THE 
PRINCIPLES AND PRACTICE 
OF. 
MODERN SURGERY. 
BY ROBERT DRUITT, 
SURGEON. 
" Id potissimum agdns, ut omissis hypothesibus, in praxi nihil adstruat quod multiplici experientia 
non sit roboratum." 
Act. Erud. Lips., 1722. 
FROM THE 
THIRD LONDON EDITION. 
ILLUSTRATED WITH ONE HUNDRED AND FIFTY-THREE WOOD 
ENGRAVINGS. 
WITH NOTES AND COMMENTS 
BY 
JOSHUA B. FLINT, M.D.-M.M. S.S., 
LATE PROFESSOR OF SURGERY IN THE MEDICAL INSTITUTE OF LOUISVILLE. 
PHILADELPHIA: 
LEA AND BLANCHARD. 
1844. Entered according to Act of Congress, in the year one thousand eight hundred 
and forty-two, by 
LEA AND BLANCHARD, 
in the Office of the Clerk of the District Court for the Eastern District of Penn- 
sylvania. 
T. K. & P. G Collins, Printers. TO 
CHARLES MAIO, ESQ., 
SENIOR SURGEON TO THE WINCHESTER HOSPITAL, 
IN ADMIRATION OF HIS SOUND JUDGMENT AND SKILL IN SURGERY, 
AND 
IN GRATEFUL ACKNOWLEDGMENT OF EARLY KINDNESS, yv 
THIS WORK 
IS DEDICATED BY HIS AFFECTIONATE NEPHEW 
AND OBEDIENT SERVANT, 
ROBERT DRUITT. 
6, Bruton Street, Berkeley Square, 
1st November, 1843. PREFACE TO THE FIRST AMERICAN EDITION. 
The American Editor of the present volume can claim but little 
participation in the merits of it beyond what is due to an early 
appreciation of the excellencies of Mr. Druitt's book, and an earnest 
and sucessful effort to procure its republication. Upon a thorough 
examination of it with a view to this undertaking, it appeared that 
its author had been so eminently successful in collecting and arrang- 
ing whatever could be introduced into such a work with advantage, 
as to forbid any aspirations for the honours of authorship to a revis- 
ing Editor, even in the humble offices of annotation and commentary, 
and he engaged in the enterprise, ambitious only to be instrumental 
in introducing to his profession in this country, and especially in 
the West, the best compend of the principles and practice of surgery 
extant. 
The only work of the kind, to be compared with it, is the admi- 
rable Dictionary of Mr. Samuel Cooper, and though a high com- 
pliment, it is not an undeserved one to this volume, to say that, in 
view of its final purpose and uses, it is, in many respects, entitled 
to a preference. Mr. Cooper's disquisitions-historical and specu- 
lative-on various subjects, though always learned, ingenious and 
interesting, are frequently too elaborate and discursive for a book 
of practical reference, and the substance of them may generally be 
found given in brief and comprehensive paragraphs, by Mr. Druitt, 
and accompanied by such ample bibliographical references as will 
enable the surgical student to prosecute his inquiries under the 
light of all the best guides and authorities which the science can 
supply. The systematic and methodical arrangement of topics in 
one volume, while it may be a little less convenient in a manual 
for the practitioner, than the alphabetical order of the "Dictionary," 
nevertheless contributes essentially to its excellencies as a text-book 
for the student. In this respect it will be found to answer an im- 
portant desideratum in the apparatus of teaching, and cannot fail 
to become a favourite as well with Professors of Surgery as with 
their pupils. 
A full course of surgical instruction, of which this should be an 
epitome or synopsis, would be as nearly a complete one, both in 
arrangement and matter, as the present state of the science and the 
didactic genius of the best teachers, could produce. 
The extensive circulation which such claims cannot fail to secure 
to a work of this kind, among the teachers and practitioners of our VI 
PREFACE TO THE FIRST AMERICAN EDITION. 
art, in this country, offered a tempting opportunity for the Editor 
to introduce to their notice such views and principles of practice, 
on the various surgical topics, as his own observation and reflection 
had contributed to establish and render favourite and important 
ones, in his own estimation. Among these results of his personal 
investigation are certain conclusions respecting the natural history 
of calculous affections, and the causes of their greater frequency on 
this than on the other side of the Alleghenies, which it would have 
been particularly agreeable to him to have communicated to the 
profession in this way, and which probably would have been inte- 
resting to most medical readers. But a fear of rendering the book 
too voluminous for its peculiar uses, inability to find a single chapter 
or section in the original which could be dispensed with, and, espe- 
cially, a reluctance to violate its rigid eclecticism determined him 
to abstain in the present reprint, from any such additions. 
A few brief notes of a practical character, the transposition of two 
or three sections, and the change of name, from " The Surgeon's 
Vade Mecum" to the one now substituted-comprise the only 
material alterations on which he has ventured. The latter altera- 
tion was made partly as a matter of taste, but chiefly upon con- 
siderations of significancy and pertinence. " Vade Mecum" is a 
title by no means expressive of the true character of this work-it 
indicates, indeed, the modesty of its author, but is far from com- 
porting with the real dignity and merit of his production. 
"The Principles and Practice of Modern Surgery" is 
certainly a significant title for a book which, like the present, is a 
faithful codification of the opinions and practice of Hunter, Pott, 
B. Gooch, Abernethy, the Bells, Physick, Dupuytren, Hennen, 
Macartney, Larrey, the Coopers, Scarpa, Lawrence, Liston, Guth- 
rie, Mayo, Brodie, Carmichael, Warren, Wardrop, Key, Travers, 
Dudley, Breschet, Tyrrell, Green, Dieffenbach, Civiale, Leroy, 
Arnott, Barton, Ricord, Colles, Stanley, and most of the other dis- 
tinguished surgeons who nave flourished since the commencement 
of the Hunterian epoch. Without any of the adventitious aids to 
which most publications of the present day owe their success-the 
previous heralding, and subsequent puffing which are usually in 
requisition at a literary debut-without the prestige of rank or 
official distinction on the part of its author, the " Vade Mecum" 
has secured an extraordinary popularity in Great Britain, and the 
most flattering commendations of medical critics. 
Such testimony to its intrinsic merits has encouraged its republi- 
cation here, and will bespeak for it a favourable reception among 
the practitioners of our country, to whom it is respectfully com- 
mended, by 
Their Friend and Brother, 
J. B. F. 
Louisville, April 51 h, 1842. PREFACE TO THE SECOND AMERICAN EDITION. 
If it were as much the fashion now, as it formerly was, to pro- 
pitiate the readers of a new book, and forestall a favourable judg- 
ment by complimentary and gracious appeals in the way of preface, 
I should be tempted to trespass on the privileges of private corre- 
spondence so far as to quote a paragraph or two from a letter of 
Mr. Druitt, indicative of his gratification at the republication of his 
work in the United States. 
But the encouraging considerations which have determined the 
Publishers to issue this second reprint, furnish the best of evidence 
that the author has already secured so extensive and favourable an 
acquaintance among the medical public of the United States, as to 
render all the usual forms of introduction quite superfluous. 
In his Preface to the present Edition, Mr. D. has noticed all the 
material alterations and additions which the work has received, and 
his readers will perceive that, although they are not considerable 
enough to affect its essential characteristics, they have, nevertheless, 
been the means of extending its practical details, and of rendering 
the information it contains more completely conformable to the 
actual position of Surgical Science and Art. In these changes they 
will, moreover, recognize the same extensive and exact acquaintance 
with the accomplishments and authorities of Modern Surgery, the 
same judicious eclecticism, and the same happy talent at didactic 
writing, which are so conspicuous in the entire composition of the 
volume. 
As the leading surgical authorities in the United States are, at 
present, in harmony with their distinguished British cotemporaries, 
and as the interval which has elapsed since the publication of our 
first Edition-although a period of most praiseworthy activity and 
enterprise in the profession-has produced no important American- 
isms which are sufficiently tested and sanctioned to claim a place 
among doctrines and practice so cautiously received as are the ma- 
terials of this work, the Editor has forborne to enlarge the present 
volume by any contributions beyond the insertion of a few brief 
notes; and again earnestly recommends it to his professional bre- 
thren as the best compend of sound surgery to be found in the 
English language. 
J. B. F. 
Louisville, March 8th, 1844. NOTICE OF THE AMERICAN PUBLISHERS. 
Prompted by the desire of rendering this work as use- 
ful as possible to the student, the American Publishers 
have furnished upwards of sixty wood-cuts not contained 
in the English edition; and which have been selected 
entirely for the illustration of subjects of practical import- 
ance,-principally, the surgical anatomy of hernia and the 
phenomena and treatment of fractures and dislocations. 
A few wood-cuts introduced into the third edition, and 
intended to illustrate pathological conditions, but which 
they necessarily did imperfectly, from not being coloured, 
have been omitted,-and some illustrations of the former 
editions, omitted by the author in the last, being con- 
sidered useful, have been retained in this. THE AUTHOR'S PREFACE. 
In bringing out a Third Edition of the present work, my first 
impulse is, to express my great satisfaction at the very favourable 
reception which this humble contribution to Surgical Literature has 
universally met with. The rapid sale of two large editions in 
England, and the republication of the work in America, lead me to 
believe that I have been successful in attaining the objects which I 
set before myself in writing it; those objects being to produce as 
complete a system as possible of Surgical Science and Practice, in 
the smallest practicable compass; to be biassed-where matters are 
disputed-neither by name, school, nor party; but to collect facts 
and opinions from every attainable source, to compare and weigh 
them carefully, and to state the result with conscientious impartiality; 
and lastly, to lay down no rules for practice which were not amply 
tested by experience, or which were without the recommendation 
of some sound British authority. 
The present edition is about fifty pages longer than its predeces- 
sor. But the additions are solely confined to the practical depart- 
ments, whilst those chapters which treat of theory, or pathological 
principles, are rendered somewhat shorter than before. 
With respect to the sources from which the materials are gathered, 
I may say that I have taken as a foundation those doctrines which 
the present generation has inherited from John Hunter, Pott, B. 
Gooch, J. Bell, and'the other great masters of the latter end of the 
last century. The main body of the work is supplied by the labours 
of Astley Cooper, Abernethy, Travers, Lawrence, Guthrie, 
and the other great surgeons of our own times; nor must the 
writings of Liston, Herbert Mayo,Samuel Cooper, Sir Charles 
Bell, nor the admirable course of Lectures delivered at King's 
College by Joseph Henry Green be omitted; but most deeply, 
indeed, am I indebted to Sir B. Brodie's masterly contributions to 
almost every department of Surgery. Reference has been made, 
also, on most points of Pathology, to the Dictionary of Dr. Copland, 
and the Lectures of Dr. Graves and Dr. Watson. And 
throughout the whole work I have been careful to avail myself of 
those researches by which the rising generation are endeavouring 
to clear away the obscurities left by their predecessors. In particular, 
the chemical doctrines of Liebig, and the modern theory of develop- X 
PREFACE. 
ment by cells, have received due notice, whenever they seemed to 
afford a sound and rational explanation of facts previously ascer- 
tained. 
The illustrations to this edition are entirely new, and I trust, will 
be considered as adding to its utility. The liberality of my pub- 
lishers enabled me to secure the services of that well-known artist, 
Mr. William Bagg; and, I can only say, that by his extensive 
experience in anatomical drawing, by the readiness with which he 
grasps the essential part of every illustration, and the fidelity with 
which he renders it, he yields as much of comfort and assistance to 
the author, as he does of ornament to his pages by the beauty of his 
delineations. 
In order to insure fidelity to nature, all the pathological illustra- 
tions in the followihg pages are taken from actual specimens; and 
I must express my greatful acknowledgments to the Professors of 
King's College for their permission to make use of the preparations 
in the admirable museum of that Institution. To Professor Part- 
ridge and Professor Fergusson my thanks are more particularly 
due, for their kindness in supplying me with various drawings and 
preparations from their private collections. My pages will be found 
to contain many references to the latter gentleman's excellent 
" Practical Surgery," in which I believe the art of operative surgery 
to be in most points carried to the highest possible pitch of simplicity 
and refinement. 
The plan on which the work is arranged may be Very briefly 
explained. Of the five parts into which it is divided, the first two 
are more especially devoted to the principles, and the three others 
to the practice, of surgery. The first part treats of certain disturb- 
ances of the constitution at large, that accompany or follow the 
various accidents and local diseases which the surgeon is called upon 
to treat; beginning with the simple faintness or collapse that follows 
a blow, and proceeding to consider the varieties of fever and tetanus. 
The second part describes what may be called the elements of 
local disease ; that is to say, the various changes which the compo- 
nent tissues of the body may undergo,-first from direct local injury; 
-secondly, through some change in the constitution of the blood, 
whether caused by defective nutrition, by the introduction of poi- 
sonous matter from without, or by the retention of particles that 
ought to have been discharged in the excretions;-thirdly, through 
influences exerted on the vitality of the tissues, on their nutrition, 
their transformations, and their other mysterious functions, by tem- 
perature, by mental affections, and by other causes whose operation 
is yet unexplained. These elementary morbid processes are de- 
scribed in the order which seemed most conducive to practical 
utility, without any attempt at philosophical arrangement. Simple 
inflammation, and its varieties, are described first, then in succes- 
sion the processes which are commonly called consequences of in- 
flammation ; and, lastly, those diseases such as cancer and scrofula, 
which depend on some peculiarity in the constitution, and are 
consequently termed specific. PREFACE. 
XI 
The third part treats of the various kinds of injuries, beginning 
with the simplest mechanical injuries: then proceeding to the effects 
of chemical agents, and lastly, considering the effects of animal 
poisons. With regard to the last-mentioned case of morbific agents, 
I may observe, that without a knowledge of hospital gangrene, 
dissection wounds, and glanders, no one can have very clear ideas 
on the subjects of infection and contagion, or of the action of those 
other morbid poisons, whose effects come within the so-called do- 
main of physic. 
The fourth part considers the various tissues, organs, and regions 
of the body in order, and describes the various accidents they are 
liable to, and such of their diseases as are commonly assigned to the 
care of the surgeon. 
The fifth part describes the amputations, the ligature of arteries, 
and such other operations as were not included in the former parts. 
To the whole is appended a collection of formulae, the number of 
which is very much increased in this edition. 
London, 1844. LIST OF WOOD CUTS. 
FIG. PAGE. 
1. Fibrine as seen under the microscope, ------ 58 
2. Pus globules as seen under the microscope, ----- 63 
3. Mucous pus as seen under the microscope, ----- 64 
4. Softening of the brain, showing the granules mixed with broken nerve 
tubes, ----------- - 65 
5. Roller bandage applied to foot and leg, ------ 87 
6. Miliary tubercle as seen under the microscope, - - • - - - 107 
7. Malignant growths, showing the granules and nucleated cells of which 
they are composed, - - - - - - - - -114 
8. Interrupted Suture, - -- -- -- -- - 123 
9. Twisted Suture, ---------- - ib. 
10. Quilled Suture, - -- -- -- -- -- 124 
11. Syphilitic caries of cranium, - -- -- -- - 204 
12. Apparatus for treatment of rupture of tendo-achillis, - - - - 216 
13. Ganglion formed by the synovial sheath of the flexor tendon of a finger, 218 
14. Chronic inflammation of bone, - -- -- -- - 223 
15. Abscess of bone, ---------- 224 
16. Necrosis, - -- -- -- -- -- - 225 
17, 18. Caries, 226 
19. Osteo-sarcoma of femur, - -- -- -- -- 228 
20. Fractured bone, united, - -- -- -- -- 230 
21. Bandage for fracture of the lower jaw, ------ 236 
22. Stellate or figure of 8 bandage for fracture of clavicle, - - - 238 
23. Clavicle bandage, ---------- ib. 
24. Fracture of neck of scapula, - -- -- -- - 239 
25. Fracture of Acromion, --------- ib. 
26. Fracture of surgical neck of the humerus, ------ 240 XIV 
LIST OF WOOD CUTS. 
FIG. PAGE. 
27. Fracture of surgical neck of the humerus united, - - - - 241 
28. Fracture of the head of the humerus, with dislocation forwards, under 
the pectoral muscle, ib. 
29. Fracture of the lower extremity of the humerus, - - - 242 
30. Fracture of the internal condyle of the humerus, - - - ~ ib. 
31. Fracture of the external condyle of the humerus, ... - ib. 
32. Fracture of the external condyle of the humerus within the capsular 
ligament, ib. 
33. Fracture of the olecranon, 243 
34. Fracture of coronoid process of ulna, ------- 244 
35. Fracture of lower extremity of radius, 245 
36. Fracture and dislocation of bones of the pelvis, .... 247 
37. Descent of the neck of the thigh-bone in advanced life, - 248 
38. Changes incident to the neck of the thigh-bone in old age, and which 
might be mistaken for united fracture, ------ ib. 
39, 40. Fracture of neck of the thigh-bone internal to the capsule, - - 249 
41. Do. do. do. external to capsule, - - - 251 
42. Liston's splint for fracture of femur, 252 
43. Apparatus for fracture of neck of femur applied, .... ib. 
44, 45. Oblique fracture through the great trochanter, .... 253 
46. Fracture of the femur just below the trochanters, showing the extreme 
shortening and hideous projection forwards, which is the conse- 
quence of ill treatment, - ib. 
47. Fracture of the shaft of the femur, showing the influence of the psoas 
and iliacus in tilting the upper fragment forwards, ... 254 
48. Fracture of the condyles of the femur into the knee-joint, ... 255 
49. Bandage for fractured patella, - - - ib. 
50. Fractured patella, ligamentous union, 256 
51. Tailed bandage for fracture of the leg, ib. 
52. Macintyre's leg splint for fractured leg, 257 
53. The same applied, ib. 
54. Dupuytren's splint and bandage for fracture of internal malleolus, - 258 
55. Disease of the hip-joint, 270 
56. Disease of the hip-joint, advanced to a destruction of the acetabulum 
and capsular ligament, and dislocation of the bone upwards, - ib. 
57. Dislocation of the jaw, 274 LIST OF WOOD CUTS. 
XV 
FIG. PAGE. 
58. Dislocation of the sternal extremity of the clavicle, and dislocation for- 
wards of the shoulder-joint on the left side ; and dislocation of the 
acrominal end of the clavicle with dislocation of the shoulder down- 
wards on the right side, - ib. 
59, 60. Dislocation of the humerus into the axilla, ..... 275 
61, 62. Dislocation of the humerus forwards, 276 
63. Dislocation of humerus upon the dorsum scapulse, .... 277 
64. do. do. do. do. ib. 
65. Partial dislocation of the humerus upwards, ib. 
66. Method of reducing luxation of the humerus into the axilla, by pulleys, 278 
67. do. do. do. by the heel in the axilla, - ib. 
68. do. do. do. by the method of Mr. White, 279 
69. do. do. do. by the knee in the axilla, . ib. 
70, 71. Dislocation of elbow-both bones of forearm backwards, - - 281 
72, 73. Dislocation of ulna alone backwards, ...... ib. 
74. Dislocation of the radius alone forwards, ...... 282 
75. Dislocation of the radius backwards, ....... ib. 
76. Dislocation of the first phalanx of the forefinger; with a piece of tape 
fastened with the clove hitch to efiect extension, .... 283 
77. Dislocation of the hip-joint upwards on the dorsum ilii, ... 284 
78. Method of reducing the above, - 285 
79, 80. Dislocation of the hip-joint backwards, ib. 
81. Method of reducing the above, 286 
82. Dislocation of hip-joint downwards, 287 
83. Method of reducing the above, ........ ib. 
84, 85. Dislocation of the hip-joint upwards and forwards, ... 288 
86. Method of reducing the above, ib. 
87. Dislocation of the femur upwards on the space between the anterior 
spinous processes of the ilium, 289 
88. Dislocation of the knee, 290 
89. Dislocation of ankle inwards, with fracture of the lower end of fibula - 291 
90. Simple dislocation of the tibia forwards, ...... ib. 
91. Partial dislocation at the ankle-joint, the end of the tibia resting in part 
upon the astragalus, but a larger portion of its surface resting on 
the os naviculare, (see Cooper on Dislocations, p. 13, Phila. 1844.) ib. 
92. Simple dislocation of the astragalus, ....... 293 XVI 
LIST OF WOOD CUTS. 
FIG. PAGE. 
93. Aneurismal varix, - - • - - - - - - 304 
94. Varicose aneurism, 305 
25. Aneurism by anastomosis, - - ib. 
96. Method of extirpating erectile tumours by ligature, .... 307 
97. Twisted suture, for cure of varicose veins, - - - - - 311 
98. Angular curvature of the spine from caries of the bodies of the verte- 
bras, 330 
99,100. Dislocation and fracture of the vertebrae, 331 
101. Treatment of fistula lachrymalis by the stile, 339 
102. Healing stage of ulcer of the cornea, ------- 347 
103. Nodules of lymph effused in syphilitic iritis, 351 
104. Extraction of cataract, --------- 35g 
105. Operation for strabismus, 371 
106. Nasal polypus, 381 
107. Perforation of the antrum with a trocar for abscess of that cavity, - 383 
109. Hare-lip, - 397 
110. Fissure of the palate, 388 
111. Forceps for extracting teeth of upper jaw, 396 
112. Forceps for extracting teeth of lower jaw, - - - ib. 
113. Key for extracting teeth, - - - - - - - - 397 
114. Conical curved tube for trachea, 407 
115. Bronchocele, - - - - 410 
116. Dupuytren's forceps for strangulating the septum in artificial anus, - 426 
117. Common oblique inguinal hernia, 436 
118. Direct inguinal hernia, - - - 437 
119. Congenital omental hernia, 438 
120. Hernia infantilis, showing its two sacs, 438 
121. Variety of hernia infantilis, in which the sac is apparently formed of 
tunica vaginalis, but its communication with the testicle closed, - 438 
122. Inguinal hernia, 439 
123, 124. Surgical anatomy of femoral or crural hernia, - - - - 442 
125. Obturator or thyroid hernia, 446 
126. Section of a prolapsed rectum-the whole substance of the bowel 
everted and coming down, - - 454 
127. Puncture of bladder by the rectum, ------- 459 
128. Stricture of the urethra, 460 LIST OF WOOD CUTS. 
XVII 
FIG. PAGE. 
129. Enlarged Prostate, catheter in the urethra, 468 
130, 131, 132. Weiss's screw lithotrite, 488 
133. Lateral operation of lithotomy, - - 491 
134. Diagram exhibiting an internal view of the parts of the neck of the 
bladder concerned in lithotomy, 493 
135. Paraphymosis, - 497 
136. Talipes equinus, - - 512 
137. Talipes varus, 512 
138, 139. Parts concerned in venesection at the elbow, showing the veins at 
the bend of the elbow, and the relation of the brachial artery to 
the median basilic vein, and the nerves, 521 
140. Tourniquet, 526 
141. Amputation of the thigh,-flap operation, 529 
142. Amputation of the leg,-flap operation, 531 
143. Amputation of the arm, circular method, ...... 531 
144. Amputation of the forearm,-flap method, 533 
145. Amputation of the wrist, 533 
146. Amputation of the finger at the last joint, 534 
147. Amputation of the finger at the metacarpal joint, .... 535 
148. Amputation of the head of a metacarpal bone, 536 
149. Amputation through the tarsus,-Chopart's operation, ... 538 
150. Ligature of common carotid, 542 
151. Surgical anatomy of the arteries of the forearm and palm of the hand, 545 
152. Surgical anatomy of the femoral artery, 547 
153. Surgical anatomy of the posterior tibial artery, 549 
154. Surgical anatomy of the anterior tibial artery, 550 CONTENTS. 
PART I. 
OF THE CONSTITUTIONAL EFFECTS OF LOCAL INJURY AND DISEASE. 
CHAP. PAGE. 
I. Of Prostration or Collapse - - - . - - 17 
II. Of Prostration with Excitement - - - - - 20 
III. Of Fever ------- - 21* 
Sect. 1. Of Fever generally - - - - - 21 
2. Of Inflammatory Fever - 22 
3. Of Irritative Fever - - - - - 27 
4. Of Hectic Fever ----- 27 
5. Of Typhoid Fever - - - - - 29 
IV. Of Tetanus - -- -- -- 31 
PART II. 
OF THE PRINCIPAL PROCESSES OF LOCAL DISEASE. 
I. Of the General Phenomena of Inflammation - - - 41 
II. Of Acute Inflammation ------ 48 
III. Of Chronic Inflammation . - - - - - - 54 
IV. Of Effusion of Serum ------ 57 
V. Of Adhesion or the production of New Tissues - - - 58 
VI. Of Hsemorrhage ------ - 61 
VII. Of Suppuration and Abscess - - - - - 62 
Sect. 1. Of the Theory of Suppuration and Properties of Pus 62 
2. Of Acute Abscess - - - - - 67 
3. Of Chronic Abscess ----- 71 
VIII. Of Erysipelas and diffuse Inflammation of the Cellular Tissue - 74 
Sect. 1. Pathology of Erysipelatous Inflammation - - 74 
2. Of the Cutaneous and Cellulo-Cutaneous Erysipelas - 75 
3. Erysipelatous or Diffuse Inflammation of the Cellular 
Tissue -------80 XX 
CONTENTS. 
CHAP. PAGE. 
IX. Of Ulceration ------- 81 
Sect. 1. Of the Pathology of Ulceration - - - - 81 
2. Of the Varieties of Ulcers ... - 84 
X. Of Mortification - -- -- --97 
Sect. 1. Of the Pathology of Mortification ... 97 
2. Of the Symptoms and Treatment - - - 99 
XI. Of Scrofula 104 
XII. Of Malignant Diseases - - - - - -113 
Sect. 1. Introductory - - - - - - 113 
2. Of Scirrhus, or Carcinoma Simplex ... 115 
3. Of Medullary Sarcoma, and Fungus Haematodes - 191 
4. Of Gelatiniform Cancer, Melanosis, and other rarer va- 
rieties of Malignant Disease - - - 120 
PART III. 
OF THE DIFFERENT SPECIES OF INJURIES. 
I. Of Incised Wounds ------- 122 
II. Of Punctured Wounds ------ 125 
III. Of Lacerations and Contusions - - - - - 126 
Sect. 1. Of Contusion and Ecchymosis ... 126 
2. Of Lacerated and Contused Wounds - 129 
IV. Of Gunshot Wounds ------ 130 
V. Of the Effects of Heat, Burns, and Scalds - - - - 141 
VI. Of the Effects of Cold 148 
VII. Of the Effects of Mineral and Vegetable Irritants - - - 151 
VIII. Of the Effects of the Poison of Healthy Animals, and of the Treat- 
ment of Poisoned Wounds generally - - - - 153 
IX. Of the Poisons contained in Dead Human Bodies, and of Dissection 
Wounds 158 
Sect. 1. Of the Poison contained in Dead Bodies, and of the Influ- 
ence of Dissection on the Health - - - 158 
2. Of Dissection Wounds .... 160 
X. On the effects of Poisons generated by Diseased Animals - - 166 
, Sect. 1. Of Hydrophobia ----- 166 
2. Of the Glanders ------ 174 
XI. Of the Venereal Disease - - - - - 177 
Sect. 1. Of its general History and Pathology - - - 177 
2. Of Gonorrhoea ..... 182 
3. Of Primary Syphilitic Ulcers .... 191 
4. Of the Diagnosis of Chancre, and of the Affections that 
may be mistaken for it ... - - 194 CONTENTS. 
XXI 
CHAP. . PAGE. 
5. Of the Treatment of Primary Syphilis - - 195 
6. Of Bubo ....... 200 
7. Of Secondary Syphilis .... 202 
PART IV. 
OF INJURIES AND SURGICAL DISEASES OF VARIOUS TISSUES, ORGANS, AND REGIONS. 
I. Of the Diseases of the Cellular Tissue .... 207 
Sect. 1. Carbuncle and Boil ----- 207 
2. Tumours - - ... - 208 
II. Of the Surgical Diseases of the Skin - - - - 210 
III. Of Diseases and Injury of Muscles, Tendons, and Bursse - 214 
IV. Of the Diseases and Injuries of the Lymphatics - - 219 
V. Of the Diseases and Injuries of Bone - - - - 221 
Sect. 1. Of the Diseases ----- 221 
2. Of Fracture generally ----- 229 
3. Of Non-union and False Joint - - - 233 
4. Of Compound Fracture ----- 234 
5. Of Particular Fractures ... - 236 
VI. Of the Diseases and Injuries of the Joints ... - 259 
Sect. 1. Of the Diseases of the Synovial Membrane - - 259 
2. Inflammation of the Cellular Tissue ... 263 
3. The Ligaments - 264 
4. The Cartilage ------ 264 
5. Articular Caries ----- 266 
6. Anchylosis ------ 268 
7. Of Disease of the Hip-Joint - - - - 269 
8. Wounds of Joints ----- 272 
9. Of Dislocation generally - - - - 272 
10. Of particular Dislocations - 274 
VII. Of Injuries and Diseases of arteries - 293 
Sect. 1. Of Wounds of Arteries ----- 293 
2. Of Inflammation of Arteries - - - 299 
3. Of Aneurism ------ 300 
4. Of Aneurism by Anastomosis and Ncevus - - 305 
VIII. Of Injuries and Diseases of Veins ----- 308 
IX. Of Injuries and Diseases of the Nerves - - - - 312 
X. Of Injuries of the Head ------ 317 
Sect. 1. Wounds of the Scalp - 317 
2. Concussion of the Brain - - - - 317 
3. Compression from Extravasated Blood - - 319 
4. Fractures of the Skull - - - - - 321 XXII 
CONTENTS. 
CHAP. PAGE. 
5. Wounds of the Brain, Hernia Cerebri, &c. - - 323 
6. .Inflammation of the Brain .... 324 
7. Trephining and Paracentesis ... 326 
XI. Of the Diseases and Injuries of the Spine - 327 
XII. Of the Injuries and Diseases of the Eye ... 334 
Sect. 1. Of Wounds and Foreign Bodies - - - - 334 
2. Diseases of the Eyelids .... 335 
3. Diseases of the Lachrymal Apparatus ... 338 
4. Of Inflammation of the Eye generally, and of the Dis- 
eases of the Conjunctiva .... 340 
5. Of the Diseases of the Cornea ... 346 
6. Diseases of the Sclerotic - - - • - 349 
7. Inflammation of the Anterior Chamber, or Aquo-Cap- 
sulitis 350 
8. Of the Diseases of the Iris .... 350 
9. Inflammation of the Capsule of the Crystalline Lens - 354 
10. Of Cataract ------ 354 
11. Of Glaucoma - - - - - - 361 
12. Of the Diseases of the Choroid; and of Synchysis and 
Hydrophthalmia ..... 362 
13. Of Retinitis 364 
14. Of Amaurosis ...... 364 
15. Of Short and Long Sight .... 368 
16. Of Squinting ...... 369 
17. Of Malignant Diseases of the Eye - - 372 
XIII. Of the Diseases and Injuries of the Ear .... 374 
XIV. Of the Diseases and Injuries of the Face, Nose, Palate, Lips, Mouth, 
Tongue, and Teeth ------ 379 
XV. Of the Surgical Diseases and Injuries of the Neck, CEsophagus, and 
Trachea ------- 401 
XVI. Of the Surgical Diseases and Injuries of the Chest - - 415 
XVII. Of the Surgical Diseases and Injuries of the Abdomen - - 419 
XVIII. Of Hernia - - - - - - - 426 
Sect. 1. Of the Nature and Causes of Hernia generally - - 426 
2. Of the Reducible Hernia - 428 
3. Of the Irreducible Hernia .... 430 
4. Of Strangulated Hernia ... - 431 
5. Of Inguinal Hernia ..... 436 
6. Of Femoral or Crural Hernia - - - 442 
7. Of the Umbilical, Ventral, and other remaining Species 
of Hernia .-...- 444 
XIX. Of the Surgical Diseases and Injuries of the Rectum and Anus - 446 CONTENTS. 
XXIII 
CHAP. PAGE. 
XX. Of the Diseases of the Urinary Organs - - - - 457 
Sect. 1. Of Spasmodic Stricture of the Male Urethra - - 457 
2. Of Permanent Stricture .... 460 
3. Of Urinary Abscess, Extravasation of Urine, and Fistula 
in Perinseo ----.. 464 
4. Of some other Affections of the Male Urethra - - 466 
5. Of the Diseases of the Prostate ... 467 
6. Of the Diseases of the Bladder - . - - 469 
7. Of Disease of the Kidneys, Hematuria, and Suppression 
of Urine ------ 473 
8. Of Urinary Deposits and Gravel; and of the Diathesis, 
or States of the Constitution which give rise to them - 476 
9. Of the various kinds of Calculi ... 482 
10. Of Stone in the Kidney and Ureter ... 433 
11. Of Stone in the Bladder .... 484 
12. Of Lithotrity - - - - - -486 
13. Of Lithotomy ...... 490 
XXL Of the Diseases of the Male Genitals .... 496 
Sect. I. Of the Diseases of the Penis - - - - 496 
2. Of the Diseases of the Testis and Scrotum - - 497 
3. Of Impotence ..... 505 
XXII. Of the Surgical Diseases of Female Genitals - - - - 506 
XXIII. Of the Diseases of the Breast ..... 508 
XXIV. Of Clubfoot, Bunion, Whitlow, contracted Joints, and other Affec- 
tions of the Extremities ----- 512 
PART V. 
OF THE OPERATIONS OF SURGERY. 
I. Of Operations in genera), and of the Extirpation of Tumours - 518 
II. Of the Minor Operations ..... 520 
III. Of the Amputations ------- 525 
IV. Of the Ligature of Arteries - - - - - 541 
Appendix of Formula ....... 551 
Index - - - - - - - - - 561 THE 
PRINCIPLES AND PRACTICE 
OF 
MODERN SURGERY. 
PART I. 
OF THE CONSTITUTIONAL EFFECTS OF LOCAL INJURY 
AND DISEASE. 
CHAPTER I. 
OF PROSTRATION OR COLLAPSE * 
Definition.-As the most proper commencement of a systematic 
treatise on Surgery, we shall begin by describing a state commonly 
known as prostration, or collapse., or shock to the nervous system; 
by which terms we signify that general depression of the powers 
and actions of life, which immediately follows any severe injury. 
Symptoms.-The usual symptoms are, that the patient lies cold, 
shivering, and half-unconscious; with a feeble pulse, and imperfect 
sighing respiration. But these symptoms are liable to great variety; 
for they may not only differ in degree, but the principal functions 
may be unequally disordered in different cases. Sometimes depres- 
sion of the vascular system predominates, and the patient lies in a 
state of perfect syncope, with the pulse and respiration impercepti- 
ble. Sometimes the nervous system is chiefly affected, the patient 
being bewildered and incoherent, as though intoxicated; or even 
comatose, as though he had taken a narcotic poison. Nausea and 
vomiting; hiccup; suppression of urine; and in children, convul- 
sions, are also very frequent symptoms. 
The duration of these symptoms is also extremely various. 
Sometimes they pass off very quickly; but they may remain even 
for forty-eight hours before reaction is thoroughly established. 
* The principal authorities to be consulted on the subjects of the first and second 
chapters, are Travers on Constitutional Irritation, third edition, and Hunter on the 
Blood, chap. ii. 18 
PROSTRATION OR COLLAPSE. 
Terminations.-The process of recovery from collapse is com- 
monly called reaction; and the manner in which the case may 
terminate must depend on the nature and degree of that reaction. 
Thus, 
First, if it is healthy and moderate, and especially if the collapse 
arise merely from concussion (or violent shaking) of an organ, with- 
out actual injury to its structure, it will lead to complete recovery. 
Thus it very often happens that a slight blow on the testicle or sto- 
mach causes an extreme degree of sickness and faintness, which, 
however, pass off gradually, and leave no ill consequences.* 
Secondly. If reaction be excessive, the state of collapse will be 
gradually succeeded by fever, symptomatic of the inflammation to 
which the local injury has given origin. 
Thirdly. If reaction be imperfectly developed, it will be con- 
verted into the state of prostration with excitement, of which we 
shall speak in the next chapter. 
Fourthly. If reaction be altogether wanting, the collapse will 
terminate in death. And death may occur immediately on the 
receipt of the injury, if it be of extreme severity; or otherwise the 
patient may die more slowly, the pulse at the wrist becoming 
fainter, and finally ceasing; and the respiration more and more slow 
and oppressed, till life is gradually extinguished. 
Causes.-These symptoms may be caused by every variety of 
injury to which the body is liable. Great and sudden extremes of 
grief, or joy, or fear, or cold;-large doses of any active poison, such 
as arsenic, or sulphuric acid, or tobacco;-the sudden impression of 
miasmata, or of morbid poisons, as the plague;-great loss of blood, 
and mechanical injuries. It is most important that the surgeon 
should know what injuries are most likely to be followed by fatal 
collapse, in order that he may have proper materials for giving his 
prognosis. They are, 
First, those of organs that are necessary to life, as the stomach 
and brain; and it is well known that a severe concussion of either 
of these organs may extinguish life instantaneously. 
Secondly. Injuries of organs which do not easily admit of repara- 
tion ; as the joints. 
Thirdly. Injuries that are severe in their nature ; as punctured, 
lacerated, contused, and especially gunshot, wounds. 
Fourthly. Injuries of great extent, although they may be trivial 
in degree;-as extensive burns. 
Lastly. Injuries occurring to young infants, or to the very aged ; 
or to constitutions that are enfeebled by excess and intemperance,! 
or by long-standing bodily disease, or mental depression. From this 
it will be learned that the slightest injury or surgical operation may 
* A case has lately been published in the Medical Journals, in which a man had 
his testicles crushed during some barbarous sports, and the shock to the nervous 
system was so great as to be speedily mortal. 
f Those who always live above par, says Hunter, are extremely liable to sink 
when attacked by disease or injury; for, as they are habitually at the full stretch 
of living, their powers cannot be excited further to meet any casual emergency. 
-On the Blood, chap. ii. sect. 1. PROSTRATION OR COLLAPSE. 
19 
prove fatal to persons who labour under chronic organic disease, 
such as tubercles in the liver or lungs, or disease of the kidneys, or 
who have been harassed by continued anxiety and despondency of 
mind; so that in almost any case a firm persuasion that recovery is 
impossible is almost sufficient to render it so. 
Treatment.-The indication is, to excite the vital organs to a 
moderate and healthy reaction. If the patient is shivering, with 
cold skin and feeble pulse, diffusive stimulants should be adminis- 
tered, such as hot brandy and water, aether, and ammonia; and 
heated bricks, or bottles of hot water, should be put under the 
axillae, and between the thighs, and the patient should be covered 
warmly till the circulation is restored, and the pulse has acquired 
permanent strength and firmness. Vomiting may be allayed by a 
large dose of solid opium (gr. ii.-iii.), or by a large dose of calomel 
(gr. v.) and opium (gr. ii.); or by an opiate enema (vide Formula 
48) if the bowels are relaxed, or an aperient enema, especially of 
turpentine (F. 49), if they are confined; or by effervescent draughts, 
containing one or two minims of diluted hydrocyanic acid, with ten 
of Battley's sedative, every hour. Counter-irritation to the epigas- 
trium, by means of very hot water, or a mustard poultice (F. 44), 
is also highly useful.-Hiccup may be relieved by a teaspoonful of 
sp. aetheris comp., or by sipping very frequently gruel, or some other 
bland fluid, and keeping very silent and quiet.-Convulsions, de- 
lirium, and coma, are to be treated according to the state of the 
circulation; by ammonia and stimulants whilst it is depressed, but 
by a very cautious bleeding, or leeching, or purging, or application 
of cold to the head, if they remain after the circulation is restored, 
and the pulse has become firm.-One remedy that it might be well 
worth while to try in an extreme case, is the wrapping a patient in 
the skin of a sheep, or of any other animal, stripped off immediately 
after its death. Baron Larrey had seen this done by certain humane 
Esquimaux, with the greatest benefit, to some shipwrecked French- 
men that were half dead with cold, fatigue, and hunger; and he 
put it in practice with equal success in the case of Marshal Lannes, 
Duc de Montebello, when he was dangerously bruised by a fall 
from his horse during one of Napoleon's Spanish campaigns. 
Cautions.-Care must be taken on the one hand to continue the 
use of stimulants long enough, and to desist from them gradually 
if there is any fear that the collapse may return; and, on the other, 
not to carry them too far-for if the action of the heart is excited 
beyond its powers, it will be more liable to be permanently ex- 
hausted. Besides, if the patient be over stimulated, the succeeding 
fever and inflammation from the injury will be aggravated; and 
the danger of haemorrhage will be increased from any blood-vessels 
that may have been ruptured. Finally, the vulgar and mischievous 
habit of bleeding patients immediately after an injury, before they 
have recovered from a state of faintness and depression, needs only 
to be mentioned to be condemned. 20 
PROSTRATION WITH EXCITEMENT. 
CHAPTER IL 
OF PROSTRATION WITH EXCITEMENT, AND DELIRIUM TRAU- 
MATICUM. 
Definition.-" Prostration with excitement and excessive reac- 
tion," is the term used by Mr. Travers to signify a state which 
sometimes follows the collapse from a severe injury; in which there 
is a violent but transient excitement of the nervous; and vascular 
systems, without the development of that more permanent and 
sthenic action which constitutes inflammatory fever. 
Symptoms.-The symptoms vary extremely in different cases, 
although they present the uniform character of extreme and ex- 
hausting excitement, without genuine febrile action. There is great 
anxiety about the region of the heart: the respiration is oppressed 
and sighing; the pulse exceedingly rapid and bounding, but soft 
and compressible; the face is flushed, and there is vomiting. But, 
in the majority of these cases, the principal feature is the excite- 
ment of the nervous system, which is manifested by a peculiar de- 
lirium [delirium traumaticum) precisely similar to the delirium 
tremens* The tongue is moist and tremulous; there is a general 
tremor of the muscles; the patient is totally sleepless, irritable in his 
temper, answers questions in a snappish, or peevish, or incoherent 
manner; is often anxious to call himself perfectly well; and as the 
malady increases he becomes restless, impatient, and talkative; 
wishes, perhaps, to get out of bed, and attempts to injure his attend- 
ants, and soon becomes most furiously maniacal. In some cases, 
however, the delirium is of a milder cast; the patient is haunted 
with extravagant ideas and spectral illusions; or fancies himself 
busied in his ordinary avocations, and talks perpetually about them. 
Terminations.-The prognosis will be the more unfavourable 
in proportion as the excitement is violent, as it cannot fail to lead to 
exhaustion; the pulse becoming irregular, the aspect livid and hag- 
gard, the extremities cold, and coma supervening, which is soon 
followed by death. There, will be some hope, however, if the 
pulse becomes more tranquil and firm, and especially if the patient 
sleeps. 
Causes.-The exciting causes of this state are (surgically con- 
sidered) the various mechanical injuries enumerated in the last 
chapter;-acting on constitutions that are weak, and consequently 
irritable;t that have "an increased disposition to act, without the 
power to act with." Some examples of it occur in children, espe- 
cially after burns ; but they are most frequently met with in the case 
of persons of middle age and plethoric habit, who habitually in- 
* Copland's Diet. Pract. Med. Art. Delirium with Tremor, 
f Omne infirmum, natura querulum. 21 
FEVER. 
dulge in excess of food and spirituous liquors, and who, as is well 
known, often die from many injuries and accidents, which more 
temperate persons might have recovered from without difficulty. 
Treatment.-The indications are to moderate the excitement 
and support the strength. If there be violent delirium, with heat 
and dryness of skin, and the pulse very sharp, the scalp should be 
shaved and kept wet with evaporating lotions; the bowels should 
be evacuated with a dose of calomel combined with camphor, fol- 
lowed by an aperient draught, or by enemata if there be much 
vomiting; taking care, however, not to purge so freely as to reduce 
the strength. At the same time hyoscyamus should be given in 
moderate doses every hour or two; such as gr. v. of the extract or 
nq xxx of the tincture-and, if these means fail, one large dose (gr. 
ii.-iii.) of solid opium, or xl.-lx. of Battley's solution, may be 
given after the bowels are opened. If, however, there be greater 
debility and restlessness, opium/'may be given in small doses, (gr. 
4-J 2nda, vel. 3tia, quaque hora,) carefully watching its effects, and 
giving it up if it seem rather to augment cerebral excitement, or to 
induce coma. Enemata containing 5 ss of laudanum may be pre- 
ferable in some cases; orrcombinations of camphor and henbane, 
with musk and anti-spasmodics. The strength should be carefully 
supported by beef-lea, arrow-root, &c.: and if the patient have been 
accustomed to ardent spirits or opium, they may often be allowed 
with great advantage in considerable quantity. The patient must 
be carefully watched, in order to prevent injury to himself or others; 
^and he should be treated with calmness and indulgence, but yet 
'with firmness. In the last stage, when coma supervenes, counter- 
drritation by means of sinapisms or blisters to the scalp, or feet, or 
halves of the legs, may be tried, but scarcely any means will avail. 
CHAPTER III. 
OF FEVER. 
SECTION I. OF FEVER GENERALLY. 
General Description.-Fever may be described as a state in 
which all, or most of the functions of the body are deranged. The 
nervous system is shown to be deranged, by the headache, pain 
in the back, lassitude, muscular weakness, mental torpor, and con- 
fusion of the senses. Chilliness and burning heat testify to disorder 
of the process by which animal heat is produced or regulated. Re- 
spiration and circulation are either slow and embarrassed, or per- 
formed with preternatural frequency and force. Digestion and nutri- 22 
INFLAMMATORY FEVER. 
tion are suspended; hence the rapid emaciation. The secretions 
are either deficient, or, if abundant, are depraved; hence the thirst, 
dry skin, scanty urine, and costiveness or diarrhoea. Moreover, 
the fluids have a tendency to be vitiated, and the solids to be dis- 
eased, as shown by congestion and effusion in either of the three 
great cavities. 
Fevers are often divided into two grand families; the idiopathic 
and the symptomatic. The former arise from agents operating on 
the blood or nervous system; ague and typhus are examples. The 
latter are called symptomatic, because produced by disease or in- 
jury of some part. It is with these that the surgeon has to deal; 
and there are the following varieties, which we shall treat of suc- 
cessively : 
(1.) If there be acute inflammation in a healthy system, the fever 
will be inflammatory, which is commonly called symptomatic 
fever. (2.) If there be acute inflammation in a weakened or ca- 
chectic system,-or if the inflammation arise from certain specific 
causes of a depressing tendency, such as morbid poisons,-or if it 
attack certain structures, as the veins;-the fever is generally called 
irritative. (3.) If the inflammation have terminated in an ex- 
hausting suppuration, or if there be a permanent disease, which the 
constitution has no power to vanquish, hectic fever will be estab- 
lished. (4.) When the vital powers are entirely exhausted, the 
fever assumes what is called a typhoid type ; which, in the empha- 
tic language of Hunter, is termed dissolution. (5.) Lastly, fever, 
even when arising from a local cause that is permanent, may be 
intermittent; that is, may occur in definite paroxysms, with inter- 
vals of health, like ague fits. This is often the case in diseases of 
the urinary organs, such as strictures and fistulae in perinseo: and 
sometimes in worms and other states of irritation of the intestines. 
SECTION II. OF INFLAMMATORY FEVER. 
Syn.-Synocha, Cullen. 
General Description.-This fever accompanies every acute 
inflammation which arises from a severe or considerable injury, or 
which affects parts of great sensibility and importance in healthy 
subjects. And it is almost a natural concomitant. "Nature," says 
Hunter, "requires to feel the injury; for where after a considerable 
operation there is rather a weak, quiet pulse, often with a nervous 
oppression, with a seeming difficulty of breathing and loathing of 
food, the patient is in a dangerous way. Fever shows powers of 
resistance; the other symptoms show weakness, sinking under the 
injury."* 
Symptoms.-Shivering; succeeded by increased heat;t preterna- 
• On the Blood. Chap. iv. sect. 6. 
f The increased heat of fever depends, according to Liebig, on an unnaturally 
rapid transformation and oxydation of the animal tissues, by which an unnatural INFLAMMATORY FEVER. 
23 
turally frequent, hard, and vibratory pulse;-pain and aching in 
the head, back, and limbs, with a sense of lassitude and weakness; 
-general deficiency of the secretions; dry skin; dry and white 
tongue ; thirst; nausea and loss of appetite; constipation; scanty 
and high-coloured urine;-the blood generally buffed and cupped; 
-slight aggravation of the symptoms in the evening, often delirium 
in the night, and slight remission in the morning. 
Terminations.-(1.) If the patient recover, the urine becomes 
more copious, and deposits a sediment;* the tongue becomes moist 
and clean, the skin cool and perspiring; the local inflammation 
either is resolved, or proceeds to a healthy suppuration; and the 
return of the appetite and of the other natural functions indicates 
the patient's recovery. The formation of pus often appears to be 
a natural crisis.! (2.) But if from the irreparable nature of the dis- 
ease or injury, or from the irritability of the system, life is destined 
to be destroyed, the pulse becomes continually more frequent, and 
subsequently weak, irregular, and intermittent, the extremities cold, 
and life soon ceases with the failure of the circulation. 
Treatment.-The treatment of this fever is included in that of 
acute inflammation, of which it is the shadow. But it must be ob- 
served in this place, that when it is symptomatic of an inflamma- 
tion that is unavoidable, (as after a compound fracture, and most 
other severe injuries,) it cannot be cut short, although its undue 
violence may be abated;-and that great care should be taken not 
to weaken the patient too much by depletion, especially if the part 
injured be not of vital importance, and its reparation will require 
time and strength. The indications are, to allay vascular action 
and nervous irritation, and to restore the secretions. And the 
means are, rest, low diet, aperient and febrifuge medicines, ano- 
dynes at bed-time when the bowels have been cleared, and general 
or local bleeding, if demanded by the exigencies of the case. We 
must add that purgatives should be avoided when it is likely that 
they may occasion an injurious disturbance of any diseased or in- 
jured part, as a compound fracture, for instance. 
Of the pulse.-It may be convenient to say a few words in this 
place about the pulse. The elements of the pulse are three; namely, 
first, the contraction of the heart, which propels blood into the 
arteries;-secondly, the yielding and dilatation of the artery, which 
when felt constitutes the pulse -and thirdly, the return of the 
amount of heat is generated, as well as of circulating force. Liebig's Animal Che- 
mistry by Gregory, p. 256. In ordinary fever, the heat of the blood does not rise 
more than three or four degrees above the natural standard; but in scarlet fever it 
has risen as high as 116°. 
* Called Lateritious, like brick-dust, from later, a brick; see the Chapter on 
Urinary Deposits. 
f any important phenomenon in a disease (mostly an evacuation of some 
sort) by which the patient's safety or danger may be judged of. 
t If the artery is perfectly straight, and the circulation tranquil, the dilatations 
will not be so great as to be perceptible to the eye, and can be appreciated only by 
compressing the vessel slightly between the fingers; whereas if it is curved, each 
impulse of the blood will slightly straighten it, and cause a sensible motion. 24 
INFLAMMATORY FEVER. 
artery to its former calibre. Now some of the properties of the 
pulse depend on the heart, and some on the arteries. Thus its 
frequency and slowness correspond to the number of the heart's 
contractions in a given time. Its quickness (or sharpness} depends 
on the velocity and impetus with which each individual contraction 
is made. On the other hand, hardness of the pulse depends on the 
resistance offered to the ingress of the blood, by the constant tonic 
contraction of the contractile coat of the arteries; whilst, on the 
other hand, if that contraction is trifling, so that the vessel yields 
readily to the impulse of the blood, or the pressure of the finger, 
the pulse will be soft. The vibratory feel, or thrill, or jar, is 
caused by an irregular dilatation of the artery, which dilates with 
an innumerable number of stops and interruptions. The full and 
small pulse depend in some measure on the quantity of blood in the 
system, but principally on the state of the vessel; for if that does 
not dilate freely, the pulse will be small. A small hard pulse is a 
much safer indication for bleeding than a full soft one. 
In the fever accompanying acute inflammation of any common 
part, such as skin, cellular tissue, or muscle, or of the eye, dura 
mater, or pleura, the pulse is generally frequent, hard, and full. 
During acute inflammation, however, if the brain and stomach- 
parts most essential to life-or of the peritoneum, testicle, and kid- 
ney, which are most intimately connected with the stomach by the 
sympathetic nerve, the vital powers seem to be more depressed, and 
the pulse is frequent, hard, and small. 
Again, during acute inflammation in a very weak and irritable 
constitution, or after great loss of blood, the pulse may either be 
very frequent, soft, and small, or frequent, soft, large, and jerk- 
ing', the soft jerking quality indicating an almost passive yielding 
to the heart's impulse, and being caused by an absence of that con- 
tractile tone which renders the pulse small and hard.! 
Buffy Blood.-The reader needs scarcely be reminded, that after 
healthy blood has coagulated, it divides into two portions, serum 
and crassamentum;-that the serum is a watery solution of the 
albumen and salts, whilst the crassamentum consists of the fibrine 
and red particle ;-and that the fibrine, which by itself is yellowish 
white, derives an uniformly red tinge from the equal diffusion of 
these particles. But, on the other hand, when blood is drawn 
during the fever which accompanies acute inflammation, the crassa- 
mentum is generally found to be covered with what is called a 
"bujfy coat," that is, a yellowish white layer of fibrine, free from 
red particles;-which layer may vary from one line to one third of 
the clot in thickness, and is frequently so strongly contracted as to 
make its surface concave, or cupped, and its edges fringed. 
We have therefore to inquire, first-what are the real changes 
in the blood which cause this deviation from its ordinary appear- 
f Wilson Philip. Experimental Inquiry into the Laws of the Vital Functions, 
p. 323, 3d edition. See also Hunter on the Blood, Chap. iii. sect. 8. BUFFY BLOOD. 
25 
ance;-and secondly, by what states of the system are they pro- 
duced. 
With regard to the first inquiry, we will briefly enumerate the 
changes in the condition of the blood which are supposed to be con- 
cerned in the production of the buffy coat. 
In the first place, it has been supposed to be owing to a slow 
coagulation, so that the red particles have time to sink, and leave 
the upper surface of the clot colourless. And it is quite true that 
the blood generally coagulates very slowly in inflammatory fever. 
But still, as Hewson says, " something more than merely a lessened 
disposition to coagulate is necessary for forming the crust, or size,"* 
because if blood be confined by ligatures in a vessel of a living 
animal, although it will coagulate very slowly, it still will be free 
from the buffy coat. 
In the second place, Hunter supposed that the specific gravity of 
the red particles was increased,! so that they would sink to the 
bottom more rapidly than in healthy blood. But this was disproved 
by an experiment of Hewson. 
Thirdly, it has been presumed that the fibrine has a tendency to 
separate from the other elements of the blood, and to rise to its sur- 
face ; and this is no doubt partially true. 
Fourthly, it has been shown by the experiments of Thackrah, 
Andral, and Gavarret, that the quantity of the fibrine in the blood 
is increased during acute inflammation. 
Lastly, we must give a brief account of the opinion which Mr. 
Wharton Jones has advanced as the result of his microscopical exa- 
mination of the blood, and which probably is nearer the truth than 
any of the preceding theories. In the coagulation of healthy blood, 
the following phenomena are observed. First, the red globules, by 
a mutual attraction, unite themselves into rolls, which soon break 
up into a kind of sponge-work, in the meshes of which all the liquor 
sanguinis is contained; then the fibrine or the liquor sanguinis solidi- 
fies ; and lastly, the sponge-work formed by the blood globules con- 
tracts itself, squeezing out most of the serum from between its 
meshes, but retaining the fibrine. In inflamed blood, on the other 
hand, the attraction of the red globules for each other is greatly in- 
creased ; so that they form themselves quickly into a sponge-work, 
which quickly contracts, and sinks towards the bottom of the vessel, 
squeezing out some of the liquor sanguinis from its meshes, be- 
fore the latter has separated into fibrine and serum. And this 
liquor sanguinis, so separated from the globules, forms the bluish- 
white layer which is well known to appear on the surface of in- 
flamed blood very soon after it is drawn. And the fibrine which it 
contains being deposited on the surface of the sponge-work formed 
by the globules constitutes the buffy coat.f 
* Hewson; Experimental Inquiry into the Blood. Lond. 1772. Chap. ii. pp. 34 
et seq. 
f He thought also that the serum was specifically lighter than usual. 
t This account is confirmed by the experiments of Mr. Addison of Malvern. 
Med. Gaz., vol. xxvii. p. 447. 26 
BUFFY BLOOD. 
We have next to consider by what states of the system these 
changes in the blood are produced. Hunter says, that they are 
produced by an increase of the powers of life, and by an increase 
of the disposition to act with those powers. And we have both 
positive and negative evidence that this is correct. For the huffy 
coat is found on the blood of healthy pregnant women and animals, 
in whom the powers and actions of life are augmented without 
doubt; and it is always most conspicuous when the circulation is 
rapid, and when the blood is drawn in such a manner as to pre- 
serve its vital properties; that is, in a full rapid stream, into a deep 
vessel, the temperature of the apartment being high. 
On the other hand, the buff will be deficient, when the blood is 
drawn in such a manner as to deprive it speedily of its life; that is, 
in a small slow stream, into a flat and shallow basin, the tempera- 
ture being low. It is a remarkable fact that the buffy coat is occa- 
sionally absent at the commencement of some inflammations, 
especially of the lungs, whilst the circulation is slow, and labouring, 
and embarrassed, and whilst it may be supposed that the nervous 
system is oppressed by the intensity of the inflammation; and that 
it may make its appearance as soon as the oppression is removed 
by bleeding. Thus, during one venesection, it has happened that 
the blood first drawn has not been buffed, owing, as we presume, 
to the embarrased circulation;-the buff has appeared in a second 
portion, when enough has been drawn to relieve that embarrass- 
ment ;-and has again disappeared in a third, when the circulation 
has become languid at the approach of syncope. 
We must observe, in conclusion, that the buffy coat is not to be 
considered as an invariable evidence of inflammation. For, in the 
first place, it may be present when there is no inflammation;-as 
in pregnant women; in the plethoric; in persons accustomed to be 
periodically bled, or who are habitually exposed to the night air.* 
Again, its quantity is by no means proportioned to the intensity of 
inflammation; for it is constant to the last in rheumatism,! even 
when subdued by bleeding. And there are certain inflammations 
of great intensity in which it does not exist at all; as in the com- 
mencement of some cases which we have just alluded to ;-in in- 
flammations that have little of the adhesive tendency, as those of 
mucous membranes, and diffuse inflammation of the cellular tissue ; 
and in the inflammations arising from certain morbid poisons, as 
glanders, or in the course of typhus fever, when the blood, having 
lost its vital qualities, scarcely coagulates at alLf 
* Samuel Cooper. First Lines of Surgery. 
f Some authors state that the blood is most buffed when there is an inflammation 
with considerable tendency to effusion of fibrine, as pleurisy or pericarditis; others 
state that it is most buffed when the inflammation has no adhesive tendency, as 
acute rheumatism, so that the fibrine cannot escape from the blood; a curious in- 
stance of contrary deductions from the self-same facts, when partially viewed and 
hastily generalized. 
1 Palmer's edition of Hunter, vol. iii. p. 39, note. For further information on this 
subject, consult also Copland's Diet. Pract. Med. Art. Blood; Thackrah, C. T. on 
the Blood, Lond. 1834; Davy's Experimental Researches, vol. i. Lond. 1839; Mill- IRRITATIVE FEVER. 
27 
SECTION III. OF IRRITATIVE FEVER. 
General Description.-The term Irritative Fever seems to be 
conventionally assigned to a form of violent and dangerous constitu- 
tional disturbance, which apparently combines the characters of in- 
flammatory fever and of prostration with excitement; and which is 
scarcely to be distinguished from the early stage of typhoid fever. 
Or perhaps it may be more convenient to describe it as the set of 
constitutional symptoms which attend phlebitis, diffuse inflamma- 
tion of the cellular tissue; the disease arising from glanders, and 
from wounds poisoned during dissection;-also severe phlegmonous 
erysipelas and inflammations in which there is great pain from the 
confinement of matter;-all of which cases exhibit a combination 
of violent local inflammation, great febrile commotion, and great 
depression of the vital powers. 
The Symptoms and Treatment will be particularized under the 
head of the various local affections which this fever accompanies. 
The leading features are great restlessness and anxiety, debility, 
depression of spirits, weight at the prascordia, oppressed respiration; 
frequent rigours; pulse rapid and sharp, but variable in force; death, 
preceded by low delirium, and signs of great exhaustion. The 
treatment must, as a general rule, be directed to the invigoration of 
the vital powers by cordial stimulants and tonics, the evacuation of 
depraved secretions, and the removal of pain and irritation, and of 
local disease, by whatever measures are most appropriate.* 
SECTION IV. OF HECTIC FEVER.t 
Definition.-Hectic fever is an habitual disorder of the system, 
when irritated by some long-standing disease, or source of weak- 
ness which it is unable to remove. It is a remittent fever, and is 
generally accompanied by a tendency to increase of one or more 
secretions. 
Symptoms.-Emaciation and debility; tongue morbidly clean and 
red, especially at the tip and edges; appetite often inordinate; dis- 
position alternately to diarrhoea and profuse respiration pulse 
frequent and small;-a febrile exacerbation comes on every even- 
ing (or oftener, especially after meals) with slight chills, followed 
by heat of skin, burning of the soles of the feet and palms of the 
hands, and a circumscribed flush in the cheeks;-thirst and rest- 
ler's Physiology by Baly, 2d ed. vol. i.; Andral, Arch. G^n. de Med. 1840, and Brit, 
and For. Med. R. vol. xi. p- 243; and T. Wharton Jones, B. and F. Med. Review, 
Oct. 1842. 
* Vide part ii. chap. viii. sect ii. on Diffuse Inflammation of the Cellular Tissue; 
and part iii. chap. ix. sect. ii. on Dissection Wounds. 
From extixoj, habit, habitual. 
t Called colliquative,- (liquo, I melt;) because they exhaust the system. 28 
HECTIC FEVER. 
lessness, preventing sleep till after the middle of the night, when 
the patient falls asleep, and suddenly wakes in a profuse perspira- 
tion ;-often buoyancy of spirits and hope to the last. 
Terminations.-(1.) If it be about to terminate fatally, the debi- 
lity increases; the diarrhoea and perspirations become more profuse 
and exhausting: the legs become oedematous; aphthae form; and 
great pain, griping, and tenesmus attend the diarrhoea, owing to an 
inflammatory or ulcerated condition of the intestines. The patient 
may expire suddenly, the heart failing from mere debility; or death 
may be preceded by typhoid symptoms. And this fatal termination 
may be owing either to the continuance of the original disease, or 
to the induction of secondary disease in the lungs or mesenteric 
glands. (2.) Recovery from hectic is often remarkably rapid, if 
the causes be removed; provided that no secondary disease has 
commenced. 
Causes.-Any chronic organic incurable disease;-whether in- 
curable from its nature, as scirrhus, or tubercle;-from its extent; 
-or from constitutional debility; also exhaustion from profuse 
suppuration;-or from any other great and continued discharge ; 
as prolonged lactation, leucorrhoea, and so forth. Hectic is so fre- 
quently caused by profuse suppuration, that an absorption of pus 
was formerly deemed to be its invariable and efficient cause. Hun- 
ter denied this theory-1st, because hectic may arise from organic 
disease, or from excessive discharge of any secretion when there 
is no suppuration; 2dly, because pus may be absorbed (as it often 
is from chronic abscesses and buboes, which are discussed without 
being opened) without the production of hectic.* It is certain, 
therefore, that absorption of pus is not the only cause of hectic. 
But it is equally certain that pus is absorbed from extensive sup- 
purating surfaces; and it is probable that its presence in the blood 
adds to the hectic and constitutional debility; and that (especially 
if it be vitiated or decomposed) it tends greatly to the production of 
colliquative diarrhosa and ulceration of the intestines. For the 
injection of pus or putrid matter into blood almost invariably causes 
diarrhoea;-an effect also which is notoriously produced among 
students, who absorb the putrid vapours of the dissecting-room.t 
Treatment.-The indications are (1) to remove the local cause; 
or (2) if that be impracticable, to enable the system to support it. 
The first indication may often be fulfilled by an amputation or 
other operation; and it is well known that hectic patients often bear 
operations extremely well, recovering from them rapidly, and mak- 
ing but one step, as it were, from death's door to perfect health.^ 
In cases not admitting or requiring an operation, local mischief must 
be remedied, and profuse discharges restrained as far as possible. 
* On the Blood. Ch. ix. sect. 1. 
+ Copland; Diet. Pract. Med. Arf. Hectic, p. 965. See also the section on Chronic 
Abscess. 
t " The removal of a diseased part which the constitution has become accus- 
tomed to, and which is rather fretting the constitution, is adding less violence than 
the removal of a sound part in harmony with the whole." Hunter on the Blood. 
Ch. ii. sect. 2. TYPHOID FEVER. 
29 
As for the second indication, the strength must be maintained by 
giving as much food as the stomach can digest with comfort; but 
the quantity of animal food and of fermented liquors must not be 
large enough to add to the excitement, nor increase the heat of skin, 
thirst, and perspirations. Arrowroot, and other farinaceous pre- 
parations ; jellies, Iceland and carrageen moss, are useful as mild 
nutritives occasionally, when there is an excess of heat and fever- 
ishness ; but these slops should not be given at such times, or in such 
quantities as to interfere with the digestion of more solid food, if 
there is an appetite for it. Tonics may be given to support the 
strength; such as bark, quinine, or cascarilla; or sometimes the 
preparation of iron; but if, at any time, in the varying progress of 
the disease, excitement appear to prevail, the pulse being more ac- 
celerated, and pain aggravated, tonics and animal food must be 
for a time exchanged for saline medicines, and farinaceous or milk 
diet. Digitalis, a remedy much abused in hectic, may be of ser- 
vice at such times, if given in a few moderate doses, for not too 
long a time. Ten minims in a saline draught, at bed-time, are a 
proper dose. Opiates must be given to procure sleep and allay 
pain. Change of air is always advantageous. Profuse perspi- 
rations may be checked by dilute sulphuric or nitric acid, with 
tonics, as in F. 1. As it will be recollected that the diarrhoea often 
depends on an inflamed or ulcerated condition of the intestinal 
mucous membrane, reason will suggest that attempts to stop it by 
port wine, and large doses of catechu, or other stimulants and as- 
tringents, will often be not only unavailing, but irritating and mis- 
chievous ;* although good enough in cases of mere debility. If, 
therefore, the diarrhoea is attended with tenderness, much pain, and 
tenesmus, the proper remedies are, rest in bed; mustard poultices 
to the abdomen;-the very mildest diet of milk, arrowroot, &c., 
enemata of starch, containing from twenty to sixty minims of lau- 
danum (F. 48);-Dover's powder at bed-time, and small doses of 
chalk mixture, with a few minims of laudanum, during the day; and 
one or two grains of blue pill, with three or four of rhubarb occa- 
sionally, if the liver is inactive. It may be added, that copious in- 
jections of warm water give great relief in all cases of diarrhoea; 
soothing the irritated membrane, washing away acrid secretions, 
and enabling the patient to pass easily at once what otherwise would 
occasion several painful efforts. 
