to the stric-
ture,  and then partially withdrawing it, the point of the catheter will start up,
and thus more readily slip in.
   The introduction of an instrument usually gives rise to  a  smarting, painful
sensation in the urethra, which is generally most severe as its point approaches
the neck of the bladder, and is then sometimes attended by nausea and sudden
faintness.   As a  general rule the instrument should be passed every  second or
third day, and when introduced should  be left in for about five  minutes, or
until  the spasm about the urethra induced by its introduction has subsided.  If,
however, the stricture is extremely tight, a very small catheter only having
been  got in, the instrument may be left for twenty-four or  forty-eight hours,
when  it will  be  found that however tightly grasped  it originally had been, it
has become loosened; a slight discharge being at the same time set up from  the
urethra.  It may then be readily withdrawn, and when the  irritation has sub-
sided at the end of a couple of days, a considerably larger one introduced.
   The augmentation of the size of  the instrument should be  very gradual.   It
is fully  sufficient to  increase it by one  number at each time of introduction.
Many urethrae even will  not bear this,  and it  becomes necessary to pass  the
same instrument on two or three successive occasions before a larger size can be
introduced.   The size of the instrument may be gradually increased  until that
is reached which  the urethral orifice readily admits; beyond this, the surgeon
should not go; but so soon as the full size, usually No. 12 or 14, can be intro-
duced with ease it should not be passed so frequently as before; once a week or
ten days, and gradually with less frequency.  But for some length of time to
come it will be necessary to introduce it at least once a month or six weeks,  lest
contraction take place again.
   If  the size of the  instrument be  increased too rapidly, irritation may be set
up, and  inflammation of the  testicles, and abscess in the perineum or prostate
induced. I have more than once had occasion to regret being in too much haste
to increase  the size of the  instrument, and by augmenting it by two or three
numbers at one  sitting, have seen  the patient thrown back for weeks by the
supervention of some of the affections just mentioned.
   When the  stricture is situated solely at the urethral orifice, the best instru-
ments for dilatation are nail-headed  styles of graduated sizes.  These strictures
are, however, very troublesome, and have a great tendency to relapse.
   An ingenious  and in some instances a valuable  method of dilating strictures
has been brought before the profession by Mr. T. Wakley.   It consists in pass-
ing a small-sized  silver stylet through the  stricture,  and then  slipping over
this,  a catheter, which is to be  gradually increased in size until the  urethra is
fully  dilated.
   By dilatation,  properly  carried  out,  most strictures may be  considerably
relieved in the course of a few weeks;  and the majority cured by continuing
the treatment for a sufficient length of time.  Some, however, cannot  be dilated
in this way;  it would appear that the  tissue of which they are composed is so
contractile  that although they may be expanded up to a certain size — say up
to No. 5 or 6 — it is impossible to get beyond this.  In other cases again there
is a great tendency to relapse, and  for the constriction to return; the stricture
rapidly becoming tighter so soon  as the  introduction of instruments  is discon- 
TREATMENT  OF  STRICTURE.                885
tinued:  in these cases other measures that will  be described must be had
recourse to.
  The introduction of instruments occasionally gives rise to certain troublesome
sequences.   Amongst these, syncope and rigors, hemorrhage, inflammatory irri-
tation about the urethra or testes  are the most  common.  In certain  constitu-
tions usually of a nervous and  irritable character, there is a great tendency to
the occurrence of shivering  and faintness after the  passage of an instrument,
more particularly as it  approaches  the neck of the  bladder.  These effects usu-
ally "-o  off after  the withdrawal of the catheter, but  in some  cases they may
continue for many hours, or even come on  after the lapse of some time; the
rio-ors under these circumstances being very distinct and intermitting, so much
so°as  to resemble an  ague fit.   In such cases  as  these a full  dose of Dover's
 powder or of laudanum  in some warm brandy and water will usually give the
 patient most relief.  This accident is seldom attended with any danger,  though
 in  one case  I have known death follow the introduction of a catheter apparently
 from syncope and nervous causes.
    Hemorrhage, which is sometimes rather profuse, may follow the introduction
 of a catheter, especially if the  stricture is congestive and the  instrument em-
 ployed small.  It generally ceases of itself, but if it be troublesome the appli-
 cation of cold will check it.
    The inflammation about the urethra and in the testes that occasionally occurs
 during the  treatment of stricture is best guarded against by not using too large
 catheters, and by directing  the patient to abstain from much  exercise  during
 the time of their introduction.
    Fake passages are occasioned by the instrument  passing out of the  urethra
 through its coats into the surrounding tissues.  They are especially apt to occur
 in tight bridle  strictures, when  a small  instrument is being  used,  and more
 especially if the direction of the constriction is somewhat  oblique, so that the
 point of the  sound is thrown  against the side of the canal  (fig. 335).  The
 extent and situation of a false passage  necessarily vary according to the  position
 of the stricture; and the danger  is usually in proportion to its depth,  lhe
 false passage usually takes a direction downwards and to one side of the urethra.
 If the stricture be far forwards, it may run into the corpus spongiosum, but if
 in the usual  situation, it may perforate the lateral lobe of the  prostate, or run
 between this and the  rectum, being unable to extend upwards on account ot the
 rio-id nature of the structures in this situation.   Wh/m the false passage merely
 perforates the corpus spongiosum, running parallel to the urethra, and  opening
 again into  the canal,  or when perforating a portion of the prostate it enters the
 Madder, it is not necessarily attended with much danger; but when it enters
  the cellular tissue between  the bladder and the rectum, breaking up this struc-
  ture to a great  extent, admitting urine into the recto-vesical  space, and about
  the neck of the bladder, then  the most serious consequences such as inflamma-
  tion and abscess in this neighborhood, are apt to ensue, which  may not  unlikely
  be followed by the death of the  patient.                    .
    At the  moment that a false passage is made, during the m reduction of an
  instrument, by the surgeon using too much force or  pressing in the wrong direc-
  tion, he feels the point make a sudden  slip, which the direction of the.shaft
  indicates to be to one side of the urethra.  The patient  ^^P^^^S
  and is often conscious of  a laceration;  there  is a grating or rough sensation
  communicated  by the  tissues  amongst which  the  ™^entJ1J* £ bladder
  though it has entered deeply,  it will be found not to have re"^ *be ^d«r
  On t&he  surgeon introducing his finger into the  rectum  he probably-feels the
  point of the instrument in  the cellular tissue between  the gut and thbladd,
  on withdrawing it, it will  be  found covered with blood,  and  there will be free
  hemorrhage from the urethra.                            „„0„„a >«t+hp *>lmno-p
    The suro-eon knows when he has entered an old  false  passage by the change
  that  takes °pTace in  the direction of the  instrument, by its not  reaching  the 
886
DISEASES  OF  THE  URETHRA.
Fig. 345.
bladder, and by the rough sensation communicated to it, very different from
that afforded by the smooth lining of the urethra.  The patient is often conscious
of the existence  and of the entry of the instrument into the false passage, and
will warn the surgeon of it.   If the surgeon is aware that he has made  a false
passage, he, if possible, should at the time of the accident pass a larger cathe-
ter into the bladder, and leave it there for a few days until the laceration has
healed.  If there be an old false passage, he must be careful, by keeping the
point of the instrument away from  it,  not to enter it, lest during the introduc-
tion of the catheter he raises with  the point of the instrument  the valvular
angle that intervenes between  it and the urethra; every time that this is  opened
up=it tends to lessen the chance of a closure of the aperture, whilst overlapping
the urethra it interferes with the onward  passage of the  instrument into the
bladder.   By withdrawing the instrument, and changing its direction, the false
passage may often be avoided, and the bladder  reached.   Should  there have
been much difficulty in getting it in, the better plan will be to retain it  for two
 or three days,  when the canal may possibly close.
   It has already been stated  that in certain forms of stricture, dilatation does
 not succeed in effecting a permanent cure.   In these cases two plans of treat-
 ment have been recommended, the destruction of the stricture by caustic, and
 its division by the knife.
    2d.  In the treatment of stricture by  caustics two objects are  endeavored to be
 attained;  the first is the destruction of the stricture; the second, the diminu-
 tion of the sensibility of  the  surrounding mucous membrane,  so that the irrita-
 bility and spasm of the canal may be  lessened.  The following is the way in
 which  the caustic is applied.   A wax bougie, well-oiled, is passed down to, but
 not through the stricture ; the surgeon then with the thumb-nail, makes  a notch
               on that portion of the instrument opposite to the  meatus. Another
               bouo-ie  of similar length and size is then taken, and armed by a
               piece of potassa  fusa, about the size of a small pin's head, being
               placed in a depression at its end.  A mark is now made on it, at a
               point corresponding  to  the notch on the first bougie, it  is then
               passed rapidly down until this mark comes opposite to the  meatus,
               and then pressed firmly for two  or three minutes  against the
               stricture, upon  which the caustic  exercises its action. This appli-
               cation, which is  followed by a gleety discharge, is to be repeated
               every seconder third day, until a proper sized bougie can be in-
               troduced ; and  then the dilatation may be  proceeded with in the
               usual way.  This practice, stigmatized by  Mr. Liston as " most
               atrocious,"  has  now but  few advocates, and indeed there appears to
               be nothing that  it effects but what can be accomplished much
               more safely  and easily by a catheter or sound in  an ordinarily
               skilful hand.
                 The division of the stricture may be practised  either from within
               the urethra or from without, through the perineum.  The division
               from within may be performed  in two ways, 1st. By passing a
               concealed steel stylet down to the stricture, and then pushing for-
               wards the  lancet-like knife, attempting to  perforate the  obstruc-
               tion.   This plan is only applicable with safety to those strictures
               that are situated in  that part of the urethra anterior to  the scro-
               tum, where the canal is  straight.   In the deeper and more curved
               parts, any attempt at perforation would be fraught with  danger;
               for as it would  of course be impossible for the surgeon to guide the
               stylet exactly in the direction of the urethra, it would be  as likely
               to perforate the walls of this canal as  to pass  through the stric-
               ture.  In hard and resisting contractions, however, in the straight
               portion of the canal anterior to the scrotum, this instrument  may
  occasionally be  used with  advantage.  The most  convenient form  of cutting
 
OPERATION  FOR  PERMEABLE  STRICTURE.
887
stylet is the one figured here, which has a probe end, that is introduced through
the stricture, and serves as a guide to the blade, which is projected and  caused
to retract into its cylinder by the action of a spring (fig. 345).
   Another mode of dividing strictures from  within the urethra,  is to  pass a
catheter containing  a stylet through the stricture, and then projecting the stylet
as the instrument is withdrawn, notching the obstruction.  As the stricture how-
ever must be of considerable size to admit of such an instrument  as this; it is
usually sufficiently  amenable to  other  modes of treatment, and will  therefore
render such a procedure necessary.  The internal division  of the  stricture has
always been a favorite method  of treatment in* France, and of  late years not a
few complicated and dangerous machines have been invented, by which  a pro-
cess of cutting or lacerating the division of the stricture is sought to be effected.
 Such contrivances  are only mentioned in order to  be  condemned as in the last
 degree dangerous and improper.
   The division of the stricture from without  by incision through the perineum,
 may be performed  by two distinct operations:  the one  being only  applicable to
 those strictures that are pervious to an instrument; the other to those which are
 impermeable.  In  the first case, a grooved staff is passed through the stricture
 and the section made upon this.   In the second case the surgeon attempts to cut
 into and through the stricture,  without any  guidance except such as his anato-
 mical knowledge may afford him.
Fig. 346.
          OPERATION  FOR PERMEABLE  STRICTURE.

  The first of these operations introduced by Mr. Syme as urethrotomy, and com-
monly called the "perineal section," is a comparatively simple procedure.  The
instruments required for its performance  are a staff, a No. 8 silver
catheter, a pointed scalpel, and a broad director.  The staff should
vary in size from No. 1 to No. 6, according to the tightness of the
stricture;  it should  be grooved along  its convexity, either the
whole of the way, or better, merely for *he lower third (fig. 346).
The stem being smooth and of full size, and joining into the lower
grooved part by a  distinct shoulder, which being passed down as
far  as the stricture forms  by its projection a guide to that part of
the urethra requiring division.   In those cases in which there are
false passages a hollow staff may be advantageously used  of the
same size and shape; the flow of urine through it indicating with
certainty its passage  into the posterior part of the urethra.
  The operation is performed as follows: —The  staff having been
passed well through the stricture so that the shoulder rests against
the upper part  of the constriction, the  patient  is  tied  up as tor
lithotomy, and  the surgeon seating himself in front, pushes the
scalpel, with  the back of the  blade downwards, into the mesial
line of the  perineum a little ahove the rectum, and cuts upwards
for an  inch or more in the raphe.   The dissection is carried on very carefully
exactly in the median  line until the staff is reached, when the,  knife, nms  be
entered into its groove behind the stricture, and carried forwards through this.
The staff having then been pushed on to ascertain that all is free must be with-
drawn, and a No. 8 catheter introduced which  is to  be  kept :n  for forty-e ght
hours  it must then be taken out, and at the end of ^\?**^^™^
dilated by the introduction every  second day  of a full-sized  sl™ ^^J
Urine  escapes for some little time by the perineal »oi*on, b£ ** ^sheals by
granulation, the flow of fluid gradually lessens  and  at last ceases  entirely.
   The principal points to be attended to in this  operationare -
   1st. To see that the staff is fairly through the stricture, and to be especially
careful in determining this if false passages exist.
 
888
DISEASES  OF  THE  URETHRA.
  2d. To cut carefully in the median line, where, as Mr. Syme has observed, a
kind of septum exists even in the deeper structures of the perineum, and where
there can be no danger whatever  of dividing any artery of magnitude, which
might happen if any lateral deviation of the knife took place.   The only vessel
indeed which is at all endangered is the artery of the bulb, and this may always
be avoided by carefully keeping in the  raphe, as it lies towards the side of the
incision.
  3d. To enter the point  of the knife behind the stricture, and to divide that
by cutting forwards in the groove of the staff.
  4th. Not to turn the edge of the knife downwards; if this.be done the deep
perineal fascia may be opened and danger of pelvic infiltration and inflammation
incurred.
  5th. Much difficulty has occasionally arisen in the introduction of the cathe-
ter into the bladder after the  division  of the  stricture.  This may always  be
avoided by adopting the suggestion of Mr. Henry Thompson, of passing a broad
director, with the groove turned up, into the posterior part of the urethra after
the stricture has been cut, but before the staff is withdrawn.   As the catheter
is passed down  the canal its point will infallibly be guided by this onwards into
the bladder.
  When  there  are more  strictures than  one,  the  division of the deepest is
usually alone necessary.
  Although  fatal cases of perineal section have occasionally been recorded, yet
this is nothing  more than we must  expect to happen from time to time  in any
operation that is performed on the urinary organs whilst diseased, more particu-
larly if there be a granular condition of the kidneys, a state  of things in which
I have known the simple introduction of the catheter followed by death in six
or seven hours.   If I  understand Mr. Syme right,  it is with the view  of pre-
venting the  ulterior inevitable fatal consequences of all intractable strictures
that he has proposed this plan of relieving the obstruction, by dividing  it from
without,  in those cases in which ordinary methods notoriously fail, and in which
there is no alternative but to perform urethrotomy, or to leave the patient to his
fate. In order that this operation should be successful we must not wait for the
occurrence of those changes that are the result of the chronic obstruction, such
as disease of the bladder and kidneys, and which must inevitably increase the
danger of any operation; but we must divide the stricture with a view  of pre-
venting them.
  The most important question in connection with  this operation, is in what
class of cases it should  be practised.   That most strictures may be  cured  by
dilatation, there can be no doubt; most  practitioners  holding with Liston, that
whenever a catheter can be got through a stricture,  its cure  by dilatation is in
the surgeon's hands.   Though this may be generally true, instances not unfre-
quently occur, however,  in which dilatation fails to effect a cure;  the  stricture,
as I have already remarked, being highly  contractile, and  not  admitting  of
expansion beyond a certain point,  relapsing whenever the  dilating means are
removed.   In other cases also the patient suffers so  much  pain and  irritation
whenever an instrument  is passed, that  he cannot bear  the  repeated  introduc-
tions which are necessary if the stricture be complicated with fistulae in perineo
or false passages, and which render its cure by dilatation tedious and almost im-
practicable.   In such  cases as these  the surgeon,  being unable to benefit his
patient materially by dilatation, must  choose between the employment  of ure-
throtomy and palliative means.
  There are  four classes of cases in which urethrotomy may be advantageously
employed.
  1st.  In very old dense cartilaginous strictures, often of traumatic origin, which
admit an instrument with great difficulty, and cannot be dilated beyond a certain
point, owing to the conversion of the urethral structures into a kind of dense, 
PERINEAL SECTION.
889
fibrous, almost cicatricial tissue, that neither admits of expansion nor of absorp-
tion by the pressure of instruments; and in which a considerable  extent, half
an inch or more, of the urethra is involved.
  2d. The same kind of  stricture complicated with fistulae in the  perineum or
scrotum, with perhaps considerable plastic infiltration of these parts.
  3d. Very tight strictures accompanied by excessive sensibility of the urethra;
in which each introduction of the instrument is  attended by intense suffering,
spasmodic movements of the  limbs and rigors, so that the patient cannot be
induced to submit to a proper course of bougies.
   4th. Very elastic, though perhaps narrow strictures, that can be dilated readily
 enough, even up to the  admission  of full-sized  instruments; but which when
 the treatment is discontinued immediately  begin  to  contract again, so that the
 patient is never out of the surgeon's hands and sees no prospect of cure.
   The whole value of the " perineal section" will at last depend on the liability
 of the stricture to return after its division, and this point has not as yet been
 by any means  satisfactorily determined.   The ultimate result  of the  cases in
 which it has  been practised has  not as yet  been fully laid before the profession,
 and until this has been done we cannot consider the utility of the operation as
 established, except as a means of temporary relief in cases of the kind just men-
 tioned.  Much will certainly depend upon keeping up dilatation of the urethra
 for some months after the  division of the  stricture,  a catheter of full size being
 passed once  in a week or ten days.  If this precaution be neglected, relapses
 will often  occur;  and even when scrupulously attended to they are, I believe,
 by no means unfrequent.
   In  order to  perform  the perineal section it  is necessary that the  stricture
 should be pervious to a grooved staff, however small  this may be; and  this  it
 might be supposed would limit  materially the  cases in which the  operation can
 be  performed.   But complete  obliteration of the urethra  cannot take place
 except as  the  result  of sloughing,  usually consequent on injury;  indeed "im-
 permeable" strictures, though frequently spoken of,  are very rarely met with.
 Mr. Syme, indeed, denies their existence, and states that if urine can escape
 through a stricture, a bougie can be got in.  A  surgeon may often be foiled in
 his first attempts in getting an  instrument through a very tight stricture, but 1
 believe  that with patience,  by attention  to  constitutional treatment, so as  to
 lessen urethral irritation, and especially by the administration of chloroform, he
 will usually  at last succeed in getting an instrument of some kind through the
 very worst strictures.   In the first  case in which I performed the perineal  sec-
 tion, almost  all the urine had for twelve years been discharged  through fistulous
 openings  in the perineum and scrotum;  and  the  principal portion  escaped
 through a large hole on the inside  of the  left  thigh, a few drops merely occa-
 sionally passing out by the lips of the urethra.  No instrument had been passed
 for four years, though repeated attempts  had been made by different surgeons
 Being foiled in getting a catheter into the bladder the  first time I tried,  I kept
  the patient in  the hospital for two or three weeks, attending carefully to  his
  constitutional  condition, but without making any further effort   He was then
  placed under chloroform,  when I succeeded in passing No. 1.  Ihe urethia was
  then dilated up to No. 5, beyond which no instrument could be  passed  when
  the perineal section was performed.  The patient  made  an  excellent erne   he
  fistukms openings closing, and the urine being discharged by the natural^channel
  In another^  case* which I attended with  Mr. Bryant, persevering  attempts had
  been made for five years to get an  instrument into the b adder  ^ ^out  uc
  cess, the  stricture not  only being excessively  tight, but  the urethra.acutely
  sensitive; under chloroform I succeeded  in  getting No^ 1 f™™****'?*
  the bladder, and speedily cured the patient   In a case of ^™U°ne°J_u™
  following stricture, consequent on  injury of the perineum, sent  to me by Mr
  Corrie of Finchley in which no catheter  had been introduced  for eight years, it 
890
DISEASES  OF  THE URETHRA.
was found after death that although the urethra had been converted into a mass
of cicatricial tissue at the  part injured, yet that it was permeated by a narrow
tortuous passage, through which the urine had escaped.
   The influence of anaesthetics in facilitating the passage of instruments through
apparently impermeable strictures, is very marked.  Shortly after the introduc-
tion of ether as an anaesthetic agent, Mr. Liston was going to cut through a
stricture that had resisted  all attempts made by his most dexterous hand at get-
ting an instrument into the bladder; but no sooner was the patient put oh the
table and  fairly rendered insensible, than the No. 8 silver catheter, which had
been passed  down as far as the stricture,  and the point of which was  to  serve
as a guide to the knife, slipped into the bladder, and thus  rendered a dangerous
operation unnecessary.
   But yet no surgeon can doubt that cases do occasionally though rarely occur,
in which, in consequence of extravasation of urine and old inflammatory action,
the urethra has become so tortuous and narrow, and the perineum so indurated
and disorganized, that an instrument cannot be got through, even though urine
pass out  readily.  It must be borne in mind that a stricture may be permeable
to urine, but impermeable to a catheter, even in the most dexterous hands.  It
does not follow necessarily, that because a fluid will trickle out of a  narrow and
tortuous channel, that  a catheter  or solid sound can be passed  into it from
without.   Hence cases will occasionally occur in which the perineal section is
not practicable.
   In the event,  therefore, of a stricture being  so  tight  and tortuous that no
instrument  can  be got through it, or where a  portion of the urethra having
sloughed away,  its canal  is  obliterated, neither the  cure by dilatation nor
urethrotomy can be performed, and it may then be necessary to have recourse
to incision of the stricture without a guide.
         OPERATION  FOR  IMPERMEABLE  STRICTURE.

  This operation is performed as follows: A No. 8 silver catheter is passed down
to the stricture, the patient is then tied up as if for lithotomy, and the surgeon
sitting in front, pushes  a bistoury, with the back  turned towards the rectum,
into the raphe of the perineum  as far as the apex of the prostate, so  as,  if pos-
sible, to  open the dilated urethra behind the stricture.   He then cuts forwards
through  the stricture on to the point of the catheter, and thus having opened a
passage,  endeavors to pass that instrument  on  into the bladder.  It is often
extremely difficult to find the posterior part of the urethra; but in some cases
this part of the operation may be  facilitated by passing a grooved director or
straight  female catheter into it to act  as  a guide.  When the tissues  of the
perineum are hard and gristly, altered  by the effusion  of plastic matter, and
condensed by repeated attacks  of inflammation and the existence of fistulae, it
is a most difficult matter to  dissect through such an altered  mass and  hit the
urethra beyond it; and the difficulty is still further increased  by the  bleeding,
which is often  profuse.   This operation, I have no hesitation in saying, is per-
haps  the most troublesome  in  surgery.  I have more than once seen the most
skilful operators foiled  in their endeavors  to accomplish  it, and compelled to
relinquish the  operation without concluding it, or only succeed after prolonged
and most painful attempts.  Fortunately this  operation is now scarcely ever
necessary; with patience, and under chloroform, the surgeon  may almost inva-
riably get a staff, however small, into  the  bladder; he  then has a sure guide
upon which  to cut, by following which  he must certainly be led  through the
stricture into  the urethra beyond  it.   In  all cases,  therefore,  urethrotomy
should, if practicable, be substituted for the division of  the stricture without a
guide. 
COMPLICATIONS  OF  STRICTURE.             891
               COMPLICATIONS  OF  STRICTURE.

  1st. Retention of urine has a tendency to occur in all tight strictures, by the
gradual  and progressive contraction of the canal.   It  most usually, however,
takes place in consequence of a congestive  or spasmodic condition being  super-
added to the organic constriction.   It commonly happens that a patient having
a moderately tight organic stricture commits an excess, or becomes exposed to
cold and wet, and  thus gets such a congested condition superadded, that the
urine will not pass at all, or only in such  small  quantity by drops,  and with so
much pain and straining, that the bladder cannot be completely emptied.  In
these  cases, the  retention always  eventually becomes  complete;  the bladder
speedily fills, rises up  above the pubes, with much distress and constitutional
disturbance; and, if relief be  not afforded, the distended portion of the urethra
behind  the stricture  will ultimately give way, and extravasation of urine ensue.
Under  these circumstances,  it becomes imperatively necessary to empty  the
patient's bladder as speedily as possible.
   The  treatment to  be adopted varies with the severity of the symptoms and
irritability of the patient.   If the retention have not continued very long, and
if the patient be not very irritable, an  endeavor might be made at  once  to give
relief by passing a small catheter  into the bladder.   In this the surgeon may
 often succeed  more readily than  might have  been expected, the stricture fre-
 quently yielding before an instrument, more easily when there is retention than
 when  this condition does not exist.   Even if the catheter do not  enter the
 bladder, its point or that of a catgut bougie  merely being got well into the
 stricture, it will generally happen, as Sir B. Brodie  has pointed out, that on the
 withdrawal of the instrument, the urine will follow in  a full stream; but  it a
 sufficiently small catheter be used—in many cases not larger than halt ot JNo. 1
 is  admissible —the instrument may usually be got fairly into the  bladder,   it
 the patient be very  irritable, it is better, before attempting the introduction of
 the instrument, to give him an opiate enema, consisting of £j  0*  laudanum in
 about §ij of starch, and to put  him  in  a warm hip-bath; the introduction of
 the catheter may now be  attempted, and will very generally succeed   Should
 it still  fail, the effect of the inhalation of chloroform should be tried,  when it
 almost invariably may be made to  pass without the employment of anygr eat or
 dangerous degree of force.  There are no cases in surgery in which  chloroform
 I of more value than in these; under its influence it is  Beldoin  indeed  Aat
 the catheter will not pass.   After the instrument has been got into the  bladder
 it should be left there, being tied in by means of tapes passing from^its rings
 under  the patient's  thighs, to a bandage that is passed  round his waist.  Anti-
 phlogisti Remedies must'then  be employed in rather  an active manner a free
 Lr-e  leeches to the perineum if there be tenderness in this region,  and salines
 with antimony   The catheter will be found to be loosened at the  end of forty-
 Tight hTs when it should be withdrawn, and the cure by dilatation proceeded

 WilV^rlWsu'rCTeon is unable to introduce a  catheter in the ordinary

 way^^^






  pass it down to the, t™ure and   h n by-,*~  *•  .P ^        „

  ""V1: the  v£caS 7uTh™e  point of the instrument into  the tissues
  Troundlh neckof the-'bladd-er or the prostate, and  thus mduetng great, and 
892
DISEASES OF  THE  URETHRA.
 perhaps even fatal, mischief in these regions.   If he should, by some fortunate
 accident, get into the bladder, it is not by any skilful, though forcible, expan-
 sion  of the  stricture, but  rather  by perforating the  urethra, and  burrowm"
 through  the corpus spongiosum and  prostate, " tunnelling," as  it has  been
 termed, until he again enter that canal, or in some such way reach the neck of
 the bladder.
   2d.  In the kind of retention of urine  that we are now discussing, the safest
 mode of affording relief after the failure of the catheter, is to make an incision
 into the middle line of the perineum, and to open the urethra behind or through
 the stricture.   In doing this there is often  much less  difficulty in cases of
 retention than when the  bladder is  empty. In consequence of the urethra being
 distended by the accumulation of urine, and by the straining of the  patient, it
 sometimes attains  a considerable  magnitude, though, if this  be  not the case,
 the operation may prove a very serious and difficult  one.   The operation, which
 is essentially the same as that described at p. 890, for impermeable stricture, is
 performed by passing a catheter down  to the stricture;  opening the distended
 sinus of the urethra  beyond this; cutting upwards through  the stricture upon
 the end  of  the instrument;  and then  passing  the instrument on into  the
 bladder, or allowing the urine to flow from the aperture  thus made in the peri-
 neum.   In doing this, care must  be taken to  keep strictly in the direction of
 the mesial line, so as not to wound vessels of importance.  One  advantage of
 this operation is, that the stricture may by it be cured at the same time that the
 retention is relieved; and as the incisions do not  extend into the bladder, but
 are limited to the urethra, there is less danger to the  patient  than when that
 viscus is opened.
   Another advantage of the perineal incision in these cases is, that it not unfre-
. quently happens that urinary abscess  has begun  to  form, or the  extravasation
 of a few drops of urine has taken place sooner than  the  surgeon may have had
 any idea of; and if so, the incision through the perineum  will afford an exit for
 any extravasated matters, at the same time that it relieves the patient from the
 distress and  danger of the retention.   Should any mischief of this kind have
 taken place, it is not necessary to be  so  particular  about  opening the urethra
 with the knife,  for an aperture having  already been established in it, the urine
 will readily flow through the artificial channel thus formed by free incision into
 the inflamed or suppurating perineum.
   3d. The relief of retention from stricture may also be obtained by puncturing
 the bladder  through the rectum.   After emptying  the bowel  by means of an
 enema, the surgeon passes the left index finger well into the gut, feeling for the
 posterior margin of the prostate; he then carries the trochar and canula, which
 are long and  somewhat  curved, upon this as a guide, and when the  extremity
 of the  instrument has reached the posterior edge  of the  prostate, pushes it
 upwards into the bladder (fig. 340,6).  In introducing the instrument into the
 rectum, the surgeon should withdraw the point of the stylet into the canula, so
 as to avoid wounding the gut, and not push it forwards until he has the end of
 the canula fixed  against the spot where  he intends to make the perforation.
 After withdrawing the stylet and emptying the bladder, the canula should be
 tied in  by means of tapes, and left for  a few days until  means  can be taken to
 restore  the passage through the stricture, when it must  be withdrawn  and the
 aperture left to close. In performing this operation the surgeon perforates the
 bladder in that  portion of its fundus which is uncovered by peritoneum, being
 bounded behind by  the reflection  of  the  serous membrane, anteriorly by the
 prostate,  and on  either  side by the  vesiculae seminales.   In order to avoid
 wounding any of these  structures, he  should  keep  strictly  in the mesial line,
 and puncture immediately behind the prostate.
   This operation has the advantage of being far easier of performance than the
 last, and  may doubtless occasionally be  required in those  very rare cases of 
EXTRAVASATION OF  URINE.
893
retention from stricture in which.there is no sign of abscess or extravasation in
the perineum, in which the urethra appears not to be dilated behind the stric-
ture, in which the prostate is not enlarged, and in which, under chloroform, and
with patience, a catheter cannot be got  into the  bladder, a combination of cir-
cumstances that will but very rarely indeed  occur to a surgeon skilled in the use
of his instruments.
   2d.  Extravasation of urine.—In consequence of the ulceration or disorgani-
zation  of the coats of the urethra, this canal may give way behind the stricture,
and the urine become infiltrated into the surrounding tissues.  The part of the
urethra that gives way is invariably the membranous  portion of the canal, just
anterior to, or between the layers of the  triangular ligament, where it is weak,
being least supported by surrounding structures, and  usually most dilated  and
attenuated by the pressure to which it has been subjected.   This circumstance
is a strong argument in favor of the opinion that stricture of the urethra never
occurs at or behind the deep perineal fascia; did it do so, we should necessarily
have extravasation of urine in a deeper situation than we do.  Were it possible
for the urethra to give way altogether behind the deep perineal fascia, the urine
would become effused into the cavity of the pelvis.  But as it is, the connection
of the triangular ligament with the rami of the pubes and ischium prevents the
extension of the infiltrated urine  in that  direction, and the manner in which
the superficial fascia of the perineum is connected with the deep fascia uniformly
causes the fluid to take a course  forwards into the perineum, scrotum, and up-
wards upon  the external  organs of generation,  the groins, and the anterior
abdominal wall; ascending contrary to its gravity rather  than soaking  back
into the  more  dependent parts of  the body, as it would do, were it not for the
particular connection of the fasciae  that has just been alluded to.  I have, how-
ever, known the superficial fascia to give way, and the  urine then gravitating
backwards give rise  to extensive sloughing in the  ischio-rectal fossae and about
the nates, denuding the rectum.
   The effects of urine that has become acrid and concentrated by long retention
are most  deleterious upon those tissues with which it comes in contact.   The
vitality of whatever portion  of cellular tissue it  infiltrates  is immediately de-
stroyed by it, the tissue becoming converted into a kind of putrid stringy slough,
intermixed with and soddened by a quantity of fetid dark-colored acrid pus and
urine.  The ravages of extravasated urine are often extensive; the  urethra
giving way suddenly behind  the stricture, the fluid is driven with all the force
of the vital and physical  contractility  of the over-distended bladder into the
perineum, and  thence  rapidly finds its way through the scrotum upwards.   In
other cases, again, the  extravasation occurs more slowly;  a few drops appear
first of all to escape  from the urethra through a small rent or ulcer in it; these
give rise to inflammation in the surrounding structures, by which the progress
of the extravasation is for a time  limited.  It is  especially upon the  cellular
tissue of the scrotum that  the  effects of the extravasation manifest themselves
in their full intensity,  causing  great distension and rapid sloughing of it.   The
skin speedily participates  in  this action, becoming  of  a  dusky-red or purple
color, and then  falling into a state of gangrene.   In this way the testes may
become denuded, and  the cords exposed.   It is remarkable, however, if the
patient survive these destructive  effects,  with what rapidity  the  reparative
action goes on in this region.  It is seldom  that infiltration extends higher than
the groins, or the anterior portion  of the  abdominal wall;  but it may run up
as high as the costal cartilages before proving fatal.
   When the extravasation  is deep, the urethra being  opened between the layers
of the triangular ligament, the patient  experiences a sensation as if something
had o-iven way in the perineum, with much throbbing and pain; there  may be
but little  swelling for a day or two,  but  then a doughy diflused intumescence
takes place,  with rapid extension forwards.  When  the rupture is  altogether 
894
DISEASES  OF  THE  URETHRA.
anterior to the deep perineal fascia, then rapid  swelling and  infiltration  take
place, partly urinous, partly inflammatory, of the scrotum and penis; these parts
become enormously distended, oedematous, crackling, and  emphysematous,  with
the local signs  that have  already been mentioned.   The constitutional disturb-
ance is  always  considerable; at first of an irritative type, but speedily followed
by asthenic and typhoid symptoms, by which the patient is at last carried off.
  The treatment consists  in making a free and ready outlet  for the urine as
early as possible.   This should be done as soon as the extravasation is known to
have occurred,  by a deep incision into  the middle of the perineum.  So soon as
any  pain and throbbing, with diffused  swelling, occur in the perineum, the sur-
geon should introduce his left index finger into the rectum, so that the gut may
not be wounded,  and then pushing a long sharp-pointed bistoury deeply in the
raphe of the perineum, cut upward to a sufficient extent into the extravasation,
and  in  the  direction of the urethra.   A catheter  should then, if possible, be
introduced and secured in the bladder; in this way no further effusion can occur,
an outlet will be  afforded to matters already effused, and the greater part of the
urine will commonly be found to escape after a time by the aperture thus made.
Should  the case not be seen until extravasation has spread widely, a free  inci-
sion should  not only be made into the perineum, but  also into the scrotum on
either side of the  septum, into the penis, and wherever else swelling is observed.
The sole chance  of safety for the patient lies in making these free incisions,
through  which the  parts  may, to  a certain extent, empty themselves.  How-
ever extensive the infiltration  and serious  the mischief  may  be, we need  not
despair of the patient if a free outlet can be obtained for the acrid and putres-
cent urine and effused matters, and in order to secure this, the infiltration must
be followed  by incisions as high  as it extends.  The  parts  must, at the same
time, be covered with chlorinated  and yeast  poultices, and the  constitutional
powers of the patient must be  supported  by good nourishment and a sufficient
supply of stimulants.
  If the patient survive the immediate impression upon the system produced by
the gangrene and the urinary infiltration,  he must be prepared to go through a
severe trial to  his constitutional powers,  in the separation  of  the sloughs, the
profuse discharge, and other sources of irritation that  are set up.  During this
period he will require abundant support;  the brandy-and-egg mixture, ammonia
and bark, with any  nourishment that he can take; and much attention  should
be  paid  to  the removal of  the sloughs, the  giving a ready outlet  to the dis-
charges, and to keeping the patient as clean and  as free from all local irritation
as possible.
  3d.  Urinary abscess  may be considered in  many cases as a limited effusion
of urine mixed with pus, and circumscribed by plastic matter that is deposited
in the tissues  with  which the urine  comes in contact.   It is generally occa-
sioned by the irritation of the passage of instruments, but may arise simply as
the  effect of stricture, or from inflammation of some  of  the urethral follicles.
From some cause of this kind a small abrasion or aperture forms in the urethra,
a drop or two of urine escapes into the subcutaneous cellular tissue, this becomes
bounded or circumscribed by plastic deposit around  it, so that extravasation does
not occur.   Such an abscess as this may form at any part of the urethra, but it
is most frequently met with in the perineum, appearing to take its origin  from
the bulb or membranous part: such an abscess  is rarely dangerous, but is chiefly
of consequence by being commonly followed by urinary fistula.
  A urinary abscess is indicated by the formation of a small, somewhat circum-
scribed, hard, and painful tumor, situated in  the neighborhood of the urethra.
It is usually unattended by constitutional disturbance, unless it attain any con-
siderable bulk, when some pyrexia may ensue.   It is principally in the perineum
that it  attains any degree of magnitude, then constituting a  perineal  abscess,
characterized  by a deeply-seated, hard, tense tumor, brawny and without fluctu- 
URINARY  FISTULA.
895
ation;  attended by considerable weight and throbbing in this region.   It does
not readily point, owing to the manner in which it is bound down by the super-
ficial fascia.
   In the treatment of these abscesses early incision is required; when occurring
in the scrotum or anterior to it, the  surgeon should wait for fluctuation; but
when they are seated in the perineum, he need not do so, making a free incision
into the hard, brawny mass, which must then be well poulticed.
   4th.  Urinary fistulae commonly form  in  the perineum and scrotum  as the
result of abscess in these  regions communicating with the urethra; occasionally,
however, they  are  met with in other situations, as  in the  groin, the anterior
abdominal wall, or the inside of the thigh.   They usually communicate with the
bulb, or membranous portion of the urethra, but occasionally occur anterior  to
 this.   In  number they vary considerably; when  occurring in the scrotal and
 penile portions of the urethra, they are usually single; but when  in the perineal,
 they are often  pretty numerous; several apertures being occasionally met with
 about the  perineum, scrotum, and  nates.  In one case Civiale found as many as
 fifty-two.  Their  size also differs considerably, some  only admitting the finest
 probe, whilst others are  large cloacae.   In a case recently under my care the
 patient had a  tunnel of  this kind in  the groin that would  readily admit three
 fingers.    They are  usually  tortuous, elongated,  and narrow,  sometimes con-
 stricted externally and more widely dilated behind.   The surrounding parts are
 greatly condensed, the whole of the scrotum  and  penis enormously enlarged,
 indurated, and almost cartilaginous in structure.   The urine may escape almost
 entirely through  them,  scarcely  any being discharged through the  urethral
 orifice; or there may be but a slight exudation from the  fistulous openings.
    The treatment  of urinary fistula varies according as it  is complicated with
 stricture,  and  as it is situated in the anterior or posterior parts of the canal.
    If there be a stricture, this, as  the cause of the fistula, will  require removal
 either  by dilatation or the perineal section.  If the stricture is not very tight
 and hard, dilatation commonly succeeds; the instrument being introduced every
 second or third day, until the urethra is dilated to its normal size, when the  fis-
 tulous tracks  will in many cases close.  In some instances, however, the fre-
 quent introduction and withdrawal of the catheter is a source of irritation, and
 then it had better be left in.  When this  practice is adopted a moderate sized
 elastic catheter should be used.   If this be too small, the urine will flow between
 it and the sides of the urethra, and thus escape through  the fistulae; if too large,
 it stretches the urethral  orifice of the fistula injuriously.
    If  the  stricture be very tough  and  irritable, the better plan is to perform
 urethotomy at once, as  in this  way we remove  all obstruction and give free
 exit to the urine, which instead of  escaping by  tortuous and sinuous passages,
 finds its way out readily through  the new aperture that  has been made.
    The fistulae, especially if small and recent, will sometimes heal kindly enough
 after the removal of the  obliteration,  but if  extensive, old, and  cartilaginous
 they are of course little  disposed to take on reparative action; and although the
 cause  that  in the first  instance  gave  rise  to them may be removed, yet they
 constitute an  independent affection which requires special treatment for its cure.
    The  special treatment for urinary fistula, must vary  according to the size of
 the  canal, but more particularly with  regard to the part  of the urethra with
 which it  communicates; whether it is a perineal, scrotal, or penile, fistula.
    If the fistula is perineal, and of small size, a probe coated with melted
 nitrate of siver, or a wire made red-hot in the ordinary  way,  or by the galvanic
 current, and  passed down it occasionally, may cause  its contraction   If  large,
 a gum-catheter  should  be kept in  the bladder, and the  edges of the fistula
 freely rubbed with the nitrate of silver, or deeply pared and brought together by

 ^When^hefistula is scrotal it often  requires to be laid open, and to be made
, 
896
DISEASES  OF. THE  URETHRA.
Fig. 347.
Fiq. 348.
to granulate from the bottom, when it may be found to communicate with large
sloughy and ill-conditioned cavities in this situation.
   When penile, the fistula is usually  much more troublesome to heal, its edges
are thin, and the track is short and shallow.
                      Urethroplasty may in such cases be advantageously prac-
                    tised.  Operations of this kind require for  their success
                    very careful management and
                    minute  attention  to  detail;
                    they very  commonly  fail in
                    consequence of  a small quan-
                    tity of urine  or  of mucus es-
                    caping  through the  wound,
                    and   thus  interfering  with
                    union of its lips.
                      Urethroplastic   operations
                    must be varied  according to
                    the situation  and the size of
                    the fistula. In all cases a full-
                    sized gum catheter should be
                    passed into  the bladder and
                    properly  secured  there.   It
                    should be left without a plug,
                    so that no distension  of the
                    bladder, and  consequent like-
                    lihood of escape of urine be-
                    tween  the urethra and  the
instrument may  take  place.  In  order  to  prevent  urinous  diffusion over the
integuments  of the penis and scrotum, a vulcanized  india rubber tube should
be attached to the  end of the catheter,  by which means the flow of the urine
is directed away from the patient.
   If the  fistula be in  the  perineum  or  scrotum,  the parts  around being
thickened, and indurated, its closure may often  be  attained, by  freely and
deeply  paring the  edges, and then  bringing  them together with the quilled
suture.
   When the fistula is penile, there is not sufficient thickness of parts for ready
union.  In these cases  Nelaton has recommended the following operation, which
I have  successfully practised.  The  edges  of the  fistula having been pared,
the skin around to the extent of about one  inch  must be dissected  up  sub-
cutaneously (fig. 347)  through  an opening  made below the fistula, the edges
of which  must then  be brought  together by a  few  points of  suture.  The
displacement  of the skin causes granulations to spring up by which the fistula
is closed.  This procedure may sometimes be advantageously modified by paring
the edges of the fistula, making  lateral incisions, and then passing across but
underneath the flap a  slip of india rubber  to prevent contact  of  the urine
disturbing the adhesions (fig. 348).
                  URINARY VAGINAL FISTULAS.