SECTION V. OF TYPHOID FEVER. 
I 
General Description.-This fever is an acute form of constitu- 
tional disturbance, occurring when the powers of life are much 
exhausted or depressed. It may be a sequel of the hectic; or of 
* The author has known large doses of catechu purge violently, when adminis- 
tered to a young woman for passive menorrhagia. 30 
TYPHOID FEVER. 
the state of prostration with excitement; or it may supervene very 
soon after an injury. 
Symptoms.-Pulse very frequent and weak, or jerking; skin hot 
and very dry; all the secretions deficient; tongue dry, brown, and 
tremulous; lips parched;-if there be a wound, it becomes dry, 
livid, and glassy, and ceases to suppurate. 
Terminations.-(1.) If the patient is to die, the pulse becomes 
more rapid, thready, and tremulous,and at last is imperceptible at the 
wrist; the eyes look dull, and glassy, and sunken; the temples and 
nostrils are pinched, from atony of their muscles;-the patient lies 
on his back, and sinks toward the foot of the bed ;-there is fre- 
quent hiccough ; the abdomen is tightly distended with flatus, and 
the sphincter is relaxed, so that stools are passed involuntarily; the 
patient dozes imperfectly, awaking with a start; he picks imaginary 
objects on the bedclothes, and mutters to himself;-there is starting 
or twitching of the tendons; at last the skin becomes cold and 
clammy, respiration slow and laborious, and coma supervenes, soon 
followed by death. (2.) If recovery occurs, the surest sign of 
amendment is a diminution of the frequency and increase of the 
firmness of the pulse, with sound sleep ; the patient being sensible 
and composed, the eyes brighter, the tongue cleaning, and above 
all, suppuration returning, if there be a wound. 
Causes.-Typhoid fever may be caused, (1.) by some circum- 
stances producing immediate and direct depression of vital power ; 
such as traumatic grangrene; a wound poisoned during dissection; 
or asevere injury or operation suffered by an habitual drunkard. (2.) 
It may be caused by some disease of long standing, which has com- 
pletely exhausted the constitutional powers-as profuse suppuration 
with hectic. And both these conditions may be, and frequently 
are, combined with a third; (3.) namely, contamination of the 
blood by putrid or other poisonous matter. Thus it is sure to super- 
vene if putrid pus be confined in an abscess, or if putrid urine escape 
into the cellular tissue of the perinaeum. M. Bonnet has proved 
incontestably that the hydrosulphate of ammonia, the product of 
putrefaction, is absorbed in these cases, and is one cause of typhoid 
fever.* 
Prognosis.-The prognosis will, of course, be always doubtful; 
but there may be a chance of recovery, if the cause is of recent 
existence, and admits of removal by operation or otherwise; whilst 
there can be scarcely any, if the constitution has been exhausted 
by its long continuance. Thus, if this fever comes on in erysipelas 
or small-pox, diseases of no long continuance, the constitution may 
rally ;-or if it is caused by a recent injury, or by extravasation of 
urine, it may be removed, perhaps, by an amputation, or incisions 
in the perinaeum ; but it will scarcely be cured if caused by chronic 
abscess or disease of a joint, and preceded by hectic. And thus, if 
the hectic has been suffered to pass into the typhoid state, the sea- 
son of amputation and hope of recovery are also past. " It is," 
* See Chronic Abscess. TETANUS. 
31 
says Hunter, " the more incurable, as it is more connected with the 
past than with the present." 
Treatment.-The indications are to remove the cause; allay 
irritation, and support the strength. If the removal of the cause 
by operation is likely to be successful, upon the principles just 
laid down, it should be done without delay; and, even if not, it 
may be better to try a doubtful remedy than none at all. 
As for the general treatment, opium, or some of its preparations, 
should be given in small doses, repeated frequently, or in a large 
dose at once, according to the judgment of the practitioner, for the 
relief of restlessness and delirium. The strength must be supported 
by quinine and tonics; by wine, and other stimulants, and by mode- 
rate quantities of broth, beef-tea, arrowroot, &c., if the patient will 
take them. Hiccough is best relieved by a teaspoonful of sp. aether, 
c.; and flatulence by an enema of turpentine. The catheter should 
be used if the patient cannot pass his water; a point that should 
always be inquired into. 
CHAPTER IV. 
OF TETANUS. 
Definition.-Tetanus is a disease manifested by tonic* spasm 
and rigidity of some, or many, of the muscles of voluntary motion. 
Divisions.-There are several varieties of tetanus. (1.) It is 
divided into the idiopathic, or that which arises solely from some 
disorder of the system, and the traumatic, or that which is caused 
by a wound. (2.) It may be acute or chronic; the former arising 
suddenly, and soon terminating, generally affecting the whole body, 
and being often fatal; the chronic being of less intensity and of 
longer duration, usually partial in its extent, and mostly terminating 
in recovery. (3.) Tetanus may be general or partial; and when 
partial it is mostly confined to the neck and jaws, constituting tris- 
mus, or locked jaw. (4.) It may be divided according to the set 
of muscles predominantly affected: being called opisthotonos, when 
the body is curved backwards so as to rest on the occiput and heels, 
which it most commonly is; emprosthotonos, when it is curved 
forward from a preponderance of the abdominal muscles; and 
pleurosthotonos, when it is drawn to one side, this being the most 
uncommon.! (5.) The trismus infantum, or neonatorum, which 
* Spasms are of two kinds; the tonic, in which the rigidity is permanent; and the 
clonic, in which contraction alternates quickly with relaxation, as in epilepsy and 
hysteria. 
f See a case of acute pleurosthotonos, Med. Gaz. May 12th, 1838. 32 
ACUTE TETANUS. 
attacks children soon after birth, is usually made a distinct species. 
(6.) Tetanus may in its type be intermittent, when it is caused by 
marsh miasmata, as it may be occasionally, like almost every other 
nervous affection. (7.) Lastly, there is the hysterical tetanus; in 
which all the outward symptoms of tetanus are produced, as a con- 
sequence of an hysterical state of the system. 
We shall first describe the acute tetanus; then the chronic; and 
afterwards the infantine and hysterical varieties. 
Symptoms.-The patient first complains of stiffness and pain of 
the neck and jaws, as from a cold; and his countenance is observed 
to have a peculiar expression, resembling a painful smile, because 
the corners of the mouth and eyes are distorted and puckered by 
incipient spasm of the facial muscles. In the next place, the mus- 
cles of mastication and deglutition become fixed and rigid with 
spasm, so that the mouth is permanently closed, and there is great 
difficulty of swallowing, especially liquids. To these symptoms 
succeed a fixed pain at the pit of the stomach, shooting to the back, 
and a convulsive difficulty of breathing, indicating that the dia- 
phragm and muscles of the glottis are affected; and the spasm now 
extends to the other muscles of the trunk and limbs, rendering them 
completely fixed and rigid. The abdomen feels remarkably hard; 
there is obstinate constipation, and frequently difficult micturition 
from spasm of the perinaeal muscles; the pupils are contracted1; and 
the saliva flows from the mouth, because the patient is unable to 
swallow it. This spasm never ceases entirely; but it has occasional 
remissions of violence, alternating with aggravated paroxysms, 
which are easily induced by the slightest irritation or disturbance. 
Meanwhile the intellects are undisturbed, and the pulse may be 
natural, except during a severe paroxysm, which quickens it, and 
causes perspiration and thirst. 
Terminations.-(1.) If the case is about to end fatally, the 
paroxysms become more frequent and violent, and the breathing 
more and more embarrassed by spasm of the diaphragm and of the 
muscles of the glottis; and at last the patient dies, either from ex- 
haustion or from suffocation;-the nervous system being either 
worn out by the violence of the spasm, or the respiratory action 
being suspended long enough to cut off the necessary supply of 
arterial blood from the brain, and so induce insensibility. The 
most usual period of death is the third or fourth day; sometimes it 
is postponed till the eighth or tenth, but rarely later. On the other 
hand, there is the case* recorded of a negro who injured his hand, 
and died of tetanus in a quarter of an hour: and cases of death 
within twenty-four hours are by no means uncommon. (2.) When 
acute tetanus terminates favourably, still the patient's recovery is 
not complete for weeks or months;-partly because of the strain- 
ings and lacerations which the muscles have suffered,-partly be- 
cause of the remaining tendency to spasm, which very slowly yields, 
and is apt to be temporarily aggravated by very slight causes, espe- 
* Rees's Encyclopaedia, Art. Tetanus. ACUTE TETANUS. 
33 
cially cold and damp. But in some rare instances the disease has 
been removed almost instantaneously by the removal of its exciting 
cause. 
Prognosis.-The prognosis in acute tetanus is extremely unfa- 
vourable, especially if traumatic; it is more favourable in the 
idiopathic, and the chronic generally gets well of itself. Death very 
seldom occurs after the twelfth day. Dr. Parry* attempted to found 
a prognosis on the state of the pulse, and thought that if on the 
fourth day it was under 100 or 110, the patient being an adult, the 
prognosis was favourable;-but if above 120, unfavourable. But 
although it is true that the pulse is in general accelerated towards 
the close of the malady, still some fatal cases have occurred in which 
it never rose above 80 or 90. As a general rule, it may be said 
that the prognosis is favourable if the complaint is partial;-if it 
does not affect the muscles of the glottis ;-if it has lasted some days 
without increasing materially in severity;-if it is sensibly mitigated 
by the remedies employed;-if the pulse is not much accelerated;- 
if the patient sleeps; and if he has been subject to it before in an 
intermittent form. On the other hand, the prospect will be unfa- 
vourable, if the spasms continually increase in severity, and espe- 
cially if they affect the muscles of the glottis. 
Diagnosis.-Tetanus resembles hydrophobia in the difficulty of 
swallowing and aggravation of the spasms by slight external irri- 
tants ; but it may be distinguished by the spasms being continuous, 
and by the patient being in general sensible, and calm to the last;- 
whereas in hydrophobia, there are fits of general convulsions with 
perfect intermissions, and the patient is mostly delirious, with a 
peculiarly wild haggard expression of countenance. Inflammation 
of the spinal cord, or its membranes, resembles tetanus in having 
opisthotonos and spasmodic difficulty of swallowing; but it may be 
distinguished by the pain in the back, and fever being more pre- 
dominant than in any case of mere tetanus, and by the paraplegia 
and coma which supervene in most cases. 
Morbid Anatomy.-The morbid appearances that have been 
found in different cases are as follow: Increased vascularity of the 
membranes and substance of the spinal cord, with or without effu- 
sion of serum;-more rarely the same appearances have been found 
in the cranium;-flakes of cartilage and spiculse of bone deposited 
in the membranes of the spinal cord ;t-vascularity of the nerves 
leading from the wounded part;-of the mucous membrane of the 
stomach;-and of the sympathetic ganglia;-and congestion of the 
lungs. But there is not one of these morbid changes that is con- 
stantly, and, except the first, there is not one of them that is even 
frequently found. The muscles are extremely rigid after death, and 
ecchymosed or ruptured in many parts;-the blood is mostly un- 
coagulated. 
* Caleb Hillier Parry, M. D. Cases of Tetanus and of Rabies Contagiosa. Bath, 
1814. 
f Refer to the cases at p. 35. 34 
ACUTE TETANUS. 
Causes.-Tetanus may be caused by wounds and external in- 
juries of every description, but especially by lacerated and punctured 
wounds of the hands and feet, gun-shot wounds, compound fractures, 
compound dislocation of the thumb, and wounds irritated by foreign 
matters, or in which nerves are exposed. Mr. Morgan has known 
it even caused by a blow with a schoolmaster's ferule; but it is 
very rarely caused by clean simple incisions. The periods at which 
it may come on after the injury are very uncertain. Sometimes it 
occurs very quickly, if the patient is predisposed to it. Sometimes 
it seems to be induced by the great pain and irritation of a wound 
during its inflammatory state: but the most common period is, when 
the wound is nearly healed. Why this is so, is very difficult to ex- 
plain; but some attribute it to a rapid cessation of suppuration, and 
others (as Trnka and Travers) to an irritation of the nerves by the 
contraction of the cicatrix. 
It is probable, however, that in most instances some concurrent 
or predisposing cause, in addition to an external injury, is required 
to produce tetanus. Thus, in a case which occurred in St. Bar- 
tholomew's Hospital, ten days after a wound on the toe, and proved 
fatal in a fortnight, almost all the intestinal canal was inflamed, and 
there were ulcers in the ilium and coecum.1 Dr. Dickson2 and Mr. 
M'Arthur3 relate cases in which the intestines were filled with a 
peculiar unhealthy yellow viscid secretion;-Mr. Abernethy4 com- 
memorates the peculiarly unhealthy stools, like sloughs, in a case 
which he observed; Mr. Travers5 strongly suspects that dysentery 
and ulcers of the intestines may be coincident causes; and some 
authors6 have affirmed that intestinal worms are a strongly predis- 
posing, if not really efficient, cause. But of all the concurrent causes 
which are liable to induce tetanus in the wounded, exposure to cold 
damp night air during warm weather, or in a warm climate, is the 
most frequent; and consequently it is much more prevalent and 
fatal in warm than in cold or temperate climates. 
The same causes, cold and visceral irritation namely, which pre- 
dispose to the traumatic variety, may of themselves produce the 
idiopathic tetanus. Thus the latter has been a consequence of 
gastritis; of strangulated hernia ;7 of the irritation of an emetic on 
a stomach disordered by habitual drunkenness.6 Begin8 states that 
it has arisen from pericarditis; Gooch9 gives a case produced by 
disease of the breast; and Farr7 knew it caused by pulmonary ab- 
cess. Uterine irritation is by no means an uncommon cause. Whytt7 
gives the case of a girl, aged twenty, who caught cold during the 
menstrual period, and died of tetanus in eighteen hours; and the 
(') Med. Gaz. vol. i. p. 646. (2) Med. Chir. Trans, vol. vii. p. 459. (3) Ibid, 
vol. vii. p. 474 et seq. (4) Lectures on Surgery. Renshaw, London, 1835, p. 23. 
(6) Travers. Further Inquiry concerning Constitutional Irritation. London, 1835, 
p. 39'7. (6) Vide F. Pescay, Diet, de Sc. Med. Paris, 1821, vol. Iv. p. 0. (7) Quoted 
in Wencelslai Trnka de Kr'zowitz, Commentarius de Tetano, Vindoboniae, 1777- 
the very best work on the subject extant. (8) Dictionnaire de Medecine et Chirur- 
gie Pratiques. Paris, 1836. Art. Tetanos. (9) B. Gooch, Chirurgical works. 
Lond. 1792. Vol. ii. ACUTE TETANUS. 
35 
case related in the adjoining note gives a good example of fatal 
trismus from irritation of the womb.* 
Tetanus may also be caused by certain narcotic acid poisons, 
especially the mix vomica, cicuta aquatica, and a Javanese poison 
called chetih. 
Pathology.-With regard to the seat of tetanus, it must be the 
spinal cord and medulla oblongata ; the parts namely where all the 
nerves of voluntary motion arise; and we may believe that the 
brain and ganglionic system are unaffected, except towards the fatal 
close of the malady, when delirium, and a permanently quick pulse 
are superadded to the purely tetanic symptoms. 
With respect to its nature, it cannot be regarded as essentially 
inflammatory, because the spinal cord is often found after death 
without a trace of vascularity, and because tetanus may be estab- 
lished during a state of depression and collapse that would be quite 
incompatible with inflammation.! 
Although, however, it is most certain that inflammation is not 
essential to the existence of tetanus, still it is equally certain that 
there is one class of tetanic cases which presents a well-marked in- 
flammatory character. They commence with shivering and pain, 
are attended with fever, and, if fatal, display on inspection, conges- 
tion, serous effusion, softening or purulent deposit, in some part of 
the brain or spinal cord.! But if we except this class, (which is by 
*A young lady miscarried in the second month of pregnancy; but as the abdomen 
continued to enlarge, and the breasts to fill, and the menses to be absent, it was sur- 
mised that one ovum only of a twin had been expelled, and that the other was pro- 
ceeding in the regular course of development. About the fifth month she was 
seized with violent flooding, which yielded for a time to the ordinary remedies, but 
recurred repeatedly. Soon after this she was suddenly attacked with stiffness of 
the jaws, spasmodic difficulty of swallowing, and spasm of the glottis. A physician- 
accoucheur was now called in, who introduced bougies into the womb, with the 
view, as he said, of inducing delivery; this manifestly aggravated all the symptoms. 
The remedies used were calomel and opium; she was not bled, as she had been 
much reduced by the flooding. She died in two days from the accession of trismus, 
having become comatose. On a post-mortem examination, the womb was found 
swelled and congested, but containing no ovum; the other abdominal and thoracic 
viscera were healthy: the base of the brain and cervical portion of the spinal cord 
immensely congested and loaded with serum. Similar cases are to be found in 
Trnka. See also Cooke's Morgagni, vol. i. p. 129; and the Lancet for June 2d, 1838. 
-j- "I have observed, sometimes after severe gun-shot wounds, attended with great 
disturbance and stunning, {fracas et commotion,} and after considerable haemorrhages, 
a state of constant atony {atonic} during the course of tetanus. The pulse was slow, 
intermittent, small, and thready;-stupor and apparent insensibility preceded the 
spasms, and, so to say, announced them. The tetanus was universal, but the 
rigidity and tension of muscles were moderate. This state was but of short duration; 
death occurred in fifteen or twenty hours."-Fournier-Pescay, Op. Cit. 
4: The following are examples. (1.) Case in which the disease was caused by a 
blow on the back of the neck-next day patient was seized with shivering and fixed 
pain at the injured part-pulse 130, and full-death in thirty-six hours. Head found 
loaded with blood, and cervical portion of the cord softened.-Med. Gaz. vol. i. p. 
645. (2.) A cavalier cut his hand, and applied cold-was immediately seized with 
shivering and fever and tetanus-was bled, but died in fourteen hours.-Fournier- 
Pescay, Op. Cit. (3.) Patient was labouring under simple continued fever from cold 
and wet-tetanus came on after a week, with aggravation of fever and pain in the 
head and back; treated successfully by large bleedings, warm bath, purgatives, and 
mercury.-t-Burmester in Med. Chir. Trans, vol. ii. (4.) A man after violent exercise 36 
ACUTE TETANUS. 
no means a majority,) and the very small class of cases in which 
there exists collapse, the remainder cannot be associated with any 
morbid condition of the circulating system. 
It must be concluded, therefore, that tetanus is merely a mani- 
festation of functional disorder in one department of the nervous 
system, and that the nearest approach we can make to a correct 
pathological definition is to say, that it consists in an unnatural ex- 
citability of the spinal cord, through which it produces spasm of 
the voluntary muscles; a spasm that is aggravated by the slightest 
impressions on the sentient or afferent nerves. In fact, (like other 
spasms,) it is to the motor system just what nervous pain is to the 
sentient, and delirium to the intellectual; for all these functional 
disorders of the nervous system have many points in common. 
They may all be symptomatic of the most varied states of local 
disease. They may all be accompanied with the most opposite 
states of vascular excitement and bodily strength. They may all 
be caused by the greatest conceivable variety of morbific agents; 
cold, mental anxiety, mechanical injury, sympathetic disorder, and 
poisons. And lastly, they all seem to be fatal, in the ratio in which 
they interfere with the actions of life, or exhaust its powers.* 
Treatment.-The indications are, to remove all sources of irri- 
tation, and diminish the spasm. 
In the local treatment, the first points to be accomplished are, 
to remove all extraneous bodies from the wound, if there be one; 
to make incisions, if necessary, for the free discharge of pus, or for 
the relief of inflammatory swelling and tension ; and if any isolated 
portion of nerve or tendon happens to be on the stretch, to divide 
it. Then the part may be fomented with warm decoction of pop- 
pies ; after which a solution of a scruple of opium, or extract of 
belladonna in an ounce of water, may be applied on lint, and the 
whole part be enveloped in large soft poultices. Sundry other 
measures have been proposed, in order more effectually to remove 
local irritation : such as the division of the principal nerve leading 
from the wound ; or, as Mr. Liston has proposed, the making a a 
incision above, so as to isolate it and cut off as much nervous com- 
munication as possible; or the destruction of a ragged, contused, 
ill-conditioned wound by actual cautery, as Larrey and others have 
practised with great benefit; or the excision of the wound if cica- 
trized or nearly so. Sometimes, when the wound is nearly cicatrized, 
or has ceased to suppurate, the application of a blister or of strong 
was seized with rigors-fever-pain in forehead-emprosthotonos, and subsequent- 
ly opisthotonos-was bled, but died comatose in five days-serum and blood found 
effused between the membranes of brain; cervical portion of cord softened.-Fran- 
cesco in Forbes's Review, Jan. 1838. (5.) A woman died of tetanus from cold, with 
decided inflammatory symptoms. The spinal canal contained much bloody serum; 
the pia mater was inflamed in the anterior columns, the white substance was con- 
verted into a number of whitish yellow bodies, from the size of a millet to that of a 
lentil, very soft, with red spots; the posterior columns healthy.-Poggi, Lund. Med. 
and Phys. Jour. vol. Ixi. p. 132. 
* Vide Dr. M. Hall's fourth Memoir on the Nervous System, Med. Chir. Trans, 
vol. xxiv. ACUTE TETANUS. 
37 
stimulating ointments has been of service; but, as Mr. Curling* 
observes, it happens, unfortunately, that the tetanic condition of the 
spinal cord, when fully established, is mostly independent of its local 
exciting cause, and does not cease on its removal. Hence amputa- 
tion of the injured part has very rarely been successful, and has 
even aggravated the mischief; so that, as a general rule, it ought 
not to be performed, unless desirable for some other reason besides 
the tetanus. 
We must next review the constitutional remedies that have been 
employed in tetanus, stating their relative utility, and the cases in 
which they are most likely to be beneficial. 
1. Bleeding.-In all cases attended with marked inflammatory 
symptoms, or if the habit be full, and the wound hot, swelled, and 
painful, bleeding from the arm, and cupping from the spine, are 
clearly indicated. And even if there should be no inflammatory 
diathesis, provided the patient be young, bleeding may be performed 
in moderation, both to prevent congestion, and to facilitate the ab- 
sorption and operation of remedies. But, in by far the majority of 
cases, it should not be employed at all; for its influence on the 
muscular system is but secondary; and though it may diminish 
spasm for a time, it consumes the materials of life, and hastens death 
from exhaustion. 
2. Purgatives are always indicated, unless there is some peculiar 
cause to the contrary; both because there is always obstinate con- 
stipation, and because worms, or vitiated secretions in the digestive 
tube, may be among the exciting causes: and the most active ones 
must be chosen. Thus, at the outset of the malady, a scruple of 
calomel mixed with butter should be put at the back of the tongue 
for the patient to swallow, and should be followed in an hour with 
a draught containing gj. of turpentine and a similar quantity of cas- 
tor oil, or by a drop or two of croton oil; and enemata of turpentine 
should be frequently administered until the bowels are completely 
unloaded. The circumstances which forbid the use of purgatives, 
are previous disease of the alimentary canal; dysentery, ulcers, &c.; 
but even then there would be no objection to unirritating enemata. 
3. Mercury, given so as to induce ptyalism, has often cured 
tetanus; therefore two or three grains of calomel may be given 
every two or three hours; or large quantities of strong mercurial 
ointment may be rubbed in the thighs and legs. 
4. Tobacco has certainly proved more efficacious than any other 
remedy in tetanus. An enema, therefore, of four ounces of the 
enema tabaci (F. 50) should be given after the bowels are cleared, 
or without waiting for that, if the symptoms are urgent. It soon 
induces deadly sickness, cold perspiration, fainting, and relaxation 
of the muscles, followed perhaps by sleep. And the enema should 
be repeated twice or thrice a day, or just often enough to keep the 
muscles constantly relaxed. But care must be taken to keep up the 
* A Treatise on Tetanus, being the Jacksonian Prize Essay for 1834. By T. 
Blizard Curling. London, 1836, p. 122. 38 
ACUTE TETANUS. 
strength, and to administer hot brandy and water, or other stimulants, 
if the heart's action appear enfeebled. 
5. Cold is of eminent service to animals affected with tetanus; 
and a soldier was once most unexpectedly cured by exposure all 
night in severe weather. It may therefore do good in some in- 
stances to apply cold extensively to the surface by means of bladders 
filled with various frigorific mixtures; taking care to support the 
circulation by internal stimulants. But the cold bath, and cold 
affusion, although they are of great service in chronic tetanus, are 
most hazardous in the acute, and have more than once proved in- 
stantly fatal. 
6. Tonics, especially the muriated tincture of iron, quinine, &c., 
are likely to be of great service in cases attended with debility. 
They should be given in large doses every two hours ; it being as 
important to support a right action as to diminish a wrong one.* 
7. Opium is of most undoubted efficacy in some instances, 
probably those attended with a painful wound, and weakness. 
When it produces good effects, they are soon manifest. The best 
way of using it appears to be by frictions with liniments contain- 
ing it; or by removing a small portion of cuticle over the spine 
with a blister, and sprinkling a grain of finely powdered acetate, 
or hydro-chlorate of morphia, on the denuded cutis. Very large 
doses may be given without any effect. 
8. Nutriment.-It is in all cases necessary to keep up the 
strength by beef-tea, wine, arrow-root, &c., especially towards the 
close of the malady. Mr. Travers believes that more patients have 
been lost from want of nutriment than from want of medicine. 
But it is often by no means easy to administer food or medicine, in 
consequence of the closure of the jaws, and difficulty of deglutition. 
The former difficulty may sometimes be overcome by passing an 
elastic catheter through the nose, or behind the last molar teeth. 
But if the attempt at swallowing is attended with much spasm in 
the larynx, it must be abandoned, and our remedies be introduced 
solely through the skin, or by enema. It is both unnecessary and 
barbarous to force the jaws asunder, or to extract any of the teeth. 
9. The resin of the Cannabis Indica, or Indian hemp, a mild 
stimulant and narcotic, has been employed by Dr. O'Shaughnessy 
and others at Calcutta, in doses of gr. iij. every half hour till the 
symptoms are mitigated. It cured eight out of twelve cases. 
10. It is scarcely worth while to mention the various antispas- 
modics, such as camphor, musk, aether, castor, the warm bath, assa- 
fcetida, nor yet antimony, stramonium, belladonna, or digitalis. 
Colchicum has been of service in some few cases; phosphorus, 
given in the quantity of one grain daily, gradually increased to four 
in divided doses, is also said to have produced a cure in twelve 
* The carbonate of iron was employed successfully by Dr. Elliotson, but it is apt 
to lodge in the bowels; and moreover it is doubtful whether the benefit which he 
supposed it to produce in one case, was not really owing to the opening of an abcess 
on the foot. Vide Elliotson, Med. Chir. Trans, vol. xv., and Tyrrell's ed. of Sir. A. 
Cooper's Lectures, vol. iii. ACUTE TETANUS. 
39 
days; and Cruveilhier thought that in one case, great relief was 
afforded by making the patient breathe rapidly and voluntarily 
with the diaphragm.* 
11. Wourali.-It is well known that narcotics are of two kinds. 
Some of them, including opium, prussic acid, and alcohol, act on 
the brain, suspending sensibility and voluntary motion, and causing 
death by causing the breathing to cease. Others (as digitalis and 
tobacco) act immediately on the nerves of organic life, and cause 
death by stopping the motions of the heart. Now there is a poison 
belonging to the former class, called wourali or woorara, which 
was brought to England by Mr. Waterton from Guiana, where the 
natives use it to poison their arrows, and which, when introduced 
in inconceivably minute quantities into the circulation, instantly 
suspends the functions of the brain; sensibility and consciousness 
are lost, and the movements of respiration cease. But the heart 
continues to beat for a little while after this apparent death, and if 
respiration be kept up artificially, so as to maintain the purity of 
the blood, the heart will continue to beat, and after a time the 
nervous system will recover its suspended faculties, and life will 
be restored.! Animals have been repeatedly subjected to the 
action of this poison, and have been restored to perfect health 
afterwards and Mr. Sewell has tried it in two instances on ani- 
mals affected with tetanus, and with perfect success ;§ for the 
nervous system, when it recovered from the poison, was perfectly 
free from the disease. The same practice has therefore been pro- 
posed by Mr. Morgan to be hazarded in the human subject when 
afflicted with hopeless tetanus;-the poison to be introduced into 
a small wound in the finger,-a ligature to be placed above, so as 
to regulate its admission into the system; (it acts in fifteen seconds;) 
and as soon as apparent death has ensued, artificial respiration to 
be kept up assiduously till signs of reanimation appear. And in a 
hopeless case the experiment would certainly be justifiable. || 
Chronic Tetanus is very seldom fatal, although in some rare 
instances the patient has died completely exhausted by its long 
continuance; for it sometimes lasts several weeks. The principal 
remedies are aperients, tonics, and the shower-bath. The bowels 
should be kept freely open, but the indiscriminate exhibition of 
* Lancet, May 29, 1824. 
f An ass that was experimented on in this manner in 1814, died in 1839 at 
Walton Hall. Vide Waterton's Wanderings; and Brodie's papers, Phil. Trans. 
1811, p. 178, and 1812, p. 205. 
4 Human beings poisoned with opium or alcohol have often been saved by 
artificial respiration. 
§ But unfortunately one of the animals, a horse, died subsequently of repletion, 
and the other, an ass, of inanition. 
|| A most unique and preposterous remedy is recorded in Trnka, (Op. Cit. p. 
444.) A ship was trading on the coast of Angola in 1763, and a native boy, who 
was ill with tetanus, had been treated for some days without benefit by the ship's 
doctor. His case was considered hopeless, when one of the savages cured him in 
the following extraordinary manner. He made a small wound in the thigh, into 
which he inserted a pipe, and then blew with all his might, till the whole body was 
inflated with emphysema. Strange to say, the boy recovered from that moment. 40 
acute tetanus. 
drastics should be avoided. Electricity, in the form of sparks, or 
weak shocks down the spine, would probably be of service.* 
Trismus Infantum is a form of tetanus which is almost unknown 
in England. It was formerly, however, exceedingly prevalent in 
Ireland, and appears to be met with there occasionally even at 
present. It carries off a vast number of children in the West India 
Islands; and we learn from Dr. Holland, that in the desolate rocky 
Vestmann islands, on the south coast of Iceland, one hundred and 
eighty-six infants perished of it in twenty-five years, although the 
population does not exceed one hundred and fifty souls. The 
causes appear to be, want of ventilation, and filth, or the innutri- 
tious and unwholesome diet of the parents, such as the fish and 
sea-bird eggs that form the only sustenance of the Vestmann 
islanders; and the use of irritating applications to the wound left 
by the falling off of the naval string. The time at which the dis- 
ease appears is generally from the fifth to the tenth day after birth; 
hence the popular Irish term, nine-day fi ts. 
The symptoms are, locked jaw, spasmodic difficulty of breathing 
and swallowing, and general convulsions. They are almost inva- 
riably attended with diarrhoea, and preceded by fretfulness, start- 
ings during sleep, and unusual greediness for the breast. 
Treatment of any kind is seldom successful; but it may be pre- 
sumed that the warm bath, four or five doses of calomel (gr. i.-ii.) 
at intervals of four or five hours, a tea-spoonful or two of castor oil 
to clear the bowels, and minute doses of laudanum (one-eigthth of 
a minim cautiously increased) every two hours afterwards, are the 
measures most likely to be of service.! 
Hysterical Tetanus. It is one characteristic of hysteria, that 
it frequently assumes the more palpable outward symptoms of va- 
rious diseases, so as to simulate them pretty completely, although 
proper investigation may always detect the real features of hysteria, 
under any mask whatever. Thus an hysterical female may be 
seized with stiffness of the muscles of the face and jaws, which may 
extend to the neck, and gradually invade the trunk and limbs, so 
as completely to close the mouth, and render the whole body rigid 
and motionless. The chief points of diagnosis are, the hysterical 
state of the mind; and the fact that the muscular contraction, how- 
ever great, may almost always be overcome for the moment by 
forcing the patient to exert her volition. The best remedies are, 
warm aloetic purgatives, and turpentine enemata, and valerian, 
galbanum, and other antispasmodics of that class. 
* Holland, Med. Notes and Refl.; and Addison on Electricity in Convulsive Dis- 
eases, Guy's Hosp. Rep. vol. ii. 
f See a paper by Joseph Clarke, M. D., in Med. Facts and Obs. vol. iii., Lond. 
1792; Dr. Holland's Med. Notes and Reflections, 2d ed. p. 29; Maunsell and Evan- 
son on Diseases of Children, 4th ed. Dublin, 1842, p. 219; and Maxwell on Yaws 
and Tetanus, Edin., 1839. PART II. 
OF THE PRINCIPAL PROCESSES OF LOCAL DISEASE. 
CHAPTER I. 
OF THE GENERAL PHENOMENA OF INFLAMMATION. 
Definition.-Inflammation may be defined to be a state of 
increased vascularity and sensibility, with a tendency to morbid 
secretion and change of structure.* 
Symptoms.-The symptoms are redness, pain, heat, and swelling, 
with impaired function of the inflamed part;-and each of these 
symptoms requires a few observations in detail. 
(1.) The redness is owing to the increased quantity of blood in 
the inflamed part; so that the smallest capillaries are distended with 
red particles, and rendered visible to the naked eye. When in- 
flammation is acute, the redness is of the bright scarlet tint of arte- 
rial blood; when chronic, it is of a dark venous hue ; and in certain 
specific inflammations it is purple or copper-coloured.t Again, in 
common inflammation it is gradually diffused, and lost in the neigh- 
bouring parts, whilst it is abruptly circumscribed in some forms of 
specific inflammation.^ There are several terms used by authors 
to express the varieties, degrees, and appearances of redness.§ 
Thus, 1. It is called ramiform, when seated in the small arteries 
and veins only, and not in the capillaries. 2. It is said to be capil- 
liform when some of the capillaries are also distended. 3. It is 
nniform, when all the capillaries are injected; as in erysipelas. 
4. It is punctiform when occurring in minute dots; as when the 
villi of a mucous membrane are injected, but not the mucous tissue 
itself. 5. It is called maculiform, when the blood is either ex- 
tremely accumulated, or else extravasated at certain points. This 
form of redness accompanies haemorrhagic inflammation. 
(2.) The pain of inflammation may be attributed partly to a 
stretching of the nerves by the distended blood-vessels, partly to a 
disorder of sensation, accompanying the disorder of nutrition and 
function. It is occasionally the first element of inflammation pre- 
• P. H. Berard, Diet, de Med. vol. iii. Paris, 1837. Perhaps it would be more 
correct to reverse the terms of the definition, and say that it is a state in which 
there is a tendency to morbid secretion and change of structure, accompanied by 
increased vascularity and sensibility. 
f The dusky hue is probably caused by some effusion under the cuticle, which 
generally peels off afterwards. Macartney on Inflammation, Lond. 1838, p. 17. 
t Hunter's Works by Palmer. Vol. iii. p. 330. 
§ Carswell, Illustrations of the Elementary Forms of Disease. Lond. fol. 1837. 42 
GENERAL PHENOMENA OF INFLAMMATION. 
sent; preceding the existence of vascular disturbance. It differs in 
its character and intensity according to the cause producing it, and 
the part which is affected. Thus it is burning or tingling in the 
skin ; throbbing in the cellular tissue; sharp and lancinating in the 
pleura; a mere sense of heat and soreness in the bronchial mucous 
membrane ; and extremely dull and oppressing in a part supplied 
with ganglionic nerves; as the stomach, kidneys, or testicles. It is 
always less severe if the fluid products of inflammation can readily 
escape, than if they are confined;-and comparatively slight if the 
part inflamed be yielding and extensile, but most severe if it be 
hard and dense, as bone or ligament; although these structures pos- 
sess very little sensibility in health. It is also in general greater in 
common inflammation than in specific, with the exception of the 
gout. It is sometimes felt at a distance from the inflamed part; 
thus pain in the shoulder is often the first symptom of inflamed 
liver, and pain in the knee of diseased hip. Lastly, it may be 
entirely absent; as where inflammation occurs in a healthy consti- 
tution, and merely produces adhesion; so that adhesions are often 
found between the pleurae after death, that never were suspected 
during life ; or where inflammation, although disorganizing, is very 
insidious and indolent, as in scrofula ; or where the patient's mental 
and physical sensibilities have been benumbed by the habitual use 
of intoxicating liquors.* 
(3.) The heat of inflammation was supposed by Hunter to be a 
mere effect of the increased afflux of blood. For it is most re- 
markable in inflammation of those parts which are furthest from 
the heart, and naturally the coldest; and in them it often does not 
rise so high as the mean temperature of the blood;-whilst in in- 
flammation of internal parts, whose heat is uniform, and not de- 
pressed by externa] vicissitudes, it sometimes does not rise at all. 
We may however suppose with Liebig, that, together with this in- 
creased afflux of blood, there is also a more rapid oxydation of the 
tissues of the inflamed part, which will of necessity produce a greater 
evolution of lieat.t 
(4.) The swelling is caused at first by the increased quantity of 
blood, and subsequently by the effusion of serum, blood, lymph, 
and pus. It is most remarkable in loose textures; also in the breast, 
testicle, and lymphatic glands. 
(5.) The impairment of function which inflammation produces, 
consists at first in an increased irritability and morbid sensibility of 
external impression; but, subsequently, of an utter incapability of 
performing the usual offices, in consequence of structural change. 
(6.) Inflammation may produce every possible alteration of 
secretion. First, in quantity; secretion is invariably diminished 
at the commencement of inflammation, but often increased at its 
close, as is the case with mucous membranes. Secondly, in chemi- 
* Latham, Lectures on Subjects connected with Clinical Medicine.-Leet. iv. 
f Berard, op. cit.; James on Inflammation, p. 239; Macartney, op. cit. p. 14; 
Latour, Revue Med., Jan. 1840; Leibig, op. cit. p. 254. GENERAL PHENOMENA OF INFLAMMATION. 
43 
cal composition;-as the tears which in certain cases become hot 
and scalding, and excoriate the cheek. Thirdly, the secretions 
may be mixed with the products of inflammation; thus mucus is 
often mixed with blood, serum, lymph, and pus. 
(7.) Alteration in Structure.-Inflammation is capable of 
altering all the mechanical qualities of parts. 1. The toeight is 
always increased if the inflammation be recent, and if it have not 
existed long enough to induce atrophy. 2. Cohesion or hardness 
is always diminished in acute inflammation, although this is apt to 
be overlooked in consequence of the increased density. This soft- 
ening arises from the effusions which infiltrate the tissues. Hard- 
ness may be increased in chronic inflammation ; sometimes because 
the whole bulk of the part is shrunken ; sometimes because of the 
organization of lymph. Hardening from chronic inflammation was 
formerly termed scirrhus; and the term is still used in this sense by 
the French, although it is far better to employ it solely to designate 
a definite malignant disease. 3. Transparency and polish are 
always impaired. 
Morbid Anatomy.-The ordinary post-mortem appearances of 
recent inflammation are, redness, softening, swelling, and infil- 
tration with serum. It is necessary, however, to make a few ob- 
servations respecting these phenomena, and especially concerning 
redness; because, in the first place, it may disappear altogether after 
death-secondly, it may be simulated by redness from congestion 
which existed during life-and thirdly, it may be simulated by cer- 
tain appearances produced after death. 
In the first place, then, redness, if very slight, may disappear 
from inflamed skin after death; but if the blood-vessels were in- 
jected, the vascularity would be found increased; besides that the 
part would be softened, and slightly infiltrated with serum, and that 
the epidermis would peel off more readily than natural. 
Secondly. Redness may have been caused during life, not by in- 
flammation, but by congestion, from an obstacle to the return of 
blood; and congestion may also be attended with softening, and 
serous effusion, so that in some instances it cannot be distinguished 
at all from inflammation, and in others not with certainty. The 
general distinction is, that in congestion the larger veins are dis- 
tended more than the capillaries, and previously to them; whereas 
it is the reverse in inflammation. The diagnosis will be aided by 
observing whether there is any cause of obstruction to the venous 
circulation.* 
Thirdly. The redness of inflammation may require to be distin- 
guished from certain appearances produced after death. And these 
may be produced, (1.) By the action of the capillaries, which con- 
tinues after that of the heart has ceased; so that the arteries are 
emptied, and the blood accumulated in various internal organs, 
especially the lungs and spleen. (2.) By gravitation; by which 
the most depending parts of the body, and especially of the lungs, 
* Andral, Anatomie Pathologique, tom. i. p. 56. 44 
GENERAL PHENOMENA OF INFLAMMATION. 
are always more or less congested. (3.) By transudation of the 
serum and colouring matter through the coats of the vessels in 
incipient putrefaction; which is a frequent cause of red spots and 
stains on internal surfaces, and of collections of bloody serum in the 
various cavities. But the author's space does not permit him to 
dilate upon these topics; they are merely adverted to for the pur- 
pose of showing, that redness, swelling, softening, and serous eflu- 
sion must not be hastily received as evidences of inflammation, 
unless accompanied by some more decided effect, such as lymph 
or pus; seeing that they may be produced by other causes, both 
before death and after it. 
Effects and Terminations.-Inflammation has only one gen- 
uine termination, namely, resolution, or recovery; the inflamma- 
tory action subsiding, and the part returning to its former state;- 
but, beside resolution, it may have either of the following six ter- 
minations, or effects, or consequences, as they ought rather to be 
called. 1. Haemorrhage; an escape of blood from the distended 
vessels. 2. Effusion of serum. 3. Effusion offibrine, or of coagu- 
lable lymph, constituting adhesion. 4. Suppuration, the forma- 
tion of a peculiar fluid called pus, closely allied with which is the 
change called ramollissement, or softening. 5. Ulceration; the 
disappearance or removal of the inflamed part. 6. Mortification, 
or its death. To each of these effects a chapter will be devoted.* 
Forms of Inflammation.-Inflammation may be divided- 
1. Into healthy and unhealthy,-the former being that which natu- 
rally ensues in healthy constitutions, when a part of the organiza- 
tion is impaired ;-being restorative in its tendencies, injurious only 
if excessive or misplaced, and usually concentrated towards one 
point: whereas the unhealthy is essentially destructive, has little or 
no spontaneous tendency to recovery, and is liable to be diffused 
widely. 2. Into common and specific; the common arising from 
ordinary causes acting on healthy constitutions;-the specific aris- 
ing, either because the constitution is unsound, as in scrofula, so 
that (to use Hunter's words) it gives or reflects back upon the part 
inflamed a diseased disposition or action;-or because it is produced 
by a cause which is specific; as the poisons of small-pox or syphilis. 
3. It may be divided into acute and chronic; the acute being sud- 
den in its seizure, violent in its action, and rapid in its progress;- 
the chronic being less violent and more tardy. Acute inflamma- 
tion is sometimes called active; and the term passive is applied to 
chronic inflammations in weak constitutions. 4. It may be classi- 
fied according to its tendency to produce particular and local effects; 
thus we speak of adhesive, suppurative, haemorrhagic, ulcerative, 
and gangrenous inflammation.' 
Modifications.-Inflammation always is modified by the state 
of constitution in which it occurs; being active and rapid in the 
* It must be understood that, except suppuration and adhesion, these effects may- 
all be produced by other causes besides inflammation-congestion in particular 
may cause haemorrhage, serous effusion, ulceration, and gangrene. GENERAL PHENOMENA OF INFLAMMATION. 
45 
young and healthy, but more indolent, and tending to destructive 
processes (such as ulceration and mortification) in the aged and 
debilitated. It also presents divers variations, according to the 
cause producing it; and will be greatly influenced by the epidemic 
constitution of the air. It is further modified by the structure of 
the parts which it invades; for it has a greater tendency to produce 
certain effects in some structures than in others. Thus in the serous 
cavities and cellular tissue, parts which have no natural outlet, it 
is more disposed to produce adhesion than suppuration. But on 
the mucous membranes, it tends to produce suppuration before ad- 
hesion ; because suppuration is but a trifling evil, compared with 
the danger that would ensue if the mucous canals were closed by 
adhesive matter, from the slight inflammations to which they are 
perpetually subject. Yet if inflammation be of extreme violence, 
or if there be something particularly morbid in its cause or in the 
constitution, the natural precedence of these two effects will be in- 
verted. Thus in violent inflammation of mucous membranes, as 
croup, lymph is poured out on the surface ;-and inflammation of 
the cellular tissue, arising in a vitiated habit or from a morbid poi- 
son, may induce a diffuse and widely spreading suppuration, which 
is not limited by adhesion; as, for example, in phlegmonous ery- 
sipelas and the disease arising from dissection wounds.* 
Predisposing Causes.-The predisposing causes of inflamma- 
tion may be constitutional or local. The constitutional predispos- 
ing causes are plethora, the sanguine temperament, excess in food, 
drink, bodily exertion, and exposure to noxious miasmata. When 
inflammation arises from these causes alone, it is said to be spon- 
taneous or idiopathic, or constitutional. The local exciting causes 
are chiefly over-stimulation or exertion beyond power; besides pre- 
vious disease, and original weakness of organization. 
Exciting Causes.-The exciting causes may be divided into 
two classes. 1. Those which act primarily on the structure of a 
part,-as mechanical and chemical injuries of all sorts. 2. Those 
which act primarily on its functions and vital endowments,-as 
over-exertion ;-and the poisons, such as cantharides, which affect 
living matters only. The former class act directly; that is, they 
inflame the part which they are applied to : the latter class may act 
indirectly; just as cold applied to the feet causes inflammation of 
the lungs. The former also act immediately; whilst some of the 
latter may take some time (which is called the stage of incubation) 
to produce their effects. Lastly, causes may be common or spe- 
cific;-the former being those which are daily met with, and which 
can act on all constitutions;-the latter being unable to affect all 
constitutions, being peculiar in their origin, and producing a modi- 
fied inflammation, with a specific train of consequences. The 
vaccine virus may be an example. 
Diagnosis.-It must be understood that both the blood-vessels 
* See John Hunter's observations on Erysipelatous Inflammation, in Palmer's 
edition of his works, vol. iii. 46 
GENERAL PHENOMENA OF INFLAMMATION. 
and nerves are concerned in inflammation;-it must also be under- 
stood, that although either of these elements, if disordered, will 
tend to implicate the other, still that one of them may for a long 
time be deranged solely. Inflammation, therefore, requires to be 
distinguished from disordered action of the blood-vessels merely, 
or hyperxmia-in the forms of congestion and determination of 
blood-and from pain caused by disordered nervous influence. 
(a} Congestion signilies an accumulation or stagnation of venous 
blood in a part, which may be caused by some mechanical obstacle 
to its return; or by weakness and atony; it is a very frequent 
sequel of inflammation. It produces more or less weight and pain, 
with disturbance of function, especially of secretion; but it does 
not cause fever like acute inflammation, nor interstitial deposition 
like chronic; although it may terminate in either.* 
(5) Active determination of blood is produced by a dilatation 
and expansion of the capillaries, whereby they attract more blood 
to a part, and circulate it more rapidly. It is a process necessary 
to many natural actions; as, for instance, the enlargement of the 
womb during gestation, and the secretion of milk after delivery; 
-blushing affords a very familiar example of it. When morbid, 
it causes excitement and functional derangement. Instances of it 
are seen in the injected capillaries of the intestines in cholera, and 
in headaches from excitement;-in many cases it is the first stage 
of incipient inflammation. 
(c) Irritation of the nerves, or neuralgia, is a peculiar state, 
attended with severe pain and tenderness. The irritable breast, 
irritable testicle, tic douloureux, neuralgic toothache and headache, 
and the mock inflammations which occur in weak, irritable, and 
hysteric subjects, (especially from abuse of blood-letting,) are ex- 
amples. The pain of nervous irritation may in general be distin- 
guished from that of inflammation, by its sudden accession and 
subsidence;-by its being often relieved by measures that would 
aggravate inflammation, such as pressure, friction, and stimulants; 
by the pain being severe out of all proportion to heat, redness, and 
swelling, even if they exist at all; and by the circumstance that 
although the pain may last for weeks or months, no local disorgan- 
ization or suppuration follows. 
Theory of Inflammation.-It is not compatible with the scope 
of this work to give a detailed account of the various theories that 
have been invented respecting the proximate causes or essential 
nature of inflammation. Of the older writers, some attributed it 
to a lentor or viscidity of the blood;-others to an error loci, that 
is, an obstruction of the capillaries by the entrance of globules too 
large to pass through them. Cullen supposed that it consisted in 
spasm of the extreme vessels. Hunter ascribed it to an increased 
action;-Wilson Philip and Hastings to a debility;-Henle to a 
* The red noses of drunkards present instances of permanent congestion, dis- 
tinct from inflammation. GENERAL PHENOMENA OF INFLAMMATION. 
47 
paralysis;-and Mr. J. W. Earle to an obstruction of the capil- 
laries. 
Dr. Macartney considers that the proximate cause of inflamma- 
tion is a sense of injury felt by the organic nerves; and shows that 
inflammation after an injury may often be prevented by soothing 
and allaying this nervous irritation, and inducing a comfortable 
state of feeling. 
Mr. Wharton Jones believes that the red globules have an unna- 
tural attraction for each other, and for the sides of the capillaries. 
Nor must we omit to mention Liebig's theory, that there is an 
unusually rapid union of the tissues of the inflamed part, with the 
oxygen carried by the arterial blood. But as far as the author is 
capable of judging, Dr. Bennett has made one step towards the 
solution of the mystery by considering inflammation merely as one 
mode of deviation from healthy nutrition, and examining in what 
respects it differs from the process in health. He shows that as in 
health the liquor sanguinis exudes through the capillaries into the 
interstices of tissues, furnishing materials for the formation of cells 
which may be developed into bone, muscle, and so forth;-so in 
inflammation the liquor sanguinis which exudes from the dilated 
capillaries, forms a blastema? or formative fluid for the develop- 
ment of morbid cells:-in some cases the small corpuscles called 
exudation cells, which are found in parenchymatous organs when 
hepatized ;-in others the plastic cells found in adhesive matter;- 
in others, pus-corpuscles; in others again, the irregular cells of 
cancer and other morbid growths. He considers inflammation 
therefore as only a part of one great morbid action which may be 
called abnormal nutrition; and more especially that species of it 
which depends on increased exudation of liquor sanguinis;-and 
shows that what are considered the cardinal symptoms of inflam- 
mation, namely, heat, pain, swelling, and redness, are merely con- 
sequences, partly of the exudation, partly of the hypersemia which 
precedes it. 
With regard to the processes that actually occur in the inflamed 
part, many statements have been promulgated, that appear to be 
totally contrary to fact, and to have arisen from ill-devised micro- 
scopical experiments. It is well known, for instance, that after the 
application of a red-hot needle or of some acrid salt to the web of 
the frog's foot, or the fins of fishes, the capillaries may be seen to 
become dilated and loaded with blood, which moves in them very 
slowly, and at last coagulates and does not move at all: and it 
has been concluded that these phenomena are inflammatory, and 
consequently that a retardation of the circulation is the essential 
element of inflammation. M. Latour, however, has shown satis- 
factorily, that this coagulation is merely the chemical effect of the 
heat, acids, or other irritating matters employed to create the so- 
called inflammation; and besides Latour, Gulliver, Macartney, and 
* EXaj-nj^a, germen,- germino, pullulo. 48 
ACUTE INFLAMMATION. 
other late authors of good credit, affirm most positively, that it is 
impossible to excite inflammation in cold-blooded animals at all. 
The facts that seem to be the best established are the following: 
-That in the capillaries of every acutely inflamed part, and the 
larger vessels in its vicinity, the blood is circulated with preterna- 
tural rapidity and abundance; that this vascular excitement is 
followed by exudation of serum or lymph through the capillaries 
into the interstices of the part; or perhaps by rupture of the capil- 
laries and extravasation of blood; that subsequently, in the focus 
of the inflammation, the blood stagnates, and the red globules 
adhere to each other, and to the sides of the capillaries. And that 
if the inflammation continue, the tissues become completely broken 
down and disorganized at the points where the inflammation is 
most intense, and that pus is formed out of the exuded lymph;- 
or if the inflammation increases in severity, the blood ceases to 
circulate in the vessels, the tissue becomes soft and flaccid, and in 
fact mortifies. * 
CHAPTER IL 
OF ACUTE INFLAMMATION. 
Definition.-Acute inflammation is that which is sudden in its 
origin, violent in its action, and rapid in terminating; and it is 
attended with fever, either if it be considerable in its extent, or if 
it affect parts of great sensibility and importance, or if the consti- 
tution be highly irritable. 
Treatment.-In the treatment of acute inflammation and its 
attendant fever, the indications are, to reduce the increased action 
of the heart and arteries; to allay pain and nervous excitement, 
and to restore the secretions. The chief means are, evacuants, 
sedatives, and narcotics. 
(1.) Blood-letting,! Objects of.-The first and most important 
• Vide Cullen's First Lines, book ii. chap. i. sect. 2; Hunter on the Blood; 
Thompson's Lectures on Inflammation; Gendrin, Histoire Anatomique des Inflam- 
mations; Andral, Anatomie Pathologique; Wilson Philip's Treatise on Fevers, and 
Experimental Inquiry into the Laws of the Vital Functions, 3d ed.; Mayo's Out- 
lines of Physiology, 5th ed.; the Papers by Mr. J. W. Earle in Lond. Med. Gaz. 
vol. xvi.; Latour, op. cit.; Macartney, op. cit.: Gulliver, Phil. Mag. Sept. 1838; Kal- 
tenbrunner de Statu Vasorum et Sanguinis in Inflammatione, 1826; T. Wharton 
Jones in B. and F. Med. Rev., Oct. 1842; Liebig, op. cit.; Bennett, Lond. and Ed. 
Jour. Med. Sc., Dec. 1842; and the Lecture on Inflammation in Graves's Clinical 
Medicine. 
t [On the subject of blood-letting, the surgical practitioner should always bear 
in mind the difference between the suppression of inflammatory action and the 
prevention of it, in determining the extent to which he may safely carry the means 
of depletion and depression. 
In the case of a healthy man, for instance, who has received a wound involving ACUTE INFLAMMATION. 
49 
measure is general blood-letting;-which, if carried far enough, 
induces a state of insensibility, and suspended circulation, to which 
the name syncope, or fainting, is given. Now it requires to be 
understood, that this suspension of the heart's action depends upon 
two causes; first, on the abstraction of its natural stimulus, the 
blood;-secondly, and principally, on a peculiar sedative influence 
transmitted to it from the brain, when the latter does not receive its 
due share of arterial blood. And although the mere loss of blood 
per se may be of service (when that fluid is morbidly abundant) 
by relieving the system from a source of excitement, still the prin- 
cipal good effects of bleeding in inflammation depend on its seda- 
tive effects on the brain, and through the brain on the heart. And 
as it is often absolutely necessary to bleed persons in acute diseases 
who are extremely debilitated, it is of importance to produce as 
much of that sedative effect with as little loss of blood as possible. 
Manner of Bleeding.-For this purpose the blood should be 
drawn as quickly as possible, from a large orifice; and, above all, 
the patient should sit or stand upright. For if the blood is drawn 
slowly, so that the vessels have time to adapt themselves to their 
diminished contents, or if the patient is in the recumbent posture, 
so as to assist the flow of blood to the brain, the bleeding may be 
continued almost to death without the occurrence of faintness. 
Quantity to be taken.-As a general rule, the blood should be 
permitted to flow till paleness of the lips, lividity about the eyes, 
sighing, nausea, fluttering pulse, and relief of the pain, indicate the 
approach of syncope ; but full syncope should always be avoided, 
for reasons that will presently appear. Then the patient may be 
suffered to lie down, and should be kept perfectly quiet, without 
any attempts to restore the circulation by stimulants,-that so the 
inflamed capillaries may resume their natural calibre, whilst re- 
lieved from the influx of the circulation. 
< Tolerance.-The tolerance, or power of bearing bleeding with- 
out fainting, varies according to the age, sex, and temperament of 
the patient. It is less in the very young and old than in the 
either of the cavities of the trunk, where it is of the utmost importance to prevent 
inflammation, the lancet may be employed largely and frequently, the practitioner 
being careful only not to reduce the organic energies below the point at which 
immediate union of divided parts may be effected. But, violent reaction having 
taken place-inflammatory processes being fairly established, whether in spite of 
blood-letting, or by default of its more seasonable employment, the utmost discre- 
tion is necessary in the use of this potent means of subduing inordinate vascular 
action. 
The circumspect practitioner will have in view the various consequences of 
inflammation which he cannot hope altogether to avert, and most of which require 
a good deal of constitutional vigour in the patient, to dissipate or render them 
harmless. 
Of all therapeutical appliances there is none in which art ventures on such 
extreme liberties with nature as in this of blood-letting, and unfortunately there 
are few in regard to which the principles that are to regulate its administration 
are so unsettled and contradictory. Those which are briefly stated in the text, are 
the most approved and important the authorities furnish. F.] 50 
ACUTE INFLAMMATION. 
middle-aged;-less in the female than in the male;-and less in 
the nervous and lymphatic temperaments than in the sanguine and 
phlegmatic. But the tolerance, is besides affected most remarkably 
by the existing disease. Thus it has been ascertained by Dr. Mar- 
shall Hall, that 15 oz. is the average quantity that will produce 
syncope in an adult if healthy; but that in some diseases much 
more requires to be taken, and in others much less. 
The diseases in which bleeding is best borne, are inflammations 
of the head, or of other wital parts. Those in which it is most 
injurious and worst borne, are putrid fevers and diseases of de- 
bility. And so, an observation of the tolerance is sometimes a 
very important aid to diagnosis. Supposing a woman to complain 
of violent pain in the head or abdomen, which is suspected to be 
inflammatory. If faintness occurs from the loss of a very small 
quantity of blood, it will be certain either that it is not inflamma- 
tory, but nervous ;-or, that if inflammatory, it must be treated by 
other measures than blood-letting. But the junior practitioner 
must bear in mind that he may occasionally meet with some thin, 
bloodless patients, whom it would be very injurious to bleed, but 
who, nevertheless, from some peculiarity of constitution, do not 
faint, even though bled to excess. 
Reaction.-After the depressing effects of bleeding there naturally 
ensues a degree of reaction; the pulse rising in frequency, and the 
local pain returning; and this reaction will be the greater if the 
venesection has been carried to the extent of producing full syn- 
cope ;-hence the importance of stopping short of this point. This 
reaction is, if possible, to be prevented by the sedatives, which we 
shall mention presently; but if, notwithstanding, well-marked in- 
flammatory symptoms return, the bleeding must be repeated till the 
disease- is permanently vanquished,-provided that the strength 
permit. 
Indications for Bleeding.-But as general venesection is not to 
be resorted to indiscriminately in every case of acute inflammation, a 
few words must be added on the principles that regulate its em- 
ployment. And there are three things to be considered; viz. 1st, 
the patient's strength, and state of his constitution ; 2dly, the part 
affected; 3dly, the nature and amount of the injury or exciting 
cause which has produced the disease. 
(1.) With regard to the state of the constitution: bleeding is most 
required, and best borne, when the temperament is sanguine, or 
that mixture of the sanguine and phlegmatic termed rustic;-when 
the muscles are large and firm;-when the blood-making powers 
are vigorous and the circulation strong, as indicated by redness of 
the face and lips, and by a full, hard, and frequent pulse. On the 
other hand, it will be borne worse when the muscles are large and 
flabby, and the pulse habitually open, soft, and full. And it will 
be borne worst of all, when the complexion is sickly and pale,-the 
pulse quick, small, and feeble,-the lips, conjunctiva, and tongue 
pale. And if there should happen to be a state of passive dilatation 
and weakness of the heart, syncope would most likely be instantly acute inflammation. 
51 
fatal;-and if there should be any organic disease which impedes 
the formation of blood, its loss is liable to be followed by irrecover- 
able sinking and exhaustion. Fat people generally bear bleeding 
worse, and in fact contain less blood, proportionably to their bulk, 
than those of a spare, lean habit and rigid fibre. 
The propriety of a second bleeding must in a great measure be 
determined by the effect which the first has had on the pulse ; for 
if that be more frequent and quick, or more sharp and jerking, in- 
stead of slower and softer, it would seem that the bleeding had dimi- 
nished the strength more than it had reduced the disease. The state 
of the blood must also be regarded; for if the surface of the coagulum 
be flat, and its consistence loose, it is a sign that the vital powers 
are depressed; that further bleeding will be injurious; and that the 
case must be committed to the other antiphlogistic powers. 
(2.) Respecting the part affected, it may observed, that the 
necessity for venesection, and its beneficial effects, will be greater 
in proportion as the tolerance is greater,-and that it would be in- 
dispensable where the organ affected is important to life, or to its 
enjoyment; whilst it might not be so, if an equal degree of inflam- 
mation affected an unimportant part,-and that its good influence in 
inflammation of a vital organ will often be marked by a rise in the 
strength and in the fulness of the pulse. 
(3.) With regard to the nat ure of the cause: bleeding is not well 
borne when that is such as to produce great depression of the vital 
powers, as in the case of dissection wounds;-nor when the inflam- 
mation itself causes great depression, as in phlebitis;-nor in the 
case of an injury requiring great constitutional efforts for its restora- 
tion, as a compound fracture;-nor if the disease be advanced 
towards suppuration or gangrene. 
II. Evacuant Sedatives.-Under this title may be included a 
number of antiphlogistic remedies, which reduce vascular excite- 
ment, either by increasing certain secretions, or by some specific 
lowering agency independent of any evacuation,-most of them 
being capable of acting in both manners, (a) Purgatives are ad- 
missible at the commencement of all cases, except when they would 
cause irritation or disturbance of a diseased or injured part, as might 
be the case in wounds of the alimentary canal, and in compound 
fracture. Those should be selected which excite free secretion from 
the liver and intestines, and evacuate them rapidly: such as a good 
dose of calomel, followed by F. 4. (6) Mercury* reduces the heart's 
action, restores the secretions, and excites the absorption of diseased 
products; it is chiefly advantageous in idiopathic inflammations of 
serous structures, with a tendency to adhesion. But when the 
nature of the disease and state of the pulse demand blood-letting, 
* [I am disposed to think that very seldom if ever, shall we realize any advantage 
from the administration of mercurials in inflammations occasioned by mechanical 
injuries, involving only the textures, usually the subjects of such injuries. 
I have long since ceased to use it myself in such cases, and generally when I 
have seen it employed by others, it has proved to be any thing but antiphlogistic in 
its effects. F.] 52 
ACUTE INFLAMMATION. 
mercury cannot be regarded as a substitute, but only as an auxiliary; 
and, if employed to the neglect of bleeding, will most likely do more 
harm than good.* The best form for its administration is calomel, 
of which from one to five grains maybe given, at intervals of from 
two to six hours, till a slight affection of the mouth is manifested, 
which should be kept up by smaller doses if necessary; but all 
violent salivation is an evil. The calomel should be combined with 
opium or hyoscyamus, to prevent it from purging too freely, (c) 
Antimony is another direct antiphlogistic; it may be administered 
in doses of 8-2 grain, with each dose of calomel and opium; in 
larger doses, such as gr. ii., it is a most potent remedy, especially in 
pneumonia; it does not cause vomiting after the first few doses, but 
exerts its sedative influence without producing an evacuation, (rf) 
Colchicum is a remedy of precisely the same character; it is most 
useful in gouty and rheumatic affections. It may and frequently does 
produce bilious stools; but it is a vulgar error to suppose that they 
are indispensable to its good effects, (e) Nitre and the other salines, 
as in F. 5, may also be given with great advantage; they abate heat 
and thirst, purify the blood, and increase the secretion of urine. 
III. Sedatives not evacuant.-These remedies reduce fever 
and inflammation, by acting on the nervous system without increas- 
ing the secretions ; they are hyoscyamus, conium, and digitalis, the 
two first of which in particular are of eminent service, when com- 
bined with calomel and antimony, (F. G,) to prevent reaction, and 
soothe pain in inflammatory cases attended with great nervous irri- 
tability. 
IV. Narcotics. - Opium primarily decreases the secretions, and 
increases vascular excitement; hence it must not be given in acute 
inflammation till after bleeding; but then a large dose (such as gr. ii.) 
may be given in combination with five of calomel, to allay pain and 
prevent reaction. But it is the sine qud non, and may be given 
without reserve in inflammations occurring in very debilitated 
habits, such as peritoneal inflammations from perforation of the in- 
testine after fever; or acute inflammations occurring after profuse 
haemorrhage. 
The warm bath acts in every way analogously to opium, and 
requires the same precautions ; viz. as it stimulates before it soothes, 
it must be preceded by evacuations, if the habit be plethoric. The 
proper temperature is 97° Fahrenheit, and it should be continued 
long enough to induce complete relaxation. 
V. Diet.-The diet in acute inflammation should, as a general 
rule, be of the least stimulating nature. But although water-gruel 
and tea might for many days suffice for the robust and plethoric, 
the starving system must not be indiscriminately applied to children, 
or to the old or debilitated; on the contrary, their strength must be 
supported by mild fluid nutriment, arrowroot, beef-tea, &c., and even 
by wine if necessary. 
VI. Regimen.-There must be a total avoidance of every thing 
* Vide Art. Calomel by the Author, in the Cycl. Pract. Surgery. ACUTE INFLAMMATION. 
53 
that would irritate mind or body. Perfect rest in the recumbent 
posture, and in a position as easy as it can be made,-cool air,- 
tree ventilation,-the exclusion of light and sound,-with mental 
consolation to allay doubts and fears, and inspire resignation and 
cheerfulness, are most potent aids to medical treatment, which with- 
out them would often be utterly fruitless. 
Local Treatment.-In the local treatment of inflammation, 
the first thing to be done is to remove all exciting causes, if possi- 
ble, and to place the part at perfect rest, and in an elevated posture, 
so as to favour the return of blood from it;-and then the indica- 
tions are, to diminish the morbid heat and afflux of blood, and to 
allay irritation and pain. 
1. The local means of abstracting blood are leeches, cupping, 
and scarifications. In order to apply leeches, the parts should first 
be washed, and if they will not stick, a little milk or blood should 
be smeared on it, or some small punctures should be made with the 
point of a lancet; and the leeches should be well dried in a cloth. 
The best plan of stopping haemorrhage from leech-bites is to dip 
small pellets of lint in the tinct. ferri sesquichloridi, and press them 
on the holes for a few minutes, or to insert a finely pointed pencil of 
lunar caustic into them. Sometimes it is expedient to touch them 
with a red hot knitting needle, or to stitch them up with a very 
fine needle and silk. But in order to prevent the very serious con- 
sequences that sometimes happen from this source to children and 
delicate persons, directions should always be given that the bleed- 
ing from leech-bites should be stopped before the patient is left for 
the night. Moreover, it will be prudent to apply them over some 
bone, so that the pressure may be applied effectually. Again, 
leeches, if they stick too long, should be removed by touching them 
with salt, and should not be pulled off forcibly, nor should they be 
applied to the eyelids or prepuce, otherwise they will probably be 
followed by cedematous swelling, or even erysipelas. Cupping, 
when it can be adopted, is a more active measure, and relieves pain 
sooner than leeches. Scarif cations or incisions are of use when 
inflamed parts are covered with a dense unyielding fascia, as in 
whitlow; or when there is great tension, as in phlegmonous ery- 
sipelas ; or when the inflamed part is infiltrated with an irritating 
fluid, as in extravasation of urine, or with unhealthy matter, as in 
carbuncle. 
2. Cold applications are of use to diminish heat, and cause con- 
traction of the capillaries; but they should be applied continuously, 
otherwise the pain will be aggravated when the heat returns. The 
best lotion is one containing lead and spirit, as F. 11; it should be 
applied by means of a single piece of thin linen frequently changed; 
and-care should be taken that the vapour may pass off freely, other- 
wise the cold lotion will soon be converted into a hot fomentation. 
In some severe cases, ice or frigorific mixtures (F. 12) may be ap- 
plied in bladders. The following very effectual means of applying a 
continuous degree of cold, is recommended by Dr. Macartney. The 
inflamed limb is to be placed in a trough or piece of oilcloth, with 54 
CHRONIC INFLAMMATION. 
a piece of lint on the inflamed part. A large vessel full of cold 
water being then placed on a table by the bedside, one end of a 
broad strip of cloth should be dipped in the water, and the other 
end (which should be cut to a point) laid on the lint; and so the 
water will be carried in a constant gentle stream down the cloth to 
the inflamed part. 
3. Warmth. Very often cold adds to irritation, and perhaps in 
most cases tepid applications (85° Fah.) are preferable ; for they do 
not stimulate like heat, nor occasion painful reaction like cold, and 
are more directly sedative than either. Warm fomentations (92° 
-98° Fah.) are useful by relaxing the skin, soothing pain, and pro- 
moting perspiration, and are especially indicated in inflammations 
of dense tendinous parts. But in every case the patient's feelings 
should be consulted, and the applications be warm or cold accord- 
ing to his choice. Dr. Macartney very justly insists on the neces- 
sity of producing an agreeable state of feeling in inflamed parts, as 
a means of relieving that sense of irritation in the organic nerves 
which he considers as the point de depart in inflammation. He 
has contrived an apparatus for conveying steam to any part of the 
body, which affords an excellent means of applying heat and 
moisture. It consists of a tube of woollen cloth, three feet long, 
twelve inches wide, and fitted with hoops of whalebone to keep it 
open; one end of it is applied to the part which it is desired to foment, 
the other is tied round the neck of a tin boiler in which the steam 
is generated. 
4. Stimulants, and astringent solutions, are of great service in 
inflammation of mucous membranes, by decomposing and washing 
away their irritating secretions, and inducing contraction of the 
capillaries. 
5. Counter-irritants. Blisters are the best form of counter-irri- 
tants in recent inflammation; but they should never be applied too 
near the seat of an acute disease, and never till its activity has been 
subdued by previous antiphlogistic measures. 
CHAPTER III. 
OF CHRONIC INFLAMMATION. 
Definition.-Inflammation is said to be chronic when it is slow 
in its progress, and tends to last long, or even indefinitely. Its con- 
sequences may be adhesion, thickening, induration, ulceration, or 
suppuration. 
Causes.-Its causes may be local or constitutional. Thus it may 
in the healthiest subjects be caused by any slight and continued CHRONIC INFLAMMATION. 
55 
irritant;-or it may be the sequel of acute inflammation, the vessels 
being left dilated, weak, and irritable. But more frequently it is 
the local manifestation of some constitutional disorder, such as gene- 
ral debility, with a tendency to local congestion,-or over-stimula- 
tion and plethora,-or disorder of some important organ, as of the 
stomach or liver. 
Treatment.-The indications are, to remove all constitutional 
disorder, to allay local irritation, and restore the tone of the dis- 
tended vessels. 
Constitutional Treatment.-On this part of the subject, our 
space forbids us to do more than make a few remarks on the most 
obvious forms of constitutional derangement, which accompany 
chronic inflammation, and on the remedies that are known by 
experience to be most useful as alteratives. 
If the patient is bloated and plethoric, with red lips and conjunc- 
tiva, and a full hard pulse, and indulges freely in stimulating food 
and drink, and has unimpaired digestive organs, so that blood is 
constantly formed in too great abundance, the diet must be lowered 
and restricted chiefly to vegetable substances; free exercise should 
be taken in the air; the bowels should be actively purged with 
calomel and black draught; and then a course of alterative medi- 
cine should be commenced in order to increase the secretions, and 
relieve the system of its superabundant material. Mercury, given 
in small doses at bed-time, with saline aperients in the morning, 
deserves to be mentioned first: Plummer's pill, in doses of gr. v. 
every night, is an excellent form; but in severe and obstinate cases 
it may be necessary to administer larger doses of the mercury so as 
to bring the system fully under its influence; taking care, however, 
to desist at the least appearance of ptyalism, and maintain a gentle 
and Continued, but not violent action. Next to mercury, tartar 
emetic, given in very small doses three or four times daily, F. 103, 
is most deserving of notice ; it is highly advantageous to combine it 
with the mercury, as in F. 104. 
But if the chronic inflammation occur in an enfeebled and irrita- 
ble constitution, (as when it succeeds an acute attack that has been 
too actively treated by bleeding and mercury,) a nutritious and 
liberal diet must be adopted, wine and tonics (F. 26, 53, 62, 63, 
101, 1, 2, 3, 28,) should be administered, in order to improve the 
digestion and vigour of the circulation; irritation and pain must be 
allayed by sedatives and opiates; and the secretions of the bowels 
be maintained by the gentlest laxatives. 
If the tongue is furred and red at its tip and edges, and there are 
heartburn, flatulence, pain at the chest after meals, and other signs 
of a weak and irritated stomach, the diet should consist of the 
plainest and most easily digestible articles; and small doses of alkalis 
(F. 54) may be given after meals, whilst some tonic is given before 
them; and the bowels may be kept open by the compound rhu- 
barb pill. 
If the complexion and eye are sallow, and the stools clay-coloured, 
a few doses of blue pill, with morning aperients, are indicated. 56 
CHRONIC INFLAMMATION. 
When steel or bark is administered, it is always necessary to 
have a proper action of the liver and bowels, otherwise headache 
and feverishness will ensue.* 
If the skin is dry and harsh, it should be stimulated by exercise, 
by warm clothing, especially flannel, by the flesh-brush or horse- 
hair gloves, and by an occasional ten minutes' immersion in the hot 
bath; 92°-102° Fah. 
In females the uterine system must be regulated by the exhibition 
of steel, aloes, galbanum, or other emmenagogues, if necessary. 
Of the alteratives that are most useful in dispelling chronic in- 
flammation, we have already mentioned mercury and antimony; 
next to these in importance is the iodide of potassium, F. 93, 106, 
74,107, IOS, in combination with tonics, sedatives, alkalis, iodine or 
steel, as circumstances may direct. Its powers of unloading con- 
gestion, allaying irritability, and restoring secretion, no one can 
doubt. Alkalis, especially the liq. potasses, are of great service in 
full-blooded people, with scanty red urine; the best rule which we 
can give is, that they will most likely be useful if the face is flushed 
after meals. On the value of sarsaparilla, we shall speak when 
treating of scrofula. Serpentaria and senega are of great service in 
chronic inflammation of mucous membranes. Small doses of cor- 
rosive sublimate in tincture of bark, F. 48, and the liquor arseni- 
calis, F. 109, are also useful in certain cases; but their employment 
is so purely empirical that we cannot give any definite rules on the 
subject. 
Local Treatment.-This has for its objects, to remove exciting 
causes, to unload the distended vessels and make them contract to 
their natural calibre, and to exercise the part in its proper functions, 
so that it may gradually resume the actions and sensations of health. 
Local bleeding must be employed at intervals to unload the ves- 
sels, whilst they must be excited to contract by various stimulants 
and astringents; such as the sulphates of zinc, copper, and alumina, 
nitrate of silver, salts of mercury, &c. The application of cold by 
pumping is often highly serviceable. These or any other measures 
will be known to do good if they make the part feel stronger and 
more comfortable, although their first application may have been 
painful; but if they render it hotter and more vascular, it is a sign 
that they stimulate too highly, and may thus endanger the produc- 
tion of acute inflammation. 
Counter-irritants are more useful in chronic inflammation than 
in the acute, especially those which establish a permanent suppura- 
tive discharge. 
* See the chapter on Scrofula. effusion of serum. 
57 
CHAPTER IV. 
OF EFFUSION OF SERUM. 
General Description.-Effusion of serum, as a local disease, is 
generally produced either by obstruction to the return of venous 
blood, or by inflammation. It is the earliest and most constant 
effect of inflammation, occurring equally into the interstitial cellu- 
lar tissue,-into the parenchyma of organs,-from mucous and 
serous surfaces, and from the skin. If it is followed by any of the 
other effects of inflammation, it is always more widely extended 
than they are. But it may be the chief or only effect of inflamma- 
tion, as in acute dropsy, which is an example of an inflammatory 
state rapidly producing serous effusion into the cellular tissues or 
serous cavities. The serum in these cases is always of greater 
specific gravity, and contains more albumen, than in dropsy from 
debility. In patients of a lax, flabby habit of body, and in parts of 
loose and cellular structure, inflammation always produces more of 
this effect than in those of a firmer texture. 
After inflammation in any part, some degree of oedema is apt to 
remain in consequence of the distension and weakened tone of the 
capillaries; and if the habit be weak, great oedema may arise from 
a very slight cause, as a blister. It must be treated by flannel or 
other bandages, gentle friction, cold affusion, and attention to the 
general health. 
When any parts, especially the legs, are very much distended 
with serum, it may be necessary to evacuate some of it, in order to 
prevent the sloughing of large patches of skin. But instead of 
making scarifications, as was formerly recommended (which are 
almost certain to degenerate into ulcers) numerous punctures should 
be made with a grooved, or acupuncture needle; and they should 
always be made as near the heart as possible. 
GiIdematous Inflammation.-Under this term Hunter describes 
a peculiar form of inflammation terminating rapidly in serous effu- 
sion, which occurs in those who are affected with dropsy, or disposed 
to it. It mostly attacks the lower extremities; the swelling is bright 
red, much diffused, very sore, but not throbbing. It is very apt to 
terminate in sloughing or suppuration, but not adhesion, and is the 
frequent cause of large ulcers on the legs of the dropsical. 
Treatment.-The bowels must be well cleared; but other con- 
stitutional measures (whether antiphlogistic or tonic) must depend 
on the state of the system. The best local application is a tepid 
spirituous lotion (F. 13); leeches should be avoided, as they may 
cause ulceration and sloughing. The needle should be used if there 
is much distension from serum.* 
* Mayo, H., Outlines of Pathology, p. 428; Copland, Diet, of Pract. Med. Art. 
Dropsy; Andral, Anatomie Pathologique, vol. i. p. 320; Hunter on the Blood, 
Palmer's ed. vol. iii. pp. 314, 331. 58 
ADHESIVE INFLAMMATION 
CHAPTER V. 
OF THE ADHESIVE INFLAMMATION, AND THE REPARATION OF 
TISSUES. 
Adhesion, or the Adhesive Inflammation, is a process in which 
the fibrine of the liquor sanguinis is effused, organized, and con- 
verted into some of the normal tissues of the body. It is the means 
by which wounded and fractured parts are united by which loss 
of substance is restored, whether produced by injury or disease;- 
by which cysts are formed for abscesses, so as to prevent the diffu- 
sion of pus or other morbid fluids through the cellular tissue;-by 
which wounded intestines are glued together so as to prevent the 
extravasation of their contents;-and which in disease produces 
thickening, consolidation and hypertrophy of organs, and oblitera- 
tion of their cavities. 
When first effused, the fibrine appears to the naked eye a soft, 
and gelatinous mass of a yellowish-white or pinkish colour. At 
first it is very soft, or almost diffluent; but it gradually increases 
in consistence, and acquires a reticular texture, containing serum in 
its meshes; and, when squeezed between the fingers, it is com- 
pared by Dr. Carswell, to a mass of cobwebs moistened with 
water. Under the microscope it appears com- 
posed of a number of very thin transparent 
fibrils, running in a straight and parallel direc- 
tion, and having numerous very small molecules 
interspersed amongst them. These molecules, 
through their own vital forces, collect themselves 
into groups of nuclei, which become converted 
into cells, from which the future tissue is deve- 
loped.* The fibrine soon becomes permeated 
with blood-vessels, which convey the materials 
for the future nutrition and growth of the tissue 
into which it is converted: and these are most 
probably formed, as in the embryo, by the 
Fig-1' 
* Theory of cellular development.-According to the researches of modern 
physiologists, the manner in which the tissues are originally formed in the embryo, 
and in which they are restored after injury, as well as the manner in which acci- 
dental and abnormal tissues (such as scirrhus) are formed, is identical. The first 
step towards development in the structureless jelly of the embryo, and also in the 
recently effused fibrine, is the formation of minute granules or molecules, called 
nuclei or cytoblasts (cell-germs')-, the fibrine or other structureless medium in which 
they are imbedded being called cytoblastema. The next step is the conversion of 
the granules into cells, which appears to be effected in several ways. Sometimes 
a number of granules collect and become fused together into spherical globules, in 
which a central cavity is afterwards produced, as if by an attraction of their solid 
matter to their circumference. In this manner the globules of pus appear to be 
formed. Sometimes a group of two or three granules, imbibing fluid from the 
cytoblastema, throw out a delicate vesicle, which projects from them as a watch- AND REPARATION OF TISSUES. 
59 
development of cells which open into each other in continuous 
lines. The time within which recently effused fibrine may acquire 
vascularity, varies according to the vigour of the constitution. Sir 
E. Home relates a case in which some lymph, effused on the sur- 
face of the peritoneum, became vascular within twenty-nine hours; 
but in feeble habits it may require some days. 
Fibrine appears capable of being converted into almost any of 
the tissues of the body; the conversion in any particular case being 
determined by the surface from which the fibrine was. effused, or 
by the function which it is made to perform. Thus, if a bone be 
broken or inflamed, the effused fibrine will be converted into bone. 
If a bone die, or is abstracted, still the lymph effused from the 
surrounding parts-from bone, muscle, fascia, cellular tissue, indis- 
criminately-will become bone. If (as in the case of unreduced 
dislocation) the limb is subject to frequent motion, part of it will 
be converted into bone, part into ligament, so as to form a new 
joint. But there are some tissues which cannot be replaced; and 
then the lymph which they secrete is transformed into some other 
tissue, which occupies a similar place in other animals. Thus, 
muscle cannot be formed anew; but if divided, the uniting lymph 
will become ligament, or dense fascia-like cellular tissue, which 
occupy the place of many muscles in animals of inferior develop- 
ment. 
It appears that almost all the simple tissues are capable, if 
divided, of being thus united by a tissue similar to themselves, and 
of being to a certain extent restored, if partially abstracted. But 
complex organs, such as muscle or gland, do not enjoy this faculty. 
All newly formed tissues possess certain common properties. 
They are less vascular, and less endowed with vitality than the 
original;-they are more prone to run into disease during states of 
constitutional cachexy ;* and they are liable to shrink and become 
atrophied, (which is especially the case with new cellular tissue,) 
glass does from a watch, and increasing in size becomes a cell, with the primary 
group of granules imbedded in its parietes, and called its nucleus. The nucleus 
again becomes hollow itself, and one of the largest of the granules composing it 
becomes a nucleolus. Nucleated cells thus formed are divisible into five varieties. 
1st. Those which float in a liquid, as the globules of the blood and pus. 2dly. 
Those which cohere and form a tissue, as the cuticle. 3dly. Those which remain 
imbedded in a substance formed out of the cytoblastema, as the corpuscles of bone 
and cartilage. 4thly. Those which become elongated into fibres. 5thly. Those 
which are converted into tubes and cavities, as the blood-vessels and nerve tubes. 
It must be added, that the structureless cytoblastema has an important share in the 
constitution of many tissues, forming a basis in which the cells are imbedded; and 
the febrillae observed in recent fibrine are certainly not developed from cells, but 
from the cytoblastema. We may thus readily comprehend how, in inflammation, 
the effused liquor sanguinis, according to the particular variety of cellular develop- 
ment which occurs in it, may be converted into pus, or into some normal tissue, 
or into some abnormal tissue such as scirrhus, tumours, &c. Vide Paget's Report 
on the Use of the Microscope, Lond. 1842, p. 6; Dr. Goodfellow's translation of 
Griiby on the Morphology of Diseased Fluids, in the Microscopical Journal for 
1842; and Gulliver's translation of Guber's General Anatomy. 
* Thus, in the scurvy, old cicatrices have been known to break out afresh into 
ulcers, and old fractures to become disunited. 60 
ADHESIVE INFLAMMATION AND REPARATION OF TISSUES. 
or even (as in the case of pleuritic and peritonaeal adhesions) to dis- 
appear altogether.* 
As we observed in the introductory-chapter on inflammation, 
serous membranes are much more liable to tlie adhesive inflamma- 
tion than mucous membranes. In the latter, suppuration is the result 
of a less degree of inflammation than adhesion; in the former, the 
reverse. But although the layers of lymph formed on mucous 
surfaces, when violently inflamed, (as in croup,) never become 
organized, but are detached by subsequent secretions of mucus or 
pus; still, if two abraded and inflamed mucous surfaces are placed 
in apposition and left undisturbed, they may adhere ; as sometimes 
happens in the vaginae of female children; in the os uteri and Fal- 
lopian tubes of prostitutes, and in the ureters and biliary ducts when 
abraded by the passage of calculi. 
When adhesion occurs for the normal purpose of reparation after 
injury, and proceeds favourably, it is attended with a very slight 
amount of inflammatory action; in fact, if there be more than a 
certain degree of excitement, the lymph effused will be broken up 
by fresh exudations, pus will be formed, and the process of repara- 
tion must be commenced anew by means of granulations, as will be 
described in the section on acute abscess. Hence, Dr. Macartney 
and others have denied that adhesion is an inflammatory process at 
all. The process, however, is essentially the same,-namely, in- 
creased vascularity, and effusion of lymph,-as that which occurs in 
other cases where the presence of heat and pain renders its inflam- 
matory nature indisputable. 
Is blood organizable?-It has been a matter of dispute, whether 
coagulated blood, like pure fibrine, is capable of becoming organized. 
Hunter believed that it was capable of being so, and in his work 
on Inflammation he adduced two cases which he thought to afford 
examples of it. The first is the coagulum in an artery that had been 
tied, in which he had been able to inject what he thought was an 
incipient vascular formation; the second is a piece of coagulum 
adhering to a testicle, which he had certainly injected. Coagula in 
blood-vessels have also been injected by Home, Macartney, and 
Kiernan; and the coagulum in an apoplectic cyst in the brain is 
gradually converted into a fl bro-cellular organized substance. It 
must be alleged on the other side, however, that the coagula in tied 
arteries, and the laminated coagula in aneurismal sacs are not mere 
solidified blood, but either most probably exudations of colourless 
fibrine from the parietes of the vessel, or else depositions of pure 
fibrine from the blood: and further, that whether coagulated blood 
is capable of being organized or not, it very seldom is so, but is 
either absorbed or else discharged by suppuration; and that lymph, 
* In examining the body of a madman who had stabbed himself in the abdomen 
fifteen different times during his life, the parts near the most recent wounds were 
found united by considerable false membranes;-at the situation of some that were 
older, there were only a few thin cellular adhesions; whilst, at the oldest, there 
was no trace of adhesion of false membrane whatever. Andral, Anat. Path. vol. i. 
p. 486. HEMORRHAGE. 
61 
and not blood, is the material employed by nature for the production 
of new tissues, and reparation of injuries.* 
Treatment.-If it be the object to promote adhesion, the general 
principles of treatment are, to maintain the most perfect rest and 
apposition, and to use such local and constitutional measures as will 
prevent heat, pain, and throbbing; in other words, to prevent the 
inflammation from proceeding to a grade of greater intensity than 
the adhesive. In a few cases (as after the operation for harelip, in 
a languid scrofulous habit) it may be necessary to excite the energies 
of the system by wine, to render them sufficient for the production 
and organization of lymph. 
If it be wished to counteract the adhesive inflammation, then use 
must be made of the antiphlogistic treatment generally, and of 
calomel in particular. 
If it be wished to remove adhesions, or thickening, the results of 
previous acute or existing chronic inflammation, the rules must 
be attended to which were laid down for the treatment of chronic 
inflammation. Plethora, or debility, or any other existing disorder, 
must be removed by appropriate remedies. Absorption is to be 
excited by the administration of mercury, with which it is often 
necessary to affect the system. Such local means should also be 
used, if possible, as will make the circulation vigorous and promote 
absorption; such as friction with the hand, or with the flesh-brush 
-aided by stimulating liniments, (F. 14,) or by ointments contain- 
ing iodine, F. 25, 75, or mercury; gentle exercise ; passive motion, 
shampooing, pressure by bandages or otherwise; cold affusion; 
electricity and galvanism; discutient lotions, especially those of zinc, 
F. 15, or muriate of ammonia, F. 16; blisters, or other counter- 
irritants-taking care not to reproduce active inflammation by too 
violent stimulation. 
CHAPTER VI. 
OF HEMORRHAGE. 
Haemorrhage, like serous effusion, maybe a consequence, 1st, of 
inflammation or excitement; 2dly, of obstruction to the return of 
venous blood; and 3dly, of structural weakness of the blood-vessels 
and thinness of the blood, as in scurvy and putrid fevers. The first 
form is called active, the last two passive. 
(1.) Active haemorrhage consists in an escape of arterial blood 
* Vide Palmer's ed. of Hunter, vol. iii.; Catalogue of the Hunterian Museum, 
vol. i., Carswell, op. cit.; Macartney, op. cit. p. 51.; Home, Phil. Trans. 1818, and 
Wardrop on Aneurism, in the Cyclop. Pract. Surgery. 62 
SUPPURATION AND ABSCESS. 
from the capillaries, which are most probably ruptured by the dis- 
tension caused by acute inflammation or violent excitement; and 
more or less of it doubtless occurs in every case of violent inflam- 
mation. It occurs during the formation of abscess in the cellular 
tissue and in the liver. But the most common seat of inflammatory, 
haemorrhage is mucous membrane, especially that of the lungs. 
The principal instances of it which fall under the surgeon's care, 
are epistaxis or haemorrhage from the nose; haemorrhois or haemor- 
rhage from the rectum; haemorrhage from the urethra during gonor- 
rhoea; and from granulating wounds. It has also been known to 
occur from the conjunctiva; and more rarely from the pleura, peri- 
cardium, and peritonaeum. 
Diagnosis.- Inflammatory or active haemorrhage is distinguished 
from that which is the result of congestion or debility, by the pre- 
sence of local pain, heat, and throbbing, and of a febrile state of the 
pulse and system generally. 
Treatment.-This form of haemorrhage is to be treated by bleed- 
ing, if it can be borne; and it may be observed, that it is less debili- 
tating to employ one full venaesection, so that the cause may be at 
once removed, than to let the blood dribble perpetually away from 
the part in small quantities. Purgatives and sedatives, especially 
lead, (F. 60, 61,) are also useful. Cold, if it can be applied, perfect 
rest, and an elevated position, are the local measures. 
(2.) In passive haemorrhage the blood which escapes is venous, 
and most probably the blood globules pass through the parietes of 
the capillaries without rupture. The principal instances of it are 
haemorrhage from the nose in old subjects with diseased liver, 
melaena, or haemorrhage from the liver, and passive menorrhagia 
and haemorrhois. The chief remedies are, dilute sulphuric acid, 
sulphate of alumina, catechu, and ergot of rye. 
CHAPTER VIL 
OF SUPPURATION AND ABSCESS. 
SECT. I. OF THE THEORY OF SUPPURATION AND PROPERTIES 
OF PUS. 
Properties of healthy Pus.-Pus is a yellowish-white, opaque 
fluid, of the consistence of cream; free from smell, neither acid nor 
alkaline, said to have a sweetish, mawkish taste, insoluble in water, 
although freely miscible with it, and very slow to putrefy. Like 
many other animal fluids, it consists of a thin serum, holding a vast 
number of solid particles in suspension, from which it derives its 
colour and opacity. VARIETIES OF PUS. 
63 
Pus Globules.-When these solid particles are examined under 
the microscope, they are found to be opaque spherical globules some- 
what granulated like mulberries. They measure from 1-5000th to 
1-2000th of an inch in diameter; some even are much larger ; espe- 
cially if they proceed from a surface that is actively inflamed.* 
They evidently consist of several central opaque molecules which are 
enveloped in, and connected by, a transparent homogeneous sub- 
stance. When mingled with water they soon appear plumper, 
more regular in shape, and more transparent; but after a time be- 
come ragged and flabby, as if torn, or partially dissolved. If acetic 
acid is added, it first of all renders the capsular en- 
velope clear and transparent, so as to show the cen- 
tral molecules distinctly; and after a little while 
completely dissolves it, and sets the molecules at 
liberty. Besides the globules, other smaller albu- 
minous molecules are also found in pus in great 
abundance, of the same nature apparently as the 
central molecules of the globules. 
Many of the properties of pus depend on these globules. Its 
specific gravity for instance, (which varies from 1-021 to 1-040,) and 
its density, depend on the number of them. Moreover, pus is coagu- 
lated by a strong solution of hydrochlorate of ammonia. But this 
coagulation is not produced by the solidification of matters pre- 
viously fluid, like the" coagulation of blood or milk; neither is it 
caused by the salt merely abstracting the water of the pus, as 
Pearson supposed; but it depends on a change in the globules, 
which become more transparent, elongated, and adherent. Freez- 
ing also renders pus viscid, and has a similar effect on the glo- 
bules. A heat' of 165°, however, coagulates it by coagulating the 
albumen of the serous portion.! 
Chemical Analysis.-The most recent analyses, especially those 
of Bonnet of Lyons,f Gueterbock,§ and Davy, show that pus con- 
tains all the proximate elements of blood, except the colouring mat- 
ter. Thus, it contains according to Gueterbock, water, (86-1 per 
cent.,) fat soluble in hot alcohol, (1-6,) fat and osmazome soluble 
in cold alcohol, (4-3,) and albumen and the matter of the globules, 
soluble in neither hot nor cold alcohol, (7-4.) The substance of 
which the globules are composed has received the name of pyine; 
but it seems to differ very little from fibrine. Pus also contains 
about 0-8 per cent, of salts; chiefly common salt, and muriate of 
ammonia. 
Varieties of Pus.-1. Healthy Pus (called also creamy or 
laudable} is that which has already been described, and is the pro- 
Fig. 2. 
* Mayo, Med. Gaz., Oct. 19th, 1839. 
f The uppermost group gives a pretty accurate idea of the appearance of pus 
globules, under the microscope. The middle figures represent globules ragged 
after maceration in water. The lowest group shows, very imperfectly, the action 
of acetic acid. Vogel, tiber Eiter und Eiterung, p. 35; Davy, op. cit., vol. ii. p. 468. 
+ Bonnet, Med. Gaz., vol. xxi. 
§ Gueterbock de Pure et Granulatione, Berol, 1837. 64 
VARIETIES OF PUS. 
duct of healthy inflammation in healthy parts. It is album, lasve, 
liquidum, et laudabile. 
2. Serous Pus is thin, almost transparent, and yellowish or red- 
dish. It differs from the last in containing very little fatty matter 
or fibrinous globules, and in being the product of a low degree of 
inflammation in weak constitutions. 
3. Clotty or Curdy Pus resembles the serous, but has numerous 
white clots and flocculi of coagulated fibrine floating in it. Under 
the microscope it displays the globules of healthy pus, and nume- 
rous other particles of irregular shape. It contains very little fatty 
matter, and is commonly found in scrofulous abscesses. 
4. Mucous Pus or Muco-purulent matter.-The mucus which 
proceeds from healthy mucous membranes, is seen under the micro- 
scope to be composed of abraded epithelium cells-flat, irregularly 
five-sided, and with a central nucleus;-with nume- 
rous granular masses, and a few spherical globules 
very much like pus globules; and these are sus- 
pended in a viscid ductile fluid. Under inflam- 
mation, the epithelium cells are shed more quickly, 
before they have become flattened out; the quan- 
tity of globules is greatly increased, and they ac- 
quire the exact character of pus globules. Thus 
mucus is converted into muco-purulent matter by an increase of 
albuminous exudation, and of the formation of spherical globules. 
A very viscid pus, like mucus, is occasionally found in chronic 
abscesses, containing a large quantity of hydrochlorate of ammonia, 
-a salt which abounds in unhealthy pus.* 
5. Concrete or Lardaceous Pus may either consist of common 
pus, thickened by the absorption of its watery parts, in conse- 
quence of having remained for a long time in a chronic abscess, or 
bony cavity!-as the antrum and nasal sinuses:-or it may origi- 
nally be secreted in a thick condition; and in this latter case differs 
little or nothing from the melicerous and aetheromatous matter 
found in wens or other encysted tumours. 
6. Putrid Pus has a foetid smell, and alkaline reaction, in conse- 
quence of the presence of hydrosulphate of ammoniawhich is 
formed by the decomposition of albumen, when pus is exposed 
long enough to air and heat. 
7. Specific Pus, capable of producing the venereal disease or the 
small-pox, may not differ in its sensible qualities from the healthiest, 
but must include some matter in a peculiar state of decomposition, 
which state is capable of being imparted to other living matter. 
8. The pus from spreading ulcers and cancers is thin and serous, 
containing blood-globules, and shreds and debris of the ulcerating 
tissue. It is said to be ichorous when thin and acrid; sanious when 
Fig. 3. 
* Pearson, Phil. Trans. 1810. Mucus gives out more ammonia, when treated 
by lime or potass, than pus does. 
f Mayo, Pathology, p. 159. 
+ A compound of sulphureted hydrogen and ammonia. Albumen contains 
sulphur, hydrogen, and nitrogen;-all the elements of this salt. SUPPURATION. 
65 
thin and bloody; and grumous when mingled with dark half- 
curdled blood. 
Productioi^of Pus.-We showed, when treating of the adhe- 
sive inflammation, that when the liquor sanguinis is effused, 
whether in the proper course of nutrition, or through inflammation, 
the living fibrinous molecules which it contains, have a tendency 
to aggregate themselves into masses, which are converted into 
nucleated cells, out of jvhich a tissue, normal or abnormal may be 
developed. But when these plastic cells are thrown out on a sur- 
face where they are remote from the contact of living matter, and 
exposed to external influences; or when they are formed in the 
interstices of an organ or tissue whose vitality is impaired by vio- 
lent inflammation, they degenerate in their organization, and are 
converted into pus globules.* So that pus may be defined to be 
liquor sanguinis, whose fibrine has assumed a peculiar low form of 
organization. 
Ramollissement.-This is a peculiar effect of inflammation 
which is observed in greatest perfection in the brain and spinal 
cord, portions of which become soft, pulpy, and at last diffluent, 
like thick cream. It has been shown con- 
clusively by Dr. Hughes Bennett, of Edin- 
burgh, that this process is a mere variation 
from the ordinary course of suppuration. 
The affected tissue is first infiltrated with 
fibrine, which " coagulates in the form of 
granules which may be seen coating the 
vessels, and filling up all the space between 
the ultimate tissue of the organ." Thus 
the organ affected is rendered perfectly dense or hepatized. The 
granules next form themselves into nucleated cells, which after a 
time break up, and are disintegrated, together with the tissue which 
they infiltrate; and on examining the softened mass with the micro- 
scope, it is seen to consist of a mass of granules, either diffused, or 
amalgamated in masses, or contained in nucleated cells, and mixed 
with the debris of the softened tissue.! 
Suppuration of the Cellular Tissue.-1The successive steps in 
the formation of pus in this tissue are as follow: First, there is an 
effusion of serum;-next, an effusion of fibrine, known by its faculty 
of coagulating spontaneously; and this fibrine may be combined 
with more or less blood;-or pure blood may even be effused with 
it at the spots where the inflammation is most intense. These effu- 
sions increase; the tissues become distended and broken down, and 
Fig. 4. 
* The second edition of this work contained a tolerably copious account of the 
previous theories of Home, Gendrin, &c., on this subject; especially of Gendrin's 
theory that pus might be formed of softened and disintegrated fibrine, and that pus 
globules are enlarged and decolorized blood globules; but it did not seem worth 
while to repeat it in the present edition, as the statement in the text seems pretty 
well established. 
j- See Microscopical Journal for Jan. 1843, and Bennett on Softening of the Brain, 
Ed. Med. and Surg. Journ., Dec. 1842. The foregoing cut represents the granules 
mixed with broken nerve-tubes; from a case of softening of the brain. 66 
at last pus appears in the thin reddish mixture of serum and lytnph 
with which they were infiltrated. It is at first dispersed in minute 
collections; but these soon communicate by the solution of the in- 
tervening parts, and form a cavity termed an abscess. Meanwhile 
(in healthy inflammation) the lymph which is effused into the parts 
around the pus becomes organized and converted into a cyst or sac, 
-which circumscribes the pus already formed, and may secrete fresh 
quantities of it, or absorb some of it, according to circumstances. 
Mucous Membrane and Skin.-The mucous membranes, and 
the cutis deprived of its cuticle, readily produce pus by a process 
of secretion. They at first exude a thin serous fluid, which gra- 
dually becomes thick and opake, and perfectly purulent. 
Serous Membranes.-The suppuration of serous membranes is 
preceded by an effusion of serum and lymph; and the pus may be 
secreted, either from the surface of lymph which has become vas- 
cular and organized,-or from the surface of the serous membrane 
itself,-the layer of lymph having been disintegrated and detached. 
Pus in the Blood.-There is a peculiar state of the system, 
sometimes called the suppurative or purulent diathesis, in which 
abscesses form in rapid succession in the liver, lungs, joints, or other 
parts of the body; and this diathesis generally accompanies some 
disease such as phlebitis, erysipelas, or puerperal fever, in which 
there is great vitiation of the blood, and also a profuse formation of 
pus at the part originally affected. 
One peculiarity of these local suppurations is the extreme rapidity 
with which they often form; insomuch that authors have denied, 
that the pus can be elaborated in consequence of inflammation at 
the parts where they are found; but have considered them to be 
deposits of pus, which has been absorbed into the circulation from 
some other part; hence they have been called commonly purulent 
depots, or consecutive or metastatic abscesses. 
But although it is very probable that pus, if present in the blood, 
might be deposited in the lungs or liver, (because we know that 
quicksilver, when injected into the blood, is quickly found in those 
parts,) still it is very certain that consecutive abscesses are not uni- 
versally caused by a deposit of pus in an uninflamed part. For 
abscesses in the liver often follow injuries of the head; and other 
consecutive abscesses sometimes follow other injuries, which have 
not given rise to any suppuration, and from which consequently 
there was no pus to be absorbed. 
Again it appears certain that after abscess in the liver, large 
quantities of pus find their way into the circulation through veins 
which open by large orifices into the cavity of the abscess; and this 
pus is excreted by stool, urine, and vomit, without the formation of 
consecutive abscesses. So that at all events, healthy pus can pass 
through the system without occasioning any severe derangement.* 
SUPPURATION. 
• Vide Copland, Diet. Med., Art. Abscess; Carswell, op. cit.; Ferguson on Puer- 
peral Fever, Lond. 1839; Ancell, case of purulent deposit into all the joints after 
small-pox; Med. Chir. Trans, vol. xxi. The author has also borrowed from a 
lecture on Phlebitis delivered by Sir B. C. Brodie, at St. George's Hospital, in 
Nov. 1839. ACUTE ABSCESS. 
67 
But if pus be taken into the blood which is vitiated or putrid, it 
will cause severe constitutional derangement and diarrhoea; as will 
be exemplified in the remarks on Chronic Abscess.* 
SECTION II. OF ACUTE ABSCESS. 
Definition.-An abscess may be defined to be a collection of 
pus in the substance of any part, or in any cavity. There are two 
kinds: 1. The acute or phlegmonous; 2. The chronic or cold; 
besides the diffused abscess, or diffused suppuration in the cellular 
tissue, of which we shall speak in the next chapter. 
Symptoms.-Acute abscess (which, when occuring in the subcu- 
taneous cellular tissue, is called phlegmon} commences with all the 
ordinary signs of acute inflammation ; namely, inflammatory fever; 
severe throbbing pain ; bright redness; and much swelling;-firm 
in the centre, and oedematous around. The occurrence of suppu- 
ration is indicated by severe rigors, by an abatement of the fever, 
and a change in the pain,-which is converted into a sense of weight 
and tension, with a pulsatory feel at each beat of the arteries. Then 
the tumour becomes softer, and loses its bright arterial colour; 
and as the quantity of matter increases, its centre begins to point, 
that is, to project in a pyramidal form, and fluctuation can be felt 
by alternate pressure with the fingers. 
Progress.-The pus having been formed, the next step is its 
evacuation, which is effected either by what Hunter called pro- 
gressive absorption; that is, the successive absorption of all the 
parts intervening between the abscess and the surface;-or, just as 
probably, by their successive softening and disintegration. Be this, 
however, as it may, the tumour becomes more and more prominent 
and soft; the surrounding inflammation and tumefaction subside; 
the centre becomes of a dusky red or bluish tint, the cutis is removed, 
the cuticle bursts, and the pus escapes. 
Although abscesses may burst into serous cavities, or mucous 
canals if they happen to be near, still their general course is that 
which is least prejudicial;-namely, towards the skin. The cause 
of this happy provision has much engaged the attention of patholo- 
gists. The best explanation that can be offered, although not quite 
a satisfactory one, is, that the pus, as it increases in quantity, ad- 
vances towards the skin, because in that direction it is opposed by 
the least pressure. 
Granulation.-The matter having been discharged, the cavity 
of the abscess contracts, the pellicle of lymph which lines it is cast 
off, and its surface becomes covered with numerous small, red, 
* Gerber, (Anatomy translated by Gulliver) as well as his translator, thinks that 
pus cannot be absorbed, as such; but only the elements of it when its globules have 
become liquified by decomposition. Griiby (on the Morphology of Pathological 
Fluids, translated by Dr. Goodfellow in Microscopical Journal, vol. ii.) believes 
that absorption of pus occurs by the rupture of the globules, and liberation of the 
central granules, which latter he believes to be able to permeate the coats of the 
capillaries. 68 
ACUTE ABSCESS. 
vascular eminences called granillations. These are formed by the 
effusion of lymph in successive layers,-each of which soon becomes 
organized and vascular, and secretes pus. The reason why the 
lymph is effused in the form of these eminences is supposed to be, 
that each of them is formed by one minute artery, which runs through 
its centre, and then divides into numberless ramifications on its 
surface. So that if the restorative actions are vigorous, and the 
blood-vessels numerous, the granulations will also be numerous, 
but small and florid;-whilst in the opposite state they will be large, 
pale, and flabby. And the pus from healthy granulations will be 
laudable and creamy,-from the other, thin and flaky.* 
Cicatrization.-When the cavity has become filled up by the 
growth and union of granulations, the red inflamed skin around 
its orifice is removed by ulceration, so that the margin of the sore 
becomes adherent and fixed;-and then cicatrization begins. A 
white pellicle extends from the circumference, gradually covers the 
whole surface, and becomes organized into a new cutis and cuticle, 
called a cicatrix. The cicatrix is at first thin and red, but soon 
becomes denser and paler than the original skin, and, like all new 
textures, is less vascular and less vital. The colouring matter be- 
tween the cutis and the cuticle is later in appearing. But this pro- 
cess is accompanied by two others, namely, the contraction of the 
surrounding skin, so that the surface to be healed is very much 
diminished before cicatrization commences, and the contraction of 
the cicatrix subsequently. The preliminary contraction of the skin 
appears, intended to diminish the labour of an extensive reparation; 
-the subsequent contraction of the cicatrix is in conformity with a 
law mentioned in the chapter on Adhesion, and depends on the 
atrophy of the newly-formed subcutaneous cellular tissue. It is 
always greatest where the preceding granulations have been pale, 
flabby, and exuberant, as in burns. 
But it is to be remarked, that the filling up of a vacancy in the 
tissues, whether in consequence of accident, abscess, or ulceration, 
need not necessarily be attended with suppuration, nor with peculiar 
appearance of granulations. On the contrary, if all inflammation 
be subdued, and all irritation excluded, the chasm may fill up with 
red lymph, which speedily cicatrizes. This is constantly observed 
after trifling injuries; they speedily become covered with a scab 
formed of dried bioodor lymph, under the protection of which they 
soon cicatrize ; and when it can be effected, larger wounds should 
be made to heal in the same way. This form of reparation is called 
by Macartney, the modelling process; and he contends that neither 
this process, nor adhesion, ought to be considered inflammatory, 
but rather processes of growth or nutrition. 
Causes.-Acute abscess is mostly idiopathic, that is, depends on 
constitutional causes, and is a frequent sequel of fevers ;-it may, 
however, be caused by blows, ecchymoses, or by foreign bodies 
introduced into the skin or flesh. 
* Granulations are often extremely sensible, and of course supplied with nerves; 
perhaps also with absorbents. ACUTE ABSCESS. 
69 
Treatment.-The indications, in the first stage, are, to procure 
resolution of the inflammation, and prevent the formation of mat- 
ter. After it has formed, the indications are, to cause its evacuation, 
and induce granulation and cicatrization. 
In the first stage, therefore, the patient should be purged; the 
diet should be low, and leeches should be applied to the part. But 
when the cold applications feel chilly and uncomfortable, (as they 
will when suppuration begins,) they should be exchanged' for warm 
fomentations or poultices ;-and when fever abates, the diet should 
be increased. 
Poultices are admirable remedies : they relax the skin, promote 
perspiration, soothe pain, encourage the formation of pus, and 
expedite its progress to the surface. They should be large,-so as 
not soon to become cold or dry; they should be soft, that they may 
not irritate,-light, that they may not fatigue,-and they should be 
renewed very frequently. They may be made of bread and water, 
or of oatmeal, boiled till it is soft, or linseed meal, F. 45, 47, or of 
camomile flowers boiled till they are soft, or of bran sewed up in 
a linen bag, which may be dipped into warm water as often as it 
becomes cold. 
The ivarm-water dressing,-that is, a piece of soft lint or folded 
linen dipped in warm water, and covered with oiled silk to prevent 
evaporation,-is a good substitute for poultices in many cases, 
especially for irritable sores; but when there is much pain it is not 
so soothing as the large soft warm mass of a well-made poultice. 
If, after the formation of matter, the inflammation does not sub- 
side, but swelling, hardness, and pain remain, then the application 
of leeches may be repeated; but in other cases the continuance of 
depleting measures after matter has formed, or when its forma- 
tion is inevitable, will only weaken the patient, and delay the cure. 
Respecting the opening ofi abscesses, it may be laid down as a 
general rule, that if they point and become pyramidal, with out 
enlarging in circumference, they may be left to burst of themselves; 
but that if they enlarge in breadth and circumference, without tend- 
ing to the surface, they should be opened. In the following six 
cases, however, the surgeon's aid is imperatively demanded : 
1. When matter forms beneath fasciae and other dense ligamen- 
tous textures, such as the sheaths of tendons, or under the thick 
cuticle of the fingers. Because, as these are absorbed or softened 
with the utmost difficulty, the pu£, instead of coming to the surface, 
will burrow amongst muscles and tendons, extending the abscess to 
great distances;-producing extreme pain and constitutional dis- 
turbance, by its tension of the fascise which cover it, and pressure 
on the parts beneath,-endangering extensive sloughing, and im- 
pairing the future motions of the part. Hence, as a general rule, 
all abscesses beneath fascise, or among tendons, or under the thick 
cuticle of the fingers, should be freely opened, as soon as the exist- 
ence of matter is suspected. 
2. When abscess is caused by the extravasation of urine, or other 70 
ACUTE ABSCESS. 
irritant fluids, or when it contains an unhealthy matter, which 
might diffuse itself and spread the disease; as in carbuncle. 
3. When an abscess is formed in loose cellular tissue, (as around 
the anus,) which would readily admit of great distension and en- 
largement of the sac, and more especially if the cellular tissue is 
partially covered with muscles, (as in the axilla,) under which the 
matter might burrow. 
4. In suppuration near a joint; or in the parietes of the chest or 
abdomen; or under the deep fascia of the neck; lest the abscess 
burst into the serous cavities, or the trachea; or cause compression 
of the trachea, oesophagus, or jugular veins.* 
5. In suppuration of very sensitive organs, as the eye or testis. 
6. When it is desirable to avoid the scar which always will 
ensue when an abscess ulcerates spontaneously. 
And in the first three of these cases it is much better to make an 
opening before matter has formed, than to delay it for one moment 
afterwards. 
The best instrument for puncturing abscesses is a straight- 
pointed, double-edged bistoury. Holding it like a pen, the surgeon 
should gently plunge it in at a right angle to the surface, till it has 
entered the cavity; which may be known by a diminution to the 
feeling of resistance, or by gently turning the instrument on its long 
axis, so that a drop of pus may well up by -its side. Then the 
aperture may be enlarged sufficiently as the instrument is being 
withdrawn. The puncture should be made either at the most 
depending part of the abscess, or else where the matter points most 
decidedly and the skin is the thinnest; and a very fine strip of oiled 
lint (formerly called a tent} may be gently introduced between the 
edges of the opening, and be allowed to remain for the first forty- 
eight hours, to prevent them from closing again. When there is a 
doubt of the existence of matter, some surgeons pass in a grooved 
needle, by way of exploration ; but the author does not recommend 
this practice. No rude attempts should be made to squeeze out 
matter, as they might induce inflammation; but it should be allowed 
gradually to exude into a poultice or fomentation, which may be 
changed as often as necessary. 
The poultices may be continued till all the pain has subsided, and 
the cavity has begun to granulate ;-but not too long, lest the granu- 
lation become weak and flabby. And then the best plan is to apply 
a compress of linen, and a bandage If the cavity does not contract 
speedily, it must be treated as a weak ulcer or fistula. If the sup- 
puration continues profuse, tonic, change of air, and a good diet, 
are advisable, in order to prevent hectic, and enable the constitution 
to repair the local mischief. 
It occasionally happens that acute abscesses (especially those 
occurring in glandular textures and venereal cases) are cured by 
the absorption of their pus. This is likely to happen when, after 
acute inflammation, the matter remains without tending to come to 
* In Dr. Cormack's Lond. and Ed. Med. Journ., March 1843, is related a case in 
which an abscess burst into the internal jugular vein. CHRONIC ABSCESS. 
71 
the surface, and without pain;-the means best adapted to promote 
it are leeches and cold,-mercurial ointment worn as a plaster,- 
purgatives and remedies adapted to increase the secretions gene- 
rally,-and above all things a sea voyage, so as to cause consider- 
able sickness. 
SECTION III. CHRONIC ABSCESS. 
General Description.-Chronic abscesses are the result of a 
low degree of inflammation; so slight, indeed, that their existence is 
often unsuspected for a long time. They are mostly lined with a 
thin, reddish-gray, distinctly-organized cyst;-and there is little or 
no vascularity in the parts adjoining;-and the pus usually is serous 
or curdy. But sometimes the cyst is thick and cellulo-fibrous, and 
the matter concrete^ so as hardly to differ from an encysted tumour. 
Chronic abscesses are often deep-seated, whilst the acute are mostly 
superficial. 
Causes.-The causes are chronic disease of bone, or other source 
of slow irritation, in a weak and scrofulous habit. 
Symptoms.-When first detected, a chronic abscess appears as 
an obscure tumour, with a fluctuation more or less distinct accord- 
ing to its distance from the surface. It is free from pain, tender- 
ness, swelling, and redness, unless far advanced or accidentally 
inflamed. 
Progress.-These abscesses may attain an enormous magnitude, 
partly because the sac being thin is readily extensible,-and partly 
because of the atonic and indolent grade of the inflammation, which 
is insufficient to implicate the adjoining textures, and make the 
coverings ulcerate. When, however, from the increasing disten- 
sion, or from some accidental irritation, this does happen, the skin, 
reddens, inflames, and ulcerates, and so the matter is discharged. 
Terminations.-(1.) In slight cases the stimulus of the air 
causes the interior of the sac to pour out granulations;-the red- 
dened skin around the orifice ulcerates;-and the sore so formed 
may heal. (2.) If the restorative powers are weak, or the parietes 
of the sac have been unequally pressed together, or the abscess is 
caused by a piece of diseased bone or some other permanent source 
of irritation which is not removed, one or more sinuses may remain. 
(3.) If, on the other hand, the abscess is very large, or if, after the 
admission of air, the pus have not a free exit, a most serious train 
of consequences will ensue. The pus, exposed to the atmosphere, 
putrefies; the hydrosulphate of ammonia (the product of putre- 
faction) is absorbed into the blood;*-the interior of the sac 
inflames, partly from the irritation of the air, but chiefly from that 
of the putrid pus;-and then the grave and irreparable local dis- 
* It may be detected in the blood and urine. The blood in these cases is black, 
and refuses to coagulate;-which is precisely the effect produced by adding the 
hydrosulphate of ammonia to healthy blood. Vide M. Bonnet's Papers in the Med. 
Gaz. vol. xxi. 72 
CHRONIC ABSCESS. 
ease, together with the contamination of the blood, induces typhoid 
fever, under which the patient sinks. 
Prognosis.-Hence the danger of these abscesses will be great; 
if the sac has attained a large size, and has advanced so far towards 
ulceration, that a spontaneous and permanent aperture is inevitable; 
-more especially, if it is connected with diseased hip or vertebrae, 
which will keep up the secretion of pus, and prevent it from closing. 
Treatment.-There are three indications; (1.) To amend the 
general health, and remove all causes; (2.) To procure absorption 
of the matter; (3.) If that be impracticable, to open the abscess 
with such precautions as may induce a speedy contraction and 
obliteration of the sac. 
(1.) In order to fulfil the first indication, the necessity of whole- 
some and sufficient food, pure air, warm clothing, and freedom from 
avocations that fatigue the body or harass the mind, need scarcely 
be adverted to ; whilst the appetite, digestion, strength, and secre- 
tions of the skin, liver, and bowels, must be improved after the 
manner detailed in the chapter on Chronic Inflammation. If (as 
in the case of psoas and lumbar abscess) the abscess has been 
caused by some local disease, the latter must, if possible, be ascer- 
tained, and removed by proper measures. 
(2.) The best local means for causing absorption of the matter 
are stimulants and counter-irritants applied to the tumour or its 
vicinity. Plasters of emp. ammoniaci cum hydrarg.; or of F. 25; 
or a succession of blisters, when one is nearly healed, another 
being placed beside it; or friction with ung. iodin.; electric sparks; 
and cold affusion, are the most useful remedies; but they do harm 
if they cause heat or pain. Leeches, cold lotions, and purgatives 
must be employed if the tumour should inflame from any constitu- 
tional or local cause of irritation. 
(3.) But if, notwithstanding these efforts, the tumour continues 
to enlarge, it cannot be opened too soon:-especially if there is any 
incipient redness of the skin. And a different proceeding is requi- 
site in different cases. 
If the abscess is superficial and small, without a hardened 
base, and freely fluctuating, it may be opened with a lancet or bis- 
toury. It is a great object to evacuate all flakes of unhealthy 
lymph, which, if retained, would be sure to prevent adhesion, and 
cause an open sore to be formed; but no violent pressure or squeez- 
ing must be employed. After the opening, the patient should 
observe quietude; some strips of adhesive plaster, or a compress 
and bandage wetted with zinc lotion, should be passed round the 
part, so as to keep the sides of the sac in apposition with a mode- 
rate degree of pressure; and thus a free exit being provided for 
the pus, the opposing surfaces will often granulate and adhere ;- 
then the external aperture heals, and the case is cured. If from 
deficiency of action this adhesion will not take place, weak stimu- 
lating injections maybe used, such as F. 15, diluted; or another 
aperture may be made, and a seton be passed through the sac;-or CHRONIC ABSCESS. 
73 
if it be long and fistulous, it may be slit up, and made to heal from 
the bottom. 
In some cases, when a considerable portion of skin has become 
thin and red-evincing that it will certainly ulcerate and form a 
large aperture, it will be advisable to apply the caustic potass, so 
as to destroy it, and avoid the more painful and tedious process of 
ulceration. 
If an abscess is seated in the neck of a female, it is of the 
greatest consequence to make an early opening, so that no scars 
may be left. The instrument recommended by Sir A. Cooper for 
this purpose is a very fine lancet, only one-eighth of an inch broad. 
The puncture should be large enough to extract all flakes, but no 
larger; and it should be made transversely, so that its minute cica- 
trix may be hidden by the folds of the neck. Adhesive plaster 
should then be applied with moderate pressure;-and weak injec- 
tions, especially F. 76, may be used, if the sac does not become 
obliterated in the course of a few days. 
Large Chronic Abscesses.-If the abscess is so large that the 
exposure of its cavity would lead to the evil consequences that 
have been enumerated;-or, if it is connected with disease of the 
spine or other bone, (as in the case of psoas abscess,) the following 
plan should be resorted to, with the view of inducing a contraction 
of the sac, and of diminishing the danger from a permanent open- 
ing, should one be established subsequently. A small puncture 
should be made at the most depending part of the tumour. It may 
be made valvular, by drawing the skin a little to one side before 
introducing the bistoury; but this is not of much consequence. As 
much matter as flows spontaneously should be permitted to escape, 
and then the puncture should be carefully closed by lint and plaster, 
and the patient be kept at rest till it is healed. During the flow of 
the matter, the greatest care ought to be taken to prevent the 
admission of air into the sac. At the expiration of ten days or a 
fortnight, when it is nearly refilled, a second puncture should be 
made (but not too near to the former), and should be healed again 
in like manner. This operation should be repeated at proper inter- 
vals, taking care never to let the abscess become so distended as it 
was before the previous puncture,-and using moderate support 
by bandages in the intervals. Thus, in fortunate cases, these 
repeated partial evacuations, combined with proper constitutional 
measures, will cause the abscess gradually to contract;-so that it 
either becomes completely obliterated, or degenerates into an insig- 
nificant fistula.* 
This method of treatment was introduced by the late Mr. Aber- 
nethy. He, however, recommended as much as possible of the 
matter to be evacuated at each operation, instead of allowing it to 
run spontaneously;-which latter method is much better calculated 
* Vide Fergusson's Practical Surgery, p. 69, and Lancet, Nov. 6, 1841, for an 
excellent case treated successfully in this way by Mr. Fergusson in the King's 
College Hospital. 74 
to preclude the admission of air, and avoids all irritation of the cyst 
by rough handling or squeezing. 
But if air have gained admission into the cavity of the abscess, 
and the pus has become putrid, and prostration of strength and dry 
brown tongue show its influence on the system, then the indications 
plainly are, to make free openings and counter-openings, so as to 
prevent all lodgment of the putrid pus; and to wash out the sac 
occasionally with injections of warm water, containing a very little 
of the solution of chloride of soda. At the same time the general 
treatment of typhoid fever must be adopted, and the strength be 
supported, in order that the absorption of noxious matter may be 
prevented, and its elimination be facilitated. The sedulous ad- 
ministration of wine, nourishment, opium, and bark, F. 1, 2, 3, may 
in fortunate cases enable the patient to recover, and at all events 
will retard his passage to the tomb. 
M. Bonnet has suggested an expedient in these cases, that might 
often be worth the trouble of adopting. He proposes to immerse 
under water the part in which the abscess is situated, at the time 
it is punctured. This would, of course, render the ingress of air 
impossible;-an occurrence which, in the ordinary way of operat- 
ing, will often happen in spite of every precaution. 
ERYSIPELAS. 
CHAPTER VIII. 
OF ERYSIPELAS AND DIFFUSE INFLAMMATION OF THE CELLULAR 
TISSUE. 
SECTION I. PATHOLOGY OF ERYSIPELATOUS INFLAMMATION. 
Instead of treating of erysipelas amongst the diseases of the skin, 
as if it were a mere example of ordinary inflammation, attacking 
the skin, and deriving its peculiarities solely from the structure 
affected, we shall adopt the opinion that was doubtfully held by 
John Hunter,* but which has been dearly substantiated by recent 
pathologists, and describe it as a peculiar unhealthy form of inflam- 
mation, which may attack various tissues, but which, wherever 
situated, exhibits certain characters that distinguish it from ordinary 
healthy inflammation. 
These characters of erysipelatous inflammation are the following: 
-It has a disposition to spread widely along the surface of mem- 
* Hunter's words are, "in some constitutions, every inflammation wherever it 
exists, will probably be of this kindand (speaking doubtfully of the erysipelatous 
nature of inflammations of mucous membranes he adds), " whatever the inflam- 
mation may be, it is certainly attended with nearly the same kind of constitutional 
affection. The fever in both appears to be the same i. e. as in erysipelas. ERYSIPELAS. 
75 
branes, or in the cellular tissue. The lymph which is secreted is 
incapable of organization, and instead of confining effusions into the 
cavity of an abscess, permits them to be diffused widely, and thus 
to extend the disease into sound parts. Erysipelatous inflammation 
is liable to attack different parts, sometimes simultaneously, some- 
times by metastasis; that is, leaving one part and flying to another, 
thus giving evidence of its origin in a vitiated state of the blood. 
Lastly, the different varieties of erysipelatous disease prevail epi- 
demically together, and are capable of propagation by infection and 
contagion. 
The diseases which may be grouped together as partaking of the 
erysipelatous character, and which are all probably caused by the 
admission of some nearly-allied varieties of putrid miasmata into 
the blood are, the simple or cutaneous, and the phlegmonous or 
cellulo-cutaneous erysipelas; the diffuse inflammation of the cellular 
tissue; acute phlebitis; puerperal fever, and the suppurative dia- 
thesis, i. e. the peculiar state of constitution in which abscesses or 
purulent depots are liable to form suddenly and unexpectedly in 
the liver, joints, lungs, and other parts of the body. Thus Dr. 
Ferguson tells us, that erysipelas and puerperal fever are generally 
co-existent in his lying-in hospital, the mothers perishing of one, 
and the infants of the other. Instances are now common enough, 
showing that the infection of either of these two diseases may pro- 
duce the other: and it has long been known that inoculation with 
the fluids of a female who has died of puerperal fever is a most 
fatal source of diffuse cellular inflammation to the dissector.* More- 
over, during the prevalence of erysipelas in the London hospitals, 
phlebitis and purulent depot^ are generally prevalent likewise. 
In the present chapter we shall speak first of the simple or cuta- 
neous and phlegmonous or cellulo-cutaneous erysipelas; and in 
the following section of the diffuse cellular inflammation ; which, 
however, will be treated of more fully under the head of dissection 
wounds. 
SECTION II. OF THE CUTANEOUS AND CELLULO-CUTANEOUS 
ERYSIPELAS.! 
Definition.-Diffused inflammation of the skin, or skin and 
cellular tissue, with a tendency to spread. 
* Vide Ferguson on Puerperal Fever, p. 29; Storrs, R. in Prov. Med. Jour. 23d 
April, 1842, and Paley, Lond. Med. Gaz. June 6, 1842, on the Production of Puer- 
peral Fever by infection from Erysipelas; and Nunneley on Erysipelas, Lond. 1841, 
a work that deserves to be attentively studied. 
f The terms cutaneous and cellulo-cutaneous, which Mr. Nunneley has pro- 
posed, are far preferable to the terms simple and phlegmonous. Erysipelas is 
called phlegmonous when it affects both skin and cellular tissue, because inflam- 
mation of the latter tissue is sometimes called phlegmon. But it is better to aban- 
don this use of the term, because the word phlegmonous is often used in contra- 
distinction to erysipelatous, to express a different kind of inflammation: the former 
circumscribed and adhesive; the latter diffused. In this opposite sense the two 
words are used by Mr. Guthrie, in speaking of inflammation of the blood-vessels. 76 
ERYSIPELAS. 
Symptoms.-The cutaneous or simple erysipelas is known by 
redness of the skin, which disappears momentarily on pressure; 
-considerably puffy swelling from serous effusion into the cellular 
tissue;-and severe stinging, burning, or smarting pain. The red- 
ness is generally of a vivid scarlet hue; but it will be faint and 
yellowish if the disease is attended with much debility, or if it 
affect the eyelids, scrotum, or other loose cellular parts, where it 
always produces a good deal of serous effusion. 
In the cellulo-cutaneous, or phlegmonous erysipelas, the redness 
is deeper, and sometimes dusky or purple, and it is scarcely, if at 
all, dispelled by pressure;-the swelling is much greater, and is 
hard, brawny, and tense;-and the pain is not only burning, but 
throbbing. 
Constitutional symptoms.-Both varieties are ushered in with 
shivering, headache, pain in the back, nausea and bilious vomiting; 
and both are attended with fever, which will vary in its type 
according to the intensity of the cause, the vigour of the constitu- 
tion, and the nature of the prevailing epidemic. It may be of an 
ardent, sthenic, inflammatory character, requiring free blood-let- 
ting, if the disease affect a young robust countryman; but it soon 
assumes a low typhoid character, if the patient is old and weak; 
or if the disease were contracted in some close, foul, ill-ventilated 
hospital, or if a large portion of cellular tissue has begun to slough. 
When erysipelas is situated on the face and scalp, it will be liable 
to be complicated with delirium in its early stages, and coma in the 
latter, from the irritation propagated to the brain and its mem- 
branes. 
Terminations.-The cutaneous erysipelas may terminate, 1, in 
resolution, leaving nothing but desquamation of the cuticle with 
slight oedema; 2, but more frequently it produces large vesicles 
from effusion of serum under the cuticle;-and these dry into scabs, 
which peel off and leave the cutis either healed, or superficially 
ulcerated. 3. Sometimes, however, it is followed by small abscesses. 
The ordinary duration is from seven to fourteen days. 
Before its termination, however, this variety of erysipelas some- 
times assumes a lingering erratic character, wandering progres- 
sively along the skin, and spreading in one direction as it fades in 
another. Sometimes it disappears entirely from one part, and flies 
by metastasis to a distant one; and sometimes it quits the skin 
suddenly, and some internal organ is affected with an inflammation 
having the same constitutional characters. 
The phlegmonous or cellulo-cutaneous erysipelas may termi- 
nate as favourably as the simple variety;-but it more generally 
leads to unhealthy suppuration and sloughing of the cellular tissue; 
-in which case the swelling becomes flaccid and quaggy;- 
patches of the skin become purple and covered with livid vesica- 
tions, and these patches slough, giving exit to a thin sanious pus, 
and to flakes of disorganized cellular tissue. And not only the 
subcutaneous, but the intermuscular tissue and fascia? may slough, 
rendering the limb useless, even if the patient escape with his life. TREATMENT OF ERYSIPELAS. 
77 
Prognosis.-This must be guarded if the patient is old, enfee- 
bled, and habitually intemperate;-if the constitutional affection 
is low and typhoid;-if the malady is situated on the head or 
throat, and there is coma or great dyspnoea;-or if the erysipelas 
is of the phlegmonous variety, and a large portion of the cellular 
tissue and skin is on the point of sloughing. Mr. Nunneley ob- 
serves, that if the frequency of the pulse is not abated by the 
seventh day, the prognosis will be unfavourable, even although 
the local symptoms appear to be improving. 
Causes.-The causes which render the constitution liable to 
erysipelatous inflammation, are threefold. First, intemperance, 
fatigue, close confinement in foul air, and whatever other causes 
are capable of irritating the digestive organs, exhausting the 
nervous system, and vitiating the blood. Tile origin of erysipelas 
in the close air of hospitals is unhappily too notorious to need 
mention. Secondly, the disease may be epidemic; that is, may be 
produced by certain states of the atmosphere at large, affecting 
several people in the same district simultaneously. Thirdly, it 
may be propagated by contagion or infection, by means of the 
emanations from patients affected with it. 
These causes may be sufficient of themselves to produce the dis- 
ease (which then is said to be idiopathic}; or they may merely 
predispose the patient to suffer, on the occurrence of some injury to 
the skin, which acts as an exciting cause ; such as leech-bites, caus- 
tic, and burns. Idiopathic erysipelas generally attacks the head. 