  Preternatural communications  between the urinary passages and the vagina
commonly arise  from injurious pressure upon and consequent sloughing of the
anterior wall of this canal, to a greater or less extent during parturition.   They
may, however, occur from idiopathic abscess, or from malignant disease involving
these parts.
  Urinary vaginal fistulae  are  essentially of two kinds, according as the com-
munication is established between the urethra or the fundus of the bladder and
the vagina.   Hence  they may be divided into urethral and vesical. 
         TREATMENT  OF V E S I C O-V AG I N AL  FISTULA.      897

  The  urethrovaginal fistule are, so far as  my observation  goes,  of  most
common occurrence, and this is readily explained  by the fact that the urethra
passes  along  the  anterior aspect of  the  vagina  for some distance before  it
terminates in the  bladder, and  occupies that portion of the vaginal wall that
is most likely to be compressed during labor,  under the arch of the pubes.
These fistulae are  usually of small  size and linear.   The vesico-vaginal fistule
establish a communication between the neck or fundus of the bladder and the
vagina.   They are consequently situated further back than the other, and are
usually larger and  more ragged.
  The existence  of a urinary fistula in the  vagina,  is always a source of
serious  discomfort and  distress to  the  patient.    The  dribbling  of  urine
through the preternatural aperture is generally continuous, although if this
be situated far back behind  the orifices  of the ureters it might  be somewhat
intermittent, a flow taking place as the lower portion  of the bladder fills.  The
incontinence  of urine  thus produced, gives rise  to  irritation and excoriation
about the external parts, and occasions a strong ammoniacal odor to hang  about
the patient.
  The precise seat and extent of the  fistulous opening, are best ascertained by
examination with a bivalve  speculum, or with a conical one having a slit made
at its upper part, at the same  time  that the introduction of a bent probe, or of
a female catheter into the  urethra, will guide the surgeon to  the artificial
opening in the urinary passage.
   Treatment.—The cure of one of these vaginal fistulae can only be effected by
causing a coalescence of their sides.   When small and urethral,  this may  some-
times be effected by touching the walls of the aperture with the electric cautery
or a red-hot wire, introduced between the blades of an  open  speculum, and
repeating this application  once a fortnight  or three  weeks, until a cure is
effected.
   When the fistula is larger, and  especially when vesical, its cure can only be
accomplished by paring the edges, and bringing  them  together  with sutures,
and thus attempting to procure union  by the first intention.  In effecting this,
however, two difficulties present themselves: — The sutures either cutting their
way out too soon,  or the trickling of urine between the freshly pared edges, in-
terfering with adhesion.   In  order to overcome these difficulties, a variety of
ingenious contrivances have been introduced by different surgeons.   The most
useful of these are, in my opinion, Mr. Brookes' bead sutures, and the " clamp
suture " of Dr. Marion Sims.
   The treatment recommended  by Dr. Marion Sims  leaves little  to be desired
in  the management of these cases;  Dr. Sims  uses a suture of fine silver wire,
well annealed, which  after being  introduced across the  lips of the wound, is
properly fixed to  leaden  or silver  cross bars; these  sutures are introduced by
passing a silk thread by means of a  nevus or corkscrew needle, about half an
 inch from the freshened edge of the  fistula, and bringing it out through a cor-
responding point on the other side of the fistula, without having transfixed  the
 mucous membrane of the bladder.   As many threads as necessary having been
 passed in this way, a piece  of silver wire about eighteen inches long is attached
 to the silk, which is then drawn out, leaving the wire to occupy its place, so
 that its centre corresponds  to the fissure, and  both ends hang out  of the vagina.
 The uppermost free ends are  then passed through holes made in a narrow silver
 or leaden bar, and clamped by having split shot fixed upon them in  the same
 way as is done on a fishing line.   The undamped wires  are  now drawn down
 until the bar is pulled close to  the upper suture holes, and a second clamp is
 then fixed to these ends,  and is pushed up against the  lower suture apertures.
 In  this way the edges of the fistula are brought and held together by a clamp
on  either side, which may be allowed to remain in from seven to  ten days.
These may then be removed by clipping off the  flattened shots from the anterior
        57 
898
DISEASES  OF  THE  URETHRA.
clamp, which  is thus detached from its bed.   The posterior one, with the wires
attached, may then be hooked up, pushed backwards, and lifted out of the vagina
with forceps.
  In  the  after-treatment,  especial attention is required; and here the great
point is to prevent  the  contact of the  urine with the edges of the  fistula.
With this view a catheter should be introduced, and worn  in the bladder, so
that no urine  may collect in this organ.   For this purpose, Dr.  Sims has in-
                                                    vented a very ingenious
                      Fig. 349.                       catheter,  represented  in
                                                    the annexed  cut  (fig.
                                                    349),   which  may   be
                                                    worn with more comfort,
                                                    and with less chance  of
                                                    slipping than the ordi-
                                                    nary instrument.   After
                                                    the patient has been put
                                                    to bed, and  the catheter
introduced, a full opiate should be given, and continued throughout the treat-
ment, with the view of preventing  the action of the bowels, a point on which
Dr. Sims lays  much stress, and to which the success of his operations may be in
a great measure attributed.   It  is very seldom that  they are  required  to  be
opened for ten or  fifteen  days, provided the patient be kept on a rigid diet.
During this treatment the catheter may be removed once or twice a day, in order
to be cleansed and to be kept  free from phosphatic or mucous accumulations,
and free ablutions of the external genitals by sponge or syringe and warm water
should be practised during the whole of the treatment.  After the removal  of
the sutures, Dr. Sims advises that the catheter should  be continued, and great
care exercised  not to move too soon, lest the weak cicatrix be strained.
   More recently a very simple and successful mode of closing these fistulae has
been  invented by Dr. Bozeman, of Alabama, by what he terms  the " button
suture."   After paring the edges of the fistula, and passing silver wires across
in the usual way, he  draws the parts together by passing both ends of the wire

                Fig. 350.                              Fig. 351.
through an aperture in a steel rod, which, being carried  along  them, closes the
opening.  A thin silver or leaden plate, " the button," properly perforated down
the middle, is then slipped along the wires so as to cover the fistula (fig. 350),
and  split  shot  having been  pushed along  their free extremities, are  pressed
tightly against the button, the wires are then properly nipped, and the apparatus
is left on for about ten days (fig. 351).

                    TUMORS  OF  THE  URETHRA.
  Small polypoid tumors  are  not unfrequently  met with  inside the urethral
orifice.  They  have occasionally a gonorrheal origin, though they commonly
arise irrespective of such disease.  They are always very vascular, and are most
frequently met with in or around the female urethra, where they are of a bright
red color, have a florid hue, bleed freely when touched, and are composed of a
 
URINARY  DEPOSITS.
899
spongy kind  of erectile  tissue; they  are  commonly  conoidal or oval,  encir-
cling the urethral orifice on one side, or even forming a complete zone around
it.  They grow slowly, and seldom attain a larger size than that of a raspberry.
They are not unfrequently accompanied by a vast deal of sympathetic irritation,
great pain in  micturition, attended by an admixture of mucus or pus in the urine,
uneasiness of the lower part of the abdomen, and often aching in the loins.
   These vascular tumors are far less frequent in the male than  in  the female
urethra.   When they occur in men,  they  usually constitute a small  granular
florid mass inside the orifice of the canal.
   When seated in or around the female  urethra, these tumors not unfrequently
give rise to very great and continuous irritation; much  pain  during and after
making water, radiating through the whole  pelvic region, and in fact  many of
the symptoms of stone; so that patients  laboring under this affection are often
 sounded on the supposition of there  being calculus.
   Vascular urethral tumors may be  removed in four ways: — by excision, liga-
 ture, caustics, or the actual cautery.
   1st. Excision. When situated within the male urethra, they should be snipped
 off with a fine pair of curved  scissors.   When situated in or around the  female
 urethra, if of small size and  pediculated, they may readily enough be removed
 by the scissors or  dissected away, the  canal of the urethra being  encroached
 upon  as little  as  possible.   This operation is, however always attended or fol-
 lowed by very  considerable and continuous arterial  hemorrhage, which has even
 in some instances been of a fatal character.  Hence when the tumor is of large
 size, and the patient weakly,  excision should be practised with  much caution.
 If it be done, the hemorrhage may be arrested by the introduction of a catheter
 into the urethra, and by firm pressure  on  the  bleeding  surface  by means of a
 pad of lint supported by a "f" bandage.
   2d.  The Ligature is not a convenient  mode of removing these  growths, being
 difficult of application, very painful and tedious.
   3d.  Caustics, more particularly the strong nitric  acid or the potassa cum calce
 may be very conveniently employed where  the tumor is of small size and very
 vascular.  In  applying them, the upper wall of the canal must be protected by
 a broad director introduced along it.
   4th.  The  actual Cautery is  the  most convenient agent for the removal of
 these growths  from the female urethra.   By it they are at once destroyed with-
 out hemorrhage, and the eschar that is formed protects the subjacent raw sur-
 face from the irritation of the urine.  If situated deeply within the urethra and
 of small size, the galvanic cautery or a red-hot wire will most easily reach them;
 but if at or around the orifice, I always employ  a small olive-shaped cautery.
 During its  application the surrounding parts must be protected from the action
 of heat by spatulse, and the urethra by a director or silver catheter, which should
 be retained  after the operation.
   CHAPTER  LVIII.

STONE IN  THE  BLADDER
  The urine is liable to the deposit of various solid matters which when amor-
phous and impalpable are termed  sediments;  when  crystaHine they cons^ute
aravel  and when concrete, form calculus or stone   These deposits  wbatever
form they assume, are always the result of constitutional causes; and these con- 
900
STONE IN  THE  BLADDER.
stitutional conditions giving rise to them  are  commonly called diatheses.  Of
these, surgeons usually recognize three: the lithic, oxalic, and the phosphatic;
besides  these, however, others doubtless exist, the precise characters of which
have yet to be determined.
   The lithic acid diathesis chiefly occurs in individuals of robust habit of body
and florid looking, who have lived high and suffer from irritable gastric dyspep-
sia.   It is often  associated  with a gouty or rheumatic tendency, or with some
of the more chronic forms of skin disease, especially psoriasis.   It is charac-
terized  by scanty and acid high colored  urine, which deposits on cooling two
kinds of sediment, a yellow and a red.   According to Lehmann, these sediments
consist of urate of soda; but Golding Bird, and, I believe, most of the chemists
in this country, regard them as lithates of ammonia.  The yellow sediment, con-
taining an admixture  of  the coloring matter of the urine, is usually dependent
on slight disorder of the digestive organs and skin, coming and going under the
influence of very trivial causes.   The red sediment, owing  its color, according
to Bird, to an admixture of purpurine, a highly carbonaceous ingredient, and
indicative  of  imperfect  assimilation, is met with in persons of full habit, who
live too freely.   A variety, or rather an admixture of these sediments,  consti-
tute the lateritious deposit  so common  in gout and rheumatism.  The red sand
or gravel is a crystallized variety of the lithic  acid sediment.  It may be com-
pared, in general appearance, to cayenne pepper, and under the microscope pre-
sents the  characters  seen  in fig. 352.   It is not unfrequently met with in
Fig. 352.                               Fio. 353.
Lithic Acid.                        Litbate of Ammonia.
children of a strumous habit, who are allowed more animal food than they can
well assimilate.  Occasionally crystals of lithic acid are found intermixed with
these  deposits, presenting the characters figured in 352.
  The calculi that occur in this diathesis are of two kinds;  the lithic acid, and
the lithate of ammonia.  The lithic acid calculus is usually of small or moderate
size, varying from  a pin's  head to a pigeon's egg; it is oval, somewhat com-
pressed and flattened, smooth on the surface, and  of a fawn color.  On section
it is seen to be laminated and to present various shades of a light brown or fawn
tint.   The lithate  of ammonia calculus is of very rare occurrence; when met
with,  it is chiefly in  children, and is composed of concentric rings, having a fine
earthy appearance,  and being clay-colored.
  The treatment of  the lithic acid diathesis must be directed to the removal of
the prime causes of this condition, viz., mal-assimilation, defective oxygenation
of the blood, and the ingestion of too large a quantity of stimulating food.  All
this may be  remedied by attention to ordinary hygienic  measures; the patient 
OXALIC  AND PHOSPHATIC  DIATHESIS.         901
must live sparely, should avoid fermented liquors, especially red and effervescent
wines, and abstain from sweets, pastry, &c.   He should take plenty of out-door
exercise, and keep the skin  in  healthy action by warm or vapor bathing, and
the use of horse-hair gloves.   The bowels must also be carefully regulated by
means  of  saline and  other aperients, with occasional alterative doses of Plum-
mer's or blue  pill;  to which, if the constitution be  peculiarly rheumatic  or
o-outy, some colchicum may  advantageously be added.  A very  good aperient
for general use in these cases, is 3j of Bochelle salt in giss of  the compound
decoction of aloes, taken  at night or early in the morning; or a dessert-spoonful
of the following powder every morning: R Pulv. Rhei, |ss., Potass, tartrat. gj.,
Mao-nesiae ustae, £ij.,  Pulv. Zingiberis, £j.; f. pulvis.  The patient may also be
directed to drink some of  the  natural alkaline waters,  as  those of  Vichy or
Fachingen.  The Vichy waters, containing as they do a large quantity of car-
bonate  of  soda, with free  carbonic  acid, are extremely serviceable for  the
correction of this diathesis.   If they cannot  be procured, a very good alkaline
drink consists of 9 j of bicarbonate of potass and 5 grains of nitre dissolved in a
tumbler of cold or tepid  water, to which about 5 grains of citric acid, or a table-
spoonful of lemon-juice  may be added, and taken  early in  the  morning or in
the middle of the day.
   When lithic acid calculus  has actually formed, it is not well to give the alka-
line remedies too long, or in  too large quantity, lest the stone rapidly increase
in  size by becoming encrusted with phosphates.
   The oxalic diathesis is characterized by the formation of oxalate  of lime in
the urine.  It generally occurs in individuals in whom there  is defective assimi-
lation, dependent upon exhausted nervous energy, arising from over work, mental
anxiety, or venereal excesses.  The patient is usually pale and hypochondriacal,
suffers from dyspepsia, acidity of stomach, and disturbed sleep.  In these cases
there is often loss of sexual power;  a state
 of debility of the generative organs, con-
 nected  either  with  the  want  of erectile
 vigor, or too speedy emissions.  The urino
 is  usually very pale,  abundant,  and acid,
 and there is heat and smarting during its
 passage along the urethra.   In  this dia-
 thesis  there is no sediment  or gravel pro-
 perly speaking, but the crystals float in the
 urine, subsiding  however when it stands,
 but not occurring in  sufficient quantity to
 constitute a true sediment (fig.  354).
    The oxalate of lime  or  mulberry  cal-
 culus is usually of a dark brown  or almost
 black color, moderate in size, being seldom
 larger than  a walnut, and  round;  it  is
 always rough, tuberculated, and sometimes
 almost spiculated on  the surface.  .                     .   ,    .. •   _ppp„-rv
    In tht treatment of this diathesis  when there is no calcu ui; is  n cessary
 to nut the natient  upon a light and nourishing diet, especially fish, as recom-
 mended by Dr BirdTcautionlng him to avoid sweets and all fermented liquors,
 S the  exception of a moderat! quantity of brandy. Tomes, -gcM
 rhP mineral acids iron,  zinc, and quinine may be given, and the residence, n


 OT^Sr»^X^^^54.budte,«1^og

 ^T^V^t^^cteV ooeurs in old  persons, or in those who are
Fiq. 354.
 
902
STONE IN THE  BLADDER.
Aramoniaco-Magnesian Phosphate.
prematurely aged, with a broken constitution and  an anemic  condition of the
                                  system.   In this diathesis the sediment and
             Fia. 355.             calculi may occur in three distinct forms.
                                    1st. Triple or ammoniaco-magnesianphos-
                                 phate.
                                    2d. The Phosphate of Lime, and
                                    3d. The mixed phosphates, consisting of a
                                  mixture of the preceding varieties.
                                    The triple phosphates (fig. 355)  usually
                                  occur in urine that is copious, pale and barely
                                  acid, sickly to  the smell, and soon  decom-
                                  posing and  becoming  very offensive.   In
                                  other cases it is dark, alkaline, and mucous.
                                  This condition especially occurs in old people,
                                  is associated with much debility, irritability
                                  of mind, pallor, and anemia.
                                    The phosphate of lime sediment is not of
                                  such common occurrence;  it usually occurs
                                  in pale,  and  offensive, readily  putrescent
urine, mixed with much mucus, and in some cases apparently produced  by the
mucous membrane of the bladder.
   The mixed phosphates commonly occur after injuries of the spine as the result
of general impairment of the health, or in advanced cases  of  prostatic disease.
They are occasionally met with in large quantity, forming a kind of  mortar-like
sediment in the bladder.
   The phosphatic calculi are very common, the  most frequent is the mixed,  or
fusible calculus as it is termed, on account of the  ready way in which it melts
when  exposed to heat.  This calculus is friable, laminated,  and has a chalky,  or
earthy look.   The calculus composed of phosphate of ammonia and magnesia is
not so common, it resembles the preceding  pretty  closely in its general charac-
ters, but is whiter and has a more chalky look; the phosphate  of lime calculus
is extremely rare — it is laminated and harder than  the other varieties.
   The treatment of the phosphatic diathesis consists principally in  improving
the digestive powers, and restoring the general strength of the patient by the
administration of good food, wine, or beer.  The exhibition of tonics, especially
of nitric acid, should be attended to, and exercise in the open air enjoined.  As
                                 there is usually  much pain  and irritability  of
            Fia. 356.             system in this diathesis, opium may advanta-
                                 geously be administered.
                                    Besides the calculi mentioned, various other
                                 kinds of concretions form in the urine, each of
                                 which doubtless represents  a diathesis; the
                                  characters of  which, however, are not so dis-
                                 tinctly marked,  or so well recognized as those
                                 that have just been described.
                                    Cystine is one  of  the  rarer  forms   of
                                 morbid  product  occasionally met with  in
                                 the bladder.   It   differs from all other  in-
                                  gredients, in  containing a  large  quantity—
                                 about 26 per cent. — of sulphur.  It is very
                                 rarely seen  as a sediment  in the urine, but
                                  when it occurs  in  this  form it presents the
              Cystine.             microscopic characters seen in fig 356, being
                                  composed of hexagonal  laminae.  Calculi con-
 taining cystine have occasionally been met with.  Dr. G-olding Bird states in  his
 work, that in Guy's Hospital Museum there are eleven composed of this peculiar
 
STRUCTURE  OF  CALCULI. — RENAL  CALCULI.      903
animal matter;  and in the Museum of University College we have some good
specimens.   Cystine in calculus has a peculiar yellowish or greenish  and waxy
look, very different from any other ingredient met with in urinary concretions.
  Xanthine, uric,  or  xanthic oxide, was  first noticed by Dr. Marcet, and  has
since  been observed by Laugier, Langenbeck, and  others.  It is of  extremely
rare occurrence, and  has  only been found in  a few recorded instances in  the
form of calculous  concretions.   These have  generally been of small size, with
the exception of the one removed by Langenbeck, which weighed 388 grains.
For the chemical characters  and constituents of this  substance I must refer to
Dr. Bird's work.
   Carbonate of lime has occasionally been met with as an amorphous powder
in alkaline or very faintly acid urine.  I  am not aware of any calculus of  this
composition having ever been found,  but  Dr. Bird  states that he has  detected
 carbonate of lime as  forming a distinct stratum in some phosphatic calculi.
   Structure of calculi.—Calculi, though sometimes composed throughout of the
 same deposit,  are not  unfrequently made up  of layers or strata, differing in
 chemical composition from one another,  and then usually go by the name of
 alternating calculi.  Most frequently  the  nucleus consists  of  lithic acid or
 lithates; next in  the order of frequency  comes the oxalate of lime;  and then
 the phosphatic nucleus.   It is very seldom  that the  nucleus  is absent; but
 concretions have occasionally been met with in which none could be detected,
 or in which it was even replaced by  a cavity.   The nucleus is usually as nearly
 as possible in the centre of  the  calculus,  and is generally pretty  regular  in
 shape;  occasionally,  however, it is branched or curiously radiated, and then the
 concretion generally  affects a corresponding  outline.   Calculi containing two or
 three nuclei have sometimes been found,  consisting probably of an equal number
 of concretions agglomerated together.
    The body of a calculus having  the uric acid nucleus is usually composed  of
 some of the lithates; but not unfrequently  these are incrusted  by a deposit of
 phosphates.  In  other instances again,  the body may be wholly composed  of
 some of the earthy phosphates, which more rarely alternate with the oxalate of
 lime or the triple phosphates.
    An oxalate  of  lime nucleus usually has a  body of the same constitution; but
 in some cases it is incrusted  by phosphates or urates.   When  the  nucleus is
 phosphatic, the concretion is always  of the  same constitution.
    Vesical  calculi may be formed  either in the kidneys or the  bladder; those
 that contain a nucleus of the urates  or oxalates are  probably renal m  their
 origin; whilst those that have a phosphatic nucleus are usually vesical from the
 first; renal nuclei being rarely met with of this composition.
    Renal calculi—When a stone forms  in  the pelvis of the kidney, it usually
 gives rise  to  pain in  the  loin.   When of small  size it may descend into the
 bladder with but little suffering to the patient; but, if large enough to irritate
 the ureter  and to pass with some difficulty,  it then  gives rise to a peculiar  train
 of symptoms that will immediately  be described.   In some  cases the calculus
 attains  a very large  size, occupying  the  whole of  the  pelvis of  the kidney, ex-
 tendino- into the calices and ureter,  and  being moulded, as it were, to the shape
 of the parts amongst which it lies;  it then  gives rise, by its pressure to  absorp-
 tion of the substance  of the kidney, and  occasions, by the  magnitude  that it
 attains, excessive pain and  irritation in this region, the patient usually eventu-
 ally chins, worn out by constant suffering, and the irritation of incurable kidney
 disease.  In some instances, stone in this situation has been known  to give rise
 to abscess in and around the kidney, and has even been discharged  through an

 ^InThos: cts^n  whichtrenal calculus descends into the bladder, the patient
 is seized with pain  in the loin that has been the seat of  previous  irritation.
 ThTs pain is usLlly of the most agonizing character, extending into the cord 
904
STONE  IN THE BLADDER.
 and testis and down the thigh of the  affected side.  There is retraction of the
 testicle, with  constipation and vomiting; frequently accompanied by the passage
 of scanty, high-colored, and bloody urine, and great constitutional disturbance.
 This pain usually continues of a somewhat remittent character, until the calculus
 enters the bladder, when, unless  expelled, it gives rise to a peculiar train of
 symptoms, depending on its presence in that organ.
   During the descent of a renal calculus, which always occupies many hours,
 and perhaps  some days, the patient  should  have  full doses of opium adminis-
 tered, be put into a warm hip-bath, and have mustard poultices applied to the
 loin, or be cupped  in this  situation, if  necessary; the bowels should also be
 thoroughly emptied by enemata.   It is well  to  bear in mind that a somewhat
 similar train of symptoms to that induced by the descent of the calculus, may
 be excited by some forms of irritation or flatulent distension of the ccecum and
 descending colon, which will require appropriate treatment.
    Vesical calculi.—Though vesical calculi occasionally owe their  origin to the
 descent of a stone from the kidney, yet it not unfrequently happens that there
 is no evidence of their coming from such  a source, but every appearance of their
 being  deposited in the bladder; a nucleus  being  originally formed in  this
 viscus  by the aggregation  of some sabulous matters, around  and upon which
 fresh  deposits take place, until a true calculus is formed.  In  some instances,
 vesical calculi have been found deposited upon, and incrusting foreign bodies
 accidentally introduced into the  bladder, such as  a piece of straw, a  pin, a bit
 of bougie, &c.
   The number of calculi in the  bladder varies considerably; most commonly
 only one  is encountered; but in about one-fifth or one-sixth of the cases ope-
 rated  upon, several will be  found: from two to six  or eight are by  no means
 uncommonly  met with.   Occasionally several dozens  have been  detected,  and
 there  are even instances on record  in which some  hundreds  of distinct  and
                separate calculi have  been  found  in  one bladder.  The  most
                remarkable case of this kind is one, in which Dr. Physick re-
                moved from a judge in the United States, upwards of a thou-
                sand calculi varying in size from a partridge-shot to a  bean, and
                each marked with a black spot.  Several calculi may become
                matted  together  in one  large concretion, as in the annexed
                representation of a calculus that  I  removed last year from  a
. child (fig. 357),  which is formed  of eleven distinct lithic  acid  calculi soldered
 together  in this way, besides which three others were  lodged in the bladder.
   When there are several calculi in the bladder,  the  attrition  of one against
 the other usually causes the opposing surfaces to  become  smooth, thus consti-
 tuting  facets.  In some cases, however, the calculi are numerous, and  there are
 no signs  of attrition.   In a patient of mine  who had fifteen calculi in his blad-
 der, all the stones were round, about the size and shape of marbles, without any
 signs of rubbing.
   Calculi have been occasionally  known to undergo spontaneous rupture in the
 bladder,  by a kind of  concussion against one another, or, as Civiale  supposes,
 by the contraction of  a hypertrophied bladder, by  which one stone may be
 broken into a number  of fragments.   In some  instances  these have  agglome-
 rated  together, by the  deposit of a quantity of phosphatic matter upon  and
 around them.  In other instances the  different  fragments may each  form the
 nucleus of a fresh calculus, so that the bladder may afterwards contain several
 concretions.
   The size of calculi varies from that of a hemp-seed or a pin's head to a con-
 cretion of immense magnitude. One of the largest with which I am acquainted
 is a calculus  removed  by the  high operation by Dr. Uytterhoeven of Brussels,
 which I saw some time ago in his possession, and of which he has been obliging
 enough to give me a cast; it is of pyriform  shape, and measures 16^  inches in
 
VARIETIES AND  CAUSES  OF  CALCULUS.        905
its longest circumference, and 12^ inches round at its broadest part, being 6^
inches long, and about 4 wide.  In the celebrated case of Sir W. Ogilvie, Cline
attempted, but failed, to extract a calculus measuring  16 inches round one axis
and 14 round the other.   It weighed 44 ounces, and must have been about the
size of  Dr. Uytterhoeven's.  These enormous  concretions are  happily rarely
met with, the  usual size of  stones removed by  operation being from about one
to two inches in the longest diameter, somewhat narrow, and perhaps flattened.
   The weight of calculi commonly varies from a few  grains to several ounces;
the commonest size is from three drachms to about an ounce or two in weight,
occasionally from three to six; from this they may range upwards  until several
pounds  are  reached.   Thus, in Cline's  case the stone weighed 44  ounces, Des-
champs saw one of 51 ounces, and Morand one weighing 6 lbs.: none of these
admitted of removal.   The largest calculi are usually composed of phosphates,
in greater part if not in whole.
   The hardness of calculi varies considerably; the oxalate of lime is the hardest;
 the lithates come next in consistence, and are  often very hard, though brittle;
 the phosphates are always comparatively soft  and friable.
   The  shape  of calculi  presents great variety; most  commonly, however, they
 have an ovoid figure.   Concretions of urate of ammonia and uric acid are gene-
 rally pretty regularly ovoidal, smooth, and disc-like.   Those  composed  of  oxa-
 late of lime  are usually somewhat globular or square-shaped, and generally rough,
 nodulated, or  spiculated upon the surface.  The phosphatic calculi present  usu-
 ally the most irregular  outline; most  commonly, it is  true, they  are ovoid  or
 globular, but  not unfrequently branched as  if moulded to  the interior of the
 kidney, constricted, or of an  hour-glass shape.   The  cystine calculi are gene-
 rally tolerably oval and regular in outline.
   Most frequently calculi  lie loose  in the bladder; but occasionally they may
 be fixed in  this viscus, owing either to their  being encysted, and then lying in
 one  of the sacculi that have already been  described within the walls  of the
 bladder (figs. 358 and 359), or by being fixed  in  and embraced by one of the
 ureters, and in other cases by being  deposited upon,  and  partly included  in
 fungous growths.
Fio. 358.
Fig. 359.
Exterior of bladder containing an encysted cal-
               culus at a.
Interior of the same bladder, showing small
   orifice leading into cyst at a, ureter b.
  The causes of calculi are somewhat obscure.  There can be little doubt, it is
true, that the different forms of concretion are connected  with the varieties of
diathesis that have  already been described, and we may look upon the forma-
tion  of a calculus as  an indication  of the existence, in  a  greater degree of 
906
STONE IN  THE  BLADDER.
intensity than usual, of the same causes that,  under ordinary circumstances,
give rise to sediments or gravel; but why, in particular cases, the aggregation
into a calculous mass takes place, it is impossible to say.   Age appears to exer-
cise considerable influence upon the  production of calculi;  for  though stone
may occur  in the bladder  at  all periods of life, and even, according to Stahl,
be  congenital, it  is  certainly more frequent  amongst  children a few years
old, and at advanced  periods  of life, than during  middle age.   Mr.  Coulson
has  collected 2972 recorded cases of lithotomy from various sources; of these,
1466 occurred under the age  of ten, 731 from eleven  to twenty, 205 from
twenty-one  to thirty, 264 from  thirty-one to fifty, and 306 from fifty-one and
upwards.
  It would  appear that in  some parts of the world  calculus is a far more com-
mon disease than in others.   It is generally more  frequently met with in cold
than in warm climates; indeed, in  tropical  countries I believe the disease is
scarcely known.  The Negro race also is remarkably exempt from this affection.
It is a singular fact that in some parts  of the same country calculous disorders
are of far more frequent occurrence than in others.  Thus it is well known that
the  inhabitants of the east coast of England and Scotland are peculiarly liable
to  these disorders, and that in Norfolk,  stone occurs with especial frequency;
this district furnishing, in  all  probability, as many cases as the half of the rest
of  England.  In America also, it would  appear that the  inhabitants of certain
states  are peculiarly obnoxious to this affection; and I understand that in some
districts of  Germany the disease may be said to be almost unknown, whilst in
others  it is of common occurrence.  To what these differences are owing it is
impossible  to say.   Peculiarity of race, of constitution, and of  diet, with
exposure to prevalent easterly winds, have all been assigned as reasons for them,
but probably not on  very sufficient grounds.   Sex  influences  materially  the
occurrence  of stone, which is  far more  frequent in the male than  in the female.
   The symptoms of stone in  the bladder vary somewhat according as the cal-
culus lies loose in the cavity of the viscus or is encysted.   They  also vary con-
siderably according to  the size  and shape of the  stone, the condition of the
bladder, and the constitution  of the patient.   Most commonly the severity of
the symptoms are in proportion to the magnitude of the  calculus.   This, how-
ever, is not always the case.  In a patient whom I recently cut, the most intense
suffering  and repeated attacks of  cystitis had  been  occasioned by a small but
sharp-pointed calculus, not weighing more than gj  ; and some years ago I saw
a patient in whose bladder five calculi were found  after death, nearly as large
as  chestnuts, though their presence  had never been  suspected during life by the
different surgeons  under whose care he had been for stricture, so little distress
had they  occasioned.  In some cases the symptoms of stone  very suddenly
 declare themselves, and then  the surgeon finds  on examination that the patient
has a largish calculus, which must have been a long time forming without attract-
ing attention.  Rough calculi usually  give rise to more  severe symptoms than
smooth ones, owing to their  inducing  a chronic form of cystitis; and, as the
 constitution is usually a good deal  shattered and the nervous system very irri-
 table in those conditions of the system in which the phosphates  are deposited,
 phosphatic calculi are usually attended by more suffering and constitutional dis-
 turbance than other forms of the disease.
    The symptoms induced by stone may be divided  into the rational and physi-
 cal.   The rational signs, consisting of pain, increased frequency in micturition,
 the occasional stoppage of the urine, and various morbid conditions of that fluid.
 The physical signs are those by which alone the surgeon can positively deter-
 mine the presence of the calculus,  feeling it with the sound.
    The pain in calculus is usually the  first symptom that attracts attention; it
 is  not only experienced  in the region of the  bladder and  the  perineum,  but
 radiates widely in the course of the sacro-lumbar nerves.  The patient complains 
SYMPTOMS  OF  CALCULUS.                 907
of a heavy and dragging sensation in the groins, extending down the outside or
back of the thighs, and not uncommonly experienced in the soles of the feet.
The penis likewise is the seat of a good deal of uneasiness, frequently of a sharp
and cutting pain in the glans.   This is especially noticed in children, in whom
attention is often attracted to the complaint by their constantly squeezing and
pulling the  organ to relieve the distress they suffer in it.   The pain is much
increased by any movement  by which the stone is jolted  about in the bladder,
as in driving, riding, or jumping; and  is especially severe in those  cases in
which cystitis occurs.   It is always most severe towards  the termination of, or
immediately after micturition, as there is then a tendency for the calculus to
roll forwards towards the neck  of the bladder, where it  comes in contact with
and is grasped by the most sensitive part of that organ.   Hence it is not unfre-
quent in cases of calculus occurring in children  to  find  that the little  patient
instinctively lies upon its back or side whilst making water, and thus escapes
much  of the  agony that it would otherwise suffer. In adults in whom the pros-
tate  happens to be enlarged,  the calculus usually lies in a depression behind this
gland, and hence, being  prevented coming in contact  with the neck of  the
bladder, occasions less suffering than in  other cases.
   An occasional stoppage commonly occurs in the flow of urine before the bladder
 is emptied, owing to the  stone being impelled against its neck,  and thus block-
 ing up the urethra; but  on  the patient lying on his back or on his  side the
 stream flows again, the situation of the calculus being changed.
   In consequence of the irritation  set  up in the bladder occasioning  chronic
 inflammatory action of the  mucous membrane, there is an increased frequency
 of micturition.   The urine  is  passed in small quantities,  and usually  contains
 some mucus or pus, and is occasionally tinged with blood.   The occurrence of
 blood in  the urine of children leads strongly to  the suspicion of stone,  and
 should always induce the surgeon to make an examination  of the bladder with
 the  sound.   If the kidneys  are irritated, the urine is commonly albuminous.
   As a result of the straining and general irritation about the genito-urinary
 organs, prolapsus of the anus, accompanied by tenesmus, is  by no means uncom-
 mon, and in some cases there is very troublesome priapism.
   When a stone is encysted,  those symptoms that depend upon its being loose
 and rolling about in the bladder, are necessarily absent;  thus there is  no stop-
 page in the water, the urine is seldom  bloody, and  the pain is not materially
 increased by jolts and rough movements, though  there is weight and pain in the
 usual situations, and  increased frequency of micturition  from the pressure  and
 irritation of the calculus.
   The existence of stone is                     FlG- 36°-
 finally determined by sound-
 ing the bladder.
   A sound is a solid steel
 instrument  shaped like a
 catheter, but shorter in the
 curve, so that  it may ex-
 plore more  thoroughly all
 parts  of the bladder,  espe-
 cially those behind the pros-
 tate.   It should also  have
 rather a  wide and smooth
 steel handle. The operation
 of sounding should be con-
 ducted as  follows : — The
 
908
STONE  IN THE  BLADDER.
to contain three or four ounces of urine.   The surgeon then using his left hand,
or crossing over to the patient's right side, whichever he finds most convenient,
carefully directs the beak of the instrument towards the back of the bladder,
turning it from right to left over the whole of that region (fig. 360); he next draws
it forwards on one side as far as the neck, tapping as it were gently with its beak;
he repeats the same manoeuvre on the other side, and lastly directs the end of the
instrument by raising its handle into the lower fundus, which he carefully explores.
Should he  not detect the calculus in any of these situations, he depresses the
handle between  the thighs, and tilts up the beak so as to examine the subpubic
                                             portion  of the organ (fig. 361).
                   Fig. 361.                   In the event of his not meeting
                                             with a stone, he  may direct the
                                             patient  to stand up, and then
                                             explore the bladder, first upon
                                             one  side,  then   on  the  other.
                                             Should  the  rational   signs  of
                                             stone be well marked, though no
                                             calculus  be struck, the surgeon
                                             must not give a decided opinion
                                             in the negative  after the first
                                             exploration, but should examine
                                             the  patient  again  a few days
                                             later, with  the  bladder  in  dif-
                                             ferent states as  to its contents.
In making this  second examination, I have found  it  of great service to use a
hollow steel sound, by which the organ can be injected  or emptied at pleasure
(fig. 362).  The patient should on this occasion have his bladder injected through
such an instrument as this, with four or six ounces  of tepid water, so as to dis-
tend the organ slightly, and prevent the folds of mucous membrane overlapping
any  concretion that may exist  in it.   Its interior is then carefully explored in

                                 Fia. 362.
the way already described, and  if the stone cannot then be detected, the con-
tents of the bladder are gradually allowed to escape through the sound, and the
patient desired to stand up whilst the exploration is being proceeded with.   In
this  way, by examining a patient in  different  positions and in different con-
ditions of the bladder as to capacity, a calculus is sure to be  detected if one
exist.   A lithotrite may occasionally be advantageously used as a sound for the
detection of small calculi lying behind the prostate, a situation more  readily
reached by its short beak than by an instrument of larger curve. These exami-
nations must not, however, be too protracted;  the time occupied  should not
exceed above five minutes, lest cystitis be induced.  When a stone is struck by
the sound, there is not only a characteristic and distinct shock communicated to
the instrument, but there is a tolerably loud click heard, which  can  be detected
by the by-standers, and frequently by the patient  as well as by the surgeon.
  By conducting the sounding properly, the surgeon  may usually ascertain not
only the existence of a stone, but its size, and  hardness;  whether  it is single,
if it  be encysted, and the general state of the bladder, all of which it is of im-
 
SOUNDING FOR STONE.
909
portance that he should be acquainted with before undertaking any operation.
A good  deal of this information  may be  elicited  by the ordinary sound, but
some of the  points can  only be accurately determined by sounding with the
lithotrite.
  The hardness of the stone may usually be judged of by the more or less clear
ringing character of the click;  a lithic acid or oxalate of lime calculus giving a
sharper sound than a phosphatic concretion.
  A calculus may generally be known to be encysted if the sound strikes it at
times, but not  at others (fig. 363); if the stone always appears to be fixed  in

                                  Fio. 363.
one situation; and if the beak of the instrument cannot be made to pass round
it, so as to isolate it, but feels a kind of tumor projecting through the walls of
the bladder, around or on one side of the point where the calculus is struck.
   The fasciculated, roughened, and sacculated  condition of the bladder may
generally be detected by the way in which  the beak of the instrument grates
and rubs over the organ.
   The size of the calculus is best determined by a lithotrite.  It is true that a
surgeon may sometimes come to a decision  as to the bulk of a calculus by ob-
serving the extent of surface along which the sound is in contact with the stone
as the instrument  is being withdrawn.   But a very rough  guess only can be
arrived at in  this way, and I have  frequently seen very experienced  surgeons
deceived in their estimate of  the size of a  calculus, mistaking  perhaps several
small  ones lying together for one large one.   By introducing  a lithotrite  and
seizing the calculus gently between its blades, a correct estimate of its size may
always be arrived at.
   In order to determine that several calculi exist in the bladder it is sometimes
sufficient for the surgeon to feel that the beak of the  sound comes in contact
with a stone on either side of the organ, or that it can  be distinctly insinuated
between  two concretions.   In some  cases, however, these points cannot  clearly
be made out;  and then the surgeon introducing a lithotrite and  seizing the first
calculus  that he  meets with should hold this between the blades of the  instru-
ment, and whilst it is so fixed move it  and the lithotrite from side to side,
when, if a click is  heard and felt, he may be sure of the existence of another

S Errors occasionally occur in sounding; the surgeon mistaking  a hardened and
fasciculated  bladder, having its ridges perhaps incrusted with sabulous matter,
for a calculus; this  is especially apt to  happen in  children.   In  thesepeases,
however, the  mistake may usually be guarded against by the absence of a dis-
tinct click, though  a rough grating sensation be experienced, and by the  sur-
geon being unable to isolate a stone.  Yet the difficulty in some cases is great;
Velpeau states that he is  acquainted with four instances, and S. Cooper with 
910
STONE  IN THE BLADDER.
 seven, in which patients have been cut and  no calculus found;  and when we
 reflect that these  accidents have  happened to such men as  Cheselden, who on
 three  occasions cut a patient and found no stone; to Crosse, to  Roux, and to
 Dupuytren, it  is easy to understand that in some cases the difficulty of coming
 to a correct decision must be very great.
   In women the symptoms of stone closely resemble those met with in men, and
 the detection of the calculus is usually very easy, owing to the shortness of the
 canal and the facility with which the stone may be tilted up by introducing the
 fingers of the left hand into the vagina.  The sound used in these cases should
 be shorter and less curved than that employed for the detection of calculus in
 the male bladder.
   After a stone has existed for some time in the bladder it induces serious
 pathological changes in the whole of the urinary apparatus.  The urethra usually
 becomes slightly dilated, and  the prostate not unfrequently somewhat enlarged
 and irritable, in consequence  of which a kind of pouch is formed behind it, in
 which the calculus is apt to lodge.   The most important changes, however, take
 place  in the bladder and  kidneys.  The bladder becomes extremely sensitive,
 especially about its neck, and is  consequently unable to contain as much  urine
 as usual; hence  it  becomes contracted.  In some  rare  instances, however, as
 will be more especially noticed when we come to speak of lithotrity, it falls into
 an atonic condition, and then is apt to become rather largely dilated.   The
 mucous membrane is  commonly a good deal inflamed  and irritated by the pre-
 sence of the calculus, and the muscular coat becomes thickened and hypertro-
 phied, so as to give  it a very fasciculated or  columnated appearance.   Cysts
 occasionally form containing sabulous matter and fetid pus or urine, and in  some
 cases lodging a concretion, which then constitutes an  encysted calculus  lying
 altogether outside  the cavity of the bladder, with which it merely communicates
 by a very narrow aperture, as in figs. 358 and 359, representing a case that was
 under my care some years  ago, and which is fully described in the Journals for
 March, 1853.  The kidneys are usually irritated, often  congested, frequently in
 a state of granular degeneration,  and ultimately become  the seat of such struc-
 tural changes as are incompatible with life.   When death occurs as the conse-
 quence of stone, the patient usually sinks, worn out by protracted suffering and
 kidney disease.


      OPERATIONS  FOR THE REMOVAL OF STONE FROM THE BLADDER.

 _  Calculus may be removed from the  bladder by two distinct operations.  By
 lithotomy, or the cutting operation; and  lithotrity, or the crushing one.   We
 shall first consider lithotomy, as the more  ancient, and  perhaps even yet the
 more common,  operation of the two.
   It is not my intention to enter into the general history of lithotomy—an
 operation that  has been practised from the earliest ages; and a sketch of the
 gradual modifications  of which,  that  have  at various times  been introduced,
 from the rude attempts of the Greek and  Roman surgeons to the barbarous and
 unscientific procedures adopted by the itinerant operators after the revival of
 letters, would occupy much space and be attended by but little advantage.  For
 all this I would refer the reader to the classical works of Deschamps and of
 John Bell.   The operation, as now generally practised in  this country, is essen-
 tially that introduced by Cheselden, and modified more or less according to the
 peculiar views  of particular surgeons.  Hence  there are a variety of ways in
which  it  is performed, though surgeons  generally are  agreed upon the great
principles involved in it.  It is  in carrying these out that they differ — as in
the direction and  extent of the incisions, and in the  instruments  employed,
which  have been  much varied to suit the taste of particular operators.   This
detail would  be foreign to this scope of the work: I shall, therefore, in a great 
LATERAL  OPERATION OF  LITHOTOMY.          911
measure confine myself to the description of  that particular modification of
Cheselden's, or the lateral operation introduced by the late Mr. Liston, most
skilfully practised by him, and now very generally adopted by most of the best
surgeons of the day in this country.
  Before subjecting a patient to operation, his general health must be properly
attended to; and, indeed, if we find the constitution much broken by prolonged
suffering, the  bladder or  kidneys  seriously diseased, as indicated by the exist-
ence of pus or albumen in his urine in large quantity, it will be wise to postpone
the operation  for a time, or  perhaps even to defer it altogether.   Supposing,
however, that  the stone  is of moderate size, that the  patient's health is in a
pretty good  state, that the urine  is either healthy or contains but a moderate
quantity of pus or albumen, and that there is  no visceral complication to prevent
the performance of the  operation, it will only be necessary to subject him to
proper preparative treatment for a short time,  so as to allay or remove irritabi-
lity of the urinary organs, before proceeding with it.  With this view, he should
be kept as quiet as  possible for about a week or ten days preceding the opera-
tion ; his diet should be properly regulated, but not be of too low a kind; pain
lessened  by the administration of opiates or henbane, and the bowels properly
relieved.  On the day preceding the operation, a dose of castor-oil or some other
aperient should be administered; and, on the  morning of the operation, the
rectum must be emptied  by means of an enema.


              LATERAL OPERATION OF LITHOTOMY.