Treatment.-The indications for the constitutional treatment 
are, to diminish inflammatory action and febrile excitement-to sup- 
port the strength-and to correct the secretions-and for the local 
treatment to allay irritation-to arrest the extension of the disease 
-and to give free exit to sloughs and discharge. But the surgeon 
must never forget, that erysipelas varies so much in its type at dif- 
ferent periods, sometimes requiring free antiphlogistic measures, and 
sometimes bark and opium, that when a new epidemic arises he 
must carefully study what Sydenham calls the genius of the disease, 
and observe the effect of remedies, in order to determine what plan 
of treatment is the best.* 
Emetics and Purgatives.-On the first occurrence of the symp- 
toms an emetic may be given, composed of a scruple of ipecacuanha 
with a grain of tartar emetic. It should be followed by a good dose 
of calomel, and by black draughts (F. 4.) containing a few grains of 
soda, every six or eight hours, as long as they bring away hardened 
lumps of faeces, or as long as the secretions continue to amend under 
their use. If, however, the patient be weak, an emetic of ipecacu- 
anha and ammonia (F. 94) may be substituted for the tartar emetic. 
If the constitution is very much broken down, or if there are symp- 
toms of early coma or typhoid debility, Copland recommends the 
calomel to be combined with camphor, and to be followed by the 
turpentine draught (F. 12) or turpentine enemata. 
* See also Graves's Clinical Medicine, p. 575. 78 
ERYSIPELAS. 
Antiphlogistic measures.-Bleeding will be required if the 
patient is young and vigorous, the pulse full and strong, the face 
flushed, and delirium violent;-and if the inflamed part is full , tense, 
and vividly red, and especially if seated on the head or throat. In 
similar active inflammatory cases, calomel may be given in doses 
of two grains every six hours with antimony (F. 6); or colchicum, 
in doses of ntxx. of the wine; and saline draughts with excess of 
alkali, (such as F. 5, or liq. am. acet., &c.) in the intervals;-but in 
most cases of simple erysipelas a small dose of mercury at bed-time, 
(F. 7, 10,) and purges and salines during the day will suffice. For 
it must be recollected that as the disease is not purely inflammatory, 
it can very rarely be cut short by mere antiphlogistic measures; and 
that debility is much to be dreaded; especially in cases occurring 
in the crowded habitations of London. 
Tonics and stimulants.-Bark should be given in all cases as 
soon as the tongue becomes clean and the skin moist; but it should 
be resorted to without delay if the pulse is soft, tremulous, or very 
rapid, the heat moderate, and the delirium low and muttering; or 
if the patient is naturally delicate, and subject to periodic or recur- 
rent attacks;-or if antiphlogistic measures do not arrest the disease, 
or if suppuration or sloughing have commenced. If there be any 
doubt of its propriety, it should be given in small doses;-but, in 
decided cases of debility, a strong decoction should be administered, 
with the acids or ammonia,-and wine or spirits should also be 
given in sufficient quantities to support the circulation. 
Opium may be given in full doses at bedtime in the later stages, 
to allay restlessness, provided there is no cerebral congestion nor 
coma. 
If there is great irritation of the stomach with sickness or diarrhoea, 
small repeated doses of hydr. c. creta et pulv. ipec. c. should be 
given with effervescing draughts; and fomentations or rubefacients 
be applied to the abdomen. 
And in what may be called chronic or habitual erysipelas, when 
it comes on at intervals, when the stomach is disordered, or the 
general health deranged, a course of aperients, alteratives, and tonics, 
(especially sarsaparilla and alkalis,) should be administered accord- 
ing to the principles laid down in the chapter on Chronic Inflam- 
mation. 
Local Measures.-Leeches are useful in the early stages, pro- 
vided the patient can bear the loss of blood. Minute punctures 
about one-fifth of an inch deep, made with the point of a lancet, 
may be used as substitutes; and often permit the discharge of con- 
siderable quantities of blood and serum. 
Cold Lotions may be used when the heat is great, the redness 
vivid, and the pulse good, and especially in erysipelas of the head. 
But they must be avoided if the circulation is languid, or if the 
erysipelas is manifestly connected with gastric irritation, or any 
other internal disorder. 
Warm or tepid fomentations of dec. papav. should be preferred ERYSIPELAS. 
79 
in cases arising from local irritation; and perhaps are safest at all 
times; but the patient's feelings are the best criterion. 
Flour, dusted on the inflamed part, is a very soothing application; 
and is well calculated to allay the heat and itching of simple ery- 
sipelas, and to absorb the acrid serum that escapes from the vesica- 
tions. 
Pressure by bandages is serviceable in the latter stage of most 
cases:-and from the very first, if the inflammation be atonic and 
oedematous. 
Mercurial ointment smeared on the part, or applied as a plaster, 
has been much praised by some people, but its efficacy is question- 
able. 
Stimulants.-The nitrate of silver in substance or solution; or 
blisters, or fomentation of dec. cydonii oj. cum liq. am. sesquicarb. 
5j. are of great use in putting a stop to tedious erratic cases of sim- 
ple erysipelas, after proper constitutional remedies have been used. 
In similar cases, the extension of the disease may sometimes be 
arrested by applying a strip of blistering plaster, or still better, the 
nitrate of silver, so as completely to encircle the inflamed part. The 
skin should be well washed first, and care should be taken to leave 
no interstices through which the disease might creep and extend 
itself. When there is a tendency to sinking, warm cloths moistened 
with turpentine or sp. camp, may be applied externally, whilst dif- 
fusive stimulants are administered internally. 
Incisions are, to use a French expression, the heroic remedy in 
phlegmonous erysipelas. When the swelling is great and increases 
rapidly;-when it is hard, tense, and resisting, not soft and cede- 
matous as in simple erysipelas;-when the pain is severe, and 
throbbing, and not relieved by leeches;-when there is the least 
sensation of fluctuation or quagginess;-or when the skin is 
becoming livid or dusky, or covered with livid vesicles, they are 
imperatively demanded. They are absolutely necessary for the 
discharge of pus and sloughs;-for, as James observes, these mat- 
ters are neither brought to the surface by pointing, nor walled in 
by adhesion. But it must be recollected, that they are not to be 
considered merely in the light of apertures for the discharge of 
matter; but as the most effectual means of cutting short the inflam- 
mation, by relieving the tension, and by emptying the distended 
blood-vessels. They are also requisite in erysipelas of the throat, 
when great swelling threatens suffocation by pressure on the tra- 
chea. They should be made of sufficient length,-in as many 
places as required;-they should be carried quite deeply through 
the diseased tissues, and should be repeated as often as necessary. 
Two, three, or four inches will be a sufficient length in most cases; 
but no precise rule can be laid down on this subject. At all events 
they should be made long enough, but no incisions should be made 
from hip to ankle out of wantonness or bravado. They should 
not be permitted to bleed longer than the strength permits;-and 
haemorrhage, if profuse, is best stopped by continued pressure with 
the fingers on the bleeding points. The subsequent measures are 80 
DIFFUSE CELLULAR INFLAMMATION. 
poultices, followed by nitric acid lotion; and bandages to prevent 
lodgment of matter and sinuses.* 
SECTION III. ERYSIPELATOUS OR DIFFUSED INFLAMMATION OF THE 
CELLULAR TISSUE. 
Symptoms.-This disease exhibits the symptoms of cellulo-cuta- 
neous erysipelas, without the affection of the skin. A rapidly 
increasing swelling appears on one of the limbs, or on some part 
of the trunk. Its surface is tense, shining, and usually pale. When 
pressed upon it feels in some cases hard and resisting, but more 
frequently it yields that peculiar, semi-elastic sensation described 
by the term boggy., or quaggy. There is always most excruciating 
pain,-which in some cases is burning and throbbing, in others 
heavy and tensive. The disease is invariably attended with fever 
of an irritative or typhoid character. The pulse is always frequent; 
-it may be sharp and jerking, but is without strength and steadi- 
ness. The countenance is anxious and haggard;-the mind irri- 
table and desponding, and delirious at intervals. Respiration is 
quick and laborious,-more especially if the disease be seated on 
the chest, as it frequently is,-because the pleura is affected through 
contiguous sympathy. In unfavourable cases, low muttering de- 
lirium, subsultus tendinum, copious offensive perspiration, and 
jaundiced skin, usher in the fatal termination. 
Causes.-The predisposing causes of this disease are those of 
the other varieties of erysipelas. The exciting causes may be of 
the most trivial nature, if the patient be predisposed ; such as very 
slight punctures or abrasions. This is the disease which is excited 
by the bites of venomous serpents;-and by inoculation with 
septic animal poisons;-especially by that which is generated in 
bodies recently dead;-it also occasionally follows certain surgical 
operations, as lithotomy and venEesection. It was extraordinarily 
prevalent in the Plymouth dockyards in 1S24, owing to some epi- 
demic state of the air. 
Morbid Anatomy.-On examination of the parts affected, at an 
early period of the disease, the cellular tissue is found loaded with 
a limpid reddish serum. In a more advanced stage, this fluid 
becomes thicker, and less highly coloured. Subsequently, the cel- 
lular tissue is found to be gorged, partly with white semifluid mat- 
ter, partly with a brownish purulent sanies, which is mingled with 
detached flakes of the sphacelated tissue. The muscles, and other 
structures in the vicinity, are discoloured and softened;-and the 
larger veins which permeate the diseased part, have their coats 
inflamed, and often in a state of suppuration. 
Diagnosis.-This disease is to be distinguished from the common 
phlegmonous abscess, by its having a smooth and level surface, 
* Vide James, op. cit.; Copland, Diet.; Higginbottom on Nitrate of Silver; Cop- 
land Hutchinson's Surgical Observations; the Lectures of Abernethy, and Cooper; 
and two Lectures by Velpeau, Med. Gaz., Aug. 14 and 21, 1840. ULCERATION. 
81 
without any tendency to point;-also by the asthenic nature of the 
accompanying fever. 
Treatment.-This will be more fully discussed in the chapter 
on Dissection Wounds, (Part iii. ch. 9.) It may, however, be sum- 
marily observed, that leeches, hot fomentations, and free incisions, 
-emetics, purgatives, and enemata, followed by ammonia, bark, 
opium, and wine, are the measures that are sanctioned by the most 
authoritative and experienced writers.* 
CHAPTER IX. 
OF ULCERATION. 
SECT. I.-OF THE PATHOLOGY OF ULCERATION. 
Pathology.-The observations of the most recent pathologists 
have shown that ulceration consists in the progressive softening, 
disintegration, and removal of successive layers of the ulcerating 
tissue. 
Now ulceration, like mortification, may occur through two oppo- 
site processes. First, from inflammation ; secondly, from conges- 
tion ; that is, from a stagnation of venous blood in the capillaries. 
(1.) Inflammatory Ulceration.-The formation of an ulcer 
through inflammation is precisely similar to the formation of an 
abscess; the only difference being that the former commences on 
the surface, the latter in the substance of a part. Supposing the 
skin to ulcerate from the application of venereal poison, for instance. 
In the first place, its surface inflames, and secretes serum or un- 
healthy pus, which elevates the cuticle into a pimple or pustule. 
When the pustule is opened, there appears a little hollow, filled 
with a whitish or grayish tenacious matter, consisting of the skin 
which is softened and becoming ready to separate, and of unhealthy 
flaky pus. If this is wiped off, the surface underneath is seen to be 
red, and it easily bleeds. Supposing the case to proceed, there is 
formed a chasm, eaten into irregular hollows, with intervening red 
eminences, which easily bleed if touched; its edges are ragged, 
loose, and undermined; the surrounding skin red, hot, and swollen; 
there is a thin serous, or bloody discharge, and a constant, severe 
gnawing pain. An ulcer having these characters may always be 
considered as extending itself. 
An excoriation is sometimes the first stage of this ulcer; that is 
* Vide two papers in the Edinburgh Medical and Surgical Journal for 1825, vol. 
xxv.; Copland's Diet., Art. Cellular Tissue; James on Inflammation; Travers on 
Constitutional Irritation, and Butter on Irritative Fever, Devonport, 1825. 82 
ULCERATION. 
to say, a portion of skin inflames, discharges matter, and loses its 
cuticle, and the excoriated portion may either heal, or as we have 
just observed, may ulcerate. 
Of course, ulcers spread with varying degrees of rapidity. An 
attack of violent inflammation may cause the death of a consider- 
able portion in a very short time; this is said to be a sloughing 
ulcer. When an ulcer spreads very rapidly, but regularly and 
without sloughing of any great portion at one time, it is called 
phagedecnic. And when it spreads more rapidly still, not by one 
fit of sloughing, but by the constant reiterated mortification of con- 
siderable layers, it receives the name of sloughing phagedsena. 
(2.) Congestive Ulceration.-This may be very briefly described 
as it occurs on the legs of old dropsical people. A small portion of 
skin has its capillaries distended with venous blood, whose return 
is nearly or quite suspended. Some of the serum (with which the 
cellular tissue is already distended) exudes under the cuticle, raising 
it into a blister. When this is removed, there is seen a darkish 
layer of sloughing skin. This, like the last, may spread with every 
degree of rapidity; but whether a large tract of skin mortifies at 
once, or whether the smallest portion ulcerates, the process is one 
and the same. 
(3.) Combination of the two Forms.-But it most generally 
happens that ulceration consists in a combination of inflammation 
and congestion; that is, in the inflammation of a part already con- 
gested, or incapable, through weakness, of supporting inflammation 
without loss of life. It may be observed also, that ulcers which 
have commenced through congestion may be extended by inflam- 
mation. 
As this account which we have given of the ulcerative process 
differs very materially from the doctrines of Hunter, it is necessary 
to say a few words in proof of its correctness. 
Now Hunter taught, that ulcers are formed by a variety of ab- 
sorption, which he denominated ulcerative; the substance of his 
theory being, that the ulcerating tissue feels its want of vitality, and 
therefore is absorbed by its own lymphatics. 
But to this doctrine it must be objected, first of all, that it is void 
of all proof. Hunter says that it is so, and that he was the first to 
show it; but nowhere does he attempt to prove it. 
In the second place, it is opposed by the following undoubted 
facts. (1.) Ulcers often spread rapidly when inflamed; but absorp- 
tion is always diminished during inflammation; so that a quantity 
of nux vomica, which would prove fatal if applied to a recent 
wound, or to a healthy mucous membrane, may be applied with 
impunity if these parts are inflamed. (2.) The tissues best supplied 
with absorbents, do not ulcerate so readily as others (cartilage, for 
instance) which are very imperfectly supplied. (3.) Parts (such as 
bone) which are very quickly absorbed before the progress of an 
aneurism, do not ulcerate so readily as cartilage, which is absorbed 
before an aneurism very slowly, if at all. (4.) The state which 
favours ulceration in the legs, is one adverse to the action of absorp- ULCERATION. 
83 
tion either by lymphatics or veins. (5.) Absorption is a very slow 
process; ulceration often very rapid. (6.) Granulations ulcerate 
more readily than cicatrices; although they cannot be presumed to 
be better supplied with lymphatics. (7.) A surface to be absorbed 
by the minute lymphatics must necessarily become fluid; but if so, 
what is to hinder it from passing off, at least in part, with the dis- 
charge? (8.) Injections demonstrate that old ulcers are always 
attended by a dilated state of the surrounding veins, but show no 
development of the lymphatics.* 
Predisposing Causes.-The Tissues most disposed to ulceration 
are the skin, with the mucous and synovial membranes. From 
these it may spread to the subjacent tissues, which yield to it with 
varying degrees of rapidity. The cellular tissue ulcerates very 
easily; but muscles, blood-vessels, and nerves, very slowly; so that 
they often appear to be as it were dissected out in spreading sores, 
by the destruction of the cellular tissue around them. Tendons 
and ligaments are also very slow to ulcerate ; but cartilage, bone, 
and the cornea, are in certain constitutions extremely liable to it. 
The Constitutions most liable to ulceration, are those which are 
debilitated by intemperance or privations;-tainted with syphilis 
or scrofula ;-or broken down by the excessive use of mercury. 
The parts most disposed to it are those whose circulation is most 
weak and languid; such as the lower extremities; and more espe- 
cially if the return of their venous blood be in any way impeded 
by a varicose state of the veins. On this account tall persons are 
much more frequently affected with ulcers of the legs than the short. 
Sir E. Home shows, on the authority of Dr. Young, that twenty- 
two out of one hundred and forty-five tall men, and only twenty- 
three out of two hundred and seventy-six short men, were dis- 
charged from a regiment in the West Indies in four years, on 
account of ulcers. 
Parts newly formed are, as has been before said, more liable to 
ulcerate than those of original formation. And this is equally true, 
whether they have been produced, first, in consequence of injury, 
as cicatrices and callus; or, secondly, whether they are developed 
from hypertrophy of a standard structure; as cutaneous tumours 
which often remain stationary for years, and then, from some slight 
irritation, will give rise to the most destructive and spreading ulcer- 
ation ; or, thirdly, whether they consist in the deposit of a texture 
* Consult J. W. Earle, Med. Gaz., for 1835. C. Aston Key, Med. Chir. Trans., 
vol. xviii. and xix.; Copland, Did. Prad. Med., Art. Inflammation; Pearson's Prin- 
ciples of Surgery,- and particularly Wallace on the Venereal Disease, Lond. 1838, p. 
47; and S. Gaskell, Jacksonian Prize Essay on Ulceration, MS. in the Library of the 
College of Surgeons in London. An inspection of the preparations accompanying 
Mr. Gaskell's Essay, would convince the most sceptical. The circumstance that 
patches of cartilage sometimes ulcerate, without any fluid debris being found in the 
joint, is no argument against the above account of the real nature of ulceration, 
because, although cartilage does not ulcerate through absorption, still its fluid 
debris may be absorbed by the surface of the synovial cavity. In the same way, a 
chancre is not formed through absorption; but its surface, especially when it begins 
to granulate, may imbibe some of the poisonous secretions, which will pass by 
transudation into the veins and lymphatics. Vide Lancet, Feb. 15, 1840. 84 
VARIETIES OF ULCERS. 
alien to the normal organization. Thus cancerous diseases consist 
in the deposit of a new texture, which, from its low powers of 
vitality, yields after a time to disorganization. 
Exciting Causes.-In constitutions of parts predisposed to it, 
the slightest irritation may be sufficient to excite ulceration. In the 
healthy it may be produced by the continuous application of some 
irritant, so as gradually to exhaust the vital powers of the part;- 
such as continued pressure; the presence of irritating fluids; or 
depraved secretions. But it is not easy to excite genuine spreading 
ulceration in the healthy, unless by some specific cause, such as the 
venereal poison. 
SECTION II. OF THE VARIETIES OF ULCERS. 
It is not easy to give a rigorous definition of the term ulcer, nor 
is it necessary. For all useful purposes, it will suffice to say, that 
it signifies a chasm on the surface of any organ caused by the de- 
struction of a portion of its substance by disease ; or by an injury 
which has not been repaired. 
Ulcers present many varieties, which may be classed under three 
heads. 1. They may be in a state tending to reparation; as the 
healthy ulcer. 2. They may acquire an imperfect organization, 
and be incapable of healing, although not necessarily spreading; 
the weak and indolent ulcers are examples. 3. They may be under 
the influence of the destructive process which formed them origin- 
ally, and which is still causing them to spread; as the phagedaenic. 
1. The Healthy Ulcer is nothing more than a healthy granu- 
lating and cicatrizing surface. The granulations are small, nume- 
rous, florid, and pointed, and yield a moderate secretion of healthy 
pus. The edges are smooth, and covered with a white semi-trans- 
parent pellicle, which is gradually lost on the margin of the granu- 
lations. It will be recollected that a healthy sore of this description 
will be greatly diminished by the contraction of the surrounding 
skin, before any cicatrization has actually occurred. 
Treatment.-The only treatment required will be a little dry 
lint, if there be much discharge,-or the water-dressing, or simple 
ointment, if there be not. If there be not much discharge, the 
dressings should not be changed more frequently than every second 
or third day. If the granulations are too luxuriant, they may be 
touched with lunar caustic, and dressed with dry lint;-or the sore 
may be exposed to the air for some hours. If the granulating sur- 
face is very extensive, or if all applications disagree with it, as 
sometimes happens, it will be expedient to form a scab on its sur- 
face. This may be done by allowing the pus to dry, or by sprink- 
ling a little flour, or calamine, or chalk, to absorb it. But the best 
plan in these cases is to pass a stick of lunar caustic over the sur- 
face of the sore, as recommended by Mr. Higginbottom. This salt 
instantly coagulates the fluids on the sore, and forms a white pelli- 
cle, which soon becomes dry and black, and is much less irritating IRRITABLE ULCERS. 
85 
than an ordinary scab. If the scab act favourably, suppuration 
ceases, and cicatrization will be found complete when it is detached. 
No other dressing is required, except a piece of goldbeater's skin, 
and a slight bandage, to prevent injury. If pus continue to be 
formed, a small hole should be made in the middle of the scab to 
let it out. 
II. The Inflamed Ulcer has already been described. 
Causes.-Ulcers (though not originally formed by inflammation) 
are liable to inflame from any of the ordinary local or constitutional 
causes, especially errors in diet. Sores situated over projecting parts 
of bones or ligaments, as the outer ankle, or over the bellies of 
muscles, are apt to assume this character; hence care should be 
taken to avoid making issues in such situations. 
Treatment.-In a few instances, when the patient is very ple- 
thoric and strong, it may be expedient to bleed, and to administer 
calomel, antimony, and opium till the mouth is slightly affected. In 
all cases, the bowels should be cleared, the secretions kept up, and 
the diet be regulated. The patient should keep at rest, with the 
affected member in an elevated posture. Leeches may be applied 
in the vicinity of the sore ; but not too near it, and not to any place 
where the skin is much thickened and congested, lest the leech-bites 
themselves take on ulceration. The part should be fomented night 
and morning for half an hour with poppy fomentations, and then a 
poultice or the water-dressing be applied, or the steam bath described 
at p. 54 may be tried;-and if the pain be very severe, the poultice 
may be medicated with opium, F. 63, or conium. If the ulcer dimi- 
nish under these applications, but yet its surface remain foul, they 
may be continued till it is healed; but if the surface become healthy, 
it may be treated as an ordinary ulcer.-If warm applications 
aggravate the pain, cold evaporating, or saturnine lotions (F. 11) 
should be used, the sore being protected by a piece of oiled silk or 
simple dressing. 
If all these soothing measures prove ineffectual, as they occasion- 
ally will, even though aided by the most judicious constitutional 
treatment, recourse must be had to the measures directed for irrita- 
ble ulcers. 
III. The Irritable Ulcer is a variety of the inflamed. It is 
defined by Mr. Skey* as having an excess of organizing action, 
with a deficiency of organizable material; so that the granulations 
are too small, and .are morbidly sensitive and vascular. 
Treatment.-In the first place, the constitution, which is gene- 
rally out of order, must be corrected by alteratives and tonics. 
Plummer's pill, or F. 6, 7, 10, 52, at bedtime; and sarsaparilla, 
soda, and hyoscyamus, F. 56, 57, during the day; or the extract of 
conium in doses of gr. v., ter die, will be of great service. 
In the local treatment, all sources of irritation must be removed, 
and the soothing applications directed for the inflamed ulcer may 
be tried first. But the most successful plan, generally speaking, is 
* F. C. Skey, F. R. S. A new mode of treatment employed in the cure of various 
forms of ulcer. London, 1837. 86 
INDOLENT ULCERS. 
the application of a succession of mild stimulants, so as to alter the 
actions and exhaust the irritability of the part. Weak lotions of 
nitric acid (F. 17), of nitrate of silver (gr. i. ad. $j.), of arsenic (F. 
68), of sulphate of zinc (gr. i.-v. ad. gj.), of sulphate of copper 
(gr. i.-ii. ad. 3j.), of acetate of zinc (F. 21), of corrosive sublimate 
(F. 37), of chloride of soda (F. 39), of iodine (F. 76), the linimen- 
tum aeruginis, black wash (F. 70), yellow wash (F. 71), lime water, 
solution of sulphate of iron (gr. i. ad. 5}.), forge water, that is, water 
in which red hot iron has been extinguished, strong green tea, pow- 
dered chalk or charcoal mixed with cream, ointments of Peruvian 
balsam, of oxide of zinc, chalk, lead, and calamine ; weak mercu- 
rial ointment, liniment of ung. hydr. nitratis (F. 73); moderate pres- 
sure with strips of soap plaster, or of linen spread with soap cerate, 
or with a smooth piece of sheet lead; all of these measures will 
occasionally be of service in the cure of obstinate and irritable 
ulcers. For it very often happens that an application which at first 
soothes the pain will soon lose its good effects, and then become 
positively hurtful. 
IV. The Weak Ulcer is the direct reverse of the preceding. Its 
powers of organization are deficient. The granulations are large, 
pale, flabby, and insensible, rising above the margin of the skin, and 
showing no disposition to cicatrize. 
Causes.-This state of ulcer may be owing to debility of the 
system; but the healthiest granulations, if their healing be delayed, 
become weak;-and conversely, if any granulations do not cicatrize, 
they should be considered as weak, and treated accordingly. 
Treatment.-The indications are to augment the vital forces of 
the granulations, and to restrain the exuberant growth. A liberal 
diet and tonics should be resorted to. If the granulations are ex- 
tremely exuberant, they may be destroyed by escharotics, such as 
cupri sulphas ;-or sometimes they may be shaved off with a thin 
knife;-but it is better to cause their removal by over-stimulation 
than by actual destruction. So that the best applications are, fine 
dry lint, which by itself is an excellent stimulant; or lint dipped in 
a lotion of sulphate of zinc, or of sulphate of copper, or of nitrate of 
silver, or the ung. hydr. nit. The formation of a crust or scab with 
the lunar caustic, on Air. Higginbottom's plan, may be often resorted 
to with advantage. At the same time, pressure by means of strips 
of plaster, or compresses, and bandages, is necessary to prevent lan- 
guor of the circulation;-especially if the muscles are wasted and 
flabby. In some cases a scab may be formed by covering the sore 
with powdered rhubarb, taking care to oil the edges, so that they 
may not be irritatpd by it. If the patient is young and weakly, 
with great coldness and blueness, and tenderness to oedema in the 
extremities, the limb may be immersed in tepid salt water for fifteen 
minutes twice a day; to which an equal part of decoction of poppies 
may be added if pimples are produced. 
V. The Indolent Ulcer is characterized by a deficiency of 
action as well as of power. Its surface is smooth and glassy, and of 
a pale ashy colour, like a mucous membrane. Sometimes, however, INDOLENT ULCERS. 
87 
it displays a crop of weak fungous granulations. The edges are 
raised, thick, white, and insensible ; the discharge scanty and thin. 
The most frequent situation of these ulcers is the small of the leg, 
and they are almost exclusively met with amongst the lower orders. 
They are often stationary for a great length of time ; but, from any 
slight cause of irritation, may enlarge rapidly by ulceration or 
sloughing; and even when they have made considerable progress 
in healing, the granulations and cicatrices that have been months in 
forming may perish in a few hours from some constitutional disturb- 
ance or local injury. 
Treatment.-The general rules are, to promote constitutional 
vigour by good diet and tonics, and to excite the local actions by 
various stimulants. The patient should take moderate exercise; 
but when he is at rest, the affected limb should not be permitted to 
hang down. In treating these cases, we must endeavour not only 
to effect a cure, but to make it permanent; and this can be insured 
only by attending to the growth of the granulations, and rendering 
them as healthy and firm as possible. 
Fig. 5. 
The following is, perhaps, the best plan of curing these ulcers. A 
number of pieces of lint, thoroughly soaked in the nitric acid lotion, 
should be laid on the sore, and be covered with a warm soft poul- 
tice. These applications should be changed twice a day, and be 
continued till the discharge becomes healthy, and granulations 
begin to arise. If there is any degree of inflammation about the 
parts, (which often happens when these ulcers first come under 
treatment,) the patient must be confined to bed and be purged. 
Afterwards, when the surface is clean, the following mode of 
dressing should be adopted. First, some pieces of lint, saturated 
with the nitric acid lotion, or zinc lotion, or with some other stimu- 
lating substance, should be laid on the sore. Then strips of adhe- 
sive plaster, about H inch wide, should be applied two thirds 
round the limb, from an inch below the ulcer to an inch above it; 
and in applying each strip, the edges of the sore should be drawn 
together with a moderate degree of force. Next, a compress of 
soft linen must be placed over the plaster, and finally, the limb 
must be well and evenly bandaged from the toes to the knee; 
observing that the bandage is to be applied most tightly below, and 
more loosely by degrees as it ascends. 
Baynton's Plan.-If, however, the whole limb is very much 
thickened, and the edges of the ulcers are very callous, it will be 88 
INDOLENT ULCERS. 
better to follow Mr. Baynton's method ;*-that is, to encircle the 
ivhole circumference of the limb with strips of plaster, from an 
inch below to an inch above the ulcers. Each strip is to be first 
applied by its middle to that part of the limb which is opposite the 
ulcer, and then the two ends are to be brought forwards over it, 
and they should be long enough to overlap about two inches. A 
compress and bandage are to be applied afterwards. These modes 
of dressing almost always cause severe pain ;-but it ought soon 
to subside, and the part to feel stronger and more comfortable 
afterwards. If, however, it continue to be painful and hot, some 
pure water should be poured on the bandage from a watering-pot 
or tea-pot. 
If the adhesive plaster irritate the skin, it may be diluted with 
soap-plaster;-or the isinglass-plaster may be substituted. This is 
made by dissolving isinglass in spirits of wine, and spreading the 
solution on silk. It readily adheres if moistened with a warm 
sponge. 
But although the plastering and bandaging are adapted for most 
cases, the immediate application to the ulcer will require to be fre- 
quently varied. Sometimes the strapping may be applied without 
any thing else; or dry lint may be placed under it; or lint imbued 
with lotions of sulphate of copper, or alum; or with lotions made 
by adding half an ounce of the tincture of myrrh, or of benzoin 
(comp.), or aloes (comp.), to four ounces of water; or the balsams 
of copaiba or Peru; but metallic preparations agree better in gene- 
ral than the vegetable. Ointments agree better with the indolent 
than with the other varieties of ulcer, because they do no harm if 
rancid. The ung. hyd. nitric, oxid. is very useful; and the ung. 
hydrarg. nitrat. dilut. is praised for its efficacy in reducing thick 
callous edges. Mr. Stafford recommends old deep indolent ulcers 
to be treated by filling up their cavity with a mixture of one part 
of Venice turpentine, and four of beeswax, melted and poured in 
warm. 
If a crop of granulations threaten to slough, they should be 
fomented with hot decoction of poppies, to which a little spirit of 
wine has been added. The gastric juice of animals is said to be a 
specific for certain sloughing ulcers occurring in persons debilitated 
by the use of ardent spirits and salt provisions, and by residence in 
hot climates. During any febrile disturbance of the system, the 
local applications must be mild. 
Mr. Skey's Plan.-Mr. Skey, conceiving that the chief obstacle 
in the cure of these ulcers is the want of a vigorous capillary cir- 
culation,-and seeing that opium produces an uniform warmth of 
skin, and excites the circulation in the remotest parts, proposes to 
employ it in the treatment of these cases. He recommends it to be 
given in doses of half a grain night and morning, which may be 
increased gradually, according to its effects. He says that this 
treatment, without any local applications, will suffice for the cure 
* Baynton, T., Descriptive Account of a New Method of Treating Old Ulcers of 
the Legs. Bristol, 1797. FISTULOUS ULCERS. 
89 
of all weak and indolent ulcers, especially if the patient be old, and 
reduced by intemperance or starvation. He observes that, in gene- 
ral, the opium proves rather laxative than otherwise; and that it 
will have no ill effect in any case, whilst artificial support is needed; 
-or whilst the natural powers are languid;-or "so long as there 
remains a drain on the circulation.'* Mr. Skey also recommends 
the employment of opium with a similar view in other cases of 
deficient circulation, or passive congestion,-as in chronic catarrh, 
and the red noses of drunkards; and in phagedoma after the active 
symptoms have been combated. 
Should old ulcers be. healed?-The propriety of healing old 
ulcers will sometimes be made a question, inasmuch as certain dis- 
eases, and especially apoplexy and palsy, are apt to supervene on 
their suppression. Sir E. Home has specified the following cases 
in which a cure ought not to be attempted. 1. If the ulcer be 
" evidently affected with the gout, having regular attacks of pain, 
returning at stated periods; and those attacks similar to what the 
patient has experienced from gout in other parts." 2. If an ulcer 
habitually occur whenever the constitution is disordered. 3. If the 
patient be very infirm and old; for under these circumstances the 
removal of an habitual source of irritation, or the diversion of an 
habitual afflux of blood, may prove fatal;-more especially as very 
old ulcers have been known to heal spontaneously a short time 
before death. In the first two cases, however, an issue placed in 
a convenient situation might be substituted for an ulcer in an 
inconvenient one. But in other cases, when the ulcer has not dis- 
played any connection with constitutional disorder, there need be no 
reluctance to heal it, provided that the secretions are properly main- 
tained during the cure, and for some time afterwards. And if any 
symptoms of congestion in the head or other organ should arise, an 
issue may be inserted in the arm. Whately* mentions a case in 
which an ulcer was healed, but some time afterwards it reappeared 
of itself, and soon after that the patient died suddenly; and he ob- 
serves that his death would infallibly have been attributed to the 
healing of the sore, if it had occurred before its second outbreak. 
VI. The Fistulous Ulcer (Fistula or Sinus) is a variety of the 
indolent, and consists of a narrow channel lined by a pale pseudo- 
mucous membrane, which may or may not lead to a suppurating 
cavity. In old cases the parietes of the tube are often dense and 
semi-cartilaginous. 
Causes.-Fistulae are produced when abscesses are not tho- 
roughly healed from the bottom, and when their sides have been 
too hastily approximated, or when there is some standing cause of 
irritation, as a ligature, or a piece of dead bone, which keeps up a 
discharge of pus. 
Treatment.-1The first indication is to remove any source of irri- 
tation-diseased bone for example-that may happen to exist. 
The second, to prevent lodgment of matter; for which purpose it 
* Whately, T., Practical Observations on the Cure of Wounds and Ulcers. 
Lond. 1816, p. 144. 90 
SLOUGHING ULCERS. 
may perhaps be necessary to make another opening. The third 
indication is to produce the adhesive inflammation;-to which the 
mucous lining of the fistula is naturally indisposed. The means 
to be adopted are, stimulating injections, tents smeared with irri- 
tating ointments ; the caustic bougie ; or a seton consisting of a few 
threads of silk, which may be passed through the fistula, and may 
be gradually diminished as the passage contracts. At the same 
time, the sides of the fistula should be kept constantly pressed toge- 
ther with compress and bandage. If these means fail, the fistula 
should be slit up with a bistoury; and then a thin piece of lint be 
introduced in order to prevent premature union of the cut edges, 
and make it heal from the bottom. 
If there have been a succession of small unhealthy abscesses in 
a part;-or if ulceration have spread irregularly in the cellular tis- 
sue, so as to leave the skin ragged, and extensively undermined 
with tortuous sinuses, it will be advisable to destroy the whole of 
the parts so diseased by the potassa fusa; and this will stimulate 
the neighbouring sound parts, so that when the slough separates, 
a healthy surface will be left, which may be healed by the ordinary 
means.* 
VII. The Varicose Ulcer occurs in consequence of a varicose 
state of the veins of the lower extremity. This greatly impedes 
the return of blood, and, by producing habitual venous congestion, 
weakens the parts, and renders them prone to ulceration. The 
ulcers are usually three or four in number; situated above the 
ankle. They are oval in shape, indolent in their progress, and 
neither extensive nor deep;-but they are attended with consider- 
able pain, which is of a deep-seated, aching character, and not sore 
like that of ordinary ulcers. 
The Treatment must be directed principally to the veins, and 
for this, we must refer to the chapter on that subject. We will 
merely observe here, that the applications to the ulcers must be 
suited to their condition, whether irritable or indolent;-and that 
great relief to the pain is frequently obtained by opening one of the 
enlarged vessels, and abstracting a moderate quantity of blood. The 
advantages of proper support by bandages or laced stockings need 
scarcely to be noticed. Sometimes there is a constant desquama- 
tion of the cuticle, with serous discharge, for which the best reme- 
dies are equal parts of lime water and milk, or the ointment of chalk, 
(F. 102,) or of oxide of zinc. 
VIII. The Sloughing Ulcer is formed whenever either of the 
other varieties of ulcer is attacked with sloughing;-which is par- 
ticularly liable to occur to the indolent, when subjected to undue 
irritation. Or, this name may be given to ulcers originally pro- 
duced by a sloughing of the skin;-as on the legs of the dropsical. 
Treatment.-The best applications are warm fomentations of 
poppy decoction, to which a little spirit has been added ; and stimu- 
lating poultices of yeast or carrots; or the nitric acid lotion on lint, 
with a warm poultice over it. 
* Liston, Elements of Surgery. PHAGEDENIC ULCERS. 
91 
IX. Phagedena is a peculiar variety of ulceration, extremely 
rapid in its progress. The surface of the sore is irregular, generally 
whitish or yellowish; the discharge serous, or bloody, and often 
extremely profuse; and the pain extreme. Some cases are attended 
with fever and acute inflammation, the margin of the sore being 
highly painful, swelled, and red;-others with atony and debility, 
the margin being pale, dusky, or livid. 
Causes.-This disease may be induced either by extraordinary 
local irritation, or by some peculiar constitutional disorder. It may 
attack primary or secondary venereal sores in consequence of filth, 
intemperance, the abuse of mercury^or of a weakened and vitiated, 
or scrofulous habit, or of some peculiarity in the venereal virus. 
Sometimes it appears in the throat after scarlatina;-it may attack 
a blistered surface when the constitution has greatly suffered from 
an acute and exhausting disease, as measles, &c.;-sometimes it 
affects the mouth or genitals of children, constituting cancrum 
oris* noma, &c. 
Treatment.-If the habit is inflammatory, and the pulse full and 
strong, bleeding and the antiphlogistic regimen should be employed, 
and opiate lotion be applied to the sore. If the condition of the 
system is the reverse, tonics and narcotics, (F. 1, 2, 3,) should be 
administered, and the diseased surface should be destroyed by nitric 
acid in the manner to be presently described. 
X. Sloughing Phagedena or Hospital Gangrene seems, 
says Mr. Lawrence, to be the state of phagedaena carried to its 
fullest extent;-or, as was explained at the commencement of this 
chapter, it may be described as a process intermediate between 
common ulceration and gangrene. Its causes are, (1) local irrita- 
tion acting on a vitiated state of the constitution. (2) Contagion; 
that is, the application of poisonous matter to a wound; and (3) in- 
fection; that is, the reception of poisonous miasmata into the blood. 
We shall first treat of it as it occurs sporadically in civil practice, 
where it bears the name of sloughing phagedsena; and next, of 
those more serious visitations that decimate the patients in crowded 
naval or military hospitals, whence it derives its other name, hospi- 
tal gangrene. 
In the cases seen in civil practice, the disease is mostly seated in 
or near the genital organs; in the cleft of the nates, in the groin, or 
at the upper and inner part of the thigh. It often, but far from 
invariably, supervenes on syphilitic ulcers; especially in young 
prostitutes who have been exposed to cold and wet, and privation of 
solid food, and the abuse of ardent spirits. It is especially liable to 
be induced by the too free administration of mercury, or by intem- 
perance and exposure to wet during a mercurial course. The worst 
cases, however, appear to arise from neglected local irritation, with- 
out any specific virus; as from acrid discharges and defective clean- 
liness. Mr. Lawrence mentions the case of a young woman who 
had suffered from severe small-pox, and from diarrhoea after it. 
* Vide Part IV. chap. xiv. 92 
HOSPITAL GANGRENE. 
The continual moisture from the rectum, with a mucous discharge 
from the vagina, irritated and inflamed the skin of the nates, and 
caused a large sloughing phagedaenic excavation on both sides. 
Symptoms.-a It usually commences as a highly irritable and 
painful boil, surrounded by a halo of dusky red inflammation, and 
much elevated; the patient also in general having mucous dis- 
charges from the vagina, and a diffused redness of integument in 
the vicinity of the pudenda." There are severe darting and sting- 
ing pains; which are at first intermittent, but gradually establish 
themselves as a constant symptom, with occasional exacerbations. 
When the pustule is ruptured, the exposed surface of the ulcer dis- 
plays a stratum of adherent straw-coloured flocculi, mottled with 
darker points of reddish brown and gray. The sore thus formed 
soon enlarges in breadth and depth;-the edges become everted, 
and attended with a circumscribed thickening, which is surrounded 
by dusky inflammation and diffused puffy swelling. The surface 
is composed of gray or ash-coloured sloughs, which may become 
brown, or resemble coagula of blood. The discharge is reddish- 
brown and peculiarly fetid, and there is occasionally severe haemor- 
rhage. Meanwhile the agonizing pain, the haemorrhage, and the 
absorption of putrid matters, soon induce severe irritative fever,- 
ushered in by loss of sleep, anxiety, restlessness, and thirst; which, 
with an exhausting diarrhoea, produce death in about three weeks; 
and, as delirium is rare, the patient retains a miserable conscious- 
ness of severe suffering till the end. The disease is highly conta- 
gious, but it appears to be a local disease, and both the constitu- 
tional and local symptoms may be removed by measures which 
destroy the acrid secretions of the ulcer.* 
Hospital Gangrene is the name given to this affection when 
occurring in military and naval practice. 
Causes.-Like other putrid maladies, it is engendered by crowd- 
ing together a number of sick and wounded men;-and by inatten- 
tion to cleanliness and comfort, and to free ventilation, which is so 
necessary for carrying off the noxious miasmata always generated 
under those circumstances. It frequently is a concomitant of dysen- 
tery or typhus, originating in the same sources. It may affect any 
kind of wound, or even a mere bruise. 
Propagation.-This disease, when once generated, may either 
spread by contagion; that is, by the contact of its morbid secre- 
tions;-or by infection; that is, through the medium of its vapour 
or effluvium. It may, although rarely, occur sporadically ; that is, 
may be induced in isolated cases by improper and irritating local 
and constitutional treatment of the wounded. 
Symptoms.-According to Mr. Blackadder, it begins in the form 
of a livid vesicle at the edge of a wound or sore, accompanied with 
an occasional painful sensation like the sting of a gnat. Sometimes 
it first appears as a small livid spot on the sore, and near its cir- 
cumference. In either case the disease soon spreads, and converts 
* Welbank, Med. Chir. Trans, vol. xi.; Lawrence, Lectures in Med. Gaz. vol. v. HOSPITAL GANGRENE. 
93 
the whole surface of the ulcer into an ash-coloured or blackish 
slough. The discharge, if previously healthy, is at first diminished 
in quantity, and sanious;-but soon becomes profuse, and dirty 
yellowish or brown. According to this gentleman, the hospital 
gangrene is at first a purely local affection, like the sloughing pha- 
gedama-and he says that the constitutional symptoms (typhoid 
fever, &c.) do not make their appearance before the third or fourth, 
sometimes not till the twentieth, day.* 
Dr. Hennen's account.-The following quotations, however, 
from Hennen, display a slight variation from Mr. Blackadder's 
account. " Let us suppose," says Dr. H., " that our wounded have 
all been going on well for several days, when suddenly one of our 
most promising patients complains of severe pain in his head and 
eyes, a particular tightness about the forehead, loss of sleep, and 
want of appetite; and that these feelings are accompanied with 
quickness of pulse and other symptoms of fever; his wound, which 
had been healthy and granulating, at once becomes tumid, dry, and 
painful, losing its florid colour, and assuming a dry and glossy coat. 
This is a description of the first stage of our Bilboa hospital gan- 
grene, and if a brisk emetic were now exhibited, a surgeon, not 
aware of the disease that was about to form, would be astonished 
at the amelioration of the sore, and the unusual quantity of bile 
and of indigested matter evacuated by vomiting."-" If this inci- 
pient stage was overlooked, the febrile symptoms soon became 
aggravated; the skin around the sore assumed a higher florid 
colour, which shortly became darker, then bluish, and at last black, 
with a disposition to vesicate ; whilst the rest of the limb betrayed 
a tendency to oedema. All these threatening appearances occurred 
within twenty-four hours;-and at this period the wound,ivhatever 
might have been its original shape, soon assumed the circular 
form. The sore now acquired hard prominent ragged edges, giving 
it a cup-like appearance, with particular points of the lip of a dirt- 
yellow hue; while the bottom of the cavity was lined with a 
flabby, blackish slough. The rapid progress and circular form 
were highly characteristic of hospital gangrene."-"The discharge 
in this second stage became dark-coloured and fetid, and the pain 
extremely poignant."-"The face of the sufferer assumed a ghastly, 
anxious appearance ; his eyes became haggard, and deeply tinged 
with bile; his tongue loaded with a brown or blackish fur; his 
appetite entirely failed him, and his pulse was considerably sunk in 
strength, and proportionably accelerated."-"The third and last 
stage was now fast approaching. The surface of the sore was 
constantly covered with a bloody oozing; and on lifting up the 
edge of the flabby slough, the probe was tinged with dark-coloured 
grumous blood, with which also its track became immediately 
filled; repeated and copious venous bleedings now came on;"- 
" at length an artery sprung, which, in the attempt to secure it, 
most probably burst under the ligature."-"Incessant retchings 
* Observations on Phagedsena Gangrenosa. By H. Home Blackadder. Edin- 
burgh, 1818. 94 
HOSPITAL GANGRENE. 
soon came on, and, with coma, involuntary stools, and hiccough, 
closed the scene."* 
It thus appears, by collating the observations of these two mili- 
tary authorities, that the hospital gangrene may either be a local 
disease; being produced by local contamination of a wound, and 
existing for some days before the system at large is affected by it; 
-or it may be constitutional from the first;-that is, may be 
introduced by the absorption of poisonous miasmata into the blood; 
in which latter case the constitutional symptoms precede the local 
mischief.! In fact, the ordinary constitutional symptoms of hospital 
gangrene might be induced in the nurses and attendants on the 
sick, from washing the bandages, and from general exposure to 
noisome effluvia, without being followed by any local affection 
whatever. 
Treatment.-The indications in the treatment of all the forms 
of sloughing phagedaena are, 1, to destroy the diseased surface and 
its secretions;-and, 2, to correct the concomitant contamination of 
the system. 
The first indication is to be carried into effect by means of 
caustics. The French use the actual cautery; Mr. Blackadder 
recommends the liq. arsenicalis;-but the following mode of using 
the concentrated nitric acid, as directed by Mr. Welbank, is pre- 
ferable to either. In the first place, the sore must be thoroughly 
cleansed, and all its moisture be absorbed by lint or tow. If 
the sloughs are very thick, they may be removed by means of 
forceps and scissors. The surrounding parts must next be de- 
fended with a thick layer of ointment; then a thick pledget of 
lint, which may be conveniently fastened to the end of a stick, is 
to be imbued with the acid, and to be pressed steadily on every 
part of the diseased surface till the latter is converted into a dry, 
firm, and insensible mass. This application of course causes more 
or less pain for the moment, but, when that subsides, the patient 
expresses himself free from his previous severer sufferings. The 
part may then be covered with simple dressings, and cloths wet 
with cold water. " It is always prudent, often necessary," says 
Mr. Welbank, "to remove the eschar at the end of sixteen or 
twenty hours ; and then, if the patient be free from pain, and the 
ulcer healthy and florid, it is to be treated with common stimulating 
dressings;-such as cerat. calaminae, or solution of argenti nitras; 
-or a cerate of turpentine, which may be melted and poured in 
warm." If, however, there be any recurrence of pain, or the least 
reappearance of the disease, the acid is again and again to be 
applied till a healthy action is restored. 
As for the general treatment;-if the constitution is not affected, 
* Principles of Military Surgery. By John Hennen, M. D., F.R.S.E., 3d ed. 
London, 1829, pp. 217, etseq. 
f Of the various writers on Military Surgery, Pouteau, Rollo, Ollivier and Cop- 
land Hutchinson, believe the disease to be primarily local; Thompson and Sir 
James M'Grigor believe it occasionally constitutional in its origin. Their opinions 
are quoted in Sir G. Ballingall's Military Surgery. MALIGNANT PUSTULES. 
95 
opium may be given to allay the pain caused by the disease, and by 
the application of the escharotic; the bowels should be opened, and 
the diet regulated so as to support the strength without exciting 
feverishness. 
If the disease, as observed by Hennen, begin with fever of an 
inflammatory type, and the patient be robust, and the local inflam- 
mation intense, a moderate blood-letting may be performed with ad- 
vantage ; with an emetic, purgatives, and the antiphlogistic regimen 
generally. Mercury is for the most part highly pernicious* (although 
Mr. Babington says that it may be employed with advantage, if the 
surrounding inflammation be vivid and intense). 
If, however, the constitutional affection assume a low or typhoid 
type, either from the beginning or subsequently, the principle de- 
pendence is to be placed on opiates and tonics, in order to allay irrita- 
tion and support the strength, keeping open the bowels by cordial 
laxatives. If there be much diarrhoea, bark will be hurtful. 
Prevention.-It will be most necessary to prevent the spreading 
of this dreadful affection by the freest ventilation, by frequent ablu- 
tion of the bodies of the sick and wounded, and changes of their 
bed-clothes and linen;-by the instant removal of all excrements or 
filth ;-and by the most scrupulous care in washing the bandages 
in boiling water, if they are to be used again, and in destroying them 
immediately if they are not. The walls also should be daily white- 
washed, and the floor perpetually sprinkled with a solution of the 
chlorides. All the affected patients should be instantly removed to 
the greatest possible distance from the others; every thing connected 
with them should be thoroughly cleansed, and the utmost care be 
taken not to convey the contagion by means of sponges or dressings, 
or even by the fingers or instruments of the surgeon; in fact, tow 
or lint might well supersede sponges, as they might be destroyed 
after using. 
XL Malignant Pustule (Charbon) is a contagious and very 
fatal disease common in France, but almost unknown in England. 
It commences as a little dark red spot, with a stinging or pricking 
pain ; on which there soon appears a pustule or vesicle seated on a 
hard inflamed base. When this is opened, it is found to contain a 
slough, black as charcoal; and the sloughing rapidly spreads, in- 
volving skin and cellular tissue, and sometimes the muscles beneath. 
The account given of this malady by the continental writers is 
exceedingly confused; but it appears certain, that it is caused by 
infection or contagion from horned cattle, which at certain seasons 
are affected with a precisely similar disease ; and it further appears 
that, like hospital gangrene, it may commence in two ways :- 
1st. By general infection of the system, from respiring air loaded 
with miasmata from diseased animals; or from eating their flesh. 
In this case it commences with constitutional symptoms; and it is 
this form which is more particularly styled charbon. 
2dly. By inoculation of the diseased fluids ; and in this case the 
* Babington on Sloughing Sores. Lond. Med. Journ. vol. Ivii. p. 204, and vol. 
Iviii. p. 288. 96 
MENSTRUAL ULCERS. 
local symptoms begin before the constitutional. Mr. Lawrence 
gives an account of a man in Leadenhall Market, who accidentally 
smeared his face with some stinking hides from South America. 
The part touched by the putrid matter very soon became red, and 
swelled, and mortified, and the mortification spread over half the 
cheek. It is believed that flies which have alighted on the ulcers 
of the diseased animals, convey the virus, and infect other animals 
and human beings. 
The constitutional symptoms and* morbid appearances are those 
of putrid typhus; the treatment, both constitutional and local, is the 
same that we have directed for hospital gangrene.* 
XII. Morbid Ulcers.-Under this term Sir E. Home includes 
a variety of ulcers connected with a disordered state of the constitu- 
tion, and capable of being removed by particular remedies. Arsenic 
is said by Mr. Ecclest to be highly useful in sores which are dry 
and little inflamed, and surrounded by much scabbing and exfolia- 
tion of the cuticle. Ulcers about the instep and foot, with their 
edges and the surrounding skin much and extensively thickened 
like elephantiasis; and often occurring in the lazy and over-fed 
servants of the opulent;-sometimes yield to mercurial fumigations, 
or the application of mercurial ointment with camphor. 
XIII. The Cutaneous Ulcer spreads widely but superficially 
over the skin, and often heals in one part whilst it spreads to 
another. Some ulcers of this kind are contagious. 
Treatment.-Any constitutional disorder must be ascertained 
and remedied. The best local applications are stimulants, especially 
the arg. nit., employed in solution, or rubbed lightly over the sore, 
so as to form an eschar. 
XIV. The Ulcer of the Cellular Membrane,-which bur- 
rows under the skin and destroys that tissue, must be treated as 
the fistulous or weak, according to circumstances. 
XV. Menstrual Ulcer.-This name is given to ulcers occur- 
ring in chlorotic young women, and exuding a sanguineous fluid 
at the time of their monthly discharge, if that be absent. Wounds 
made in operating will frequently do the same. 
Treatment.-The constitutional disorder must be remedied by 
proper emmenagogues, and the ulcer be treated on general prin- 
ciples. 
* Lawrence, Med. Gaz. vol. v. p. 392; Dict.de Med. Art. Charbon, pustule mallgne,- 
Schwabe, Brit, and For. Rev. vol. vii. p. 550. A case of anthrax caused by eating 
the flesh of an animal which had died of the disease, is quoted from an Italian 
journal in Lond. Med. Gaz. 21st Oct. 1842. 
f Eccles on the Ulcerative Process and its Treatment. Lond. 1834. MORTIFICATION. 
97 
CHAPTER X. 
OF MORTIFICATION. 
SECTION I. OF THE PATHOLOGY OF MORTIFICATION. 
Definition.-Mortification signifies the death of any part of the 
body, in consequence of disease or injury. 
Varieties.-Some persons use the terms mortification, gan- 
grene, and sphacelus, indiscriminately; but it is better to signify 
by sphacelus an utter and irrecoverable loss of life ;-and to restrict 
the term gangrene to the state which precedes, and commonly (but 
not inevitably) terminates in sphacelus;-a state in which, as 
Thompson says, "there is a diminution, but not a total destruction, 
of the powers of life;-in which the blood appears to circulate 
through the larger vessels; in which the nerves still retain a portion 
of their sensibility, and in which, perhaps, the part may still be sup- 
posed to be capable of recovery." 
Another distinction is made between humid and dry gangrene. 
The humid is the consequence of inflammation, or of obstacle to 
the return of the venous blood, and the mortified part being loaded 
with fluid effusions soon undergoes decomposition;-whilst the 
dry gangrene is generally a consequence of deficient supply of 
blood, or of constitutional causes, and is either preceded by no 
inflammation at all, or by one so rapid that there is no time for 
interstitial effusions to occur, and the mortified part becomes dry 
and hard;-in the first case being called a slough, in the latter an 
eschar. 
Another and a most important division is into constitutional and 
local. By constitutional mortification, is meant that which pri- 
marily originates in constitutional disorder;-or that which, having 
begun from a local injury, is propagated and maintained by consti- 
tutional disorder. By local mortification is understood that by 
which the system is not implicated, and with which it does not 
sympathize in a violent or dangerous degree.* 
Causes.-The local predisposing causes, are the same as those 
of ulceration;-namely, congestion, deficient arterial circulation, 
and structural weakness. 
The constitutional causes of mortification are,-debility from 
old age, poverty, starvation, heemorrhage, scurvy, or long-continued 
disease of any kind!-disease of the heart, with contraction of the 
* Guthrie, G. J., F.R.S. A Treatise on Gun-shot Wounds, p. 116,3d ed. Lond. 
1827. 
f Sir B. C. Brodie, in his Lectures on Mortification, Med. Gaz. vol. xxvii., gives 
the case of a man who caused himself to be largely bled when intoxicated, and 
the next day one of his feet mortified as high as the instep ; and a case of equally 
sudden mortification of one foot in a child aged six, following one or two days' 98 
MORTIFICATION. 
aortic orifice, so as to impede the arterial circulation;-and the 
peculiar state induced by the use of diseased grain, especially by 
the ergot of rye. These causes are in general predisposing 
merely; but sometimes they are sufficient of themselves to induce 
mortification, which is then mostly seated in the lower extremities. 
The gangrene of the feet, which was so common amongst such of 
the soldiers of the wretched Anglo-Spanish expedition as recovered 
from the Vittoria fever, is a good example of mortification from 
constitutional causes. 
The exciting causes may be divided into-First, mechanical 
and chemical injuries, especially gun-shot wounds, and compound 
fractures;-the injection of urine or other stimulant fluids into 
the cellular tissue;-the application of irritants to constitutions 
weakened by previous disease; as the application of blisters to 
children after measles or scarlatina;-long-continued pressure 
under the same circumstances; hence the sloughing of the skin 
over the sacrum or trochanters of patients confined to bed with 
some exhausting disease,-or the application of heat after exposure 
to cold. 
Secondly, an insufficient supply of arterial blood; whether 
from ligature of a main artery,-from thickening of its parietes so 
as to contract its calibre,-from coagulation of the blood within it, 
or effusion of fibrine into it, as in arteritis,-or from ossification of 
illness, attended with considerable constitutional depression, is narrated by Dr. 
Flint in the American edition of this work. 
[A very extraordinary instance of mortification resulting from constitutional 
disturbance, came under my observation last autumn, in the case of a little girl 
about six years old, living in Indiana. The child was well nourished and deve- 
loped. and in good health, until about the middle of September, when an intelligent 
practitioner of the neighbourhood, visiting another member of her family, was 
requested to prescribe for her, as she appeared to be slightly indisposed. He 
examined her, and perceiving no symptoms of serious illness, ordered some gentle 
cathartic medicine and departed. During his visit the next day, he was summoned 
from the room of his patient to another apartment, where the little girl had been 
amusing herself, as usual, in the morning, and found her prostrate, unconscious, 
almost pulseless, and somewhat convulsed. The symptoms of sinking became 
more and more urgent, and, while the surface of the whole body was rapidly losing 
its temperature, that of the left half-trunk and extremities-became almost uni- 
formly livid. She was placed in the warm bath, frictions employed, and, as soon 
as the power of deglutition was restored, diffusible stimuli were carefully adminis- 
tered. Consciousness and sensibility were restored in about three quarters of an 
hour, and after the operation of some cathartic medicine, the next morning she 
seemed to be as well as ever, with the exception of the left foot and ankle, which 
continued to be cold, livid, and insensible, notwithstanding the most diligent and 
assiduous employment of the proper means of restoration. No considerable con- 
stitutional reaction attended her recovery from the sudden prostration, and, neither 
about the foot nor elsewhere was there any pain or any of the usual phenomena 
of inflammation. About the seventh day from the attack, a circle of demarcation 
began to form between the dead and living parts, about two inches above the ankle. 
It was thought best to accelerate the separation by artificial section, and I ampu- 
tated at the usual point below the knee. The vessels and other textures at the 
point of division appeared to be sound-the wound healed kindly, and the patient 
made a good recovery. The foot was black, dry, and wrinkled-no dissection of 
the wounded part was permitted. The patient resided in a neighbourhood subject 
to epidemics of what is called bilious fever, and where, during this season, ady- 
namic symptoms were more or less urgent in most of the cases. F.] MORTIFICATION. 
99 
the artery, and its conversion into a ligamentous cord, which is the 
cause of senile gangrene. Patches of skin often mortify in oedema, 
and cellulo-cutaneous erysipelas, because its blood-vessels are ob- 
structed by the distension of the subcutaneous tissue with fluid. 
Thirdly, impediments to the return of venous blood; whether 
from ligature of a venous trunk,-from coagulation of the blood 
in it,-from tumours (diseased liver for instance) compressing it, or 
from disease of the heart. 
Fourthly, injury or division of nerves.-Thus the cornea has 
been known to slough after division of the fifth nerve. But, in 
general, deficient nervous influence operates merely as a predis- 
posing cause. 
The tissue most disposed to mortification is the cellular; and next 
to it, tendinous and ligamentous structures, if the cellular tissue sur- 
rounding have been destroyed; then bone, if deprived of its peri- 
osteum ;-next the skin, especially if the subjacent cellular tissue 
have mortified, or have become infiltrated with fluid; and lastly, 
parts of higher organization, as muscles, blood-vessels, and nerves, 
resist it most. 
Like ulceration, mortification may either be preceded by inflam- 
mation or not. On the one hand, a part which has been injured 
may mortify, because it has not strength to support the inflamma- 
tion which ensues;-or, on the other hand, it may mortify slowly, 
and the mortification may spread slowly, without there being 
energy enough in the system to set up inflammation,-which in its 
adhesive form is necessary to check the mortification and repair its 
ravages. 
SECTION II. OF THE VARIETIES, SYMPTOMS, AND TREATMENT. 
Inflammatory Mortification.-Symptoms.-When inflam- 
mation is about to terminate in mortification, its redness gradually 
assumes a darker tint, and becomes purple or blue; the heat, sen- 
sibility, and pain diminish: but the swelling often increases in con- 
sequence of the continued effusion of sanguinolent (or sometimes 
of a peculiarly yellow) serum, which not unfrequently exudes 
through the skin, and elevates the cuticle into blisters. If the gan- 
grene proceed to sphacelus, the colour becomes dirty brown or 
black; the parts become soft, flaccid, and cold, and they crepitate 
when pressed, and emit a cadaverous odour from the gases that are 
evolved by incipient putrefaction. Whilst gangrene is spreading, 
the dark colour is diffused, and insensibly lost in the surrounding 
skin; but when its progress is arrested, a healthy circulation is re- 
established up to the very margin of the sphacelated portion, and a 
bright red line of adhesive inflammation (called the line of demar- 
cation} separates the living parts from the dead. And the appear- 
ance of this line is most important as a means of prognosis, because 
it shows that the mischief has ceased, and that there is a disposi- 
tion to repair its ravages. 100 
TREATMENT OF MORTIFICATION. 
Separation of the Mortified Part.-It is at this line that the 
dead part is separated, which separation is said, according to Hun- 
ter's theory, to be produced by ulcerative absorption; although, 
according to J. W. Earle, it is more probably the mere result of the 
softening and suppuration of that layer of the living parts which 
is contiguous to the dead. Be this, however, as it may, a narrow 
white line, consisting of a narrow circular vesicle, and formed by 
a separation of the cuticle, first appears on the bright line of adhe- 
sive inflammation before mentioned;-and when this is broken, a 
chain of minute ulcers is seen under it. These gradually unite and 
form a chink,-which widens and deepens till the slough is entirely 
detached;-and then a granulating and suppurating surface re- 
mains. In this manner the whole of a mortified limb has been 
spontaneously amputated;-the bone and tendons separating higher 
up, and being more slowly detached than the skin, muscles, and 
blood-vessels. When the adhesive inflammation has duly occurred, 
this process of separation is unattended with haemorrhage,-the 
vessels being obliterated by the effusion of lymph, and coagu- 
lation of the blood within them. And this coagulation extends 
some distance from the mortified part, so that a limb has been 
amputated in the thigh for mortification of the leg, without the loss 
of any blood from the femoral artery. Sometimes, however, as in 
hospital gangrene, these vital processes of adhesion are deficient, 
and the blood is found fluid in the vessels, so that the separation of 
the slough is attended with severe haemorrhage. 
Constitutional Symptoms.-1The constitutional symptoms of 
mortification vary with its cause. If it arise, in a healthy subject, 
from acute inflammation which is still progressing, there will be 
inflammatory fever;-but, on the other hand, if the mortification 
be very extensive;-if the inflammation of the adjacent parts be 
unhealthy, with no disposition to form the line of demarcation, but, 
on the contrary, with a greater tendency to serous effusion;-or, if 
the mortified part be of great importance, as intestine or lung;- 
the constitutional symptoms will be of a low typhoid cast;-there 
will be great anxiety, hiccough, a jaundiced skin, a soft or rapid, 
thready, and jerking pulse; and frequently profuse perspiration of 
a cadaverous odour. 
Diagnosis.-It is important not to mistake the lividity and vesi- 
cations of bruises, especially when they accompany fractures, lor 
gangrene. They may easily be distinguished by their sensibility 
and temperature; and by the fact, that in gangrene the whole cuticle 
has lost its adhesion to the cutis, so that pressure will cause the 
vesicle to shift its place. 
Treatment.-The general indications are, to allay inflammation 
if excessive;-to support the strength; and to cause the formation 
of a line of healthy adhesion, by which the mortification may be 
arrested. 
If gangrene occurs in a healthy, young, robust subject, with great 
pain, and a full, hard, strong pulse; and if it appears likely to 
spread from the violence of inflammation, of which the best ex- TREATMENT OF MORTIFICATION. 
101 
ample is sloughing of the penis from inflamed chancre; it will be 
necessary to use bleeding, purging, and the general antiphlogistic 
treatment; whilst leeches and fomentations may be applied locally. 
But care must always be taken to reduce the strength as little as 
possible, whenever a large part is so injured that its death is pro- 
bable. 
But an opposite treatment must be pursued if the pulse is quick 
and feeble, and there are the other signs of deficient vital power 
that have been before mentioned. The principal remedies for this 
state are wine and opium,-whose united effect should be to render 
the pulse slower and firmer, and to induce a warm, gentle perspi- 
ration, and sleep;-whilst it will be a sign that they are injudi- 
ciously administered, if they induce or aggravate delirium and 
restlessness. Sir B. Brodie believes that alcohol is by far the best 
stimulant, and that it is better to trust to it in urgent cases than to 
load the stomach with bark. Fluid nutriment, such as beef-tea, 
arrowroot, &c. may be given with it. Opium is of prodigious 
utility from its powers of allaying irritability; so that it renders the 
constitution insensible as it were to the local mischief;-or, in 
Hunter's language, " It does good by not letting the disease do 
harm to the constitution." At the same time, by supporting the 
capillary circulation, as justly insisted on by Mr. Skey, it favours 
the production of the much desired boundary line of adhesive 
inflammation. It may either be given in small doses frequently 
repeated, or if there be at any time very great restlessness, especially 
towards night, it will be better to give a full dose at once; such as 
forty or fifty minims of the tincture, or two grains of the solid opium. 
The remedy next in importance is bark; of which the most effi- 
cacious preparations are the quinine, liquor cinchonas flavae, and 
decoction of the cinchona lancifolia. It may be given in moderate 
doses every four or six hours, combined with the acids, or with a 
small quantity of ammonia; but Sir B. Brodie believes that ammo- 
nia, if too long persevered in, depresses the vital energies. 
Local measures.-If a part be gangrenous, but not quite dead, 
its temperature must be carefully maintained, and its actions sup- 
ported by warm poultices and fomentations. 