  The surgeon  must see that the table is firm and of a convenient height, so
that,  when he sits on rather a low stool,  the patient's nates will be on a level
with his breast; a few blankets  doubled should be laid upon the table, covered
by a piece of tarpaulin hanging over the end,  and a tray of sand placed under
it on  the floor.  The  instruments  necessary are the following: a pair of lithot-
omy tapes, a sharp and a probe-pointed scalpel, a staff, forceps, and scoops of
various sizes,  and a tube.  To  these  may be  added  a searcher, and  a brass
injecting syringe.
  The tapes should be of coarse flannel, about three yards long, by three inches
broad.
  The scalpel for the adult  may be of the size and the shape represented (fig.
364); for children it may be made proportionately small.   A probe-pointed

                                  Fig. 364.
Fig. 365.
c—
lithotomy-knife should also be at hand, of the size and shape here represented
(fig. 365).                                         .,         .        .
  The staff should have  a  deep groove on its left side, occupying nearly one-
third  of the  instrument; it  should be well  curved, of as large  a size as the
urethra will admit, and have a roughened handle (fig. 370).
  The forceps  must not  be  too  heavy,  but should be of a good length in the
handles, and  have the joint well set back; the inside of the blades, as recom- 
912
STONE IN THE  BLADDER.
mended by Mr. Liston, should be lined with linen, to prevent the stone slipping
(fig. 366).  Mr. Coxeter has lately made them with  open blades, but lined with
linen  as heretofore (fig. 372); in this way, as there is less metal, the  weight is
Fig. 366.  Fig. 367.
Fig. 368.   Fig. 369. Fig. 370. Fig. 371.
iWJ
diminished, and the diameter of the instrument  with a stone in its grasp is
materially lessened.  The ordinary forceps  are  straight, but it is  advantageous
to be provided with some that are  curved (fig. 367).  The handles should be
                made with a loop on one side and a ring on the other; the ring
    Fia. 372.    for the reception  of the thumb should  be  placed  somewhat
                obliquely.  The scoops of different sizes, and curved, can most
                conveniently be used when fixed in a roughened handle (figs.
                368 and 369).  The tube should be of gum-elastic, well rounded
                at the end, and provided with silver rings.   The searcher is a
                slightly curved sound having a bulbous  extremity (fig. 371).
                The syringe presents nothing peculiar.
                   In describing  the operation of lithotomy, we shall first of
                all consider  the  different  steps seriatim of  an operation that
                presents no  unusual complication  or difficulty;  we shall then
                consider the  difficulties that  may  be  met  with during  the
                operation, the accidents that may occur, the  principal  sources
                of danger, and the causes of death.
                   Ordinary lateral operation.—The patient should  be desired
                to hold his water for two or three hours  before the operation,
                but if he has not done so, and the bladder is  empty, it must be
                injected with about six ounces of tepid water, in order to steady
                it and to facilitate the  seizure and extraction  of  the  stone.
                After chloroform  has  been  administered, the  surgeon  should
                introduce a full-sized  staff, which he uses as a sound, in order
                to feel for the  calculus  If he detects it, he  proceeds with the
                operation; if he cannot detect it, it is usually  recommended
                that he should withdraw the staff and introduce a sound, with
                which he examines the bladder, and in the  event of  his  still
                failing to discover its presence, the operation must be deferred,
for it is an imperative rule in surgery that lithotomy should never be performed
unless the stone can be felt at the time that the patient is actually on the table.
It is, however, safer not to proceed with the operation  unless the stone can be 
LATERAL  OPERATION  OF  LITHOTOMY.         913
felt with the staff^lest the  point  of this, though apparently in the bladder, be
actually engaged in a false passage.   The patient is then to be firmly tied up
and brought to the end of  the table, so that his nates project beyond it, where
he is to be securely held by an assistant on either side, who grasps the foot in
his hand, places the patient's knee under his arm, and draws the limbs well
aside, so that the  perineum may be  fairly exposed.  It is desirable that the
perineum be thus fully exposed to the surgeon.  In a patient, however, on whom
I once operated, this could  not be done, owing to the left hip being stiffened by
chronic rheumatic arthritis; but I did not experience any particular difficulty
in the operation, though somewhat inconvenienced by the position of the limb.
The surgeon then seating himself before the patient, shaves the perineum — if
this  have not already been  done — and introduces his finger into the rectum to
see that the gut is empty.   He then gives the staff in charge of a trusty assist-
ant,  who  stands on the  patient's left, and who raises and draws aside the scro-
tum with the left hand whilst he holds the staff in the right (fig. 373).   The
surgeon then sees that the staff is  held  in  the way in  which he prefers it.
There are two ways in which  it may be held; it may either be drawn well up
into the arch of the pubes, or it may be  pushed  somewhat down, and slightly
turned towards the left  of the perineum.   Liston always employed the  first
method, which  I certainly  think  is  the best, as it tends  to increase the space
between the urethra  and  the rectum, and consequently lessens the danger of
wounding  that gut, which more than counterbalances  the  advantage of  the
other method — that of approaching the membranous portion of the urethra to
the surface.
   The external incision is  made by entering the knife in the raphe of the peri-
neum one inch  and a half  above the anus, and carrying it downwards and  out-
wards until it  reaches a  point
that is just below  the anus, but                  Fia. 373.
about  one-third nearer to the
tuberosity  of the  ischium  than
to the margin of the anal  aper-
ture (fig. 373).  It is useless to
prolong the incision beyond this,
as  any freer division  of the
structures  of the  scrotum and
on the nates cannot facilitate the
extraction  of the  stone; but  it
must occupy the  extent  indi-
cated, otherwise   considerable
difficulty may be experienced in
the later steps  of  the operation.
The depth  to which this incision
should be   carried  must  vary
according  to the obesity of the
subject, usually from about three-
quarters  of an  inch to an inch.  By this incision the  skin, superficial fascia,
and  subcutaneous  fat are divided.  After it is completed, the knife  is introduced
again towards the upper part of the wound, and the blade  run lightly down-
wards  over any resisting  structures,  the left fore-finger being placed at  the
middle of the wound so as  to protect the rectum.  In this way  the transversalis
perinei muscle  is divided together with some  cellular tissue  and  small vessels,
and  the triangular space is opened  between the accelerator unnae and erector
penis muscles; the knife  is then withdrawn, and the left index finger pushed
deeply into this space until the edge  of the nail is lodged in the groove of the
staff (fio-. 374), which can  be felt just anterior to  the prostate, thinly covered
by the membranous portion of the urethra.   The point of the  knife  is then
       58
 
914
STONE IN THE  BLADDER.
pushed through the  urethra  at  its membranous part into the  groove  of the
staff, above the index finger, which protects and presses to the right, the  rectum
lying beneath it (fig.  375).
  When the knife is  felt to be well lodged in the groove, its handle is slightly
                                               depressed so  that  the point
                   Fig. 374.                    may  be raised, at the same
                                               time   the  blade  should  be
                                               somewhat lateralized, so that
                                               its side lies parallel  to  the
                                               ramus of the ischium.  If the
                                               edge is turned too directly
                                               downwards towards the mesial
                                               line  the  rectum  may  be
                                               wounded, and if directed too
                                               much outwards the internal
                                               pudic artery will  be  endan-
                                               gered (fig. 377); hence  the
                                               mid course is the proper one.
                                                  The surgeon keeping  the
                                               knife steadily in this position
                                               and pressing the point firmly
                                               against the side of the  groove
                                               of the staff, which he must
                                               never  for  a  moment  lose,
                                               pushes it  forwards through
                                               the deep perineal fascia, a few
                                               fibres of the levator ani, and
                                               the prostate, and thus makes
an  entry into  the bladder  (fig.  376);  he  then  withdraws  the  knife by
keeping its back against the  staff so as not  to  enlarge  the extent of  the
incision in the prostate.  Through this, and along the staff, he then pushes his
left  index finger until it reaches the bladder, when he endeavors to feel  the
                                     calculus with its tip.   Should  his finger
                                     be short, the  perineum deep, or the pros-
                                     tate enlarged, he may be unable to reach
                                     the  bladder in this way; and  must then
                                     introduce a blunt gorget, as recommended
                                     by Cheselden and Martineau, in order to
                                     dilate the aperture in the prostate.   K
                                     he  uses  his  finger for this purpose,  he
                                     gives  it  a twist or two after  passing it
                                     through the prostate so as to expand and
                                     dilate the aperture through which  it is
                                     entered.   Having made sure that  it is in
                                     the bladder,  and having  felt  the stone,
he directs the assistant to withdraw the staff from the urethra.
  Here let us pause  and examine the  principal points in  this the first  and
second stages of the operation. It will be observed,  that in accordance with the
best authorities upon  the subject, and with my own experience, I have  recom-
mended the external  incision  to be free, the rectum to  be protected  by the left
index  finger, and the knife to be somewhat lateralized during and after the
opening of the urethra.
  1st.  The position of the knife must be carefully attended to, especially during
the deep or second  incision.  At this stage of the operation the edge should be
lateralized, that is,  directed about midway between the horizontal and perpen-
Fig. 375.
 
             LATERAL OPERATION  OF  LITHOTOMY.          915

dicular position, so that the surface of the blade lies nearly parallel to the ramus
of the ischium.   The manner of holding the knife has  been much  discussed,

                                  Fia. 376.
and necessarily and naturally varies with different surgeons.  I believe it signi-
fies little  how  the handle  of the instrument  is held between  the surgeon's
Fig. 377.                                 Fig. 378.
fino-ers provided the edge is  never turned  upwards, but is always kept well
lateralized, and the point steadily pressed into the groove of  the staff. 
916
STONE IN THE  BLADDER.
  Provided a surgeon knows what he is about, he may safely hold his knife as
                                 best suits his own convenience.  In the first
           Fig. 379.              incision, most operators, I  believe, hold  the
                                 knife under the  hand, as represented in fit:.
                                 379, a position that that excellent lithotomist
                                 and accomplished surgeon,  Mr. Fergusson,
                                 preserves  throughout the  operation.   Mr.
                                 Liston, in the early part of his career, appears
                                 to have held the knife, in  the second  stage
                                 of the operation,  above the hand;  and  in
                                 all the representations, published  as well as
                                 unpublished, that he has left of his operation,
                                 has depicted the knife and hands in  the
position as shown (fig. 380), which, in the last edition of his Practical Surgery,
he describes as a correct sketch of " the position of the hands and knife" at
                                   the commencement of the  second stage of
              Fig. 380.               the operation.  There can be no doubt,
                                    however,  as Mr.  Fergusson has  pointed
                                    out, that  in actual  practice, at least after
                                    his first few years as an  operator,  he  held
                                    the knife  under the hand with the index
                                    finger upon the side  or the back of the
                                    blade.
                                      For my own part, I believe  that every
                                    surgeon  will  hold the knife in the  way
                                    which he finds most convenient, and  as it
                                    were natural to him.  If any rules are to
                                    be laid down  on  this  point, I should say,
that when operating  on a child, or  on  an adult with a shallow perineum, the
knife is most conveniently held as represented in fig. 379.  But if the patient
be fat and the perineum deep, then 1 think that it is a question  whether greater
steadiness may not sometimes be secured by holding the knife  somewhat in the
manner of a gorget, with the index finger, perhaps, a little more upon  the side
                                          of  the  handle (figs. 376 and 381);
                 Fig.  381.                  in  this way  the  point is firmly
                                          pressed into the groove of the staff,
                 _^J^v                   out of  which it cannot slip, as it is
    """   v^^      ^'^F>r!l*«%Sl'   secured and supported by the index
    "■"^   -k"~*    --j  t ,   mi.......'■"'——fr^1-   >^   finger  being  somewhat under  it.
     k^   i   „^k_^            "^^e sect*on 0I> *he prostate is thus
     *i!ij|«gj|p*ifc""*^                   made by a steady  push or thrust
         J                                of the  knife forwards, and not by
                                          any cutting movement downwards.
No danger can result  in the deep incision from pushing the point of the knife
up into the groove  of the staff; but there is great  risk of missing the  bladder,
and getting into the recto-vesical space, if it be at  all depressed and the handle
raised, though this cannot always be avoided if the staff be pushed deeply into
the bladder.
  2d. The incision into the prostate should be of very limited  extent: on this
point all  surgeons, I  believe, of the present day are  agreed.   Scarpa advises
that the incision into  it should not exceed 5 lines in  adults and 2 in children.
It is difficult to measure the extent of the incision: it is sufficient to say, that
it should be as limited as possible; and if care be taken to push the knife in,
with  the  point well pressed  against  the groove, and the blade forming but a
limited angle with the shaft  of the  staff, and especially in withdrawing it that
it be brought carefully back over the finger and still in contact  with the instru-
 
LATERAL  OPERATION  OF  LITHOTOMY.         917
ment, there will be no  danger in cutting too widely, or in doing  more than
merely notching the apex  of the prostate (fig. 378, a).  The danger, however,
it must be borne in mind, does not consist in the section of the gland itself,__
which is in reality a structure of but little importance,—but in cutting beyond
it into the reflections  of the pelvic fasciae, which will be opened up  if the base
of the prostate be cut,  and the wound of which will, almost to a certainty, be
followed by urinary infiltration and diffuse inflammation.
  In the section  of the  prostate then, two points have specially to be attended
to: one is, that the knife  in entering be not pushed forwards at too great an
angle with the staff, so  as  to  cut widely;  and  the other is, that in  its with-
drawal the blade  be  kept steadily in contact with  the staff; indeed, I believe
there is more  danger of  doing mischief in the withdrawal than in the entry of
the knife, for  if it leave the staff for a moment all  guide is lost and the edge
may sweep downwards  through the base  of the prostate and its investing cap-
sule.  As the knife is withdrawn, the left index finger is pushed forwards into
the aperture in the prostate, which is then dilated by  its pressure to a sufficient
extent for the introduction  of the forceps, which are  slipped in as the finger is
withdrawn, and the extraction of the stone.   This part of the operation may very
conveniently be performed, as was usually done by Mr. Liston, at the moment
the  surgeon is stooping down, engaged in  selecting  his forceps.   It is readily
effected; for the prostate, though dense, is friable, and breaks down easily under
somewhat forcible pressure by the finger.  In this way, by a mere notching of
the  prostate, — by a slight  section of its apex  or urethral  surface,  followed by
simple dilatation  with  the finger, — sufficient  space will be  obtained for  the
 extraction of all moderate-sized calculi, without the employment of any violence,
 or the infliction of any bruising upon the tissues.
   [In the performance  of  the lateral operation  for lithotomy  Dr. Pancoast, of
 Philadelphia, has for many years been in  the habit of dividing the prostate
 gland and neck of the bladder by a manoeuvre of a different character from that
 described in the text.   The staff  employed  by Dr. Pancoast in his operation, is
 one of considerable curve, and is held by an assistant so that  the convexity of
 the  instrument shall bulge somewhat forward  in the  perineum.  The knife
 which he prefers is an  ordinary scalpel slightly concave on the back.  This is
 made to reach the groove by the usual incision, and the blade  being lateralized,
 is held like a gorget, with its point in the groove of  the staff.
   The operator  then takes the handle  of the staff  in his  left hand, and as he
 brings  it down, carries by the same motion the  blade  of the knife  and the
 curved portion of the staff upwards in the direction  of the longitudinal axis of
 the  bladder.   The edge of the knife in its  transit will thus effect the necessary
 division of the prostate gland.  The peculiarity of this manoeuvre  depends upon
 the  fact, that the position of the knife with regard  to the  staff, is not changed
 during the execution  of  the process just  described.  The point of the blade
 held fixed  in position  enters the  cavity of  the  bladder  synchronously with
 the  curve of the staff against which it rests; and it is not thrust forwards along
 the  groove of the latter, according to the usual custom.    ^   _
   The advantages possessed by this procedure are, in  the estimation of Vr. .Fan-
 coast, the  facility and  quickness with which it is performed^ the diminished
 risk of injury to the rectum, and  the comparatively limited division of the pro-
state gland.   In  consequence also  of the  upward movement of the  knrie, an
absolute degree  of immunity is  afforded to the base of  the bladder  so  fre-
quently wounded by the horizontal thrust" of the  instrument  through the pro-
state gland, which, it  must be remembered, is often depressed by  the staff,
nearly to the  level of the lower fundus.                   .
   In the opinion of Dr. Pancoast there is also  much less risk of hemorrhage
as the circular movement of the knife divides to a less extent, the vascular and 
918                  STONE  IN THE BLADDER.
dilatable parts anterior to the prostate, for the protection of which the angular
knife of Blizard was devised.]
  But another obstacle exists which will prevent the dilatation of the neck of
the bladder to any very material  extent, without an amount of bruising, or
laceration, or even rupture that would probably prove fatal to the patient.  This
obstacle consists of a tissue, which has been described  by Mr. Tyrrell as " an
elastic ring" surrounding the neck of the bladder; by Mr. Liston, as " a fibrous
or ligamentous band surrounding the orifice of the  bladder, into  which the
muscular fibres of  the  organ are  inserted."  If this band be ruptured, either
by the finger or by the expansion of the forceps, fatal consequences will ensue;
but if it be divided, the other tissues, as Mr. Liston  observes, will yield to an
inconceivable  extent, without injury to the ilio-vesical fascia.
  In thus describing the mode of incising the prostate and neck of the bladder,
I have, generally, used the term " dilatation;" and I believe, that by a simple pro-
cess of dilatation or  expansion of these parts, and without any violence what-
ever, small calculi of or under an inch in diameter may be extracted.  In fact,
for the removal of such stones, no  force whatever is required, either  in opening
up the  prostate or  in withdrawing the  calculus.   But  in  removing stones  of
greater magnitude  than this, I believe that the process of expansion  of the pro-
state and neck of the bladder, whether effected by  the finger, a blunt gorget, or
the opening up of  the blades of the forceps, is a process of laceration  rather
than of dilatation, as I have frequently had occasion to observe in experiments
on this point made on the dead  subject.  This laceration is, however, confined
to the  substance of  the  prostate,  and  does  not  extend  through its  capsule, or
into the fasciae of the pelvis, without the employment of an extreme degree of
violence,  which would probably prove fatal.
  3d. The next stage  of the operation consists in the extraction of the stone.
A pair of forceps  of sufficient length and size, proportioned to that  of the cal-
culus, and previously warmed  by immersion  in tepid water, must be slid along
the  index finger, which is  kept in the wound, and by which the neck  of the
bladder should be drawn somewhat down so as to meet the instrument.  In this
way, also, the stone may often be fixed by the point of the finger, and its posi-
tion thus accurately determined.   The forceps  having  been introduced closed,
the finger is withdrawn, when  a gush  of urine will usually take place through
the wound, if that fluid have not already escaped  at  the time that the incision
                                                      is made through the pro-
                                                      Btate.   By  this  gush
                                                      the calculus may,  as
                                                      Mr. Fergusson observes,
                                                      sometimes  be  carried
                                                      into the  grasp of the
                                                      instrument;  most com-
                                                      monly,  however,  the
                                                      stone requires to be felt
                                                      for with the closed for-
                                                      ceps.   When its posi-
                                                      tion  has  been ascer-
                                                      tained, usually at the
                                                      inferior   fundus,  the
                                                      blades are opened, and
                                                      by pushing one against
                                                      the wall of the bladder
                                                      and giving it a slight
                                                      shake,the calculus gene-
rally drops  between  them,  though occasionally it  is somewhat troublesome  to
seize, and this indeed often constitutes  the  most tedious and annoying part  of
 
             LATERAL  OPERATION OF LITHOTOMY.          919

the operation.   The forceps having the stone in their grasp are then closed and
the stone drawn downwards through the wound.   If it be  small, it may be
extracted at once without any difficulty; if of moderate size, the finger should
be introduced along the blades, in order to feel whether it is in a proper posi-
tion for extraction.  If its long axis lie across the wound, this must be changed,
and it must then be withdrawn by a kind
of to and fro movement in the direction of             Fig. 383.
the axis  of the pelvis  (fig. 382).   Should
the stone be broken,  or should  there  be
several small calculi, they may generally be
best removed by means of the scoop (fig.
383).  In  the event of fracture occurring,  ^gRaT^
it would be  necessary to wash   out  the
bladder with  tepid water, injected by means of a brass syringe, through a tube
introduced by the wound.
   In children, and  indeed in most cases  in which the perineum is not very
deep, so that after the introduction of the finger the  stone can be felt and hooked
forwards, the scoop is  a most convenient  instrument for its extraction, and in
these cases I usually employ it in preference to the forceps.
   After  the calculus has been removed it must be examined for facets, or the
interior of  the bladder explored by means of a searcher; and if other stones be
found they must be dealt with in the same way as the first.
   The gum-elastic  tube may then be introduced, and secured with tapes to a
band round the  patient's abdomen. This tube must be kept free from  coagula
by the introduction  into it, from  time  to time, of the feather of a pen.   By
means of this tube a ready outlet is given to the urine, and  the chance of infil-
tration is lessened.
   The patient must then  be removed  to a bed, which should be properly ar-
ranged by having a large square of Macintosh cloth put across  it.   On this a
folded sheet should be laid, which must be rolled up on the  further side so that
as it becomes wetted by the escape of urine, it may be drawn across from under
the patient.  This must be changed frequently in order to keep  him  clean and
dry.  A full dose of tincture of opium in barley water should then be given;
a warm flannel laid across the abdomen; plenty of  barley or gum water  allowed
for drink, and nothing but rice-milk or light pudding for diet during the first
three or  four days.   After this some broth may  be allowed, and  the quality of
the  food gradually increased.  Occasionally, however, it may be necessary to
depart from this rule.   I have, indeed,  on several occasions found it necessary
to depart from the  routine system of dieting the patient after lithotomy, and
have with  great advantage allowed wine, and even brandy, a day or two after
the  operation.   In an old man,  on whom I recently operated at the hospital,
there was  so  great  a  tendency to depression, that  it became necessary to  ad-
minister  the brandy-and-egg mixture freely from the first, and to this I believe
he owed  his good recovery.
   At the end of thirty-six or forty-eight  hours the tube may be removed, the
sides of  the incision by that time  having  become glazed over, and little danger
of  infiltration  existing.  The  water continues  to  flow entirely through the
wound for the first four or five days.   About this  time it frequently suddenly
ceases to do so, escaping by the urethra.   This is owing to the prostate  be-
coming turgid by inflammatory action,  and thus blocking up the  aperturein
it; but as  this  swelling goes  down, in the course of a day or two, the urine
usually escapes  by the wound  again, and  continues to do  so in gradually  de-
creasino-  quantities until the aperture is finally closed, which usually happens at
about the end of fourteen or eighteen days; though in patients who suffer from
phosphatic calculus  it sometimes takes a longer period, owing to  the  broken
state of  the  general  health.   After the  operation appropriate  constitutional
 
920
STONE IN  THE  BLADDER.
treatment should be  continued for some time in order to prevent a recurrence
of the disease.
  Lithotomy in children  is performed much in the same way as in the male
adult; though it is worthy of note that the urethra will  commonly be found
larger than might  be expected from  the  age of the child, readily admitting a
No.  8 or 9 staff.  The  perineum  also is usually proportionately more vascular
in consequence of  the irritation  and  straining.  The  most  important point,
however, is, that in the child the bladder lies high, being rather in the abdomen
than in the pelvis; hence, it is of importance to raise the point of the knife
somewhat more than in the adult in  making the deep incision, and to be careful
that it does not slip into the recto-vesical space,  which may happen unless this
precaution is taken.  I have known this occur in  several  instances to hospital
surgeons;  the forceps being  passed  into this space under the supposition of its
being the bladder, and in every case the patient died unrelieved. This accident
is the more likely to  happen, because  in children  the parts are very yielding,
and readily admit of being pushed before the  knife or finger, and  the finger
may thus pass between the neck of the bladder and the pubes, or into the loose
cellular tissue of  the  recto-vesical space.  The urethra  being opened urine
escapes, and the surgeon  gets his  finger into a distinct cavity, which he believes
to be the interior of the bladder, but which is not so, but the recto-vesical space.

   DIFFICULTIES  DURING AND  DANGERS  AFTER  LITHOTOMY.

   The  difficulties during  the operation are two-fold; — getting into the bladder,
and extracting the  calculus.
   The  difficulty of getting into the bladder is rarely experienced.  It may, how-
ever, arise in  consequence of the surgeon  neglecting to keep the point of the
knife well lodged in the groove  of the staff, and  thus  letting it slip into the
recto-vesical space, the tissue of which being broken up,  leaves a kind of cavity
that he mistakes for the interior of  the bladder.  If the perineum is very deep
and the prostate enlarged, he may also experience some difficulty in reaching
 the bladder, but he  can  scarcely fail  to do so if he push  the knife well on in
 the groove of the staff,  and dilate the incision in the prostate with a blunt
gorget, if his finger fail to reach the cavity beyond it.
   If, after the groove in the staff has been exposed, care  is not taken to insin-
uate, as it were, the nail  into the  opening in the urethra thus made, the mem-
branous portion may be  torn across, and the neck of  the bladder may easily be
 pushed away  from  the surface, receding before the finger, the surgeon failing in
 reaching its cavity.   When the road  is once lost in this way,  there is the very
 greatest difficulty in  finding it again.   The course that should be pursued is, I
 think,  as follows:  If the staff has not been withdrawn, the surgeon must again
 place the knife in its groove, and carefully push it on towards the  neck of the
 bladder,  notching  that structure and passing the finger  cautiously  along  the
 groove, and hooking down, as it were, the parts  with his nail until he reach the
 inside  of the  bladder.  Should the staff have been withdrawn, the surgeon must
 endeavor to pass it again; if he succeed in this, he may act as just stated;  but
 if he cannot succeed in introducing the staff fairly into the bladder, he must, on
 no account whatever, endeavor to open that viscus, or continue his attempts at
 the extraction of the calculus, but should at once  abandon the operation until
 the parts have healed, and then repeat it.  The great danger in these cases arises
 from the  surgeon  losing his  presence of mind, and  endeavoring to enter the
 bladder without a  guide, a procedure  that  must be unsuccessful, and can  only
 end in the destruction of the patient.
   In adults,  the difficulty is to get out the stone;  in children, to get into the
 bladder.
    Difficulty in seizing the stone  not unfrequently occurs.  This is likely to 
DIFFICULTIES  IN LITHOTOMY.               921
happen in all those cases in which, whether from the depth at which the bladder
is from the surface, or the peculiar position of the calculus, the stone cannot be
felt with the finger after the incisions have been made  into the neck of the
bladder.   This is especially apt to happen if the  patient is old and fat, and has
a deep perineum, with perhaps some enlargement of the prostate, which consti-
tutes the greatest difficulty in this respect, the calculus  resting behind  it in the
deep fundus of the bladder.   In such  cases as these, long and curved forceps
should be used.   So, also, if the stone is very round, it is usually more difficult
to seize than when flat or elongated.  Flat, disc-shaped calculi, however, occa-
sionally fall into the fundus of the bladder behind the prostate, and then cannot
be readily reached by the forceps, which pass over them.  Under these circum-
stances they are best  extracted by the  curved scoop.
   Difficulty in extracting the calculus  is far more frequently met with than in
reaching the bladder.   This  may be owing to a variety  of causes.  The position
of the stone may be such that it can scarcely be reached with the forceps; thus,
when it is situated in the  upper fundus of the bladder above  the  pubes, it is
altogether out of the axis of the incision, and in such a case can only be extracted
with great difficulty.  Key recommends that in such cases the abdomen should
be compressed, and thus the  calculus pushed down into reach.  This suggestion
is a  very useful one;  and it was only by employing this manoeuvre, and using a
very curved scoop, that I could remove a calculus lodged  above  the pubes, in a
patient whom I cut at the hospital some years ago.
   The calculus may be  lodged in the  lower fundus,  behind  an enlarged  pros-
tate. Here the best plan is to use a much-curved pair of forceps, and to tilt the
bladder up by introducing  the finger  into the rectum, and thus bringing the
stone within reach.
   Difficulty in extraction may occur in consequence of  the stone being in some
way fixed to, or retained in the bladder;  thus, a small calculus may be envel-
oped by the folds of the mucous membrane, and in this way elude the grasp of
the forceps.  Under these circumstances, there is nothing for the surgeon  to do
but  patiently to try to  disentangle  and remove  the  calculus by means of the
finger and scoop, if it can be  so reached; if not, by expanding the forceps in the
bladder, to try to push aside  the mucous membrane that surrounds it.
  In consequence of  spasm of the bladder, it has occasionally happened that a
calculus is so firmly fixed as not to admit of the application of  the forceps, the
blades of which  cannot  be introduced between the walls  of the viscus without
using an improper degree of  force, and giving rise to the danger of rupturing
the  neck of the bladder.   Under  these  circumstances,  I  think it would  be
safer for the surgeon  to  desist from  the operation, and in the  course of a few
hours or the following day, when  the spasm might possibly be relaxed, complete
the extraction, and thus perform the operation " a deux temps"  of Deschamps.
  The stone may be so  fixed  between hypertrophied fasciculi in the interior of
the bladder, as to be detached with  considerable difficulty.  In  such  cases as
these the scoop will  be  found to be the  most useful instrument.  When the
calculus is encysted, its  extraction  will probably be  impracticable, or attended
with the most dangerous consequences.  Hence, it is expedient  not  to operate
in cases of  encysted calculus that  are known to be such.  If, however, the
surgeon has been unfortunate enough  to cut into a bladder containing an en-
cysted  calculus, he must be guided in  the course  he should adopt by the condi-
tion  in which he finds the stone.  If the aperture leading into the cyst be very
small, as in fig. 359, the  better plan will be to proceed no further with the opera-
tion, as it would be clearly impossible  to remove  the stone.   If, on the other
hand, the aperture into  the cyst  be  large, he might feel  disposed to make  an
effort to extract the calculus.   With  this view he  might adopt the plan pursued
by Sir  B Brodie in such a case, and endeavor to  enlarge the  orifice of  the cyst
by means of a probe-pointed bistoury cautiously applied, and then finish the ex- 
922
STONE IN THE  BLADDER.
traction by  means of a scoop.   Such a proceeding, however, is in  the highest
degree hazardous, on account of the readiness  with which  the section might
extend into the  peritoneal cavity; as well as difficult in execution, from  the
depth at which the parts are lying.  I believe that a calculus  may occasionally
be encysted, or rather encapsuled, in another way, — by being covered in by a
kind of false membrane whilst lying on the floor of the bladder. This condition
I found in a child that I cut for stone some years ago. After removing a calcu-
lus about the size of a pea, I felt, with the end of the finger,  a hard,  irregular
body, covered apparently by mucous membrane, lying at the inferior fundus of
the bladder.  On scraping through the membrane covering this with the point
of the nail and a curved scoop, I exposed the calculus (fig. 357), and  removed
it, with a cyst  attached to it.   On  examining the structure of  this cyst, which
was about the thickness of ordinary writing-paper,  of a reddish color, and re-
sembling a piece of mucous membrane, it was found to  be a  false  membrane,
composed of organized fibro-cellular tissue.  The patient made  a good recovery,
with  the exception of a slight attack of secondary hemorrhage which occurred
on  the eighth day after the operation.
   The principal difficulty in extracting a calculus generally depends upon  the
shape and size of the stone.   Very flat, broad calculi, those that are round, egg-
shaped, or branched, are the most difficult to remove, even though  their size be
not very great.   As a general rule, however, it may  be stated  that the larger
the calculus, the more  difficult is its extraction.   This arises not so much from
the outlet of the pelvis being too narrow, but from the necessity of making the
internal  incisions through the  prostate to a very limited extent.   There will
always be considerable difficulty experienced in  extracting calculi weighing six
or eight ounces and upwards, though  cases are recorded by Cheselden, Klein,
and others,  in which calculi from twelve to fifteen ounces in weight have been
extracted by the lateral operation.   Any calculus above one-inch and a quarter
in its shorter diameter will present considerable  difficulties in being extracted
through  an  incision in the prostate of the ordinary size;  viz., about eight lines
in length, even though this be considerably dilated by the pressure of the fin-
gers ; and, I think it may be safely said, that a calculus two inches and upwards
in diameter, can  scarcely be removed by the ordinary lateral operation  with any
degree of force that it is safe to employ.  In the facility with which the calculus
is extracted, however, much  will depend upon  the make of the forceps.  As
Liston most truly observes, " There can be no more fatal error than to attempt
the extraction of a large stone with short  and shabby forceps."  In these cases,
I think  the open-bladed forceps (fig. 372) will be found useful, the absence of
metal in the most convex part  of the blade lessening materially their diameter
when grasping a stone.
   In the event of the calculus being too large to be extracted by  the ordinary
lateral operation, what course  should the surgeon pursue ?  Three are open to
him : 1st. The division of the right side of the prostate from the interior of the
wound.   2d.  Crushing the calculus in the bladder,  and then removing it;  and
3d. The performance  of  the high  or supra-pubic operation.   The incision of
the right side  of the prostate gives considerable additional space,  and is suffi-
cient for most ordinary purposes;  very large  calculi  being  fortunately very
rarely met  with.  This section may be  made by introducing a probe-pointed
scalpel (fig.  365) into the wound, guided by the index finger, and cautiously divi-
ding the right side of the prostate downwards and  outwards, in the same  way
that the section of the left  has been made.   This procedure must be carefully
done, with due regard to the important parts in the neighborhood of the gland
In two cases I have seen Mr. Liston do this.  In one the patient recovered, in
the other he died of diffuse cellular inflammation  of the  pelvis; and  I  had
occasion recently to practise it on  a  patient whom  I cut at the hospital, and
who made an excellent recovery. The second plan, that of crushing the calculus 
DIFFICULTIES IN LITHOTOMY.
923
Fia. 384.
in the bladder through the wound in the perineum, would certainly be a very
hazardous procedure.  The irritation that
would necessarily be set up by the large
lithotrite or crusher (fig. 384) that has
been invented  for this purpose, by the
presence of the fragments  of stone, and
by  the  necessary difficulty and  delay  of
clearing them  out  of the  viscus, would
probably be fatal to the patient.  In the
event of its being impossible to extract
the  calculus through the  perineum, I
think it would be  safer to  adopt the
third course, and to  perform the high
operation,  which will presently be  de-
scribed.
   The principal accidents that may occur
during  the performance  of the  lateral
operation of lithotomy are hemorrhage;
wound  of the rectum; cutting  the bulb,
 or  missing the membranous portion of the
 urethra.
   Hemorrhage  during lithotomy  may
 occur  from  three  sources: — 1st. The
 superficial arteries of  the perineum; 2d,
 the deep  arteries  of this  region;  and,
 3d, the prostatic  veins.   Hemorrhage
 from the division of the superficial or the
 transverse artery of the perineum is sel-
 dom of a very serious character, though
 occasionally if these vessels are of larger
 size  than  usual,  they may  furnish  a
 serious  quantity of blood; under  such
 circumstances  their  ligature would  be                        •    » i.    i
 required, and might be practised either before or after the extraction of the cal-
 culus   It is  better,  if possible, to wait  until the completion of  the operation,
 lest the ligature be pulled off during the  removal of the stone.  The division of
 the deep arteries of the perineum, that of the bulb and the internal pudic, will
 be attended by far more serious  and perhaps even fatal consequences; as, from
 the depth at which the vessels  are seated; it would almost  be impossible  to
 apply a ligature to them unless the patient be very thin, and the perineum propor-
 tionately shallow.   In the event of a ligature not being applicable, the surgeon
 would  have to trust to plugging the wound  around the tube, or to the pressure
 of an assistant's fingers continued for a considerable time.   The pressure of the
 fingers of relays of assistants, kept up for a considerable length of time  is per-
 haps the surest mode of arresting the hemorrhage.   The pressure must be kept
 up for many hours; thus South  relates a case in which  it was  maintained for
 fourteen hours, and Brodie one in which, after twenty-four hours, it succeeded.
 The assistants should not be changed more frequently than necessary, each keep-
 in* up pressure for two or three  hours, and  removing his fingers as cautiously as
 possible  It is, doubtless, very rare for these arteries to be  wounded when they
 follow  their usual course, though such accidents ^W^^j£^  ft
 some of the most skilful lithotomists, such as Home, Bell, Roux, and .Desault.  It
 waTthe opinion of the late Mr. Key that the artery of the bulb was generally
 Z dnrinSTithotomy, but  in this I believe he was mistaken so far as its trunk
  s concerned,  though doubtless  in  many cases the bulb itself may be wounded,
 and the S  0f twigs in which the vessel terminates divided;  but this would
 Totyie d an alarming°hemorrhage.  The trunk  of the artery of the bulb would,
 
924
STONE  IN THE  BLADDER.
however, be endangered by opening the urethra too high up, and lateralizing
the knife too early, and might bleed very freely.
   The internal pudic artery, bound down by a strong fascia and under cover of
the ramus of the ischium, runs but little risk unless the knife be lateralized too
much, and the incision be carried too far outwards.  It is in some of the anoma-
lous distributions of these vessels that the greatest danger would be occasioned.
The artery of the bulb, the inferior hemorrhoidal, the dorsal artery of the penis,
or the internal  pudic may take such an anomalous course that their division
must be inevitable;  and as the surgeon has no  possible means of knowing
beforehand whether the distribution of the  arteries is regular or not, and as
his incisions are all planned on the supposition that they are, he is not to blame
in the event of a vessel  being accidentally divided when  taking an abnormal
direction, which it is impossible to be acquainted with until  after  the accident
has occurred.
   Venous  hemorrhage of an alarming and even fatal extent has been known to
occur from division of the prostatic plexus.   This is especially apt to  happen in
old people, in whom these vessels not only become greatly enlarged, but do not
readily contract on  account of the rigidity of the neighboring parts.  Plugging
may avert  this.
   A wound of the bulb is not  of very uncommon occurrence in lithotomy, and
I believe is of no consequence beyond furnishing a small additional quantity of
blood.  Indeed, the bulb is so situated, in many cases overlapping the mem-
branous portion of  the urethra, that this can scarcely be opened without wound-
ing it.  In other  cases,  again, the surgeon may go into the  opposite extreme,
and open the urinary passages altogether beyond the membranous portion of the
canal.  I was present some years ago at the post-mortem examination of a fatal
case of lithotomy, in which perhaps the most skilful operator of that day had
opened the bladder beyond the prostate, leaving the urethra altogether untouched.
   Wound  of the rectum may occasionally occur either in  consequence of the
staff being too much depressed, the edge of the knife turned  too directly down-
wards, or the rectum being distended and overlapping the sides of  the prostate*.
If the aperture in the gut be but of moderate size, it will probably close as the
wound  granulates and fills up.   If, however, the incision be  more extensive
there will  be the risk of  a recto-vesical fistula being induced;  under  such
circumstances,  treatment such  as  recommended  for  that disease should be
adopted;  or, perhaps it might be better at once to meet  the difficulty by laying
open the rectum through the sphincter into the wound.

   SOURCES  OF  DANGER   AND CAUSES  OF  DEATH  AFTER
                              LITHOTOMY.

   Lithotomy, even in healthy subjects,  is always a dangerous  operation, and
though the rate of mortality doubtless depends greatly upon the dexterity and
skill of the operator, more  is, I believe, due to the constitution and age  of the
patient.   Sir  B. Brodie most  justly  says, " Success  in  lithotomy most un-
doubtedly  depends in a great degree on the manual skill of the surgeon, and on
the  mode in which the operation is performed;  but it depends still more on the
conditions of the  patient with respect to his general health, especially on the
existence or non-existence of organic disease."   That the mere cutting into the
bladder is not a very  dangerous  proceeding,  provided  that  viscus and the
kidneys are healthy, is evident from the fact that in those  cases in which
surgeons have had  to extract bullets, bits of catheter, &c, from this organ, bad
consequences  have rarely  occurred, though the operations  have often  been
tedious; but in lithotomy the case is different, for here the bladder is not only
usually in  a state of chronic irritation, but the kidneys are frequently diseased,
and these conditions  influence more materially the result of these  operations 
I
                    DANGERS  OF  LITHOTOMY.                 925

than any other circumstances.   Hence an operator may have  a run of unsuc-
cessful cases; or by a fortunate concurrence  of favorable cases it has occasion-
ally happened that  a surgeon has  cut 20 or 30 patients in succession without
losing  a single one; but several deaths then occurring, though  the operation
was performed in the  same way and with the  same care as before, his average
falls to about the usual level.   The late Mr. Lynn had cut 25 patients without
losino- one, and he said that he thought he had at last discovered the secret of
performing lithotomy with success; but, he added, the  Almighty punished him
for his presumption, for he lost the next  4 cases that he  cut.  Mr. Liston,
during a  period of six years, in which he  operated  24 times, lost no patient
from  lithotomy at University College Hospital; but out of the whole 37 cases
which he  cut during the period  of his connection with that  Institution  there
were 5 deaths; reducing the  average to 1 in 7-2.  This success was, however,
very "Teat when it is taken into consideration that most of these  cases occurred
in adults, and that many of them were  of a very  serious character.   I find on
reference  to the  Hospital Records, that only 7 of the patients were under 10
 years of age, whilst 14 were above 50; of these, two were 80 years of age, of
 whom one  died  and the other recovered.   I believe that Mr. Liston only lost
 one patient under 60 years of age, and that was a lad of 18 in whom he  found
 it necessary to divide the right side of the prostate as well as the left, and who
 died of infiltration  of  urine.  Thirty-eight  patients, successively operated on at
 the Norwich infirmary,  recovered; but the average rate  of mortality in that
 Institution, calculated from  704 cases, has been  1 in 7|.'  Cheselden only lost
 1 in every lOf;  and according to  Mr.  South at St. Thomas's, the mortality has
 not amounted to more  than 1 in 9f;  but a good many of these patients were
 probably  children.   Sir B. Brodie states, that  of the 59 cases operated on in all
 the London Hospitals in the year 1854,  10  died;  making the  mortality as
 nearly as possible 1 in 6.  According  to Mr. Coulson the average mortality in
 England  deduced  from  1743 cases of the lateral operation  is 1 in 693  cases;
 whilst in France it is  1  in 5-7; and for Europe generally 1 in 5-14.
    Age exercises a  marked influence on the result of lithotomy; which may be
 looked upon as one of the most successful operations in surgery at early periods
 of life, a hazardous one at middle age, and  an extremely dangerous  one  at
 advanced age.   At the Norwich  Hospital lithotomy has been found to be four
 times as fatal in adults as in children.  Mr. Coulson finds  on  analyzing 2972
 cases of  lithotomy that  the mortality  at each successive decennial period is  as
 follows.   Below 10 years it is 1 in 13, and thence gradually augments from 10
 to 80 years to 1  in 9,  1 in 6, 1 in  5, 1 in 4, 1 in  3-65, 1 in 3-23, 1 m 2-71.
    The shock of the  operation occasionally proves fatal, though probably much
 less  frequently so  since  the introduction of chloroform, than was formerly the
 case.   Yet, even now,  patients occasionally die from this cause, induced eithe
 by a very much prolonged operation, or by the system  being  weakened, and
 hiving lost its resisting power in consequence of disease of the kidneys perhaps
 of a latent character   A  prolonged operation,  even  under chloroform
 dangerous, and although it is certainly not well to operate against^ tame, yet
 is undoubtedly advantageous  to finish the operation ^  » ^J^JJ M *
 consistent with the safety of the patient even though he .be ««*f ^
    Hemorrhage does not so often prove fatal, either shortly after the operation
 or atTkter period, as might be expected  from the great vascularity of the
   ar   Ltd. "Secondary hemorrhage*; of a dangerous oreven  a  al character
 may, however,  come on six, eight or ten days  aftei^ the^operation    1  have



 not givmg any externa  evidence oi                   d   ith          or  hnt
 hemorrhage will usually cease on piugain0 
926
STONE  IN THE BLADDER.
soaked in alum solutions.   Should it prove serious, however, the actual cautery
may be advantageously employed.  In a case  that occurred to me on the ninth
day, the bleeding was stopped by wiping out the wound with the actual cautery,
a practice that  Mr. A. Dalrymple  informs  me was  occasionally  successfully
practised by that excellent lithotomist, his father.
  Diffuse inflammation of the cellular tissue of the pelvis, especially of those
layers around the neck of the  bladder, between it and the  rectum, and  that
extend from thence under the peritoneum, is the most frequent  cause  of death
after lithotomy. This inflammation, which is always of the diffuse or erysipeloid
kind, followed  by rapid  sloughing  of the textures that it invades, may arise
from two causes.
   1st.  From the urine getting infiltrated into the cellular tissue, in  consequence
of the incision extending beyond the limits of the prostate, into the loose layers
of tissue that surround that gland.
   2d. In consequence of the bruising and laceration to which the neck of the
bladder, the prostate and  the textures between it and the rectum are subjected,
in prolonged attempts to extract a large  calculus from  the bladder.
   The danger of cutting beyond the limits of the prostate has already been ad-
verted to.   In the extraction of calculi of ordinary size there can  be no neces-
sity to extend  the  internal incision; but when  the calculus  is of  considerable
magnitude, the  surgeon,  wishing to get  as much space as possible, may inadver-
tently carry his knife beyond the prostate; or, if he make a  cut into the right
side of this gland,  he may perhaps prolong it a little too far,  and thus open the
loose cellular tissue or fascia that surrounds it, and that is continuous with the
pelvic and sub-peritoneal  planes of cellular membrane.  By dilating the incision
in the prostate  downwards and  outwards, either with the finger or with  a blunt
gorget, the dense envelope surrounding the gland is not divided, and injury to
this tissue is prevented.
   If the incision extends beyond the prostate, the  urine, as  it escapes through
 the wound, sinks into the meshes of the loose cellular tissue over which it flows,
 and  thus  gives rise to infiltration, followed  by rapidly extending  inflammation
 and sloughing,  which speedily  involve  the whole of  the neighboring textures.
 This mischief generally  occurs within  the first forty-eight hours, and  is  indi-
 cated by the patient being  seized with rigors, followed by dry heat of skin, a
 quick pulse, which, after a time, may become intermittent, and a dry and brown
 tongue.  At the same time he will complain of some tenderness about the lower
 part of the abdomen, and in  the groins; the belly becomes tympanitic, the body
 covered with a profuse sweat; hiccup comes on, the pulse becomes more  weak
 and fluttering, and death usually occurs about  the fourth  or fifth day after the
 operation.  In  some  cases there are more decided signs of peritoneal inflamma-
 tion ; but, as Brodie very truly remarks, this is not the primary disease, but is
 only induced secondarily by the inflammation and sloughing of the cellular tissue
 of the pelvis spreading to the contiguous serous membrane.
   The  treatment of such cases must  be conducted on the  ordinary principles
 that guide us in the  management of diffuse inflammations.   It is only by admi-
 nistering ammonia with  such a quantity of wine or brandy as  the state of the
 system  may indicate, together with such nourishment  as the patient can take,
 that life can be preserved.  The  disease is a depressing one, and requires a
 stimulating plan of treatment.   Brodie has recommended that in these cases a
 free incision should be made through the sloughy  tissues about the wound into
 the rectum, in  accordance with the general principles that guide us in the ma-
 nagement of similar affections elsewhere.  In one case of the  kind  that occurred
 under his care, he saved the patient by passing a curved probe-pointed  bistoury
 into the wound to its furthest extremity, to the left side of the neck of the blad-
 der; he then pushed it through the tunics of the rectum, and, drawing it down-
 wards, divided the lower part of the gut together with the sphincter; thus laying 
HIGH  OR SUPRA-PUBIC  OPERATION.          927
the wound and the rectum into one.   The relief was immediate, and the patient
recovered.   This plan of treatment certainly seems rational and worthy of trial
in similar cases.
   Diffuse inflammation of the cellular tissue around the neck of the bladder and
prostate  arising  from bruising and over distension of the parts during the ex-
traction of a large calculus  is, I believe, a more  frequent occurrence than infil-
tration of urine, and fully as fatal.  This sequence of lithotomy is especially apt
to occur in those  cases  in  which, in consequence of diseased kidneys, or the
existence of other organic  mischief, the  patient is more than usually liable  to
the supervention of diffuse or erysipeloid inflammation; indeed it is in this indi-
rect way that I believe diseased kidneys constitute such  a formidable obstacle to
the safe performance of lithotomy.
   In the extraction of large calculi, considerable traction is required and force
 must be exerted, hence undue bruising and pressure are very apt to be inflicted
 upon the parts  that constitute the line of incision.  It is  in  this way that the
 danger of  lithotomy increases almost in exact proportion to the size of the cal-
 culus :  for here the  surgeon  is often placed between the horns of a dilemma.
 He must either cut beyond the limits of the prostate and thus incur the risk of
 inducing urinary infiltration of, or diffuse inflammation in, the pelvic fasciae; or
 else by limiting his incision to the margin of the gland, and thus having, per-
 haps, an aperture  of insufficient size, inflict severe  injury by the bruising and
 laceration  of parts during  forcible and  possibly prolonged efforts  at extraction.
 It must, however,  be borne in mind, that the larger the stone the more proba-
 bility is there of the existence of old-standing disease of the bladder or kidneys,
 and an unfavorable result  from this cause.   Mr. Crosse, of Norwich, has drawn
 up a table  that shows the  influence of the weight, or in other words, the size of
 a calculus on the results of lithotomy.   He found that when  the  stone was one
 ounce  and  under  in weight,  the deaths were  in the  proportion of 1 in 11-25
 cases.   When  from 1  to 2 ounces in weight there was 1 death  in 6-61 cases.
  When from 2 to 3 ounces 1 death  in 2-18 cases.  When from 3 to 4 ounces 1
  death  in  1-57  cases.  When from 4 to 5 ounces 1 death in 1-66 cases.   This
  table, which has been constructed on  the results of 703 cases,  illustrates very
  clearly the fact, that the  operation for the removal of a large calculus, is  far
  more dangerous than that  for the extraction of a small  one.
    The symptoms of diffuse inflammation of the cellular tissue arising from  the
  cause  now under  discussion, very closely resemble  those from  infiltration of
  urine,  and the treatment must be conducted on precisely similar  principles.

                HIGH  OR  SUPRA-PUBIC  OPERATION.

    Although the lateral operation for lithotomy is perhaps the safest for the ex-
  traction of stones of small or moderate size, yet there  can  be no doubt that its
  results are extremely unfavorable, as has already been shown, when the calculus
  exceeds a certain  magnitude; and under these  circumstances it may be deemed
  expedient to  perform the high operation in preference to it.   It is fortunate,
  however,  that large calculi are comparatively rarely met with.  Thus of the 7Ud
  Norwich  cases, that form the basis of  Mr. Crosse's tables, and  indeed of  our
  chief  information  on  these  points, 529 were  under  1 ounce in weight;  liy
  weighed  from 1 to 2 ounces; 35 from 2 to 3;  11 from 3 to 4;  5 from 4 to 5;
  and only 4 were  above this  size.   Hence if we confine the high operation to
  those  instances in which  the calculus is above such a size as will  readily  admit
  of extraction through  the perineum, we shall seldom have occasion to perform
  it;  but yet instanced occasionally occur in which no other method of extracting
  the calculus presents itself.   Thus, by this method, M. Uytterhoeven succeeded
  in  extracting a calculus, of which he  has  kindly given  me a cast which rnea-
  sured  16* inches in one circumference, and 12* in the other, which was per- 
928
STONE  IN  THE BLADDER.
fectly moulded to the shape of the inside of the bladder, and which clearly could
not have  been removed by any incisions through the  perineum, as the outlet
would  have been insufficient for its  extraction.   The patient survived  the  ope-
ration eight days.  But not only may the high operation be required on account
of the size of the calculus, it  may  be  rendered necessary by the existence of
such rigidity about  the hips in consequence  of rheumatic disease,  as would
prevent the  proper  exposure of the perineum; or, that  region  might be the
seat of  disease  that would interfere  with any operation  being  practised
through  it.
   The high operation consists  in making an incision  through the abdominal
wall, above the  pubes, and  opening the anterior part of the bladder under-
neath  the reflexion  of the peritoneum that passes  upwards from  its superior
fundus.
   In performing this operation, it is necessary that means should be taken to
raise up  the fundus  of the bladder,  so that it may project above the pubes, and
thus admit of being safely opened.   With this view various contrivances have
been invented, such  as catheters containing sliding stylets, which  can be pushed
through the bladder when  that viscus is exposed.   These instruments, though
ingenious,  are not  necessary, for the end of an ordinary catheter introduced
through the urethra, and  made  to  project above the pubes, would serve  as a
sufficient guide.  In performing  the operation, an incision about four inches in
length should be carried from the  pubes  directly upwards  in  the  mesial line.
The pyramidales are then to  be cut across near their  origin,  the linea  alba
exposed,  cautiously  opened near  the pubes, and divided  upwards some little
way.   The peritoneum must next be pushed back and the dissection carefully
carried through the cellular tissue  above  the bone, until the instrument previ-
ously introduced can be felt through the bladder, when, if it contain a sliding
and pointed stylet,  this may be  pushed through the coats of the  bladder; if
not, an incision must be made down upon  it, and  the aperture in the organ
enlarged downwards  towards the neck of the bladder by means of a probe-pointed
bistoury,  so as to admit the fingers.   The forceps must  then be introduced, and
the calculus extracted.  After the operation there will always be risk of urinary
infiltration into the cellular tissue around the margins of the wound.  In order
to prevent this,  the  older surgeons kept the bladder empty by making incisions
through  the perineum into the membranous portion of the urethra or neck of
the bladder, thus complicating seriously the operation; but this accident  may
best be  prevented  by  introducing  a  gum-elastic catheter  into the  urethra,
and leaving it there  for a few days until consolidation has taken place  and
the  wound shows a disposition  to  close, pressure being  at  the same time
kept  up  on  the  lips of  the  incision.  Another cause of danger  in  this
operation is wounding the peritoneum, which  may occur in consequence of
the  contracted state of the bladder, causing it to lie low in the pelvis, and
thus  preventing the proper introduction  of instruments to carry it up above
the pubes.
   Mr. Humphrey, of Cambridge, has collected 104 cases in which this opera-
tion has  been performed; of these 31 proved fatal, chiefly from peritonitis and
urinary infiltration, the mortality amounted consequently to 1 in 3£; and M. Son-
berbielle, one of the greatest modern advocates of this  operation, lost 1 patient
in 3.  The general  result, therefore, is by no means satisfactory, though, as in
many instances the  operation was performed in cases in which the lateral me-
thod was  not applicable, we cannot with justice compare the two procedures.

                        MEDIAN LITHOTOMY.

   The median  operation of lithotomy is  that  procedure  by which a stone  is
extracted through an incision in the raphe of the perineum, extending into the 
MEDIAN LITHOTOMY.
929
urethra behind the bulb.   An external incision having been made, and the ure-
thra opened, the membranous and prostatic portions of the canal were forcibly
dilated or rather lacerated by specially constructed  instruments, until a suffi-
ciently large  aperture was  made  for  the introduction  of  the  forceps and  the
removal of the  stone.  This operation, under the name of the " Marian," from
Sanctus Marianus,  one of its inventors,  or  "the operation of the apparatus
major," from the complexity of the instruments used, held  its ground in Europe
for two centuries, until its tediousness, the terrible pain attendant upon its per-
formance, and the  mortality following it, caused it  to  give way to the lateral
operation.   It has, however, under  various  modifications, kept its  ground in
some schools of surgery, in that of Paris  more especially, and has of late years
been reproduced in a simplified manner in Italy by Borsa and Mauzoni, and in
 this country by Mr. Allarton.
   With the old Marian operation, which has justly been  discarded from surgi-
 cal practice, we have  now nothing to do, but its modern  modification deserves
 some attention.
    The steps of the median operation as modified by Mr. Allarton are as follow:—
 The patient having been  placed in the proper position for lithotomy, and a staff
 deeply-grooved along the  convexity introduced into the bladder, the surgeon
 passes the left index finger into the rectum, and feels for the prostate.  He then
 pushes a long sharp-pointed bistoury, with the  edge turned  directly upwards,
 into the mid line of the perineum, a little above the  anal aperture, so as to open
 the membranous portion of  the urethra immediately in front of the apex of the
 prostate.   The finger in  the rectum serves as a guide to this part of the canal,
 and prevents the point of the knife  wounding the gut, warning the  surgeon of
 its too near approach. When the staff is reached the incision is carried upwards
 to a sufficient extent.  A steel  ball-probe is then passed  along the  groove into
 the bladder, and the staff withdrawn.  The surgeon, using the probe as a guide,
  now proceeds gradually  to insinuate his left index finger along it into the pros-
  tatic portion of the urethra  and the  neck of the  bladder, dilating these passages
  as he proceeds.  Having got his  finger into the bladder  and felt the  stone, he
  withdraws the probe, introduces  the forceps, and extracts the calculus in the
  usual way.  This operation  is said by its advocates to possess several advantages
  over the lateral one, being more  simple and easy of execution, attended by less
  hemorrhage, by the dilatation and not the section  of the prostate,  and admitting
  of the easy extraction of the stone.                                       .
    Let us briefly examine these  supposed advantages, and compare the mesial
  and lateral operations.                                       ...,.,,
    As to simplicity and ease of execution, there can be little doubt that that ope-
  ration will be  easiest of execution which a surgeon is most in the habit ot per-
  forming, and in this  respect the mesial and lateral  appear to me to be much on

  * With regard to the avoidance of hemorrhage, the  mesial  has certainly the
  advantage.   If the surgeon carefully cut in the middle line  no blood-vesse  of
  importance can possibly be divided, and even though the bulb be freelypoised,
  we know that, as  in the  perineal section, no bleeding of ^sequence    likely
  to ensue, whilst in the lateral, the artery of the bulb, if  not Ae internal pudic,
  must always be in some  danger; and even from the superficial vessels the bleed-

  ^e^e^j difference in the  treatment of  the prostate^s dihata
  tion in the mesial, and its section in the lateral, I believe it to be m man, c,es
  more  imaginary than real.   In the lateral operation  most «™^» »f*^£
  that the internal or deep incision should be as limited as P,°«f ^ ™Vv  fte
  ing the apex of the prostate, and  that  dilatation  ^ould be effec ed Jy  the
  pressure of the fingerf so in the mesial, the apex of theprostate is  notehed
  and dilatation is effected with the  finger.   In both cases I believe that the so
         59 
930
STONE IN THE  BLADDER.
called dilatation is in reality a partial  laceration, a breaking down or opening
out of the structure  of the  prostate rather than a true expansion of its sub-
stance.   I have often examined the prostate in the dead  subject  after it has
been subjected to this  process of dilatation, and  have always found it more or
less torn.
   The next point for comparison is as to the relative facilities presented by the
two operations for the manipulation of the  forceps and the extraction of the
stone.   In the adult, the  main  difficulty of  lithotomy does  not lie in getting
into the bladder, but in getting out the stone.  And the difficulty and danger
increase in proportion to the  size of the calculus; the tissues between the neck
of the bladder and the perineal integuments must either be widely cut or exten-
sively torn and bruised to allow of the passage of a large stone.   No amount
of simple dilatation of which these tissues  are susceptible can make a passage
through them  that will allow of the extraction of a stone H or  2  inches in
diameter;  such a stone must either be  cut or torn out.  Now what space  have
we in the median operation for the introduction of the forceps and the  extrac-
tion of  a large stone ?  Here, I think,  is the  weak point of the modern opera-
tion.   In it the incision is made, and all the manipulation is practised towards
the apex of the narrow triangle formed by the rami of the pubes.  The base
of this  triangle is represented by a horizontal line corresponding to the level of
the membranous  portion of  the  urethra, and consequently does not occupy the
widest  part of the perineum, and is formed  by the transverse muscles of the
perineum and the lower portion of the  deep fascia, supported and  filled up  by
the rectum and the tissues which are attached to and support the gut on either
side, and which  form a rigid wall  or  barrier stretching across the perineum,
which cannot be depressed, and which  requires to be divided  laterally into the
ischio-rectal fossa, before a stone of any considerable magnitude can be removed.
It was in consequence of the extensive bruising  and laceration of these struc-
tures, and the difficulty experienced in  getting the stone through them, that the
old Marian operation fell into disuse.  This difficulty, however, is only met with
in the extraction of calculi of large size. Small flat  or elongated calculi, foreign
bodies, such as bits  of broken catheter, pencils, etc. may  very readily, conve-
niently, and safely be removed through the narrow space in which the incision
of the median operation is carried.
   In summing up the comparative merits of the modern median and the lateral
operations of  lithotomy, I think it may be said that  the  great advantage pos-
sessed by the median is in the absence of all  serious  danger from hemorrhage,
but that the great objection  to it consists in the triangular space  in which it is
performed being too  narrow  to allow of the extraction of large calculi.  In the
lateral  operation  there is undoubtedly more danger from hemorrhage, but this
is more than  counterbalanced by the  greater facility for  extracting the stone.
In conclusion, I should say that in all  cases  in which the  calculus is large, the
lateral  operation  should  be  performed; but  when of small size, and especially
if narrow, whether single or multiple, the median operation, as recommended
by Mr. Allarton, might be substituted, provided it be not thought advisable, as
is now  generally done, to subject such  cases to lithotrity; and that, in cases of
the lodgment  of foreign  bodies, especially of pieces of broken  catheter, the
median possesses advantages over the lateral operation.   In the case also of cal-
culi which are too large to be successfully subjected to lithotrity, but which, if
removed by the  lateral operation, are attended by a frightful rate of mortality,
it seems to me that the median operation might possibly be advantageously com-
bined with lithotrity.   The  stone having  been broken up  at one sitting,  the
fragments might at once be  extracted  through a limited incision, in  the mesial
line of the perineum.
   The  bi-lateral operation  of Dupuytren  is a modification of the median.  In 
LATERAL  AND  MEDIAN  LITHOTOMY  COMPARED.   931
made across  the perineum, half an inch above the
Fio. 385.
it a transverse  incision is
anus,  the horns  of the
incision extending to two-
thirds of the distance be-
tween  the anus and the
tuber ischii on either side
(fig. 385). The dissection
is carefully carried  down
to the central point of the
perineum, and  the  mem-
branous  portion of  the
 urethra  is opened on a
 grooved  staff  previously
 introduced; along this the
 double lithotome cache* is
 passed  (fig.  386),  the
 blades expanded to a pro-
 per distance,  previously
 regulated, and both lateral  lobes  of the  prostate divided to a corresponding
 extent downwards and outwards in withdrawing the instrument.   The extrac-
 tion of the stone is then effected in the usual way.   This operation appears to
 me not to  have received the  attention from surgeons  in this  country that it
              deserves.  By it  the prostate is divided equally on both sides in
               its greatest diameter; if the expansion of the  lithotome is care-
              fully guarded, there is no danger of  going beyond  the  limits of
              that  organ, or of wounding the internal  pudic arteries, and the
              interior of the bladder is reached by the most direct and the readiest
               passage.  In withdrawing the lithotome, its concavity should be
               turned downwards and the handle well depressed.
                 The  median and  bi-lateral operation might, I think, be advan-
               tageously combined, and  thus the chief objections to both be got
               rid of.   This kind of operation I have often practised on thedead
               subject, and  it appears  to  me to  be  one well deserving  a trial on
               the living.  It is easy of execution, seems likely to be attended
               by little nsk  of  hemorrhage, of urinary extravasation, or of pel-
               vic inflammation, and opens  the  bladder  at the  part where it is
               nearest  the perineal surface.  It may be performed as follows:
               The patient having been tied up,  and a staff deeply grooved along
               the  convexity passed into  the bladder, the urethra is opened at
               the membranous part with the edge of the knife turned upwards,
               as described  in  the median operation; the double lithotome is
               then slid along  the staff into  the bladder, its concavity turned
               downwards, the blades expanded to but a  limited  extent, and the
               prostate and the soft structures between it and the surface incised
               as it is withdrawn.   If  the stone is of but moderate size, the in-
               cision may be confined  to  one side only,  and made with a probe-
               pointed bistoury. It will be found that sufficient space is obtained
  by the  perpendicular  incision  in  the  skin, whilst the limited transverse^cut re-
  ufoves  that tension and resistance of the  deeper structures  which inhe ™li-
  nary median operation interfere seriously with  he ^^^^^^
  and the extraction of the stone, and by the division of both sides of the prostate
  to a limited extent abundance of space is obtained.
 
932                  STONEINTHEBLADDER.
                        URETHRAL  CALCULUS.

   Calculi are not unfrequently met with in the urethra, especially in children,
passing from the  kidney perhaps  into  the  bladder, and from thence into  the
urinary canal, through which  they occasionally escape, but in other  instances
lodge, more especially at the bulb  or in the navicular fossa.  These  calculi  are
commonly of the lithic  acid, lithate of ammonia, or  oxalate  of lime varieties;
they are frequently round, but not uncommonly  elongated or spindle-shaped.
                            There is reason, however, to believe that  calculi
          Fig. 387.           may  form in the urethra.   One of the most re-
                            markable instances of this kind  is represented in
                            the annexed cut (fig. 387), taken from a drawing
                            in Sir R. Carswell's collection at University College.
                            In cases of tight stricture, sabulous or calculous
                            concretions may occasionally be formed  behind  the
                            constriction.  The presence of a calculus  in  the
                            urethra may always be determined by the difficulty
                            that is occasioned in micturition, by the possibility
                            of feeling the  stone through  the walls of  the
                            canal, or detecting it by introducing a  sound into
                            the urethra.
                               The  removal of these calculi may be effected
                            either by extraction or excision.  When situated
                            towards  the  anterior part of  the canal, a urethral
                            calculus may frequently be  extracted  by passing
                            a long and very narrow-bladed pair of forceps down
                            to it, by which  it is seized  and drawn forwards;
occasionally when it has reached the navicular fossa, it cannot be got through
the urethral orifice without dilating this by incision with a probe-pointed bistoury.
If the calculus is too large to be extracted in this way, and appears to be firmly
fixed, an incision may be made  down  upon it, through the urethra, by which it
may be removed.   It is a good  rule not to make this incision in any  part of the
urethra anterior to the scrotum, for  in consequence  of the  coverings  of the
penile portion of the urethra being very thin, the aperture  will probably  not be
closed, but a fistulous opening left.  When the stone is situated in  the scrotal
portion of the urethra, there would be some risk  of abscess and  of  urinary in-
filtration if the incision were  made through the lax tissues of the  scrotum.
Hence, it is better, if  possible, to push the stone back towards the membranous
portion of the canal, to  cut  down  upon, and extract  it here.  This operation
may readily be done by passing a staff, grooved, along its convexity,  or an ordi-
nary director as far as  the calculus, and making an incision upon the end of this,
so as to lay open the urethra; the  staff is  then removed, and  the calculus ex-
tracted by means of a slender pair of forceps. A catheter should next be passed
into, and retained in the bladder for a few days, in order to lessen the tendency
to the formation of urinary fistula.   It may happen that the  calculus, which is
impacted in the urethra, is only one of several that are lodged in  the bladder.
In order to ascertain this, the surgeon should, after removing the calculus  for
which the operation has been performed, pass a sound into the bladder, so as to
ascertain whether  any other  concretions  exist in  that organ; and  if so, they
should at once be removed by extending the incision made into the membranous
portion  of  the urethra into the  bladder, by the  lateral operation of lithotomy.
In  this way I once  saw Mr. Liston  extract two vesical  calculi  after having
removed one that had blocked up the urethra.
 
PROSTATIC CALCULI. — LITHOTRITY.          933
                       PROSTATIC  CALCULI.

  Prostatic calculi differ from all  other urinary concretions in  situation  and
composition, being formed in  the  ducts of the prostate gland, and composed
principally of phosphate of lime and some animal matter; usually about 85 per
cent, of the phosphate, to 15 of the organic ingredient.  They generally occur
in  old  people, though  they may  sometimes  be met with in young subjects.
From a lad of nineteen, whom I cut for vesical calculus, I extracted two of these
prostatic concretions.
  They are  usually of  a grey or ashy  color,  somewhat triangular in shape,
smooth and  polished (fig. 388);  having facets, being very  hard, and  seldom
much larger  than a cherry or plum-stone; though they may
occasionally attain a considerable bulk, having been  met with as   Fig. 388.
large as a hen's egg, and then  presenting a branched or irregular
appearance.   Though  usually  but one or  two  exist, which  are
sometimes deposited in  a kind  of  cyst  in the gland, as  many as
thirty or forty have been met with, its whole tissue being studded
with them.
  Prostatic calculi give rise to a sense  of weight, pain, and irritation in the
perineum, and  often occasion  a  tolerably free  secretion of  mucus from the
gland.  On introducing a sound this passes over them, striking the calculus with
a distinct click before  its beak enters  the bladder.   This is increased by the
finger in the rectum pushing the gland up, and  thus bringing the stone in  more
direct contact with the  sound.   In  some cases the  stone may be felt through
the coats  of  the rectum.
  The  treatment consists in introducing a grooved staff and cutting down  upon
the prostate in the mesial line, until the calculi are  reached, when they may be
extracted with the forceps or  scoop.   When complicated with vesical  calculus
the lateral or modified  median  operation should be  performed, and the stones
removed as they present themselves.

                              LITHOTRITY.

  The  operation of lithotrity,  by which the stone is crushed in the bladder and
the fragments expelled through the urethra, is  of modern, and indeed,  of very
recent  invention; for notwithstanding that various rude and incomplete attempts
may at different times have been made with this view, it was not until about the
years 1818 or 1820 that the subject began to attract serious  attention.  About
this  time Civiale, followed  by Amussat, Leroy, and  others, began constructing
instruments, which though very imperfect, yet were  sufficient to break down  a
calculus in the bladder.  From this period the system made rapid progress, and
the successive improvements made by the surgeons whose names have just been
mentioned, together with the  ingenious  mechanical  adaptations  introduced by
Weiss,  Heurteloup, Costello, and Charriere, enabled  the  surgeon to  attack the
stone with certainty and effect.  It is,  perhaps, principally due to the labors of
Civiale and Amussat in France, and of Brodie  and Liston in this country, that
the system has been reduced to its present state of perfection.
  Before proceeding to the operation of lithotrity, it is necessary that the patient's
constitution should be carefully attended to, and especially that all local irrita-
bility about the urinary organs should be subdued by ordinary medical treatment.
This is even  of much  greater importance  in lithotrity than  in lithotomy.  In
lithotrity we must always expect that any existing irritation or inflammation of
the bladder will be increased by the necessary introduction of instruments and
the presence of sharp fragments of calculus  in  the  bladder, and their  passage
aloncr the urethra; but in lithotomy all source of irritation is at once removed
 
934
STONE IN  THE  BLADDER.
by the extraction of the stone.   Before determining to perform lithotrity then,
it is necessary to examine very carefully the condition of the urinary organs, and
if  these be diseased, it will probably be requisite to abandon  the operation.
   The conditions that the surgeon has principally to look to  before lithotrity is
determined on  are, 1st, the characters of the stone; and, 2d, the state of the
urinary organs.   In order  that  lithotrity should be  successful, it is necessary
that the  stone should  not be above a certain  size, that it be not  too hard, and
that more calculi than one do not exist.   The urinary organs must also be  in a
healthy state and free from irritation.
   1st. As to the characters of the stone.  With  regard  to the size of the cal-
culus, it may be stated  generally, that the smaller it is, the  greater will be the
success of the operation.  As a general  rule,  it is not well to attempt to  crush
a calculus above an inch or an  inch and a half in diameter.   It is not that a
large stone cannot be broken; because in most cases, this might readily enough
be done; but because  the quantity of fragments resulting would be so great that
the  bladder would in  all probability not be  able to get  rid of them; or, the
necessary operations for their disintegration and removal would occasion a dan-
gerous amount  of irritation.   The  size  of the  calculus may always be readily
ascertained  by seizing it in the lithotrite, and then measuring it  by the gradu-
ated scale upon the handle of the instrument.
   If there are several stones, lithotrity is not a very successful procedure;  for
although  each  calculus may be a small  one, yet the aggregate of the whole is
considerable; and  besides this, the small  calculi will each  require a separate
operation, as it were,  and may each contain a hard and  possibly  very  resisting
nucleus.
   The hardness of the  calculus influences materially the question of lithotrity.
If the concretion is very hard, especially if composed of oxalate of lime or lithic
acid, giving a very clear and ringing sound, the case will not be a veiy favorable
one for crushing.  For not only may the density of the calculus  be such as to
cause it to resist any  force that it may be safe to bring to bear upon it; but if
broken, it will  splinter into sharp and  angular fragments which cannot readily
be ground down, but  will greatly irritate the  bladder, and will probably escape
with difficulty through the urethra.   The most  favorable calculi for  crushing
are  those that  are soft and friable, as the different forms of phosphatic concre-
tions ; though in this  diathesis the shattered  state of system and  irritable con-
dition of the urinary organs often counterbalance the advantage that would other-
wise have been derived from the character of the stone.
   2d. The conditions of the urinary organs that influence the propriety of per-
forming lithotrity have reference to the state of the  urethra, of the prostate, the
bladder, and the kidneys.
   If the urethra be  the seat  of stricture, or is very irritable, lithotrity, which
may require the frequent  introduction  of instruments and will entail the  con-
tinued passage  of fragments of calculus, cannot be performed.
   If the prostate be enlarged,  more particularly if the third lobe  is very promi-
 nent, the introduction of the lithotrite will be  attended by considerable difficulty,
 and a dependent  pouch will be found at the lower fundus  of the bladder, into
 which the fragments of the crushed stone are apt to fall, and from which they
 cannot be  expelled;  hence  such a condition of  the gland  as this, is a serious,
 though  perhaps not  an insuperable bar  to  the performance of any  crushing
 operation.
   The state of the bladder deserves  especial attention; the circumstances con-
 nected with it  that principally militate against lithotrity are a very irritable con-
 dition of it; its being contracted, hypertrophied, or sacculated.  A very irritable
 and sensitive bladder not only will  be the seat of severe  suffering, but may not
 admit  of holding sufficient water to  make the operation a safe  one,  and may
 readily become dangerously inflamed  in consequence of the repeated  introduc- 
                   OPERATION  OF  LITHOTRITY.               935

tion of instruments, and the presence of angular fragments.  Hence, if the ordi-
nary operation of sounding occasion much distress; if the patient cannot hold
his water long, and passes it in small quantities; if it be bloody, or much loaded
with viscid mucus, he will scarcely be  able to bear the procedures necessary for
the operation.  In some instances, however, the irritability of the bladder may
be overcome by keeping the patient in bed, and, as Sir B. Brodie recommends,
daily injecting  tepid water.  At the same time  it must be borne in mind that
the bladder may be in an opposite condition in cases of stone, having fallen into
a state of atony; and this, as Civiale has pointed out, may be a source of great
danger after lithotrity, the organ not possessing sufficient expulsive power to  rid
itself of the fragments with which it is encumbered.
   A sacculated condition of the bladder is also a serious objection to lithotrity,
 as not only are the fragments  likely to lodge in  the sacculi, but these  cysts
 become  filled with an offensive puriform fluid, and thus  may occasion low or
 typhoid  cystitis, followed perhaps by pyemia.
   Lastly, the condition of the kidneys merits special attention.  If these organs
 be much irritated, as  indicated by the presence of casts of tubes, or of a consi-
  derable  quantity of albumen in the urine, or in any other way, the performance
  of a series of operations in the bladder would be likely materially to increase the
  mischief in them, and consequently ought not to be undertaken.
    The ao-e also of the patient must be taken into account, though lithotrity can
  doubtless  be performed at all  periods  of life.  The small size of the urethra
  before puberty is  such as scarcely to  admit of the ready introduction of the
  necessary instruments, or of the escape of fragments of calculus; and hence it
  is rarely had recourse to at this period of life.  So also  at advanced ages the
  irritable state of the urinary organs, the tendency to the supervention of low
  cystitis, and the  condition of the prostate, are usually such  as to prevent the
  performance of the operation.                       _                .
    Supposino-, however, that a case is met with in which  the calculus is ot  mo-
  derate  size, single and  not too hard, the urinary organs healthy, and not  over
  sensitive, and the  patient an  adult  but not  too aged, the  surgeon may have
  recourse to lithotrity with every prospect of readily and  permanently Seeing the
  patient of his calculus.  In  performing the operation in  such a case  but little
  preparatory treatment  is needed, though it  is well to keep the patient quiet for
  a few days, and to regulate his bowels  before anything is  done
     Operlton of Lithotrity. -The instruments required  for lithotrity^ are.the
  following  An  ordinary sound with  a  short beak to examine the condition of
   he bladder   Ahollow steel  sound, through  which the  bladder may, if neces-
   ary be iniectfd after or during sounding, without the necessity of changing
   he^ bstrument rfit  362).  This I have found of especial  service in the  later
   tag«  of™: opSion for detecting small foments.   A£j«^ synnfe  fitted
   with rin«s  and havino- a large  piston rod, so that it may work easily, this stiouia
   Idmit  of ad^tation  to  ih? follow sound.   A ^"f-d sdver cathet    Wlth

   large round o oval eyes and^^^^^^^2^

   ^Isy^
   fragments  consist of Weiss' lithotrite as  represer^ed  in the an^ «ed ™t (^
   389) ;  or a similar instrument worked by a rack «d pm^on ,  his  ^oweve
   the d sadvantage of possessing less  power than the tra ^fcjcrew   _L
   trite must be m'ade of well-tempered steel i^^^^^T^a^

   tt ^zHs'^ 
936
STONE  IN THE  BLADDER.
the case with some cheap instruments, be made of a plate of this metal, turned
up  at  the  edges; as such a one possesses  too  little strength  to be used with
safety.  The scoop may, however, be so constructed without danger.
Fig. 389.
  The scoop, such as is represented (fig. 390) and invented by Civiale, has a
double action, enabling the surgeon to work it either by the hand or a screw;
it is furnished with a kind of spoon-shaped beak, which is somewhat flattened,
and  admits of the extraction of a certain quantity of detritus.  Of late, this
instrument has been improved  by Mr. Coulson, by being made more solid and
strong, and having a fenestrum in its beak, so that it can be used as a litho-
trite.   Besides these instruments,  a small lithotrite is occasionally used for
crushing fragments in the urethra;  and another instrument, shaped like that
represented  (fig. 131), for withdrawing them from that canal.

                                 Fig. 392.
  The operation of lithotrity may be divided into three stages.   1st. The intro-
duction of the instrument.  2d. The search for and seizure of the stone.  3d.
The crushing of the stone.  These we shall consider successively.
  1st.  Lithotrity may be performed with the patient either lying  on his back
upon a hard mattress, or a couch or table; or it may be practised, and in some
cases most conveniently, in  the sitting posture.   The surgeon, standing on the
right side of the patient, carefully introduces the hollow sound or catheter, and 
OPERATION OP LITHOTRITY.
937
draws off the urine; he then slowly and very cautiously injects the bladder by
means of the brass syringe, with from four to eight ounces of tepid water.  The
use of  drawing off  the urine is to make sure of the bladder holding the proper
quantity of fluid when it is afterwards injected, and the object in injectino- it is
to distend it with fluid to such an extent as to prevent the mucous membrane
being seized in the grasp of  the lithotrite, or injured by the splintering of the
stone.   The instrument is then withdrawn after the situation of the stone has
been detected by it, and the lithotrite is introduced.  As this is straight, with
a sharp elbow near the beak, some little skill is  required in  passing  it.  In
doing so, the surgeon  must  keep his eye upon  the short curved beak of the
instrument, the direction and position of which must be constantly observed or
rather judged of, and especial care must be taken in carrying it under the pubes,
not to injure the urethra by pushing  the  beak of the  lithotrite forwards too
suddenly, instead of winding it, as it were,  under  the  arch  of  that bone.  In
doing this, the instrument should  first be introduced nearly parallel to the abdo-
men, the penis being held between the left  fore and  middle finger and drawn
over it.  As the  lithotrite passes  down, it must be gradually raised to  the per-
pendicular position ; and as its curve passes  under  the pubes, the handle should
be depressed between the thighs.   The direction of the curve  is the thing to
bear in mind, and the position of the handle must  be varied in  accordance with
the course that this takes.   The  lithotrite should  be well greased with olive-
oil, so that the branch and screw may work smoothly.  Lard or ointment should
not be used for this purpose, as it is apt to clog and to entangle gritty bits of
calculus.
   2d.  The  next point is to search for the stone, which will generally be found
in the situation where its  pressure was detected during  the sounding of the
bladder; most frequently at the  right side  or at the inferior fundus.   Should
it be situated in a sacculus or depression in this region, it may  most readily be
seized by introducing a finger into the rectum, and  raising up the lower part of
the bladder.   Sir B. Brodie strongly advises that the lithotrite  should never be
used as a sound to ascertain the position  of the stone; by doing so, the patient
suffers  pain, the bladder is irritated,  the  water expelled,  and the stone not
readily seized.  In seizing the calculus, a good  deal  of  tact is required;  this

                                   Fig. 393.
part of the operation may generally be best done by pushing the female blade
of the lithotrite against the inferior fundus of the bladder, pressing gently down 
938
STONE IN THE  BLADDER.
with it so as to make a conical depression in this situation, and then inclining
the beak towards the stone, drawing back the male blade with the thumb (fig.
393); with a slight shake or jerk, the surgeon then tries to get the calculus
between the blades at the same time that the male branch is being pushed for-
wards to seize it.   In this manoeuvre the female blade should be moved as little
as possible, but the stone must be seized by pressing the thumb upon  the half
circle of steel fixed on the male  branch.   In this way the stone may often be
seized at the first attempt, but in other cases it is not grasped until after several
efforts have been made to fix it;  the calculus, especially if round, slipping awav
from between the blades of the instrument, and being merely scraped by thenl'.
In these manoeuvres  all  rough handling must be most carefully avoided, and
the instrument should be turned  about as  little as possible.  It is  far safer to
desist in the operation if there  be any difficulty in seizing the stone, than to
persevere  in repeated and fruitless  attempts, by  which the bladder  may be
severely injured  and inflamed.  Bather than do this  the  patient should be
allowed to get up and move about for a few minutes, when the position  of the stone
may be so far altered that it admits of being seized.
                            3d.  When  the stone  has been seized, it is gently
                         raised  in the grasp of the lithotrite, so as to be placed
                         about the middle of the bladder, and it is then crushed.
                         This important step of the operation, like all the others,
                         requires to be deliberately and  carefully done (fig.
                         394).   If Civiale's improved lithotrite be used, the
                         stone,  if small, may readily be crushed by the pres-
                         sure of the hand alone, without the action of the screw
                         (fig. 392).   If, by the  ordinary lithotrite, it should not
                         be effected  by suddenly and forcibly screwing up the
                         instrument, but the screw should be gradually worked
                         by a series  of short and sharp turns, so as to consti-
                         tute almost percussive movements (fig. 391). In this
                         way, the calculus is generally made to crumble down,
                         rather than to fly asunder, and as it yields, the screw
                         must be worked  tightly home.  The blades of the in-
                         strument may then  be  opened  again, a fragment of
                          the broken calculus seized and crushed  in  the  same
                         way as before, and thus the disintegration of the stone
                         is  in  a  great  measure effected and sometimes com-
                         pleted at one sitting.   It is of the greatest moment,
                         however, that too much time be not consumed  at one
                          sitting.  Nothing is more dangerous than the long-
                          continued contact of instruments with the interior of
                          the bladder;  in  this way great irritability, or an ato-
                          nic condition of this organ, terminating in low cystitis
                          and pyemia, is apt to be produced, and death may
                          thus result.  The shorter the sittings, the more likely
                          will the case  do well.   The  first sitting should not
                          exceed ten  minutes, and the subsequent ones five. In
                         the repetition of the sittings, the surgeon  must be
 guided by the effect produced on the stone and on the  bladder.  The calculus
 may be entirely destroyed in one sitting, but most  commonly from  three  to five
 or six are required;  these should,  if possible, be conducted at intervals of three
 or four days, though this must  depend upon the amount of irritation induced
 by them.
   Usually at the first sitting, it  is  sufficient to break up the stone; the frag-
 ments  being left  to be dealt with subsequently.   In crushing these, especially
 when they  lie behind  the prostate,  M. Civiale turns the concave part of the
Fig. 394.
 
ACCIDENTS OP  LITHOTRITY.
939
beak  downwards,  and seizes  the fragment  in  this position.  In doin°- this,
however, great care must  be  taken not to nip the mucous membrane of the
bladder.
  Before withdrawing the  lithotrite, the surgeon must be careful to see by the
scale on the handle, that the male blade is well home.   If this be not the case,
and the instrument be enlarged by any fragments  or detritus being  entangled
between the blades, laceration of the neck of the bladder or urethra might occur
in attempting to withdraw  it.
  After the stone  has been crushed, but little detritus will usually escape during
the first twenty-four hours, but after this it begins to be expelled; in some cases*
in considerable quantity each time the  urine is passed.   In others, it does not
escape so readily, and then the  surgeon requires  to introduce the scoop (fig.
390), by which he can seize the smaller fragments, crush them up, and screw-
ing the instrument home, extract the beak filled with  detritus.   In usino- this
instrument, care must, however, be taken  not to  get  hold of too large a frag-
ment, for in breaking this  up, whether  by the hand or  screw, the beak may be
clogged with the detritus in such a way that it does not readily close, and then
there might be considerable difficulty in withdrawing it.  Should this accident
occur, the scoop may be emptied  by passing its beak back into the bladder, tap-
ping sharply upon the instrument, and  moving the  male branch to and fro.
  After each sitting, the  bladder  should  be washed  out  by injecting it with
tepid water through  a catheter with large eyes;  or, what is better, a double-
current catheter.   In using the latter instrument, the  point of which  should
be  directed towards  the inferior fundus, a considerable quantity of water  may
sometimes  with advantage be pumped  through the bladder by  adapting  a flute-
valve syringe  to it.
   When the surgeon believes that he has pretty well emptied the bladder of the
detritus, he must  carefully explore the organ  by means of a short-beaked  or
hollow sound; and if he detect any fragment, however small, it must be seized,
crushed, and removed with the scoop.
   During the whole of the treatment,  it is  necessary to adopt means  to allay
irritation;  with this  view the patient  should be  kept in  bed, or on a  couch;
a moderate diet only should  be allowed, plenty of demulcent drinks given,
such  as barley-water, soda-water, or milk, and opiates or henbane, if  necessary,
exhibited.

          ACCIDENTS  AND  DANGERS OF  LITHOTRITY.

   In considering the accidents  of lithotrity, I put out of consideration  those that
may arise from the surgeon acting carelessly or with improper force, and thus
occasioning laceration of the urethra, or injury to  the coats of the bladder;  so
also accidents occurring from  the bending or breaking of  the  instruments will
scarcely happen if these have been properly  tested on a piece of sandstone grit
before being employed in the bladder.
  The most dangerous accident arises from the impaction of some of the angular
fragments of stone in the  urethra.  They are especially apt to lodge about the
bulb and there give rise to a very great degree  of irritation, and even of fatal
mischief  producing  great constitutional  disturbance  of  an irritative  and
asthenic'type.   When  the fragments are impacted low down in the urethra, it
is absolutely necessary to remove them from the canal as speedily as possible, 
940
STONE  IN THE  BLADDER.
lest the constitutional disturbance occasioned by them prove fatal to the patient.
This may be done in various ways;  it has  been proposed to push them back
into the bladder with a soft bougie, or by injecting a stream of water into the
urethra through an open-ended  catheter; but these devices are not very likely
to be successful, and may give rise to risk of laceration of the urethra.  It has
been proposed to  crush  them in the  urethra with a small lithotrite (fig. 395);
but this plan is somewhat hazardous,  as it is  very difficult to avoid pinching up
                   the mucous  membrane of the  canal with the bit  of stone.
     Fig. 396.      The  safest practice seems  to  be,  either to extract  them
                   through the  urethral orifice, or to cut them out through the
                   perineum.  Extraction through the urethral orifice may be
                   effected by the forceps (fig. 396), or by Civiale's instrument
                   (fig.  131).   Should this  means fail, or should the  fragment
                   be very deeply seated, as in the membranous portion of the
                   urethra, the better  plan would  be  to  make an  incision
                   directly down  upon  it,  and  to  remove  it  through the
                   perineum.  If such  an  operation  as  this be  required, the
                   surgeon might possibly feel disposed  to extend the incision
                   a little, and  empty the  bladder of any remaining detritus
                   by means of a scoop.
                     The principal dangers in lithotrity arise  from the state
                   of the bladder and kidneys; — by the induction of cystitis
                   of a  low form, atony of the bladder,  or renal irritation, or
                   by the occurrence of pyemia, with much constitutional
                   disturbance of a low type.
                      Cystitis may occur  in consequence of the increased irrita-
                   tion  to which the bladder is subjected.  When  it sets in
                   it speedily assumes a low form, and is apt to prove  fatal by
                   the induction of  typhoid symptoms; even  if it do not do
                   so, its  occurrence  is an  insuperable obstacle to the further
                   crushing of  the stone, and in such cases as these, the best
                   course that  could be pursued would  be, after getting the
                   patient into as favorable a state as possible, to remove the
                   fragments by lithotomy.
                     Atony of the bladder  is one of the most dangerous con-
                   ditions that  can occur in lithotrity.  This  state of things
                   happens  usually  in  elderly people,  in  whom the urinary
                   organs may appear to be  in a  peculiarly  quiet  and  favorable
condition before the operation,  the patient being able to hold his water for six
or eight hours, and  to  bear  the injection  of ten or twelve ounces  of fluid.
Under these circumstances the surgeon should be upon his guard, for the danger
of this condition is, that the bladder does not  possess sufficient  contractile
power  to expel the fragments.   These  consequently  accumulate in  the  lower
fundus, and  irritate the mucous membrane, and thus the foundation may be
laid for fatal cystitis, which in these cases always assumes a typhoid type.
   The atony of the bladder appears  to arise partly from that natural want of
expulsive power, which is not unfrequent in  old people, and partly from a kind
of paralysis of the organ, induced by the contact of the instruments and the
pressure of the fragments; this happened  in a  patient whom  I lithotrized  at
University  College Hospital some  years  ago,  and  who  died with  severe
constitutional depression, and with pyemic symptoms.
   When  atony of the bladder  has come on, it  is essential that the surgeon
should rid the patient of the fragments which he  is unable to expel.   This may
sometimes be done by means of the scoop, assisted by washing  out the bladder
through the double-current catheter, but the  safer plan would probably be  to
get the patient into as good a condition as possible, and then cut him.  This I
 
LITHOTOMY AND  LITHOTRITY  COMPARED.       941
once did in an interesting  case  under my care at the  hospital; the patient, an
old man, had been lithotrized by a surgeon  out of doors a few weeks before
admission, but no fragments had passed;  on sounding him, I found a moderate-
sized calculus, with what appeared to be a large mass  of soft concretion, of the
nature of which I was not aware until  after its removal;  the patient having
concealed the fact of his having been lithotrized.   On cutting him in the usual
way, I removed a lithic acid calculus  about as large as a pigeon's egg, and a
handful of fragments of another calculus of  the  same composition, which  had
been crusted over and matted  together by phosphatic deposit.   The  patient
made a very good recovery.
   Irritation  of  the  kidneys,  giving  rise to suppression  of urine, occasionally
occurs.  In  such cases, cupping the  loins, .and the warm  hip-bath,  would be
the proper treatment to pursue.
   Very considerable constitutional depression occasionally follows the operation
of lithotrity, the  pulse becoming quick, feeble, and intermitting; the skin hot
and dry; and the tongue brown.   This condition is apt to prove fatal either
directly or by intercurrent visceral mischief; it appears  to arise in many cases
from causes independent  of the  operation, or  that are  called into activity by
the  shock and  slight constitutional  disturbance induced by it.  This is more
 especially apt to happen when there is latent disease of the kidneys.   In other
instances, again, it is more directly dependent on the irritation  induced by the
 operation being the  result of the formation of abscess in the neighborhood of
 the  prostate, or around the neck of the  bladder; and in other instances, again,
 from the supervention of unhealthy suppuration  in some of the sacculi that are
 occasionally met with  in this organ; — from  whatever  cause  arising,  this
 condition is  usually eventually  fatal by the supervention  of pyemia.