If sphacelus has actually occurred, and the powers of the system 
are languid, and there is little disposition to form the line of demar- 
cation, or throw off the dead parts, stimulating applications are 
necessary, especially the nitric acid lotion, F. 17, on lint under the 
poultice;-the ung. resinae, thinned with turpentine;-the balsam 
of Peru;-tincture of myrrh, or of benzoin ;-solution of the chlo- 
rides properly diluted (F. 39);-or poultices of yeast, (F. 46,) or of 
stale beer grounds. Any loose portions of slough may be cut away 
by scissors, taking care not to tear them away violently. 
Incisions are of great service in spreading inflammatory mortifi- 
cation, attended with extensive effusion of serous or purulent fluids; 
which not only contaminate the blood, and depress the nervous 
system by their absorption, but also propagate the disease by dif- 102 
treatment of mortification. 
fusing themselves along the cellular tissue, into parts that are still 
sound. 
Question of imputation.-The rule formerly given on this 
subject was, that we ought to wait till the gangrene is arrested, and 
a line of demarcation is formed, otherwise the stump may become 
gangrenous. And this rule still holds good in mortifications arising 
from constitutional causes; in that caused, for instance, by arteritis, 
loss of blood, and fever. But even after the line of demarcation 
has formed, it is necessary to take care that the patient has vigour 
enough to bear the loss of blood which must in some degree neces- 
sarily ensue. Sir A. Cooper mentions a case in which a mortified 
leg was separating favourably by itself through the calf, when the 
projecting bones were sawn off, with a view of expediting the pro- 
cess. A few granulations were accidentally wounded, and the 
trivial haemorrhage that ensued was fatal.* 
But it will be proper to amputate, without waiting for a line 
of separation, if the mortification be local as to its cause; as, for 
instance, in mortification of a limb from severe compound fracture, 
or from injury or aneurism of the large arterial trunks. This prac- 
tice is sanctioned by Larrey, Guthrie, Brodie, S. Cooper, Lawrence, 
James, and Porter, of Dublin. We may add, that amputation seems 
to be justifiable as a last resource whenever there appears little or 
no disposition to limit gangrene, and whenever it spreads rapidly. 
" Where gangrene," says Mr. Guthrie, " is rapidly extending 
towards the trunk of the body, without any hope of its cessation, 
the operation is to be tried; for it has certainly succeeded, where 
death would in a few hours have ensued.t 
Mortification from obstacle to the return of venous 
blood. -This form of mortification mostly affects the lower extremi- 
ties of persons who labour under dropsy from diseased heart, and 
it is always preceded by great oedema. It may occur without 
inflammation, or may be a consequence of inflammation, which if 
it attack oedematous parts is always liable to terminate in gangrene. 
In the former case, the skin of the oedematous limb having become 
pale, smooth, glossy, and tense, assumes a mottled aspect of a dull 
red or purple colour from distension of the subcutaneous veins. 
" Then, at some part where the congestion is greatest, or where 
the skin is less yielding, as over the tibia, or above the malleoli, 
phlyctenae, or large bullae, are formed by the effusion of serosity, 
either alone or mixed with blood, under the cuticle. When these 
burst, the cutis beneath presents a dark red or brown colour, and 
very soon is converted into a dirty-yellow, or ash-gray slough."f 
After the spread of the mortification to a given extent, inflammation 
occurs; and the slough, which is mostly an oval patch of skin, and 
cellular tissue, separates. 
Treatment.-The part should be placed in an elevated position, 
and the needle, or a fine lancet, should be used to let the serum 
exude. The mortified part, and the ulcer that results, are to be 
* Lectures by Tyrrell, vol. i. p. 237. 
t Op. cit. p. 132. $ Carswell, op. cit. SENILE GANGRENE. 
103 
treated by warm poultices of yeast, carrots, or stale beer grounds, 
and stimulating dressings, of which the nitric acid lotion is the best. 
Mortification from pressure.-When a patient is confined 
to bed with some very tedious and debilitating malady, as a fever; 
-and especially if he has not strength to shift his posture occa- 
sionally, the skin covering various projecting bony parts, (as the 
sacrum, brim of the ilium, or great trochanter,) is apt to inflame 
and rapidly ulcerate or slough; and more particularly if irritated 
by neglect of cleanliness, or by contact of urine. The first thing 
often complained of by the patient is a sense of pricking, as though 
there were crumbs or salt in the bed. The part, if examined at 
first, looks red and rough; then becomes excoriated and ulcerates, 
or turns black, and mortifies. This accident is particularly liable 
to happen if the spinal cord has been injured. 
Treatment.-When long confinement to bed is expected, it is a 
good plan to apply some stimulant to the skin, to cause it to secrete 
a thicker cuticle, and enable it to bear pressure better. Brandy is 
commonly used for this purpose : but Brodie recommends a lotion 
of two grains of corrosive sublimate to an ounce of proof spirit, to 
be applied twice or thrice a day. If the part seems likely to suffer, 
it may be covered with a broad piece of calico spread with soap 
plaster, and small pillows, or Mackintosh cushions, should be 
arranged so as to take off the weight from the part affected; and 
the patient should be made to shift his position often, and occasion- 
ally lie on his face; or be placed on a water-bed. The soft poultice 
(F. 47) will be found of great service. After sloughing has com- 
menced, the ung. resinte is the best application. 
Senile gangrene. Symptoms.-This affection commences by 
a purple or black spot on the inner sides or extremity of one af the 
smaller toes; from which spot "the cuticle," says Pott, " is always 
found to be detached, and the skin under it to be of a dark red 
colour." " In some few instances, there is little or no pain; but in 
by far the majority, the patients feel great uneasiness through the 
whole foot or joint of the ankle, particularly in the night, even be- 
fore these parts show any mark of distemper, or before there is any 
other than a small discoloured spot at the end of one of the little 
toes."* Its progress in some cases is slow, in others rapid and 
horribly painful. After its first appearance, the actual gangrene 
will generally be preceded by a dark red congestive inflammation. 
The dead parts become shrunk, dry, and hard; and when the dis- 
ease makes a temporary pause, which it frequently does, they 
slowly slough away; but a fresh accession of gangrene mostly super- 
venes before any progress has been made towards cicatrization. 
In this way the patient may live several winters, but generally sinks 
exhausted with the nocturnal pain before the whole of the foot is 
destroyed. 
Pathology.-This disease is supposed by Andral to be the result 
of debility of the capillaries, with coagulation of the blood in them; 
* Pott's Chirurgical Works. 8vo. Lond. 1771. 104 
SCROFULA. 
but the more correct opinion, according to Brodie, is, that it is caused 
by ossification of the arteries, or by their degeneration into gristly 
impervious cords. Hence the foot is imperfectly nourished; it is 
weak, and liable to pain and numbness if heated after being cold, 
and a chilblain, or any other trivial source of inflammation, is sure 
to terminate in gangrene. A similar kind of gangrene sometimes 
attacks the skin of the leg. 
This affection mostly happens to old persons of the better class, 
especially if they have been great eaters. They are generally found 
to have lost their hair and teeth, and their face and hands betray a 
languid circulation. It mostly attacks men. Air. James,* how- 
ever, has seen it in a woman of forty-two who had disease of the 
heart; and Brodie in a man of thirty-six. 
Treatment.-The patient must be kept in bed; the diet be gene- 
rous ; opium be given in sufficient doses to allay pain; and the 
bowels be kept open by purgatives. Then a piece of calamine 
dressing may be laid on the part, and the whole foot and limb be 
loosely wrapped in repeated folds of cotton wool, and afterwards 
sewed up in a silk handkerchief. If there is much discharge, this 
may be changed every second day; if not, it may remain for a week. 
Thus the limb will be placed in the most favourable circumstances 
for maintaining its circulation, and the gangrene will probably cease. 
If, however, the inflammation is very acute, and heat great, the 
wool must be delayed for a few days. Bark and stimulating dress- 
ings may be used afterwards to hasten the separation of the sloughs. 
Amputation is inadmissible. 
White gangrene of the skin.-In this curious affection, a cir- 
cular portion of skin, generally of the arm, becomes painful, and 
suddenly mortifies; becoming hard, white, and dry, and showing 
the red streaks of the vessels with the blood dried up in them. It 
sometimes spreads by the gangrene of a circle of the surrounding 
skin. The cause is quite unknown. The treatment must depend 
on the circumstances of the case; but tonics will probably be of 
service.! 
CHAPTER XI. 
OF SCROFULA. 
Syn.-Struma, King's Evil. 
Definition.-Scrofula is a state of constitutional debility, with a 
tendency to indolent inflammatory and ulcerative diseases, and to 
the deposit of tubercle. 
* James on Inflammation, pp. 445 and 552. 
f Vide Sir B. Brodie's Lectures on Mortification, Med. Gaz., vol. xxvii., and 
Mayo's Pathology, p. 231. 105 
SCROFULA. 
General Description.-There are two varieties of scrofulous 
habits, which, although they agree in the main essentials of consti- 
tutional debility, are yet totally opposite in many respects. In the 
first, (or sanguine variety,} the skin is remarkably fair and thin, 
showing the blue veins through it, and presenting the most brilliant 
contrasts of red and white ;-the eyes are light blue ; the hair light 
or reddish, the forehead ample, and the intellect lively and preco- 
cious. Sometimes, however, as Mayo observes, the skin is dark 
and transparent, and the eyes dark, although there is the same 
general characteristic of delicacy and vivacity.* 
In the second (or phlegmatic} variety, the whole aspect is dull 
and unpromising ;-the skin thick and muddy, the hair dark and 
coarse; the eyes greenish or hazel, with dilated pupils-the belly 
tumid, and the disposition dull, heavy, and listless to outward ap- 
pearance ; although persons of this conformation will very generally 
be found to possess a clear vigorous intellect, and powers of applica- 
tion far above the average. The great Dr. Johnson is an example. 
In both varieties the natural functions are liable to be performed 
irregularly. Digestion is weak, the tongue often furred, and red on 
its tip and edges;-the upper lip swelled ;-the appetite sometimes 
deficient, but more usually excessive, and attended with a craving 
for indigestible substances;-the bowels torpid;-the blood thin and 
watery;-the muscles pale and flabby;-and the heart and arteries, 
as well as the intestines, thin and weak. 
In the sanguine variety, the growth is generally rapid, and the 
bodily conformation good, as far as outward form is concerned;- 
the limbs well made, the stature tall, and the chest broad. Puberty 
also is early, and sexual passion is often strongly manifested before 
the degree of bodily strength permits it to be indulged in with im- 
punity. This is peculiarly the case with the females; who are 
usually remarkable for that early and evanescent beauty which 
arises from a great development of the adipose tissue. In the phleg- 
matic variety, on the other hand, the growth is often stunted, the 
chest narrow, and the limbs deformed with rickets, and puberty 
retarded, especially in the females, who are liable to prolonged 
chlorosis. 
Causes.-Scrofula being thus defined to be a peculiar state of the 
constitution, it may be shown, first, that it may be congenital and 
hereditary ; that is to say, the scrofulous parents may transmit their 
peculiar organization and predisposition to disease to their children. 
Not that it follows (as some foolishly quibble), that all the offspring 
of all scrofulous parents will necessarily have scrofulous disease; 
nor yet does it follow that the parents must necessarily be scrofulous, 
although the children are so born. For parents may beget scrofulous 
children, if debilitated by privation or disease;-if either of them is 
very old or very young; and probably if either of them labours 
under a venereal taint, or has been profusely treated with mercury, 
or has a decided tendency to gout. 
* Philosophy of Living, 2d edit. 1838, p. 24. 
10* 106 
SCROFULA. 
2dly. The scrofulous habit, if not congenital, may probably be 
created by any circumstance capable, directly or indirectly, of 
lowering the vital energies;-by poverty and wretchedness ;- 
meagre, watery, and insufficient food;-neglect of exercise ;-con- 
finement in close, foul apartments ;-deprivation of solar light;- 
insufficient clothing;-and habitual exposure to damp and cold. It 
is exceedingly common in the insular and variable climate of Eng- 
land, and still more so in Scotland;-and it is well known that 
monkeys and parrots, as well as human beings, brought to this 
country from the tropics, not unfrequently die of consumption or 
other scrofulous disease. 
3dly. The scrofulous habit may be so intense, that the child is 
attacked with some of the diseases that we shall presently describe, 
in spite of all care. Or, on the otl^ier hand, actual scrofulous disease 
may not appear unless the health is first depressed by some other 
disease, such as scarlatina, measles, the small-pox, or any other acute 
malady, especially if treated by too much bleeding and mercury. 
Moreover, every thing that disorders the digestive organs may bring 
it into action. Hence, it may be excited in the rich by gross, stimu- 
lating, irregular diet, as well as in the poor by their flatulent fare of 
potatoes or oatmeal. It rarely breaks out belbre two or after thirty 
years of age;-although it may be called into active operation at 
any age by circumstances which lower the health. 
Pathology of Tubercle.-The most characteristic element of 
scrofulous disease is the deposit of a peculiar kind of unhealthy 
lymph, generally found in round masses, whence it derives the name 
of tubercle. Like the unhealthy formations that will be spoken of 
in the next chapter, it may be deposited in three forms; viz.-1st. 
In distinct masses, rounded or irregular. 2dly. It may be infiltrated 
generally through the tissues of an organ. Or, 3dly. It may entirely 
usurp the place and form of some tissue; which is then said to be 
converted into it. In the first form it is most frequently found in 
the lungs, (where it gives rise to pulmonary consumption,) in the 
follicles of the intestines, in the cancelli of bones, in the brain, in the 
pleura or peritonaeum, and in the cellular tissue. In the second and 
third forms, it is found in the lymphatic vessels and glands, and in 
the breast, testis, liver, and kidneys; although it is frequently 
deposited in these glands or in their tubes, in distinct nodules. But 
wherever it may be, its course is the same. In its first stage it is 
deposited slowly and insidiously ;-causing no pain or other symp- 
tom, unless it mechanically interfere with some function. In this 
quiescent state it may remain for an indefinite period, till at length 
the second stage arrives. Then the surrounding tissues inflame, 
and form an abscess, which contains the tubercle, softened and 
broken down by the effusion of serum and pus. After a time, the 
abscess bursts, allows the tubercle to escape, and then, in favourable 
cases, may contract and heal. Sometimes the tubercle undergoes a 
natural cure by being converted into a chalky or earthy substance, 
which may be quiescent for years.* 
* Vide Latham's Lectures, xii.; Carswell, op. cit. Fascicular Tubercle. 107 
SCROFULA. 
With respect to the origin of tubercle, it appears to depend on a 
defect in the vitality of the fibrine of the blood, which is incapable 
of developing within itself the germ-cells of healthy tissues, and 
falls into a state of imperfect organization. It is not necessarily a 
product of inflammation, although it is often found blended with 
inflammatory exudation of fibrine, and it is more liable to occur in 
an organ whose structure and vitality are impaired by inflamma- 
tion ; but it is generally a mere perversion 
of nutrition. Under the microscope the 
small 'miliary tubercle is seen to consist 
of a mass of granular matter containing 
nucleated cells, whose envelopes are either 
wanting, or else blended with the granular 
matter. The yellow caseous tubercle dis- 
plays the granular matter with minute 
spherules and shapeless flakes of frag- 
ments, and with a few perfect cells only at 
its periphery. For there are two states in 
which it is found; sometimes in minute 
masses from the size of a pin's head to 
that of a millet-seed, of a lightish gray colour, and semi-transparent; 
sometimes yellow, opaque, and cheesy. The former variety is called 
miliary; and is also sometimes called crude, or unripe, on the 
supposition that it passes gradually into the cheesy form; but it is 
more probable that the two forms are distinct from the commence- 
ment ; and that the miliary has a higher degree of organization 
and supports a low kind of vitality. The yellow tubercle is some- 
times found soft in its centre; but it is doubtful whether this is 
through a process of degeneration, or whether in some cases, it is 
not originally deposited in a fluid state as a kind of pus, and soli- 
dified at its circumference by the absorption of its watery consti- 
tuents.* 
Besides tubercular disease, scrofulous patients are liable to a 
variety of insidious, lingering and obstinate inflammations and 
ulcerations. The lymph effused is often frail and curdy;-the pus 
viscid or serous and flaky;-and scrofulous ulcers, weak, with pink 
surface, flabby granulations, and loose edges. 
General Treatment.-The indications are to strengthen the 
system and prevent local disease, by rendering the blood pure and 
the circulation vigourous, and by keeping up the secretions. The 
means are both regimenial and medicinal. The former, which 
are infinitely the more important, are food, air, exercise, and 
bathing. 
(1.) The diet of the scrofulous should be nutritious, digestible, 
and abundant, consisting of meat, bread, and farinaceous sub- 
Fig. 6. 
* Mr. Grant Calder (Med. Gaz. vol. xxii. p. 286), and Dr. Kingston, (on the 
Pathology of Tubercle, in the Med. Chir. Trans, vol. xx,) supported the idea of the 
original vitality of tubercle, and of its gradual degeneration and softening; Andral 
and Graves, contra. The figure above is taken from Mr. Gulliver's appendix to 
translation of Gerber; see also Gru by, Microscop. Jour. 1842. 108 
SCROFULA. 
stances generally, with a sufficient quantity of beer or wine to 
promote digestion, without creating drowsiness or feverishness. 
The greatest attention should be paid to the quality of the milk of 
the mother or nurse; and to feed the child judiciously during the 
second year. 
(2.) The clothing should be warm, especially for the neck, chest, 
and feet,-so as to keep up the cutaneous circulation, and prevent 
congestion in the chest or abdomen. Flannel should be worn 
nearest the skin both in winter and summer;-in the former for 
direct warmth; in the latter to neutralize any accidental changes 
of temperature. 
(3.) Free exercise of the muscles and lungs in pure open air is 
indispensable. The accelerated venous circulation which it causes, 
and the compression of the abdominal viscera by the contraction 
of its muscles, are, as Mr. Carmichael has justly shown, the best 
means of promoting the action of the liver, and of preventing 
costiveness with its attendant evils. But exercise should be volun- 
tary,-because then it will not be likely to be carried to the pitch 
offatigue, than which nothing can be more injurious. Gymnastic 
exercises should be used with the utmost caution. 
(4.) The best residence for the scrofulous is one that is warm, 
without being damp in the winter, and cool and bracing in the 
summer. The high lands of the interior, Malvern, for instance, or 
Clifton, in the summer;-"in the late autumn, when the air loses 
its freshness, and is tainted with the falling leaf and decaying vege- 
tation, the seaside;"*-in the winter and spring, the mild climate 
of the Isle of Wight or coast of Devon, or a town residence, are 
alternations that are advisable for those that can afford them. But 
if the habit be extremely delicate, and disposed to phthisis, nothing 
can be better than a removal to Madeira, or perhaps, rather to 
Egypt, or some tropical country;-provided that it be adopted in 
time;-and that the sufferer be not expatriated (as is too often the 
case) merely to die. 
(5.) Daily washing and friction of the skin are as beneficial to 
the scrofulous as they are to every one else; and if the patient be 
precluded from taking exercise, friction is indispensable. Cold sea- 
bathing is in general so advantageous, that it has been deemed a 
specific. An aperient dose should be given before commencing it, 
if the habit be gross; and it is a good plan to use a tepid bath or 
two (90°-80°) first. The object in using the cold bath is to pro- 
duce a vigorous reaction;-consequently, before taking it, the 
nervous and circulating systems should be in some degree of 
excitement;-and the skin should be warm, although not per- 
spiring. If the bather be strong, he may plunge into the open sea 
early in the morning on an empty stomach, not only with impunity, 
but with advantage ; but the forenoon is the best time for a weakly 
child, when the air has become warm, and the system is invigorated 
with a breakfast. Bathing will be injurious if a short immersion 
* Mayo, Philosophy of Living. SCROFULA. 
109 
renders the surface cold, numb, and pinched. In many cases, 
especially of scrofulous ulcers, river bathing will be found more 
efficacious. 
Medicinal Treatment.-The medicines of use in scrofula, are, 
first, aperients, to restore and maintain a proper action of the liver 
and bowels;-secondly, antacids;-and, thirdly, medicines capable 
of promoting digestion, and rendering the flesh and blood more 
sound and healthy. 
(1.) If at any time the bowels are much confined, or if there is 
a state of feverishness, or if there is any scrofulous disease going 
on that is attended with pain and inflammation, it will be advisable 
to give an active dose of calomel with jalap, or scammony. And 
the bowels should be kept always regular by some mild aperient, 
such as rhubarb, magnesia, or castor oil; with a little aloes, blue- 
pill, or hyd. c. creta occasionally, F. 52, if the stools are not pro- 
perly tinged with bile. But the patient must not be weakened 
by unlimited purging, nor must calomel be used without con- 
sideration.* 
(2.) Alkalis are of great service in scrofula, not only by neutral- 
izing acrid secretions in the stomach and bowels, but (as we may 
suppose) by altering the constitution of the blood. They are espe- 
cially indicated if the patient complains of heartburn, or great 
thirst, or if the tongue is very red, or if there is a sinking and crav- 
ing for food soon after meals. Carmichaelt recommends a combi- 
nation of chalk and sesquicarbonate of soda, (gr. x. of the former, 
gr. v. of the latter,) thrice a day after meals: F. 27, 54 will answer 
the same purpose. The liq. potassse is more useful for adults. 
(3.) Before reviewing the remedies that come under our third 
head, we must warn our junior readers not to be too credulous when 
they hear of a new specific for scrofula. Common sense ought to 
teach, that diseases depending on an original vice of constitution 
are not in every instance to be cured by one remedy; still less that 
an organization feeble in every tissue, and low in vitality, is infal- 
libly to be renewed and perfected by any remedy. If a medicine 
improves the appetite and flesh and strength, it may be persevered 
in ; but if it causes feverishness, emaciation, or debility, no vague 
idea of its specific virtues ought to induce the practitioner to con- 
tinue it. 
Bark is of immense service when there is great exhaustion from 
suppuration, or when ulcers spread rapidly, and when it is neces- 
sary to make a sudden impression on the system. The decoction 
with quinine, or liq. cinchonge flavse (F. 26,110) are the best forms. 
Iron is better adapted for permanent administration than bark; 
* Dr. J. B. Flint, the editor of the American impression of this work, has added 
a most excellent note on the ill consequences of the indiscriminate abuse of mer- 
cury in the cure of supposed biliary affections, and as an alterative in various 
kinds of minor derangements that might easily be cured without it. To this cause 
he justly attributes many inveterate dyspeptic and rheumatic affections; ulcera- 
tions of the nostrils and fauces; malignant and semi-malignant degenerations of 
the glandular system; and the engendering of weakly, scrofulous children. 
f Essay on Scrofula, Lond. 1810. 110 
SCROFULA. 
especially for thin, pale, flabby children, whose liver and bowels 
are kept in proper action. The muriated tincture, F. 63; the 
ammonia-chloride, F. 62 (whose advantage is, that it can be com- 
bined with alkalis, although it is often too stimulating for children); 
the sesquioxide, F. 82 ; the ammonio-citrate, F. Ill, the sulphate, 
F. 114, and a combination of the protoxide, with aloes and an 
alkali, will all be found useful.-(F. 28.) 
Sarsaparilla often produces the most unlooked-for benefit, espe- 
cially the alkaline infusions, F. 56, 57, or the compound decoction 
(without mezereon and guaiacum) given in a concentrated form, so 
that the stomach may not be offended by the bulk of fluid in which 
it is too much the fashion to prescribe it. As we cannot explain 
its operation, the existence of the disease is the only indication for 
its administration. It may always be given in cachectic diseases, 
for which there is no palpable cause; in fact, when we are at a 
loss what to prescribe. But it is of most peculiar service when 
there is great weakness with great irritability; when tonics and 
nutriment cause feverishness, when the tongue is flabby, coated 
and rather sore, and nothing seems to agree. 
Iodine should always be administered in combination with a 
metal, or alkali, or salt that renders it soluble-not in the form of 
simple tincture dropped on water. It should, moreover, be given 
in small doses for a long period; half a grain per diem, gradually 
increased to a grain, is quite enough for an adult. A slight action 
on the bowels and increase of the urine may be expected; but it 
should not be permitted to cause emaciation. The iodide of iron 
in doses of gr. $ ter die; or a combination of tinct. ferri. mur. 
iq xv. with the tinct. iodin. comp. (P. L.) iq v. ter die; the iodide of 
potassium in doses of not more than gr. iii. ter die, with decoction 
of sarsaparilla; and F. 74; are convenient forms of administration. 
Burnt sponge in doses of gss. ter die; and the oil of the cod's 
liver, of which two drachms may be given daily to a child, and 
four to an adult, are said to have similar virtues. The latter is said 
to relax the bowels gently, and promote nutrition, and contains a 
little iodine.* 
The sulphates of zinc (F. 53) and copper in small doses are 
sometimes serviceable as tonics. The chlorides of calcium and 
barium were formerly much praised, but seem to have fallen into 
merited oblivion. A decoction of walnut leaves has been used by 
Dr. Negrier, of Angers, both internally and externally. 
Pain, when violent, must be relieved by opium or other anodynes; 
and the extracts of conium and aconite in regular doses thrice a 
day, are often of great service when there are intractable ulcers. 
The aconite requires caution in its use. 
We may add, that F. 26, 28, 52, 54, 58, 80, 82, are combinations 
of various tonics, aperients, antacids, and alteratives, which will 
occasionally be found serviceable; that of all medicines, steel is the 
most important, since it is an ingredient in healthy red blood, and 
* Taufflied, Lond. Med. Gaz. Feb. 28, 1840. SCROFULOUS DISEASES. 
111 
that it ought to be continued for months, or perhaps for two or 
three years; with occasional intermissions of a week; but that 
wholesome food, pure air, and warm clothing, are more important 
than any medicines. • 
PARTICULAR SCROFULOUS DISEASES. 
I. Of the Skin.-Scrofulous children are extremely subject to 
eruptions of small flat pustules about the ears and mouth and other 
parts, with extensive excoriations of the skin, and exudation of thin 
acrid matter which dries into scabs. These eruptions are generally 
contagious. 
Treatment.-The general health must be attended to, according 
to the foregoing rules; and the local disease be treated by the fre- 
quent use of soap and water, and the application of the ointments 
of oxide of zinc, white and red precipitates or nitrate of mercury, 
or of lead. This description and treatment may include almost 
all the multifarious forms of impetigo and porrigo. 
II. Chronic Scrofulous Abscesses (independent of those which 
are caused by diseased glands or bone) may occur under three 
forms. 1st. They may commence imperceptibly in the cellular 
tissue. 2dly. A circular piece of skin, of the size of a shilling or 
half-crown, with the tissue immediately beneath, may slowly 
inflame and swell, forming a hard red painless tumour, like a car- 
buncle. After a time it suppurates imperfectly, and it does not 
get well till the whole of the diseased part is destroyed by ulcera- 
tion. 3dly. A small hard tumour of unhealthy lymph may form 
in the cellular tissue, which after a time inflames, causes abscess, 
and then sloughs out. 
The treatment of the first variety is the same as that of chronic 
abscess generally. The two others should be left to themselves till 
they suppurate;-then it may be expedient, if there is a great piece 
of thin purple skin, to destroy it by pptassa fusa; and the case after- 
wards comes under the head of scrofulous ulcer. 
III. Disease of the Lymphatic Glands, especially in the neck, 
is the commonest of scrofulous maladies, and depends on a deposit 
of tubercle into them or their vessels adjoining. One or more 
glands enlarge, and form tumours that are perfectly indolent and 
painless. Thus they may remain for years, stationary or slowly 
enlarging, till at length, from local irritation or disorder of the health, 
they inflame, and chronic abscesses form between them and the 
skin. In some few cases after the abscess is opened, the cyst con- 
tracts and heals, the glands remaining nearly as before. But more 
generally, all the skin covering the abscess becomes red and thin, 
and ulcerates; and the ulcer heals with an ugly puckered cica- 
trix, but not till the whole gland has wasted with suppuration. 
These swellings have been known to destroy life by compressing 
the trachea or cervical vessels, or by bursting into them. Some- 112 
SCROFULOUS DISEASES. 
times they undergo a cure by the chalky transformation before 
spoken of.* 
Treatment.-The health must be amended by the measures 
before detailed;-and an endeavour must be-made to cause absorp- 
tion by fomentations with hot salt water, or the zinc lotion, or cold 
poultices made with sea-weed;-by an occasional leech when irri- 
tated ;-and by ointments of iodine or emp. hydrargyri when indo- 
lent. It may sometimes be expedient to extirpate one or more 
glands. But if suppuration occurs, and if the skin begins to 
redden, an opening should be made in the manner, and»with the 
precautions, laid down in the section on chronic abscess. 
IV. Tabes Mesenterica, or Marasmus, consists in a tubercular 
disease of the mesenteric glands, and of the follicles of the intestines, 
precisely similar in its course and phenomena to the same disease 
in the cervical glands. The numerous abscesses that form in the 
mesentery burst into the intestines, or into the abdominal cavity; 
and on examination the peritonaeum is found as thick as leather, 
and the intestines resembling a collection of cells rather than a 
simple tube. 
Symptoms.-Emaciation and voracity, owing to the obstructed 
course of the chyle; the belly swelled and hard;-the skin dry 
and harsh:-the eyes red;-the tongue strawberry-coloured;- 
the breath foul;-the stools clay-coloured and offensive, sometimes 
costive, sometimes extremely relaxed. The patient of course dies 
hectic, although he often lasts wonderfully long. 
Treatment.-Animal food and other nutriment given in small 
quantities at short intervals;-mild mercurials to amend the intes- 
tinal secretions, especially the combination of hydr. bichlorid. with 
tinct. cinchonae, F. 58;-tepid salt bathing;-stimulating liniments 
to the abdomen;-change of air;-and the cautious administration 
of the antiscrofulous remedies before mentioned. 
V. Scrofulous Ulcers may be a result of the pustules and 
excoriations of the skin that have been spoken of;-or they may 
be formed by the ulceration of chronic abscesses; in which case 
they sometimes destroy extensive tracts of skin and cellular tissue, 
and may kill the patient by exhaustion, or render a limb rigid and 
useless if he recover. Or they may be attended with a hardened 
base, thick everted edges, a copious formation of pale granulations, 
and deposit of unhealthy lymph into the adjoining cellular tissue, 
which, with the granulations, is liable to fits of sloughing, preceded 
by severe pain. 
Treatment.-We have nothing to add to the treatment of the 
iveak and irritable ulcer, to which classes these must be referred. 
The preparations of iodine, F. 15 et seq. should have a fair trial. 
* [Ulceration of the tonsils and chronic disease of the mucous membrane of the 
fauces, whether of a specific character or not, are often exciting causes of these 
engorgements of the cervical lymphatics, and the surgeon should always examine 
the throat in such cases, with a view to this connection. The use of stimulating 
gargles or the application of nitrate of silver will generally relieve the throat, and 
the glandular enlargements on the outside will often disappear immediately, unless 
they have already proceeded to suppuration. F.] MALIGNANT DISEASES. 
113 
Scrofulous diseases of the bones, joints, eye, breast, and testicle ; 
the scrofulous lupus, and ozaena; caries of the vertebrae, and psoas 
abscess, will be described under the head of the respective tissues 
or organs which are affected.* 
CHAPTER XII. 
OF MALIGNANT DISEASES. 
SECTION I. INTRODUCTORY. 
Definition.-Malignant diseases consist in the deposit and ulte- 
rior changes of a substance altogether alien to healthy structure. 
They possess the following characteristics: (1.) They terminate in 
the gradual destruction or transformation of the tissues which they 
affect. (2.) They progressively invade and destroy the tissues in 
their vicinity. (3.) They travel in the course of the lymphatics, and 
attack the nearest glands. (4.) They generally affect several organs 
in the same individual; and (5.) If mechanically removed from any 
part, they mostly reappear in or near the cicatrix.t 
Anatomical Characters.-It appears from the researches of 
* [Genuine tuberculous scrofula is less common in the Valley of the Mississippi 
than on the Eastern coast of the Union. But a very large portion of what is 
regarded and treated as scrofulous disease in this part of the country appears tome 
to be merely the result of indiscreet mercurialization. Under the prevalent idea 
that biliary derangements either constitute, or co-exist with, every departure from 
health, some form of mercury is administered, in almost every prescription, and the 
whole capillary system of persons who happen to be occasionally unwell, soon 
becomes impregnated and poisoned by this subtile mineral. 
So, too, if an alterative impression be desired, under any morbid condition what- 
ever, instead of employing regimen, diet and more harmless medicaments, it is 
common to resort indiscriminately to mercurial agents. The consequences of such 
reckless medication present themselves to the physician in dyspeptic affections, 
chronic headaches, pains in the limbs called rheumatic, &c., and to the surgeon in 
the more striking forms of alveolar absorption and adhesions, inveterate ulcerations 
of the fauces and nostrils where no specific taint has been suspected, and in various 
degenerations, malignant or semi-malignant, of glandular organs. 
Moreover, the evil does not stop with the individual,-for where important ele- 
mentary tissues are so deteriorated in the parems, a constitutional infirmity will be 
impressed on the offspring, which, if it may not properly be called scrofulous from 
birth, is the most favourable condition possible for the development of the pheno- 
mena of that diathesis, whenever co-operating influences shall assail the unfortunate 
subject. 
The interests of humanity, no less than the honour of medicine demand that those 
who observe and understand these things, should utter, on all proper occasions, the 
most unqualified protestations against such abuses of a medicinal agent whose 
timely and judicious use is so important to the healing art, and thus prevent it from 
becoming so detestable, that its employment will not be tolerated at all. F.] 
f Carswell's Pathology. 114 
MALIGNANT DISEASES. 
Muller, that malignant growths are composed of two parts. 1st, of 
granules and nucleated cells of different forms; as represented in 
the adjoining figures;-and, 2dly, of a fibro- 
cellular tissue, in which the former parts are 
imbedded; which fibro-celhilar tissue is formed 
sometimes of elongated cells, that adhere by 
their extremities; sometimes of the distended 
parietes of old cells which have become filled 
by the growth of new ones in their cavity; 
sometimes, perhaps, of a structureless blastema. It must be added, 
that malignant growths are almost entirely composed of albumen; 
-that they are all supplied with ordinary blood-vessels, some more 
and some less ;-and that they scarcely differ from some innocent 
albuminous growths in their chemical composition and microscopic 
elements.* 
Pathology.-The development of malignant disease seems to 
depend on a perversion of nutrition. The lymph which exudes 
through the capillaries, either in the ordinary course of nutrition, or 
through some accidental inflammation, appears to have its vitality 
perverted ; so ^hat instead of forming in.itself the normal cells out 
of which the proper tissues of the body are developed, it forms the 
irregular abnormal cells depicted above, which constitute a malig- 
nant tissue. 
Causes.-The causes of this perversion of function are twofold. 
1st. Perpetual local irritation; hence the origin of cancer of the penis 
in persons whose prepuce is long, and who are not careful to wash 
away the irritating secretions of the corona glandis; and of chimney- 
sweeper's cancer from the irritation of soot. 2dly. A peculiar 
cachexy or morbid state of the constitution, which sometimes is 
congenital and seems nearly allied to scrofula; sometimes appears 
to be caused by depression of mind and other circumstances that 
impair the powers of digestion and nutrition. 
Whether the disease arises from local irritation, or from constitu- 
tional disposition, the cancer cells are not long confined to the part 
where they are first developed; but their nuclei most probably per- 
vade the entire mass of fluids, and are deposited into other parts. 
Yet, when the constitutional predisposition is not strong, the disease 
may be supposed to be for some time confined to the part first 
affected; and hence, if removed at an early period, the contamina- 
tion of the system at large may be prevented. • 
There is a class of diseases which is termed semi-malignant; 
which differ from the malignant in the circumstance that the morbid 
changes are purely local; and that although incurable or destructive 
to life if left to themselves, they do not attack several organs at a 
time, and if removed thoroughly do not return. For examples, see 
Part IV. Chapter II. 
It has long been a question whether cancerous disease is con- 
Fig. 7. 
* Vide Carswell, op. cit.; Mailer on Cancer and Morbid Growths, translated by 
C. West, M. D. Lond. 1840; and Dr. Walsh's admirable article on Cancer in the 
Cyclopaedia of Practical Surgery. SCIRRHUS. 
115 
tagious. Gooch gives one case of a girl who had an obstinate nicer 
on her tongue, after drinking water impregnated with cancerous 
matter, and who died of cancer many years afterwards ; and Mr. 
Mayo another of a man with malignant disease of the penis, which 
might possibly have been communicated from his wife. But these 
cases cannot be considered as conclusive ; more especially as ex- 
periments made to propagate cancer by inoculation with its dis- 
charge have repeatedly failed. Whether the discharge, however, is 
contagious or not, Langenbeck has shown, that if the cancer-ceZZs 
are injected into the blood, they may take root and propagate them- 
selves. He injected some soft matter from a medullary tumour into 
the femoral artery of a dog; and on killing the animal nine weeks 
afterwards, two or three circular, flattened, light blue tumours, 
exactly resembling medullary sarcoma in man, were found on the 
surfaces of both lungs.* 
Varieties.-There are four varieties of malignant disease, viz. 
scirrhus; medullary sarcoma; gelatiniform cancer; and melanosis. 
That they are very nearly allied to each other is shown by the cir- 
cumstance that two or more of them may affect different organs in 
the same individual; or may even exist together in one tumour; and 
that if one variety be extirpated, another may make its appearance 
in the cicatrix. But it does not seem probable that they are iden- 
tical, or that one can be transformed into another by any process 
of development. 
SECTION II. OF SCIRRHUS, OR CARCINOMA SIMPLEX. 
Symptoms.-Scirrhus begins usually as a rounded and peculiarly 
hard tumour, subject to occasional fits of severe lancinating pain. 
Anatomical Characters.-When examined, it is found to be 
hard, heavy, and nearly of the consistence of cartilage. It cuts with 
crispness like a potato or unripe pear. On a section, it appears to 
be composed of numerous dense white bands, intersecting each 
other irregularly, and having their interstices filled with a bluish, 
yellowish, or reddish granular substance. 
A thin slice examined under the microscope appears to be com- 
posed of a cellular tissue filled with globules, granules, and cells. 
One variety, called by Muller carcinoma reticulare, contains a net- 
work composed of opaque granular bodies, three or four times the 
size of blood-globules. 
Seat.-Scirrhus may occur in any organ or any texture; but by 
far the most frequently in the glands, especially in the female breast, 
and the lymphatic glands in the vicinity. 
Progress and Termination.-The progress of this disease is 
twofold. On the one hand, it spreads and successively invades all 
the adjoining tissues;-and at the same time the older portions of 
the morbid growth perish by ulceration or sloughing. At first the 
* Vide Microscopical Journal, vol. ii. p. 185. 116 
SCIRRHUS. 
tumour is indolent and painless, so that the patient may be for a 
long time ignorant of its existence; it is also circumscribed and 
freely movable. After a time it is affected with fits of severe lan- 
cinating pain, which gradually increase in frequency and severity. 
Then it slowly enlarges;-loses its distinctness, becomes blended 
with the adjacent parts, and adheres to the skin and to the parts 
beneath it. At last the destructive stage commences. Portions of 
the tumour soften down, and form irregular abscesses; the skin 
ulcerates or sloughs,-and thus an open sore or cancer is formed. 
This ulcer enlarges in every direction; its edges are thick and 
jagged;-sometimes undermined and inverted; sometimes swelled 
and everted. The surface is tawny or ash-coloured, and eaten into 
irregular hollows. The discharge is thin, sanious, fetid, and irri- 
tating,-and there is an almost constant burning pain. Sometimes a 
feeble attempt is made towards reparation;-pale, flabby granula- 
tions are thrown out, and a portion of the sore cicatrizes for a time. 
In some few cases, the whole of the diseased growth has sloughed 
out, and a permanent cure has followed.* But in general the 
ulceration spreads, the neighbouring glands or viscera become 
contaminated, and the patient sinks from the constant pain and 
irritation. 
Constitutional Symptoms.-From the first there is a state of ill 
health which cannot be solely attributed to the local disease, and 
which is denominated the cancerous cachexia. The patient is 
languid, depressed, and emaciated;-the complexion is leaden and 
sallow, the appetite bad, and digestion imperfect. As the disease 
advances, hectic is induced by the pain and exhaustion,-the vital 
energies are further lowered by the absorption of deleterious secre- 
tions ;-and the patient suffers perhaps from the co-existence of the 
disease in other organs. An extraordinary fragility of the bones, 
so that the femur might be broken by turning in bed, is by no means 
an uncommon phenomenon;-partly arising from atrophy, partly 
from scirrhous disease.t 
Diagnosis.-The diagnosis of scirrhus from other chronic tumours 
is at times most uncertain. Its principal characteristics are, hard- 
ness, lancinating pain, the co-existence of the cancerous cachexia, 
the patient's age, and the situation of the tumour. But as none 
of these characteristics may be well marked; and as tumours which 
have been harmless for years may ultimately assume a malignant 
aspect, the diagnosis must often be guarded;-that is, hedged in 
with intimations of its fallibility. 
Prognosis.-Although the destiny of a scirrhous tumour and of 
the patient are pretty certain, still the time in which the disease may 
prove destructive is most uncertain. So that if the patient is old;- 
if the disease has lasted long, and has been slow in its progress;- 
if the health is tolerable, and the cachexia not well marked;-much 
comfort may be derived from the assurance, that although the dis- 
* Travers on Malignant Diseases, Med. Chir. Trans., vol. xv. p. 213. 
f Salter in Med. Chir. Trans., vol. xv. SCIRRHUS. 
117 
ease is incurable, yet life may be prolonged for many years, and 
may perhaps at last be terminated by some other malady. 
Causes.-The causes of cancer have been alluded to in the last 
section. Females are more liable to it than males;-persons above 
forty than those under it;-and persons of spare, bilious tempera- 
ment and dark complexion, than those who are light, fat, and ruddy. 
But it has occurred in girls under twenty. Some authors think it 
most liable to attack the unmarried or barren; others state the direct 
reverse. Blows or other injuries may act as exciting causes, and 
produce it in a particular part;-but they are insufficient unless the 
constitutional tendency exists. 
Treatment.-The general rules for the treatment Of malignant 
disease are these : I. If the case is decided, any palpable disorder 
in the health should first be removed, by alteratives and tonics, and 
then the disease be extirpated as soon as possible, provided it can 
be done with safety. 2. If the case is doubtful, an alterative plan 
of treatment must be pursued, which will cure the disease if it be 
not really malignant,-retard its progress if it be. 3. Again, if the 
case is decidedly malignant, but extirpation is deemed impossible 
or unjustifiable, the rule is the same: the health must be improved 
and the disease as much as possible retarded. 
If, therefore, the diagnosis is clear, and no circumstances forbid, 
a scirrhus should be extirpated with the knife, and care should be 
taken to remove every particle that appears unsound. Extirpation, 
however, will not effect a cure. In ninety-nine cases out of a hun- 
dred the disease returns. But (to use the words of an accomplished 
author*) "the period of the return of scirrhus varies from six 
months to two or three years, or even longer. The interval may 
be one of health and hope ; and even when the disease reappears, 
it does not in general return in a character of such formidable suf- 
fering as in its ordinary course it presents." The operation may 
be performed with some confidence if the disease is recent, mova- 
ble, circumscribed, and indolent. If, however, the skin is exten- 
sively tuberculated and adherent to the scirrhus;-if the surround- 
ing fat and cellular tissue are implicated;-if the tumour is firmly 
adherent to the parts beneath ;-if it is extensively ulcerated;-or 
if the original disease is much less in degree than co-existent scir- 
rhus of the adjoining lymphatic glands;-or if the patient's health 
is fast sinking-or if there is any palpable internal disease;-the 
operation should not be attempted. Yet, although there be exten- 
sive ulceration, it may be justifiable occasionally, in order to give 
even a desperate chance, or to afford even a month's respite from 
agonizing pain. 
Sundry caustics have been proposed, in order to cause slough- 
ing of the diseased growth. But they are on the whole more 
painful and dangerous than the knife, and infinitely less effectual. 
Arsenic and the chloride of zinc are the most useful, and may 
occasionally be resorted to in the case of flat superficial cancerous 
* Mayo, Pathology, p. 573. 118 
SCIKRHUS. 
affections of the skin; but the use of either of them in glandular 
scirrhus is much to be reprehended.* 
Supposing the case to be incipient and as yet doubtful, the indi- 
cations are to amend the general health; to restore the secretions; 
-to diminish irritability;-to support the strength;-to counteract 
any accidental inflammation;-to promote absorption;-and to 
allay pain. 
If the patient is young and plethoric,-and the fits of pain are 
frequent, and accompanied with heat and throbbing,-the diet 
should be reduced, the bowels be freely opened, and leeches be 
applied. In fact, frequent leeching is almost always of service in 
the early stages of any form of malignant disease; retarding its 
progress, and relieving the common inflammation with more or less 
of which it is always accompanied. As a general rule, Sir A. 
Cooper recommends the administration of five grains of Plummer's 
Pill at bedtime, and a draught containing ammon. sesquicarb. gr. 
v., sodse sesquicarb. 3ss; tinct. calumbae 3j; inf. gentianse giss, 
twice in the day. But mercury, although highly useful as an 
alterative, must never be given in such quantity as to affect the 
system, or the ravages of the disease will be hastened. 
Of the alteratives that are most likely to be of use: the prepara- 
tions of iron may be given with benefit when the lips are pale, the 
pulse weak, and the patient low and emaciated. The ammonio- 
chloride in pills, in doses of gr. ii. ter die, was a favourite medicine 
of the late Mr. Cline, and often effected the dispersion of chronic 
indolent tumours not really scirrhous. The iodides of potassium, 
and of iron ; liquor potassae; small doses of liquor arsenicalis; and 
sarsaparilla, F. 7, 10, 30, 54, 56, 62, 82; and F. 25 as a local appli- 
cation, are all worth trial in doubtful cases. 
Change of air, freedom from anxiety, a diet that will support the 
strength without heating the system, wine in moderation, if the 
patient is weak and is accustomed to it; and narcotics in sufficient 
quantities to allay pain (and they require to be given in very vari- 
ous forms and combinations), are other measures that we need not 
do more than allude to. Vegetable diet, or low diet approaching 
starvation, has been recommended. But by weakening the system, 
and increasing the irritability of the heart and nervous system, it 
cannot fail to be mischievous. 
Any mild plaster, (E. saponis, plumbi, belladonna vel opii,) 
may be applied to preserve the part from mechanical injury, and 
from changes of temperature. Fine flax is often used for the same 
purpose. It is sometimes useful to make an issue in the vicinity. 
Pressure has been recommended in order to delay the growth of the 
tumour, but is as likely to do harm as good. 
In the ulcerated or cancerous stage, the objects of local treat- 
ment are, first to endeavour to procure a cicatrization, or at least to 
allay pain, and to correct the foetor and acrimony of the discharge. 
A copious list of applications for these purposes will be found in 
* Vide Lupus, in Part IV. Chap. ii. MEDULLARY SARCOMA, AND FUNGUS HaEMATODES. 
119 
the remarks on irritable ulcers. Poultices made of the pulps of 
carrots;-or with the leaves or extracts of conium, hyoscyamus or 
belladonna;-or with opium, or the extract of poppies;-ointments 
or lotions containing the same narcotics, or the salts of morphia, 
may be tried in succession. Sometimes relief is afforded by alter- 
nation with mild stimulants; as weak lotions of the chlorides of 
lime and soda;-or of the nitric or nitro-muriatic acidor nitrate 
of silver. Affusion with very cold or iced water is sometimes of 
use. Carbonic acid, a powerful narcotic and allayer of irritability, 
may be often advantageously applied by means of fermenting poul- 
tices ;-or by generating the gas in a bottle, and directing the stream 
on the surface of the sore through a tube. 
SECTION III. - OF MEDULLARY SARCOMA, AND FUNGUS HjEMATODES. 
Syn.-Carcinoma medullare,- encephaloid disease,- soft cancer,- spongy inflammation. 
Symptoms.-Medullary sarcoma usually commences as a soft, 
rounded, elastic tumour, growing rapidly, generally free from pain 
or tenderness, and not circumscribed or movable, but blended with 
the surrounding tissues. 
Anatomical Characters.-On a section this tumour appears 
to be composed of a white opaque substance of the colour and con- 
sistence of brain, streaked with numerous blood-vessels. But its 
appearance varies very much according to certain pathological 
conditions. Thus it very often happens that its delicate blood- 
vessels are ruptured, and the tumour, becoming infiltrated with 
blood, resembles a coagulum: in this state it is called fungus 
haematodes. Sometimes after rupture of a vessel the effused blood 
is absorbed, as after apoplexy of the brain, and there is left in its 
place a cyst containing a clear or coffee-coloured serum. Some- 
times large masses of it are softened and sloughy, and of the con- 
sistence of thick cream or putrid brain. Under the microscope 
this form of malignant disease is seen to be composed of a delicate 
fibrous tissue, filled with rounded and caudate nucliferous cells. 
Progress and Termination.-This tumour enlarges rapidly; 
and its arterial circulation is sometimes so vigorous as to cause 
pulsation like an aneurism. The skin covering it soon becomes 
purple or livid; and the subcutaneous veins enlarged and tortuous. 
It is now subject to fits of aching or throbbing pain, but by no 
means so severe as that of scirrhus. At length one of the most 
projecting points ulcerates, and discharges a grumous fluid,-and a 
rapidly increasing fungus grows from the aperture. Sometimes 
this fungus exudes an enormous quantity of a thin, colourless 
serum;-sometimes it is covered with a slight crust of coagulum; 
-sometimes its blood-vessels give way, and there is a profuse 
haemorrhage;-and sometimes large portions of it soften down or 
slough. The constitution suffers in the same manner as in scir- 
rhus, but much more early and severely; and the patient expires 120 
GELATINIFORM CANCER AND MELANOSIS. 
after a few months, worn out by the irritation of the external 
malady, and by its invasion of the viscera. 
Diagnosis.-This disease is to be distinguished from scirrhus 
by the absence of hardness and lancinating pain;-by the greater 
rapidity of its growth;-by the earlier and more decided cachexia; 
-by its attacking persons of every age, and being more frequent 
in the young; whereas scirrhus is exceedingly rare under thirty;- 
and by its disposition to fungate rather than to ulcerate. 
Prognosis.-This of course will be highly unfavourable, the 
patient sinking much sooner than in scirrhus. 
Causes.-Some unknown constitutional peculiarity. 
Treatment.-The constitutional treatment is the same as 
directed for scirrhus. Leeches frequently applied at the earliest 
appearance of the disease will sometimes retard its progress. Cold 
or iced applications, and the ligature of the principal arteries sup- 
plying the tumour, have been recommended for the same purpose, 
but are not worth trying. Early extirpation of the whole of the 
diseased growth is the surest method of prolonging the patient's 
life, because it gets rid of, at once, what otherwise would cause 
protracted sloughing. But the disease is sure to return, and if the 
operation is delayed, it may return before the wound has healed.* 
Haemorrhage in this disease, or in cancer, may be restrained by 
pressure with a piece of lint. 
SECTION IV. OF GELATINIFORM CANCER, MELANOSIS, AND OTHER 
RARER VARIETIES OF MALIGNANT DISEASE. 
Gelatiniform Cancer.-(Syn. Tumeur Colloid, Carcinoma 
alveolare.}-This remarkable growth is seen, on a section, to be 
composed of innumerable white interlacing fibres, containing cells 
in their interstices. These cells vary from the size of a grain of 
sand to that of a pea, and are filled with a soft, viscous jelly, which 
generally is clear and transparent, but occasionally turbid and 
opaque. This jelly-like matter is composed entirely of albumen, 
and retains its transparency in alcohol. Its structure differs from 
that of the other species of carcinoma in the greater size and con- 
tinued growth of the cells. 
* [Exceptions to this discouraging fact are nevertheless occasionally observed, 
and justify the attempt to rescue the sufferer from impending death,by the removal 
of the local disease, when it is so situated that the whole of it can be excised, when 
the neighbouring glands and lymphatics appear to be unaffected, and when no sus- 
picious tumours or induration can be detected in the abdomen. 
I frequently meet with a gentleman of this city, from whom I removed the left 
testis, affected with decided fungoid degeneration, between three and four years 
ago. In his case the cord was sound, and the inguinal glands were unaffected at 
the time of the operation, although they had been enlarged, at a previous period 
of the disease. On the other hand, I performed a similar operation for another 
gentleman just two months since, in whose case the appearances were still more 
promising than in the former one; but last week I received information that 
although the wound had healed perfectly and the cicatrix remained sound, the 
disease had manifested its wonted inveteracy by symptoms which boded certain 
and speedy destruction to the patient. F.] GELATINIFORM CANCER AND MELANOSIS. 
121 
Melanosis is a disease consisting in the deposit of a brown or 
black substance like the pigment of the choroid coat of the eye. 
According to Muller it is composed of organized cells and granules 
like the other malignant growths, but differs from them in contain- 
ing a black pigment. In the human subject it is generally found 
in combination with medullary carcinoma,* or in the substance of 
semi-malignant tumours of the skin. 
Besides the well-marked varieties of malignant disease, of which 
we have given an account in the preceding sections, there are, no 
doubt, numerous other varieties of less frequent occurrence, which 
have not yet been accurately examined, or classified, and which 
appear to form, as it were, transition-stages between the real malig- 
nant growths, and those which are commonly called benign. Of 
this kind are the tumours described by Abernethy under the name 
of mammary and pancreatic sarcoma, from their resemblance to 
the outward configuration of those glands; and the tumours which 
have recently been described by Mr. Ancell, Mr. Dorrington, and 
Mr. Harrison. It will be sufficient for the author's purpose to 
make known to his readers the existence of these tumours, and to 
refer them to the original authors for fuller information; merely 
adding, that they appear under the microscope to be composed of 
nucleated cells larger and more irregular than those of normal 
tissues; whilst as regards their appearance to the naked eye, "the 
terms scirrhus, fungoid growth, encephaloid in a crude state, albu- 
minous sarcoma, and colloid cancer," were applied by different 
observers to the tumours in Mr. Ancell's case; thus showing the 
present uncertainty of their real nature, f 
* Carswell, op. cit. Fawdington on Melanosis, Lend. 1826; Mackenzie on the 
Eye, p. 553. 
f Vide Abernethy's Surgical Works; Ancell on a remarkable case of tumours, 
Med. Chir. Trans., vol. xxv.; Dorrington, Med. Gaz., Feb. 4, 1842; Harrison, ibid. 
Feb. 24, 1843. These tumours, for which Mr. Dorrington proposes the name 
"disseminated globose carcinoma," were scattered in tuberous masses under great 
part of the integument, and in many of the viscera. PART III. 
OF THE DIFFERENT SPECIES OF INJURIES. 
CHAPTER I. 
OF INCISED WOUNDS. 
Definition.-These are wounds made with clean-cutting instru- 
ments ; they generally bleed more at first than the other kinds of 
wounds. 
Treatment.-There are four indications :-1, To arrest haemor- 
rhage ; 2, to remove foreign bodies; 3, to bring the divided parts 
into apposition, and keep them in union; to promote adhesion. 
(1) To arrest hamiorrhage, moderate pressure, a raised position, 
and the application of cold, will be sufficient in most cases;-but 
if an artery have been wounded, or the bleeding prove obstinate, 
the measures must be adopted which will be indicated in the Chap- 
ter on Wounds of Arteries. 
(2) The removal of foreign bodies will be much more easy both 
for surgeon and patient if done at once, than if delayed till inflam- 
mation supervene. The best instruments for this and every other 
surgical purpose which they can perform, are the fingers;-but they 
may be aided by probes and forceps, if necessary. Dirt, gravel, 
&c., are best got rid of by affusion with water. All clots of blood 
must likewise be removed, or they will act as foreign bodies and 
prevent adhesion. 
(3) In order to bring the sides of the wound into apposition, the 
part must be placed in such a position as will relax any muscular 
fibres that have been divided, or that may be subjacent to the 
divided parts. Then the edges must be made to meet as nicely as 
they can without undue straining, and must be retained by cross 
strips of adhesive or isinglass plaster, one end of the plaster being 
first applied to that side of the wound which is loosest, and the 
other being brought across with a mild traction. If the wound, 
from its severity or situation, compel the patient to keep his bed, 
no further application will be needed save a strip of lint spread 
with spermaceti ointment;-otherwise a light compress and band- 
age may be applied to keep on the dressings, and protect the parts 
from injury. If the wound is so situated that the plasters cannot 
be applied smoothly, a slip of lint may be laid on it first. 
Sutures.-In some cases it is requisite to have recourse to sutures; 
in order to get a better purchase upon the edges of the wound, and 
hold them securely in contact. They should be used in wounds INCISED WOUNDS. 
123 
of parts that are naturally loose and movable, or that have no firm 
part underneath against which they can be fixed. Thus the inter- 
rupted suture is used in wounds of the eyelids, scrotum, and female 
perinaeum, and when a portion of the nose or ear has been detached; 
and the twisted suture in wounds of the lips; in the cases in fact in 
which adhesive plaster would be insufficient. But adhesive strips 
should always be placed in the intervals of the stitches, to prevent 
any strain upon them. They may be removed in from three to 
four days;-sooner if violent irritation comes on;-but not so soon 
if there is no great action. The surgeon must never employ them 
in order forcibly to drag the lips of a gaping wound into contact, 
-or they will give great pain, and his intentions will 
be frustrated by their speedily ulcerating. Five species 
are enumerated in the older authors. 
1. The Interrupted Suture is thus made. A needle 
armed with a single ligature is passed through one lip 
of the wound from ivithout, inwards;-then at a cor- 
responding part through the other lip from ivithin, 
outwards. Then the ends of the ligature (which may 
be made of silk, or stout hempen thread, well waxed 
and flattened, that it may lie easily in the wound) are 
to be drawn together, without, however, any great 
straining, and are to be tied tightly in a double reef 
knot, as represented in the adjoining figure. 
The needle should be carried deeply enough to 
obtain a firm hold, but should not include any tendi- 
nous part. As many of these stitches are to be made 
as are necessary; half or three quarters of an inch is a 
proper interval. 
2. The Twisted Suture is made thus. The edges of the wound 
having been placed accurately in contact, a suffi- 
cient number of pins are to be passed through 
both of them at convenient distances. The first 
pin should be placed at any loose angle which 
there may happen to be. When all the pins have 
been introduced, and the parts are accurately ad- 
justed, the middle of a long piece of silk is to be 
twisted around the uppermost, in the form of a 
figure 8. Then the two ends are to be brought 
down and twisted round each of the other pins successively in like 
manner;-and lastly, are to be secured by a knot. 
The pins were formerly made of silver, with steel points, that 
were removed after they were inserted ; but the fine pins used by 
entomologists for fixing insects, or fine steel needles with lancet 
points, are excellent substitutes. They are so small that they excite 
little irritation; and a great number of them may be employed, so 
as to insure as nice an adaptation as possible. But after they are 
inserted, their points must either be cut off, or else be guarded with 
a lump of wax, in order that they may do no mischief. 
3. The Glover's or Continuous Suture is nothing more than 
the ordinary way of sewing things together practised by seam 
Fig. 8. 
Fig. 9. 124 
CURE OF OPEN WOUNDS. 
stresses and housewives. It is employed in wounds of the intes- 
tines, and abdominal parietes. 
4. The Quilled Suture is performed by passing a sufficient 
number of ligatures, as in 
the interrupted suture. But 
instead of being tied to their 
opposite neighbours, all the 
threads on each side of the 
wound are fastened to a 
quill, or bougie, or roll of 
plaster. This suture is now 
nearly or quite obsolete; it was formerly supposed to be very advan- 
tageous in pressing the deep parts of a wound together. 
5. The Dry Suture was made by sticking a strip of adhesive 
plaster, or (before that was invented) a strip of linen, smeared with 
white of egg and flour, to the skin on each side of the wound. 
The adjacent margins of the plaster or linen were then sewed 
together. 
(4) The fourth indication is to keep down inflammation; that is, 
to prevent it from surpassing the degree necessary for adhesion. 
This is to be effected by opening the bowels, lowering the diet, 
enjoining rest, avoiding tight bandages, and every other source of 
irritation and constriction, and maintaining the injured part in as 
comfortable a state of feeling as possible; which, as was before 
observed, is the surest means of preventing inflammation. If, 
however, much pain and swelling supervene, leeches and cold 
applications (or warm if the patient prefers them) must be resorted 
to, and plasters, bajidages, and sutures be abandoned till granula- 
tion commences. Then the parts may be again greatly approxi- 
mated, that they may heal by the second intention; that is, by the 
inosculation of their granulations. 
Cases of complete Disunion.-If any small portion of the body 
(a finger or part ol' the nose for instance) has been completely cut 
off, and if it be reapplied as soon as possible, and retained by plas- 
ters or sutures, and wrapped up so as to preserve its temperature, 
it will very probably unite again. And even if such a part have 
been separated for a considerable time, the attempt should not be 
given up ;-but it should be well washed in warm water to free it 
from dirt, and the stump should also be bathed, so as to remove 
any dry coagulated blood, before they are reapplied to each other. 
Part of the left fore-finger, an inch and a half long, having been 
cut off for twenty minutes, was replaced and united perfectly in 
four days. The case is related by Dr. Balfour of Edinburgh, and 
is quoted in Sir A. Cooper's lectures. 
CURE OF OPEN WOUNDS. 
If a part has been abstracted which cannot be restored;-or if any 
kind of wound cannot be covered by skin, there are two ways in 
which it may heal-either with suppuration, or without it. 
Fig 10. PUNCTURED WOUNDS. 
125 
According to the first process, it inflames and suppurates, then 
granulates and heals like an ordinary ulcer. 
There are two ways in which open wounds may heal without 
suppuration; viz. by scabbing; the surface being dry;-or by the 
modelling process, if the surface is kept moist. 
The ordinary form of the second method of cure is that by scab- 
bing;-the natural and simple way in which most slight accidents 
heal when not interfered with by art. It may be effected by per- 
mitting the blood to dry on the surface of the wound;-or perhaps 
in some few cases a crust may be formed with the nitrate of silver, 
on Mr. Higginbottom's plan. Under this protection the wound 
heals without suppuration.-Mr. Wardrop has seen the large sur- 
face exposed by the removal of a diseased breast heal completely 
under a crust of blood in thirty days, without suppuration. Com- 
mon experience shows that it is better to leave slight scratches and 
abrasions to heal by themselves in this natural manner, than to 
interfere with them by plasters or ointments. 
The second form of healing without suppuration, is that first 
described by Macartney, under the term modelling process. When 
the water-dressing is applied, and the part is kept under the most 
favourable conditions of rest and temperature, the wound fills up 
by a process of growth as it were; its surface being pale and moist, 
without the least sign of suppuration, till, having attained its natural 
level, it forms a small pliant cicatrix. 
CHAPTER IL 
OF PUNCTURED WOUNDS. 
General Description.-These are justly esteemed the most dan- 
gerous of all wounds. (1.) Because from their depth they are 
liable to implicate blood-vessels, nerves, viscera, and other deep- 
seated parts of importance. (2.) Because the parts which they 
traverse are stretched and torn, and consequently are disposed to 
inflame and suppurate. (3.) Because matter when formed has no 
free exit, and is liable to burrow extensively. (4.) Because foreign 
bodies may be carried into great depths without being suspected, 
and create long-continued irritation. (5.) Because they are most 
liable to be followed by tetanus. 
Treatment.-The first point usually mooted in discussing the 
treatment of these wounds is the propriety of dilating them, and 
converting them into simple incisions, in order to avert the deep- 
seated suppuration and confinement of matter. But as those evils 
are incident on the. inflammation that supervenes, and as they by 126 
CONTUSION AND ECCHYMOSIS. 
no means follow of necessity, an endeavour should be made to 
prevent or mitigate inflammation, so that there may be no necessity 
for such a severe measure. 
In the first place, therefore, rest, low diet, purgatives, cold lotions,* 
and leeches, must be sedulously employed, to counteract all excess 
of inflammation, and to cause the absorption of any blood that may 
be effused in the course of the wound;-and perhaps of pus. if 
formed in very small quantity. But if, notwithstanding, there 
should be severe pain, and swelling, and fever, a free incision must 
be made for the relief of tension and the discharge of matter;-and 
the case must be treated in the same manner as a deep-seated 
abscess. 
Diagnosis.-If the instrument with which a puncture is made be 
angular, the shape of the wound will in general be the same. But 
it is a remarkable fact that a punctured wound made with a circular 
conical zoeapon is not round but linear, as though it had been 
made with a narrow, flat instrument. And the direction of the 
wound varies in different situations;-thus in the neck, in the axilla, 
and near the linea alba, it is vertical; and on the sides of the ab- 
domen, oblique. 
CHAPTER III. 
OF LACERATIONS AND CONTUSIONS. 
SECTION I. OF CONTUSION AND ECCHYMOSIS. 
Definition.-A contusion signifies an injury inflicted by some 
obtuse, blunt object, without perforation of the skin. 
Consequences.-The consequences of contusion are, (1.) a degree 
of concussion, or benumbing, which may be pretty severe, without 
much further mischief; (2.) some structural injury, which will be 
followed by inflammation. The degrees of this structural injury 
are three. 
1. There may be rupture of the smaller vessels, the blood from 
which infiltrates the cellular tissue, and causes an ordinary ecchy- 
mosis. 
2. A large vessel may be ruptured, so that blood is effused in 
considerable quantity, and tears up the cellular tissue, in which it 
coagulates; or if an artery is ruptured, a false or diffused aneurism 
will be the result. 
* [The warm water or vapour bath sedulously employed, will be much more 
likely to relieve the pain of such injuries at first, and to prevent serious conse- 
quences, than any cold applications. F.] CONTUSION AND ECCHYMOSIS. 
127 
3. The tissues may be irretrievably pulpified and disorganized; 
as happens from the contact of a spent ball for instance. 
Ecchymosis.-When ecchymosis has been produced in the skin 
or immediately beneath it, there appears a swelling of a reddish 
colour, which speedily becomes black. On the third day it is violet, 
and the margin, which was at first well-defined, is found to be faint 
and diffused. About the fifth or sixth day the colour becomes 
green; on the seventh or eighth, yellow; and it gradually disappears 
about the tenth or twelfth-sooner or later, according to the vigour 
of the individual and the quantity of blood effused. 
If an ecchymosis be formed in the cellular tissue without injury 
of the skin, no discoloration may appear for twenty-four hours ;- 
and if it be more deeply seated among the muscles, it will not affect 
the skin for some days, and may then appear as a part quite remote 
from the seat of injury ;-and, in this last case, will usually be in 
the form.of irregular yellow spots, marbled with green and blue.* 
Causes.-Ecchymosis may be produced by many other causes 
besides contusions. It is a symptom of certain diseases, as scurvy, 
purpura, and the last stage of fevers. It may be a consequence of 
oblique wounds, which do not permit the blood to flow freely out; 
-of spasms, and other violent contractions of the muscles;-it may 
also be caused by suction, (as after leech-bites,) especially in a part 
where the skin is thin. It may further be simulated by the appli- 
cation of colouring matters to the skin. Lastly, ecchymosis produced 
during life may require to be distinguished from various appearances 
arising after death. 
Diagnosis.-Ecchymosis produced by suction may be distin- 
guished from that which is the result of injury, by being generally 
in the form of small round spots, and situated on the inside of the 
arms, or female breasts; and the surgeon required to decide on the 
cause of such marks should consider whether they correspond in 
their appearance to the date which is assigned to them. 
Artificial discoloration of the skin may be distinguished from 
ecchymosis by its being generally in round or irregular spots, fringed 
at the edges.! 
Ecchymosis produced during life may be distinguished from the 
livid discoloration of incipient putrefaction, or that which is caused 
by the gravitation of blood in a dead body, by noticing that in the 
first case, blood is effused into the cellular tissue, and is incorporated 
with the cutis, which is thickened ; whereas in the latter two cases, 
the blackness will be confined to the surface of the cutis, and if blood 
is effused into the cellular tissue, it will be only at some depending 
part, and it will be fluid, and not coagulated.^ 
Treatment.-The indications are, (1) to check extravasation of 
blood; (2) to prevent inflammation; (3) to produce absorption of 
the effused fluids and restore the use of the parts. 
\Devergie, Medecine Legale. Paris, 1836, tome ii. p. 57. 
f Fallot de la Simulation et de la Dissimulation des Maladies. Bruxelles, 1836, 
p. 67. 
$ Beck's Medical Jurisprudence. 128 
CONTUSION AND ECCHTMOSIS. 
If the patient be robust, and the bruise seated on the head or 
trunk; or if it be extensive elsewhere, and the swelling increase 
rapidly, and become very tense, it will be expedient to bleed. The 
bruised part should, if possible, be placed in a raised position ;-and 
cold water, or the white of an egg curdled with alum, or evaporating 
lotions, or a bladder filled with water, in which an ounce or two of 
nitre or common salt has been dissolved to render it cold, should be 
applied at once;-and a sufficient number of leeches, as soon as there 
are any signs of inflammatory pain and swelling, but not before. 
These measures, together with purgatives and low diet, will suffice 
for the first two indications;-whilst the third will be fulfilled by 
friction with stimulating liniments; by cold or hot affusion; and 
passive motion after inflammation has subsided. The roots of 
briony, and Solomon's seal, bruised, and applied as a poultice, 
appear to have some efficacy in hastening the disappearance of the 
lividity of bruises. 
Sometimes, however, the effusion of blood increases very fast, and 
the tumour becomes tense and shining, so as to threaten rupture of 
the skin. It will be well in this case to imitate the practice of 
prize-fighters, and make a very small aperture with the point of a 
lancet, and let as much blood be sucked out as can be without dif- 
ficulty; although this should not be done unless absolutely necessary, 
because the pressure of the blood already effused tends to prevent 
the escape of more. If, however, this cannot be done, because the 
blood has coagulated,-and if the skin is so tense that it will 
inevitably either burst or slough,-and if the pain and tension are 
not adequately relieved by the free employment of antiphlogistic 
measures, so that the clot, instead of being absorbed, will be removed 
by suppuration, an incision of sufficient length should be made into 
the swelling, and a poultice be applied. Then the clot will most 
likely be gradually extruded by the contraction of the cavity, and a 
simple granulating wound will be left. But it is very bad practice 
to squeeze or scoop out the coagulum, as the bleeding might be 
brought on afresh, and severe inflammation be excited.* 
If an artery of considerable size is lacerated, which will be 
known by the situation of the contusion, and the great and rapid 
swelling, the case becomes a diffused aneurism, and must be 
treated accordingly. 
If the skin is so much injured as to endanger sloughing, tepid 
applications are to be preferred, especially the water-dressing, the 
steam-bath, or poppy fomentation and spirit of wine. 
If the fingers or toes have been severely bruised, so that it may 
seem impossible to save them, they should not be too hastily ampu- 
tated, as they often recover under unfavourable circumstances. 
If any superficial part have been killed by injury, the water- 
dressing or a poultice will be the best and most convenient appli- 
cation till the slough separates. 
If any bruise be attended with severe collapse, the measures 
* Hunter on the Blood, part ii. sect. i. CONTUSED WOUNDS. 
129 
described in Part I., Chapter I., must be adopted. In no case 
should cold be applied extensively to the trunk; extensive super- 
ficial extravasation (to counteract which it was recommended 
above) rarely occurs there;-and if there be extravasation into 
the cavities, it must be combated by bleeding. 
SECTION II. - OF LACERATED AND CONTUSED WOUNDS. 
General Description.-These wounds are attended with less 
haemorrhage than the incised,-both because their surface being 
irregular, renders it easy for the blood to adhere and coagulate,- 
and because arteries, when torn, do not bleed so much as when 
cut. But in all other respects they are infinitely more serious. 
(1.) They are liable to inflame violently and slough; (2.) they are 
often complicated with foreign bodies; and (3.) they are more 
liable than simple wounds to occasion severe constitutional dis- 
turbance and tetanus. 
Treatment.-In the first place, bleeding must be restrained;- 
secondly, foreign bodies must be removed;-thirdly, the divided 
parts must be brought into apposition, in case the whole or any 
part of them may be inclined to unite by adhesion. But as this is 
not very likely to occur, and as the wound mostly inflames highly 
and suppurates, there should be no straining with plasters or tight 
bandages. Then the patient must observe rest and low diet, and be 
purged;-and a cloth dipped in cold water, or a soft poultice, or 
the water-dressing, or a poppy fomentation, or the steam-bath, may 
be applied locally, according to his feelings. Cold must not be 
applied too extensively, especially if the injury is seated on the 
trunk, or is very severe, or if much blood has been lost, or the 
patient is very old, or young, or feeble. 
When pain and inflammation appear, bleeding may be per- 
formed, if the injury is important enough to require it, and the 
patient's strength can bear it; otherwise leeches should be applied. 
But the patient must not be reduced too much, or tetanus will be 
more liable to come on. Openings are to be made if necessary, in 
order to prevent the lodgment of putrid blood in the early stages, 
and of matter subsequently. When sloughs have suppurated, and 
suppuration is kindly established, the parts should be brought into 
apposition, as much as can be done without leaving sinuses, and 
the case must then be treated as an ordinary sore. 130 
GUN-SHOT WOUNDS. 
CHAPTER IV. 
OF GUN-SHOT WOUNDS. 
Definition.-Under the term gun-shot ivounds are included all 
the injuries caused by the discharge or bursting of fire-arms. They 
consist of "severe contusions, with or without solution of con- 
tinuity." 
Symptoms.-When a musket or pistol-ball has penetrated an 
ordinary fleshy part, there is seen a hole, perhaps rather smaller 
than the ball itself, with its edge livid and inverted;-and if the 
ball have passed completely through, there will be another larger 
and more ragged orifice, with its edge everted. The wound will, 
besides, be attended with more or less pain, haemorrhage, and con- 
stitutional disturbance. 
(a) The pain in these cases is said, by most authors, to be incon- 
siderable at the moment of infliction. Mr. Guthrie, however, both 
from observation and personal experience, affirms that this is by no 
means the case, and says that in general the pain is severe;-that 
it is a dead, heavy, painful blow;-although still the injury may 
not be felt at the moment, if it is inflicted while the patient's whole 
attention is absorbed by other objects. 
(6) Most authors state that gun-shot wounds are attended with 
very little haemorrhage, unless some considerable blood-vessel has 
been divided, lint Mr. Guthrie asserts that this is equally errone- 
ous ; that there is in general considerable hasmorrhage of an arte- 
rial colour; but that a wound of a large artery is only to be feared 
if the blood continue to be poured out in great quantity and per 
saltum, in spite of pressure. 
(c) The constitutional disturbance accompanying these wounds 
is severe and peculiar. The surface is pale, and bedewed with cold 
perspiration;-every limb trembles; the patient cannot stand with- 
out support; and suffers from vomiting, faintness, and peculiar 
alarm, anxiety, and confusion of the mind. The severity of these 
symptoms will, in general, be determined by the extent of the 
injury, the importance of the part wounded, and the habitual forti- 
tude of the sufferer; but the anecdote related in the subjoined note 
will show that they may be most severe under circumstances the 
most trivial.* 
* During a rapid advance of part of the British army in Portugal, "one of the 
skirmishers suddenly came upon his adversary, with only a small bank between 
them; both parties presented, the muzzles of the pieces nearly touching; both fired, 
and both fell. The British soldier, after a minute or two, thinking himself hit, but 
still finding himself capable of moving, got up, and found his adversary dead on 
the other side of the bank. I saw him," says Mr. Guthrie, "immediately after- 
wards in considerable alarm, being conscious of a blow somewhere, but which, 
after a diligent search, proved to be only a graze from a ball on the ulnar side of 
the arm; yet the certainty he was in of being killed, from the respective positions GUN-SHOT WOUNDS. 
131 
Course of Balls.-A remarkable circumstance connected with 
gun-shot wounds is the facility with which the ball may be diverted 
from its course by the slightest obstacles. Any trifling obliquity of 
surface, or difference of density in the parts which it traverses, may 
cause it to take a most circuitous route. Thus a ball may enter on 
one side of the head, chest, or abdomen, and may pass out at a point 
exactly opposite, just as if it had gone entirely through the cavity, 
whereas it may be found to have travelled round beneath the skin. 
Sometimes it will make a complete circuit, as in the case of a friend 
of Dr. Hennen, who was struck about the pomum Mami by a 
bullet, which passed completely round the neck, and was found 
lying in the very orifice by which it entered. The track of the 
ball in these cases will often be indicated by a blush, or dusky red 
line, or wheal on the skin, or sometimes by a peculiar emphysema- 
tous crackling;-and the diagnosis will of course be aided by the 
presence or absence of the symptoms of wounds of the great cavi- 
ties. In a similar manner balls will run along concave surfaces. 
Thus a soldier may be struck on the wrist when the arm is bent in 
the act of firing, and the ball may graze along the arm, and fly off 
at the shoulder; or a ball may strike the outside of the calf of a 
mounted officer, and be thrown up into the popliteal space; or one 
may enter the thorax or abdomen, glide along the inner surface of 
the peritonaeum or pleura, and pass out or be lodged near the spine. 
Lodgment of Balls.-It is always important to ascertain 
whether the shot has passed out of the body, or whether it is 
lodged;-and supposing that there are two holes, it must be con- 
sidered whether they are produced by the entrance, and exit of 
one, or by the entrance of two distinct balls. If there are two 
holes, and they are distant from each other, some light may be 
thrown on the question by ascertaining the position of the patient 
at the time he was wounded, and the posture of his assailant. 
Thus a soldier has presented himself with two shot-holes, one on 
the outside of the ankle, the other near the trochanter; but they 
were both caused by the same ball, which entered at the ankle 
when the foot was raised in the act of running.* In another 
instance, a soldier, who was ascending a scaling-ladder, was 
wounded in the right arm, and the ball was found under the skin 
of the opposite thigh.t But even though there may be only one 
opening, it by no means follows that the ball has lodged; for it may 
have escaped by the very hole at which it entered, after having 
made the circuit of the body, as in the case of Dr. Hennen's friend 
just mentioned. Or it may have impinged against some part, such 
as the cartilage of a rib, which has caused it to recoil; and a ball 
has been known to drive a piece of bone into the brain, and fall 
out of the wound afterwards. In some instances a ball has been 
of the parties, had such an effect upon him at the moment of receiving this trifling 
injury, as nearly to deprive him, for a short time, of his powers of volition: whereas, 
had the wound been received from a concealed or distant enemy, it would in all 
probability have been little noticed."-Guthrie, op. cit. p. 11. 
* Guthrie, op. cit. p. 17. f Hennen, op. cit. p. 35. 132 
GUN-SHOT WOUNDS. 
unable to perforate a fold of linen, but has carried it for the dis- 
tance of one, or even three or four inches into the wound; and on 
drawing this out, the ball of course comes out with it.* 
Again, it is very possible that two balls may enter by the same 
aperture, one of which may pass out, and the other diverge and 
wound some important organ. So that, in many cases, the prog- 
nosis should be guarded, especially if the state of constitutional 
alarm and depression, instead of diminishing, increase considerably, 
and disproportionately to the apparent extent of the injury. Some- 
times it will happen that a ball splits, either from a defect in the 
casting, or from its striking against some sharp bony ridge, as the 
vomer or shin.t 
But it frequently happens that large masses of metal are impacted 
in the substance of a part without much external indication of 
their presence, it appearing as though they made room for them- 
selves by compressing the surrounding soft parts.i 
Foreign Bodies.-Gun-shot wounds may be complicated by 
the presence of other foreign bodies besides the ball; and these are 
divided by Dr. Hennen into two classes; namely, 1st, pieces of the 
clothing, or of matters contained in the pockets, or portions of the; 
body of some unfortunate comrade ;§ 2dly, pieces of bone or muscle 
belonging to the individual, but which have become virtually 
extraneous, in consequence of being dead and detached. These 
are infinitely more mischievous than the former. 
Spent Balls.-Injuries from spent balls have at all times at- 
* A silk handkerchief sometimes saves life in the same way; and Mr. Home, in 
his Report on Gun-shot Wounds in Canada, in 1838, speaks of the great power 
which the canvas lining of soldiers' stocks has in resisting the passage of balls.- 
Edinburgh Med. and Surg. Journ., July, 1840. 
f A Brunswick soldier at Waterloo "was struck by a musket-ball on the tip of 
the nose, which split upon the bony edge where joined by the cartilage. A piece 
of the ball was extracted on the spot, and it was supposed that the ball itself had 
been purposely cut into pieces, as is sometimes done by foreign riflemen. The 
cure went on without accident until the tenth day, when the man was seized with 
a violent hcemorrhage from the nose and mouth, which came on suddenly, and car- 
ried him off in the course of the night. On dissection, it appeared that a very 
minute portion of the ball had penetrated along the basis of the skull, lodged in the 
sinus of the left internal jugular vein, forming a sort of sac for itself close upon the 
vein, and which having inflamed the coats of the vessel, they at last ulcerated and 
burst."-Hennen, op. cit., p. 91. 
| Hennen relates the case of a young officer who was killed at the siege of 
Seringapatam by a cannon-ball of thirty-two pounds, which completely buried 
itself in the muscles of his hip. A mass of grape-shot, the size of the closed fist, 
has been extracted from under the plantar aponeurosis. Guthrie gives a case in 
which a ball of eight pounds' weight lodged in the thigh without making a large 
opening, and was not discovered till it accidentally rolled out on amputating the 
limb. 
§ A pocket of coarse linen, containing two five franc pieces and two copper 
coins, have been extracted after some days from the vastus externus muscle, in 
which they were deeply imbedded. Three pieces of coin were extracted on the 
fifth day after the battle of Waterloo, from a wound in the thigh of a poor Hano- 
verian soldier. As he possessed neither money nor pocket to put it into, they evi- 
dently came from a comrade who stood before him, and who was killed by the 
same shot. Part of the cranium has been found imbedded in the thigh,-a tooth 
in the temporal muscle,-and the olecranon of one man in the bend of another 
man's elbow. GUN-SHOT WOUNDS. 
133 
traded great attention from the extreme violence of the injury 
inflicted, with very little external appearance of it. In some rare, 
cases, a cannon-ball has passed close to the head, and has caused 
death, either immediately or within a few hours, without leaving 
any morbid appearance that could be detected by dissection.* But 
in the majority of instances it is found, that although the skin may 
be intact, or but trivially grazed, still that the parts beneath have 
been irreparably disorganized;-the muscles pulpified, the bones 
comminuted, and large vessels and nerves torn across. The patient 
is severely stunned ; and the part injured is motionless, and sense- 
less, and benumbed for some distance. Swelling soon comes on, but 
more from extravasation than from inflammation, which, although 
attempted to be set up, never attains any height. Gangrene occurs 
speedily, and is propagated to the neighbouring parts, weakened 
as they are by participation in the injury, and by their contact with 
tissues that have ceased to live. 
These cases were formerly called wind contusions, being ascribed 
to a compression and displacement of the air by the ball. Some 
later theorists have conceived that they are produced by a cur- 
rent of electricity, which it generates in its passage through the 
atmosphere;-and others have imagined that a vacuum is formed 
behind it, and that the dreadful consequences we have enumerated 
arise from the eagerness of the living tissues to start from their 
places to fill up the vacuum. If, however, as these theorists 
assume, a ball can produce such effects merely by passing near 
the body, and without actually touching, it must, d fortiori, pro- 
duce them when it indubitably touches;-as when a leg is knocked 
off;-but this is not the case. The subjoined quotation from Baron 
Larrey offers the most probable explanation of the phenomenon.! 
Progress and Consequences.-In favourable cases.-Inflam- 
* A lad was carrying a sand-bag on his head, -when it was struck by a twenty- 
four pound shot from a distant battery. He immediately fell, senseless and coma- 
tose, with a slow, weak pulse, labouring respiration without stertor, and incessant 
attempts to vomit. The pupil of one eye was dilated and motionless, that of the 
other natural; the hair along the sagittal suture was erect, resembling that of a 
person placed on the insulating stool and electrified. In this state he remained 
for twenty-four hours, and then expired in convulsions. No cause of death was 
discovered on a minute examination, so that it must be attributed to a violent con- 
cussion; but it is remarkable that the ball should cause such a concussion, without 
also causing some more palpable lesion.-Hennen, p. 96. 
f "A cannon-ball is propelled at first with a rectilinear movement; and if, during 
this part of its course, it strikes against any part of the human body, it carries it 
away; but the ball, after having traversed a certain distance, undergoes some 
change in motion, in consequence of the resistance of the atmosphere and the 
attraction of the earth, and turns on its own axis, in addition to the direct impulse 
received from the explosion of the powder. If it should strike any part of the body 
when the velocity with which the ball is passing is greatly diminished, it does not 
carry it away, as in the preceding case; but in consequence of its curvilinear or 
rolling motion, it turns round the part, in the same manner as a wheel passes over 
a limb, instead of forcing a passage through it. The soft elastic parts, such as the 
skin and cellular membrane, yield, whilst the bones, muscles, tendons, arteries, &c., 
offering a greater degree of resistance, are either bruised or ruptured. If the ball 
should strike one of the cavities of the body, the viscera suffer in like manner."- 
Mem. de Chir. Mil. quoted by Guthrie. 134 
GUN-SHOT WOUNDS. 
mation generally comes on from twelve to twenty-four hours after 
a gun-shot wound of some common part. The wound becomes 
swelled, stiff, and painful, and exudes a little reddish serum. On 
the third or fourth day the pus begins to be formed; but the sup- 
puration is limited by the effusion of lymph around the wound. 
About the fifth day the parts in the immediate track of the ball, 
which have been killed by the violence of the contusion, begin to 
separate, and change from a blackish red to a brownish yellow 
colour;-and on the tenth or fifteenth day, sooner or later, accord- 
ing to the vigour of the constitution, the slough is thrown off.* In 
the mean time granulations form, the wound contracts and becomes 
impervious at the centre, and generally heals with a depressed 
cicatrix by the end of six weeks or two months,-the lower aper- 
ture always healing first. These are the symptoms observed in 
healthy constitutions, and they will be attended with little constitu- 
tional disturbance, and that of no long duration. 
Inflammatory Complication.-But if the patient, previously to 
the receipt of his wound or after it, has committed excesses, or has 
been exposed to vicissitudes of temperature,-or if the wound has 
been irritated by want of rest, or improper applications, the local 
and constitutional affections will be much more formidable. The 
pain will be more severe, the redness and swelling more extensive, 
the wound dry, and fever violent. When suppuration is estab- 
lished, instead of being confined to the track of the ball, it is dif- 
fused amongst the neighbouring muscles and under fasciae, forming 
numerous and irregular sinuses;-so that the treatment is pro- 
tracted for many months; and even after the cure is completed, the 
limb remains disabled by contractions and adhesions of the muscles, 
and is liable to oedematous swellings from the structural and vital 
weakness which a continuance of inflammation always induces. 
Lodgment of Foreign Bodies.-If the ball or any other foreign 
bodies remain lodged, the present inflammation and constitutional 
disturbance will be proportionably more severe, and the resulting 
suppuration more profuse and exhausting; and it will, besides, be 
accompanied with more or less pain, till the exciting cause is got 
rid of. But if the constitution or parts do not possess much irrita- 
bility, if the ball be small and polished, and if it press against no 
nerves, or vessels, or other sensitive parts, it may, and often does, 
remain for years without creating any disturbance-a cyst being 
formed for it in the belly of a muscle, or in the interstitial cellular 
tissue. And this is much more likely to happen if the force with 
which it was propelled was not very great;-because, in that case, 
the wound is formed rather by penetration than by contusion,- 
it is a slit, rather than a hole,-and it may close by adhesion, with 
very little suppuration or separation of sloughs. 
Rare Complications.-Air. Guthrie has described two rare and 
peculiarly fatal forms of inflammation occasionally supervening on 
* It is by no means true, as is generally stated, that ihe whole track of the ball 
must slough, for the separated parts are never equal in extent to the depth of the 
wound.-Guthrie. GUN-SHOT WOUNDS. 
135 
gun-shot wounds. The first is a most acute inflammation, attack- 
ing the muscles and other deep-seated parts, with very little aflec- 
tion of the skin. In the instances related, the wounds were 
apparently going on well, when they became extremely painful 
towards evening; the pain increased during the night, and death 
occurred before morning. " On dissection," says the learned author, 
"the whole limb seemed so stuffed or gorged with blood, that the 
texture of the parts, muscular as well as cellular, was soft, and 
readily giving way to a moderate pressure with the fingers. I can 
only compare it to the appearance of a part just falling into a state 
of gangrene." 
The second variety made its appearance after the first two days, 
and in every case which Mr. G. saw, the wound was in the upper 
extremity. The part swelled, and was rather oedematous, and 
affected with a burning pain : the skin was bright and glossy. In 
fatal cases, the swelling rapidly extended up to the axilla, and then 
difficulty of breathing came on, and was soon followed by death. 
One patient only, out of six, was saved, by the most vigorous anti- 
phlogistic treatment. The first three cases were not examined after 
death; in the fourth, the great veins were inflamed, and in the fifth 
there was effusion into the chest. 
Mortification supervening on gun-shot wounds may occur under 
the following conditions:-(1.) When the injured parts are irrecover- 
ably disorganized, so that they immediately cease to live; which 
sometimes happens to the tissues in the immediate track of a musket- 
ball, or to a whole limb struck by a spent shot. (2.) From excess 
of inflammation following a wound;-either because the action 
induced is too great to be borne by the weakened powers of the 
part;-or because the excess of inflammation is due to a disordered 
state of the constitution. (3.) From division of the great arterial 
and venous trunks. This is indicated by its commencing in the 
extremity of the limb; the foot or the hand for instance; and it pre- 
sents a combination of the two forms of dry and humid gangrene. 
The most distant parts become cold, pale, and insensible; this state 
spreads up the limb; then the patient complains of pain and numb- 
ness ; and the parts above those which are actually dead become 
slightly tumefied and discoloured. In the course of three or four 
days heat and redness supervene, and the swelling greatly increases. 
The constitution now becomes affected with restlessness, anxiety, 
and fever;-the swelling rapidly increases, with great pain, the 
skin being yellowish and streaked with bluish lines. The patient 
mostly sinks;-there being but few cases in which, if the first stage 
has passed by, and the constitution has become affected, (as indicated 
by the rapid extension of the gangrenous swelling,) there will be 
power to arrest the disease, and form, a line of separation. 
Secondary Hemorrhage.-This is the last complication of gun- 
shot wounds that will here require notice. It may be caused, first, 
in consequence of excessive arterial action, by which the coagula 
in the mouths of the divided vessels are displaced. This may occur 
at any time from the first day till the fifth. Secondly, by the sepa- 136 
TREATMENT OF GUN-SHOT WOUNDS. 
ration of a slough from a large artery. This may occur from the 
fifth till the twentieth day; and it is this peculiar variety of second- 
ary haemorrhage which is generally thought to be so frequent in its 
occurrence, but which Mr. Guthrie asserts does not happen in more 
than three or four out of a thousand cases. Thirdly, from ulcera- 
tion of the coats of an artery; and this may happen at any time 
until the wound is healed. The fourth and most common variety 
is a real inflammatory haemorrhage; the blood not being poured 
out from any particular trunk, but exuding from the general surface 
of a granulating wound. This kind of haemorrhage may be caused 
by every thing capable of exciting the circulation;-by excess in 
food, drink, or muscular exertion, and particularly by venery;* 
and the same causes will, of course, tend greatly to induce either of 
the other varieties.-It is most liable to occur in persons of a san- 
guine temperament; and especially if they have been exposed to 
the close air of a crowded hospital. The haemorrhage is preceded 
in these cases (and in the other varieties also, if partially induced 
by the same causes) by pain, heat, and throbbing of the wound. 
TREATMENT OF GUN-SHOT WOUNDS. 
Of Simple Cases.-When a ball has passed completely through 
some common fleshy part, such as the thigh or buttock, the wound 
should be sponged clean;-and when the ordinary haemorrhage is 
arrested, the best application is a piece of lint, (which may or may 
not be dipped in oil,) and which should be secured by two or three 
cross strips of plaster. Tremor and mental confusion may be 
allayed by a mouthful of wine or spirits, and by a few consolatory 
words from the surgeon ;-or, if severe, by an opiate. When they 
have subsided, a compress, wetted with cold water, or with some 
innocent lotion, will be the only other application needed. If the 
patient can be kept at rest in bed, all bandages, at this stage, will 
be unnecessary and injurious. In military practice, one or two 
turns of a roller may be necessary to keep on the dressings, but 
they should not be applied with any degree of tightness;-and as 
a general rule, their application on the field of battle should be as 
limited as possible, lest there be a deficiency of them in the later 
stages of treatment, when they can scarcely be dispensed with. 
These primary dressings need not be removed for the first three 
or four days; and if they have become dry and stiff, they should 
be well moistened with warm water previous to their removal. 
* The tendency of the great excitement produced by the venereal orgasm to 
cause haemorrhage is well known. Hennen (p. 189.) enumerates three cases; in 
the first of which, fatal haemorrhage from the lungs took place from this cause; in 
the second, " an officer died from uncontrollable bleeding from an amputated arm, 
from the same;" in the third, " a young officer with an amputated thigh, which was 
healed within half an inch, had, seven weeks after the amputation, an haemorrhage 
so violent from an excess of this nature, and a subsequent opening up of the stump 
to such an extent, as detained him under cure for three months longer." Instances 
of death in coitu are mostly to be assigned to a like cause. TREATMENT OF GUN-SHOT WOUNDS. 
137 
During the succeeding inflammatory stage, there is the choice of 
hot or cold applications, each of which has its advocates. Mr. 
Guthrie greatly prefers the use of cold water;-but if it make the 
patient feel chilly or uncomfortable, or if it augment stiffness and 
pain, warm poultices, or the water-dressing, should be substituted. 
But it is found that the too frequent use of poultices weakens parts, 
and renders them incapable of the necessary restorative actions; 
whilst they too often serve as a cloak for negligence, and prevent 
the adoption of more active measures;-in fact, the experienced 
military surgeon just quoted considers a poultice applied to a com- 
pound fracture, or wounded joint, as the sure precursor of ampu- 
tation.* When suppuration is well established, the cure is to be 
completed by mild stimulating lotions and bandages. Particular 
care must be taken to prevent sinuses, by pressing out all stagnant 
matter, and preventing its accumulation by compresses; or by free 
openings, if requisite, to insure its discharge. Gentle frictions and 
passive motion, are the best means for preventing or removing sub- 
sequent stiffness. The constitutional treatment must be antiphlo- 
gistic. If inflammation be slight, purging, low diet, and rest may 
suffice;-but if it be severe, and the patient robust, bleeding may 
be employed freely.t A combination of sulphate of magnesia and 
tartar emetic, F. 59, is a most convenient form for the military sur- 
geon. Leeches may be applied to allay inflammation. Opiates 
should be given at bedtime, if there be any spasmodic twitching 
and pain. 
Superficial wounds, made by musket or cannon-balls, are to be 
treated in the same way. It must be recollected that cold lotions 
are never to be extensively applied to the trunk. 
Dilatation.-The same observations are to be made concerning 
the dilatation of gun-shot, as of punctured wounds. Scarifications 
or incisions are never to be made from routine, nor without some 
definite object.f But if there be a great swelling of muscular parts 
confined by fasciae, or if matter form in the same, there can be no 
doubt of the propriety of a sufficiently long and deep incision to 
relieve tension and discharge matter. Dilatation may also be re- 
quired in compound gun-shot fracture, to remove splinters of bone. 
The two peculiarly fatal forms of inflammation specified by Mr. 
Guthrie are to be combated by various antiphlogistic measures and 
incisions. 
Foreign Bodies.-In every case the surgeon should ascertain 
whether foreign bodies are lodged in the wound; for even although 
it may be satisfactorily demonstrated that the ball has passed out, 
* They were recommended by Hunter, on the plea, that it is expedient to pro- 
mote suppuration; whereas, it is a great object to have as little suppuration as 
possible. 
f Soldiers, from their generous diet, active exercise, and regular discipline, bear 
depletions of every kind much better than rustic labourers or mechanics, although, 
perhaps, more ruddy and healthful in appearance. 
t Yet we read of the orifices of these wounds being scored in a radiated manner 
by foreign surgeons, as though in compliance with some religious ordinance. Sir 
C. Bell's Dissertation on Gun-shot Wounds, p. 459. 138 
TREATMENT OF GUN-SHOT WOUNDS. 
-or although there may be a mere laceration from grapeshot or 
shell, still pieces of the clothing or other matters may remain in the 
wound. If there is only one opening, such an examination is indis- 
pensable. The parts should be put as much as possible into the 
posture they were in when the injury was received; and the finger 
should be passed in as far as it will reach, counter-pressure being 
at the same time made on the opposite side of the limb. In unim- 
portant parts, the finger may be aided by a long probe or bougie, 
or a deeply-seated ball may sometimes be detected by a long, fine 
acupuncture needle. 
If the foreign body is found lying under the skin, it should be 
immediately removed by an incision, which will require to be 
larger than at first would be imagined. Pressure should be made 
to prevent the ball shifting its place during the incision, otherwise 
the operation will be long and vexatious. If the foreign body is 
near the wound, it should be removed by forceps,-the simpler the 
better. The orifice will mostly require to be dilated for this pur- 
pose, because from the natural elasticity of the skin, and the ensu- 
ing tumefaction, it will be too much contracted to allow it to repass. 
It is a well-established rule, that on no account are incisions to be 
made for the removal of foreign bodies, unless they are certain of 
being successful-/both because of the fruitless pain created, and 
because of the depressing effects of a failure on the patient's mind. 
If a ball is lodged in the middle of the thigh or other thick fleshy 
part, and from the direction of the wound it cannot be extracted 
without a very considerable incision, it should be left to itself;- 
and it will probably be either brought within reach by the natural 
contraction of the parts, and by the flow of matter, or it may 
become encysted, and give no further trouble. Bullets that have 
become encysted are to be cut out, if they come near the skin, or 
if, during any of their extraordinary changes of position, they 
impede the functions of any important part, otherwise they are to 
be left to themselves. The cyst that envelopes them is frequently 
so dense, and adheres so firmly, that a portion of it must be re- 
moved at the same time. 
If a ball has lodged in the substance of a bone, it should be 
removed by a chisel or trephine ; otherwise caries, or necrosis, and 
so much mischief as to necessitate amputation, may follow. In a 
few rare cases, however, balls have remained imbedded in bone 
without mischief. 
Secondary Haemorrhage.-The first three varieties of secondary 
haemorrhage, described at p. 135, require the ligature; the fourth 
is to be treated by rest, by the application of cold or iced water, or 
by ice itself; - by pressure on the bleeding surface, or on the arterial 
trunks above ;-and if the blood seem to ooze from any particular 
spot, it may be touched with nitrate of silver. If there be fever 
and plethora, bleeding and purging;-if weakness and irritability, 
tonics, opiates, and the mineral acids;-and, in all cases, removal 
from a crowded hospital will be expedient. 
Necessity of Amputation.-It will not be wondered at that TREATMENT OF GUN-SHOT WOUNDS. 
139 
this operation will be frequently required in gun-shot injuries of 
the limbs, on account of the fracture and comminution of bones, 
the exposure of joints, the division of blood-vessels, and the irre- 
parable violence inflicted on the skin and soft parts. 
The points for consideration in determining its necessity are two- 
fold;-viz. 1st, Would the preservation of the limb endanger the 
patient's life ?-and, 2dly, supposing that it would not, would the 
limb be of use, if saved ? In deciding on the first point, we must 
be guided by the patient's age; for an old person would succumb 
to an injury that a young one might recover from ; - by his habits, 
-for temperance, sobriety, and a well-disciplined mind, will be 
greatly in his favour ;-by previous disease,-for (as has already 
been insisted on in Part I. chap, i.) if there be organic disease of 
any viscus, the patient will be infinitely more liable to sink;- 
lastly, by the supply of necessaries, and extent of accommodation ; 
-hence, in compound fractures, and other cases demanding perfect 
quietude, many more limbs may be saved in civil practice than in 
the accidents of naval and military warfare. 
Primary or Secondary ?-But, supposing amputation to be 
decidedly required,-that the limb, if preserved, could be but a 
burthen to the patient, and that the attempt to preserve it would 
endanger his life;--the question next arises, whether amputation 
ought to be primary; that is, performed within the first forty-eight 
hours, before fever and inflammation have set in;-or whether it 
ought to be secondary ; that is, delayed till inflammation has sub- 
sided, and suppuration is established,-which is not generally the 
case in less than from three to six weeks. 
Now this question is one which cannot be decided by argument, 
but by experience; and the general experience of modern military 
surgeons has decided that amputation when necessary ought to be 
primary. We may gather from Mr. Guthrie's* works, that the loss 
after secondary operations is at least three times as great as that 
after primary. 
Hunter, however, and some surgeons before his time, advocated 
secondary amputations; the arguments in favour of their practice 
being, that persons in a rude state of health do not bear operations 
so well as those who have been labouring under some chronic sup- 
purating complaint of the part to be removed; and that if the 
patient is not able to support the inflammation arising from the 
accident, it is more than probable that he would not be able to 
support the amputation and its consequences ;t and further, that 
the patient is liable to sink sooner or later from the shock of the 
amputation speedily succeeding that of the injury. Moreover, 
Mr. Alcock, surgeon to the Anglo-Spanish legion, found in his 
practice, that secondary was less fatal than primary amputation.| 
But it may be seen at a glance, that there is not one reason in 
* Guthrie, op. cit. p. 224. 
f Hunter on Gun-shot Wounds. 
t Notes on the Medical History of the British Legion in Spain, by Rutherford 
Alcock, K.T.S. Lond. 1838. 140 
TREATMENT OF GUN-SHOT WOUNDS. 
favour of secondary amputation that is worth much. For, in the 
first place, it must be evident that many will die of the inflamma- 
mation of an extensive lacerated and contused wound, who would 
not die of the minor inflammation arising from a clean incision; 
and that many will die of secondary amputation, when exhausted 
by suffering, and weakened by confinement in an hospital, who 
might have survived a primary operation. In the second place, 
Mr. Alcock's experience in Spain is neutralized by another isolated 
set of cases, viz. the secondary amputations after the battle of 
Navarino, all of which proved fatal.* And lastly, it must be recol- 
lected that the question is,-not whether a hundred men just 
wounded and requiring amputation are more likely to survive it 
than a hundred who have gone through the ordeal of six weeks in 
an hospital;-but whether the first hundred would live to that 
period; which most probably they would not. 
When amputation is decided upon, it should then be primary. 
But there are two errors as to time, that even here must be avoided. 
The first is, that of amputating too soon;-of "letting the knife 
follow the shot," before the patient is in any measure recovered 
from the immediate shock and collapse; the second is, that of 
waiting too long, so that he becomes exhausted by pain. There- 
fore, when the patient is brought to the surgeon with a limb knocked 
off, and with a low pulse, cold skin, hiccup, fainting, or other symp- 
toms of extreme collapse, the first endeavour should be to comfort 
him; to explain the nature of his loss; to assure him of his safety, 
and to administer small quantities of wine or cordials, and apply 
warmth; at the same time providing by the tourniquet against 
immediate peril from bleeding. And in this way, by waiting an 
hour or two, the agitation of mind and body will be appeased, and 
the operation may be performed without further delay. But if the 
pain be so intolerable that the patient eagerly demands to be 
relieved from his sufferings, the request should be immediately 
complied with; for the shock of the operation will be infinitely less 
detrimental than the endurance of such torments. 
Care should always be taken, before amputating, to ascertain the 
whole amount of injury; for it would be of little use to cut off a 
leg, if the patient was shot through the liver. 
If, from any unavoidable circumstances, the favourable period 
has elapsed, and violent fever and inflammation have set in, still the 
operation must be done without delay in some few cases, to give 
the patient a chance of surviving. But, in the majority, free anti- 
phlogistic measures should be first employed; and then, " On the 
very day," says Hennen, " that a subsidence of fever is effectually 
announced by a free and healthy suppuration, by the abatement of 
local inflammation; by a restoration of the skin to its functions, 
demonstrated by returning coolness and elasticity, particularly on 
the affected limb; we should proceed to perform our amputation on 
* Lizars' Practical Surgery. BURNS AND SCALDS. 
141 
those patients in whom no hope of an ultimate recovery without it 
can be entertained."* 
Rules for Amputation.-1. When a limb has been completely 
knocked off by a cannon-ball, the stump must be amputated; and if 
the bones be splintered and shattered up to the next joint, or if the 
wound be so near the joint that mischief is to be apprehended, the 
operation must be performed above it. 
2. Gun-shot fracture of the femur always requires amputation, 
and so does division of both femoral artery and vein, or of the 
sciatic nerve. But it is not necessary for considerable destruction 
of the soft parts, provided the bone, vessels, and nerves are intact, 
and that there are conveniences for the cure. 
3. Injuries of the knee, or ankle-joints, or extensive fracture of 
the tibia, with division of the arteries, require it, but not mere lacera- 
tion of the calf. 
4. The arm should not be amputated for almost any musket-shot 
injury. If the head of the humerus is shattered, it should, if possible, 
be sawn off;-if the elbow is shot through, it may be cut out;-and 
the fore-arm will bear so much fracturing and cutting, that it should 
not be condemned without very great injury both to bones and arte- 
ries. But extensive injury of the wrist joint, or of the humerus, 
with division of the vessels, generally requires the operation. 
5. When a main artery is wounded, and gangrene is commencing 
and spreading beyond the toes or fingers, amputation should be per- 
formed just above the level of the wound. 
CHAPTER V. 
OF THE EFFECTS OF HEAT, BURNS, AND SCALDS. 
The degree of heat which can be borne without inconvenience 
or injury, depends very much on the conducting power of the me- 
dium through which it is applied. Thus, Sir C. Blagden and Dr. 
Fordyce,t ascertained by experiment, that the body may be ex- 
posed to air (whose conducting power is almost a nullity) of a 
temperature above 212° without injury; whereas, the contact of a 
solid or fluid of the same heat would instantly cause burning. 
Again, some parts of the body will from habit tolerate a degree of 
heat that would be extremely painful to others. 
Diagnosis.-It is sometimes important in medico-legal investiga- 
* Hennen, op. cit. p. 256; Guthrie, Clin. Leet. Med. Gaz., March 10th, 1838. Sir 
G. Ballingall's Military Surgery, p. 219, et seq. 
f They found that they could bear the contact of heated spirits when cooled down 
to 130 degrees; of oil at 129; water at 123; quicksilver at 117. Vide Phil.Trans 
vol. Ixv. 142 
BURNS AND SCALDS. 
tions, to determine exactly the manner in which burns have been 
inflicted. Those caused by the contact of heated liquids are generally 
diffused in their extent, and equable in their severity; they are also 
generally superficial; for the heat of boiling-water is not sufficient 
to cause the death of the cutis, unless immersed in it for some time; 
although that effect may be readily produced by boiling soap or oil, 
or other liquids whose point of ebullition is high. Burns caused by 
some sudden and intense heat of short duration,-as by the ignition 
of turpentine or gunpowder, or the inflammable gases, are more 
diffused, uniform, and regular than those occasioned by the contact 
of heated substances;-and all the hair is burnt off smoothly. 
After burns from the explosion of gunpowder, the injured parts 
are said to be of a peculiar bluish white. The irritation of these 
injuries is often aggravated by the numerous grains of gunpowder 
that escape combustion, and are projected with such force as to 
stick into the skin. In many cases, caused by the explosion of gas 
in coal mines, particles of the coal-dust adhere to the skin in the 
same manner. 
Division.-The most useful division of burns, for practical pur- 
poses, is the three-fold one which has existed from time immemo- 
rial, into, 1st, burns producing mere redness ; 2dly, those causing 
vesication ; 3dly, those causing death of the part burned. 
1. The first class is attended with mere superficial inflamma- 
tion, terminating in resolution, with or without desquamation of 
the cuticle. The pain is philosophically said to consist of a per- 
petuation of the original sense of burning. 
2. In the second class, there is a higher degree of inflammation, 
causing the cutis to exude serum and form vesicles. These in 
trivial cases dry up and heal; but if the injury to the cutis has been 
sufficient to cause it to suppurate, they will be succeeded by obsti- 
nate ulcers. The pain in these burns is much more severe than in 
the former class, especially if the vesicles have been torn, and the 
surface of the true skin exposed to the air and the contact of foreign 
bodies. The formation and increase of vesicles may often be pre- 
vented. They generally appear immediately after the accident, 
although cases are recorded in which they did not rise for three 
days. 
3. The third class of burns is attended with mortification from 
disorganization of structure. These are, for obvious reasons, not 
attended with so much pain as the last class; but in every other 
respect they are infinitely more serious, and the sores which re- 
main after the separation of the sloughs, are often months or years 
in healing. 
Constitutional Symptoms.-The constitutional symptoms of 
severe burns are those of great collapse. The surface is pale, the 
extremities cold, the pulse quick and feeble ;-there are violent and 
repeated shiverings, and the patient often complains most urgently 
of cold. In some fatal cases these symptoms arc soon succeeded 
by laborious breathing, coma, and death;-in others, dissolution is 
preceded by a period of imperfect reaction, with delirium, sharp BURNS AND SCALDS. 
143 
jerking pulse, and the other symptoms indicative of prostration 
xvith excitement. 
Prognosis.-The danger of burns must be estimated by their 
extent, their severity, their situation, the age and constitution of the 
patient, and by the symptoms actually present. Extensive burns, 
even of small severity, are always dangerous; and especially if 
vesication has occurred early, and the cuticle has been stripped off. 
Burns on the trunk are always more dangerous than those of an 
equal extent on the extremities; and it need not be said that 
infancy and old age will be alike unfavourable. With regard to 
the symptoms actually present, it may be noticed, that although 
the severe pain, such as is common in burns of the second class, is 
in itself a source of great danger, from its tendency to exhaust the 
vital powers, still that it is on the whole a favourable symptom, if 
the injury is extensive; and that the want of it indicates urgent 
peril. « The early subsidence of complaint," observes Mr. Travers, 
" unwillingness to be disturbed, apathy approaching to stupor, as 
if the scale of sensibility had shrunk below the point of pain, is 
invariably a fatal symptom. Constant shivering is an ill omen. 
The failure of the pulse and consequent coldness of the extremities, 
with a livid hue of the transparent skin of the cheeks and lips from 
congestion in the capillaries, drowsiness, with occasional muscular 
twitchings, are sure prognostics of death." Subsidence of swelling 
is an equally ominous symptom. 
The periods of danger in burns are three; 1st, during the first 
three to five days ; from collapse or imperfect reaction; 2dly, dur- 
ing the sympathetic fever which follows, in which the patient may 
sink with an affection of the head, chest, or abdomen; 3dly, during 
the suppurative stage, in which he may die from the profuse dis- 
charge, or from pulmonary consumption induced by it. Kentish 
observes that very many cases prove fatal on the ninth day. 
Morbid Anatomy.-A post-mortem examination readily ac- 
counts for the coma and laborious breathing which are such con- 
stant symptoms of fatal burns. Congestion and serous effusion are 
found on the surface and in the ventricles of the brain;-and the 
air cells of the lungs are loaded with a thin muco-serous fluid, as in 
the "suffocative catarrh of the dying" of Laennec. Moreover, 
it has been shown by Curling,* that severe burns in young people 
are sometimes followed by an acute ulceration of the duodenum, 
commencing probably in Brunner's glands, and liable to terminate 
fatally, by perforating the intestine and causing peritonitis; or by 
opening some large artery and causing effusion of blood, part of 
which may be evacuated by vomiting and purging. The cause of 
these visceral affections is supposed to be the cessation of the exha- 
lent function of the injured portion of skin;-but this explanation 
merely adds to the obscurity. 
Treatment.-The treatment of burns in their early stage has 
been a matter of great dispute. Some authorities direct them to 
* Med. Chir. Trans, vol. xxv. 144 
BURNS AND SCALDS. 
be treated in the same light as any other injuries which have pro- 
duced an equal amount of inflammation. Thus, for a slight burn 
or scald, insufficient to produce any constitutional depression, they 
recommend the immediate application of cold in any convenient 
form, and its continuance until pain and inflammation have sub- 
sided. 
Other persons, however, advocate a directly contrary method. 
They contend, that although the application of cold is most plea- 
surable, and continues to be so as long as it is employed unremit- 
tingly, still that if it is discontinued for a moment, the pain returns 
with infinitely greater force ; but, on the other hand, that if heat 
or other stimulants are applied to the burn, the pain, although 
aggravated for the moment, shortly subsides, and permanent ease 
is obtained much sooner than by the cooling treatment. 
The beneficial effects of stimulants were, about forty years ago, 
attempted to be explained by Mr. Kentish of Newcastle, in the fol- 
lowing manner: lie assumed that the injurious effects of cold arise 
from its diminishing action;-and that those of heat depend on its 
causing an increase of action. He then shows that the treatment 
of frost-bites, and of burns, ought to be analogous, although reverse. 
And that, as in the treatment of frost-bite, we first cautiously avoid 
heat, but apply snow, then cold water, and so on in an ascending 
series until the part is able to bear an ordinary degree of heat;- 
that so, in treating burns, we ought at first to avoid cold, but apply 
a moderate degree of heat, or some other stimulant, and proceed in 
a descending series, gradually diminishing the stimulant power of 
the applications, until the part is restored to its ordinary powers 
and actions. 
On the merits of this theory, the author will not attempt to decide. 
Some grave writers have pronounced it to be visionary and unin- 
telligible-and it very possibly is so. It would, perhaps, be a sav- 
ing of trouble, if the good effects of stimulants in burns were con- 
sidered as illustrations of the ultimate fact, that inflammations 
caused by one irritant may sometimes be dispelled by another. 
But as regards the practice,-the author believes that in cases of 
but little severity it is a matter of perfect indifference as to the ulti- 
mate result which treatment is adopted; but that if the burn is 
severe, or extensive enough to cause constitutional depression or 
danger to life, the first application should be of a stimulating 
nature : and that if one or the other plan is to be used indiscrimi- 
nately in all cases, the stimulating is the safer. 
Local Treatment of minor cases.-In slight cases of the firstand 
second degrees, the vesications should be pricked with a needle, to 
take off their tension, and then the whole burned part be wrapped 
in soft cotton wool, which should be kept constantly wetted with a 
spirit lotion; cold or tepid, according to the patient's choice. After 
the first two days a lotion maybe substituted of zinci sulph. gr. ij; 
aquse f. 3); and the chalk ointment be applied afterwards till the 
cure is complete. The part should be kept thickly wrapped in BURNS AND SCALDS. 
145 
cotton wool during the whole period, to preserve it from cold and 
injury. 
The surgeon, however, may make his choice from a most multi- 
farious list of remedies. In very slight cases it is a good plan to 
apply heat, if it can be done conveniently, either by holding the 
part near a fire, or by dipping it in water of 112°, and continuing 
this until the burning pain begins to subside ; or it may be bathed 
with tepid oil of turpentine, or alcohol, or aether, (which may be 
warmed by putting them into a teacup, immersed in boiling water,) 
and then should be warmly wrapped up in lint or cotton. But if 
he prefer the cooling plan, he may apply any evaporating or 
refrigerant lotion-cold water is as good as any others : pounded 
ice mixed with lard was recommended by Earle: a poultice of 
potato or grated turnip is not to be despised; but whatever is used, 
it must be renewed often enough to keep up the sensation of cold. 
The following remedies also have acquired popularity in the 
cure of burns; and all, as Mr. James observes, either possess cer- 
tain stimulating qualities, or else exclude the influence of air and 
temperature. 
The liniment composed of equal parts of linseed oil and lime- 
water, or Carron oil, (so called because in general use at the iron- 
works of that name,) is a good defensative, but has a most sordid, 
nauseous odour. It is sometimes applied after cicatrization, to pre- 
vent contraction. Lime-water and milk is an analogous prepara- 
tion. Soap-liniment is a good stimulant; but it is more expensive 
than turpentine, and not better. Common thick white paint has, 
according to Sir C. Bell,* been used at the Middlesex Hospital; 
but, from its containing white lead, its protracted application might 
be hazardous. Copaiba has been employed at the Exeter Hos- 
pital, by Mr. Luscombe, and Treacle by Mr. Greenhow,t but 
neither of the last-named applications is to be compared with Ken- 
tish's linament. Flour, applied thickly with a common dredger, 
and Cotton, very soft and finely carded, are popular applications. 
They are directed to be laid on the raw surface, and to be perpetu- 
ally strewed on in thick layers, so as to soak up the discharge; but 
without removing any which is already applied. The good effects 
of these two substances depend on the same principle. They 
exclude the air, and form a soft covering. But they are apt to 
become dry, hard, and irritating, and not unfrequently are con- 
verted into a noisome mass of putridity and maggots. Vinegar.- 
Mr. David Cleghorn, an Edinburgh brewer, very strongly recom- 
mends the application of warm vinegar for the first twelve hours, 
then poultices till suppuration is established, and chalk afterwards. 
Although not a surgeon, he has the rare merit of writing on a 
surgical subject with common sense and modesty. He agrees with 
Kentish, in recommending that stimulant applications should be 
applied only during the first few hours, whilst the injury is recent. J 
* Institutes of Surgery. London, 1838. 
f Greenhow, Med. Gaz. Oct. 13, and Leach, Med. Gaz. Nov. 3, 1838. 
i Med. Facts and Obs., vol. ii. 146 
BURNS AND SCALDS. 
Of severe cases.-When a burn is severe or extensive enough to 
cause danger to life, Kentish's plan of first bathing the burnt parts 
with tepid turpentine, then with all possible expedition applying a 
liniment, composed of ung. resinx §j; ol. terebinth. gss, thickly 
spread on lint, and lastly, wrapping them up warmly in flannel, 
seems to be the most judicious. These dressings should be allowed 
to remain as long as possible, and should not be removed unless 
there is a profuse discharge or bad smell from the wound. 
Constitutional Treatment.-If there is an urgent degree of 
collapse, the measures directed in Part I. chap. i. are to be dili- 
gently adopted. Care should, however, be taken not to push the 
use of stimulants too far, lest congestion in the head or chest be 
induced or aggravated ;-and, on the other hand, not to abandon 
them too soon, lest the collapse return, as it is very apt to do. 
Arrowroot, beef-tea, and other forms of mild nutriment, must be 
judiciously administered, according to circumstances. 
Use of Opium.-If there be much pain, a good dose of opium 
should be given without delay. For children, nothing can be better 
than the compound tincture of camphor, of which 5j - $ij may be 
given according to the age. (Each fluid drachm contains i of a 
grain of opium.) Yet it must be added that certain great authori- 
ties altogether condemn its employment. " Opium," says Larrey, 
"is injurious, whether used externally or internally. Externally, 
it stupefies the parts, instead of exciting them to a salutary inflam- 
mation; internally, if used in a considerable quantity, it enfeebles 
all the organs, after producing a momentary stimulation."* Tra- 
vers objects to it because of its tendency to produce or increase 
congestion in the head. He says that " in small doses it is ineffi- 
cacious, and in large ones injurious." Notwithstanding these ob- 
jections, however, it may be given in moderation when demanded 
by urgent pain. If there be a tendency to coma, it is of course 
inadmissible; but then the patient will most probably perish, whe- 
ther it be given him or not. 
During the symptomatic fever, the bowels must be kept open by 
some mild laxative, such as castor oil or rhubarb; and the diet must 
be unirritating, but not too low. In the event of any inflammatory 
or congestive attack of the head or chest, purgatives, and leeches or 
bleeding, must be cautiously employed, according to circumstances. 
If there is any tenderness under the right hypochondrium, or vomit- 
ing, or other sign of irritation of the duodenum, the diet should be 
of the blandest description, and small doses of hyd. c. creta and 
henbane be administered. 
Treatment of the remaining Ulcers.-The ulcers resulting from 
burns are often extremely intractable. The granulations are pale, 
flabby, and exuberant; they secrete pus profusely; and many 
months often elapse before they are healed. The cause of this 
disinclination to heal is not well understood; but one cause there 
is which may be easily detected and remedied; namely, too full 
* Mem. de Chir. Mil. t. i. p. 96. BURNS AND SCALDS. 
147 
a diet, which is often needlessly used on the plea of supporting 
strength under the profuse discharge. " There can be no doubt," 
says Kentish, "that full diet and stimulants, during the suppurative 
stage, keep up irritation in the system, and cause the immense con- 
tinued discharge by the exposed surfaces of the wounds."* And 
it is equally certain that many cases will rapidly get well when the 
diet is lowered and purgatives are diminished. 
There should be no hurry in removing the first dressings, but 
when they are removed, the succeeding applications must be suited 
to the state of the ulcer. 
If it is irritable and painful, or hot and swelled, or seems inclined 
to spread by ulceration, or if small abscesses threaten to form under 
the skin, poultices, or the water dressing, Dover's powder at bed- 
time, and aperients, should be resorted to. If sloughs are tardy in 
separating, the case must be treated like the sloughing ulcer. 
When the irritable state is removed, a succession of mild stimu- 
lants and astringents will be advisable ; especially the zinc lotion ; 
chalk, zinc, or calamine ointment; simple lint; and pressure with 
sheet lead or strips of plaster. When the' discharge is very pro- 
fuse, the sore should be constantly kept thinly covered with very 
finely powdered chalk. An ointment of carbonate of magnesia 
has been used with good effect by Mr. Partridge in the King's 
College Hospital. 
Treatment of the Cicatrix.-The cicatrix of severe burns is 
very liable to become excessively hard, dense, and cartilaginous, 
and to contract in such a -way as to occasion the most serious 
deformities. Thus the eyelids or mouth may be rendered incapa- 
ble of closing; the chin may be fixed to the breast, or a limb be 
rigidly and immovably bent. This contraction may, perhaps, be 
sometimes successfully opposed, by keeping up extension with a 
splint, and by frequently moving the part during cicatrization; and 
the cicatrix may be lubricated with pure oil. If the fingers are 
severely burned, lint should be interposed between them, and they 
should be kept apart as much as possible, although it will be very 
difficult to prevent them from adhering together.! In burns of the 
head or face, the edges of the ulcer may be drawn asunder by 
strips of adhesive plaster. When any of the orifices of the body 
are involved they should be kept dilated with canulae, or plugs of 
oiled lint. But if, notwithstanding every precaution, the cicatrix 
contracts, and produces deformity, or prevents any necessary motion, 
the knife should be resorted to. Sometimes the whole cicatrix may 
be extirpated;-sometimes an incision may be made in the sound 
skin on each side of it, so as to form gaps, which will be filled up 
with granulations;-sometimes it will be useful to divide it trans- 
versely by several incisions, at the same time dissecting it up from 
the parts beneath if it firmly adheres to them;-if the cicatrix is 
prominent it may be shaved off, and the wound touched frequently 
with lunar caustic;-and, lastly, there is a plan which has been 
* Second Bssay on Burns. Newcastle, 1800, p. 64. 
j Vide Part iv. chapter xxiv. 148 
THE EFFECTS OF COLD. 
adopted with success by Dr. Mutter, an American surgeon, of 
dividing the cicatrix, dissecting it up where adherent, and even 
dividing any muscular fibres in order to liberate the parts com- 
pletely; and then filling up the gap with a portion of sound skin 
transplanted from some neighbouring part.* 
CHAPTER VI. 
OF THE EFFECTS OF COLD. 
Effects of Severe Cold.-When a person is exposed to very 
severe cold, especially if it be accompanied with wind,-or if it be 
during the night,-or if he have been exhausted by hunger, watch- 
ing, and fatigue, he feels almost an irresistible impulse to sleep, 
which, if yielded to, is soon succeeded by coma and death. During 
the state of coma, the body of the sufferer is found to be very pale 
and cold; the respiration and pulse almost imperceptible, and the 
pupils dilated; but the limbs are flexible as long as life remains, 
unless the degree of cold be very great indeed. On a post-mortetn 
examination, the chief morbid appearances observed are great 
venous congestion and serous effusion in the head. 
Frost-bite.-But if the trunk of the body be well protected, the 
cold may affect only some exposed part, such as the nose, ears, or 
extremities. The first visible effect is, that the part becomes of a 
dull red colour;-an effect of cold which is notoriously frequent, 
and which depends on a diminution of the quantity of blood con- 
veyed by the arteries, and a stagnation of it in the veins. If the 
cold continue, the venous blood will be gradually expelled by a 
contraction of the tissues, and the part will become of a livid, 
tallowy paleness, perfectly insensible and motionless, and much 
reduced in bulk. When in this condition, a part is said to be frost- 
bitten. The patient may be quite unconscious of the accident that 
has befallen him until he is told it by some other person; especially 
if it be his nose or ear that is affected, or some other part that he 
does not move. 
A frost-bitten part may mortify in two manners;-1st, by direct 
sphacelus, if no reaction whatever is induced; 2dly, by gangren- 
ous inflammation; if reaction, when induced, be rendered too 
violent. 
The degree of cold required to produce frost-bite under any ordi- 
nary circumstances of exposure must be considerably below the 
freezing point. Mr. Guthrie states it at ten degrees below zero of 
* Vide Earle's Lectures on Burns, Lond. 1832; Dupuytren Clinique Chirurg.; 
Mutter on Deformities from Burns, in the American Journ. Med. Sc., July 1842. THE EFFECTS OF COLD. 
149 
Fahrenheit.* The natives of warm climates may be severely 
injured by cold that would be innocuous to the inhabitants of 
colder regions. Thus during the siege of Ciudad Rodrigo, when 
the troops were obliged to sleep on the ground without cover, 
three of the Portuguese actually died of the cold in one night, 
whilst the British escaped without being frost-bitten. But very 
much depends on the temperament; for according to Larrey, the 
phlegmatic Dutch, Hanoverians, and Prussians, suffered much 
more during Napoleon's winter campaigns than the darker and 
more sanguine soldiers of France and Italy.! Those who indulge 
in spirituous liquors, exhausted as they are by perpetual stimula- 
tion, are much more liable to suffer than the temperate. 
It is well known that a small part of the body may be frozen so 
as to be quite white, and hard, and brittle, and yet recover with- 
proper care. This fact was frequently exemplified in Hunter's 
experiments on the ears of rabbits, and combs of cocks. And 
some of the lower orders of animals may be entirely frozen and 
yet survive. But it is not credible that a whole limb of a human 
being, much less that the whole body, could be frozen without 
death ensuing; although stories of such occurrences have long been 
current amongst authors. J 
Treatment.-The indications of treatment whenever a part or 
the whole of the body has been exposed to severe cold, are, 1st, To 
produce moderate reaction, and restore the circulation and sensi- 
bility; 2dly, To avoid excessive reaction, which would surely lead 
to violent and dangerous inflammation. 
Of Frost-bite.-The best remedy for a frost-bite is to rub the 
part well with snow. For whilst the friction restores the circula- 
tion and sensibility, the snow prevents any excessive reaction. 
After a time cold water may be substituted for the snow, and the 
friction may be rendered brisker. These applications must be 
made in a room without a fire; and a high, or even a moderate, 
temperature must be avoided for some time. By these means no 
other inconvenience will ensue, save slight swelling and tingling, 
with vesication and desquamation of the cuticle; although the part 
will remain weak and sensible to cold for some time. 
For the coma induced by cold the treatment must be similar. 
At first the body should be rubbed with snow;-afterwards, when 
its warmth and sensibility are a little restored, it should be wiped 
quite dry, and be rubbed with fur or flannel. Then the patient 
should be put into a cold bed in a room without a fire, a stimulant 
enema should be administered, and a little warm wine and water, 
very weak, be given as soon as he can swallow. The enema may 
be composed of water and salt, with a little oil of turpentine ; but 
tobacco, which was formerly recommended by the profession in 
such cases, and is still popularly considered to be of great service, 
• Guthrie, op. cit. p. 141. 
f Larrey, Mem. de Chir. Mil. tom. iv. p. 111. 
+ See an account of some experiments on the revival of toads after freezing, in 
the Lond. and Ed. Journ. Med. Sc., Feb. 1843. 150 
THE EFFECTS OF COLD. 
must not be thought of;-it would surely be prejudicial-perhaps 
deadly. The after-treatment must be entirely regulated by the 
state of the patient;-the strength must be supported by mild cor- 
dials and nutriment; care being taken not to excite feverishness or 
headache. 
The contact of any intensely cold body (such as frozen mercury) 
causes severe burning pain, followed by vesication. It thus appears 
that the effects of sudden abstraction may be similar to those of too 
great communication of heat. The best application is snow gra- 
dually permitted to thaw. 
Violent Gangrenous Inflammation may be caused, if heat is 
injudiciously applied to frozen or frost-bitten parts. It may also 
ensue if a part has been exposed for a long period to a low tem- 
perature which is suddenly raised;-although the cold may not 
have been sufficient to cause actual frost-bite, and may have been 
tolerated without inconvenience. A good example of this accident 
is narrated by Baron Larrey,* as it affected the French troops during 
their campaign in Poland in 1807. During the few days preceding 
and following the battle of Eylau, the cold was most intense, ranging 
from ten to fifteen degrees below the zero of Reaumur.! But 
although the troops were day and night exposed to this inclement 
weather, and the soldiers of the Imperial Guard, in particular, were 
nearly motionless for more than twenty-four hours, there were no 
complaints of its effects. On the night of the 9th of February, how- 
ever, a sudden thaio commenced, and immediately a great number 
of soldiers presented themselves at the "ambulances," complaining 
of severe numbness, weight, and pricking pain in the feet. On ex- 
amination, some were found to have slight swelling and redness at 
the base of the toes and dorsum of the foot; whilst the toes of others 
had already become black and dry. And in this manner, the toes, and 
sometimes the whole foot, perished; the mortification being so rapid 
that it was difficult to say whether it was preceded by inflammation 
or not-although it probably was so for a very brief period. The 
best treatment for such cases is the application of snow or very cold 
water, followed by evaporating lotions. These, if employed early 
enough, may prevent gangrene; or even if that have actually 
occurred, they should be used as long as it appears to be spreading. 
Subsequently, stimulating poultices and ointments should be em- 
ployed to hasten the separation of the sloughs, and to promote 
granulation. 
Chilblains consist in an atonic inflammation of the skin, induced 
by sudden alternations of temperature; such as warming the feet 
and hands by the fire when cold and damp. They may present 
themselves in three degrees. In the frst, the skin is red in patches, 
and slightly swelled; with more or less itching or tingling, or per- 
haps pain and lameness. In the second, there are vesications-the 
skin around being bluish or purple. In the third degree there is 
ulceration or sloughing. 
* Mem. de Chir. Mil., tom. iii. p. 61. 
f From 20° to 25° below the freezing point of Fahrenheit. EFFECTS OF MINERAL AND VEGETABLE IRRITANTS. 
151 
Causes.-Chilblains are most frequent in women, children, and 
weakly persons generally. Some constitutions (especially those of 
a rheumatic diathesis) appear to be greatly predisposed to them; 
others are, from some unknown reason, totally exempt. 
Treatment of the First Degree.-The best treatment consists in 
a combination of local stimulants and depletion. When there is 
much heat and itching, it is an excellent plan to apply a leech;-or 
to make punctures with a needle or lancet (or with holly-leaves, if 
preferred). It would be impossible to name any stimulant that has 
not been recommended by the public or profession. Perhaps the 
best is that proposed by Mr. Wardrop, and consisting of six parts 
of soap liniment, and one of tincture of cantharides. But lini- 
ments of mustard, turpentine, camphorated spirit, and ammonia;- 
friction with snow;-strong brine, or, in fact, any ordinary stimulant, 
will answer the same purpose. Whichever is chosen, it should be 
used cold, with considerable friction, and should be strong enough 
to excite some increase of heat and smarting. 
If there are vesications, care must be taken not to break them; 
and the liniment must be applied lightly with a feather. 
If there are ulcers or sloughs, and they are attended with much 
heat, pain, and irritation, poultices are required. But as a general 
rule, they are too relaxing, and stimulating ointments or lotions 
(such as ung. resinx, calaminx, zinci, &c.) should be preferred. 
CHAPTER VIL 
OF THE EFFECTS OF MINERAL AND VEGETABLE IRRITANTS. 
General Observations.-These substances, considered with 
regard to their local effects, may be divided into two classes. First, 
those which produce inflammation of the animal tissues through 
their tendency to decompose, them chemically. Secondly, those 
which operate by producing violent irritation, but which have no 
power of causing chemical decomposition. 