   COMPARISON BETWEEN LITHOTOMY AND  LITHOTRITY

   Lithotomy and lithotrity differ so entirely from one another in  principle and
 detail, that  it  is useless  to attempt to establish  a comparison  between  the
 different steps  of these two operations.  It is, however,  a question of  very
 considerable importance and interest to ascertain by which operation a patient
 can most  safely have a calculus removed from  his  bladder.  In determining
 this point, it is not only necessary to make  a comparison  between the general
 results of cases  that have been subjected  to  the two procedures,  but  more
 especially to determine those circumstances that influence the result  of either
 operation  in particular cases — to  determine, in fact, in what cases  lithotomy,
 and  in what lithotrity, holds  out the best  prospect to the patient.   It  is,  I
 think, in the  highest degree unpractical  to enter into a discussion as to which
 should be the general method of treatment in cases of stone.  Both operations
 have  been reduced  to great simplicity  and certainty;  but neither  should be
 exclusively  practised.  It is undoubtedly the duty of  the surgeon to make
 himself familiar with the practice of both,  and to adopt that one which promises
 best in the particular instance with which he has to do.   If, however, I were
 called upon to say which operation I consider most generally applicable, then
 I should  unquestionably  answer  lithotomy.   But  yet there  can  be no  doubt
 that there are many cases in which lithotrity is the preferable method;  and in
 those in which lithotomy or lithotrity may be  done with  an  equal  chance of
 success, the preference should, I  think,  be given to the  crushing  over the

 ^Th^stoStoT'that are before the profession do not represent the  true  state
 of the question, so far as a general comparison between the operations is con-
 cerned  For it must be borne in mind that those cases that are lithotrized have
 invariably been picked cases;  whilst  lithotomy has been  performed on almost
 all  patients as they have presented themselves.  It has  already been stated 
942
STONE IN  THE  BLADDER.
(page 934) that for lithotrity to be  successfully done, it is necessary that  the
stone be of  moderate size, single, not too hard, and that the urinary organs be
in a healthy state and free from irritation.  x\nd this is the state in which most
of the cases have been in which crushing has been done.  In lithotomy cases,
on  the  other hand, the surgeon has had to contend with all the difficulties of
large or multiple calculi,  diseased bladders, and bad constitutions.   Hence on
comparing the statistics of the results of lithotrity with  those of lithotomy, we
compare the statistics of the results of  operations performed  under the most
favorable circumstances on a series of selected cases, with those of cases taken
indiscriminately and often presenting most unfavorable conditions.
   Another  cause  of  uncertainty with  regard to the statistics of lithotrity is,
that those we  possess are chiefly from a professed lithotritist, M. Civiale, the
accuracy of which has  been denied in a very decided and emphatic  manner by
many of the leading surgeons in Paris, who have  inquired fully  into the matter;
and the conclusions  from which must  necessarily be received with much hesi-
tation in this country, where it is difficult to arrive at the real truth of the state-
ments advanced on either side.
   If we compare Civiale's statistics of  lithotrity with  those  of lithotomy, as
practised by the most skilful surgeons, Cheselden, Liston, and the Norwich ope-
rators, we should at once decide in favor of the crushing method; for Civiale
states that out  of 591 operations he had  but 14 deaths, or 1 in 42-2; whilst, as
we have seen, the most skilful lithotomists in this country, where the results of
the cutting operation have been far more successful than elsewhere, can  only
boast of such a rate of mortality as 1 in 7-9, or at most in 10.   But though the
success is thus stated by Civiale to have been great in his own cases, the accu-
racy of this statement has been denied by other French  surgeons, and it is  cer-
tainly very different to what has occurred  elsewhere.  Thus of 162 cases ope-
rated upon by  lithotrity by various surgeons in Paris, Civiale states  that death
resulted in 38, and a cure in 100 instances; the results of the remaining cases
being unknown, or the cure incomplete.  In this country it is impossible to  say,
even approximately, what the average mortality after lithotrity has been; those
surgeons who have had most experience in this operation not having published
any account of their  cases; but I believe there is a pretty general  feeling that
in the different London hospitals in which it has been performed, lithotrity has
not been a very successful operation.   The same remark appears to hold good
with regard to the Parisian hospitals;  Malgaigne  estimates the mortality from
lithotrity in those institutions at 1 in 4, while  he calculates that of private cases
at 1 in  8.   The difference between the results of this operation in  hospital  and
private  practice can  easily be accounted for by the difference in the constitu-
tions of the patients, and by  their applying for relief in private in a  less
advanced form of the disease than in hospital practice.   We find the same hold
good with regard  to the results of lithotomy.  Thus Mr. Coulson  states that
Dr. Dudley lost only  1 in 36 of the private patients that he cut; Dr. Mettauer,
1 in 36£; Mr. Martineau, 1 in 42; and  Dr. Mott,  1 in 50.  These results are
fully as favorable as Civiale's statistics of lithotrity, and show the influence  that
the constitution  of the patient, and a proper selection  of cases  may exercise
upon the results of the cutting operation.  The only statistics of lithotrity that
we at present  possess  are those  given by Sir B. Brodie, as  the  result of his
practice, chiefly on private patients.   That eminent surgeon states, that out of
115 cases of lithotrity,—not all, however, on different individuals, the operation
having  been repeated more than once on  several of the patients,—he lost 9.  Of
these, death was directly  attributable to the operation in  5 instances,  and in the
remaining 4, appeared to  be dependent on organic disease, brought into activity
by the shock of the operation.
   Lithotrity, as has already been stated,  cannot  be applied to all cases  of stone,
but in  many that are unsuited to this operation, lithotomy may be  done with 
LITHOTOMY AND  LITHOTRITY  COMPARED.        943
success.   In some cases, however, no operation can be practised in consequence
of serious disease of the genitals, bladder, or kidneys, or of some visceral mis-
chief that would necessarily interfere with the performance of any capital ope-
ration.  The necessity of selecting cases of lithotrity is well instanced by a state-
ment that Civiale has given with reference to this point.   This dexterous litho-
tritist considered  that of 838 calculous patients that applied to him during a
series of twenty years, only  548 were fit cases for  lithotrity, and 290,  or more
than one-third, were not operated  on by this method; of the last 332 cases
included  in  this list, 241 were lithotrized, 1 in 3-6 being considered  unfit for
that operation.  Of the 91 cases not crushed, 28 were cut, and in 8 others litho-
trity and lithotomy were combined.   Of these 36 cases subjected to lithotomy,
 M. Civiale lost 18, or exactly one-half. These figures show that lithotrity cannot
be considered the general operation  for stone; but must, even in the hands of
 the most dexterous  and successful practitioners, be in many instances replaced
 by the cutting operation.
   The circumstances that  must chiefly determine the surgeon in the  selection
 of the particular operation that is  to be performed  are,  1st, the  age of the
 patient;  2d, the size and character of the stone, and 3d, the conditions of the
 urinary organs.
    1st, the age of the patient is an important element.  As a general rule it may
 be stated, that it is at the middle and advanced periods of  life that lithotrity is
 most successful, whilst at early ages lithotomy is the preferable operation.  The
 success of lithotrity at advanced periods of life is as good as in middle age, and
 has been very great in the hands of some surgeons.  Thus, Segalas states, that
 of  14  octogenarians whom he lithotrized he did not lose one; and of  27 septu-
 agenarians, but two.  Lithotomy, on the other hand, is extremely fatal  in aged
 persons. In children, under or about the age of puberty, lithotrity is a difficult
 operation, though it may be performed even at very early periods; but the small
 size of the  urethra and the restlessness of the child interfere materially with
 the success of this operation.  Lithotomy, on the  other hand, is  so successful
 an operation in children, that the surgeon would probably gain nothing by sub-
 stituting lithotrity for it.   Thus,  of 35 children  under  ten, operated on by
 Cheselden, but one died; and of 58 cases of children operated on at St. Tho-
 mas's, but one proved fatal, and the average mortality in them is not more than
 about 1 in  14 cases.   Hence, lithotomy, being probably  equally safe and far
 speedier, should be preferred to lithotrity in all cases  under about twenty years
 of age.
     2d. The size and character of the stone influence in a very important manner
  the choice of an operation.   Surgeons generally recognize the fact that a small
  stone is more favorable  to lithotrity than a large one, and that the  operation
  should not be  undertaken if the calculus exceeds  one  and a half inch in dia-
  meter  Below one inch in diameter all calculi may be crushed, provided other
  circumstances are  favorable.  Much, however, will depend upon their composi-
  tion.   Phosphatic calculi of larger size may even  readily be crushed,  and  thus
  be got rid of   Lithic  acid concretions, the fragments of  which do not disinte-
  grate, but split up into sharp and  angular  spiculae and scales do not, it large,
  admi  of lithotrity.   Oxalate of lime calculi  occurring as they do chiefly-in
  young people, comparatively rarely require lithotrity, but, when crushed break
  ud verv readily, and, as there is usually a  co-existing healthy state of the un-
  narv  organs the cases have a favorable issue.  Some of the French hthotrizers
  Le in the habit of breaking up friable phosphatic calculi from fifteen to twenty
  line  o  more  in diameter; but stones of this size are, I think, usually and more
  prudently  subjected  to  lithotomy in this  country.  The existence of several
  calcuU, even when small, though not a bar, is yet an objection to lithotrity, for
  rea^sons^aheady^ate  ^ ^ ^.^ ^^ ^ ^^ ^ ^^ importance thaQ 
944
STONE IN THE  BLADDER.
the size and character of the stone.  As a general rule, it  may be stated that
the greater the irritability and inflammatory tendency of these parts, the less
successful will lithotrity  be.  The repeated introduction of instruments, how-
ever carefully and skilfully conducted, the presence of fragments of calculus
and  their tendency to impaction or entanglement in the urethra, necessarily
dispose to inflammation even in the most favorable cases, and very readily excite
it, if there be any tendency to such action existing in the parts.   If, however
the stone be  of small or moderate size, friable, the bladder healthy, and with
good contractile power, the urethra capacious, and the patient of  sound consti-
tution  and quiet temperament, the stone may often be broken up and the frao--
ments  expelled with  remarkably little suffering.   In fact, under a combination
of favorable  circumstances such as these,  lithotrity ought unquestionably to be
preferred to lithotomy.
   If, however, the bladder be very irritable, or if the  patient's constitution  is
an excitable one, so that he does not bear the introduction of instruments  well;
and more particularly if it  be found that this local and constitutional sensitive-
ness, instead  of being blunted by the methodical  introduction  of sounds or
bougies, is rather increased by them; and especially if the stone be of a medium
or large size, so that  several sittings would be required before the fragments
could be expelled,— lithotomy should be had recourse  to.
   The existence of  organic disease, however, about the urinary organs, consti-
tutes the greatest obstacle to  lithotrity, and when extensive must form a com-
plete bar to  the performance  of that  operation.  It is not easy, however, to
determine the amount of local disease that should thus be held to contra-indicate
lithotrity.  On this  point the  opinions  of surgeons  differ  much, and it is par-
ticularly in the management of these cases that the advantage of that tact and
dexterity in the use of the crushing instruments, which habit can alone give, is
so well exemplified.
   Organic disease  of the kidneys is  a more serious obstacle to lithotrity than
to lithotomy, on account of the  prolonged nature  of the  operation, and the
greater liability to sympathetic or propagated  irritation in these organs, giving
rise to purulent nephritis.  It is not only by the operation  increasing the renal
mischief that harm might result, but rather in  consequence of the tendency to
low and  diffuse inflammation, to pyemia, etc. that always co-exists with kidney
disease.
   A chronically inflamed state of the bladder, more  particularly if the organ is
thickened and fasciculated, so that it will not bear  the injection of a few ounces
of tepid water, seriously interferes with  the success of lithotrity.   If the blad-
der be  sacculated, there will be a still greater risk of an unfavorable result, these
sacculi not only retaining fragments of calculus, but also becoming the seats of
unhealthy inflammation,  in consequence of which  typhoid  cystitis of a very
serious character, followed by pyemic symptoms and metastatic abscesses, may
result.  In such cases as these, lithotomy offers the  only chance to the patient.
The existence of a moderate amount of  vesical catarrh, if the bladder is other-
wise healthy, is no objection to lithotrity.
   Atony of the  bladder is a serious inconvenience, and a great source of danger
in lithotrity.   It cannot well be positively ascertained, though it may be sus-
pected if the patient can hold his water  for a great many hours, and can bear
without complaint the injection of a large quantity — eight or ten ounces — of
fluid, the interior of  the bladder feeling large  and smooth to the sound.   This
condition chiefly occurs in old  men of feeble habit of body;  and,  if ascertained,
should call for the performance of lithotomy.
   In encysted calculus, lithotrity is for  obvious reasons inadmissible.
   Moderate  enlargement  of the  prostate, such  as  is  habitually met with  in
elderly people,  does  not necessarily prevent  the  performance of  lithotrity,
though it undoubtedly complicates the  operation  and  increases its difficulties, 
RECURRENCE  OP  CALCULUS.
945
the fragments having a tendency to become lodged in the lower fundus behind
the enlarged gland.  This  more  especially happens if the middle lobe  is en-
larged, and, under these  circumstances, though the stone may undoubtedly be
crushed, yet the fragments would probably require to be removed by the  scoop;
the operation would consequently be very tedious and prolonged, and lithotomy
would probably be found to answer best.   Any inflammatory disease or abscess
of the prostate must necessarily prevent the performance of  lithotrity.
   Stricture of  the urethra does not prevent the performance of lithotrity, but
only retards the operation until the constriction can be properly dilated.  Should
this, however, not be practicable to the full extent of the urethra, lithotomy on
 a small staff  must be practised.
   I have said nothing, in  this comparison between lithotrity and lithotomy, of
 the  comparative painfulness  of  the two  operations;  for, as chloroform may be
 administered with equal advantage in  both sets of cases, there is little difference
 in this respect, except that perhaps the advantage  lies on the side of lithotomy,
 as being the shorter proceeding.
   From all that precedes, then, it would appear that useful as lithotrity unques-
 tionably is in many cases, it cannot be looked upon as a general means of  treat-
 ing stone  in the bladder; being only applicable under very favorable circum-
 stances; and that a large number of cases will always be left in which lithotomy
 offers the sole  means of relief.                                          .
   Recurrence  of calculus after operation  may take  place from  three  distinct
  causes—1st, in consequence  of a continuance of the constitutional condition,  or
  diathesis, under the influence  of which the calculus was originally formed;
  2d, from the descent of a renal calculus; and 3d, from a fragment  of calculus
  having been accidentally  left behind.                           %       .
    Relapse from the first cause is probably not very common, but its occasional
  occurrence shows  the necessity of continuing constitutional treatment adapted
  to the particular diathesis, after the  removal of the  calculus  from the bladder.
  It is relapse from this cause that probably occurs  in cases of lithotomy, though
  even in this  operation a fragment of calculus may accidentally be broken off
  durin- extraction,  and left behind.  Yet such an  accident is not very frequent;
  for if°the calculus happens to be  broken  during extraction,  the fragments, it
  not completely cleared  out of the bladder, will usually be washed away through
  the wound by the  flow of urine.  The registers  of the Norwich Hospital show
  1 relapse in  58 cases; and those of Luneville,  1 in 116 cases of lithotomy

  ^In^thotrity, on the other hand, relapse is far more common.   In the prac-
  tice of M. Civiale it has  occurred about once in every tenth  case  This must
  evidently arise from some fragment  of calculus  having escaped^ detection  and
  beino- left behind, thus  constituting  a nucleus for a fresh  formation.   Ihe fre-
  quency  of  the occurrence of secondary calculi  after  lithotrity,  even in such
  pSed hands as M. Civiale's, certainly constitutes an objec ion, to tiua  opera
  tion,  and shows the necessity of the  surgeon most  carefully examnmg  the
  bladder before he pronounces the patient cured; and  even then watching him
  forborne^length o/time, in order to meet the calculus at its first formation, and

  tolf l^nt^tSnd^Senlu. forming, whether after lithotomy or
   lithotr tv most surgeons would feel  disposed to extract it by the cutting opera-
   5oT& iXlT/Lve previously b-P^                 ^geon

   thG T\  M? LiS's  dvicTJfeu  troughthe'right shle of the  perineum on
   may adopt  Mr. Liston s aavice           °xity.  As this procedure, however,
   & St ft WtiiathSrr    h  left hand forcutting and extracting, most surgeons
      U 7 think  prefer either the operation through the  site  of the old  wound
   Trie' U^eS^tio*.  Whatever procedure, however, is adopted, it should

          60 
946
STONE  IN THE BLADDER.
be borne in mind that the rectum may have become pretty firmly adherent to
the membranous portion of the urethra and the apex of the prostate, in conse-
quence of the contraction of the old cicatrices, and may thus be endangered.

                    CALCULUS  IN THE  FEMALE.

   Stone  is of rare oecurrence in women; in London,  certainly, I believe it is
not often met with.   Thus, South states, that during  a period of twenty-three
years, 144 males were operated on for stone at  St. Thomas's Hospital, and only
2 females.   In some districts, however, stone would appear to be more common
in women than this:—Thus, according to Mr. Crosse, at the Norwich Hospital,
the proportion has been about 1 woman to 19 men.  Civiale states, as the result
of his researches, that in the North  of Italy, the proportion is as 1 to 18; and
in France, as about 1 to 22.   Calculus in women  is most  frequently deposited
upon foreign bodies, accidentally or purposely introduced into the bladder, such
as pins, pieces of pencil, &c.
   At the University  College Hospital  we had  not had a case  of stone in the
female for many years until 1855, when three came under my care in the course
of a few months.
   The symptoms of stone in the female closely resemble those that occur in the
male, and  its presence may usually be  easily detected  by means of a short and
nearly straight sound, or a female catheter.  It is often  simulated very closely
by the irritation occasioned by a vascular urethral tumor, or by an irritable
bladder, but exploration of the viscus  will always determine the diagnosis.
   Calculus in the female bladder,  if allowed to remain unrelieved, will not only
occasion the various  morbid conditions in  the urinary organs^ that have been
described  as following the long-continued presence of stone  in the male, but
will give rise to diseased states peculiar to the  female.  Thus the stone may  be
spontaneously  discharged through the urethra:  if of small size, without any
bad results following; but if large, by a process  of ulceration, in  consequence
 of which permanent incontinence of urine will remain; or it may slough through
into the vagina; or lastly, it might offer a serious obstacle  during parturition to
the descent  of the foetal head, when if it could not be pushed aside to be dealt
 with afterwards, it must be cut out or craniotomy be performed.
   A stone may be extracted from the  female bladder by one of three methods:
 1st, lithectasy, through  a dilated  urethra; 2d, by lithotomy;  3d,  by lithotrity.
 These different operations cannot be employed indiscriminately, but each one is
 more especially adapted to certain kinds of calculus.
   1st.  Lithectasy may be performed in two ways—either by simply dilating the
 urethra by means of a sponge tent  or dilator, or else by incising the mucous
 membrane at the same time that the canal is being expanded.
   a. Simple dilatation of the urethra may be effected quickly by the mtroduc-
 tion of  a tent of compressed sponge, or a three-bladed dilator which is rapidly
 screwed up.  In this way in  from two hours to a few  minutes the canal may be
 easily dilated sufficiently to admit of the introduction of a pair of forceps, and
 the extraction  of a  calculus of moderate size.   Some surgeons  prefer a slow
 process  of dilatation, continued through many hours;  but this appears to me to
 possess  no advantage over the more rapid expansion, and  has  the very decided
 disadvantage of prolonging the patient's  sufferings.  The plan  that  I have
 adopted with most success is to introduce a sponge tent two  hours before  the
 intended extraction, and then, when the patient is under chloroform, to dilate
 the urethra to the required extent, with a two or three bladed dilator.
   |3. Incision may be employed conjointly with dilatation, in  order  to prevent
 injurious  stretching of the urethra,  and consequent laceration of its  mucous
 membrane.   The incisions recommended with this view should be made after
 the urethra has been dilated to some extent; a probe-pointed bistoury being in- 
LITHOTOMY  AND LITHOTRITY IN  THE  FEMALE.    947
troduced by the side of the canal, and the mucous membrane divided.  Brodie
makes an incision directly upwards, Liston  downwards and  outwards on either
side; on the whole, I think, the best direction for the incisions, as more space
may thus be obtained.
   By dilatation, either alone or with incisions of the  mucous membrane, small
stones may readily be extracted; but in the  removal of moderate-sized calculi,
the great objection to this operation is the liability to incontinence of urine re-
sulting  from it.   It is  difficult to say to what extent the urethra may be dilated
without incontinence resulting;  this must necessarily vary in different individ-
uals.   It certainly can be expanded sufficiently to admit of the introduction of
the index finger, and to allow of the extraction of a stone  eight or ten lines in
 diameter, without any evil resulting.  The  incontinence of urine  that may be
 left after the removal  of larger  calculi than  this may not be by any means com-
 plete ;  but a weakened state of the sphincter of the bladder results, so that the
 patient cannot hold  her water for more than an hour or two at the  most.
   2d.  Lithotomy in the female may be performed in a variety of ways.   There
 are, however, only two modes of practising this operation that appear to me to
 deserve serious attention, viz., the supra-pubic and vaginal.   The supra-pubic
 or high operation in women differs in no very material  respect from  the  same
 procedure in men; except that it requires additional care in consequence of the
 difficulty there is in causing the female bladder  to retain  a  sufficient quantity
 of urine to make the  viscus rise sufficiently above  the pubes.  The extraction
 of the stone is easy, as it can be raised into the grasp of the forceps by being
 pushed up from  the vagina.
    Vaginal lithotomy  is an operation easy of performance.  It may be practised
 by passing a straight grooved staff into the  bladder, pressing the end wett down
 against the anterior wall of the vagina, and fixing it there with  the left index-
 finger.  A scalpel is then pushed  through the anterior wall of the vagina and
 inferior fundus of the bladder into the groove in the staff, which it is made to
 enter just  behind the urethra, and is then   run backwards for about 1£ inch;
 through the aperture thus made the forceps are passed, and the stone extracted.
 This operation is necessarily  followed by a yesico-vaginal fistula, which will  be
 required to be closed by a subsequent plastic procedure.
    Of  these two methods the high operation is, I think, the  preferable.  With
 care, there would be  but little risk of injuring the  peritoneum, and the chance
 of urinary infiltration, which is a serious objection in the male, may be prevented
 in the female by the  introduction  of a syphon catheter into the urethra.  The
 vaginal operation, though easier of performance, is open  to the  objection of
 leavino- a permanent  urinary fistula.  It may, however, be the only alternative.
 In a case recently under my care,  I extracted a calculus measuring eight inches
 by six in  circumference, from the bladder  of a young woman, by this method.
 The stone havino- by its size offered so serious an obstacle  to the descent ot the
 foetal  head during parturition, that craniotomy had  been rendered necessary;
 the anterior vaginal wall had  been  a good deal  bruised,  and I feared that
 sloughing of it might take place, hence I  extracted  the stone  by the vaginal

 ^M  Lithotrity in the female requires to  be practised on the  same principles
 as in "the  male.  The  details  of the operation differ, however in  some important
 naviculars   The chief difficulty in the performance  of the  operation in the
 frmalP consists in causing the bladder to retain urine or water that is injected
 f„To t   In consequence of  this there is not only great difficulty in seizing the
   tone  the bladderqc0llapSing and falling into folds around it, but also danger
   finVrin^ the mucous membrane with the lithotrite.  In  order to cause  he
 bidder toVetain the necessary quantity of urine, the pelvis must be well tilted
 up and the  urethra  compressed against the lithotrite.  It is well not to dilate 
948       DISEASES  OF THE PENIS AND  SCROTUM.

the urethra before  the  introduction of the instrument, as the incontinence is
thereby increased.
  The ordinary male lithotrite  is  not  a very convenient instrument to use in
the female bladder, the handle  being awkwardly long.   This is especially the
case in female  children.  Hence I have found it convenient to have a shorter
instrument constructed, with which it  is  far more easy to manipulate in the
female bladder.  If urine or water cannot be retained, the  calculus may more
safely be seized and crushed  by  means of a small and strong-bladed pair of for-
ceps; or if the stone be larger,  a  crushing instrument, made of the  shape of
that depicted (fig. 384), but smaller and lighter.
  After the stone has been crushed, the urethra (unless this has previously been
done) may be dilated by means of the  two-bladed  instrument  to a  moderate
degree, and the larger fragments removed by means of a pair  of slender for-
ceps.  The shortness and wide capacity of the female urethra will readily allow
of the escape of the detritus.
  For all calculi in the female  bladder, except those of  the  very largest size,
this operation is the most applicable.   By it the stone may be removed piece-
meal as it were, without the  necessity of dilating the urethra to such a degree
as to incur the risk of incontinence of urine resulting.   Lithotrity may be had
recourse to at all  ages, in  the very young as well  as the old; I have crushed
and successfully removed a large calculus in a child three and a-half  years of
age.  Although the urethra of a female child is not very dilatable, yet it can
readily, by means of a sponge tent, be enlarged  sufficiently to admit a from 11
to 12 lithotrite.
                         CHAPTER  LIX.

            DISEASES OF THE PENIS  AND  SCROTUM.

  The penis is liable to certain malformations.   Thus  it occasionally happens
that there is an arrest of union in the mesial line, so that a slit or fissure is left
communicating with the urethra.  This  gap commonly occurs on  the  under
surface of the organ, constituting hypospadias, and is confined to the glans and
anterior part of the penis, though it occasionally  extends backwards  to the root
of the organ, and then may be associated with  some of those kinds of malforma-
                tion that are erroneously considered  as examples  of  herma-
    Fig. 397.    phroditism.   These  conditions  are mostly incurable, though
                plastic proceedings have occasionally  been devised for their
                relief.
                   The upper surface of the penis  is less frequently fissured;
                only, I believe, in cases of extroversion of the bladder.   This
                condition, termed epispadias, may be looked upon as incurable.
                   The prepuce  is not unfrequently the seat of malformation
                or  disease.   That  condition  of it in which  it is so  much
                elongated that it extends beyond and covers in the  glans, and
                at the same time so much contracted that it  prevents the proper
                exposure of  this portion of  the organ, is termed phymosis.
                This may be either congenital, or acquired, as the result of
                inflammation or disease.
                   In  the congenital phymosis  the  penis is usually somewhat
atrophied, and the development of the  glans  prevented by  the pressure  of the
 
PHYMOSIS. — CIRCUMCISION.               949
Fig. 398.
narrow prepuce.   In the majority of cases this condition is simply a source  of
inconvenience, but it may become a source  of disease from the retention of the
sebaceous secretion of the part, setting up irritation and repeated attacks of in-
flammation (fig.  397).   Congenital  phymosis especially becomes  a source  of
inconvenience if any gonorrheal or venereal disease is contracted, as it renders
the exposure of the diseased part difficult or impossible, and interferes with the
necessary treatment.
   Phymosis that is acquired has usually resulted from repeated attacks of inflam-
mation, or of specific disease  in the part, giving  rise to solid oedema, or false
hypertrophy of the prepuce.
   The treatment of phymosis, when not congenital, must be conducted in accord-
ance with its cause; thus, if resulting from  inflammation, that must be subdued ;
if from venereal disease, that must be remedied, when perhaps the contraction
and elongation will gradually subside.  If, however, the phymosis be congenital,
or if it be acquired, but permanent, it must be  subjected to operation, and
indeed, I think, that  all  cases of congenital phymosis  in children should be
operated upon with the view
of" preserving the health and
cleanliness of the parts  in
after-life.
   Operations for  phymosis
may  be  conducted  on  two
 plans; the elongated and con-
 tracted prepuce may be slit
 up, or  circumcision may  be
 performed.  Slitting up of the
 prepuce,  whether upon  its
 upper or  under  surface, is
 always,  I think,  an objec-
 tionable  procedure,  leaving
 the prepuce of its abnormal
 length,  and  more  or  less-
 fissured  and  knotted.    In
 all  cases  I  prefer  circum-
 cision,  as the  simplest  and
 speediest  operation,  and as
 leaving  the most satisfactory
 rpmilt"
    Circumcision may most conveniently be performed in the following way (fig.
 398) : —The surgeon draws  the elongated prepuce slightly forwards, until that
 portion  of it which  corresponds to the back of the
 glans is brought just in front of that structure.  He
 then seizes the  projecting prepuce with a pair of nar-
 row-bladed polypus-forceps, which he gives to an assist-
 ant, who must hold them tightly.  With one sweep  of
 the bistoury he cuts off all that portion of integument
 which  projects beyond the forceps,  which are then
 taken away.  It will now be found that he  has only re-
 moved a circle of skin, but that the mucous membrane
 linino- it, still tightly embraces the glans;  this he slits
 up, by introducing the  point of a  pair of scissors  at
 the preputial orifice; and then, trimming off the angles
 of the flaps  of mucous membrane and snipping across
 the frenum, he turns back the mucous membrane, and
 attaches it to the edge of the cutaneous incision by five
 points of suture, two on
Fig. 399.
each side  and one at the frenum.  Before introducing 
950         DISEASES OF  THE  PENIS  AND SCROTUM.
these he will generally find it necessary to ligature a small artery on either side
of the penis, and sometimes one in the frenum.   Union  readily takes place by
simple dressing, and a very narrow line of cicatrix is left by which the patient
is by no means inconvenienced.  In some cases, I have found adhesions between
the prepuce and the glans which require to  be dissected through, but no incon-
venience results from this slight addition to the operation.
  If sloughing of the prepuce have occurred, allowing the glans to protrude as
in fig. 399, circumcision must be practised.
                            PARAPHYMOSIS.

   In paraphymosis the prepuce has been forcibly drawn back behind the glans,
which becomes strangled by  the pressure exercised  by the preputial orifice, so
that the parts cannot  be  replaced  in  proper relation to one another (fig. 400).
                                       This accident principally  occurs  in
                 Fig. 400.               boys, or in individuals who have natu-
                                       rally got a tight prepuce, and who  on
                                       uncovering the glans find it difficult to
                                       get this part of the organ back again.
                                       This difficulty is speedily and  greatly
                                       increased by the swelling from conges-
                                       tion that is set up in the  constricted
                                       glans.
                                          The  treatment  of  this condition is
                                       sufficiently simple. The surgeon should
                                       first try to  reduce the swollen organ.
                                       He may often succeed in doing this  by
seizing the body of the penis between the  index and middle  fingers  of either
hand, and then endeavoring to draw the prepuce  forwards, at the same time that
he compresses the glans between the two thumbs and pushes it back (fig. 401).
                                    Should reductions not be effected  in this
                                    way, the constricted and strangulating pre-
                                    putial orifice must be divided.   In doing
                                    this, the surgeon will  observe that the
                                    glans  is  separated from  the  body of the
                                    penis  by a  deep and narrow sulcus, which
                                    is especially evident on the upper part  of
                                    the organ  (fig. 400,  a).   This  sulcus,
                                    which  is overlapped  on  one side by the
                                    glans  and  on  the other by a fold of in-
                                    tegument, corresponds to the  inner mar-
                                    gin of the preputial orifice, and it is  by
                                    the division of this, in which the stricture
                                    is situated, that immediate relief will  be
                                    given.   This  operation  may  readily  be
                                    done by drawing the glans forwards, then
                                    passing the point of a narrow-bladed scal-
pel into the sulcus on the dorsum of the penis, and making a perpendicular inci-
sion about one-third of an inch in length through the integuments at the bottom
of the groove  directly across  it.   In consequence of the great stretching of the
parts, the incision will immediately gape widely,  so that instead of being longi-
tudinal it will appear  to  be  transverse, and then reduction of the glans may
readily be effected.
Fig. 401.

 C^  r
 
BALANITIS.— CANCER  PENIS.
951
                              BALANITIS.

   Inflammation of the prepuce commonly occurs as the result of local irritation
not unfrequently set up by a gonorrhea.  When confined  to the  prepuce, and
constituting balanitis,  that structure is much swollen, infiltrated, and reddened
and  while the inflammation lasts, continues  in  a state of  phymosis.   When
the mucous membrane of the glans is  affected  as  well, constituting posthitis
there is a good deal of irritation and smarting, together  with muco-purulent
discharge.
   The disease requires to be treated on  ordinary antiphlogistic  principles; the
continued application of lead lotion, with the internal administration of salines
will generally remove it;  but in many instances the most effectual plan will be
found to consist in rapidly sweeping the  inflamed surfaces with a stick of nitrate
of silver  passed down  between them  on one side of  the  frenum, and carried
round to the opposite side.
   Herpes of the glans and prepuce is characterized  by the formation of small
vesicles or excoriated points upon the mucous membrane of this region, attended
by much  smarting  and itching, and chiefly occur-
ring  in persons of a gouty habit of body, with an
irritable mucous membrane.  This slight affection
is often very rebellious to treatment.  In many in-
stances,  local  means  alone  will  not  suffice;  for
though  relief may be  obtained  by powdering  the
part with the oxide of zinc, by using slightly astrin-
gent  and cooling lotions, yet no permanent benefit
will be  derived unless  constitutional irritation be
removed  by  treatment of a cooling or alterative
character, modified  according to the circumstances
of the case.
   Hypertrophy of the prepuce not unfrequently oc-
curs  as the result of chronic irritation or disease;
it is  usually of limited extent, and requires no spe-
cial interference on the part of the surgeon; but
in some instances it may become so extensive as to
demand operative interference.  Thus Vidal has related and  figured  a case that
had  attained such an enormous size, that the organ reached to below the knees,
and was as large as a thigh.  This monstrous growth was successfully excised.
   Warts  on  the penis have already been described.  They may  attain a very
large size, as in fig. 402, and are best treated by excision.

                       CANCER OF  THE  PENIS.

   The penis  is liable to cancerous disease, which commonly  assumes  the schir-
rhous form, and usually  springs  from the sulcus  behind the glans, and may
thence invade the neighboring  portion of the  organ or the  prepuce.   It may
assume the primary form either of a tubercle, of infiltrated cancer  of the glans,
or of a cancroid ulcer.   It has been supposed, and with some  show of reason,
that congenital phymosis predisposes to the affection, probably by confining the
secretions, and thus keeping up irritation of the part.   Hey found  that of  12
patients with this disease, who came  under his  observation, 9  had  congenital
nhvmosis • and Travers states that the Jews who are circumcised are seldom
subiect  to this affection.  But as they are a limited community in  this country,
and as  the disease  is rare, we cannot draw any conclusive  inference from this
observation   The affection, however, can occur in individuals who have not
suffered from phymosis; of this we have  had several instances at the  University
College  Hospital.
 
952        DISEASES OF THE PENIS AND  SCROTUM.

  The progress of the disease is usually somewhat slow; the organ  enlarging
and hardening, without any very great degree of pain. If it form as a tubercle,
it may, after a time, give rise to a large irregular and sprouting mass, having a
granular fungous appearance, bleeding with  much fetid discharge, enveloping
and at last implicating the glans, prepuce, &c. In  other cases it may commence
as a hard scirrhous mass, of a pale reddish-white color, situated on the glans, or
between the prepuce and the glans.   This increases  in size, at last cracks, and
allows a serous fetid  discharge to exude.   Ulceration  then rapidly takes place.
Sometimes this  scirrhus appears to be very distinctly localized;  but after its
removal it will always present the  character of an infiltrated cancer.  It is, I
believe, always primarily situated at the anterior extremity of the  penis, not
occurring in the body of the organ, except as a secondary deposit.
  Cancer of the penis requires to be diagnosed from warts of a fungoid  charac-
ter.  This may usually be done readily  enough by comparing the  indurated state
of the malignant, with the soft and lax condition of the non-malignant affection.
From chancrous induration, the  history of the case and the way in which it is
influenced by treatment, will enable the  surgeon to effect a diagnosis.   In in-
durated plastic effusions into the corpus spongiosum, no pain is experienced, and
the disease remains in a stationary condition.
  The treatment of cancer of the penis must be conducted on the principles that
guide us in  the malignant affections wherever situated, viz.: to remove the dis-
eased organ, provided the affection is localized, the glands not implicated, and
the constitution  not poisoned.  In  the  case of cancer of the  penis, this  may
readily be done by an operation that is  simple  in its execution and  devoid of
danger.   In many cases, doubtless, a return may take place, and that speedily,
either in the part itself or in the neighboring lymphatic glands; but yet, even
if this occur, it is clearly the duty of the surgeon  to rid the patient of a loath-
some  disease, and to  put him in a state of comparative comfort for some months;
the more so, as there can be no doubt  that, in some instances, the disease  may
be  entirely  extirpated from  the  system, evincing no tendency to  return.  In
some  of Hey's cases, which continued under his observation, there was no recur-
rence of the disease for several years; and I have lately seen a gentleman who
had his penis amputated for cancer more than  twenty years ago, and in whom
no return has taken  place.   The fact is, that we see and hear of those cases in
which a recurrence takes place;  but those patients who remain free from a re-
turn of the infection, do not divulge their infirmity; and it is exceedingly rare in
hospital practice  to find a patient come back with recurrent cancer in the stump
of the  penis or  the  lymphatic  glands, which he  would certainly do if relapse
took place.  In those cases in which the operation  is not successful, it generally
happens that the disease has already implicated  the lymphatic glands.
  Amputation of the penis must always be performed towards the root of the
organ, so as to get well  clear of the disease; at the same time care must be
taken not to remove it too  near the pubes, lest the  stump retract under that
bone.   The operation may  readily be done  by  the surgeon putting  the penis
upon  the stretch, drawing the integument well forward, and then  severing the
organ at one stroke of the bistoury.  It is well not to leave too much skin, lest
the flap, falling over the face of the stump, makes the  search for any bleeding
vessels somewhat difficult, and afterwards may pucker  inconveniently.   There
are usually five arteries requiring ligature; the dorsales penis, one in each corpus
cavernosum, and one in the septum.   In securing these, trouble is not unfre-
quently experienced in consequence of the retraction of the stump that is left.
The liability to this, however, is lessened by passing a hook through the root
of the organ before  the  operation is commenced,  or  by directing the assistant
to hold it firmly  between the fingers, and then to  prevent  the retraction of the
stump, which may otherwise draw back and be buried almost in the  perineum.
Should it do so and oozing continue, a female catheter must be passed into the 
DISEASES  OF  THE  SCROTUM.
953
urethra and a firm compress  applied with  a *]" bandage.   During and after
cicatrization, the  urethral orifice has a tendency to contract.  This may, how-
ever, be prevented  by drawing  forwards  the mucous membrane, making four
cuts in it with a pair of scissors, and then stitching it to the edge of the cut
skin.   If the amputation be performed high up, this may be somewhat difficult,
and then it may be  safer to introduce an elastic catheter before the operation, to
perform the amputation upon this, and to  leave it in during  cicatrization. After
the operation, the urine will not be projected forwards, but  always passes
directly downwards between the legs.  Any inconvenience  in this respect may
best be avoided by  adopting Ambrose Pare's advice of adapting a funnel, which
may be made  of metal or ivory,  to the pubes over the stump, and thus carrying
the urine clear of the person.

                    DISEASES OF THE SCROTUM.

   Inflammatory edema of the scrotum is  an erysipeloid inflammation of this
 reo-ion, which derives its chief peculiarity from the circumstances of  its giving
 rise to great effusion into, and  swelling of the cellular tissue, with a tendency
 to the rapid formation  of slough in it, by which the integument may likewise
 become affected  to such an extent  that the  testes and cords speedily become
 denuded.   This  disease usually originates from some local  source of irritation,
 as fissures, cracks,  or urinary extravasation.
    The treatment consists in elevating the scrotum, fomenting it well, and making
 early and free incisions into it, more particularly at the posterior and  dependent
 parts, with the view of relieving the tension to which the tissue is subjected by
 the effusion into its cells; and thus preventing the liability to sloughing. Should
 this occur, the case must be  treated on  ordinary principles, when cicatrization
 will  speedily ensue, however extensive  the denudation  of parts may be; the
 constitutional management must always be conducted in accordance  with those
 principles laid down in the first division  of this work, and with especial  atten-
 tion to the maintenance of the patient's strength.
    Hypertrophy of the scrotum seldom occurs in this country, though  Mr. Liston
 once had occasion  to remove such a mass weighing 44 lbs.; but in some tropical
 regions more particularly India and China, it is of frequent occurrence, and  may
 eo on until it attain an enormous  bulk, forming a tumor nearly as large as the
 trunk, and perhaps weighing 60 or 70 lbs.  These enormous growths are  of a
 simple character, and constitute the disease termed elephantiasis of the scrotum.
 Tumors  of this kind  necessarily require extirpation, and in performing such
 onerations there are two points that demand special attention:  the  first  is the
 nrese ^ on  of  the penis and testes, which will usually be found buried towards
 the upper part of the mass, and which  may be done if the  tumor is  of small
   £  and  thesecond is to endeavor  to prevent  the hemorrhage Deing of too
   refuse^a character.  With this view the  operation ought not  on£ to he>  per
  formed as rapidly as possible, but  the  suggestion  made  by Mr. D. t errall ot
  eleXrthe turner above the level of the body, for some time before its removal
  so Is to empty it of its blood, may be advantageously adopted.  If  the growth
  be very Ztfit will be better not to make any attempt at saving the  testes  or
  nenls which could only be dissected out by a long and tedmus operation, in the
  penis, ^1^h.C°hUthere would be danger of the patient dying from hemorrhage.
  ^^^S^dL^e occasionally affects the scrotum, and as it prin-
    Cancerous or Cd'1L.      sweeT)erg  it has been  appropriately enough termed
  cipally ooou^  ohmney-Bwe per.  i            ^P  ^ ^      ^

  tZTSn* in  th? folds of the scrottTm, and is  a very common form of
   ™„ 1  dise°aseD   It commonly commences as a tubercle or wart, which at last
■  ZTt crack or ulcerate, presenting the  ordinary characters  of cancerous
  ulceration   After a time the  inguinal and pelvic glands will be  seen  to  be 
954          DISEASES  OF  THE  TESTES AND  CORD.
affected, and the  patient, if deprived of his covering of soot, will be found to
be cachectic looking.
  The treatment  consists in excising widely the diseased portion of the scrotum,
provided the  inguinal  glands be not  involved, or the  patient's constitution
poisoned.   The disease has a great tendency to return, and it is seldom that the
patient long escapes with life when once he has been affected by it.
                          CHAPTER LX.

              DISEASES OF  THE  TESTES AND CORD.

                  MALPOSITION OF THE  TESTIS.

  The testis may be situated in the inguinal canal, not having properly descended
into the scrotum, and then may become inflamed, as will presently be noticed;
or it may become affected in this situation by malignant disease,  rendering its
extirpation necessary.  The testis may be met with in other abnormal situations;
thus, some time ago I saw a case in which one of these  organs was  situated  in
the perineum close by the anus,  and cases  have occurred  in which they have
been met with  in the  interior  of the  pelvis.   The organ may sometimes be
turned hindside forwards, being retroverted, so that the  epididymis is placed  in
front.  In  a case of this  kind that  I had  an opportunity of examining after
death a few years ago, the epididymis and vas deferens were considerably larger
than natural.   If a hydrocele form in such a case it will be seated  behind the
testis.
                         NEURALGIA  TESTIS.

  A painful or irritable condition of the  testicle may occur without any actual
disease of the organ; the pain being either seated in the epididymis, which is
the part naturally most tender, in the body of the testis, or stretching along the
cord to the  loins and groins.   It is usually paroxysmal, and is accompanied by
great tenderness, and commonly by some fulness  of the organ, which feels soft
and flaccid; but it is difficult  to make a proper examination  on account of the
agony that  is induced  by touching  the  part.  This  disease chiefly occurs  in
young men of a nervous and excitable temperament, and is frequently associated
with great mental disquietude and  despondency, often  amounting to a suicidal
tendency.
  The causes  are obscure; in many cases the disease appears to be connected
with a neuralgic temperament, but in others it is  associated with some dyspeptic
disorder, or may be dependent upon local irritation; thus external piles, or the
pressure of a varicocele, will often give rise to it.
  The disease is usually of a very chronic character.   In some instances, how-
ever, it ceases  spontaneously, after having lasted  for weeks or months.  When
dependent upon constitutional causes, the treatment is extremely unsatisfactory.
The administration of tonics, such as iron, zinc, or quinine, the local application
of  sedatives, as of atropine ointment, or the tincture of  aconite, may be of ser-
vice.   In other cases, cold bathing or douching will be beneficial, and in all,
keeping the part supported with a suspensory bandage will be advantageous.  In
the event  of there being any local  irritation, that  should  be removed; thus I 
INFLAMMATION OF THE  TESTIS.            955
have known the disease cease  after the excision of external piles; and when it
is connected with varicocele, proper measures must be adopted for the relief of
that affection.   In extreme cases, Sir A. Cooper recommends  castration; but
such a proceeding is altogether  unjustifiable in a disease that is either constitu-
tional or dependent on local causes readily removable.