The first class comprehends the strong mineral acids;-the pure 
alkalis, or their carbonates; sundry metallic salts, such as corrosive 
sublimate, nitrate of silver, and butter of antimony;-and the con- 
centrated vegetable acids, especially the acetic and oxalic. 
The second class includes arsenic amongst minerals,-and the 
whole list of acrid plants, garlic, ranunculus, euphorbium, and the 
like,-amongst vegetables. 
Acids.-The decomposing agency of the concentrated acids 
appears to depend mainly on their affinity for water. The sulphuric 
acid blackens or chars the tissues in destroying them; that is, sepa- 152 
EFFECTS OF MINERAL AND VEGETABLE IRRITANTS. 
rates the water and other constituent elements, and sets free the 
carbon. The nitric turns them permanently yellow. The hydro- 
chloric leaves a dead white stain. The hydrofluoric "is, of all 
known substances," says Turner, " the most destructive. When a 
drop of the concentrated acid of the size of a pin's-head comes in 
contact with the skin, instantaneous disorganization ensues, and 
deep ulceration of a malignant character is produced."* Phos- 
phorus seems to act both by the heat disengaged in its combustion, 
and by the acid which is the result of it. 
Treatment.-After injury from any of these acids, the first thing 
to be done is to wash it away, and neutralize it by repeated ablu- 
tion with warm soap and water, with a little carbonate of soda; 
then to apply poultices or any simple dressings to the ulcers that 
remain. The pain of these injuries is greatly increased by cold. 
Alkalis and Caustic Earths.-These, like the acids, appear 
to destroy animal matter by combining with its water. They also 
form a soap with the fat. Caustic potass, in the form of liquor 
polassx, and quick lime, are the substances of this class which most 
frequently give rise to accidents. The liquor ammoniac produces 
almost instant vesication and great pain when it touches the skin ; 
it is, therefore, much to be prized as a speedy and efficient counter- 
irritant. 
Treatment.-Ablution with weak warm vinegar and water, 
followed by poultices and simple dressings. 
Metallic Compounds.-The bichloride of mercury acts by its 
tendency to combine with albumen; and the chloride of zinc, and 
chloride (or butter} of antimony, probably produce their cauterant 
effects in a similar manner. The nitrate of silver is remarkable 
for the superficiality of its effects. It may vesicate the skin, or 
destroy a film on the surface of a sore, but its action does not spread. 
Hence, Mr. James deduces its utility in exciting adhesion, and 
checking spreading inflammations; erysipelas, and the like. It 
suffers decomposition at the moment of its contact with the ani- 
mal tissue; its acid appearing to be separated, whilst the metallic 
oxide combines and forms a white crust with the animal matter; 
and this soon becomes black, because the silver loses its oxygen, 
and is reduced to the metallic state. 
Treatment.-The bichloride of mercury is rendered inert by 
white of egg mixed with water;-the chloride of antimony is de- 
composed by water;-the nitrate of silver by common salt; and the 
chloride of zinc by a solution of an alkaline carbonate. These, 
therefore, would respectively be the proper applications for external 
injuries caused by these metallic compounds; although such cases 
very rarely come under the surgeon's cognizance. 
jirsenic, if locally applied, produces inflammation, or sphacelus, 
not by any chemical action, but by its influence on the vital proper- 
ties of the part;-it may also be absorbed into the circulation, and 
produce its ordinary constitutional effects as well. The surgical 
* Elements of Chemistry, 5th edit. p. 377. POISON OF INSECTS. 
153 
treatment of any local injury from this mineral must consist in 
removing it as far as possible by ablution or otherwise, and then 
applying poultices, or whatever other dressings may be most appro- 
priate. Lime-water might be useful, if applied at first. Some 
cases, almost too horrible to think of, are recorded of the destruction 
of women by the local application of this poison. 
Acrid Vegetables.-The inflammation excited by these sub- 
stances requires merely soothing fomentations and emollient dress- 
ings. The smart, from the sting of nettles may, it is said, be allayed 
by a weak infusion of tobacco, if severe enough to require any 
remedy at all. 
If an irritating fluid have been injected into the cellular tissue, 
free incisions must be made, both to allow its escape, and to afford 
exit to pus. By this means sloughing of the skin may often be 
avoided, although very likely to occur when the subjacent tissue is 
extensively disorganized. 
CHAPTER VIII. 
OF THE EFFECTS OF THE POISON OF HEALTHY ANIMALS, AND OF 
THE TREATMENT OF POISONED WOUNDS GENERALLY. 
Insects.-The bite or sting of any insects that are met with in 
England is not of sufficient importance to need surgical assistance, 
unless inflicted in extraordinary numbers, or in peculiar situations. 
Mr. Lawrence* mentions the case of a French gentleman who was 
so severely stung by bees* about the upper part of the chest, that 
he died in fifteen minutes, with all the symptoms of mortal collapse 
usually produced by the bite of venomous serpents. Children, if 
much stung by bees or wasps, may suffer severely from headache 
and fever. But the most common instance of danger from these 
insects is the alarming suffocation produced when their sting is 
inflicted in the pharynx or back part of the mouth;-which some- 
times happens when they are concealed in fruit, and are incau- 
tiously taken into the mouth. 
Treatment.-If a person have been stung sufficiently to cause 
faintness or constitutional depression, cordials and opiates must be 
administered without delay. Respecting the local treatment, the 
first thing to be done is to examine the parts with a lens, and ex- 
tract the stings with a fine forceps, if they have been left in the 
wound, as they very frequently are. Then the best remedies are 
those which are also most useful in burns, viz. turpentine, hot 
vinegar, hartshorn, spirit of wine, eau de cologne, or other stimu- 
* Lectures, Med. Gaz., vol. v. p. 582. 
14* 154 
POISON OF SERPENTS. 
lants. Cold applications give great relief, if used continuously. 
Finely-scraped chalk, flour, starch, and oil, are favourite remedies 
with some people. Mr. James recommends a combination of ung. 
hydr. fort, and liq. ammoniae. A weak infusion of tobacco or bella- 
donna might be worth trying. The soap liniment, or compound 
camphor liniment, may be used to remove the oedematous swelling 
that remains. 
In the case of a wasp or bee sting in the fauces, with urgent 
danger of suffocation, leeches should be plentifully applied both 
externally and internally;-and hot stimulating gargles (especially 
hot salt and water) should be frequently used, in the hope of re- 
ducing the tumefaction, by causing a copious flow of blood and of 
saliva: but if these measures fail of affording relief, an opening 
must be made into the larynx or trachea. 
For the bites of bugs, fleas, gnats, mosquitoes, &c., the best 
remedy is eau de cologne, or some other stimulant, so as to convert 
the itching into slight smarting. Any strong perfume will often act 
as a protective against any of these nocturnal visitants. Sweet oil 
rubbed over the body is said to have the same effect; a little colo- 
cynth pulp, powdered, and sprinkled about, is also said to be a 
sure remedy. 
Spiders.-The most celebrated of this class is the tarantula, the 
miraculous effects imputed to the bite of which are too well known 
to need repetition here; and we can feel but little hesitation m sub- 
scribing to the opinion of Ray, "that the dancing of the Tarantati 
to certain tunes and instruments, and that these fits continue to 
recur yearly as long as the tarantula that bit them lives and then 
cease, are no other than acting fictions, and tricks to get money." 
We learn, however, from the least romancing of the old writers, 
that it produces swelling, lividity, and cramps, which were cured 
by scarifications and wine; and these are just the symptoms it 
might be expected to cause, and the most rational cure. The effects 
of the scorpion are similar. There is one very singular case on 
record, of a gentleman bitten on the penis by a spider, in America, 
suffering from violent vomiting, deep-seated abdominal pain, and 
suffocative spasms in consequence. He was relieved in thirty-six 
hours, by bleeding, opium, and ammonia.* 
Serpents.-The venom of these animals operates, as Fontana 
observed, on the vitalpropertiesof the frame,by "destroying the irri- 
tability of the nerves, and disposing the humours to speedy corrup- 
tion ;" and not by any mechanical or chemical endowments. The 
symptoms produced vary in their nature and degree, according to 
the species of serpent, its degree of vigour, the frequency with 
which it may have bitten, and the strength of the sufferer. Some 
serpents can kill only small animals; the poison of some is very 
virulent, but soon exhausted by frequent biting; that of others is 
mild, but not easily exhausted; some, again, act so energetically 
on the nerves, as to cause death speedily by convulsions; others 
• Ray, Phil. Trans., 1698, vol. xxi. p. 47; Boccone, Museo di Fisica; Hulse, 
American Jourp. Med. Sc., May 1839. POISON OF SERPENTS. 
155 
produce inflammation of the lungs; and others, whose venom is 
insufficient to annihilate the nervous functions at once, kill more 
slowly by the unhealthy or diffuse inflammation which they excite 
at the bitten part. 
Viper.-This is the only poisonous snake in the British Isles, 
but it is not often that it kills human beings. The properties of its 
venom were most painfully investigated, in every possible point of 
view, by the Abbe Fontana;* who ascertained that it is a yellow 
viscous liquid, not inflammable, and neither acid nor alkaline;- 
that it contains no salts; and that it has no taste, except, perhaps, 
a slight astringent sensation if it is kept in the mouth for some time. 
It is not hurtful to another viper, nor does it appear to affect cer- 
tain cold-blooded animals, as leeches and frogs. Moreover, it is 
perfectly harmless if applied to any natural mucous or cutaneous 
surface;-so that large quantities of it have been swallowed with 
impunity. 
Cobra di Capello.-Dr. Russell found that this was capable of 
killing a serpent called Nooni Parogoodo, but not another cobra; 
and that its poison was insipid when taken into the mouth, and pro- 
ductive of no ill consequences when applied to the eyes of chick- 
ens. The symptoms produced on animals are fainting and convul- 
sions, but no swelling; the lungs were stuffed with blood.t 
Nai a Tripudians, hooded snake of Ceylon. Dr. Davy found 
that its poison tastes acrid, paralyzes the iris and levator palpebrae 
of fowls when applied to their eyes, and is soon exhausted by bit- 
ing. It acts chiefly on the lungs, which are found gorged with 
blood and serum; the symptoms being reduction of the animal 
temperature and prostration of strength. According to the same 
authority, the Trigonocephalus hypnale, or Carawilla, has a poi- 
son that is mild, but not soon exhausted; that it produces local 
inflammation chiefly, and can kill frogs, but not large animals.- 
The Viper a Elegans, or tic polonga, soon causes death by convul- 
sions ; the blood is much coagulated.f 
Rattlesnake.-This snake, unlike most others, is capable of 
poisoning itself. Capt. Hall made one bite itself, and it died in 
eight minutes. Its effects, according to Sir E. Home, may be divided 
into two stages, either of which may prove fatal. During the first, 
which may last for sixty-two hours, the symptoms are those of 
great prostration of the nervous system, and contamination of the 
blood ;-vomiting, deadly coldness, faltering pulse, the skin livid or 
jaundiced, bleeding from the nose, fainting fits, convulsions, and 
delirium. Meanwhile the bitten part swells immensely from effu- 
sion of acrid serum, and becomes mottled with blood, extravasated 
under the skin ; and this swelling extends to the trunk. Sometimes 
it is attended with excruciating pain, sometimes with mere numb- 
* Felix Fontana, Treatise on the Venom of the Viper; translated by Joseph 
Skinner. 2d edit. Lond. 1795. 
f Patrick Russell, M. D., F.R.S. An Account of Indian Serpents. 2 vols. folio. 
Lond. 1796. 
| Davy, Physiological Researches. Lond. 1839. 156 
TREATMENT OF SNAKE BITES. 
ness or coldness. During the second sta^e^x^e. diffused abscesses 
form in the swelled parts, which contain bloody unhealthy pus and 
sloughs of cellular tissue, and are attended with low fever. After 
death, the body putrefies very rapidly.* 
TREATMENT OF POISONED WOUNDS. 
In the first place, measures must be taken to remove the poison 
from the wound, or at all events to prevent its passage into the 
blood. 
If no other means are at hand, a ligature should be tightly ap- 
plied round the limb, as near as possible to the wound, and between 
it and the heart-so as to prevent the return of venous blood from 
it. Then it should be thoroughly sucked, taking care that the per- 
son who does so, has no sore nor recent abrasion in his mouth. 
A better plan, however, is to cut out the bitten part as freely as 
may be necessary, and then to suck the wound, and bathe it tho- 
roughly with warm water to encourage bleeding-a ligature being 
also applied, as in the last case. 
But the best plan of all is that recommended by Sir David Barry.t 
He directs, first, that an exhausted cupping-glass shall be applied 
over the wound for a few minutes;-next, the glass is to be taken 
off, and the wound freely excised;-and, lastly, the glass is to be 
applied again in order to promote the flow of blood, and cause the 
re-exudation of any of the poison that may have found its way 
into the neighbouring blood-vessels.-The cupping-glass, used in 
the manner we have just detailed, possesses all the efficacy, and 
none of the disadvantages, of ligatures;-for without interrupting 
the general circulation of the limb, it produces a complete afflux of 
all the fluids in the vicinity towards the wounded part, and entirely 
prevents them from conveying their contaminated contents towards 
the centre of the circulation. If the glass is applied in this man- 
ner, it is far from being advantageous (as is generally supposed) to 
make incisions or scarifications near the wound, whether before or 
after its excision. For the object is to concentrate the course of the 
blood towards the original wound itself,-so that it may carry the 
venom with it as it escapes;-and this object would be counter- 
acted by any extraneous incisions. 
The treatment of snake bites during the first stage, consists first 
in the administration of powerful diffusive stimulants, such as hot 
brandy and water, ammonia, or the eau de luce,^ to support the 
* Sir Everard Home. Phil. Trans, vol. c. Case of T. Soper, who was bitten 
by a rattlesnake. Hall on the Poison of Rattlesnakes, Phil. Trans, vol. xxx. p. 
309. Case of Mr. J. Briental, who was bitten by a rattlesnake, reported by him- 
self, Phil. Trans, vol. xliv. p. 147. Case of a man bitten by a rattlesnake to cure 
lepra, Clarke, Lancet, Dec. 15, 1838. 
f David Barry, M. D. Experimental Researches on the Influence exercised by 
Atmospheric Pressure, &c. Lond. 1826. 
| Tinct. ammonise comp. P. L. It contains oil of amber. Dose tip. xxx. every 
half hour. TREATMENT OF SNAKE BITES. 
157 
nervous system;-and, secondly, in the use of remedies which may 
be supposed to eliminate the poison from the blood. Thus, if there 
is no vomiting, it should be excited by a. mustard emetic, to get rid 
of the vast quantity of bile that is often formed in the blood and 
secreted by the liver under these circumstances; if, however, vomit- 
ing is spontaneous and too violent, it should be checked by a large 
dose of solid opium, and a mustard poultice to the epigastrium. 
But the principal remedy seems to be arsenic, which has long been 
popular for these accidents in the East Indies. It is usually admin- 
istered in the form of a nostrum, called the Tanjore pills, each of 
which contains a grain of it, combined with certain unknown acrid 
plants. The efficacy of this mineral was also fully established in 
the West Indies by Mr. Ireland, surgeon to the 16th regiment, who 
employed it with perfect success in live cases of the bite of a ser- 
pent, which had previously killed several officers and men, some 
within six hours, and all within twelve.* He combined f^ij of the 
liquor arsenicalis with gtt. x. of tinct. opii, (to prevent vomiting,) 
fgiss of peppermint water, and f§ss of lime-juice. This draught, 
which contains a grain of the arsenious acid, was given every half 
hour for six or eight doses, till it produced copious purging, (which 
was encouraged by clysters,) or till the symptoms were ameliorated. 
The swelled parts were well rubbed with a liniment of olive oil, 
turpentine and liquor ammonias;-and the patients, although for a 
time greatly debilitated, were soon able to return to their duty. 
Oil has been very warmly recommended, both as an internal and 
external remedy in these cases; and the fat of the viper, a strong 
nauseous substance, is said to be a specific for its bite; but its effi- 
cacy is very questionable.! 
If the local symptoms are very slight, stimulating embrocations, 
and hot fomentations, with leeches, may be sufficient. But if the 
swelling is rapid and extensive, or the constitution is much affected 
by the poison, free and extensive incisions into the swelled parts are 
indispensable. 
The constitutional treatment of the second stage must be regu- 
lated by the symptoms actually present; it will most likely require 
a combination of cordials, opiates, and tonics. Senega and serpen- 
taria have been in great repute in these cases; and of tonic stimu- 
lants they are perhaps the most useful. 
* A Letter to T. Chevalier, Esq., on the effects of arsenic in counteracting the 
poison of serpents. Med. Chir. Trans. 1813, vol. ii. p. 396. 
f Breschet says that the effects of a serpent's bite on birds can be prevented by 
passing a current of galvanism through the bitten part. 158 
SEPTIC POISONS. 
CHAPTER IX. 
OF THE POISONS CONTAINED IN DEAD HUMAN BODIES, AND 
OF DISSECTION WOUNDS. 
SECTION I. OF THE POISONS CONTAINED IN DEAD BODIES, AND OF 
THE INFLUENCE OF DISSECTION ON THE HEALTH.* 
It appears that two distinct classes of poisons may be contained 
in the human body after death. The first class consists of certain 
poisons found in fresh bodies; and either originating in some morbid 
condition that existed during life, or else produced immediately after 
death. The second class comprises the poisons resulting from putre- 
faction. 
1. The first class of poisons appears to contain many varieties. 
One of the most common of them is a gaseous emanation, of a 
faint, sickly, and indescribably nauseous odour. It is, perhaps, 
most commonly observed to proceed from the bodies of those who 
have died of fever; but this is not quite certain. This emanation 
is so abominably nauseous, and so sedative in its effects, that it often 
causes sickness and faintness in those who would be unaffected by 
the most advanced putrefaction. A second variety is that which 
when inoculated into a recent puncture, and sometimes even if 
applied to the unbroken skin, is capable of producing the most 
fearful irritative and typhoid fever, with diffuse inflammation of 
the cellular tissue. This poison is the most common in the bodies 
of those who have died of inflammation of the serous membranes, 
or of puerperal fever, or some other disease of an erysipelatous 
character. Both these poisons appear to be decomposed or dissi- 
pated as putrefaction advances. 
2. The second class of poisons, those, namely, arising from putre- 
faction, consists of the compounds of hydrogen, hydrosulphuric 
acid, carburetted and phosphoretted hydrogen, carbonic acid, and 
ammonia, on whose chemical and sensible qualities the author 
need not enlarge. In the last few years an attempt has been made 
to persuade people that the effluvia of putrefaction are rather salu- 
brious than otherwise, or at all events that they are not prejudicial 
to the health, because the workmen employed in the well-known 
knackeries of Montfaugon, near Paris, as well as men who grind 
bones, or who are engaged in the manufacture of catgut, or candles, 
or leather, are in no manner inconvenienced by their offensive occu- 
pations. But although it is perfectly true that healthy persons, who 
use considerable exercise, and are much in the open air, and who 
* The author is much indebted to a paper on this subject, read before the Medi- 
cal Society of King's College, by W. Bowman, Esq., Assistant Surgeon to King's 
College Hospital. SEPTIC POISONS. 
159 
live well, but not intemperately, may be able to resist those noxious 
influences; still daily experience shows that those whose natural 
strength and habits of life are not so favourable to the development 
of their vital energies, cannot be exposed to them with impunity. 
Or why banish churchyards from crowded cities ? 
If the student of anatomy be naturally vigorous, and if he care- 
fully avoid all other sources of indisposition, he will not find the 
practice of dissection to be incompatible with even a high state of 
health. But if it be too ardently followed, to the neglect of regular 
meals and sleep, it is liable to produce weakness, indigestion, and 
especially diarrhoea with fetid flatulence ;-symptoms that may be 
easily removed by the fresh air of the country; by aperients and 
alteratives, with tonics and good living; and that may generally be 
prevented by regular daily exercise, generous diet, warm clothing, 
and strict cleanliness. 
The cause of this indisposition is doubtless the absorption of 
putrid miasmata. And. the proofs of this absorption are so clear, 
-its effects on the system so marked,-and the manner in which 
the absorbed substances are eliminated, is so plain, that some light 
may doubtless be thrown on the modus operandi of other mias- 
mata, which do not present themselves so palpably to the senses. 
It not unfrequently happens that deleterious gases are absorbed 
in great quantity; either because they are present in unusual abun- 
dance, or because (as we may suppose) the vital powers of resist- 
ance are lowered. The following are instances of their effects, and 
of the manner in which they are got rid of by the system. A 
gentleman, after a hard day's dissecting, goes home;-findshim- 
self heavy, listless, and indisposed, and with the peculiar smell of 
the dissecting-room clinging to him. He changes every particle of 
his apparel, and gives himself a thorough ablution. But in a very 
short time the same odour emanates from every part of him;-and 
it is not till after copious perspirations in the night that he is freed 
from the annoyance. Three gentlemen, friends of the author, dis- 
sected a fresh subject, from which proceeded the peculiar sickly 
effluvium that has been alluded to. On their return home, the 
weakest of them vomited;-the other two suffered from nausea 
and depression;-and they all had for several hours a continual 
sickly taste in their mouths, similar to the smell which they had 
been imbibing. And it is notorious that dissectors frequently 
recognize the smell of their subjects in the secretions of their 
mouths, and in the copious flatus extricated in their stomach and 
bowels. 
From these facts it may be concluded that putrid and other dele- 
terious gases may be absorbed into the blood;-that the skin and 
bronchial membrane are the points of ingress;-that they may be 
eliminated by the skin and mucous membranes without any altera- 
tion of their sensible qualities;-and that their elimination by the 
gastro-intestinal mucous membrane is the chief cause of the diar- 
rhoea which is such a frequent consequence of diligent attendance 
in the dissecting-room. 160 
DISSECTION WOUNDS. 
SECTION II. OF DISSECTION WOUNDS. 
The two most important consequences of these wounds are- 
1. Inflammation of the lymphatics; and 2. Adynamic or typhoid 
fever, with diffuse inflammation of the cellular tissue. 
The causes of these effects may be, either-1. The irritation of 
a trivial wound, operating on an unhealthy constitution; or, 2. 
Inoculation with a morbid poison. 
And the morbid poison so inoculated may be twofold; viz. 1. 
The specific virus generated in recently dead subjects; or, 2. The 
common products of putrefaction. 
Of inflammation of the lymphatics, arising from these as well as 
from other causes, we shall speak elsewhere. In this place we 
shall describe the symptoms and treatment of the adynamic fever 
and diffuse cellular inflammation. 
Symptoms.-The poison having gained admission into the system 
through a wound, (which is in most cases so slight as to pass 
unheeded,) at a period varying from six to eighteen hours subse- 
quently, the patient feels generally unwell: he is depressed, faint, 
and chilly, and complains of lowness of spirits and nausea. These 
symptoms are soon succeeded by rigors, severe headache, and 
vomiting;-the pulse is frequent and sharp, but weak;-the tongue 
is coated, and there is the greatest restlessness and despondency. 
Then the first local symptom appears in the form of a most 
excruciating pain and tenderness of the shoulder, corresponding to 
the hand that was wounded. And in most cases there soon after- 
wards arises a pustule, on or near the wound, which sometimes 
resembles the small-pox pustule, and in other cases is a. flattened 
vesicle, containing a milk-white serum. But this pustule may be 
unattended with any pain, and the patient may be ignorant of its 
existence, or may not even be aware that he has received a wound, 
till his attention is directed to it by his attendants. As the case 
proceeds, the pain in the shoulder becomes more excruciating, and 
is attended with fulness of the axilla and neck;-and a doughy 
swelling appears on the side of the trunk, often extending from the 
axilla to the ilium. At first it is pale; but it soon assumes an ery- 
sipelatous redness, or rather a pinkish tint, like that of peach-blos- 
soms. The breathing now becomes difficult; the pulse quicker 
and weaker; the tongue dry, brown, and tremulous; the mental 
distress is truly appalling, although there is seldom delirium; the 
countenance is haggard, and the skin yellow; and the patient often 
expires before the local disease has made further progress. 
Varieties and Complications.-These symptoms often present 
considerable varieties in their progress and degree of severity, and 
may be complicated with other maladies arising from the same, or 
from some co-existent cause. 
1. In one small class of cases, the influence of the morbid poison 
is so virulent, that the patient actually dies of the precursory fever. 
before sufficient time has elapsed for any local disease to appear- DISSECTION WOUNDS. 
161 
either in the axilla, or in the wound, or elsewhere. The most 
speedily fatal case on record, that of Mr. Elcock, was of this variety. 
He died in forty hours from the receipt of the dissection-wound; 
and the nervous commotion and mental despondency which he 
suffered were even parallel to those of hydrophobia. Dr. Bell of 
Plymouth, died in the same manner. 
2. In another (and by far the most numerous) class, the general 
order of symptoms is the same as we described in the text; that is, 
there are, at first, general depression and fever;-subsequently, 
diffuse cellular inflammation begins in the shoulder and axilla, and 
spreads down the side of the trunk. 
3. In a third class, diffuse cellular abscesses occur in several 
remote parts-the knee or elbow, for instance, as well as in the 
axilla, as in the case of Mr. Shekelton.* 
4. In other cases the wounded finger inflames violently, and sup- 
purates or sloughs;-or the diffuse inflammation begins at the 
wrist, and extends up the arm. 
5. In a fifth class, inflammation of the lymphatic vessels may be 
combined with the peculiar depressing effects of the absorption of 
poison; as in the case of Mr. James, narrated in his work on 
inflammation. 
Termination and Consequences.-If the case do not termi- 
nate fatally at an early period, extensive and foul collections of 
matter form in the parts that have swelled;-and abscesses continue 
to gather under the skin, or between the muscles of the trunk and 
limbs; and from these the patient may slowly sink;-or, if he sur- 
vive, his existence may be a mere burden; one or more of the 
fingers may perish by gangrene, the arm may remain stiff and use- 
less, or the seeds of consumption or dropsy may be left in the 
system. Mr. Adam has remarked, that in most cases of recovery, 
every portion of the limb, between the original wound and the 
part first stricken with pain, was affected with swelling.! 
In some cases, severe and protracted pains of a rheumatic cha- 
racter have followed the ordinary train of symptoms. Both Sir A. 
Cooper and Mr. Abernethy suffered in this manner, and the same 
symptoms have been observed by Mr. Stafford.^ 
Morbid Anatomy.-The morbid appearances are those of the 
various grades of diffuse cellular inflammation. The following 
may be quoted as a fair description of an advanced stage. § The 
cuticle covering the affected side of the trunk, vesicated and 
wrinkled;-the cutis mottled and gangrenous in patches;-the 
subcutaneous cellular tissue, in some parts distended with serum, 
in others softened and turgid with pus; the tissue between the 
muscles of the trunk, as well as that which separates the different 
* The case of Dr. Bell may be found in Butter on Irritative Fever. Those of 
Mr. Elcock and Mr. Shekelton are quoted at length (with many others) in Travers 
on Constitutional Irritation. 
f Glasgow Medical Journal, August, 1830. 
$ Med. Chir. Trans, vol. xx. 1836. 
§ Abridged from the case of Mr. Young, in Duncan's paper in the Edinburgh 
Med. Chir. Trans, vol. i. Quoted also in Travers, op. cit. 162 
DISSECTION WOUNDS. 
muscular fasciculi, also softened and purulent;-the muscular 
Jibres, of a dirty-yellow colour, and softened;-the axillary 
glands enlarged, but not suppurating;-the axillary artery and 
nerves healthy;-but the veins (especially the smaller branches) 
dirty red, and softened ;-the brachial and median-cephalic veins 
of the wounded arm, slightly red ;-but the forearm healthy, and 
no connection whatsoever to be discovered betiveen the abrasion 
on the Jinger and the morbid parts in the axilla;-the pleura 
of the affected side greatly inflamed;-the lung covered with lymph, 
and much serum effused into the cavity of the chest. 
Diagnosis.-1. From acute rheumatism this disease may be 
distinguished by the suddenness of its invasion; by the precedence 
of the constitutional symptoms; by their low typhoid type; by the 
depression of the pulse; by the pain being confined at first to the 
axilla; by the characters of the ensuing tumefaction; and by a 
knowledge of the exciting causes.* 
2. From inflammation of the Lymphatics, which is a very 
frequent consequence of festering scratches and poisoned wounds, 
whether received in dissection or not, this more serious affection 
may be distinguished by noticing, that the disease begins at the 
wounded part,-which swells and becomes throbbing and painful; 
the inflammation extends in red lines up the arm to the lymphatics 
above the elbow, and in the axilla; and the constitutional symp- 
toms are at first those of inflammatory fever, although they may 
become irritative and typhoid, if the patient be exhausted by pain, 
or if matter be confined. Moreover there are the following broad 
features of distinction: The constitutional symptoms precede the 
local, in the diffuse cellular inflammation; but follow them in 
inflammation of the lymphatics. In the former disease, the local 
affection depends upon the constitutional; in the latter it is the 
reverse. Again, the two diseases are most remarkably at variance 
as regards their tolerance of blood-letting; which remedy is as 
eminently serviceable in cases of pure inflammation of the lym- 
phatics, as it is positively injurious in those which arise from the 
imbibition of poison. 
Prognosis.-Of the cases on record, nearly two-thirds have 
proved fatal. The danger will be proportionate to the violence 
of the constitutional symptoms;-the quickness of pulse, anxiety 
of mind, and prostration of strength. The cases in which inflam- 
mation begins at the injured part are much less dangerous than 
those in which it appears remote from it, or in several places simul- 
taneously. 
Pathology.-Some persons deny that this disease originates in 
the absorption of poison, and attribute it to mere local irritation 
acting on an unhealthy constitution.! Now it is, on the one hand, 
* Dr. Law, in a valuable paper in the Dublin Med. Journ. Nov. 1839, gives 
several cases of glanders and diffuse cellular inflammation mistaken for acute 
rheumatism. 
f Abernethy's Lectures, Renshaw's edition, p. 132. Lizars' Practical Surgery, 
Edinburgh, ed. 1838. p. 71. See the section on diffused abscesses in Partii. DISSECTION WOUNDS. 
163 
perfectly true, that severe or fatal diffuse cellular inflammation, or 
inflammation of the lymphatics, may be produced by the slightest 
conceivable injury to a vitiated habit. Witness the Plymouth 
Dockyard disease; and Mr. Abernethy's case of a young lady who 
nearly died from a prick in the finger with a clean sewing-needle. 
And it is equally certain that most medical students and practi- 
tioners are in a bad state of health, and consequently predisposed 
to suffer from such accidents. But there are reasons which, duly 
considered, place the existence and agency of a distinct morbid 
poison beyond all doubt. 
1. It is a well-established fact, that many individuals are fre- 
quently inoculated from one. subject. This happened in the well- 
known cases of Professor Dease and Mr. Egan; and numerous 
other instances of it are on record.* 
2. The disease most frequently arises from fresh subjects. Mr. 
Adam, in the excellent paper which we have before quoted from, 
has collected forty cases;-and in only two or three out of the 
whole number did the disease arise from a putrid subject. The 
most dangerous poison seems to be destroyed by putrefaction; and 
the disease caused by inoculation with putrid matters is in general 
mild, and consists of mere inflammation of the lymphatics,- 
although there are exceptions. 
3. The disease of which a subject died has a manifest influence 
on the frequency of the ill effects from dissecting it. In two-thirds 
of Mr. Adam's cases the disease affected a serous membrane; - 
and the most deadly virus of all is contained in the bodies of 
women who die of puerperal fever. 
4. The disease we have been describing begins with symptoms 
of constitutional disorder; and, in fact, it may be unattended with 
any local disease whatever. Consequently it cannot be said to 
arise from local disease, when there is none. 
Lastly, it may be induced by immersion of the fingers in the 
fluids of a dead body, although the fingers may be quite free from 
wound or abrasion. A remarkable instance of this is related in 
the third volume of Tyrrel's edition of Sir A. Cooper's Lectures.t 
The occurrence of accidents from punctures made during dissec- 
tion was frequent enough to excite considerable attention, long 
before the existence of a peculiar poison was proved. In one of 
the old histories of the conquest of South America By the Spaniards, 
it is said that a soldier, who had amused himself by hacking the 
dead body of an enemy with a sword, inflicted a very slight wound 
on himself with the same weapon, and died very soon thereafter; 
which was much marvelled at. 
* Vide Copland's Diet. p. 304 ; also Nunneley on Erysipelas. 
f Travers gives two analogous cases. A Mrs. Clifton died of diffused cellular 
inflammation following a prick. Two of her attendants become ill from the con- 
tact and effluvium of the discharge, although neither had any wound through which 
a poison might be inoculated. One of them suffered from acute fascial inflamma- 
tion of the arm; the other from low fever, and abscess in the axilla. The latter 
was engaged in folding some sheets from which a most noisome smell proceeded, 
when she was all at once seized with sickness and faintness, and excruciating pain 
in the axilla.-Constitutional Irritation, p. 373, third edition. 164 
DISSECTION WOUNDS. 
It merely remains to add, with regard to the pathology of this 
distreseing malady, that the poison appears to operate both by de- 
pressing the nervous system, and by contaminating the blood;- 
but which of these effects it produces first, it avails little to inquire; 
in fact, it is not easy to conceive how one of them can occur without 
inducing the other. 
Treatment.-The indications clearly are, to support the nervous 
system in its state of depression;-to endeavour to eliminate the 
poison by attention to the secretions;-and to relieve pain and ten- 
sion, and promote the discharge of pus or sloughs. 
As soon, therefore, as the first symptoms of indisposition make 
their appearance after a wound received during dissection, it will be 
advisable that the patient should take a mild emetic, have his feet 
immersed in hot water, and betake himself to a warm bed. Ten 
grains of ipecacuanha, with an equal quantity of the sesqui-carbonate 
of ammonia, dissolved in a warm infusion of chamomile, form the 
best emetic. After the vomiting has ceased, he should take a full 
dose of calomel, which may be advantageously combined with two 
or three grains of camphor. In an hour or two it should be fol- 
lowed by a purgative draught of oil of turpentine combined with 
castor oil or senna, to quicken its operation, and prevent any irrita- 
tion of the kidneys. (F. 18.) These remedies should be repeated, 
-and be aided with turpentine enemata until the bowels are fully 
unloaded. 
The medicines subsequently given should be of a tonic and nar- 
cotic quality. If the pulse is moderately firm, and there is much 
thirst and headache, effervescing saline draughts; or liq. am. acet., 
with the strong camphor mixture, (F. 81,) may be tried. But in 
those cases which present a more decidedly adynamic character 
from the beginning,-and in all cases towards their termination, it 
will be necessary to administer wine, ammonia, aether, and quinine; 
together with whatever articles of nutriment the patient can take. 
It will be most urgently necessary to render the patient unconscious 
of his severe pain by narcotics; and the muriate of morphia has 
proved so beneficial in Mr. Stafford's hands, that it is to be preferred 
in similar cases. It should be given in a full dose (gr. i-j) at bed- 
time, and in smaller ones during the day;-and if the bowels have 
first been properly opened, it will most probably allay the pain, 
calm the restlessness and anxiety, and reduce the frequency, whilst 
it improves the tone, of the pulse. 
Local Treatment.-As soon as pain is first experienced in the 
axilla, numerous leeches should be applied, and their bleeding be 
encouraged by warm poppy fomentations, or poultices sprinkled 
with laudanum. But as soon as any distinct swelling can be de- 
tected, an incision should be made into it,-in order to relieve pain 
and tension, and to prevent the diffusion of serum or pus that may 
have been formed in the meshes of the cellular tissue. Incisions 
are the sine qua non of the treatment; the point on which success 
mainly depends; and it is most truly observed by Mr. Stafford, DISSECTION WOUNDS. 
165 
that in most of the cases that have hitherto occurred, if swelling or 
abscess formed and were not opened, the result was fatal. 
If the patient survive, he should as soon as possible be removed 
into the country, and be put on a course of tonics and liberal diet. 
All the collections of matter which sometimes continue to form for 
months should be opened as soon as they are detected; and the ulcers 
that remain be dressed with stimulating lotions and bandages. 
Venesection.-With regard to the propriety of vensesection in 
this disease, there is but one opinion among the best authorities; 
namely, that it is uncalled-for and injurious. They who recommend 
it do so on mistaken principles. They imagine that they have 
merely a local inflammation to treat, which, it need scarcely be 
repeated, is altogether an error. But experience, no less than reason, 
testifies to the impropriety of bleeding. It never relieves the pain, 
and always aggravates the nervous depression. Besides, the blood 
is never butted nor cupped, and the coagulum is always small in 
proportion to the serum. We may therefore conclude with Mr. 
Stafford that it is injurious, " because, in the first place, the nervous 
system has already been depressed by the introduction of the poison; 
-in the second, the fever cannot be considered simply of an in- 
flammatory nature, but rather of an irritative or typhoid kind; and, 
in the third place, although present symptoms may be violent, yet 
perhaps, from the formation of abscesses, and the general reduction 
of the patient, he will afterwards require as much of the restorative 
power as possible to recover his strength." 
Calomel is very strongly recommended by Mr. Adam and Dr. 
Colles,* the former of whom concludes, that it seems to annihilate 
the disease. They recommend it to be given alone in doses of gr. 
iij every three or four hours, so as to salivate in thirty-six or forty- 
eight hours, and they say it will do so more readily if the first few 
doses act on the bowels;-an effect which may be aided by purga- 
tive draughts. 
Precautionary Measures.-We need scarcely comment on 
the expediency of using some precautions in performing post-mor- 
tem examinations, especially if the operator be out of health, or if 
the patient have died of any disease of an erysipelatous character. 
The wearing of gloves, or smearing the hands with oil or lard, 
would be of some service, and are often recommended, but seldom 
practised. Sores or scratches on the fingers should be covered 
with adhesive plaster, or touched with the nitrate of silver to form 
an eschar. If the operator should puncture himself, or should 
suffer a scratch or abrasion to come in contact with the fluids of 
the subject, he should immediately wash his hands, and thoroughly 
suck the wound. Then a stimulant should be applied to it, in 
order to decompose the poison and excite a slight inflammation, 
which will impede absorption. Some recommend the nitrate of 
silver for this purpose, others oil of turpentine; Macartney speaks 
highly of a strong solution of alum, and Copland of a solution of 
* Colles, Dublin Hospital Reports, vol. iii. and iv. 166 
HYDROPHOBIA. 
camphor in concentrated nitric acid. It will also be expedient to 
apply the lunar caustic to the wound when the constitutional 
symptoms begin to show themselves, provided that it is not much 
inflamed. 
CHAPTER X. 
OF THE EFFECTS OF POISONS GENERATED BY DISEASED 
ANIMALS. 
SECTION I. OF HYDROPHOBIA. 
Syn.-Lyssa, Rabies Contagiosa. 
Definition.-Hydrophobia is a disease brought on by inocula- 
tion with the saliva of a rabid animal, and characterized by inter- 
mitting spasms of the muscles of respiration, together with a pecu- 
liar irritability of the body and disturbance of the mind. 
Symptoms in the Dog.-The first symptoms of rabies in the 
dog are an unusual shyness and melancholy. The animal avoids 
society, refuses his food, and seems to have lost all his vivacity; 
his ears and tail droop, he looks haggard and suspicious, his eyes 
are red and watery, and he is constantly snapping at and swallow- 
ing straws, litter, and rubbish, and licking cold surfaces, such as 
stones or iron. In the next stage the respiration becomes difficult, 
and there is a copious flow of viscid saliva, with inflammation of 
the fauces, and fever. The animal is by no means so invariably 
furious as is generally supposed; and it has, in the course of expe- 
riments, not always been easy to induce it to bite. Yet it may be 
said that there is always a greater disposition than usual to bite if 
irritated;-and in some instances there is a state of extreme rage, 
the animal attacking and biting indiscriminately every person and 
thing that comes within its reach. It has been presumed that the 
former milder form occurs in the domesticated and educated dog;- 
and that the state of uncontrollable and indiscriminate fury is met 
with chiefly in ill-tempered or wild dogs, and in wolves, foxes, and 
the other unsubjugated varieties of the canine race. Be this, how- 
ever, as it may, the breathing becomes more difficult and laborious 
as the disease advances;-tremors and vomiting occur, and the ani- 
mal is carried off in convulsions. It rarely survives the fifth day. 
The difficulty of swallowing water, which gives the name of the 
disease as it occurs in man, is very rare in animals. 
Causes.-The cause of this malady in dogs is most frequently 
infection from another animal already diseased; yet it must occa- 
sionally arise spontaneously. The most probable sources of its HYDROPHOBIA. 
167 
origin are c.ose confinement, rank unwholesome food, want of the 
couch grass, the natural medicine of the dog, and deprivation of 
sexual intercourse. 
Besides the dog, it is probable that hydrophobia arises spontane- 
ously in the wolf, jackall, badger, and perhaps the cat. But it may 
be communicated to many other mammiferous animals, and there 
is no doubt but that every animal capable of taking the disease, 
can also propagate it. This is equally true with regard to human 
beings as to animals. MM. Magendie and Breschet inoculated 
two healthy dogs on the 9th of June, 1813, with the saliva of a 
man who was labouring under the disease, and who died of it the 
same day at the Hbtel-Dieu. One of the dogs ran away; but the 
other was affected with decided rabies on the 27th of July follow- 
ing, and died of it;-and some other dogs, which it was made to 
bite, died also. Well-authenticated cases are recorded, in which 
the disease was communicated to man by pigs and horses;-and 
there is no doubt but that it would be so much more frequently, if 
it were the instinct of herbivorous animals to show their rage by 
biting. Breschet in the course of numerous experiments on the 
subject, repeatedly infected dogs with the saliva of rabid horses and 
asses. One curious fact demonstrated by these experiments is, that 
when rabbits, or other rodentia, and birds, are inoculated with the 
saliva of rabid animals, they very soon die, but without exhibiting 
any of the ordinary symptoms of hydrophobia.* 
In the horse the disease commences with great distress and ter- 
ror, and profuse sweating; he soon becomes frantic and outrageous, 
stamping, snorting, and kicking.! In the sheep, the symptoms are 
similar. An instance is recorded in which eight sheep were bitten, 
and became rabid; they were exceedingly furious, running and 
butting at every person and thing, but did not bite. They drank 
freely 4 
There are several points connected with the propagation of 
hydrophobia, which are still involved in great uncertainty. It is 
not known whether the saliva is the poisonous agent, or whether 
some poisonous matter may be secreted by the mouth, fauces, or 
lungs, and mixed with it. This, however, is not a point of much 
consequence; but again, it is uncertain whether the whole solids 
and fluids of the animal are not poisonous also. In fact, there is 
some reason for believing that the disease may be communicated 
by the mother's milk.§ Moreover, it appears that it may be com-, 
municated by contact of the dog's saliva with the mucous membrane 
of the mouth, without any wound or abrasion.|| In a case related 
* Breschet sur quelques Recherches experimentales sur la Rage. L'Experi- 
ence, Oct. 8th, 1840. 
f Blaine's Outlines of the Veterinary Art. 2d edit. Lond. 1816. 
+ Lancet, 1829-30, vol. ii. p. 511. 
§ Two ewes were bitten by a mad dog, and died hydrophobic. One had two 
lambs, the other one; all three of which were seized with the disease a week after- 
wards, although they had not been bitten by the dog, nor, as was supposed, by the 
mothers.-Steele, Med. Gaz., Oct. 25th, 1839. 
|| Hutchinson, Lancet, Dec. 8th, 1838. 168 
HYDROPHOBIA. 
by Dr. Watson,* the dog's tooth merely indented the skin of the 
back of the hand, but made no wound. Lastly, a point of more 
importance and uncertainty than any is, whether the bite of an 
animal in health, or of one merely enraged, may not cause the dis- 
ease ;-or at all events, supposing it to be really infected with rabies, 
whether its bite may not be dangerous during the period of incuba- 
tion, and long before the outbreak of any apparent symptoms. 
Symptoms in Man.-These may be divided into three stages. 
First, the stage of incubation, being that which intervenes between 
the infliction of the bite and the first appearance of the disease. 
This period is exceedingly various. It is seldom less than forty 
days;-generally from five weeks to three months. But authors 
are by no means agreed as to its limits. Dr. Bardsley positively 
denies that the malady ever comes on after more than two years 
from the bite; and attributes the cases said to have occurred after that 
time to "anomalous causes," or to inoculation from some unsus- 
pected source. Other authors, on the contrary, seem to think that 
it may occur at any indefinite period-even twelve years after 
inoculation. Dr. Burnet relates the case of a prisoner in the Mil- 
bank Penitentiary, who died of it seven years after he was bitten. 
The unfortunate man had indeed kept two cats in his cell, and it is 
possible that he might have received the infection from one of them. 
They were, however, alive and well at the time of his decease. 
It must be concluded, therefore, either that hydrophobia may come 
on seven years after a bite;-or that it may be communicated by 
animals who are to all intents and purposes healthy. But if a 
surgeon is questioned on the subject by a patient who has been 
bitten, it will be his duty to allay his apprehensions as far as possi- 
ble. He may very safely assure him, that after six months have 
elapsed, the chance of the disease is very slight indeed;-and that 
scarcely more than a twentieth of those bitten by dogs really mad 
are ever affected. 
Second Stage, or Premonitory Symptoms.-The first thing that 
attracts attention is a peculiar pain of the wounded part, together 
with slight heat, redness, and swelling. The pain is observed to 
shoot in the course of the nervous trunks, and has in general a 
rheumatic character. Sometimes, instead of it, there is a stiffness 
or numbness, or partial palsy. In some cases it is unattended with 
redness or swelling;-in others, on the contrary, the wound has 
thoroughly inflamed, and has broken out into suppuration afresh, 
although healed long before. In some instances these premonitory 
symptoms have not appeared at all,-or have been so slight as to 
pass unheeded;-in a few instances they have not appeared till 
after the accession of the genuine hydrophobic symptoms;-but in 
general they are observed from two to five days previous to them. 
Third Stage.-The first of the actual symptoms of hydrophobia 
is a vague feeling of uneasiness and anxiety. The patient finds 
himself generally unwell; his mind is irritable, and his countenance 
* Lectures, Med. Gaz., May 7th, 1841. -J- Med. Gaz., April 14th, 1838. HYDROPHOBIA. 
169 
gloomy;-he experiences a succession of chills and flushes, with 
transient headache; the appetite fails; there is frequently vomiting, 
and sometimes a well-marked accession of fever. Next, the sufferer 
complains of stiffness of the neck and soreness of the throat, with 
severe spasmodic pain at the epigastrium,-the respiration also is 
embarrassed, and frequently interrupted by sighing. But these 
symptoms are in most cases attributed to cold, and their real nature 
is not suspected for a day or two, till, all on a sudden, on attempt- 
ing to drink, the patient is seized with a fit of suffocating spasm, 
and manifests extreme horror at the sight of fluids. 
The most prominent symptoms that henceforth present them- 
selves, are three, viz. difficulty of breathing and swallowing;- 
extreme irritability of the body;-and peculiar disorder of the mind. 
(a.) The difficulty of breathing and swallowing depends on 
spasm of the muscles of the pharynx and larynx. Sometimes the 
patient can swallow neither solids nor liquids; but more frequently 
the disability extends to liquids only; because they require a greater 
exertion of those muscles, and are consequently more liable to 
excite spasm. It is this circumstance that causes the aversion to 
fluids, and the alarm at the sight of them, which so generally charac- 
terize the disease. At first the spasms are excited only by attempts 
to swallow fluids;-then they are brought on by the sight or thought 
of them; or by the motions of spontaneous deglutition;-but as the 
malady advances, they recur in frequent paroxysms,-sometimes 
spontaneously, sometimes excited by the slightest noise or touch. 
When the paroxysms have become fully developed, they cause the 
most frightful struggles for breath. All the muscles are convulsed; 
-the face is black and turgid, and the eyeballs protrude from their 
sockets. They may come on either during inspiration or expira- 
tion, but more frequently the latter;-the patient struggling most 
violently to expel the air that is confined in his chest through the 
closure of the larynx. In this disease, as in tetanus, the fatal ter- 
mination may ensue from suffocation in the middle of a paroxysm, 
although it more frequently happens during an interval, from ex- 
haustion. 
(6.) Next to the spasm, the astonishing irritability of the sur- 
face of the body is the most prominent symptom of hydrophobia. 
The slightest impressions on the senses affect the sufferer most 
intensely. A look, or a sound ;-the opening and shutting of the 
door of his apartment;-the motions of his attendants;-the reflec- 
tion of light from a mirror;-the least impression on the skin; the 
touch of a feather, or impulse of the gentlest current of air,-are 
sufficient to bring on the convulsive fits, and are most earnestly 
deprecated by the patient. 
(c.) The state of mind is in most cases extremely characteristic. 
There appears to be a most profound despair;-an utter incapacity 
for all comfort and consolation;-corresponding with the patient's 
haggard physiognomy and restless movements, and his hurried 
desponding tone of voice. He is also in general unusually talka- 
tive and verbose, as though he attempted to relieve or hide his 170 
HYDROPHOBIA. 
sufferings by ceaseless conversation. But in some cases he is pos- 
sessed with wild maniacal fury, and is obliged to be confined in 
order to prevent injury to himself or others;-whilst, as a con- 
trary exception, it occasionally happens, that if he be originally of 
a strong, resolute mind, he may preserve his composure through- 
out, and be to the last endued with sufficient courage to attempt 
drinking, in spite of the impending horrors of suffocation. 
Progress and Termination.-When the disease is fully estab- 
lished, its torments are aggravated by extreme thirst; and still 
more by a peculiar viscid secretion from the fauces, the irritation of 
which brings on the convulsive fits, and causes a perpetual hawk- 
ing and spitting-which are very constant symptoms. Not unfre- 
quently there is vomiting of greenish matter mixed with blood. 
As the disease advances, the convulsions increase in frequency and 
violence ; there is constant restlessness and tremor;-the lips and 
cheeks become livid, and perpetually quiver; till at length one fit 
lasts long enough to exhaust the remaining strength and release the 
patient from his misery. An entire and remarkable remission (per- 
haps from the use of medicine) sometimes occurs; and the patient 
enjoys perfect ease, or perhaps sleeps for some hours;-but yet the 
symptoms return, after a time, with aggravated violence. Again, 
in some cases there is a perfect calm before dissolution; " the 
patient becomes tranquil, and most of his sufferings subside or 
vanish;-he can eat, nay, drink or converse with facility; and 
former objects associated with the excruciating torture of attempt- 
ing to swallow liquids no longer disturb his feelings. From this 
calm he sinks into repose, and suddenly waking from his sleep 
expires."* 
Morbid Anatomy.-The morbid appearances most frequently 
found are, great congestion of the membranes and substance of the 
brain and spinal cord, with effusion of serum. Sometimes blood is 
extravasated around the cervical portion of the cord. The lining 
membrane of the fauces, oasophagus, trachea, and bronchi, are 
mostly highly vascular; the papillas at the root of the tongue 
large; and the lungs congested. The stomach often contains a 
darkish fluid, and patches of vascularity of a dark purple colour 
are found in it and in the intestines. But although some one or 
more of these morbid appearances are detected in most cases, still 
there is not one of them that is present invariably. The brain, 
spinal cord, and fauces have been found pale, and the stomach 
without spots. Hydrocyanic acid has been detected in the blood 
after death, but this is not peculiar to hydrophobia.! 
Pathology.-It is quite clear, therefore, that no change of struc- 
ture that has yet been discovered, can be considered essential to the 
existence of hydrophobia. It is true that the difficulty of breathing 
and swallowing may be partially accounted for by the inflamma- 
tion about the fauces; and that great irritability of the surface is 
symptomatic of irritation of the spinal cord. But still no mere 
* Bardsley, Cycl. Pract. Med., Art. Hydrophobia, 
f Med. Gaz. 5th September, 1840. HYDROPHOBIA. 
171 
local changes can explain the mass of symptoms, which must 
depend on a peculiar change in the blood, or nervous system, or both. 
Diagnosis.-The disease which we read of under the title of 
spontaneous hydrophobia, or hydrophobia not caused by a dog's 
bite, consists sometimes of hysterical symptoms, sometimes of a 
state like delirium tremens, and sometimes of genuine phrenitis, 
attended with suffocative dyspnoea and great irritability of the skin. 
It usually occurs to hysterical women or to drunkards. Now, as 
we know that hysteria may simulate any disease that can be 
named, nothing can be more likely than that if an hysterical or 
nervous person have been bitten by any dog or cat, healthy or 
otherwise, the fears of the consequences, and knowledge of the 
symptoms of hydrophobia, will suffice to bring on a simulated 
attack. Or again, if a person be affected with any form of deli- 
rium after an accidental bite, what can be more likely than that 
hydrophobia will be the leading subject of his ravings ? 
But a correct diagnosis may generally be formed by attentive 
observation;-by endeavouring to detect the inconsistencies, as it 
were, that are so frequent in hysteria;-the intervals of perfect 
complacency and cheerfulness, if the patient can be engaged in 
conversation, and led to forget his malady;-and by the sudden 
accession and instant urgency of the false hydrophobia, compared 
with the more gradual accession of the real. Yet it must be con- 
fessed that the diagnosis is by no means always easy. There was 
a remarkable case at the Middlesex Hospital in the autumn of 
1837, which at first so exactly resembled hysteria, and afterwards 
the delirium of cerebral irritation, or commencing inflammation, 
that few of the medical attendants could at first persuade them- 
selves that it was real hydrophobia, and even some of those who 
believed so at first, altered their opinions afterwards. But although 
there was not much dysphagia, still the irritability of the skin,- 
the shrinking and convulsions induced by the slightest breath of 
air, and the salivation, enabled Dr. Hawkins to form a correct 
diagnosis.* 
Preventive Treatment.-As soon as possible after the bite of 
a suspected animal, the whole wound should be freely and fairly 
cut out. After this, bleeding should be encouraged by the appli- 
cation of a cupping-glass; or the wound should be long and dili- 
gently washed in warm water. But if the bite have been irregular, 
(so that it is uncertain whether the excision has been complete,) it 
should be cauterized by nitric acid, or, as Sir B. Brodie recom- 
mends, by passing a probe which has been dipped into caustic 
potass, (melted in an iron spoon,) into every nook and corner of the 
wound. 
When we consider that substances introduced fairly into the 
blood may find their way all over the body in an inconceivably 
short space of time, (probably in nine seconds,!) it will be readily 
* Lond. Med. Gaz., Nov. 4,1837. Several instructive cases may be found in the 
Lancet, especially one by Mr. Hodgson, Lancet, 1838-39, p. 582. 
f Blake, Ed. Med. and Surg. Journ., Jan. 1840. 172 
HYDROPHOBIA. 
seen that excision, although performed as soon as possible after the 
bite, may be of no avail. Yet it should never be omitted, let the 
interval be what it may. And one case is recorded in which it is 
said, that the patient was saved, although the parts were not cut 
out till the thirty-first day, and not till the symptoms had actually 
made their appearance. This, however, is doubtful.* 
By some authors caustic is recommended to the exclusion of 
excision; especially the nitrate of silver, by Mr. Youatt. This 
gentleman has certainly a good right to speak in its favour, having 
been bitten four times, and having used no other preventive. But 
other cases are narrated in which the immediate and free applica- 
tion of this substance was totally useless. Whether the wound, 
after the caustic, should be allowed to heal,-or be kept open, and 
made to suppurate by irritating ointments,-is a disputed point. 
The weight of authority certainly favours the latter practice, and 
beyond the inconvenience it can do no harm. 
As for any other preventive treatment, all that can be done is to 
keep the patient in as good a state of health, and in as good spirits, 
as possible. But there is not one of the innumerable so-called 
specifics that is worth a moment's trial. The Tonquin, Ormskirk, 
and Burling nostrums;-guaco, box, belladonna, and broom tops; 
all kinds of acids, alkalis, earths, and vegetables; half drowning 
the patient in the sea; and stewing him in hot air and vapour 
baths,-all these remedies and plans have in turn been reputed 
infallible, and found to be good for nothing. At one time it was 
confidently pretended that certain vesicles appear under the tongue 
during the premonitory symptoms, and that if these were cauterized, 
the patient would be safe. But unluckily they can never be 
found. Mr. Youatt thinks that rue acts occasionally as a preven- 
tive with dogs, but it is very far from infallible. 
Curative Treatment.-Here we are met at the outset with 
the doubt whether hydrophobia can be cured at all; whether, like 
the plague and small-pox, it will not run its course, without the 
possibility of checking it. Mr. Youatt says that he believes he has 
occasionally prevented it in the dog, and that he has occasionally 
seen a case of spontaneous recovery ; but that he has never cured 
it. And with regard to man, although it cannot be denied that a 
few rare cases have recovered;-still as the same remedies that 
were supposed to be successful in these cases, have been used again 
and again in others without benefit, the recoveries must fairly be 
considered accidental and spontaneous. 
Bleeding has been frequently tried to a most enormous extent; 
and one case in the East Indies is said to have been cured by it: 
but it rarely affords even temporary alleviation, and rather tends, 
by exhausting the strength, to accelerate the fatal issue. It may, 
however, be tried as a palliative if the patient is plethoric, and the 
face becomes very turgid during the spasms. 
Warm water.-Magendie and others have proposed, after bleed- 
* Thompson, Med. Chir. Trans., vol. xiii., and Lancet, Sep. 23, 1837. HYDROPHOBIA. 
173 
ing, to inject large quantities of warm water into the veins; and it 
certainly is beneficial, although but for a time. 
Opium in different forms has been given most profusely, and 
certainly with some success;-for whether administered by the 
mouth, or rubbed into the skin, or injected into the veins, it seldom 
fails to mitigate the patient's sufferings, although it never averts his 
death. This was most strikingly exemplified in the case of the 
Milbank prisoner, who died seven years after he was bitten. A 
blister was applied along the spine, and ten grains of the acetate of 
morphia were sprinkled on the denuded cutis. "Scarcely had one 
minute elapsed," says Dr. Burne, "when we observed the stare of 
the eyes and the dreadful alarm and anxiety of the countenance to 
diminish, then the violence of the spasm to abate, and the catch- 
ings in the respiration and the retching to subside ; and to our asto- 
nishment this general amelioration progressed, till in four minutes 
the countenance had become placid, and the respiration free; the 
retching had ceased, and the spasms vanished." This improve- 
ment, however, did not last very long;-the symptoms returned,- 
a repetition of the remedy was powerless,-and the patient died. 
And this is the general history of the effects of opium. 
The whole tribe of sedatives;-belladonna, digitalis, tobacco, 
fyc., have been repeatedly tried, but with similar results. The hot 
air bath and cold affusion,-acids and alkalis, especially ammo- 
nia',-every diuretic, purgative, and sudorific that can be thought 
of, have succeeded no better. In one instance the liquor phimbi 
diacetatis is said to have effected a cure. 
In a case which occurred in the King's College Hospital, the 
suffocative spasms were entirely relieved by letting the patient eat 
large quantities of ice, and applying it externally to the spine and 
throat;* and the last thing that has been tried is the resin of Indian 
hemp; but a brief respite from suffering is the utmost good they 
can produce. 
Mr. Hewitt, surgeon in the Bombay Medical Establishment, has 
related a single case in which the patient was saved by violent sali- 
vation. Several native soldiers and other persons were bitten one 
night by a wild jackall, which when killed was found to be very 
feeble and apparently starved, and its liver rotten and full of 
abscesses. A month afterwards two of the persons that had been 
bitten were found dead in the fields, and, from the description 
which was given of their symptoms, Mr. Hewitt judged that they 
had perished of hydrophobia. Shortly afterwards, three others were 
seized with the disease, and came under his treatment. He induced 
salivation in one of them (a woman) by the most profuse adminis- 
tration of mercury,and she recovered; but with the other two, who 
were men, the same remedy was of no avail. Strangely enough, 
the natives of these parts were entirely ignorant that such a dis- 
ease as hydrophobia existed;-a sufficient refutation of the per- 
* The case is related by Dr. Guy in his edition of Hooper's Physician's Vade 
Mecum, p. 277. 174 
THE GLANDERS. 
verse error of those who maintain that it is entirely an imaginary 
affection brought on by fright.* 
In the present state of our knowledge, the principal object in the 
treatment of this disease is to allay the patient's sufferings. This 
should be done by keeping the patient perfectly quiet and in the 
dark; and by the external and internal administration of opium in 
every form, combined with other sedatives. The strength should 
be kept up with whatever nutriment can be taken. And if the 
surgeon imagines that he can give any other remedy with a chance 
of benefit, and without adding to his patient's sufferings, let him 
do so. 
There remains, however, one grand experiment to be made; 
that is to say, the production of asphyxia by the woorali, (as was 
described in the chapter on Tetanus,) and the gradual restoration 
of the patient to consciousness by means of artificial respiration. 
And there really seems to be some reason for hoping that, by thus 
suspending the functions of the nervous system, the effects of the 
poison may gradually cease before the strength is quite exhausted. 
At all events, to use the words of Celsus, " Si nullum appareat aliud 
auxilium, periturusque sit qui laborat, nisi temeraria quaque via 
fuerit adjutus;-satius est anceps remedium experiri quam nul- 
lum."! 
SECTION II. - OF THE GLANDERS. 
Syn.-Equinia. (Elliotson.) 
Definition.-The glanders is a disease of the horse tribe, com- 
municable to man and other animals. It is chiefly manifested by 
unhealthy suppuration of the mucous membrane of the nasal 
cavities, and pustular eruptions on the skin, and unhealthy abscesses 
in the lymphatic system. 
Symptoms in the Horse.-It may occur in two forms, which, 
however, are merely manifestations of the same disease in different 
parts. When seated in the lymphatic system, it is called farcy - 
when in the nasal cavities, glanders. But these two forms are 
essentially identical; the pus of either of them will reproduce the 
other; and farcy always terminates in glanders, if the animal live 
long enough, and its progress is not arrested. 
Farcy begins with hard, cord-like swellings of the lymphatic 
vessels and glands, called farcy-buds. These slowly suppurate, 
* Account of the effects of the bite of a wild jackall in a rabid state, as the 
same occurred at Kattywar, in the East Indies, in 1822. Med. Chir. Trans., vol. 
xiii. 1825. 
f Formerly it was the custom in decided cases of hj'drophobia to smother the 
patient between feather beds; the author knows that about twenty years ago, two 
respectable surgeons, one of whom is still living, purposely bled a woman to death 
in a village in Lincolnshire; and it appears from the Dublin Medical Press (26th 
Jan. 1841), that a hydrophobic patient in France was put out of his misery by 
poison, only three years ago. It is strange that these practices have not been 
noticed by the legislature. THE GLANDERS. 
175 
and form unhealthy fistulous sores, which discharge a copious thin 
sanious matter. 
If suffered to proceed unchecked, farcy leads to glanders, although 
more frequently the latter arises first. 
Glanders.-Its symptoms are, a continued flow of discharge 
from the nostrils, which discharge is at first thin and serous; then 
thick and glairy, like the white of egg; but after a time becomes 
opaque, purulent,bloody, and horribly offensive, retaining, however, 
its viscidity. Soon after it commences, vesicles form on the Schnei- 
derian membrane, which degenerate into foul and extensive ulcers, 
and lead to caries of the bones. Then the lips and eyelids swell, 
and the conjunctivae suppurate; and the external parts of the face 
may become gangrenous, and the animal may die in a few days 
with putrid fever;-or he may perish more slowly;-the disease 
spreading to the lungs, and death being induced by cough, emacia- 
tion, hectic, and the formation of unhealthy abscesses in the lungs 
and all over the body.* 
Symptoms in Man.-This disease may appear either as glan- 
ders or farcy; either of which may be acute or chronic. 
(1) The acute glanders begins with all the symptoms that indi- 
cate the absorption of a putrid poison. There are general feelings 
of indisposition, lowness of spirits, and wandering pains; followed 
by fever, furred tongue, great thirst, profuse perspirations at night, 
great pain in the head, back, and limbs, and tightness of the chest. 
After some days these symptoms increase ; there are severe rigors 
and delirium, often of a phrenitic character; the perspirations 
become more profuse, and sour and offensive, and are attended 
with diarrhoea of a similar character. Then diffused abscesses 
appear in the form of red swellings about the joints, especially the 
knees and elbows-the patient complains of heat and soreness in 
the throat; the tongue becomes dry and brown, the respiration 
more oppressed, and the fever assumes a decidedly low malignant 
character. Next (perhaps a fortnight from the commencement of 
the illness, sooner or later in different cases) a dusky shining swell- 
ing appears on the face, especially on one side, extends over the 
scalp, and closes the eyes. Then the characteristic features of the 
disease appear;-an offensive, viscid, yellowish discharge, streaked 
with blood, issues from the nostrils; and a crop of large and 
remarkably hard pustules (compared by some to those of the small- 
pox, and said by others to be about the size of a pea) appears on 
the face. In the mean while the swelling and inflammation 
increase;-a portion of the nose or eyelids mortifies;-the dis- 
charge becomes more and more profuse and offensive;-the pus- 
tules spread, and extend over the neck and body; fresh abscesses 
form and suppurate ; the thirst is most excruciating ; and low mut- 
tering delirium and tremors usher in death, much to be wished for. 
(2) The chronic glanders is characterized by a viscid and pecu- 
liarly foetid discharge from one nostril, with pain and swelling of 
* Blaine, op. cit. 176 
THE GLANDERS. 
the nose and eyes;-and emaciation, profuse perspirations, and 
abscesses near the joints, from which the patient slowly sinks. 
(3) In the acute farcy, the patient receives the poison through a 
wound or abrasion, which inflames violently, together with the 
lymphatics leading from it. These symptoms are attended with 
considerable fever, and are generally soon followed by the diffused 
abscesses, pustular eruption, and nasal discharge, that characterize 
acute glanders. 