                 INFLAMMATION  OF  THE TESTIS.

   Inflammation of the testicle, considering the organ as a whole, may be of two
 distinct kinds, varying as to seat and as to cause.  Thus it may be seated in the
 body of the organ, constituting orchitis, or the epididymis may alone be affected.
 As to  cause, it may be gonorrheal or not.
   The seat of the inflammation, at the commencement of the disease, depends
 greatly upon whether its cause is  seated in the urinary passages or not.  Irrita-
 tion in any part of the urethra, whether occasioned  by the  passage of instru-
 ments, the lodgment of calculi, or the existence of gonorrheal inflammation,
 usually causes the epididymis  to be primarily affected,  and the body of the
 oro-an to be inflamed in a secondary manner.  When, on the other hand, the
 inflammation comes on from injuries, blows,  strains, or other causes acting gene-
 rally, the body of the testis is usually first affected.  To all this, however, excep-
 tions will often occur, and orchitis may supervene as the result of gonorrhea, or
 epididymitis, from a blow; the orchitis in such cases being  in all probability a
 kind of constitutional affection, intimately associated with inflammation of other
 fibrous tissues, especially with gonorrheal rheumatism; the inflammation of the
 epididymis, arising from gonorrhea or other irritation of the urinary passages,
 appearing to  result from direct  extension of morbid  action  along the vas
 deferens.
    The symptoms necessarily vary to a certain extent, not only according as the
 disease is of an acute or chronic character, but as it primarily affects the body
 of the testis or the epididymis.  When commencing in the  latter structure it is
 the inferior globus that is commonly first affected, which becomes swollen, hard,
 and  tender.   The disease may be confined throughout to this part, but most
 frequently it invades the whole of the organ, which becomes uniformly enlarged
 and somewhat ovoid, frequently accompanied by a good deal of effusion into the
 tunica vaginalis, then  constituting the acute hydrocele  of Velpeau.  As the
 inflammation subsides, the different characters presented by the enlargement of
 the two constituents of the organ  again become apparent.  The  swelling is
 therefore due partly to  general enlargement of the organ, but in some cases to
 inflammatory effusion into  the tunica vaginalis, which may either be of a purely
 serous,  or partly of a plastic  character.
    The  pain  is always very severe, with much tenderness and  a  sensation ot
 weio-ht, and commonly  extends up the cord into the groin and loin   It is gene-
 rally  oreatest when the body  of the  testis is affected,  owing probably to  the
 enveloping  fibrous tunic preventing the expansion of the  organ.   Hence it 1S
 often spasmodic and paroxysmal, extending up the course of the cord,  lhere
 is usually a good deal of swelling and redness of the scrotum, with  turgescence
 of the  scrotll veins, and a congested state of  the  cord, with sharp pyrexia,

 "^^S^^SS^^^e testis first resumes its normal charac-
 ter and  shape, the  epididymis often  continuing hardened  and enlarged for a
 considerable period.   In fact, the induration that forms in the  epididymis may
  ssum" aomeXt permanent character, owing to the effusion of plastic matter
 hitoTt! leaving a hardened mass, and implicating the whole or a portion of its

 ^Sutac1™orchitis usually comes on with the same symptoms, though in a less
 markedI form than in the acute variety. The swelling, however, is considerable, 
956          DISEASES OF  THE  TESTIS  AND  CORD.
though of a softer kind.   When the disease is chronic, the testis often becomes
permanently enlarged and hardened, assuming an  oval  shape, being smooth,
heavy, and uniformly expanded, with  a sensation of weight, dragging and severe
pain, and a good deal of tenderness on pressure.   This form of orchitis occa-
sionally occurs in old people.
  The treatment of inflamed testicle, whether local or constitutional, is essen-
tially antiphlogistic.  Blood  should be abstracted from the part by puncturing
the veins of the  scrotum, a far better method than  applying leeches, the bites
of which are apt to become irritated.   This little operation may be very effectu-
ally done by directing the patient to stand up and to foment the scrotum for a
few minutes with a hot sponge, so as to distend the veins; these may then be
punctured  at various points with a fine lancet, and the parts well  fomented after-
wards, so as to encourage  the  flow of blood.  In  this way six or eight  ounces
may be taken in the course of a few minutes;  when  enough has  escaped, the
further flow may be arrested by laying  the  patient  down and elevating the
part.
  The patient should be  kept in bed with the  testis raised on  a small pillow
between the thighs, poppy fomentations  being diligently had recourse to.  If
there is  much effusion into the tunica vaginalis, constituting acute hydrocele,
relief may be afforded by puncturing this sac with the point of  the lancet.
  The constitutional treatment during  the acute stage consists  in the adminis-
tration of salines and antimony, with henbane in full doses, so as to give an ape-
rient, a diaphoretic, and  a sedative  together; when this begins to act, great
relief is usually afforded.
  As the inflammation subsides, the  treatment must be changed.   When there
is merely a swelling and  hardness  left, with but little pain or  tenderness, the
testis may  advantageously be strapped with adhesive plaster, so  as to give good
support and to promote absorption of plastic matter.  Fricke of Hamburg has
strongly recommended strapping in  the  acute  stage, but I cannot say that I
have ever seen  any advantage derived from it at this  period of the disease,
though I  have  many times seen it tried; it has  usually appeared to me  to
increase, and sometimes very considerably, the pain  in the part and the general
uneasiness.
  In subacute orchitis much benefit is usually derived by a short course of Do-
ver's powder and calomel, with early strapping of the testis.  When the organ
has become enlarged  and indurated, as the result  of chronic inflammation, it
may be  advantageously strapped, either with simple plaster or with one com-
posed  of equal  parts of the Emplast. Ammoniaci  cum Hydrargyro and soap-
plaster;  mercury in small doses, more especially the bichloride, being continued
for some length of time, until the plastic  matter is absorbed  and the hardness
disappears.
  In strapping a testicle, the scrotum should be shaved, and then drawn tightly
upwards on the  affected side.  The  surgeon should next pass  a long  strip  of
plaster, about an inch broad, above the enlarged testicle and round the corres-
ponding side of the scrotum, so as  to isolate it, as it were.   Another strip is
now passed from behind, in a longitudinal direction, over the lower end of the
testis, and upwards upon the anterior part of the scrotum; and  thus, by a suc-
cession of horizontal and vertical strips, neatly overlapping and drawn tightly,
the organ  is completely enveloped and compressed.
  Abscess, as the  result of inflammation of the  testis, is of rare occurrence:
sometimes, however, the  scrotum  inflames at one point, where fluctuation  be-
comes apparent, with thinned skin and evident signs of suppuration; a puncture
should here be made, and the pus let out as soon as formed.  Sometimes abscess
may  occur in another way; inflammation is set  up  in  the  tunica  albuginea,
adhesion takes place between the testis and the scrotum, abscess  forms under
the fibrous coat, and this giving way, the pus gets  vent externally through the 
HYDROCELE.
957
integuments.  Into the aperture that necessarily results, a portion of the secre-
ting tissue of the gland sometimes projects, and, becoming inflamed, forms a
red, granular, and fungous mass, protruding through and overlapping the edges
of the aperture.  The treatment of this condition will be considered when we
come to speak of the  scrofulous testicle.
   Inflammation of  the testis in the inguinal  canal may sometimes  take place,
even in adults, when the organ has not descended through the external ring,
giving rise to  a train of symptoms of  a somewhat puzzling character, and that
closely resemble those of strangulated incomplete hernia, with which, however,
it must be borne in mind that it may  be associated (p. 799).  On examination,
in these cases, a large, irregular tumor, in some parts hard, in  othe*rs soft, very
tender to the  touch, and occasioning  a sickening sensation when pressed, will
be found in one of the groins, in the  situation of the inguinal canal.  There i3
 usually a tendency to vomiting,  and some constipation, with coliky pains in the
 abdomen.  These symptoms, however, are generally not very persistent, and the
 constipation readily yields  to the administration of purgatives.  On examining
 the scrotum, it will be found that the testis on  the affected side  is absent, and,
 on passing the finger into the external ring,  the  organ can be felt to be lodged
 in the canal.   In consequence  of the proximity of the  peritoneum to the in-
 flamed testis, this membrane occasionally becomes involved in the morbid action,
 and, as the result of  the constriction  of the  tendinous and aponeurotic tissues
 in this situation, sloughing has occasionally occurred.  Either of these  condi-
 tions may lead to a fatal termination.
    The treatment  should  be actively antiphlogistic.   Leeches must be  freely
 applied over the part, and blood should be taken from the arm if the patient is
 young and strong; salines with antimony being at *he same time administered,
 and fomentatidns diligently persevered in.
    In some cases  the inflammation  of the  testis may extend, or  the disease
 may from the first be limited  to the cellular tissue of the cord, giving rise to
 tumefaction,  with  a  good deal of pain and tenderness along it, and eventually
 the formation of abscess, accompanied by the usual signs of  suppuration.  The
 treatment  of such a case must be   conducted  on  ordinary principles — early
 discharge for the pus being secured.

                               HYDROCELE.

    By hydrocele is meant  an accumulation of serous fluid, formed in connection
  with the testis or  cord.  Most frequently the fluid occupies the sac of the tunica
  vaginalis, constituting a true dropsy of  it; in other instances, it appears to be
  formed in distinct cysts, situated either  in  connection with  the testis, or upon
  the cord.  Hence, hydroceles are commonly divided into those that affect the
  tunica vaginalis, and the  encysted variety.
    Hydrocele  of the tunica vaginalis may occur as the result of acute orchitis
  the inflammation of the testis causing the effusion of a quantity of limpidflu id
  into its serous investment.  This, however, is not he kind of hydrocele that is
  commonly met with; the fluid so poured out as the result of active mflamma-
  Z ^llTbeSoming absorbed as  the parts recover their normal condition.
  The^Xary hydrocele occurs as a chronic  disease, without any signs of inflam-
  LTtiZ nf the testicle or, at most, slight tenderness of that organ.  It is most
  C^Shidividu^^t the middle period of life, and generally
  in personl of feeble power, or in those of a cachetic or gouty constitution, com-

  TnCtts^^                               - ^y\r
   ff^wn forms- either  the ordinary one, similar to what occurs in adults in
    i^tSav   i  constitutes a closed sac filled with fluid; or a less
  Slo?vS^i"^ the accumulation of fluid in the  tunica vaginalis 
958          DISEASES  OF THE TESTIS AND  CORD.
communicates, by the persistence of a cavity or canal in the funicular prolonga-
tion of the peritoneum investing the cord, with the general cavity of that mem-
brane.  This form  of hydrocele  is congenital, and the fluid in it occupies the
same  position that intestine does in a  congenital hernia.  It may readily be
recognized by the fluid  being  made to  flow back into the general peritoneal
cavity, by raising or squeezing the tumor. But although this may be considered
to be  the true congenital form of hydrocele in infants, the other variety of the
disease also occurs in them when but a few days old, and very possibly even at
the time of birth.
   The symptoms of hydrocele are  tolerably evident.   The disease begins with
a degree of swelling and weight about the testis, which may at first be soft, but
after a while becomes hard and tense, or it may be so from the very commence-
ment.  Whatever its original condition, the tumor soon becomes oval or pyriform
in shape, being  narrowed above, rounded and  broad below;  it is  smooth and
uniformly tense  and hard, often having a semi-elastic feel.   It reaches upwards
along the cord, towards the external  abdominal ring, which, however, is never
invaded  by it, and  the cord is usually  distinctly to  be felt  above the  upper
margin of the tumor.  Most commonly the size varies from that of a hen's egg
to a small cocoa-nut, but sometimes it may attain a considerably greater magni-
tude than this, and will then cause much deformity of the parts, as it reaches
up close to  the external ring, and drags  over the  penis, causing  that organ to
be buried in it.
   The most characteristic sign of  hydrocele is its translucency by transmitted
light.  This may always be detected, by the surgeon grasping  the posterior part
of the tumor with one hand, so  as to put  the integuments on the fore part on the
stretch, then placing the edge of the other hand along the most prominent part
of the swelling,  and having a lighted candle held close behind. On making this
examination, the tumor will appear transparent;  if, however, the walls of the
sac be thick, or the fluid dark, the  transmission of light through it may not be
perceived unless the examination be conducted in a darkened room.  We have
already seen that the ordinary hydrocele of the tunica vaginalis may vary as to
size;  it may also differ as to shape; in some cases being globular, in others
constricted  in the middle, or of an  hour-glass shape.
   The quantity of liquid varies considerably; there is usually from six to twelve
or twenty ounces, but I have known a hydrocele contain more than one hundred
and twenty ounces.  The fluid is  generally clear and  limpid, and of a straw
color; but in very large and old hydroceles it may become of a dark-brownish or
chocolate hue, owing to the admixture of disintegrated blood; and will then be
found to contain flakes of cholesterine.  The sac is  usually thin, but in  some
old cases becomes  thick and  dense, lined by a kind of false membrane, and
divided  by septa or bands, occasionally to such an extent as almost to separate
it into distinct compartments.  When the sac  is  thick, and  the fluid opaque
and turbid, there may be considerable difficulty in detecting the translucency.
   The testis is  generally somewhat enlarged, especially about the  epididymis,
and frequently slightly tender, more particularly in the early stages of the com-
plaint.   It  is almost invariably situated at the posterior part of the  sac (fig.
403), but may sometimes be found towards its anterior part.  When this is the
case, the epididymis will be found turned towards the front, owing to the organ
being retroverted.
   The coverings of a hydrocele are the  same as  those of testis.   Besides the
integumental structures, aponeurotic prolongations from the intercolumnar and
cremasteric fasciae may be traced over the surface of the swelling (fig. 404).
   The treatment of hydrocele is  divided into the palliative and curative.   By
the palliative treatment the surgeon simply seeks to relieve the patient  of the
annoyance induced by the bulk or weight of the tumor; but the curative has
for its object the permanent removal of  the disease. 
TREATMENT  OF  HYDROCELE.
959
  The palliative treatment consists in  the use of a suspensory bandage  and
cooling lotion, or of tapping with a fine trochar.   These simple means, how-
Fia. 403.
Fig. 404.
ever will sometimes succeed in effecting a radical cure.   Thus, m infants it
will happen that the application of evaporating and discutient lotions  may re-
move the effused fluid; and indeed it is seldom that any other plan of treatment
than this is required in young children.   The best lotion for the purpose con-
sists of one composed  of SJ of muriate  of ammonia, §j of spirits of wine  to
5viii of water; with this the scrotum should be kept constantly wetted, and it
there be a communication with the peritoneum, a truss should be< kept applied
over the external ring.  In adults it occasionally happens that simple tapping
oT^mOThaSaffeltedaradioal cure.   Some  years ago a gentleman from
Cuba consulted me for a small hydrocele which had been  forming for  several
months I tanped it with a fine trochar, and drew off about five ounces  of fluid.
Swas foKed by a radical cure. 'This case bears  out a remark made by
SbB^rodKattLfewinBtenoes in which he  had known simple  tapping
poduce a radical cure occurred in West Indians.   This simple operation is not
alto^eher  however, destitute of  danger; I  have  known an od  man die from
ffimatonr *dem»  of the  scrotum after  being tapped.  After tapping it
uZhjr havens that the hydrocele slowly forms again, attaining its former bulk

at f Tit fhvdreceto ^precautions are necessary, the principal being
   In tapping a hydrocelea re  P              f h  gcrotal veins.   in the
to avoid injuring the test s or ^   ^ back ^ the         d ■
majority of caJ^ ^e jesaB              troch   .f ^ is introduced  as it
quently altogether  out  of  the    Y              ^ ^ ^ ^        Qn

should be, ty *e ^J.Pd witg his left band, and then pushing the trochar
stretch by g^P^f^.^ddllthird in front, carrying the instrument at first
into the lower part of its miuaie t           ,     j^ perforated the sac, direct-
directly backwards (fig. 405 «), butw soo ^^  ^P^ f^ ^ ^.^
ing its point; upwardsU,n       ;•            ^^ ^^ wh   it may some. 
960         DISEASES  OF THE  TESTIS  AND  CORD.
behind.  Before using the trochar, it is well to see that the canula fits  closely
round  the  neck of the stylet, and above all that the instrument is not rusty by
                                      having been  carelessly put  aside after
              Fig. 405.                 use on a previous occasion.
                                        The  curative  treatment  has  for its
                                      object the excitation of a sufficient degree
                                      of inflammation in the tunica vaginalis to
                                      restore the lost  balance between secre-
                                      tion and absorption; but it is not neces-
                                      sary  that the  serous cavity should be
                                      obliterated by adhesions between its op-
                                      posite sides,  though these  not unfre-
                                      quently take place.  The means by which
                                      the  surgeon sets up this inflammation
                                      are either by the introduction of a small
                                      seton  into the tunica vaginalis, or by
                                      throwing  a  stimulating  injection  into
                                      that  cavity after  tapping it.  Which-
                                      ever  plan is adopted, a certain amount
of inflammation ought to be set  up.   This is always attended by considerable
swelling of the testis, and by the effusion of a fresh quantity of fluid into the
tunica vaginalis.  As  this is absorbed, the  part gradually resumes its  normal
bulk, and the disease will probably not return.
   In order that the radical  cure,  in whichever way undertaken, should  be safe
and efficient, it is  necessary, in the first  instance, that the disease should have
been allowed to get into a chronic condition, more particularly if the hydrocele
have been  of rapid growth.  In order to  prevent its  attaining too large a size,
it will be well  to adopt palliative tapping once  or twice before attempting the
radical cure.   Care must also be taken to remove all  inflammation  and  tender-
ness about the testis, before having recourse  to  this means of  treatment.  If
attention be not paid to this, recurrence of the  hydrocele will probably ensue.
After the proper amount of inflammation has been set up, it will be well to treat
the patient as  if he were suffering under an ordinary  attack of orchitis, con-
fining him to bed or to  the  couch for a few days; indeed, I look upon  care in
the after-treatment as  of very considerable  importance in securing a favorable
result  to the case.
   The cure by the introduction of a seton, though formerly much employed, is
seldom practised at the present day, chiefly on account of the danger of exciting
too much inflammation.   It  may,  however, conveniently be  had  recourse to in
the true hydroceles of children, and in some of those cases in which the injection
fails, if practised in the manner that will immediately be described.
   The treatment by injection is the one that is commonly employed; it consists
in tapping the tumor in the  usual way, and then throwing a sufficient quantity
of stimulating  fluid into the  tunica vaginalis through  the canula, so  as to excite
a proper amount of inflammation  in  it.   The liquids  that are employed are
generally either port-wine or a solution of the sulphate of zinc of the strength
of ^i to ^xii,  or most commonly the  tincture of iodine.   If the port-wine or
solution  of the sulphate of  zinc  are  employed, a sufficient quantity partly to
distend the sac should be injected from an india-rubber  bottle or brass  syringe
that can be adapted to the canula; six or eight ounces  are  commonly required
for this purpose, and it should be allowed to remain in for some minutes before
being evacuated.
   The tincture of iodine, originally introduced by Mr. Martin whilst practising
at Calcutta, is  now commonly preferred as a more certain  and a safer mode of
treatment than any other.   It is  usually sufficient to inject about  31 or ^ii of
the pure tincture.  It should be left in for a few minutes, in proportion to the 
RADICAL CURE OF  HYDROCELE.             961
amount of pain it occasions, and then allowed to escape.  A good deal of in-
flammation will usually be set up, on the subsidence of which, the cure will be
found to have been effected.
  Useful as the iodine  injection is, it sometimes fails in producing a radical
cure of hydrocele;  this is attributable to two causes: the first is,  that in some
cases sufficient inflammation is not set up to induce that condition of the tunica
vaginalis which is necessary for a radical cure.   It is well known that when a
hydrocele is radically cured by injection, it is  so, not by any adhesion taking
place between the two opposite surfaces of the tunica vaginalis and a consequent
obliteration of its cavity, but by the  inflammation that is artificially induced,
exciting such a modification of this membrane as to restore the balance between
the secretion  and absorption  of the  fluid, by which it is naturally lubricated.
Now in some  cases sufficient inflammation is  not induced by the introduction
of the  irritating fluid, to restore the natural balance between these  two functions
of the membrane;  and the tunica vaginalis gradually fills again after the injec-
tion, as it would after the simple operation of tapping.  It occasionally  happens
that the patient may suffer excruciating agony at the time of the injection, from
the contact of the stimulating fluid with the surface of the testis, and yet little
 or no inflammation be excited.  The amount of suffering, therefore, at the time
 of the operation, is by no means proportionate to the amount of consecutive in-
 flammation likely to be set up.  Indeed the reverse would appear  to be  the case
 in many instances; and I have often observed that  in those cases which  progress
 most steadily to a radical cure, there  is but a moderate amount  of pain expe-
 rienced at the time of the injection.
   There  is a second way in which injections would appear to fail; a consider-
 able amount of inflammation is excited, effusion takes place into the tunica vagi-
 nalis, which,  in the course of three or four days becomes distended  to the same
 size, or nearly so,  that it had  attained previously to  the  operation;  but this
 effused fluid,  instead of being absorbed by the end of the second  or third week,
 remains unchanged in bulk, or absorption  goes on to a certain point, and then
 seems to be arrested ; the  tunica vaginalis remaining distended with a certain
 quantity of fluid.
   The proportion of cases in which  the iodine  injection  fails to bring about a
 radical cure of the hydrocele is variously estimated by different surgeons; thus
 Mr. Martin states  that in  India  the failures scarcely amount to  1 per cent.
 Velpeau calculates them at 3 per cent.  I am not  aware  that any statistics of
 this mode of treatment in  this country have been collected;  but  the  general
 opinion of surgeons would appear to be decidedly in its favor as being  the; most
 successful, as well as the safest plan  of treatment  that has yet been introduced
 In this opinion I fully coincide : but yet I think it by no means improbable that
 the success of the iodine injection in this country might not prove to be quite
 so great as is generally believed.  I have, during the last few years, seen aeon-
 sidfrable number of cases of simple hydrocele  of  the tunica vaginalis, both  in
 hospital and private  practice, in which  a radical  cure had  not  been  effected
 although the iodine  injection had been had recourse to  by some of the most
 careful and skilful surgeons of  the day as well as by myself..        .
   There  can be no doubt that,  as a first remedy, the iodine  injection is  prefer-
 able to the seton,  in the treatment  of hydrocele; but when  the injection  has
 Sd and this from no want of care on the part of the surgeon,  or of attention
   the' aftt-treatment of the case, but apparently from insufficien Uj-,
 action havine been set up  in the tunica vaginalis to restore the lost ba ance
 between Jecretion and absorption in this membrane, the seton will, I think  be
 found to he7themost  certain means of accomplishing our  object.  It is true
 found to be  tne: mos                     ^ q{ ^ getoQ  jt requires     h

 ^^^fj^^a^ofally apt to excite a dangerous  amount of in-
 fla^atfontn S^ tZ of tl scrotum; and these objections are to my

        61 
962          DISEASES OF THE  TESTIS  AND CORD.
mind sufficiently valid to prevent our employing it as the ordinary treatment for
the radical cure of hydrocele.  But it must be remembered, that the particular
cases to which I am now alluding are those in which ordinary means have proved
insufficient to excite proper action, and in which, consequently, it would appear
as if a greater amount of irritation could safely be borne.  Indeed, nothing is
more remarkable than the difference in the intensity of the inflammation that is
set up  in different individuals by the means that are commonly employed in the
treatment of hydrocele.   In  some  cases the most irritating injections may be
thrown into the tunica vaginalis, or a seton be drawn through the scrotum and
left there for days, not only without giving rise  to any injurious inflammation,
but without setting up sufficient action  to  bring about a cure of the disease;
whilst  in other instances simple tapping  may effect a radical cure, or may give
rise to such an amount of irritation as to terminate in fatal  sloughing of the
scrotum.
   The seton that I employ in these cases is composed  of  one or two threads of
dentists' silk.   It may  be introduced by means of a nevus needle, the fluid of
the hydrocele being allowed to drain  away through the punctures thus made;
or, far better, by tapping the hydrocele, and then passing a needle, about six
inches long armed with the  seton, up the canula, to draw it through the upper
part of the scrotum, and  then  removing the canula, and cutting off  the needle,
to knot the thread loosely (fig. 138).  The thread should not be removed until
the scrotum swells and becomes red, with  some  tenderness of the  testis and
effusion  into the tunica vaginalis.   When these effects have been produced, it
may be cut and withdrawn, and the case treated in the same way as when  the
radical cure has been attempted by iodine injection, viz., by rest and antiphlo-
gistic treatment.   The  length of time that  is necessary for the  seton to be left
in  before  sufficient, or  even any  inflammatory action is produced varies very
considerably.   In most instances the proper amount of inflammation is excited
in  from twenty-four to thirty hours; but in other cases it may be left in for ten
or  twelve days, giving  rise to but  little inflammation, although a radical cure
may result.
                       ENCYSTED  HYDROCELE.

   In  this variety of  the disease the fluid does not lie in the tunica vaginalis,
but is contained in a  cyst which projects from the surface of the epididymis or
testis, and pushes the serous investment of the gland before it.
   These cysts are much more  frequently found connected with the epididymis,
than with the body of the testicle.   Indeed, Mr. Curling has pointed out the
fact, that small pedunculated cysts about the size of currants, and composed of
a  fine serous membrane,  lined  with  tesselated  epithelium,  are very  fre-
                                 quently  found beneath  the visceral tunica
             Fig. 406.            vaginalis  covering  the  epididymis.   They
                                 are very  delicate in structure, contain a clear
                                 limpid fluid,  and  are very liable  to rup-
                                 ture.   They  are met  with  at all ages after
                                 that of puberty.  According to M. Gosselin,
                                 after the age of forty, they occur in at least
                               \  two-thirds of the testes examined with  this
                               /  view.  Cysts, such  as  these, may remain sta-
                                 tionary, of small size, and not be  detected
                                 during life, being merely pathological pheno-
                                 mena; they may rupture into the tunica vagi-
                                 nalis; or, they  may enlarge  and become
                                 developed into tumors of considerable  mag-
                                 nitude.
    The fluid of these  cysts possesses the remarkable characteristic discovered by
 
HYDROCELE OF  THE  CORD. — HEMATOCELE.      963
Mr. Liston, of containing spermatozoa (fig. 406); an observation that has been
fully confirmed  by many subsequent observers.  Though spermatozoa do not
always exist in this fluid, yet they are usually met with sometimes in small quan-
tities, at others so abundantly as to give a turbid or opalescent appearance.  This
admixture of spermatozoa, with the clear fluid  of the cyst is probably due, as
pointed out by Mr. Curling, to the accidental rupture of a seminal duct into  an
already existing cyst.  Spermatozoa have also, but very rarely, been found in the
fluid of an ordinary hydrocele  of the tunica vaginalis, and  then probably their
presence was due to the rupture of one of those cysts into the tunica vaginalis.
Hence their presence in the fluid  of a hydrocele may in most cases be consi-
dered as characteristic of the encysted variety of the disease.
   The symptoms of encysted  hydrocele differ in some respects from those pre-
sented by the ordinary  form of the disease.  The tumor of the encysted variety
being smaller, more irregular in shape, and not enveloping the testis completely,
but being situated  behind it, and rather in connection with the  epididymis.
   The  treatment  consists in  injecting  the sac with tincture  of iodine, or, in
incising the tumor and  allowing it to granulate from the bottom.   The injection
by iodine, though  successful in some cases, is not so frequently so in this as in
 the last variety of the disease,  but usually deserves a trial; if it  fail, the incision
 of the tumor will always effect a cure.

                     HYDROCELE OF  THE  CORD.

   This disease  is characterized by the presence of a round or oval tumor, situ-
 ated on the cord, below or within the inguinal canal.  It is smooth, elastic, and
 if of sufficient size may be semi-transparent on examination by transmitted light.
 It can  be pushed up into the abdomen, but receives no impulse on coughing,
 and does not alter in  size by being steadily compressed.  It appears to be formed,
 in some cases, by the funicular portion of the peritoneal investment of the cord
 beino- imperfectly  closed and  consolidated at points; though it  is possible  that
 in other instances  it  arises as a distinct cystic growth.   These tumors may occur
 at all ages,  but are chiefly met with  in  the  young,  and are  not unfrequent
 amono-st5 children.  The obliteration of the cyst is best conducted by passing a
 seton°through, or making an incision into it, and  letting it granulate  from the

    The diffused hydrocele of the spermatic  cord consists in the infiltration of it
 with serous fluid, contained in rather distinct cells, and giving rise to an oval or
 oblong  irregular  circumscribed  tumor, extending below and into the inguinal
 canal   The treatment consists in the application of blisters, or of counter-irritant
 plasters; should the disease prove very troublesome, an incision might be made
 down to and into the  swelling, so as to let out the fluid and  allow the cyst to
 become consolidated.
                              HEMATOCELE.

    Bv hematocele is meant an accumulation of blood in the tunica vaginalis, dis-
 tending that sac, and compressing the testis.   It is of two kinds, traumatic: and
 spontaneous.  The  traumatic is the most  common form of the disease usually
 Sin- from a blow on, or a squeeze  of  the testis  by which  one °f the veins
 Sying  on the surface of  the gland is ruptured and blood  poured into th
   unica vaginalis.   It may also arise in tapping  a hydrocele from the point of the
   rechar be ng pushed  too directly backwards  and puncturing the testis    The
   nontaneons hematocele is a disease of rare occurrence,  arising apparently from
   he rupture of an enlarged spermatic vein into the tunica vaginalis   It attains
  a larZ size and is altogether a more formidable affection  than the traumatic
  hematocele   In  whatever way occurring,  a  hematocele slowly  but  gradually
  increases in size, until it attains about the magnitude of a duck's egg, or even 
964          DISEASES OF THE  TESTIS  AND  CORD.
that of a cocoa-nut.  It is seldom that it becomes  larger than this, but cases
are recorded  in which these tumors have attained an enormous magnitude.  I
lately operated in a case in which a spontaneous hematocele had existed  for six
years; it was as  large  as a  good sized melon, and contained besides about a
quart of dark thin  blood, a handful of partially decolorized  and tough fibrine,
the greater portion of which was firmly adherent to the inside of the greatly
thickened tunica vaginalis in filamentary and laminated masses, with here and
there nodules interspersed.   The whole of the interior of the tunica vaginalis
closely resembled an aneurismal sac.
   The fluid contained in the hematocele, when the disease is recent, consists
of  pure blood, but  when  of old standing, is of a  dark and grumous character,
owing to disintegration  of  the  blood corpuscles.  It then  usually contains an
admixture of cholesterine.   The blood so effused will continue fluid for years;
but at last it may decompose and set up fatal  inflammatory mischief; in some
rare instances the tumor becomes partly solidified  by the deposit of masses of
fibrinous coagulum, lining the interior of the tunica vaginalis, which are some-
times  decolorized and  arranged, as in  the case  just referred to, and  in one
recorded by  Mr. Bowman, in a laminated manner, like the contents of an aneu-
rismal sac.
   The symptoms of a hematocele are generally sufficiently obvious.   The occur-
rence of the  tumor subsequently to a blow, strain, or injury when traumatic, its
gradual increase in size, somewhat heavy but semi-elastic feel, its pyriform shape,
and the absence of transparency, together with the freedom of the cord above,
and the want of impulse in it on coughing, will indicate its true character.
   The treatment of hematocele  must vary with the size and duration  of the
tumor.  When small, recent, and having fluid contents, the surgeon may try the
effect of tapping it, when it is possible that after the evacuation of  the blood,
closure and obliteration of the tunica vaginalis will take place.  This happened
in a case lately under  my care, in which, though the  disease had  existed for
 three years,  a complete cure followed  the operation of tapping.  Such simple
 treatment as this, however, cannot  be depended upon; and  it usually becomes
 necessary to lay the  sac  open, and to get it to contract  and to granulate  from
 the bottom, when the obliteration of the cavity of the tunica vaginalis necessarily
                              results.   If the tumor were of very  large size,
            Fig. 407.           and  the tunica vaginalis much thickened, hard-
                              ened  and  parchment-like,  with adherent  and
                              laminated  fibrine, castration might  possibly be
                              required.    In  the  instance  to which  I have
                              already referred, and  which  has  been  figured
                              (fig. 407), this was rendered necessary in conse-
                              quence of these conditions, and was  successfully
                              done.
                                 Hematocele of the spermatic cord has been ob-
                               served  by Pott, Curling, Bowman  and  others;
                              it is a  rare  disease,  and usually occurs in the
                               form of a tumor of considerable magnitude, sud-
                               denly arising after a strain or some violent exer-
                               tion.   It commences in the inguinal canal, and
                               thence extends downwards along the course  of
  the cord, through  the abdominal ring into the scrotum, but it does not surround
  or implicate the testis, which can be felt free and  movable at its  lowest part.
  On incising such a tumor as  this, a  quantity of blood, partly fluid and partly
  coagulated,  has been  found, sometimes contained in a cavity, occasioned by
  the laceration and separation of the tissues of  the  cord.  The most remarkable
  case of this kind on record, is one related by Mr. Bowman, in which the tumor,
  after existing for  ten years, had attained so enormous a size, that it reached to
 
VARICOCELE.
965
the patella, and was so heavy as to require both hands and a considerable effort
to raise it from its bed.   In this case, death appears to have resulted  from
decomposition of the contents of the tumor.
   In  its early stages, hematocele  of the  cord would run considerable risk of
being confounded with an inguinal hernia.  The more diffused character of the
swelling,  however,  its irregular  feel and semi-fluctuating  sensation,  might
enable the diagnosis to be made.   Hematocele  of the cord may always be dis-
tinguished from an accumlation of blood in the tunica vaginalis, by the testicle
not being implicated in the former case, but surrounded by the fluid in the latter
instance.
   The treatment of this disease must consist in incising the tumor, turning out
the contents, and allowing the parts to suppurate and granulate.

                             VARICOCELE.

   Varix  or enlargement  of the  spermatic veins, is a disease that is commonly
met with from the age of puberty to about the thirtieth  year, seldom commenc-
ing later  than this.   It usually occurs in feeble individuals having the scrotum
lax and pendulous, and in some cases appears to have been brought on by vene-
real excesses. The spermatic veins, extending as they do from opposite the upper
lumbar vertebrse to the plexus pampiniformis, which constitutes the base  of the
pyramidal tumor formed by a fully developed varicocele, are necessarily subject to
 considerable outward pressure from the weight of so long a column of blood as
 that  contained within them, to which they may eventually yield, becoming much
 dilated and tortuous.  The left spermatic veins are far more frequently affected
 than the right, partly owing to their compression by feculent accumulations in
 the sio-moid flexure of the colon, and partly to the obstacle at the mouth, occa-
 sioneof by their pouring their contents into the left  renal vein, at right  angles
 to the current of blood flowing through that vessel into the vena  cava.  The
 rio-ht spermatic veins are rarely affected,  and never, I believe, without those on
 the left side participating in the  disease.   In these cases of double varicocele
 the left is almost invariably the most seriously affected, but I have seen  excep-
 tions to this in one or two instances in which the veins on the right side formed
 the largest tumor.                                                .
    [A careful study of the  anatomy of the parts  concerned in varicocele will,
 we think clearly show, that the frequent occurrence of this disease  upon one
 side of the body, and its comparative rarity upon  the other, is not in reality due
 to the causes ordinarily assigned.  As the result of numerous and careful examin-
 ations of the spermatic veins, upon the  dead body, we  have shown that at the
 termination of the right spermatic vein  in the vena cava, there is always to be
 found a  well marked valve, previously undescribed, formed by the lining mem-
 brane  of the vein,  and sufficient to prevent all regurgitation of blood from the
 vena cava.  No such valve exists upon the left side, at the point where the left
 spermatic empties into the renal vein                              #
    As has been already observed by Nelaton, the  true  causes of varicocele are
  as vet unknown.  The greater length of the left spermatic vein is trivial, at most
 but  half an  inch;  and moreover the vein is protected from the pressure of the
  colon by a species of fibrous arch  thrown across it, at the alleged point of pres-
   ure   It must be remembered, also, that the disease most frequently originates
 between the ages of fifteen and thirty, a period of life during which constipation
 is noteenerally met  with.  With regard to the  impeded circulation on the left
   de  Nelaton remarks, that the obstacle" fc  more  fancied than real  since the
 side, iNeiaton ie     ,                    .^ contents into the renal vein in a
 vein from *e testicle curves ^                   in ^ ]atter

  dl WeWh d SSSd^po^SB of verifying the facts stated by the French
       nn  \nd we  beHeve  that the immunity of the right side from the  disease
 in^^t^aUydae to the presence of the valve, whose existence we have 
966          DISEASES  OF THE TESTIS  AND  CORD.
pointed out; and that the frequency of the affection  on the opposite side  is
mainly  attributable to the  absence of any such  valvular conformation.  We
would further state  that a similar arrangement exists in the ovarian veins of the
female; and in the opportunities we have had of examining the diseases of the
veins of the right side, we  have always found, either that the valve has been
absent altogether, or else imperfect in character.—See American Journal of the
Medical Sciences for July, 1856.]
  The  symptoms of varicocele consist of a tumor of pyramidal shape having a
knotted or knobbed feel, owing to the irregularly swollen and convoluted condi-
tion  of the veins, with its base upon the testis and the apex stretching up to the
external ring.  The swelling increases when the patient stands up, if he takes a
deep inspiration,  coughs, or makes any violent exertion.  Its size varies from
slight fulness of the veins to a large mass, several inches in circumference at the
base.  When the patient lies down it goes up to a certain extent, but imme-
diately returns to its former magnitude when he stands up again.  It is attended
by a sensation of weight and sometimes  of pain, which  is  occasionally very
acute, of a severe and neuralgic character,  even in the  scrotum, the groins, and
the  loins, more  particularly when the  tumor is unsupported.   This pain  is
greatly increased on the patient walking  or riding; so much so, that in some
cases he is almost debarred taking necessary exercise, and is prevented following
any  active occupation.   Debility of the  generative organs, with a tendency  to
seminal emissions, frequently accompany varicocele.
  The  diagnosis of varicocele is always sufficiently easy; its peculiar feel, its
broad base and narrow apex, the  manner in which it goes up when the patient
lies down; and returns again when he stands up, are sufficient to distinguish  it
from all other scrotal  tumors.  From  inguinal  hernia the disease may be
distinguished by  attention to the test described at page 800.
  The treatment  of varicocele must be conducted with  reference to the severity
of the symptoms occasioned by it, and  the extent  of the disease.  When,  as
is usually the case, it gives rise to but slight inconvenience, palliative treatment
is fully sufficient; but if, as occasionally happens, the disease  is a source of
very intense suffering, or tends to the induction of  atrophy of the testis, or  to
generative debility, with much mental disquietude or hypochondriasis, then the
surgeon may feel disposed to endeavor to cure the varicocele radically.
  The palliative treatment of varicocele  resolves itself into means of various
kinds, having for their object the support of the testis and the diminution of
the length, and of  the consequent pressure, of the  column of blood.   This  is
usually most conveniently done by supporting  the scrotum in a well-made sus-
pensory bandage, or pressure  may be made upon the part, as well as  support
given, by enclosing the  testis  in an  elastic bag.  In other cases, support may
be afforded  by drawing the lower portion of the  scrotum on the affected side
through a ring made of  soft metal, covered with leather.  And  with the same
object, the excision of the lower portion of the  scrotum has been recommended,
so that  by the contraction of the  cicatrix, the  testis may be pressed up against
the ring, and the cord thus shortened.   This plan, however, is somewhat severe,
and  though  it might be attended by temporary benefit, the advantage  accruing
is not likely to be very continuous.  The pressure of the pad of a truss on the
spermatic cord, as it issues from the external ring, will break  the length of the
column of blood  in its veins, and may thus be  of service in some  cases, though
many patients cannot bear the irksome pressure of the instrument.
  In addition  to these  mechanical  means, the part may be braced by cold
douching, sea-bathing,  and the general strength improved by the administration
of iron.
  The  radical cure of  varicocele consists in the  obliteration of the  enlarged
veins by compressing and exciting inflammation in them, on the same principle
that guides us in the management  of varix in other situations.  As these 
TREATMENT OF  VARICOCELE.
967
operations cannot be undertaken on the  spermatic veins without very consider-
able risk of  inducing an undue, and perhaps dangerous, amount of inflammation
in them, and in the loose cellular  structures  of the scrotum and  cord, they
should not be had recourse to,  unless the disease be a source  of very serious
inconvenience and pain to the patient.  The operation for the obliteration of
the spermatic veins may very conveniently be done by using the ordinary hare-
lip pins  and twisted suture, as figured at page 472.   In introducing  the pins
behind  the  veins, care must be taken  to  separate the plexus  from the vas
deferens.  This is best done by letting the patient lie down so as to empty the
vessels, when the vas  can be  distinguished by its firm and corded feel; this
must be  carefully drawn to one side, and there held between the finger and
thumb of an assistant.  The  surgeon then passes the  pins between it and the
veins, and including as little skin as possible, applies the twisted sutures in the
usual way.   Three pins are usually required.   A good deal  of redness and
swelling of  the scrotum usually ensue, but after the removal of the pins at the

                                  Fig. 408.
end  of eight or  ten days, all  irritation  will subside, and  the  disease  be
permanently cured.   The patient should afterwards wear a suspensory bandage.
  A very ingenious  mode  of obliterating the veins has been recommended  by
Vidal,  and which, as it does  not  induce compression  of the skin, and only
Fig. 409.
Fig. 410.
iwuires  the introduction  of one pin, is attended by less  irritation than the
former method.  It consists  in  passing a steel or silver pin, having a movable
head (fi-  408 a) behind the veins, between  them and  the vas deferens, in the 
968          DISEASES  OF  THE TESTIS AND  CORD.
usual way.  A fine silver wire is then carried, by means of a needle having a
slit to receive it (fig.  408 b), in front of the veins, but underneath the integu-
ments, being introduced and carried out through  the same apertures by which
the pin is passed.   In  this way the  plexus  of vessels  lies between the  pin
behind  and the silver wire  in front (fig. 409).   The  point of the pin having
now been removed, compression is made by twisting the ends of the wire round
either end  of the  pin,  and is gradually increased by the surgeon  every day
rolling up the pin so  as to twist another turn or two of the wire round it.  In
this way the veins  are not only  compressed but rolled up and shortened, and
the process  is carried on usually for eight or ten  days, until they are obliterated
by plastic deposit, without being  necessarily  cut through (fig. 410).  Vidal
speaks  very favorably of  this plan, not only as  effecting the obliteration of
the veins with less risk  of inflammation  of  the  scrotum  than attends the other
method, but as leaving a better result; and I can corroborate his  statement, as
I  have  of  late employed this practice  in  several cases  with very excellent
results.   Nelaton has proposed to obliterate  the  veins of the testis by applying
the " Vienna paste" in a grooved pair of forceps  across the neck of the scrotum,
taking care to isolate the vas deferens.  Inflammation is thus excited, and this
extending to the veins these vessels become  plugged.

                      TUMORS  OF  THE TESTIS.

   All solid tumors of the testicle  are classed together under the generic term
of sarcocele, and when these are conjoined with fluid accumulations in the tunica
vaginalis, are termed hydro-sarcocele.   Sarcocele  is usually  divided  into  the
simple, the  syphilitic, the  tuberculous, the cystic,  and the malignant: which,
indeed, Comprise  so  many distinct diseases of  the testis, requiring separate
study.
   1st.  Simple sarcocele is a chronic enlargement of the  testis, resulting from
inflammatory mischief in  the  organ.   A testicle affected  by this disease feels
hard, smooth, solid, though perhaps slightly elastic at points, is ovoid in shape,
and usually about as large as a  duck's egg. It is  heavy, and but slightly painful.
The cord is usually somewhat thickened, and, as  well as the groin,  is the seat of
pain of a dragging character.  The tunica vaginalis not  unfrequently contains
serous fluid lying in  front  of and obscuring the tumor of the testis, constituting
the affection termed hydro-sarcocele. The disease can usually be distinctly attri-
buted to a blow,  squeeze, or other injury, by  which inflammation had been
excited in the organ.  The scrotum is always healthy.
   On making a section  of a testicle thus diseased, it will be found to be com-
posed of a quantity  of  firm and hard bluish-grey fibro-plastic matter, effused
within the organ and between  the tubuli, and also surrounding the gland, often
in a series of solid  and very firm glistening layers.   In  the midst of this, opaque
yellow spots or masses, cutting smooth and firm, will be seen. These have been
mistaken for tubercles,  but  are  in  reality masses of plastic deposit  that have
undergone fatty degeneration.
   In the treatment of this disease,  strapping and the administration of an alter-
ative course of the bichloride may be tried.  If the testis do not diminish in  size
by these  means, or is a source  of much inconvenience to the patient, it must be
removed.
   2d. Tuberculous sarcocele or scrofulous testicle. —This  disease, although occa-
sionally met with in  individuals otherwise strong and healthy, chiefly occurs in
those of a feeble or cachetic  constitution, usually in early manhood, and is very
commonly associated  with  a tendency to phthisis.  It is essentially characterized
by the deposition  of tuberculous matter in the testis.   These tubercles  may
be infiltrated or encysted, varying in size from a pin's head to a cherry or plum-
stone.  When encysted, they  are of a bright-yellow color, tolerably  firm  and 
SARCOCELE.                          969
laminated, contrasting strongly with the inflamed gland, in the midst of which
they are  deposited.  Their presence between the tubuli gives rise to inflamma-
tion, and eventual disorganization of the structure of the testis with which they
become mixed up, so as to form a pultaceous cream or cheesy mass of a dirty  i
buff color.
   The symptoms of scrofulous testis are well  marked.  The patient perceives
that without  any very evident cause, or  perhaps as the result of an injury,
gonorrheal inflammation, or venereal excesses, the testes  gradually and slowly
enlarge,  often attaining a very considerable bulk, and usually becoming at the
same time nodulated and irregular, hard and craggy;  the hardness being con-
fined to the  nodules, the gland feeling soft between them, and hydrocele occa-
sionally  co-existing.  The epididymis  is most commonly the part that is first
affected  in this  way, though not  unusually it is the body of the organ that
suffers.  Though the disease commences  in one testis, both almost invariably
 eventually suffer, either simultaneously or successively.  One of the nodulated
 masses in  the affected testis usually gradually increases in size, the skin  cover-
 ing it becomes red, shining, and thinned,  and at last, adhesion forms between it
 and the testis, indolent  suppuration  takes place,
 and on the discharge of the abscess a fistulous open-          Fig. 411.
 ing is left.  Through this aperature a fungus spee-
 dily protrudes, which grows sometimes slowly, at
 others rapidly, perhaps attaining  a very consider-
 able size (fig. 411).   As  the fungus  increases, the
 organ atrophies.  This fungus is not a new growth,
 but is a granular mass composed essentially of the
 tubuli testis and  lymph.  It  is in the form of a
 pale reddish-yellow granular mass, and is  composed
 of an exuberant outgrowth of the tubuli testis, in-
 flamed  and mixed with lymph and tuberculous mat-
 ter. If the fungus continues small and firm, it may
 become a very chronic complaint;  but, if large, ra-
 pidly-growing, and  loose-textured, it speedily des-
 troys the testis.   It is, however, surprising how
  long the functions of this  organ  will  continue, though  its tissue is in a great
  measure  destroyed, and  its  structure  traversed by suppurating fistulae.   Occa-
  sionally, however, strumous  disease of the testis developes in a different manner
  the organ enlarging, generally feeling hard and semi-elastic, but uniform  and
  smooth;  in  fact, like ordinary sarcocele.   In examining such  a testis, the stru-
  mous matter, mixed  with debris of tubuli,  may be found filling up the  tunica
  vaginalis, into which it has protruded, or with which the true envelopes of the
  testis are incorporated.                                                   ,
    The treatment of strumous testis, beibre  the  fungus has protruded, must be
  conducted on the general principles laid  down when speaking of scrofula : alter-
  atives, tonics, especially the  iodide of iron,  with cod-liver oil, and general hygie-
  nic means  calculated to improve the health, must be steadily persevered in for
  some length of time.   The best local treatment will consist in the application
  of leeches from time to time, followed by discutient iodine lotions, or the iodide
  of lead ointment.                                .  „    ,
     When the fundus has protruded through one of the fistulous apertures, means
  must be  taken to°repress or remove this, lest it  go on to complete destruction
  of the  testis.  If it be of small size, the better plan will be to sprinkle it with
  the red oxide of mercury, and to strap it tightly down with a  piece of  lint and
  strapping   If larger, it may be shaved off, and the cut surface  then  dressed
  with the red oxide of mercury ointment, care being taken, during cicatrization,
  to repress the granulations  below  the level of the surrounding integument by
  strappino- and pressure.   Mr. Syme has  recommended that the pressure should
 
970          DISEASES  OF  THE TESTIS AND  CORD.
be effected  by the integument of the  part; an elliptic incision being made
round  the fungus, the edges of this depressed  down, and then brought over
the fungus, and retained there by stitches.  This  operation I  have practised
with success.
  3d.  Syphilitic sarcocele, both in its simple and strumous character, has already
been considered (page 452), to which I would refer the  reader.
  4th.  Cystic disease of the testis, or cystic sarcocele, may be of two kinds,
simple and malignant;  when simple, it is a disease  somewhat analogous to the
cystic sarcoma of the breast.   The testis becomes much enlarged, indurated, of
                        a yellowish-white and opaque appearance, and studded
         Fig. 412.        with a multitude of cysts that vary in size, from a
                        pin's head to a cherry, containing clear, amber-colored,
                        or brownish fluid (fig. 412). This affection, consisting
                        in  the alteration  and condensation of  the  orchitic
                        structure, with  the  formation of these distinct  inde-
                        pendent cysts, must not be confounded with the acci-
                        dental occurrence of  a  cyst or two in a scrofulous
                        testis.  It is a local affection, and although the organ
                        may attain a considerable  bulk, it never gives any in-
                        dication of malignancy.
                           This affection has been carefully studied by Sir A.
                        Cooper, who, with great justice, adverts to the diffi-
                        culty of distinguishing it  from  other  diseases of this
                        organ, more especially from hydrocele.  The points
                        to  be especially attended to in distinguishing the cys-
                        tic sarcocele, are its want of translucency, the  more
                        globular  shape of the  organ, its weight, and  the en-
                        larged and varicose state of the veins of the  cord.
                        If  there  is any doubt, an exploratory puncture will
 resolve this, and should always be  practised.
   According to Mr. Curling cystic disease of the  testicle is the result of mor-
 bid changes in the ducts of  the rete testis, when of an innocent character the
 cystic disease is characterized by the presence of tesselated  epithelium in the
 cysts,  when malignant, by the presence of nucleated cancer cells.   In addition
 to this enchondroma may be met with  in both forms of cystic  disease, and al-
 most invariably in old cases  of the innocent variety.
   Cystic sarcocele requires removal of the diseased organ.
   Occasionally cystic tumors of the testicle are met with, in which the substance
 of the organ is atrophied or absorbed, and its place  occupied  by one or more
 large  thin-walled  sacculi  containing fluids  of different  color and consistence,
 dark or fatty.   One of the  most remarkable of  these anomalous tumors of the
 testis that I have  seen was  under the  care  of  my colleague, Mr. Marshall, at
 the  hospital.  The diseased organ, which was  about the size  of  an  ostrich's
 egg, and felt partly solid and partly fluid, was found  after removal  to  be com-
 posed of a large cyst filled with an oily fluid, like  melted butter, which solidi-
 fied on cooling.   After removal,  Mr. Marshall  found  that  the sac contained
 some foetal debris, and was doubtless of an embryonic character.  The patient,
 who was about thirty years of age, had been  affected with the tumor from early
 infancy.
   5th. Malignant sarcocele, or cancer of the testicle, not unfrequently occurs,
 and almost invariably assumes the encephaloid character. It is, indeed, a ques-
 tion whether any other form of cancer ever occurs  in the testicle.  Dr. Walshe
 a°rees  with  most observers in doubting the existence  of the other varieties of
 malignant disease in this organ.
   Cancer of the testicle most commonly occurs in the first instance in the body
 of that organ, rarely affecting the  epididymis primarily.   The  ordinary charac-
 
CASTRATION.
971
ters of encephaloid, are always well  marked in this affection, which eventually
assumes a softened-down, pulpy, and fungous  character.   Intermixed with the
encephaloid are commonly found masses of a bright yellow color, which have
sometimes been regarded as tuberculous, but, I believe, erroneously so; for in
those instances in which I have had an opportunity of examining them I have
found them to consist, as in the simple sarcocele, of plastic matter that was un-
dergoing fatty degeneration.  A malignant testicle  may rapidly attain a very
considerable magnitude, becoming as large as a  cocoa-nut in a few weeks or
months.   When of this size it is, of course, abundantly supplied by blood-ves-
sels; consequently the spermatic artery and accompanying veins will be found
a good deal dilated.   The lymphatic glands  in  the  neighborhood speedily be-
come enlarged, those in the iliac fossa especially, as may be ascertained by deep
pressure in the flank.  The inguinal glands do not in general  become affected
until the skin has become implicated by the progress of the disease.  It is then
also  that the cancerous cachexy rapidly  develops itself.
   The symptoms of ^encephaloid testicle  are  usually somewhat obscure in the
early stages, although they become clearly and  distinctly developed  as  the
disease progresses.  The patient first begins to  complain of some degree of
dragging pain and weight in one of the  testes, which on  examination will be
found to be indurated and  enlarged,  though preserving its normal shape.  The
enlargement continues until the testicle attains about the size  and shape of a
duck's egg, being somewhat tense and  elastic, but smooth  and heavy.  As  it
increases in size,  which it usually does with  rapidity, it becomes rounded  and
somewhat  doughy or pulpy in  feel  in  parts, where, indeed, it  may almost be
semi-fluctuating,  though in others  it continues hard and knobbed.  This alte-
ration in feel is (partly due to softening of the  substance of the tumor, and
partly to  its making its way through  the  tunica albuginea.  The  scrotum is
much distended, reddened, and purplish, and becomes covered  by a net-work
of tortuous veins; the cord may be felt  somewhat enlarged, hard, and knotty.
As the disease advances, the scrotum becomes adherent at some of the softened
parts, ulceration  takes place, and a fungus projects, which presents  all  the
characteristic signs of fungus haematodes; it does not commonly happen, how-
ever, that the disease is allowed to go so far as this before  removal.  The pain
is not very severe at first, but after a time assumes a lancinating character, ex-
tending up the cord and into  the loins.
   The only treatment of any avail in encephaloid testicle, is the removal of the
diseased organ.   This operation is not performed so much with the view of
curing the patient of his disease, which will probably return in  the iliac glands,
or in some  internal organ, but as a means of temporary relief from the suffer-
ing  and incumbrance of the enlarged  testicle.   It is therefore an operation of
expediency, and  should only be done  in those  cases in which  the  disease is
limited to the testicle, the  cord being free and the lumbar glands not involved;
so that if recurrence takes place it may not be a very speedy one.

                   OPERATION  OF  CASTRATION.

   This operation  may be required for the various non-malignant affections of
the testicle that have resisted ordinary constitutional and  local treatment, and
have become sources  of great annoyance and discomfort to the patient; in the
earlv forms of malignant disease it may also be advantageously practised.  The
operation may be performed in the following way   The patient, having  had
the  pubes shaved, should  lie upon his back with the legs and thighs hanging
over the end of the table.   The surgeon should then take  his stand in front of
the  patient between his legs, and grasping the tumor at its posterior part with
his left hand  make the scrotum in  front  of it tense.  If the mass to be re-
moved  be  of small size he makes a longitudinal incision over its anterior sur- 
972         DISEASES  OF THE TESTIS AND  CORD.
Fig. 413.
face; if of large size, a double  elliptical incision, enclosing a portion  of the
scrotum.   The incision  should commence opposite to the  external abdominal
ring, and be carried rapidly down to the lower part of the scrotum.  By a few
touches with a broad-bladed  scalpel  or bistoury, whilst the skin is kept upon
the stretch, the tumor is now  separated from its scrotal attachments and  merely
left connected by the cord, which must then be divided.   In some cases it will
be found advantageous to expose and divide the cord in the first instance before
dissecting out the tumor from the scrotum, as in this way a better command
over it is obtained.
   The division of the cord constitutes the most important part of the operation,
whether this be done first or  last; as unless care be taken  it may be  retracted
                                         through the abdominal ring into the
                                         inguinal canal, where it is extremely
                                         difficult  to follow it, and where the
                                         cut stump  may pour out a large and
                                         even fatal  quantity of blood,  infil-
                                         trating the cellular tissue, and be-
                                         tween the  muscles of the  part  and
                                         into the flank.  This accident is pre-
                                         vented by giving an assistant charge
                                         of the cord before its division, and
                                         directing him to hold it tightly be-
                                         tween  his  finger and thumb  (fig.
                                         413), or, what  is better, by  passing
                                         a sharp hook through it, and thus
                                         fixing it.   After the removal of the
                                         testicle, two or three  arteries in the
                                         cord will generally require ligature,
                                         as well as  a few bleeding branches
                                         in  the scrotum.  Sutures are not
                                         required, the edges coming into ap-
                                         position of themselves; the  wound
                                         must then  be  lightly dressed, and
                                         allowed to  heal by granulation;  bag-
 ing in the lower part being prevented during the after-treatment.
   In cancer of the testicle it  is of great consequence to divide the cord  as high
 up as possible for obvious reasons. It will not, however, be  safe to do this oppo-
 site the abdominal ring in the way that has just been  described,  as there would
 not be  sufficient space  for the assistant to hold  the cord above the part to be
 divided.   In such cases as these  I have  found it a good practice to expose the
 cord by dissection  up to the  abdominal ring;  then to draw it well down and to
 include the whole in a strong whipcord ligature, tied round it as tightly as pos-
 sible.   The section is then made a quarter of  an inch below this, and the ope-
 ration completed as usual; the cut stump of the cord may retract into the ingui-
 nal canal, but cannot bleed if  properly tied, and would always be under command
 by drawing upon  the whipcord.   This plan of tying the cord, en masse, was at
 one time generally adopted in all cases of castration,  but is not  now commonly
 employed.  The objection  to it' is, that by compressing the spermatic nerves
 with the ligature the after-pain is increased; but this certainly does not always
 happen, for in three instances in which I have done it at the hospital, but little
 pain was complained of; and the practice in  malignant disease of the  testicle
 has the advantage of enabling the surgeon to divide the cord at a higher point
 than he otherwise  could; which advantage is still further increased  by the parts
 within  and below the ligature sloughing away, and thus eventually carrying the
 section to a level with the point tied.
 
GENERAL  DIAGNOSIS  OF  SCROTAL  TUMORS.       973
GENERAL  DIAGNOSIS  OF SCROTAL  TUMORS.
Fig. 414.
  The diagnosis of scrotal tumors is not only of considerable importance, but
is often attended with very great difficulty.  The more so as they are frequently
associated with one another, so that  much tact and care  are required to discri-
minate  their true  nature;  thus it is not uncom-
mon to find a hydrocele and a hernia,—a hydro-
cele and  a varicocele, — or, these affections co-
existing with a solid tumor of the testicle.  In
other cases again, as in the annexed figure (414),
an encephaloid tumor may co-exist with a hydro-
cele of the tunica vaginalis, and with an encysted
hydrocele of the cord.
   Tumors of the scrotum may,  in  a diagnostic
point  of  view,  be divided  into two  distinct
classes:—the reducible and the irreducible.  The
reducible tumors  are  hernia, congenital hydro-
cele, diffuse hydrocele of the cord, and varico-
cele ; in all of which  the  swelling can be made
to disappear more or less completely by pressure,
and by the  patient lying down;  reappearing  on
the removal of the pressure, or on his assuming
the erect posture.  The  mode in which the tu-
mor disappears tends greatly to establish its diagnosis; though the general char-
acter of the  swelling, and the history of the case, afford important  collateral
evidence  on this point.
   In hernia there are the ordinary signs of  this affection, such as impulse on
 coughing, &c.  On reducing  the tumor it will be found  that its return into the
 abdomen is accompanied  by a gurgling  noise, and by  the sudden slip upwards
 of evidently a solid body.  In the other reducible tumors, the diminution  and
 eventual  disappearance under pressure are more  gradual, and there is  no reduc-
 tion of the mass as a whole.
   The gradual squeezing out of the contents of  a congenital hydrocele, together
 with its translucency, and the early age at which it occurs, will establish its true

   In the diffuse hydrocele of the cord, there is a uniform semi-fluctuating swell-
 ing in and near the ring; in which, however, there is  no gurgling, &c, no com-
 plete and sudden disappearance as in  hernia.   It is also less defined,  and has a
 less distinct impulse on coughing.                              j-fa^ntt^
    Varicocele may always be distinguished by its pyramidal shape, and its knotted
 soft, and irregular feel.   After being reduced  when the patient lies down  it
 will when he stands up, fill again, even though the surgeon compress  the exter-
 nal ring  with his fingers.  This sign, which distinguishes it from a hernia occurs
 also ^hydrocele, from which, however, the varicocele may be distinguished by
 the absence of translucency,  the want of fluctuation, and the general feel of the

 ^reducible scrotal  tumors  are of various  kinds such as omental hernia hydro
 cele  hematocele, the various forms of sarcocele, and cancer of the testicle.
 TW tumor. thou-h presenting certain characters in common, yet differ some-
 wha tin  thrPredomi„aPnce of particular signs;  thus the shape of the tumor is
 usually pyriform in hydrocele,  globular in hematocele, and oval in  sarcocele
 titoth this is subject to much variation.   The weight is least in hydrocele and
 though this is soj         fcionately  to the siZe of the  tumor.   The  characters
 ^iuS^e^tUnde^le«itono«ilboi»ig smooth and tense in hydro- 
974    DISEASES  OF THE FEMALE  GENITAL ORGANS.

cele and hematocele;  often  irregular, hard or knotted in  the other varieties.
The rapidity of the formation of the tumor is greatest in hematocele.
  An irreducible scrotal hernia may be recognized by its irregular feel, its  im-
pulse on coughing, its occupation of the  canal, and by the  testicle being  dis-
tinctly perceptible below it.
  A hydrocele of the tunica vaginalis  is always cognizable by its translucency;
and the amount of opacity conjoined with this will enable the surgeon to  dis-
tinguish the degree of enlargement of the testis, and how far there is a sarcocele
conjoined with it.
  In hematocele the tumor is of sudden or speedy formation, somewhat globular,
opaque, but not very heavy or hard, and smooth upon the surface.
  In sarcocele generally the tumor  is heavy for its. size, frequently globular or
irregular in shape, sometimes knobbed, and usually attended by a good deal of
dragging pain in  the groin, and frequently by some enlargement of the cord.
  The point of most importance in the diagnosis  of sarcocele is  to  distinguish
the malignant from the non-malignant varieties.  In the malignant, the rapidity
of the growth,  the softness and the elasticity of the tumor, the implication  of
one testis only, and the early enlargement of the cord with its indurated  and
knobbed condition are important signs, especially if  the disease occur in young
men. In a more advanced condition, the  softening of the swelling at parts, with
a tuberous condition  of the  rest, and the occurrence  of fungus, with speedy
constitutional cachexy,  will point to the malignant nature  of the tumor.   In
cases of much doubt and difficulty  an exploratory puncture  may be made, when
the contents of the groove in the needle or the fine  canula  will probably deter-
mine the character of the growth.  In more than one  instance, in which  there
was much obscurity attending the diagnosis, I have seen the true nature  of  the
disease  cleared  up in this way.
                         CHAPTER  LXI.

         DISEASES OF THE FEMALE GENITAL  ORGANS.

  Some  of the more important surgical  affections of  these  organs, such  as
vagino-vesical and  recto-vaginal fistulae,  lacerated perineum,  and the various
forms of syphilitic disease to which they are liable, have already been discussed;
the remaining affections, implicating the vagina, the uterus, and the ovaries, are
of considerable practical interest, but as their full  consideration would lead me
far  beyond the limits  that can be assigned to them in this work, I must content
myself with a brief indication of the principal points deserving attention.

         INTRODUCTION  OF  THE  SPECULUM  VAGINA.

  Vaginal  specula of various shapes and materials  are  commonly used by sur-
geons. When the os and  cervix  of the  uterus require exploration, the most
convenient instrument is certainly the cylindrical reflecting glass speculum (fig.
415), which,  being  coated  with a layer  of tinfoil, covered by India rubber,
always presents internally a mirror-like surface, by which a strong body of light
is thrown into the bottom of the tube. It has the additional advantage of being
very cleanly, and not stained by any caustics that  may be used  in it.  These 
INTRODUCTION OF  THE  FEMALE  CATHETER.      975
Fig. 416.
Fig. 416.
Bpecula should be of different sizes, and may be  sometimes advantageously
bevelled off at the inner end.   When the wall of the vagina requires examina-
                     tion,  as  in some  operations of
                     fistula, a bivalve  speculum  (fig.
                     416), or a cylindrical one, pro-
                     vided with a  sliding  side, may
                     advantageously be used.  These
                     are generally made of some plated
                     metal, or of pewter.
                        The introduction of the specu-
                     lum may readily be effected with-
                     out  any  exposure of the person,
                     under the  dress  or  bed-clothes.
                     There are  two positions in which
                     the  patient may  conveniently be
                     placed for  this purpose.   In the
                     first, she lies upon her back, with
                     the nates well raised or brought to
                     the edge of the bed or couch, her
                     legs separated, and her feet resting
                     on two chairs; the surgeon standing
                     or sitting in front of the patient,
                     introduces the  fore  and  middle
                     fingers  of  his left hand into the
                     vagina, dilates its walls, and passes
                     the speculum well greased, gently
                     and  steadily  between and  under
                     them.  This position  is the most
                     convenient, when caustics  require
 to be applied, but is often objectionable to the patient, as it appears to  entail
 much exposure, though in reality it need not do so.  Another mode of intro-
 ducing the speculum, and that which should always be adopted when practicable,
 consists in placing the  patient on her left side  across the bed, with the knees
 drawn up, and the nates near the edge; the instrument is then introduced in
 the same way as before, the surgeon sitting by the patient's side. In whichever
 way the speculum is used, no force should ever be employed; the patient should
 be placed opposite a good light, and care should be taken that it be introduced
 fairly to the uterus, the position  of which may have been previously ascertained
 by tactile examination.

           INTRODUCTION OF  THE FEMALE CATHETER.

   The use  of the female catheter is  often required in various  diseases  and
 operative procedures about the genito-urinary organs of  women   It  should be
 introduced without exposure by  the aid of the touch alone.  This may readily
 be done,  as the patient lies in bed, under the clothes  The surgeon standing on
 her left side, passes his left index finger downwards between the nymph* until
 he fee s the projection  of the meatus urinarius, immediately above the entrance
 into the vagina; keeping his  finger just below this, he  uses it  as a guide to
 direct the point of the catheter into the canal.

     DISEASES  OF  THE  EXTERNAL  ORGANS  AND  VAGINA.

   The vulva and the  nymphse  are the seats of numerous  morbid conditions,
 nrincipaUy consisting of hypertrophy or of verrucous growths from them, or the
 formation of cysts in their substance. 
976    DISEASES  OF  THE i'EMALE  GENITAL  ORGANS.

  Hypertrophy of the  labia  to a limited  extent  is not unfrequently met with,
one labium hanging down considerably below the other.  In these cases it will
often be found that the enlargement is due to a kind of solid oedema, originally
dependent perhaps upon a fissure or ulcer of the part.  In other cases again,
large fibro-cellular tumors form as outgrowths from the natural structures in this
region; these may require removal by simple excision.
  Large  condylomata  or  verruce are often met with here, as the result  of
gonorrheal or syphilitic disease, forming at last irregular pendulous  masses,
which require extirpation, either by knife or scissors.  I have had occasion also
to remove a large  nevus by ligature from this situation, and in fact almost any
growth that occurs in the fibro-cellular tissue may be met with here.
   Cystic  tumors are not unfrequently met with in the labia, and may sometimes
resemble  pretty closely the ordinary forms of inguinal hernia, for which, how-
ever, their incompressibility, irreducibility,  and the  absence  of impulse  on
coughing will prevent their being confounded.  These  cysts which require
removal by a little simple dissection,  usually contain  a  dark,  turbid, or san-
guineous fluid, and sometimes atheromatous matter.  Tolerably free hemorrhage
may follow their removal, the excitable tissues of  the labia being cut into.  This
may however always be arrested by pressure and a "f bandage.   Occasionally
they project from the inside  of  the vagina, and then require removal by dissec-
tion or ligature, as can  be best practised.
   An imperforate vagina  is occasionally met with in young children, and occa-
sions a good deal of  anxiety to the parents.  This condition, however,  may
always be very readily and speedily removed by tearing up the canal as it were,
by dragging upon its walls  in  opposite  directions  and breaking  through  the
adhesions, which  are little more than epithelial, with  the  thumb  nail, a blunt
probe,  or the handle of a scalpel, and then introducing  a small pledget  of
greased lint.
   An imperforate hymen has occasionally been  met with, causing great incon-
venience by the retention of the menstrual secretion, which may accumulate to
an immense  extent, and become converted into a kind of chocolate-colored gru-
mous fluid; in these cases, incision of the  membrane is the only remedy.   Occa-
sionally the  surgeon's advice may be sought by married women, for a rigid and
only partially perforate  hymen, when incision  with a probe-pointed bistoury, and
dilatation with a sponge tent may be required.
   Absence of the uterus and ovaries with  imperforate vagina is occasionally met
with in women, otherwise perfectly well developed.   In such cases as these the
true condition may be  detected by an examination per rectum, and especially
by the introduction of a catheter into the bladder whilst  the  finger is in  the
rectum, when the  point of the instrument will be felt thinly covered  through
the gut.   In a case of this kind in which I was lately consulted, there had been
monthly  epistaxis.  No surgical interference can be of any avail  in such cases,
 and an attempt to restore the vagina might lead to the opening of the peritoneal
 cavity.
   Hypertrophy of the  clitoris is occasionally met  with; this organ becoming en-
 larged, elongated, and pendulous, and  in some cases attaining an enormous size.
 When enlarged,  it may give  rise to a good deal of irritation, and require
 excision, an operation  that would  probably be followed by rather troublesome
 hemorrhage.
   Removal of the clitoris, even though  not much enlarged, has of late years
 been recommended as a means of cure in some forms of erotomania.   I per-
 formed the operation for this purpose on a patient of Dr. Horsbrugh's, and found
 some difficulty in stopping the  bleeding,  which at last required the application
 of the actual cautery before it could be arrested.  The operation was I believe
 followed by  marked improvement in the young lady's mental condition.
    Tumors of various kinds are  met with in the interior of the vagina, springing 
UTERINE DISCHARGES,  DISPLACEMENTS, ETC.    977
from its walls.   These may be of a cystic character, but occasionally true mu-
cous polypi are found dependent and  projecting from  the side of  this canal.
These may most readily be removed by transfixing their base by a double whip-
cord ligature, and then strangling it.   In performing this operation, however,
when the tumor grows from the posterior wall, care must be taken to ascertain
by proper digital examination, that a portion of the rectum has not been dragged
down into its base.
   Prolapsus of the anterior  or  the  posterior wall  of the vagina  may occur,
giving rise in the first instance to protrusion of the bladder or cystocele, in the
next, to  a rectocele;  in either case, but especially in  the first, occasioning very
serious and troublesome  consequences, amongst which, chronic irritation of the
mucous membrane of the bladder, with perhaps phosphatic deposits in the urine,
 are the most marked.   These  protrusions may be supported  by the  use of pro-
 perly constructed belts or pessaries.  In  some cases  the surgeon may feel dis-
 posed to undertake plastic operations, having for their object the narrowing of
 the vao-inal orifice  by freely paring the opposite  portions of its walls, bringing
 too-ether the freshened surfaces  by means of the quilled suture, and thus pro-
 curing narrowing of  the canal and  permanent support to the protruded part.
 The  success of such operative proceedings will  greatly depend on  attention to
 detail.  The mucous membrane at the orifice of the vagina should  be  dissected
 off from about half an inch  below the meatus on one side, to a corresponding
 part on the other, in a strip  about three-quarters to an inch wide; the dissec-
 tion being carried well up posteriorly  in  the  fourchette.  Two or  three deep,
 and as  many superficial  sutures should  be passed;  the deep being left  in for
 about five, the superficial for seven days.  Great attention should be paid  to
 cleanliness, the patient lying on her  side with a catheter in the bladder commu-
 nicating with  an india-rubber tube to  carry off  the  urine, and the  bowels con-
 fined by opium.
    Various discharges connected with the female organs of generation fall under
  the observation of the surgeon; these may bccur from the external organs, from
  the mucous membrane  covering the cervix  uteri, or from the  interior of the
  cavity of that organ.  These discharges, when proceeding from  the mucous
  membrane  covering  the external organs or lining  the vagina,  are frequently,
  thouo-h not necessarily, of a gonorrheal character; and then require to  be treated
  in the way that has been mentioned at page 876.  When of a simple nature,
  proceeding from mere  hypersecretion of these parts, astringent injections, and
  attention to the general health will usually succeed  in effecting a cure.       _
    When these discharges proceed from the cervix or the interior of the os uteri,
  they will  commonly be found to be dependent  upon a chronica ly inflamed or
  congested condition  of the  organ,  or upon  a papillated, granular, fissured  or
  ulcerated condition of the mucous membrane, often  connected with more or less
  local thickening and induration  of subjacent structures   These  various con-
  ditions  often of a very persistent, insidious, and destructive character, have of
   kte vears been fully recognized by the labors of some of the French surgeons,

   mt^rt^                                 ^B1^ TdY BeT
   natholoev has been  greatly elucidated by Simpson  and Bennett   lo JJr. Ren-
   netespecial is due the great credit of having pointed out the true pathology
   of vSs uterine  diseases that were previously but imperfectly recognized, and
   of S shown that many of the so-called functional diseases of the uterus  are
   k[rJLity decent on congestion, inflammation, and other structural lesions

   of this organ.               „„„11T.r;no- nsnallv as the result of chronic inflam-
     These uterine discharge ;; occurring«suayaB                      &g ^

   7^ "to ^T^^^de* by various symptoms indicative
   of the urethra, throat,  or eye                          ^ more     iall  1Q

   1'S1  X$*%Z£*& -d  ™n'a g00d deal of 8jmpatheti0 con-
         62 
978    DISEASES  OF  THE FEMALE  GENITAL ORGANS.

stitutional irritation, terminating in impaired digestion, malnutrition, and ane-
mia.  It is in this condition of the system that many of the so-called hysterical
affections are so apt to arise; and the surgeon will often find  that the most inve-
terate case of neuralgia of the joints, the spine, the hip, or the breasts — amau-
rotic, and  other obscure  affections connected  with  nervous  irritation — are
primarily dependent on chronic uterine disease, and it is only by attacking  and
removing this that he will remedy  the  secondary mischief.  On examining the
condition of the cervix and os uteri in  these cases, by means of the speculum,
various morbid  changes will be observed in them; the cervix is perhaps thick-
ened, indurated, or knobbed on  one side, the os is frequently patulous, and the
mucous membrane  covering these  parts will be  observed to be erythematous,
congested, and  perhaps  excoriated; not unfrequently in a  granular condition,
closely resembling what  may be observed in some forms of  granular conjuncti-
vitis. In other cases, again, true ulceration may exist both upon  the cervix  and
within the os.   These ulcers, abrasions, excoriations, or  by whatever term they
may be  designated, are unquestionably a fruitful source of mischief in  this
situation, giving rise to considerable thickening of subjacent structures, usually
to abundant muco-purulent discharge and  much sympathetic irritation.  Their
characters  closely resemble  corresponding  forms of disease met with on  the
mucous  surface in  other situations, not attended by loss of .substance, but by
the development of  small pointed  granulations  or papillae, from which the dis-
charge is poured forth.
   The  treatment of these various  affections  of the uterus has been materially
simplified  since their pathology has been better understood, and practitioners
are now generally agreed as to  the necessity of the employment  of energetic
local measures for the removal of these morbid states.   To the  surgeon wbo is
in the habit of  managing local disease on other mucous  surfaces, and of remov-
ing the structural lesions that result from chronic inflammation  in other organs,
the treatment of these cases  can present little difficulty, as it  is conducted on
precisely the same  principles that guide him  in the  management of similar
affections elsewhere.
   The employment  of caustics  is of essential service in these various forms of
chronic uterine disease.  In cases of simple ulceration or excoriation, the nitrate
of silver in stick applied every third or fourth day will frequently be found to
effect a speedy cure.  For this purpose, the  hinge caustic-holder will be found
           a useful instrument (fig. 417).  If there be much chronic induration
  Fig. 417.  conjoined with  the affection of the mucous  membrane, the potassa
           cum  calce, fused into narrow sticks, may very advantageously be used.
           In doing  this, however,  care must of course be taken that the caute-
           rizing action  do not  extend too  far.  Hence  the  surgeon, after
           lightly touching the  diseased part, whether this  be on the cervix or
           inside the  os, should immediately inject  some  weak  vinegar  and
           water, so  as to neutralize the alkali.  After these applications, which
           should only be repeated at lengthened  intervals, the  patient must be
           kept quiet for some time, and any inflammatory symptoms  that  may
           be excited, combated  in the usual  way;  it very  rarely  happens,
           however, that anything  untoward will result.
             After the removal of the local disease in the way pointed out, any
           remaining congestion may be got  rid of by the application of leeches
           to the cervix.   During  the time that these local measures  are being
           adopted,  proper  constitutional treatment must be  had  recourse to,
           with the  view of improving the general health on ordinary medical
           principles, which need not be detailed  here, but for a full exposition
           of which, as well as  for a vast deal of important information on the
surgical management of uterine affections,  I would refer the reader to the last
edition of Dr. H. Bennet's work on the Uterus.
 
     UTERINE  DISPLACEMENTS,  TUMORS,  AND POLYPI. 979

   The various  displacements to which the uterus is liable, whether downwards,
constituting  prolapsus,  or in  the  direction of the  axis, being  twisted, and
either  retroverted or anteverted,  are  causes of much local suffering  and con-
stitutional disturbance, and commonly require surgical treatment.  These various
conditions will  frequently be found dependent  on inflammatory congestion of
the fundus, in consequence of  which the organ becomes as it were top-heavy,
and is  tilted  to one side, or descends bodily in the  pelvis.  The treatment, under
such circumstances, must have reference  to the  removal of the local turges-
cence  by the application of leeches, the employment of astringents, hip-baths,
and the recumbent position; occasionally assisted, perhaps, in twist of the organ,
by attempts  at replacing it by introducing the uterine sound into its cavity,
or, when it is  prolapsed, by supporting it with appropriate pessaries and the
abdominal bandage.
   Tumors of the uterus  are of various kinds.   The most common are those of
a fibrous character;  these are  often of considerable size, and have been found
weighing many pounds; they  may occupy almost any  portion of the uterus,
either  projecting into the peritoneal cavity, occupying the interior of the organ,
or dependent into the vagina.  These  tumors seldom occur  before the age of
thirty  or forty, and are not very amenable to treatment.  In some cases, how-
ever, considerable benefit results from attention to  position, the occasional appli-
cation  of leeches to the cervix, so as to lessen the  congestion of the organ, and
the introduction into the vagina every night of a ball composed of equal parts
of strong mercurial ointment,  wax, and lard, or one containing iodine, or the
iodide  of lead,  with the view of acting as an absorbent on  the morbid tissue.
   Polypi are not unfrequently  met with growing from the inner surface  of the
uterus, usually  from the posterior aspect or fundus.   These growths are gene-
rally oval or  pyriform, smooth,  hard, and  insensible, and  the cause of repeated
hemorrhage; and it is a remarkable  fact, that in many cases the most violent
bleedino- proceeds from the smallest tumors.  In other cases, the tumors  of the
uterus are of a soft fibro-cellular, vesicular, or mucous character, attended, like
the harder ones, by free  hemorrhage.
   The treatment of polypi of the uterus  is best conducted by ligaturing their
pedicle.  This  may usually be  readily enough effected by means of a whip-cord
lio-ature applied by Gooch's double canula, which has  been variously modified
and a good deal improved by different surgeons.   The ligature should be gra-
dually tightened, and usually cuts  its way through in from three to five days;
the tumor swelling, decomposing often with  a good deal of fetid discharge,
which  requires  to  be carefully syringed away by means of dilute chlorinated
lotions   It is a useful precaution not to apply the ligature too near the uterine
end of the pedicle, as cases  have occurred in which, by so doing,  the surgeon
has given rise to serious  and even fatal inflammation of the womb. Any portion
of pedicle that is left will gradually undergo absorption        <
   The cauliflower excrescence from the uterus attended by copious discharge,
is a rare  and  dangerous affection.  The only treatment that appears to  be  of any
avail is to draw down the neck of the uterus by means of a vukellum, and then
to excise the tumor with the  surface from which it grows.  This  operation is
not attended by any very  serious hemorrhage, and succeeds in ridding the
natipnt effectually of her disease.                                     .
  Malianant affections of the uterus usually commence in the form of scirrhous
tuberelfor ulceration of the cervix, attended by the  ordinary local and consti-
tational symptoms of this affection;  there is much offensive  discharge, and
cancerous cachexy speedily sets in.                  palliative  character- the
  ThP treatment  of these cases must  be of a purely palliative  character, tne
administration of opiates and the use of chlorinated lotions must be principally
  Id on   Excision of the  diseased  cervix has  been  recommended, and was 
980    DISEASES  OF  THE FEMALE  GENITAL  ORGANS.

formerly a good deal  practised; but this  is a barbarous procedure, and one
contrary to every principle of good surgery, as it is impossible to rid the patient
of scirrhous disease by the  partial removal of the affected organ, and its com-
plete extirpation cannot be  thought of. Tumors, however, of a simple character
requiring removal  are occasionally met with  springing from the  cervix; they
must be excised by putting the patient in  the  position  for lithotomy, drawing
the uterus well down with forceps and removing them with the knife; this has
been done during pregnancy, and even during parturition, with good effects.
                 OVARIAN  TUMORS AND  DROPSY.

  Ovarian tumors of a cystic  character  are commonly met with.  The cysts
may be uni- or multi-locular, and vary greatly in the nature of their contents.
These  may be either solid or fluid, — often a combination of the two.   If fluid,
the liquid is usually more or less viscid, albuminous, dark, and variously colored.
Ovarian  tumor invariably  tends to progress to  a fatal termination;  in some
cases,  rapidly, in most, gradually, occupying many years in its course.
  The treatment of ovarian tumor may be conducted :—1st, by medical means;
2d, by tapping; 3d,  by tapping,  conjoined with auxiliary measures;  4th, by
injection; 5th, by extirpation.
  1st.  Medical means exercise no influence in  curing, and but  little, if any,
in retarding the  progress of ovarian tumors.  Specific treatment  by means of
mercury or  iodine, has always  appeared to me  to hasten  the  progress  of the
malady by breaking down the constitutional powers of the patient;  and attempts
at promoting  the absorption  of  the   fluid  by purgatives, diuretics, &c, are
invariably unsuccessful.  An ovarian  cyst is a   rasitic growth, the tissues of
which  are not influenced to increased power of absorption by the action  of
deobstruents on the system generally.   The utmost that can be done by medical
means  in  such cases, is, to attend to  the general health and  to support the
tumor  by  a belt.
  2d.  Tapping in ovarian dropsy, may be done as for ascites, through the linea
alba; but not  unfrequently the tumor presents  more distinctly at some other
part of the abdominal wall, and may be emptied through the linea semi-lunaris,
or, if multilocular, may require the trochar  to be inserted at different points
into its separate compartments.   The paracentesis   of  ovarian  cysts  should,
unless  the disease be very acute, always  be  deferred as long as  is compatible
with the comfort of the patient, as it is not only followed by speedy re-accumu-
lation  of  the  fluid, and often by rapid exhaustion, few patients surviving the
first operation more than three  or four  years; but is attended by certain special
dangers,  such  as the risk  of  induction of peritonitis, or possibly even the
puncture  of the  bladder, or of a  coil  of small intestine,  which  is sometimes
adherent  to the  anterior wall of the ovarian cyst, and may be met with where
little expected.
  3d.  Tapping, conjoined  with other means,  has   occasionally  succeeded  in
effecting a cure of the disease.   These auxiliary means are of various kinds:—
firm pressure;  incision of the cyst; excision of a portion  of its wall, plugging
the  aperture in it with  a tent; the  introduction of a catheter  or tube;  the
establishment of a fistulous  opening leading into the interior of the cyst, either
through  the  anterior abdominal  wall or through the vagina, have all been
adopted  in addition to simple tapping;  and however much these  different
procedures  may vary in  detail, they are  all conducted on one principle, viz.,
that of causing the  gradual contraction  of  the cyst and the cohesion of its
walls,  a principle of treatment  which is only applicable to  unilocular cysts, and 
OVARIAN  TUMORS  AND DROPSY.
981
hence can only be had recourse to in a small number of, and those the simplest
cases of ovarian  tumor.
  4th. The injection of tincture  of iodine  has, of late, been successfully em-
ployed both in  this country and on the continent.  After the tumor has been
tapped, from four to  six ounces  of the tincture should be injected through  a
catheter  passed  down the  canula and left in.  In some cases no constitutional
disturbance follows; in others, a  severe  febrile paroxysm; and in others again,
peritonitis has resulted.  This method of treatment  has been very successful in
many cases, and is well deserving a more extended trial than it  has as  yet
received.   It is  only applicable, however, to non-adherent unilocular cysts.
   5th.  Ovariotomy.   Ovarian cysts and tumors may require removal, either on
account  of  their large size and the consequent inconvenience occasioned  by it,
or from  their rapid growth  exhausting the patient, and threatening a speedy
extinction of life. These operations have of  late years been frequently performed
with success, and their introduction into surgical  practice has been mainly due
to the labors  of Drs. F. Bird and Clay.   Much discrepancy  of  opinion  has
existed amongst practitioners as to the propriety of performing these operations,
which have been chiefly condemned on the grounds that  as  the  disease for
which they were performed, was not  necessarily fatal,  or  at all  events  not
incompatible with long life, it was not proper to subject the patient to a hazard-
ous procedure for its removal; and that the mortality from the operation was so
high as not to justify a surgeon in performing it.
   With  regard  to  the first  objection, it may be stated that ovarian disease  is
attended  by very great  discomfort and  inconvenience in  all cases;  and that
it is not  generally compatible with prolonged existence so soon as it attains such
a size as to require tapping.   Mr. Stafford  Lee states  that of 46  patients with
ovarian disease, who were  tapped, 37 died, and only 9 recovered; and that of
the  37 who died,  more than one-half did so in four months from the first
tapping, and 27  out of the 37 within a twelvemonth, and of these 18 were only
tapped once.  In those  who survive, repeated tappings are required, the interval
between each decreasing as they  are repeated.   The second  objection can have
little weight with any practical surgeon.  The mortality after ovariotomy is not
so high  as that after many operations, which no surgeon would hesitate for a
moment in performing.
   Dr. Lyman, of New York, in a valuable essay on this operation, has collected
from various sources the particulars of 300 cases; and  of these the operation
was completed by the removal of the tumor in 208> or about two-thirds of the
 cases. /In one case the result is  not stated; but of the 299 cases in which it is,
 120 died, or at  the rate of 40 per cent.}; of the 208 cases in which the operation
was completed, 89 died, or  nearly 43  per  cent.  Out of the whole 300 cases,
therefore in 119, or 39 J per cent., was the operation successful in the removal
 of the disease and  the recovery of the patient.
   Of the 88 cases in which the  operation  was abandoned, in 68 instances this
 arose from adhesions ;  in 8 cases no tumor was found; and in the remainder the
 tumor was not  ovarian.  Of the whole of  the cases in which the operation was
unfinished, 27 died.               #  .                                  .
   The mortalitv after ovariotomy is increased  by the existence  ot  adhesions.
 When these complicated  the operation, 47 per cent,  of the cases died; when
 they did not exist, 32  per cent, were  fatal.  The mortality is greater  in early
 life;  smaller between the ages of 50 and 60
   When we  compare  these  returns with  the rate of mortality after primary
 amputation  of   the thigh, amputation at the hip, that following the ligature of
 the  innominate  or subclavian arteries, or indeed even in strangulated hernia  in
 hospital practice, we cannot consider it as of a magnitude to interfere with the
 performance of the operation if other circumstances justify it. 
982    DISEASES  OF  THE  FEMALE GENITAL ORGANS.

  It has further been objected to ovariotomy,  that  it  has not unfrequently
happened  that after the operation  has  been commenced, it has  been found
impossible  to  complete it, owing to the existence of adhesions between  the
tumor and the contents of the  abdomen.   This  objection is certainly a grave
one; but 1 believe that with  care in examining the tumor, ascertaining its
mobility during respiration, the existence or not of crackling under the abdo-
minal wall  during the respiratory movements, the absence of connection with
the uterus, as  determined by finding that  organ floating on the  introduction
of the uterine sound,  and the previous non-occurrence of peritonitis, this  mis-
take is not  now so likely to happen  as formerly, when  the liability to it was not
suspected.
  It is  not my intention to enter into the difficult subject of the diagnosis of
ovarian  tumors.  From pregnancy, ascites, tumors  of  the uterus  and omentum,
enlargements  of the  liver, kidney, spleen  and  stomach, hydatids, hysterical
tympanitis, fat in the  omentum, stercoraceous accumulations, distension of  the
bladder, spinal  curvature, abdominal and  pelvic abscesses, the  diagnosis  has
carefully to be  made, and that this is a matter  of no slight difficulty is evident
from the numerous cases in which  errors have  happened  and  are  constantly
occurring to most experienced practitioners.  It is impossible for the  surgeon
to be too cautious in effecting  a diagnosis before he proceeds to open the abdo-
minal cavity in any supposed cases  of ovarian disease.  There is, however,  one
form of disease that so closely resembles an ovarian cyst,  that I may refer to it;
it is a dilated state  of the fallopian tube, containing fluid,— in fact, dropsy of
that tube.  This condition may generally be recognized by the tumor being of
moderate size, wholly  fluid, having deep pelvic adhesions, displacing the uterus
and  bladder, and drawing  up the vagina into  a pouch.  The displacement is
often very remarkable and considerable.  I have seen the bladder flattened  out
and drawn  up as high as the umbilicus—the top of the vagina above the pubes.
In these cases the abdominal wall is not so much thinned and expanded as in
true ovarian disease.  The tumor, which cannot of course  be  extirpated, is never
pediculated.
   Operation. — On the day preceding the operation a dose of castor-oil should
be administered, and on the morning of it an enema, so that the  bowels may be
completely  emptied.   The  room having been raised to a temperature of at least
75° or 80° F., chloroform administered, and the bladder  emptied by the cathe-
ter, the patient must be placed upon a table covered with blankets, in such a
way that the legs hang over the end of it, and the abdomen is fairly and evenly
exposed.  The surgeon, taking his stand between the patient's legs, makes an
incision, about four inches in  length,  from  the umbilicus downwards, directly
in the mesial line; by a few touches of the  knife, the  structures, which  are
usually  much  thinned, are divided along  the  linea  alba,  and  the  abdominal
cavity opened.
  There has been much discussion as to the length to which the  incision in  the
abdominal  wall should be made, some practitioners  recommending that this
should be of very limited extent, others that it should reach from the ensiform
cartilage to the pubes.  No definite rule can be laid down  upon this point.  The
incision must be proportioned in extent to the size and  nature  of the tumor,
and the existence or not of adhesions.  If the tumor be cystic,  and not adhe-
rent, it  may be readily enough extracted by making an incision  an inch or  two
in length, in the mid-line, tapping  it  through this, and then drawing the emp-
tied cyst forwards by  means of a vulsellum.  If, on the other hand, the ovarian
growth  be chiefly solid, a larger incision, from four to  six inches  in extent,  will
be required.   Should adhesions exist, it  may even  be necessary to go beyond
this, though  I cannot believe that it is ever necessary to rip up the abdomen 
OVARIAN  TUMORS  AND DROPSY.             983
from the sternum to the pubes, for the removal of any tumor, however large or
adherent.
  If it  be found that the adhesions are so  extensive and firm that the tumor
cannot be  removed, it must be tapped, and the wound in the abdominal wall
closed.
  The tumor now comes into view: if cystic, it must be tapped with  a large
trochar  and the  fluid evacuated.   Should  this be very thick  and  viscid, the
aperture in the  sac may be enlarged with  a probe-pointed bistoury, and thus
its contents let out.  In this way the size of the tumor may be  so much lessened
as to admit of its  more ready extraction.   If cystic and emptied, it may now
perhaps  be drawn out  through the  incision in the abdominal wall without
further  difficulty.  If solid, or if there be  any adhesions, the surgeon must
introduce his  hand,  and thus assist in removing the mass, or gently break
down any  connections it may have formed with adjacent parts.   These will
chiefly  be  found at  the anterior part, between it  and  the  abdominal wall;
seldom  or  ever posteriorly, or to any of  the  abdominal viscera, except the
uterus.   During the  withdrawal  of the  mass from  the abdomen, an  assistant
on  either side must  press upon  the sides of the incision with their hands or
with soft napkins, so as to prevent the protrusion of the intestines.  This some-
times occasions considerable trouble, especially if the  patient have taken chloro-
form and begin to vomit, when it may be necessary to discontinue the operation
for a time.
   The separation of the pedicle is the next step, and perhaps the most important
one in the operation.  This may best be done by drawing the tumor well forwards,
transfixing the pedicle with  a nevus-needle  carrying a strong whip-cord ligature,
tying it firmly on either side, and  then cutting  it across  above the constricted
portion.  In doing all  this, a few points require attention.  Care should be taken
that the needle does not transfix any large artery or vein.   This may generally
be  avoided by spreading out or unravelling, as it were, the pedicle and examining
its  structure before passing the ligature.  After it has been transfixed, and before
the cord is tied, it is well to dissect off that portion of the  peritoneal investment
of  the pedicle which  corresponds to the  line that will be constricted  by the
ligature.  In doing this great care must, however, be taken  not to wound the
vessels,  especially the veins, which are very thin-walled. In this way there will,
I think, be less risk of peritonitis, as there is less chance  of any slough  of the
pedicle  falling into the peritoneum; and I attribute much of the  success that
attended the removal  of an ovarian tumor, partly solid and partly cystic,  weigh-
ing about fifteen pounds, which I extracted from a lady, sixty-five years of age,
to the adoption of this precaution.
  After the ligature  of the pedicle, it should be divided  about  half an inch
above the part tied. If it be cut across nearer the ligatures  than this, there will
be  danger of the stump retracting under  them, and thus inducing secondary
hemorrhage, which has proved fatal in no  less than 23 per cent, of the  deaths
after this operation.                                _
  The next point in connection with the pedicle is fixing it properly out of the
peritoneal cavity, so that it  may not be drawn back into this, as it  always has a
tendency to do, and  thus excite undue inflammation  by the presence  of the
li-atures and resulting slough in the serous membrane.  I have found  the most
convenient way to fix it is to close the lower part of the incision in the abdomi-
nal wall by a hare-lip pin passed across it, about half an inch above its angle,
and drawin- the stump of the pedicle well out of the abdomen through this, to
retain it there by twisting the whip-cord ligature with which it has  been tied,
in the usual figure of 8 manner, round the  pin; in  this way it  cannot possiby
be retracted, and there is no chance of any of the slough or ligature falling into
the peritoneal cavity. 
984    DISEASES  OF  THE  FEMALE GENITAL ORGANS.

  The incision in the abdomen must be closed by a series of interrupted sutures
passed across from one lip to the other, and the  abdominal wall must be still
further supported by broad and long shps of plaster, and a laced napkin  round
the body.
  The after-treatment of the case will require the most careful attention.  The
patient should be kept in bed, in a high  and uniform  temperature.  Nothing
but ice- and barley- or Seltzer-water  should be allowed for  several  days, and
opium must be given  in sufficient and repeated doses, to keep the  system slightly
influenced by  it.  The urine must be drawn  off  thrice in the twenty-four  hours,
but the bowels should be left unrelieved for  at least ten or twelve  days, and
then merely opened by an enema.   As no solid food should  be given  during
the whole of  this time, little  inconvenience results.   If peritonitis comes on,
it must be treated in accordance with the rules laid down when speaking  of
strangulated hernia. 
INDEX.
Abdomen, contusions of, 325
    injuries of, 325
    tapping the, 849
    wounds of, 326
Abdominal injuries, treatment of, 327
Abscess, 341
    diagnosis of, 344
    in groin, diagnosis of, 642
    iliac,  643
    ischio-rectal, 831
    knife, 346
    psoas, 642
    treatment of, 345
    urinary, 894
    varieties of, 342
Acetabulum, fracture of, 222
Acromion, fracture of, 212
Adenitis, 465
Adhesion, primary,  112
Air in veins, 143
    causes of,  145
    treatment of, 146
Air-passages, foreign bodies in, 312
Ala nasi, restoration of, 695
Amputating instruments, 37
Amputations, 36
    at ankle, 57
    of arms, 57
      breast,  764
    in burns, 339
    Chopart's, 55
    in contused and lacerated wounds,
      constitutional gangrene, 359
    for disease, 44
    of fingers, 47
      foot, 54
      forearm, 51
    in frostbite, 340
    of great toe, 54
    in gunshot wounds, 128
    of hand, 49
    how influenced, 43
    Hey's, 55
    at hip, 63
    for injury, 44
    in joint diseases, 636
    at knee, 61
    of leg, 60
    of little toe, 55
      metacarpus, 50
      metatarsal bones, 54
    mortality after, 42
Amputations — continued.
    in necrosis, 592
    Pirogoff's,  58
    in popliteal aneurism, 527
    primary, 45
    results of, 44, 45, 46
    secondary, 45
        in fractures, 203
        hemorrhage after, 173
    in senile gangrene, 360
    of shoulder, 52
    special, 49
    statistics of, 44, 45, 46
    subastragaloid, 58
    Syme's, 57
    synchronous, 40
    through tarsus, 55
    of thigh, 61
       thumb, 49
       toes, 54
    varieties of, 37
    Vermale's, 61
    of wrist, 50
Anaesthetics, 29
    local, 33
Anchylosis,  618
    treatment of, 619
Anemia, 141
Aneurism, 482
    accidents alter operation for, 501
    amputation in, 528
    by anastomosis, 564
       arterio-venous, 167
    of axillary artery, 552
       bone, 604
       brachial artery, 562
       carotid, 537
    cause of, 494
    circumscribed traumatic, 166
    dissecting, 484
    diagnosis of, 492
    duration of, 487
    femoral, 520
    of forearm, 562
    fusiform, 482
    gangrene in, 506
    of iliac arteries, 515
    inguinal, 514
    ligature in, 497
    medical treatment of, 495
    mode of death in, 491
    recurrent pulsation in, 501
                           (9 85> 
986
INDEX.
          Aneurism — continued.
              popliteal, 520, 526
              pressure-effects of,  486
              sacculated, 483
              secondary, 501, 503
              structure of,  486
              spontaneous cure of, 490
              of stumps, 41
                 subclavian, 546
              suppuration and sloughing of, 504
              surgical treatment of, 497
              symptoms of, 488
              terminations of, 490
              of tibial arteries, 629
              traumatic, 166
              treatment of, 495
                   by compression, 507
                     galvano-puncture, 513
                     injection, 514
                     manipulation, 512
              Valsalva's treatment in, 496
              varicose,  169
              varieties of, 482
          Aneurismal varix,  168
          Aneurisms of  innominata, 529
                   distal ligature in,  532
          Angeioleucitis, 464
          Ankle, amputation at, 57
              dislocation of, 268
              excision of, 634
              fractures  near and through, 233
          Antiphlogistics, 86
          Antrum, diseases of, 709
              suppuration of, 709
              tumors of, 710
          Anus, artificial, 789
                   operation for, 820
              cancer of, 829
              fissure of, 829
              fistula of, 832
              imperforate, 823
              malformation of, 823
              prolapse of, 845
              spasmodic contraction of, 831
              ulcer of, 829
          Aorta, ligature of. 519
              wounds of, 325
          Aphonia, 724
          Arachnitis, erysipelatous, 381
          Arm,  amputations of, 51
              contractions of,  677
          Arteries, arctation of, 474
              atheroma of, 476
              bruised,  149
              calcification of, 477
              changes in, after ligature,  161
              degenerations of, 476
              diseases  of, 473
              dissection of, 159
t              femoral, wounds  of, 182
              of forearm, wounds of, 181
                 hand,  wounds of, 181
              injuries of, 148
              of  leg and  foot, traumatic  aneurisms
                   of,  182
                  leg and foot, wounds of, 183
              ligature of, 156
Arteries — continued.
    mode of exposing, 158
    mode of ligaturing, 168
    occlusion of, 474, 480
    spontaneous ligature of,  480
    structural disease of, 476
    torsion of, 156
    torn, 149
    ulceration of, 480
    wounded, treatment of, 164
    wounds of, 149
Arterio-venous wounds,  168
Arteritis, 473
Artery, axillary,  ligature of,  561
         traumatic aneurisms of, 177
         wounds  of, 177
    brachial, ligature of, 563
         traumatic aneurisms of, 180
         wounds of, 180
    carotid, wounds of, 176
         distal ligature of, 533, 543
         ligature of, 540
         traumatic aneurisms of, 177
    common iliac, ligature of, 518
    external iliac, ligature of, 517
    femoral, ligature  of, 523
    iliac, ligature of,  515
    innominata, ligature of, 547
    internal iliac, ligature of, 520
    subclavian,  ligature of, 549, 552
         distal ligature of, 532
         wounds of, 177
    tibial, ligature of, 529
Arthritis, 610
    chronic rheumatic, 659
    traumatic, 238
Atheroma, 476
Artificial respiration,  310
Asphyxia, 308
    from irrespirable gases,  311
    secondary, 311
Astragalus, compound dislocation of, 271
    dislocation of, 269
    excision of, 633
Atheromatous tumors, 389
Axilla, removal of tumors from, 764

Balanitis, 951
Bandage, plaster of Paris, in fractures, 197
    starch, in fractures, 194
Bed sores, 360
Bladder, catarrh of, 851
    diseases of,  850
    extroversion of, 857
    puncture of, in cases of  stricture, 892
    fasciculated, 852
    inflammation of, 850
    irritability of, in  gonorrhea, 871
    irritable, 851
         in women, 853
    paralysis of,  854
    puncture of,  864
    rupture of, 333
    sacculated, 852
    stone in, 899
    tumors of, 853
Blepharoplasty, 700 
INDEX.
987
Blood, changes of, in inflammation, 70
    extravasation of, within skull, 292
    transfusions of, 142
Blood-vessels, injuries of, 140
Boils, 365
Bone, abscess of,  581
    aneurism's of, 604
    bending of, 185
    cancer of, 601
    cystic tumors of, 598
    diseases of, 579
    fractures of,  185
    hydatids in, 600
    hypertrophy of, 593
    injuries  of, 184
    mode of sawing, 38
    pulsating tumors of, 604
    rebreaking of, 581
    softening of,  594
    structural changes  of, 598
    suppuration of, 580
    tubercle of, 596
    tumors of, 590
Brain, extravasations on, 292
    foreign bodies in, 290
    inflammation  of, 275
    injuries  of, 272
         treatment of, 277
    irritation of,  275
    wounds  of, 289
Breast,  abscess of, 748
    amputation of, 764
    cancer of, 753
         treatment of,  758
    chronic mammary tumor of, 749
    cystic sarcoma of, 752
         tumors of, 750
    diagnosis of tumors of, 757
    diseases of, 743
    encysted abscess of, 748
    hypertrophy of, 745
    inflammation  of, 746
    neuralgia of,  744
    tumors of, 749
Bridles, 102
Bronchocele, 742
Bubo, 438
Buffer accidents,  325
Bullet extractors,  127
BuDion, 663
Burns, 335
    amputation in, 339
    treatment of,  338
Bursae,  diseases of, 663

Calcaneum,  excision of, 632
    fractures of,  234
Calculus (see Stone)
Callus, 190
    ossification of, 191
Cancer, 399
    of bone, 601
    causes* of,  405
    caustics in, 407
    cells, 401
    chimney-sweeper s, 953
    compression in, 409
Cancer — continued.
    congelation of, 410
    diagnosis of, 406
    epithelial, 414
         operation for, 415
         treatment of, 415
    excision of, 410
    operations for, 411
    of skin, 462
    removal of, by ecraseur, 415
         by ligature, 416
    treatment of, 406
Counter-irritants, 85
Cancrum oris, 364
Carbuncle, 365
Caries, 582
    operations for, 583
    syphilitic, 451
Carpus,  dislocation of, 258
Cartilage, disease of, 611
Cartilages, loose, in joints, 638
Castration, 971
Catheter, caustic, 871
    female, introduction of, 975
    prostatic, 862
Catheters, 882
Caustics in cancer, 407
    in epithelial cancer, 416
Cauteries in hemorrhage, 155
Cautery, 85
Cellulitis, 372
Cephalcematoma, 281
Cerebral disturbance, 273
Chancres, 427
    diagnosis of, 430
    treatment of, 436
    of urethra, 430
    varieties of, 428
Cheeks,  diseases of, 687
    injuries of, 301
Cheiloplastic, 694
Cheloid,  394
Chest, hemorrhage into, 322
    injuries of, 318
    tapping the, 765
Cholesteatoma, 395
Chloroform, 29
    administration of, 29
    caution in using, 30
    dangers of, 31
    death from, 32
    mortality after, 29
    overdose of, 32
    in shock, 32
    treatment of overdose of, 32
Cicatrices, 102
    changes in, 101
    faulty, 116
    indurated syphilitic, 437
    structure of, 102
Cicatrization, 102
Circulation, collateral, 162
Circumcision, 949
Clavicle,  dislocation of, 247
    excision of, 625
    fractures of, 210
Cleft palate, 715 
988
EX.
Clitoris, hypertrophy of, 976
Cloacae, 588
Club-foot, 669
Coagulum in wounded arteries, 151
Cold as an anaesthetic, 33
    effects of, 340
    in hemorrhage, 155
Collateral circulation, 162
Collodion, 115
Colloid, 400-404
Columna nasi, restoration of, 694
Coma, 274
    diagnosis of, 293
Compress, graduated, 156
Compression in aneurisms, 507
    of brain, 274
Concussion, 273
    effects of, 274
Condylomata, 448
Congestion, 66
    treatment of, 67
Conservative surgery, 629
Contractions, 665
    causes of, 666
Contre-coup, 283-290
Contusions,  amputation in, 119
    degrees of, 109
    diagnosis of, 109
    treatment of, 110
    varieties of, 109
    what constitutes, 109
Coracoid process, fracture of, 213
Corns, 456
Coronoid process, fractures of, 217
Counter-opening, 347
Coxalgia (see Hip-disease)
Cranium, necrosis of, 592
Croup, spasmodic, 731
Cuboid, excision of, 634
Cut throat, 305
Cystine, 902
Cystitis, 850
Cystocele, 977
Cysts, 389
    compound, 392
    multilocular, 392
    sanguineous, 393

Deformities, 667
Delirium, inflammatory, 108
    irritative, 108
    traumatic, 108
    treatment of, 108
Determination of blood, 68
Diathesis, hemorrhagic, 569
Diet after operations, 35
    before operations, 28
Disarticulations, 36
Dislocations, 239
    of ankle, 268
      astragalus, 269
      carpus, 254
      clavicle, 247
    compound, 244
    congenital, 265
    of elbow, 253
      finger, 259
Dislocations — continued.
      foot, 268
    with fracture, 244
    of hip, 260
      jaw, 246
      knee, 266
      metacarpus, 258
      metatarsus, 271
      patella, 265
    reduction of, 242
    of scapula, 272
      shoulder,  249
      Bpine,  300
    spontaneous, 245
    of tarsus, 271
      thumb, 259
    treatment of, 241
    of vertebrae,  301
      wrist,  257
Dissection wounds, 138
Dressing of wounds,  34
Drowning, 308
Dura mater, 679

Ear, diseases of,  681
Ears, bleeding from, 284
    foreign bodies in, 302
    injuries of, 302
    serous discharge from, 284
Ecraseur, 415
Ectropium, operation for, 701
Elbow, dislocation of, 253
    excision of, 625
    fractures near, 216
Emphysema,  319
    of abdominal wall, 327
Empyema, 320
Encephalitis,  traumatic, 275
Encephalocele, 679
Encephaloid,  400-404
Enchondroma, 398
Enterotome, 791
Entropium, operation for, 701
Epicanthis, operation for, 701
Epididymitis, 955
Epispadias, 948
Epistaxis, 683
Epithelioma, 414
Epulis, 708
Erysipelas, 366
    causes of, 368
    cellular,  373
    cellulo-cutaneous, 370
    contagion of, 369
    cutaneous, 370
    external, 369
    of fauces, 379
      fingers, 377
      head, 877
      infants, 376
    internal,  379
    of larynx, 380
    phlegmonous, 370
    of pudenda, 377
      scrotum, 377
      serous  membrane,  381
      treatment of, 374 
INDEX.
989
Ether, administration of, 33
Excision of ankle, 633
    of astragalus, 633
      calcaneum, 632
      clavicle, 625
      cuboid, 634
      elbow, 625
      foot, 630
      great toe, 632
    in gunshot wounds, 128
    of hip joint, 656
      joints, 620
      knee, 635
      hand,  628
      lower jaw, 713
      radius, 628
      scapula, 625
      shoulder joint, 623
      ulna, 628
      upper jaw, 712
       wrist, 627
 Exostosis, 598
 Extravasation of blood in abdomen, 329
    of fasces, 329
 Eyeball, cancer of,  681
    Extirpation of, 681
    injuries  of,  303
 Eyelids, operation on, 700
    tumors of, 680
 Eyes, gonorrheal inflammation of, 875
    wounds of, 303

 Face, injuries of, 301
    plastic surgery of,  692
 False passages, 885
 Fatty tumors, 394
 Feet, deformities of, 669
 Femur, fractures of,  322
 Fever, hectic, 95
    hemorrhage, 141
     after operations, 27
     surgical, 27
 Fibrine, 90
 Fingers, amputation of, 47
     dislocation of,  260
     enchondroma of, 399
     erysipelas of, 377
    fractures of, 221
 Fistula, 348
     aerial, 308
    in  air passages, 308
       ano, 833
         operation for, 833
     entero-vaginal, 848
     in  perineo, 894
     lachrymalis, 680
     rectal, 848
     recto-vaginal, 849
          vesical, 848
     salivary, 302
     urethro-vaginal, 897
     urinary, 895
    vesico-vaginal, 897
 Flaps, 38
 Foot, amputations  of, 54
    conservative surgery of, 631
     disarticulation of, 57
Foot — continued.
    dislocations of, 268
    fractures of, 234
Forceps,  artery, 158
    cutting, 591
Forearm, amputations of, 51
    fractures of, 217
Foreign bodies in bladder, 333
    in brain, 290
       rectum, 334
       vagina, 334
Fractures, 185
    accidents in treatment of, 197
    of acetabulum, 222
       acromion, 212
    amputations in, 203
    near ankle, 233
    badly set, treatment of, 204
    of base of skull, 282
       calcaneum,  234
    causes of, 185
         disunion in, 205
    of clavicle,  210
    complicated with dislocation, 199
    complications of, 199
         compound, 200
    compound,  199
         of leg, 232
         treatment of,  201
    of coracoid process, 213
       costal cartilages, 235
       coronoid processes, 217
    displacement in, 189
    near elbow, 216
    of femur, 222
         treatment of, 228
       fingers, 221
       foot, 234
       forearm, 217
       great tubercle of humerus, 215
       humerus, 213
       hyoid bone, 210
       leg, 232
       lower end  of humerus, 216
       lower end  of radius, 217
       lower extremity, 221
       lower jaw, 209
       malar bones, 209
       maxillary bones, 209
       metacarpus, 221
       nasal bones, 208
       neck of femur, 222
            humerus, 213
        olecranon, 217
       pelvis,  221
       patella,  230
     re-setting of,  204
     of ribs, 235
        sacrum, 222
        scapula, 212
     near shoulder, 212
     signs of, 188
     simple treatment of, 192
     of skull, 282
       spine, 299
     treated by starch bandage, 194
     ununited, 204
L 
990
INDEX.
Fractures — continued.
    ununited, treatment of, 206
    union of, 190
    varieties of, 188
    of vertebrae, 298
       zygoma, 209
Frost-bite,  340
Fungus,  cerebri, 290
    of dura mater, 679

Galvanic cautery, 348
Ganglion, 664
Gangrens, 352
    from arrest of circulation, 354
         arteritis, 474
    in fractures, 197
    inflammatory, 103
         treatment of,  104
    line  of demarcation in, 104
         separation in, 104
    after ligature, 174
         causes of, 175
         treatment of,  176
    after operation for aneurism, 506
    from occlusion of arteries, 481
    senile, 355
         amputation in, 360
         treatment of, 357
    spontaneous, 355
    traumatic, 117
         amputation in, 120
    varieties of, 353
Gastrotomy, 819
Genu-valgum, 672
Glands, lymphatic, diseases of, 465
Glossitis, 702
Gonorrhea, 866
    complications of, 870
    sequences of, 871
    treatment of, 868
    in women, 875
Gouge forceps, 591
Granulations, 100
    vascularization of, 100
Gums, diseases of, 708
Gunshot injuries, period  of amputation in
   129
    wounds, 121
         amputations in, 128
         apertures of,  123
         excisions in, 129
         immediate attention to, 125
         peculiarities of, 122
         symptoms of,  125
         treatment of,  125

Hematoma, 393
Hand, amputations of,  47
    conservative surgery of, 629
    deformities of, 678
Hanging, treatment  of, 312
Hare-lip, 688
    treatment of, 689
Head, diseases of, 679
    injuries of, 272
Heart, rupture of, 324
    wounds of 323
Hectic, 95
Hematocele of cord, 964
    spontaneous, 963
    traumatic, 963
Hematuria, 854
Hemorrhage,  141, 149
    arrest of, 150
        in gunshot wounds, 126
    arterial,  141
    constitutional effects of, 172
    after operations, 27
    permanent arrest of, 152
    secondary, 171
    secondary, treatment of, 173
    from stumps, treatment of, 173
    surgical  treatment of, 154
    venous, 140
Hemorrhagic fever, 141
Hemothorax,  319
Hernia, 766
    accident  in operation for, 788
    adhesions in, 787
    causes of, 769
    cerebri, 290
    congenital, 802
    director, 782
    diaphragmatic, 812
    femoral,  804
        diagnosis of, 806
        operation for, 807
    infantile, 803
    inflamed, 773
    inguinal, 796
        diagnosis of, 799
        operation for, 801
    irreducible, 772
    obturator, 811
    knife, 783
    omentum in, 787
    operation without opening sac, 792
    perineal, 811
    pudendal, 812
    radical cure of, 771
    reduction in mass, 794
    state of intestine in,  785
    sciatic, 812
    strangulated, 774
        diagnosis of, 777
        operation in, 781
    stricture in, 775
    structure of, 767
    taxis in,  778
    umbilical, 809
    treatment of, 770
    vaginal,  812
    ventral,  810
Herniary peritonitis, 784
Hip, amputation at, 63
        statistics, 66
    disease,  650
        treatment of, 655
        varieties of, 652
    dislocations of, 260
    joint, excision of, 657
    rheumatic arthritis of, 650
Horns, 390
Hospital gangrene, 361 
INDEX,
991
" Housemaid's " knee, 662
Humerus, fractures of, 213
    lower end, fracture of, 216
Hydatids in bone, 600
Hydrarthrosis, 608
Hydrocele, 957
    congenital, 958
    of cord, 963
    coverings of, 958
    diffused,  of cord, 963
    encysted, 962
    radical cure of, 960
    spermatozoa in, 963
    tapping,  959
Hydrophobia, 134
Hydrosarcocele, 968
Hymen, imperforate, 976
Hyoid bone, fracture of,  210
Hypospadias, 948

Ice as an anaesthetic, 33
Impotence, 872
Incisions, 34
Increased vascular action, 67
Inflammation, 68
    active, treatment of, 78
    adhesive, 89
    asthenic, 87
    bloodletting in, 80
    causes of, 77
    changes  of blood in,  70
    chronic,  treatment of,  83
    coagulation of blood in, 71
    cold in, 79, 82
    curative  treatment, 79
    duration of. 77
    effects of, 76
    effusive,  88
    extension of, 77
    fomentations in, 83
    gangrenous, 103
    gangrenous, arrest of,  104
         causes of,  103
         treatment  of,  104
    guides to bloodletting, 80
    heat in,  82
    local bleeding in,  81
         signs of, 72
    low treatment of, 87
    mercurials in, 80
    metastasis, 76
    phenomena of, 69
    preventive treatment of, 7$
    punctures in, 81
    secondary, forms of, 88
    state of vessels in, 69
    stimulants in, 85
    suppurative, 92
    symptoms of, 71
    termination of, 76
    ulcerative, 97
Inflammatory effusions, 88
    fever, 74
Injury, effects of, 106
Insects, stings of,  132
Instruments, amputating, 37
Intestines, obstructions of, 813
Intestine — continued.
    state  of, in hernia, 786
    wounded, treatment of, 329
    wounds of, 327
        in hernia, 788
Iritis, syphilitic, 451
Irrigation, mode of applying, 79
Issues, 85

Jaw, dislocations of, 246
    fractures of, 209
    lower, diseases of, 713
        excision of, 713
        necrosis of, 593
    subluxation of, 247
    upper, excision of, 712
        diseases of, 709
Joints, diseased, amputation in,  637
    diseases of, 607
    excision of,  620
        in gunshot wounds, 128
    false, 204
        treatment of, 206
    hysterical, 666
    inflamed, incisions into, 616
        treatment of, 615
    inflammation of,  610
    injuries of, 236
    loose  cartilages in, 638
    neuralgia of, 639
    stiff,  618
    strumous, disease of, 617
    traumatic arthritis,  238
    wounds of, 237

Knee,  amputation at, 61
    anchylosis of, 673
    compound dislocations of, 267
    contractions of, 672
    deformities of, 673
    dislocations of, 266
    excision of, 635
    stiff,  forcible extension of, 674
    subluxation of, 267
Knot, clove hitch, 242
    reef,  158

Labia, cystic tumors of, 976
    hypertrophy of, 976
Lachrymal gland,  extirpation of, 68]
    sac, puncture of, 680
Laryngitis, 722
    oedematous, 724
Laryngotomy, 734
    advantages of, 738
Larynx, chronic irritation of, 724
    diseases of, 722
    erysipelas of, 380
    nervous affection of, 731
    tumors in, 732
    topical medication of, 725
    ulceration of, 730
Leg, amputation of, 59
    fracture of, 232
Leucorrhea, 977
Ligature,  156
    accidents after, 171 
992

Ligature — continued.
    in aneurisms, 497
    application of, 157
    immediate effects of, in arteries, 1
    introduction of,  156
    kinds of, 157
    mode of tying, 158
    in nevus,  567
Ligatures,  39
Limbs, artificial,  40
Lip, cancer of, 691
Lipoma, 395, 684
Lips, diseases of, 687
    fissures of, 687
    hypertrophy of, 687
    tumors of, 687
Lithectasy, 946
Lithotome cache", 931
Lithotomy, 910
     dangers in, 924
     bilateral, 930
     causes of death  after, 924
     in children,  920
     difficulties of, 920
     hemorrhage in,  923
     lateral, 911
     instruments, 911
     and lithotrity compared, 941
     Marian, 929
     median, 928
     median and lateral compared, 929
     supra-pubic, 927
     in women, 947
 Lithotrity, 933
     accidents  of, 939
     cases requiring it, 934
     instruments, 935
     stages of, 937
     in women, 947
 Liver, rupture of, 326
 Lung, hernia of, 322
     wounds of,  318
 Lupus, 459
     exedens, 460
     non-exedens, 459
     structure of, 460
 Lymph, 89
     development of, 89
 Lymphatic glands, diseases of, 465
 Lymphatics, diseases of, 464
 Lymphatitis, 464

 Mad animals, bites  of, 134
 Mollities ossium, 594
 Melanosis, 400-405
 Mercury in syphilis, 431, 442
 Metacarpus,  amputation of, 50
      dislocation  of, 258
 Metatarsal bones, amputation  of, 54
 Metatarsus, dislocation of, 271
 "Miner's" elbow, 662
 Mortification, 352
 Mummification, 352
 Mumps, 740
 Muscles, diseases of, 665
      injuries  of, 183
      ruptures  of, 183
INDEX.

      Nails, diseases of, 457
          ingrowing, 458
          removal of, 458
      Necrosis, 585
          of special bones, 592
          in stumps, 40
          syphilitic, 451
      Neck, hydrocele of, 742
          tumors of, 741
      Needles, extraction of,  131
      Nerves, inflammation of, 570
          injuries of,  140
      Nevus, 565
          treatment of, 566
      Necrosis forceps, 591
      Neuralgia,  571
          of joints, 639
      Neuroma, 573
      Nipple, cracked, 746
          diseases of, 746
      Nodes, 450
      Nose, cancer of, 684, 686
          diseases of, 683
          gonorrheal inflammation of, 874
          polypi of, 684
          restoration of,  695
      Nostrils, foreign bodies in,  302
          plugging of, 683

      Obstruction, intestinal, 813
      (Edema, inflammatory, 377
      ffisophagotomy, 318
      (Esophagus, diseases of, 720
          injuries of, 319
          structure of, 720
      Olecranon, fracture of, 216
      Omentum,  state of, in  hernia, 787
      Onychia, 457
          malignant, 458
          syphilitic, 447
      Operation, Amussat's,  820
               Anel's, 498
          for aneurisms, 497
          blepharoplastic, 700
           for cancer of breast, 761
           caries, 584
           of castration,  972
           causes of death after, 27
           cheiloplastic, 699
           of excision, 620
           hemorrhage after, 27
           for hernia, 781
           Hunterian, 498
           for impermeable stricture, 890
           on lower jaw,  713
           for necrosis, 690
           permeable stricture, 887
           Petit's, 792
           preparations  for,  29
           rhinoplastic, 694
           on tongue, 705
           of resection,  620
           results of,  25
           in scrofula, 424
           shock after, 27
           on tumors, 416
           Tagliacotian,  695 
INDEX.
993
Operation — continued.
    treatment of, after, 35
    on upper jaw, 712
    vaginal fistulae, 897
    for varicose veins, 471
    Wardrop's, 499, 532
    on windpipe, 731
    Wutzer's,  771
Operations, 25
Ophthalmia, gonorrheal, 873
Orbit, injuries of, 303
Orchitis,  955
Osteitis, 579
Osteo-aneurisms, 604
    cancer, 601
Osteomalacia, 594
Osteo-myelitis, 580
Osteo-pyelitis, 580
Osteotrite, 584
Otitis, 681
Ovaries, dropsy of, 980
         treatment of, 980
Overlaying, 311
Oxygen, use of, in asphyxia, 311

Palate, fissures of, 715
Palmar arches,  wounds of, 181
Parotid, diseases of,  740
    duct, division of, 302
    tumors of,  740
Patella, dislocations of, 265
    fractures of, 231
    necrosis of, 593
Pelvic viscera, injuries of, 332
Pelvis, fractures of, 221
    injuries of,  325
    necrosis of, 592
Penis,  amputation of, 952
    cancer of, 951
    diseases of, 948
    herpes of, 951
    warts on, 951
Pericardium, tapping the, 765
Perineal  section, 890
Perineum, laceration of,  335
Periostitis, 579
    syphilitic, 450
Peritonitis, herniary, 784
    erysipelatous, 381
    traumatic, 332
Phagedena, 361
Pharyngotomy,  318
Pharynx, diseases of, 720
    scalds of, 316
Phlebitis, 467
Phymosis, 948
Piles, 835
    caustics in, 844
    operation for, 843
    treatment of, 841
Plasters, 114
Plaster of Paris bandage, in fractures, 191
Plastic surgery, 692
Pneumocele, 322
Pneumonia, traumatic, 320
Polypi, 394
    uterine, 979
        63
Polypi — continued.
    nasal, 684
Posthitis, 951
Paraphymosis, 950
    operation for, 950
Prepuce, disease of,  948
    hypertrophy of, 951
Pressure in hemorrhage, 155
Probang, for larynx, 725
Prolapsus ani, 845
    operation for, 847
Prostate, abscess of, 857
    cancer of, 865
    chronic, inflammation of, 858
    diseases of,  857
    hypertrophy of, 859
    inflammation of, 857
    section  of, in lithotomy, 915
    stone in, 933
    tumors  of, 859
Ptosis, operation for, 701
Purulent injections,  382
Pus, 92
    characters of, 94
    diagnosis of, 94
    within cranium, 277
Pyemia, 382
    causes of, 384
    changes of blood in,  384
    treatment of, 386
Pyrexia, 74

Rabies, 134
Radius, excision  of, 628
    fractures of, 218
    impacted fracture of, 218
Ranula, 707
Rectocele, 977
Rectum, cancer of, 828
    malformation of, 823
    stricture of,  825
Resection of bones, 620
    in necrosis, 592
Resections (see Excisions)
Respiration, artificial, 310
Rheumatism, gonorrheal, 875
Rhinoplasty, 694
Ribs, fractures of,  235
     necrosis of, 593
Rickets, 593
Rupture of abdominal  organs, 326
     of bladder, 332

Sacro-iliac disease, 645
Sacrum, fractures of, 222
Salivary fistula, 302
Sarcocele, 968
     cystic,  970
     malignant, 970
     strumous, 969
     syphilitic, 452
Sarcomatous tumors, 394
Saw, Butcher's, 623
     for necrosis, 591
Saws, amputating, 38
Scabbing, 111
Scalds, 335 
994

Scalds — continued.
    of pharynx, 316
Scalp, contusions of, 280
    excoriations of, 282
    extravasations  under, 281
    injuries of, 280
    wounds of, 280
Scapula, excision of, 625
    fractures of, 212
    lower end of, dislocated, 272
    necrosis of, 592
Scars, 101
Scirrhus,  400, 402
Scrofula,  418
    causes of, 422
     operations in,  425
    treatment of, 423
Scrotum,  cancer of, 953
     diseases of, 953
     erysipelas of, 377
     hypertrophy of, 953
     inflammatory oedema, 953
     tumors in, diagnosis of, 973
Serre-fine, 114
Sequestrum, 587
Setons, 85
Shock,  106
     chloroform in,  32
     after operations, 27
     treatment of, 107
Shoulder, amputation of, 52
     dislocations of, 249
     fractures about, 212
     joint, excision of, 622
Sinus, 348
Skin, cancer of, 462
     surgical diseases of, 456
     syphilitic diseases of, 446
Skin, tumors of, 458
     ulcers of, 458
Skull, base of, fracture of, 284
     concussion of, 282
     depressed fractures of, 286
     extravasation  within, 292
     fractures of, 282
          by contre-coup, 283
     injuries of, 282
     punctured fracture of, 286
     simple fracture of, 283
 Sloughing phagedaena,  361
 Sloughs,  separation of, 104
 Snake-bites, 132
 Sounding for stone, errors in,  909
 Sounds, 907
 Speculum ani, 829, 845
     vaginae, 975
 Spermatorrhea, 872
 Sphacelus, 352
 Spina bifida, 649
     ventosa, 599
 Spinal cord, divisions of, 297
     wounds of, 297
 Spine,  angular curvature of, 640
     caries of, 640
     concussion of, 296
     diseases of, 640
      dislocations of, 300
INDEX.

      Spine — continued.
          fractures of, 299
          injuries of, 296
          lateral curvature of  645
      Splints, use of, 194
      Sprains, 183, 236
      Squint, 667
      Staphyloraphy, 716
      Starch bandage, in fractures, 194
      Sternum, necrosis of, 592
      Stomach, rupture of, 326
      Stomatitis, 364
      Stone in bladder, 899
          causes of, 905
          encysted,  905
          in kidneys, 903
          operations for, 910
          in prostate, 933
          secondary, 945
          sounding  for,  907
          spontaneous rupture of, 904
          structure of, 902
          symptoms of,  906
          in urethra, 932
          in women, 946
      Strains, 183, 665
      Stricture, complications of, 891
          of urethra, 876
      Stumps, structure of, 40
          aneurisms of,  41
          conical, 41
          degeneration of, 42
          dressing of, 39
          fatty, 42
          malignant, 42
          morbid conditions of, 40
          necrosis of, 41
          neuralgic, 41
          secondary hemorrhage from, 173
          spasmodic, 41
          strumous, 42
      Styptics, 155
      Suppuration, 92
      Surgeon, responsibilities of, 28
      Sutures,  34, 113
          beaded, 114
          continuous, 114
          figure of, 34,  114
          interrupted, 114
          quilled, 114
          twisted, 114
          in wounded intestine, 331
      Symblepharon, operation for, 701
      Synovitis,  607
      Syphilides, 446
      Syphilis, 426
           of bones, 450
             throat, 449
           consecutive, 437
           constitutional, 440
           of hair, 447
           infantile, 453
           inoculation of, 427
           of iris, 451
             larynx, 450
           local secondary, 446
           mercury  in, 435-442 
INDEX.
995
Syphilis — continued.
    of muscles, 453
       nose, 450
    primary, 426
        treatment of, 431
    secondary, 440
        treatment of, 443
    simple treatment of, 432
    of skin, 446
       testis, 452
       tongue, 449
    in women, 430

Talipes calcaneo-valgus, 672
    calcaneus, 670
    equineo varus,  671
    equineus, 669
    varus, 670
    valgus, 672
Tapping the abdomen, 849
        chest, 705
        pericardium, 765
Tarsus, amputation through, 55
    caries of, 584
    dislocations of, 271
Taxis, 778
Tendo-achillis, ruptures of, 184
    division of, 669
Tendons, ruptures of, 183
Tenotome, 666
Tenotomy, 666
Testis, cancer of, 970
    cystic disease of, 970
    gonorrheal inflammation of, 872
    inflammation of, 955
         undescended, 95.7
    malposition of, 954
    neuralgia of, 954
    scrofulous, 969
    tumors of, 968
Tetanus, 575
    state of  nerves in, 577
Thigh, amputation of, 61
    fractures of, 222
Throat, injuries of, 305
    wounds  of, 305
Thumb, amputations of,  49
    dislocations of, 259
Thyroid gland, diseases of, 742
Toes, amputations of, 54
    excision of, 632
Tongue, abscess of, 703
    cancer of, 703
    diseases of, 702
    inflammation of, 702
    ligature of, 705
    operations on, 705
    prolapse of, 702
    psoriasis of, 703
    removal of, 706
    syphilitic tubercle of,  703
    tied,  702
Tonsil-guillotine, 719
    diseases of, 718
    removal of, 719
Torsion of arteries, 156
Torticollis, 668
Tourniquets, 154
Trachea tubes, 738
     forceps, 736
     hook, 735
Tracheotome, 736
Tracheotomy, 734
     difficulties in, 734
     and laryngotomy compared, 738
Transfusion, 142
Trephining of bone, 581
     in extravasated blood, 294
     in fracture of skull, 288
     operation of, 295
     for pus within cranium, 277
     results of, 296
Trochar for tapping chest, 765
     suction, 344
Tubercle, 421
     of  bone, 596
     subcutaneous, 574
Tumors, 387
     cartilaginous, 398
     encysted, 389
     fatty, 394
     fibro-cellular, 395
     fibro-plastic, 397
     fibrous, 396
     fibro-vascular, 458
     myeloid, 397
     non-malignant, 389
     operations for removal of, 416
     recurring fibroid,  397
     sarcomatous, 394
     varieties of, 388

Ulcer, healthy, 349
     hemorrhagic, 351
     indolent, 349
     inflamed, 350
     irritable, 350
     sloughing, 350
     varicose, 351
     varieties of, 349
     weak, 349
 Ulcers, 349
 Ulceration, 97
     treatment of, 102
 Uterus,  absence of,  976
 Ulna, excision of, 628
 Union by first intention, 111
     by second intention, 113
     ^f wounds, 35, 111
 Urethra, diseases of, 865
     laceration of, 334
     stricture of, 876
          treatment by caustics, 886
              by dilatation, 882
                 division, 886
     vascular tumors of, 899
     stone in, 932
 Urethritis,  865
 Urethroplasty, 896
 Urethrotomy, 887
 Urine, deposits in, 899
     extravasation of, 893
J     incontinence of, 856
     retention of, 855 
996
INDEX.
Urine — continued.
        from enlarged prostate, 862
        in stricture, 891
Uterus, cancer of, 979
    discharges from, 977
    displacements of, 979
    polypi of, 979
    tumors of, 979
    ulceration of, 978
Uvula, elongated, 717
    excision of,  719

Vagina, diseases of, 975
    imperforate, 976
    prolapsus of, 977
    walls of, 977
Varicocele, 965
    operations for, 967
    treatment of, 967
Varix, 469
    aneurismal, 168
    ligature of,  472
Veins, air in, cases of, 145
    canalization of, 145
    diseases of, 407
    entry of air into, 143
    treatment of air in, 146
    varicose, 469
    wounds of,  142
Vertebrae, dislocations of, 360
    fractures of, 299
Vulsellum scissors, 718
Warts, 393, 456
    venereal, 440, 448
Wens,  394
White  swelling, 617
Whitlow, 377
Wind contusions, 124
Wounds, 110
    arterio-venous, 168
    of arteries, treatment of, 164
    contused, 116
         amputation in, 119
         treatment of, 118
    dissection, 138
    dressing of, 34
    gunshot, 178
    incised, 110
         treatment of, 113
    lacerated, 116
    poisoned, 132
    punctured, 131
    union of, 35, 111
    of veins, 142
Windpipe,  operations in, 732
Wrist, amputation of, 50
    dislocations of, 257
     excision of, 027
    fractures near the, 218
Wry-neck, 668
Xanthine, 903
THE  END. 
 
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