(4) In the chronic farcy, a wound poisoned by glanderous mat- 
ter degenerates into a foul ulcer; the lymphatic vessels and glands 
swell and suppurate ; abscesses form in different parts of the body; 
and if the disease is not cured, or does not destroy the patient first, 
it terminates in acute glanders.* 
Causes.-In the horse this disease may, without doubt, arise 
spontaneously, when the animal is subjected to the usual influences 
that generate putrid poisons;-namely, insufficient and unwhole- 
some food, and close confinement, and ill ventilation, especially on 
board ship. Mr. Youatt believes that it may arise if the animal is 
kept in a poor state of health, as the climax of constitutional weak- 
ness and derangement. In man, it is generally produced through 
inoculation of the matter into a wound. Whether it can be con- 
tracted by infection through the miasmata arising from it, without 
actual contact of the matter, is not yet quite decided. There are, 
however, some grounds for believing that this disease (like others 
of a similar character) is occasionally propagated by infection in 
the horse; and that the effluvia are capable of communicating 
some form of malignant fever, although not true glanders, to the 
human subject. But the matter from the abscesses or nasal cavi- 
ties of human beings is capable of communicating the disease both 
to men and animals. A man died of glanders in St. Bartholo- 
mew's hospital, in 1840, and the nurse who attended him inocu- 
lated her hand, and died of it also in a very few days; and two 
kittens which were inoculated from the nurse, became affected like- 
wise. Moreover the blood of a glandered horse injected into the 
veins of a healthy one communicated the disease, although no 
abnormal appearance could be detected in it by the microscope.! 
The time at which the disease appears after inoculation varies from 
three days to a month. 
Prognosis.-This, in the acute disease, is highly unfavourable ; 
the chronic, however, is sometimes, although rarely, recovered 
from. 
Morbid Anatomy.-The morbid appearances are the same both 
in man and in the horse. Clusters of white granules, or tubercles, 
or, as Dr. Craigie describes it, of matter like putty or thick pus, are 
found in whatever tissues the disease has invaded; in the Schnei- 
derian membrane, in the antrum and frontal sinuses, and in the 
* Case of Mr. Turner, Travers, Constitutional Irritation, p. 399; Case of Farcy- 
ending in Acute Glanders in seven months, L'Experience, Jan. 1839. 
f Reynault. quoted in Provincial Medical Journal, 18th Feb. 1843, from the 
Report of the French Academy for Feb. 2, 1843. THE VENEREAL DISEASE. 
177 
vicinity of the different abscesses. The nasal cavities mostly con- 
tain a thick brown gelatinous secretion, and are studded with foul 
gangrenous ulcers, from which project fungous clusters of tubercu- 
lar matter. 
Pathology.-The proximate cau se of the acute glanders appears 
to be a contamination of the blood with the poisonous matter. 
This is evident from the early depression of strength and spirits, 
from the profuse and foetid perspirations and purgings, from the 
consecutive or simultaneous appearance of the local suppurations, 
with their peculiarly offensive and characteristic discharge, as well 
as from the black and thin condition of the blood, which has lost 
the faculty of coagulation.-In the chronic forms, the disease, like 
Mr. Blackadder's cases of hospital gangrene, or like primary 
syphilis, appears to be at first local; the constitution is affected 
subsequently. 
Treatment.-The chief points to be attended to in the treat- 
ment of glanders are, to open all abscesses as soon as they form; 
to syringe the nasal cavities with solutions of creosote; and to sup- 
port the strength and abate the thirst with wine and soda water. 
Injections of creosote have cured both the acute and chronic glan- 
ders; but almost any other treatment that can be named has been 
found of no service. Depletion is inadmissible. The effluvia must 
be counteracted by fumigations of chlorine and aromatics. In the 
treatment of farcy likewise, the chief points are to open all abscesses 
early, and support the strength. Any swollen glands should be 
extirpated.* 
CHAPTER XL 
OF THE VENEREAL DISEASE. 
SECT. I.-OF ITS GENERAL HISTORY AND PATHOLOGY. 
Definition.-The venereal disease, using the term in its widest 
acceptation, consists in the effects of certain morbid poisons, gene- 
rated and usually communicated by promiscuous sexual intercourse. 
* Vide Elliotson's papers in the Med. Chir. Trans, vols. xiii., xviii., {with a 
coloured plate') and xix.; the Med. Gaz., vol. xix. p. 939 ; case communicated from 
father to son, Lancet for 1831-32, vol. i. p. 698; Rayer, de la morve et du farcin 
chez 1'homme; Mem. de 1'Acad. de Med. 1837; the cases of the patient and nurse 
in St. Bartholomew's Hospital above quoted, in the Lond. Med. Gaz., April 18th 
and 25th, 1840 ; case of acute glanders cured by injections of creosote by Mr. Ions, 
Lancet, April 30th, 1839; case of acute farcy cured by iodide of potassium with 
iodine, Arch. Gen. de Med., Jan. 1843 ; and an excellent chapter on glanders, 
embodying almost all that is known of the disease, with an interesting historical 
sketch of the progress of knowledge on the subject, in Dr. Burgess' Translation of 
Cazenave on Diseases of the Skin, Lond. 1842. See also a case of acute farcy by 
Dr. Craigie, Ed. Med. and Surg. Jour., Jan. 1843. 178 
THE VENEREAL DISEASE. 
It includes two distinct diseases, gonorrhoea and syphilis, which 
differ very widely in their nature and effects. 
Both diseases present two classes of symptoms; the primary 
and the secondary;-the primary being the effects of the morbid 
poison on the parts to which it is actually applied; the secondary 
being the subsequent results of some general disorder of the consti- 
tution. 
Gonorrhoja is an inflammation of the mucous membrane of the 
genitals, which is occasionally, though not very often, succeeded by 
various rheumatic affections, as secondary symptoms. 
Syphilis consists, first, of ulceration of the parts to which the 
morbid poison is applied, and inflammation of the neighbouring 
lymphatics, which are the primary symptoms; and, secondly, of 
sundry eruptions of the skin, ulcerations of the throat, inflamma- 
tions of the eye, and inflammation and caries of the bonesand 
joints, which are the secondary symptoms. 
The primary symptoms of syphilis are undoubtedly contagious, 
and communicable by inoculation with the matter from the ulcers. 
The secondary symptoms, which depend on a general contamina- 
tion of the constitution, are not communicable by inoculation, but 
are capable of transmission from a mother to the fetus in utero; 
and it is probable that they may also be communicated from the 
husband to his wife; from a nurse to a suckling infant, and from an 
infant to its nurse. 
There is, moreover, a third class of symptoms, which may be 
called tertiary; consisting of various eruptions, rheumatic pains, 
falling off of the hair, deafness, and all kinds of anomalous cachec- 
tic complaints, which are the sequelae of syphilis when it operates 
on an originally bad constitution, or is aggravated by ill-treatment. 
This vitiated state of constitution is doubtless a frequent source of 
stunted, sickly, and scrofulous children. 
We must next lay before the reader as brief an account as pos- 
sible of the various disputed opinions with regard to the history 
and origin of this disease. 
The following are the principal questions in dispute :-namely, 
First, Was the venereal disease known to the ancients? Secondly, 
Was it imported from America ? Thirdly, Are there more syphi- 
litic poisons than one ? Fourthly, Are the poisons which produce 
gonorrhoea and syphilis identical ? Fifthly, What is the origin of 
syphilis? And, lastly, what are the specific virtues of mercury? 
-These questions we will discuss seriatim. 
I. Was the Venereal Disease known to the Ancients?- 
(a) Arguments in favour of its antiquity.-Those who believe 
that it was known to the ancients argue thus: They affirm that 
writers on medicine from the earliest ages make mention of sundry 
ulcerous diseases of the genitals and the fauces, some of which were 
most probably venereal. That, in particular, some of the ulcers of 
the genitals mentioned by Celsus correspond exactly with certain 
ordinary venereal sores of the present time.* That Rhazes, an 
* De MedicinA, lib. vi. cap. 18. HISTORY AND PATHOLOGY. 
179 
Arabian writer, mentions an ulcer of the penis produced by the 
" accensionem mulieris supra virum." That sundry foreign 
authors who flourished between 1270 and 1470, mention ulcers and 
pustules of the penis as contracted by lying with foul women; 
or with women who have ulcers,-or who have lately had connec- 
tion with one whose penis was ulcerated. But the strongest argu- 
ments of all are contained in two papers presented by Mr. Beckett 
to the Royal Society in 1717 and 1718, in which he contends for 
the antiquity of the disease in England. He proves that gonor- 
rhoea was well known in 1162 under the terms brenning or burn- 
ing;-and that certain enactments were extant, which provided 
that any steivholder keeping a woman with the perilous infirmity 
of burning should forfeit the sum of one hundred shillings. Fur- 
ther, he says, that John Arden, surgeon to Richard II. (1380), de- 
fines the brenning to be an inward heat and excoriation of the 
urethra; and that, besides, he mentions certain " contumacious 
ulcers, which we now term chancres." And, moreover, that a MS. 
in Lincoln College, Oxford, written by Thomas Gascoigne, Chan- 
cellor of that University, and dated 1430, states that some men 
(and amongst them John of Gaunt) had died of diseases caught by 
frequenting women. Another potent line of reasoning is founded 
on the circumstance, that many ancient authors state the leprosy of 
their times as being contagious;-and that ulcers of the penis and 
heat of urine were contracted by men who lay with leprous 
women. But it is reasonable to infer, that what they called lep- 
rosy was in reality venereal disease. Because, in the first place, (as 
Bateman says,) " there is little doubt that every species of cachectic 
disease accompanied with ulceration, gangrene, or any superficial 
derangement, was formerly termed leprous;"*-and because, in 
the second place, there is no ground for believing that elephantiasis 
(the real tubercular leprosy) is contagious at all;-and because that 
disease is never communicated by contact in modern times, whe- 
ther in carnal conversation or otherwise;-a fact which has been 
ascertained by ample experience, especially at Madeira.! Mr. 
Beckett further mentions the occurrence of nodes on the bones at 
those early periods; and shows that some of the so-called leprous 
diseases were cured by mercury, whilst real leprosy is not. There- 
fore, those who believe in the antiquity of the venereal disease con- 
tend, that discharges from the urethra and syphilitic ulcers on the 
genitals were known in the earlier ages; and that they were known 
to proceed from fornication; although the secondary symptoms 
which followed the latter, were for the most part not known to be 
venereal, but were confounded with the leprosy. 
(6) .Arguments against its antiquity.-On the other hand, the 
opponents of its antiquity contend, that although ulcers or pustules 
on the genital organs and sundry discharges were not unknown;- 
still that neither in Celsus, nor in any other ancient writer, do we 
* Bateman on Cutaneous Diseases, 5th ed. pp. 304 et. seq, 
f Mr. Bacot and others who oppose the antiquity of the venereal disease, assert 
that leprosy is " undoubtedly contagious." 180 
THE VENEREAL DISEASE. 
find mention that such maladies were solely, or even frequently, the 
produce of sexual commerce;-or that they were peculiarly difli- 
cult to heal;-ox that they were frequently, or indeed ever, fol- 
lowed by constitutional diseases. But the most potent argument 
of all is this;-namely, that all at once, towards the close of the 
fifteenth century, whilst the French army was besieging Naples, a 
new and terrible disease sprang up; rebellious to every known 
method of treatment;-attacking high and low, rich and poor;- 
sparing neither age nor sex; consisting of ulcers on the parts of gene- 
ration in both sexes;-which were speedily followed by affections 
of the throat and nose ;-by corroding ulcers over the whole body; 
by excruciating nocturnal pains, and frequently by death. Whereas, 
" not one word that can be construed into any similar affection, is 
to be met with distinctly stated in any writer before that period." 
They, therefore, who are in favour of its antiquity, must hold 
one of these three opinions concerning that virulent disease of the 
fifteenth century:-viz. 1st, That it was a new kind of venereal 
disease ;-or, 2dly, That it was merely an aggravated variety of 
the old disease;-or, 3dly, that it was not the venereal disease at 
all; but some malady (such as sivvens, yaws, radesyge, &c.) re- 
sembling it. 
The most probable supposition is, that syphilis existed from very 
early ages, and that its increased virulence in the fifteenth century 
is to be attributed to war, famine, and the intercourse of foreigners; 
-circumstances which in all times have produced an aggravated 
type of syphilis; whilst its virulence is invariably diminished under 
the influence of peace and cleanliness. But the consideration of 
the history of this new malady brings us to our second question. 
II. Was it imported from America?-The greatest weight of 
evidence is certainly opposed to this supposition. Because no such 
disease is mentioned by the very earliest historians of the discovery 
of that continent;-neither is it mentioned by the earliest writers 
on America; and Peter Martyr, who was physician to Ferdinand 
and Isabella, and who was actually at Barcelona when Columbus 
returned from his first voyage in 1493, does not say a word as to 
its American origin. But besides-of the earliest authors on the 
venereal disease, some attribute it to the divine vengeance, some to 
an earthquake, some to a malignity of the air caused by an over- 
flow of the Tiber; not a few to a celestial influx, or malignant 
conjunction of Saturn and Mars in the sign Scorpio, or some 
other astrological nonsense;-almost all refer its outbreak to the 
siege of Naples-but not one for the first thirty or forty years 
derives it from the West Indies. 
They who conceive that the new disease was not syphilis, found 
their opinion on the fact, that the descriptions given by many of the 
oldest writers correspond pretty closely with the yaws, or fram- 
boesia or sivvens, (a disease frequent enough in America,) and that 
like yaws it often was communicated to the very young or old, and 
to persons who did not catch it by carnal conversation. 
III. Are there more syphilitic poisons than one?-Car- HISTORY AND PATHOLOGY. 
181 
michael and others assert, that there are various kinds of syphilitic 
poisons, each kind causing a peculiar primary ulcer, and a peculiar 
train of secondary symptoms. They say, in proof of their opinions, 
that every other morbid poison is uniform and regular in its 
effects;-and that it would be " an unreasonable and unwarranted 
exception to an universal law of nature," if the venereal were not 
so also. But venereal diseases are multiform and irregular; con- 
sequently they must be caused by more poisons than one. For 
what other single poison can produce papular, pustular, scaly, and 
other kinds of eruptions ? 
But these arguments are subverted by the fact, that a prostitute 
with one ulcer, may cause various kinds of primary ulcers in the 
men who have intercourse with her;-that the same kind of primary 
sore will give rise to different eruptions in different persons, and in 
the same person at different times;-that the differences of primary 
sores depend on differences of situation, constitution, treatment, and 
the circumstances of the times, as was observed in the last page:- 
and that if arguments in favour of multiplicity of poisons be drawn 
from the mere appearance of ulcers or eruptions, there may be forty 
or fifty instead of four or five venereal poisons.* 
IV. Are the poisons of gonorrhea and syphilis identical? 
-Hunter believed that they were identical, for he produced a 
chancre by inoculation with gonorrhoeal matter, which was followed 
in three months by sore throat and eruptions. But the recent re- 
searches of Ricord show, that although the pus of a syphilitic ulcer, 
like any other morbid secretion, may irritate a mucous membrane 
and produce gonorrhoea, still that gonorrhoeal matter will not pro- 
duce syphilitic ulcers, and that gonorrhoea will not be followed by 
secondary syphilitic symptoms, unless there is also a chancre or 
syphilitic sore in the urethra; which was probably the case with 
the patient from whom Hunter took the gonorrhoeal matter. 
V. What is the origin of syphilis?-On this point nothing is 
known with certainty. M. Ricord throws out the conjecture, that 
a source foreign to the human race, may have furnished the first 
germ of syphilis, which once engrafted, has been propagated by 
inoculation like the vaccine virus; and he believes that it never 
arises spontaneously. Another opinion is, that it may occasionally 
be produced de novo, if a mixture of various foul and diseased male 
and female secretions act upon a breach of surface in an unhealthy 
constitution. At least, the following facts furnish a kind of ap- 
proximation to a proof of this.-Seventeen galley-slaves were 
inoculated with gonorrhoeal matter. Slight ulcers were produced, 
which in five of the cases healed readily enough. But the remaining 
twelve patients were either scrofulous or scorbutic, or in an ill state 
of health, and seven of these suffered from eruptions and wandering 
pains.t There is certainly nothing absurd in the supposition, that 
* Carmichael enumerates five; Judd nine; which, however, he does not believe 
to be all that exist. 
j- P. H. Hernandez, quoted by Ricord. Mr. Kingdon, at the Lond. Med. Soc. 
related a case of venereal affection generated by a healthy man and his wife. 
Lancet, May 3d, 1838. See also Travers on the Venereal. 182 
GONORRHCEA. 
the same causes which' produce it at first may occasionally concur 
to produce it again; and it is far more probable that a disease so 
widely diffused, arises from some cause within the ordinary range 
of events, than that it arose from one source only, at some one 
particular time and place, and that source extrinsic to the human 
species. Of the causes of gonorrhoea we shall speak in the next 
section. 
Lastly, is Mercury a Specific?-Hunter not only considered 
that no really syphilitic disease could get well without it, but gravely 
upbraids human nature for doubting it. " Nothing," says he, " can 
show more the ungrateful and unsettled mind of man than his treat- 
ment of this medicine. If there is such a thing as a specific, mercury 
is one for the venereal disease." The following results, however, 
of experiments made by the army surgeons, and especially by Rose, 
Guthrie, and Hennen, will enable the reader to form a juster estimate 
of its capabilities. It is concluded, (1) That all kinds of primary 
and secondary symptoms may get well without mercury. (2) That 
out of 1,940 cases treated without it, ninety-six had secondary 
symptoms; and out of 2,827 treated with it, fifty-one had secondary 
symptoms. The average result of different experimenters, however, 
shows that there are at least seven, times as many cases of secondary 
symptoms, when no mercury has been given, as when it has. (3) 
That the secondary symptoms of cases treated without it are in 
general less severe, and that affections of the bones in particular are 
much less frequent. (4) That the average period of cure is much 
the same in both cases; but that relapses are more frequent when 
no mercury has been given.* 
SECTION II. OF G0N0RRHCEA. 
Sin.-Gonorrhoea virulenta ,■ Blenorrhagia ; Urethritis. 
Definition.-A gonorrhoea signifies a discharge from the mucous 
membrane of the male or female genitals; generally produced by 
contagion from a similar discharge during sexual connection. 
Symptoms.-These may be conveniently divided into three stages. 
In the first stage, the patient merely notices a little itching at the 
orifice of the urethra, with a slight serous, or thin whitish discharge. 
If the disease is not checked at once, it passes after a few days into 
the second, or acutely inflammatory stage. The discharge becomes 
thick and purulent, and when the disease is at its height is greenish, 
or tinged with blood. The penis swells; the glans becomes of a 
* Vide Aphrod'isiacus, by Daniel Turner, M. D., London, 1736; (a collection of the 
opinions of the early authors;) Hunter on the Venereal; Hennen's Military Surgery; 
Carmichael on Syphilis; Bacot's Treatise on Syphilis; Titley on Diseases of the 
Genitals of the Male; Wallace on the Venereal, {Plates') ; Judd's Treatise on 
Urethritis and Syphilis, {Plates')', H. J, Johnson, in Med. Chir. Review; Colles on 
the Venereal; Ricord, Traite des Maladies Veneriennes, Paris, 1839; Mayo on 
Syphilis. Lond. 1840; Mr. Lane's Lectures in the Lancet, 1841 and 1842; and Mr. 
Acton's Treatise on Venereal Diseases, with an Atlas of Plates, Lond. 1841. GONORRHCEA. 
183 
peculiar cherry colour, is intensely tender, and often excoriated. In 
consequence of the tumefied state of the urethra, the stream of urine 
is small and forked, and passed with much straining and severe 
pain and scalding. All the parts in the vicinity of the genitals, the 
groin, thighs, perinaeum, and testicles ache and feel tender; the 
patient's nightly rest is disturbed by long-continued and painful 
erections, and by chordee, that is, a highly painful and crooked state 
of the penis during erection. Hunter says that there are two kinds 
of it-inflammatory and spasmodic. The inflammatory arises 
from a deposit of lymph in the corpus spongiosum urethrse which 
glues together the cells, and prevents their distension ; so that when 
the penis is turgid with blood, it is bent at one part, and horribly 
painful. "The spasmodic chordee," says Hunter, "comes and 
goes, but at no stated times; at one time there will be an erection 
entirely free from it, at another it will be severely felt; and this will 
often happen at short intervals." 
Besides the above symptoms, the following complications may 
occur in various cases:- 
1. There may be severe irritation, or actual inflammation of 
the urinary organs;-sometimes of the deeper portions of the 
urethra, producing great pain in the perinaeum, and spasm of the 
accelerators and other muscles during micturition, so as to interrupt 
the stream of urine, and cause the most exquisite agony, or even 
sometimes complete retention;-sometimes of the bladder, causing 
a very frequent desire to make water, and great pain in doing so, 
which lasts for some time afterwards, together with a white mucous 
cloud in the urine;-or there may be pain in the loins, scanty urine, 
tenderness of the abdomen, vomiting, and other signs of severe 
irritation of the kidneys. 
2. Hemorrhage from the urethra;-from rupture of the dis- 
tended capillaries during violent erection. The loss of blood gene- 
rally gives relief. 
3. Inflammation and obstruction of the mucous follicles of the 
urethra, which may suppurate and burst either in the urethra, or 
externally; or both. 
4. Inflammation of the lymphatic glands of the groin; con- 
stituting sympathetic bubo. 
5. Gonorrhoea spuria, vel externa, or balanitis-inflammation 
and suppuration of the mucous investment of the glans and pre- 
puce, and of the sebaceous follicles around the corona glandis. 
This affection will be treated of in the section on the Diagnosis of 
Chancre. 
6. Phymosis, or paraphymosis, may easily arise, owing to the 
swelled condition of the glans and prepuce. When the latter is 
oedematous, it presents a curious semi-transparent appearance called 
crystalline. 
7. Inflammation of either testicle. 
8. Gonorrhoeal rheumatism;-pain, swelling, and tenderness of 
the joints, especially of the knees and ankles, and fever; this gene- 
rally occurs towards the decline of the complaint, and attacks young 184 
GONORRHOEA. 
people of a delicate strumous habit. The same persons are also 
liable to rheumatic ophthalmia, or inflammation of the fibrous 
structures of the eye; but this, which is a sympathetic affection, 
must not be confounded with the gonorrhoeal inflammation of the 
conjunctiva, which is caused by the contact of the discharge. 
Bacot says, that the rheumatism is sometimes suddenly relieved 
by the appearance of patches of minute papulae or pustules. 
In the third stage, the inflammatory symptoms and chordee 
abate, and a mucous purulent discharge is left, which, when obsti- 
nate and thin, is called a gleet. 
Varieties.-Gonorrhoea varies extremely in its severity. It is 
always most severe in first cases, and in patients who are very 
young, or who possess irritable or scrofulous constitutions. In 
such cases it may be attended with extreme fever and constitu- 
tional disturbance, and may even prove dangerous to life by lead- 
ing to extensive abscesses in the neighbourhood of the bladder.* 
But, after repeated attacks, the urethra becomes as it were inured 
to the disease, and each subsequent infection is generally (although 
not always) attended with fewer of the symptoms of acute inflam- 
mation. In some rare instances, the constitutional affection is 
extremely anomalous, and characterized by severe and continuous 
rigors. 
Gonorrhoea sicca.-There is one form of gonorrhosa which is 
occasionally met with in the male, and Mr. Acton has often met 
with it in the female, in which the mucous membrane is red, swol- 
len, and tender, but free from discharge. In the male, there are 
severe scalding and pain in making water, and the lips of the 
urethra are red and swelled. This form of disease has the popular 
name of the dry clap. 
Morbid Appearances.-On dissecting a urethra affected with 
recent gonorrhoea, the mucous membrane is found red and swollen, 
and the follicles or lacunae enlarged and filled with pus, especially 
the large lacuna in the fossa navicularis, near the orifice. 
Consequences.-1. Repeated gonorrhoea may lead to stricture 
of the urethra; 2, to irritability of the bladder; 3, to a hard, dense, 
semi-cartilaginous state of the corpus spongiosum urethrae. 
Causes.-We have shown gonorrhoea to be an inflammation and 
purulent discharge from the urethra, and have said that it is gene- 
rally produced by contagion from a similar disease. But inflam- 
mation and purulent discharge from the urethra may be produced 
by many other causes, some of which have no connection with 
sexual matters. Thus- 
(«.) In the first place, discharges resembling gonorrhoea may be 
caused by local irritation. The author some time ago treated a 
most obstinate case of this description, brought on by galloping 
several miles on a horse without a saddle. The patient was a 
married gentleman, with a constitutional tendency to irritation of 
the mucous membranes; during the treatment he suffered from a 
* For cases, vide Judd, op. cit. p. 70. severe attack of rheumatism. Immoderate and protracted sexual 
indulgence; the introduction of bougies; blows on the perinceum; 
-violent bending of the penis in erection; and long travel in a 
jolting vehicle over bad roads, are well-authenticated causes of 
similar cases.* (6.) Urethritis with discharge may be produced by 
various disorders of the constitution. It has been a symptom of 
rheumatism; and not unfrequently it precedes a paroxysm of 
gout. It may be caused by sympathy with irritation of other 
parts. Thus it may be occasioned by piles;-and it has been 
known to accompany the cutting of a tooth several times in the 
same patient, (c.) A discharge is liable to occur in patients affected 
with stricture;-and to recur in those who have been long habitu- 
ated to it, upon any neglect of their health, exposure to severe 
cold, or inordinate fatigue, or excess in food, wine, or venery. 
fl.} Lastly, discharges are sometimes (although rarely) occasioned 
by the rise of particular medicines. Guaiacum and cayenne 
pepper have been named as some. 
Again, a man may contract a pretty severe discharge from a 
woman who is perfectly chaste, and has not been previously infected 
by a third party. Thus-fl.} The menstrual fluid is capable of 
causing urethritis with violent scalding and chordee, and followed 
by swelled testicle;-and a considerable degree of irritation may 
be produced by the vaginal secretions, just previous to menstrua- 
tion.! (6.) Similar consequences sometimes ensue if the female be 
affected with leucorrhoea, or with any other discharge of any sort 
whatever. 
Diagnosis.-The question next follows, whether there is any 
means of distinguishing the simple gonorrhoea, that is, a discharge 
which does not arise from sexual connection, or which a man con- 
tracts from some accidental malady in a clean chaste woman, from 
the venereal gonorrhoea, or clap, caught from an infected prosti- 
tute. The answer is, decidedly not. The disease of the urethra, 
however produced, is the same in its nature, the same in its symp- 
toms, and requires the same treatment. 
The grand diagnostic sign laid down by writers,! whereby to 
distinguish simple gonorrhoea from venereal gonorrhoea, is the 
comparative mildness of the former, and the absence of acute 
inflammation. And this is almost invariably true. But yet, the 
author can testify that in some of the non-venereal cases, the pain, 
scalding, and other inflammatory symptoms may be of great 
severity, and of long continuance, and that they may be followed 
by rheumatism, which is so frequent a consequence of genuine 
venereal gonorrhoea. If the patient, however, strongly deny that 
his malady can arise from impure connection, and if his character 
place his statement above suspicion ;-if the existence of some one 
of the foregoing causes can be ascertained, and especially if it be 
known that he has suffered from it before in like manner ; it will 
be right to pronounce the case not venereal; and more especially 
GONORRHCEA. 
185 
* Vide Judd, op. cit. p. 32. f Judd, p. 24. | Titley, op. cit.p. 186. 186 
GONORRHCEA. 
if the patient be married, or be in circumstances which would 
render any imputation on his continence either disgraceful or ruin- 
ous. Again, if, as Mr. Bacot observes, " a discharge come on only 
a few hours after connection; and if it have continued several days 
without inflammatory symptoms; if the patient has been liable to 
some discharge after any excess of venery or of wine ;-in all such 
cases the probability is, that the patient labours under some other 
diseased condition of the urethra, and that although the intercourse 
of the sexes may have been the exciting cause, still there may be 
no imputation on the cleanliness of the female.* 
But it is most important to observe, that although discharges 
may arise from many causes besides connection, and although some 
discharges may arise from connection with chaste women, yet that 
every one of them is capable of exciting a similar discharge in a 
healthy person. 
These observations will go far towards solving another question 
that is frequently asked, viz. What is the danger of conveying infec- 
tion when the discharge is very small in quantity, or when it is 
merely gleety and mucous ? 
The surgeon should inform the patient, that the more virulent 
the disease, the greater is the danger of communicating it; but that, 
however slight the discharge, there still will be some risk. If, how- 
ever, the patient be determined to run that risk, he should cleanse 
the urethra first by making water and syringing it thoroughly with 
a mild astringent lotion. It is a well-established fact, that the con- 
tact of matter is indispensable to the propagation of the disease; 
consequently, by removing the matter, the hazard will be dimi- 
nished. A person may have received the infection, but cannot 
communicate it previous to the appearance of discharge. 
The time at which the disease usually appears after contagion is 
the fourth or fifth day. The later it appears, the less severe it 
generally is; but in some very simple cases, produced by simple 
irritation, the discharge comes on immediately after connection. 
Gonorrhcea in the Female.-This, unless the patient is very 
young and delicate, is a much more simple disease than it is in the 
male ; since the parts affected are less complex in formation, and 
less important in function. 
The symptoms are much the same. Heat and pain in making 
water; tenderness and soreness, especially in walking, uneasiness 
in sitting, and muco-purulent discharge. On examination, the parts 
are found swelled and red, and if the case is severe, there may be 
excoriations or aphthous ulcerations. Sympathetic enlargement of 
the inguinal glands, and abscesses in the mucous follicles, are occa- 
sional complications. 
Diagnosis.-Acute inflammation of the mucous membrane of 
the labia, nymphee, and vagina, is not unfrequent in young girls, 
as a consequence of teething ; or of costiveness, worms, and other 
disorders of the alimentary canal; and it has precisely the same 
* Bacot, op. cit. p. 101. GONORRHCEA. 
187 
symptoms as gonorrhoea. It of course often excites great uneasi- 
ness, and painful suspicions in the minds of parents; but the sur- 
geon may very easily remove their alarm by telling them that it is 
a common idiopathic disorder of children, and not a consequence of 
any improper treatment. 
Leucorrhoea, or fluor albus, may in general be distinguished 
from gonorrhoea by the absence of heat or pain in micturition; and 
by the pain in the back, pallid countenance, irregular menstruation, 
and signs of exhaustion and debility which generally accompany it. 
Yet a profuse gonorrhoeal discharge will cause the same appear- 
ances. 
As we have recently insisted, all discharges, however produced, 
may be contagious. Whether, however, a woman has a discharge, 
or has communicated one, the surgeon must observe some caution 
before he casts any reflection on her continence. And after all, 
both in the male and female, whatever the cause, the treatment is 
the same. 
Prophylactic Treatment.-Immediately after a suspicious 
connection, it will be prudent to make water so as to cleanse the 
urethra, and then perform a thorough ablution with soap and water. 
If the patient is subject to gonorrhoea, it will be worth while to 
wash out the front part of the urethra with a syringeful of some 
astringent lotion; and, if any fissures or excoriations are perceived, 
they should be washed with a strong solution of alum. 
Curative Treatment.-The remedies for gonorrhoea are three- 
fold; first, antiphlogistic measures, to get rid of inflammation; 
secondly, certain diuretics which have a peculiar sanatory influence 
on inflamed mucous membranes; and thirdly, injections to wash 
away the discharge, and alter the action of the inflamed surface. 
These different remedies are to be combined in various degrees in 
different cases, and at different periods of the disease. 
Of the first stage.-If the patient applies during the first stage, 
when the discharge is just appearing, and before acute symptoms 
have come on, the disease may almost infallibly be cut short, by 
employing the plan recommended by Ricord. Let him inject the 
urethra regularly once in four hours, with a solution of two grains 
of nitrate of silver to eight ounces of distilled water; let this be 
repeated twelve times: desisting, however, sooner, if the discharge 
is rendered thin and bloody, which is the ordinary effect of the 
nitrate. Then let a weak injection of sulphate of zinc, or alum, be 
substituted, and be continued till the discharge ceases. At the 
same time the patient should take a mild aperient; and after it, a 
dose of copaiba or cubebs, three times daily; he should avoid exer- 
cise, fermented liquors, salt, spice, coffee, and stimulants of every 
kind; he should take no supper; and should continue his abste- 
mious regimen for a week or ten days after all trace of the discharge 
has disappeared. 
The manner of injecting is of no small consequence, as its effi- 
cacy depends entirely on the application of the lotion to the whole 
of the diseased surface; and, as Dr. Graves observes, the ordinary 188 
GONORRHOEA. 
opinion that gonorrhoea is limited to the anterior extremity of the 
urethra, is unfounded and mischievous. The patient should be 
provided with one of the glass syringes with a long, bulbous ex- 
tremity, recommended by Mr. Acton ;* and having filled it, should 
introduce it for about an inch with his right hand. Then, having 
encircled the glans penis with his left forefinger and thumb, so as 
to compress the urethra against the syringe, and prevent any of the 
fluid from escaping, he should push down the piston with his right 
forefinger, letting the fluid pass freely into the urethra; the syringe 
should now be withdrawn, but the orifice should still be compressed, 
and the fluid be retained for two or three minutes; after which, on 
removing the finger and thumb, it will be thrown out by the elas- 
ticity of the urethra. 
Of the second stage.-Supposing it to be a first attack in a young 
irritable subject, and that it has proceeded unchecked to the acute 
stage, the patient should be confined to the house for two or three 
days, if his avocations permit it. Ten or a dozen leeches should be 
applied to the perinaeum; but not at bedtime, unless the surgeon 
wishes to be called up in the night to stop the bleeding. The penis 
and scrotum should be supported by a suspensory bandage, and be 
kept constantly wet with a cold or tepid lotion. The glans penis 
should be protected from irritation by a piece of lint spread with 
spermaceti ointment. The diet should be moderate, to the entire 
exclusion of fermented liquors, and the patient should drink barley 
water, linseed tea, gum water, and other mucilaginous fluids. But 
it is far from advantageous to increase the quantity of urine too 
much, or cause the patient to make water often; because the act of 
micturition is accompanied with very great suffering. The scalding 
will be relieved by combinations of alkalis and sedatives (F. 19,83); 
and by fomentation with tepid water, or a tepid bath; but the bath 
should not be hot, nor even warm, otherwise it will excite the circu- 
lation and bring on erections. The bowels should be opened with 
a dose of calomel at night, and some castor oil in the morning; and 
it is advisable to give half a grain or a grain of calomel, with gr. 
one-eighth of tartar emetic, and gr. x. of Dover's powder; or F. 7, 
every night whilst there is much pain and chordee. The mercury 
is not necessary as a specific, but it is highly useful to check the 
inflammatory symptoms. As soon as the patient is free from fever, 
he should take copaiba or cubebs, F. 84, 85, in moderate doses. 
The best preparation is the capsule, which should be taken just 
before a meal, and then it causes no eructations; but the pills with 
magnesia, F. 113, or the emulsion, F. 20, agree very well with 
some stomachs. Young irritable people, with light complexions, 
can seldom take these medicines without suffering from sickness or 
diarrhoea, or sometimes even from fever and a rash; and every 
combination of aromatic and opiate that can be devised will not 
enable the stomach to tolerate them. 
* Described in the Med. Gaz., vol. xxix. p. 428. The plan of treatment recom- 
mended by Dr. Graves (Clinical Medicine, p. 304) is highly judicious, and almost 
precisely similar to that of Ricord and Acton. GONORRHCEA. 
189 
If the patient is very plethoric, and suffers greatly from pain and 
fever, and has a hard pulse and white tongue; and if there be ten- 
derness in the abdomen, pain in the back, or other signs of irritation 
of the urinary organs; it may be right to take blood from the arm, 
and to administer calomel, opium, and antimony, pretty freely. 
During the acute stage, the prudence of using injections will 
depend in some measure on the constitution of the patient; for it is 
decidedly not safe to use them with young, delicate, irritable sub- 
jects, and most especially whilst there is any tenderness of the 
glands of the groin, or any aching in the spermatic cord or testicles, 
as they might easily produce swelled testicle, or great irritation of 
the neck of the bladder. And it will depend, in the next place, on 
the degree of medical control which the patient can submit to. For 
injections may be used much more early and freely with a hospital 
patient who keeps his bed, or with a person who is able to stay 
at home and apply leeches, than with a young gentleman who 
lives with his family, is obliged to conceal his malady, and to par- 
take of his ordinary avocations, and appear at the dinner-table. 
So that, as a general rule, it is best to refrain from them altogether, 
till the inflammatory symptoms are mitigated by the antiphlogistic 
remedies before mentioned. 
Treatment of Complications.-Painful erections and chordee 
may be relieved by bathing the parts with tepid or cold water, and 
the diaphoretic powder, or a small dose of camphor and extract 
of henbane, at bedtime; and if the chordee lasts long, a little mer- 
curial ointment and extract of belladonna should be smeared on 
the part at bedtime. According to Hunter, the spasmodic chordee 
is benefited by bark. Haemorrhage may be checked by cold, and 
pressure on the urethra.* Inflammation of the mucous glands of 
the uretha is to be treated by leeches and poultices. An opening 
must be made if the swelling obstructs the flow of urine, but not 
otherwise. Swelling of the glands in the groin may generally be 
removed by rest and, if necessary, a few leeches. 
Of the third stage.-As soon as the acute stage has subsided, 
the patient should use the injections of nitrate of silver, followed 
by zinc, in the same manner as was recommended for the first 
stage. If the discharge does not cease entirely, or if it comes back 
again, other injections, F. 21, 22, 23, 36, 37, may be tried; adapt- 
ing their strength to the irritability of the part, and not permitting 
them to cause severe pain. 
But a gleet is often a very tedious complaint, and requires a judi- 
cious and long-continued course of remedies that act on the urinary 
organs, together with most temperate habits of living. Copaiba, 
either alone or combined with astringents;-F. 86, 87; oil of tur- 
pentine ; F. 90; and cantharides, especially in combination with 
zinc, (F. 88,) or steel, F. 89, are most useful remedies. Mr. Acton 
has seen great benefit derived from injections of one grain prot- 
ioduret of iron and an ounce of water gradually increased. The 
* Vide Part iv. chap. xx. sect. 2. 190 
GONORRHOEA. 
bowels should be kept properly open, but saline purgatives should 
be avoided. If the patient wants to make water oftener than 
natural, and there is an uneasy sensation in the urethra afterwards, 
and the urine deposits a mucous cloud, buchu and uva ursi (F. 91) 
will be advisable. The occasional passing of a bougie, large enough 
to fill the urethra without stretching it, will also be of material ser- 
vice. It is also highly useful in these cases to inject the urethra 
with cold water from an elastic bottle, twice a day. If the urine 
is preternaturally acid, or loaded with the phosphates; or the digest- 
ive organs deranged; the case should be treated as directed in the 
section on urinary deposits. If the health is materially enfeebled 
by debauchery or malpractices, affusion of cold water on the geni- 
tals, cold sea-bathing, blisters to the perinaeum, bark and steel, 
good living, and perfect chastity of body and mind, are the neces- 
sary remedies. If all other means fail, the paste caustique of 
Lallemand may be introduced, for the purpose of slightly touching 
the whole of the canal with the nitrate of silver; or a strip of linen, 
about eight inches long, may be introduced for a few hours. This 
is pushed by a stilet into the canal of a gum-elastic catheter, which 
is open at both ends; the catheter is introduced; then it is with- 
drawn over the stilet, which keeps the linen in the urethra, and 
lastly, the stilet itself is withdrawn, leaving the linen. These two 
plans are not applicable if the urethra is very irritable. 
A scirrhous or semi-cartilaginous condition of the corpus spon- 
giosum urethras is always extremely difficult to get rid of. The 
frequent introduction of bougies, frictions with ointments of mer- 
cury or iodine, warm bathing, and the internal use of Plummer's 
pill and iodine, afford the best chance of relief. Cases are recorded 
in which portions of osseous matter have been removed from the 
septum penis by incision.* 
Gonorrhoeal rheumatism must be treated on the.same principles 
as common rheumatism;-if very severe, by bleeding; otherwise 
the bowels should be well cleared by calomel and black draught, 
and then colchicum should be given in doses of iqxx. of the wine 
with magnesia, every four or five hours, and a dose of Dover's 
powder at bedtime. In the chronic stage, F. 7 at bedtime;-sar- 
saparilla, bark, volatile tinct. of guaiacum, sea air, tonics, and warm 
bathing, are the remedies. 
The Treatment of Gonorrhoea in the Female must be con- 
ducted upon precisely the same principles. During the acute stage, 
rest in the recumbent posture, leeches, anodyne fomentations, fre- 
quent ablution, lubrication with lard or cold cream-and very fre- 
quent sponging with a weak solution of alum, a piece of lint dipped 
in which should be inserted between the labia; with laxatives and 
diaphoretics, are the measures to be adopted, until heat, pain, and 
tenderness subside; afterwards injections may be used with much 
greater freedom and benefit than in the other sex. Those of ace- 
tate of zinc and nitrate of silver appear to be the best; and they 
* Titley, p. 175. PRIMARY SYPHILITIC ULCERS. 
191 
should be continued for some time after all discharge has ceased. 
But much greater liberties may be taken with the vagina than with 
the male urethra; and the disease may often be stopped at once, 
without risk, by the application of the solid nitrate of silver, as 
recommended by Jewel and others. It should be applied, how- 
ever, either before the inflammatory symptoms have attained any 
height, or after they have subsided. Terebinthinate medicines 
(copaiba, &c.) may be given, although they do not do much good, 
unless the discharge proceeds from the urethra or its vicinity. 
Abscesses or other complications are rare; but if they occur, they 
must be treated on general principles. 
SECTION III. OF PRIMARY SYPHILITIC ULCERS. 
General Description.-Primary syphilitic ulcers or chancres 
may be caused by the application of the syphilitic virus to any sur- 
face, mucous or cutaneous, entire, wounded, or ulcerated. Their 
most frequent seat is the genitals;-and in men they are more fre- 
quently than otherwise found on the inner surface of the prepuce, 
or the furrow between the prepuce and corona glandis, or the 
angle by the fraenum;-obviously because these spots are most 
convenient for the lodgment of filth. It is notorious that persons 
with a long prepuce, whose glans is habitually protected by it, and 
covered with a delicate semi-mucous membrane, are more liable to 
suffer than those whose glans is uncovered and clothed with a 
denser cuticle. The time at which venereal sores appear is usually 
said to be from the third to the tenth day after infection; but it is 
more probable, as Ricord observes, that the syphilitic virus operates 
progressively from the first moment of its application, and that the 
ulcer is fully formed by the fifth day; although it may not be per- 
ceived by a careless person till later. The average duration of a 
syphilitic ulcer produced by inoculation is, according to Wallace, 
twenty-five days. 
Primary syphilitic ulcers present very many varieties. These 
varieties depend,-1st. On the peculiar sore from which infection 
was received; because every kind of sore, and especially the pha- 
gedsenic, has a tendency to reproduce its like. 2dly. On the state 
of constitution of the patient, and the degree of inflammation 
which is present. 3dly. On the situation ; and, lastly, on the local 
treatment. 
It is impossible in this work to collate and describe the innume- 
rable varieties of syphilitic ulcers that are spoken of by authors. 
For practical purposes it will suffice to consider them under three 
heads. 1st, the Hunterian, or indurated chancre; 2dly, the com- 
mon, or non-indurated chancre; and 3dly, chancres complicated 
with sloughing or phagedsena. 
1. The Hunterian Chancre, or indurated ulcer, is generally 
found on the common integument or on the glans penis. It may 
begin either as a pimple, or as a patch of excoriation which heals 192 
PRIMARY SYPHILIS. 
up, leaving the centre ulcerous. It is nearly circular;-deep and 
excavated; the base and edges are hard as cartilage, but the hard- 
ness is circumscribed ;*-there is little pain or inflammation ;-its 
colour is livid or tawny;-it is never so hard nor excavated when 
on the body of the penis as on the glans. 
It is this form of ulcer which is ordinarily produced when the 
pus of a chancre is inoculated into the sound skin for purposes of 
diagnosis. Supposing the inoculation to have been performed with 
the point of a lancet. During the first twenty-four hours, the 
puncture reddens. In the second and third days it swells slightly, 
and becomes a pimple, surrounded by a red areola. From the 
third to the fourth day, the cuticle is raised by a turbid fluid into a 
vesicle, which displays a black spot on its summit, consisting of the 
dried blood of the puncture. From the fourth to the fifth day, the 
morbid secretion increases and becomes purulent, and the vesicle 
becomes a pustule with a depressed summit. At this period the 
areola, which had increased, begins to fade, but the subjacent 
tissues become infiltrated and hardened with lymph. After the 
sixth day, if the cuticle and the dried pus which adheres to it be 
removed, there is found an ulcer, resting on a hardened base ; its 
depth equal to the whole thickness of the true skin, its edges seem- 
ing as if cleanly cut out with a punch-its surface covered with a 
grayish pultaceous matter, and its margin hard, elevated, and of a 
reddish brown or violet colour.! 
2. The Common, or non-indurated chancre is most frequently 
found in the inner surface of the prepuce. It may be said to have 
four stages. In the 1st, it is a small itching pimple, or pustule, 
which bursting, displays-2dly, a foul yelloivish or tawny sore, 
attended with slight redness and swelling, and spreading circularly. 
It may or may not be covered at first with a dirty brown scab. In 
the third stage it throws out indolent fungous granulations;-except 
it be situated on the glans; (for the substance of the glans penis 
has no power of throwing out granulations, although its surface 
may;) and is usually stationary for a little time after it has ceased 
to ulcerate, and before it begins to heal. In the 4th stage, it slowly 
heals; cicatrization being preceded by a narrow vascular line. The 
cicatrix is often red and indurated;-swelled, if on the prepuce ; 
but depressed, if on the glans, from want of granulations. It is 
exceedingly liable to ulcerate afresh. If the ulcer be seated near 
the fraenum, it is almost sure to perforate it. 
One sub-variety has been termed by Mr. H. .1. Johnson the 
multifarious sore;-because the discharge is so infectious that it 
excites fresh ulcers on the sound skin. Another sub-variety is 
described under the term excoriation sore, aphthous sore, or 
superficial sore; a circular, shallowish sore, much resembling an 
excoriation, not ulcerating deeply. Finally, an excoriation or a 
fissure of the prepuce may be infected, and may be followed by 
secondary symptoms. But if ulceration does not spread, it will be 
• So that it has been said to feel like a little cup of cartilage set in the flesh, 
f Ricord, op. cit. p. 89. PRIMARY SYPHILIS. 
193 
very difficult to say whether it is a venereal ulcer, or merely a 
common fissure or excoriation obstinate in healing; for, in both 
cases, it may appear yellowish and indolent. Inoculation is the 
test. 
3. Chancre complicated with Phagedena or Sloughing. 
(a) Phagedsenic chancres are extremely rapid in their progress, 
and highly painful; their surface yellow and dotted with red 
streaks; their shape irregular; their edges ragged or undermined; 
and the discharge profuse, thin, and sanious. The surrounding mar- 
gin of skin usually looks puffy and osdematous, showing a low grade 
of arterial action; but sometimes it is firm and of a vivid red. Some- 
times these ulcers eat deeply into the substance of the penis; some- 
times they undermine the skin extensively; but in general they 
spread widely but not deeply. Sores of this last description are 
called serpiginous. 
(6) Sloughing phagedsena affecting chancres requires no obser- 
vations on its symptoms distinct from those made at page 90. 
Simple or sloughing phagedaena may affect chancres or open 
buboes for two reasons. 1st, If the constitution be irritable and 
broken down by debauchery, night watching, exposure to cold and 
damp, or by the profuse administration of mercury, or by confine- 
ment in the foul pestiferous air of an hospital. Hence it is liable to 
occur to soldiers, sailors, prostitutes, and bakers;-the last-named 
class of individuals being obliged to work in the night. The ser- 
piginous variety is, as Mr. Acton observes, extremely apt to affect 
" scrofulous individuals, or old men who have led a dissipated life ; 
or men subject to the diseases of hot climates, and persons with 
skin diseases and constitutional complaints, whose health has been 
ruined by several courses of mercury." 2dly, They may probably 
be produced by some peculiar acrimony of the venereal virus. 
There is reason for believing that intercourse between foreigners 
gives rise to a very destructive kind of poison. The venereal secre- 
tions of the Portuguese women appear to have been horribly dele- 
terious to the British soldiers during the Peninsular war, who gave 
the expressive name of The Black Lion to the sloughing sores that 
resulted from connection with them. 
(c) Chancres may be affected with simple acute inflammation 
leading to gangrene, from local irritation, such as horse exercise, 
and excess in stimulating liquors. 
Chancre in the Urethra.-Ricord has proved satisfactorily, 
that this is the cause of the secondary syphilitic symptoms which 
were formerly attributed to gonorrhoea. The existence of chancre 
in the urethra may be suspected, if in a case of gonorrhoea the dis- 
charge is very capricious, sometimes thin, scanty, and bloody, 
sometimes thick and profuse; and if there is one painful indurated 
spot. But it can only be proved, either by the ulcer being visible 
at the orifice, or by inoculation with the matter. 
Syphilitic Ulcers in the Female require no distinct observa- 
tions. They do not usually cause so mucii distress as in the male, 
but they are very slow in healing, especially if interfered with by 194 
DIAGNOSIS OF CHANCRE. 
the urine. When situated high in the vagina they may cause no 
symptoms at all, except perhaps a mucous discharge, and can be 
detected only by the speculum. 
SECTION IV. OF THE DIAGNOSIS OF CHANCRE. 
The ordinary means of distinguishing a syphilitic ulcer are, that 
it is seated on the genitals; that it has followed a suspicious connec- 
tion ; that it is probably circular, with hardened base and elevated 
edges; and above all, that, if treated with simple applications 
merely, it is extremely difficult to heal. But none of these charac- 
teristics are infallible. The surest test is that of inoculation, which 
has been brought into great repute by Ricord. If some of the pus 
of a real chancre, taken whilst it is extending and before it begins 
to heal, be inoculated into the skin of the thigh, it will produce a 
regular chancre there, after the manner we have already described 
(p. 193). It may be right to adopt this practice in some few cases 
when the existence of chancre in the urethra is suspected; or when 
the characters of a sore on the penis are undecided; or when there 
is a sore suspected to be syphilitic on the face, or any other unusual 
part; or when it is wished to test the pus from a bubo ; but the sore 
produced by inoculation must be destroyed by lunar caustic, or by 
nitric acid, as soon as its character is decided, else it may give both 
surgeon and patient a great deal of trouble.* 
Affections that may be mistaken for Chancre.-This is 
the most convenient place for describing the nature and treatment 
of various affections that may be mistaken for chancre. 
1. Gonorrhoea externa, or balanitis, is an inflammation of the 
surface of the glans and inside of the prepuce, with profuse purulent 
discharge, and excoriation of the cuticle. It generally affects dirty 
people with long prepuce, and is caused either by the acrid secretions 
of the part, or by contact with unhealthy secretions in the female. 
Sometimes, however, it occurs to cleanly people whose health is 
disordered. The thick profuse discharge, the peculiar smell, the 
superficiality of the excoriations, and their appearance immediately 
after connection, distinguish this complaint from chancre; and a little 
opening medicine, common soap and water, and any mild astringent 
lotion, will suffice to cure it. Lime-water is the best lotion if there 
is much inflammation, and a grain of corrosive sublimate to an 
ounce and a half of lime-water if there is not. If the cure is not 
effected in two or three days, the excoriations should be touched 
with nitrate of silver. Sometimes balanitis is attended with very 
great inflammation and fever, and with phymosis, from the great 
swelling of the prepuce; and the pain may be so severe and gnawing 
as to make the surgeon uncertain whether there is not a phagedaenic 
ulcer concealed by the foreskin. The thick discharge, and the pain 
* It must be recollected thaUnoculation, if performed from a sore that is healing, 
will produce no pustule ; but yet that sore may be of venereal origin, and would 
have yielded an infectious matter at an earlier period. TREATMENT OF PRIMARY SYPHILIS. 
195 
being general and not confined to one spot, form the chief means of 
diagnosis; and repeated injection of warm-water and astringent 
lotions under the foreskin are the remedies. 
2. Minute aphthous-looking points, sometimes in clusters, 
sometimes surrounding the glans; some of them healing, whilst 
others break out. They are totally devoid of pain; and although 
they may last a long time, do not lead to ulcers. They are best 
treated by black wash or mere lime-water, or lotions of arg. nit. 
or cupr. sulph. and alteratives and aperients. 
3. Herpes pr&putialis* begins with extreme itching and sense 
of heat. The patient examining the part, finds one or two red 
patches, about the size of a split pea. On each patch are clustered 
five or six minute vesicles, which, being extremely transparent, 
appear of the same red colour as the patch on which they are 
situated. In twenty-four or thirty hours the vesicles become 
larger, milky, and opaque ; and on the third day they are confluent 
and almost pustular. If the eruption is seated on the inner surface 
of the prepuce, the vesicles commonly break on the fourth or fifth 
day, and form a slight ulcer with a white base and rather elevated 
edges. If this ulcer be irritated by caustic or otherwise, its base 
may become as hard as that of a chancre. If left to itself, it mostly 
heals in a fortnight:-sooner if situated on the external skin. The 
cause of this complaint is either some derangement of the digestive 
organs, or irritation within the urethra, which should be ascer- 
tained by the bougie. It is very liable to recur in the same indi- 
vidual, which of course, if known, will greatly aid the diagnosis. 
Treatment.-A little dry lint, or goldbeater's skin, at first, and 
subsequently a very weak lotion; with aperient and alterative 
medicines. 
4. Psoriasis preeputii, painful, irritable and bleeding cracks or 
fissures around the edge of the prepuce,-best treated by ung. 
hydr. nitr. dil. 
SECTION V.-OF THE TREATMENT OF PRIMARY SYPHILIS. 
Local Treatment.-It seems to be pretty well established, that 
if a chancre lasts for a few days only there will be no fear of 
secondary symptoms, and no need to administer mercury. If, 
therefore, a patient applies as soon as he perceives the chancre, it 
will be advisable to touch it thoroughly with a stick of nitrate of 
silver, and destroy it; then give an aperient, enjoin rest and low 
diet, and wrap the penis in rag dipped in warm water, to prevent 
inflammation. But if the sore has lasted more than a week, the 
nitrate of silver will not act deeply enough to destroy it effectually; 
and the potassa fusa, or strong nitric acid, must be employed 
instead. 
But the foregoing plan cannot be adopted with safety if the 
* Bateman on Cutaneous Diseases, 5th ed. p. 238. 196 
TREATMENT OF PRIMARY SYPHILIS. 
chancre presents a well-marked indurated lump, or if the penis is 
swelled and inflamed, and the patient feverish, or if there is any- 
swelling or tenderness in the groin. When this is the case, the 
local applications should consist of some liquid capable of chemi- 
cally decomposing the poisonous secretions of the sore, and of a 
strength proportioned to the existing irritation. Black wash; a 
very weak solution of chloride of soda, and decoction of oak-bark 
with a little tincture of catechu, which Mr. Acton uses as a substi- 
tute for the vin aromatique, the favourite application of M. Ricord, 
are the most useful. If there is very much irritation the penis 
should be enveloped in a poultice of boiled chamomile flowers. If 
there is much induration Ricord recommends an ointment of calo- 
mel. Afterwards, during the indolent and granulating stages, the 
sore may be treated with any astringent lotion, and be touched 
occasionally with nitrate of silver or sulphate of copper. 
Constitutional Treatment.-If there are none of the contra- 
indications that will be mentioned presently, the patient should 
take mercury. Not because it is absolutely necessary in all cases, 
but because it hastens the cure of the primary sores, and affords a 
more decided security against secondary symptoms, especially if 
the chancre is of the Hunterian variety. But before doing so, it 
will be right to open the bowels by blue pill and black draught;- 
and to prescribe low living, rest, and saline medicines, till local 
pain and inflammation and any general disorder of the system 
have been removed. Ji warm bath or two may also be useful. If 
the patient be young, plethoric, and a countryman, it may be right 
to bleed him; but great care must be taken not to induce weak- 
ness ;-and neither this nor any other measure should be needlessly 
adopted from motives of mere routine. 
Then the object is to induce a gentle mercurial action, and to 
maintain it long enough. Five grains of blue pill should be given 
every night and morning; and if no effect on the mouth is produced 
by the fourth day, the dose at night should be doubled. This will 
rarely fail, in another day or two, to produce a very slight sore- 
ness and sponginess of the gums with a slight increase of the 
saliva; which is all that is wanted; for the only use of salivation 
is to show that the system is affected. The mercurial influence 
should be steadily maintained for four or five weeks, and until the 
sore has healed and all hardness of the cicatrix has vanished. If 
the mouth become too sore, the dose should be lessened;-if the 
soreness subside too soon, it may be increased; or two or three 
doses of calomel may be added. Meanwhile the patient should 
live regularly, but not too low:-he should avoid all excess of food 
or wine, and acescent vegetables, and every thing likely to disorder 
the bowels;-his clothing should be rather warm, so as to keep 
the skin perspirableand, above all, he should most sedulously 
avoid fatigue, cold, wet, and night air. 
The strong mercurial ointment is not so likely to disorder the 
bowels as the blue pill, but it is more troublesome, and might fatigue 
a feeble patient injuriously. The dose is from 3ss-3j;-to be ILL EFFECTS OF MERCURY. 
197 
rubbed in daily upon the inside of the thighs or arms till it disap- 
pears. The morning is the best time for doing it, as the skin is 
then softer; it should be rubbed on different limbs successively; the 
patient wearing the same drawers both by night and day. If the 
skin becomes irritated, it should be well washed and bathed. If 
the patient is too weak to rub in the ointment himself, it must be 
performed by a servant, whose hands should be protected by a pig's 
bladder, well softened in oil and tied round his wrist. 
If calomel is preferred, two or three grains may be given every 
night, combined with a little opium: but it is more apt to purge, 
and should be used only with strong robust people, who would be 
unaffected by milder means. 
The ill effects of Mercury that require to be guarded against 
are as follow : 1. Griping and parging-which are to be obviated 
by combining a small quantity of opium or hyoscyamus with the 
blue pill, and giving occasionally a draught with P. rhasi Bj, tinct. 
ejusd. f$j, tinct. opii n|xx, aq. menth. f$x. It is far from uncommon 
for a slight attack of dysentery to occur, especially about the time 
that salivation commences; there being sickness and severe griping, 
with frequent straining and ineffectual attempts to go to stool. 
This should be treated by the draught just mentioned, followed by 
opiate enemata and the warm bath,-the mercury being omitted 
for the time. 
2. Sore throat; redness of the whole fauces, and sloughing or 
ulceration of the tonsils with fever. In this case the mercury must 
be discontinued, till leeches, gargles, and aperients have set the 
throat to rights;-and then it may be resumed in smaller doses. 
3. Violent salivation. This may be caused by a too liberal use 
of the remedy; or by a sudden check to the cutaneous secretion by 
cold and damp; or by loss of blood, or any thing that suddenly 
lowers the system. It is, however, very common to meet with 
persons who are salivated by the smallest quantities conceivable; 
and every practitioner should make a point of ascertaining this, 
before he prescribes mercury for any new patient. The symptoms 
of severe salivation are, swelling and inflammation of the salivary 
glands, cheeks, tongue, and fauces, with a flow of peculiarly fetid 
saliva, and ulceration or even sloughing of the gums. The best 
local applications for this state are, gargles of brandy and water, 
to which a little of the solution of chloride of lime may be added, 
or of tanin, or of hydrochloric acid. (F. 39, 40, 92.) The bowels 
should be cleared by mild aperients; and as soon as fever has 
abated, the patient should have a good diet and tonics. Change of 
air, and especially removal from the venereal wards of an hospital, 
are indispensable. If the salivation is very obstinate, repeated 
blisters should be applied behind the ears, and to the throat.* 
4. Eczema mercuriale (Eczema rubrum, Erythema mercu- 
riale hydrargyria} consists of patches of redness and inflammation, 
* Dr. Macleod relates two cases of coma following the sudden cessation of sali- 
vation ; one fatal; the other cured by reproducing it. Lond. Med. and Phys. Journ. 
vol. Ivi. p. 231. 198 
EFFECTS OF MERCURY. 
which appear first in the groins, axillae, and flexures of the limbs, 
and then spread over the trunk. These patches are covered with 
minute vesicles, which soon burst, discharging a thin acrimonious 
fluid, and leaving the surface excoriated, and exceedingly painful 
and tender. The discharge often becomes profuse and fetid, and 
the affected parts much swollen and fissured. It generally lasts for 
ten days, but may remain for many weeks.* Treatment. Warm 
bathing, mild and unctuous applications, aperients, diaphoretics, 
salines, and opiates, during the early stages;-subsequently, bark or 
sarsaparilla, and the mineral acids. Dr. Colles has described another 
and less severe form of eruption, which resembled the itch, except 
that the intervals between the fingers are free from it; the treat- 
ment is the same. When a patient who is disposed to these affec- 
tions reverts to the use of mercury, the doses should be small, 
combined with hyoscyamus, and he should carefully avoid heat, 
violent exercise, and every thing else that excites the cutaneous 
circulation. 
5. Erethismus mercurialis consists in a tendency to palsy of the 
heart. The symptoms are great depression of strength; anxiety 
about the praecordia, dyspnoea, frequent sighing, weak and tumul- 
tuous action of the heart;-frequent sense of suffocation, disturbed 
sleep, and faintness upon any exertion; which faintness may prove 
fatal. Treatment. Removal to a fresh atmosphere ; stimulants; 
especially the mistura moschi; tonics; and good living.! 
If during the mercurial course any febrile or inflammatory 
attack arises, it is a general rule to discontinue it until such a state 
has been removed. And if the patient become thin and feeble; 
losing his appetite and strength; complaining of disturbed sleep, 
night sweats, cough, or any other symptoms indicative of debility, 
his diet must be generous, and sarsaparilla or cinchona and other 
tonics must be liberally administered; and if these symptoms con- 
tinue, notwithstanding the mercury is given in diminished doses, 
it must be relinquished altogether. 
If the patient is very easily salivated, the doses must be very 
small at distant intervals, and the strength must be well supported 
by tonics and good living. If, on the other hand, as sometimes 
happens, the mercury seems to make no impression on the system, 
the patient may be bled and purged;-should use the warm bath, 
and live low. But the doses must not be very much increased, lest 
they suddenly induce violent salivation, or erethismus. 
There are some patients whom it is scarcely advisable to sub- 
ject to a mercurial course, viz. those naturally labouring under, 
or strongly disposed to, consumption or scrofula; or who are 
extremely debilitated, or who are liable to the erethismus. 
For these and other cases in which mercury is unadvisable, the 
iodide of potassium has been proposed as a substitute; in doses of 
* One variety, hydrargyria maligna, now almost unknown, is attended with 
typhoid fever. Eight out of fourteen cases died. Alley on Hydrargyria. Lond. 
1810. 
f Vide Dr. Bateman's case. Med. Chir. Trans, vol. ix. TREATMENT OF SYPHILIS. 
199 
gr. i.-iii. ter die. It produces a great flow of urine. In over doses, 
it causes sickness, salivation, and emaciation; with symptoms of 
violent cold in the head and swelling of the eyes. Mr. Smee has 
published a valuable paper on the use of tartar emetic in doses of 
gr. g-i every four or five hours, both in primary and secondary 
syphilis. It may be combined with iron or zinc if there is much 
debility.* 
Sarsaparilla and guaiacum, as combined in the compound 
decoction of sarsaparilla, appear to maintain the secretions, espe- 
cially those of the skin and kidneys, to increase nutrition, and allay 
morbid irritability of the nervous and circulating systems. Hence 
they are admirable remedies for debility during or after a mercurial 
course; and for the multifarious variety of symptoms that arise 
when the health is broken down as well by the disease as by its 
remedy. 
The gangrenous chancre (when occurring in healthy subjects, 
with firm pulse,') requires to be treated by the early and free 
abstraction of blood; and then the bowels having been opened, 
and the pulse being reduced, opium should be given pretty freely 
in combination with salines and antimonials. The poppy fomenta- 
tion is the best application at first, and the balsam of Peru, or nitric 
acid lotion subsequently, to assist in throwing off the sloughs. The 
ulcer which remains is usually healthy, and is very seldom followed 
by secondary symptoms; therefore there is no need of mercury 
unless the sore begins to ulcerate, (there being nothing in the 
general health to account for it,) or unless secondary symptoms 
appear. 
The phagedsenic and phagedseno-gangrenous chancres must be 
treated according to the state of the system. If there are fever and 
thirst, with a full habit and harsh pulse, and vivid arterial inflam- 
mation, the case should be treated antiphlogistically; if, however, 
the constitution is broken down, and the pulse quick and feeble, 
bark and opium should be given freely;-and if the application of 
a strong solution of opium does not stop the phagedaena, the dis- 
eased surface must be destroyed by nitric acid, as directed at p. 
94; and this will probably require to be done repeatedly, before the 
diseased disposition is got rid of. Mercury is inadmissible when 
chancres are affected with inflammation, sloughing, or phagedaena. 
If phymosis is present, and there is a discharge from under the 
prepuce, and it cannot be turned back, the existence of an ulcer 
will be detected by local hardness and tenderness. Whilst there is 
any inflammation, leeches and poultices must be applied, and a 
mild astringent lotion should be injected frequently between the 
prepuce and the glans. The prepuce should be slit up, if the 
tumefaction is so great that it threatens to slough; but not other- 
wise. If phymosis be caused by small ulcers at the edge of the 
prepuce, (which sometimes occur during the healing of venereal 
sores,) they should be touched with arg. nit., or cupri sulph., or 
ung. hydr. nitrat. 
* Med. Gaz. Sept. 10th, 1842. 200 
BUBO. 
As soon as the fraenum has been perforated by an ulcer, it 
should be completely divided. 
Chancre in the urethra must be treated by astringent injections; 
and by mercury if not contra-indicated by any of the circumstances 
above mentioned. 
SECTION VI. OF BUBO. 
Definition.-Bubo signifies an inflamed lymphatic vessel or 
gland leading from a venereal ulcer. 
Causes.-Any local irritation will, in certain habits, cause inflam- 
mation of the lymphatics;-in gonorrhosa, for instance, the glands 
in the groin are apt to swell. But the genuine syphilitic bubo 
arises from absorption of the poisonous secretions of a chancre; 
and the ordinary time of its appearance is, just as the ulcerative 
stage of the chancre is ceasing. 
Varieties. -(1.) Btibo of the Penis consists of an inflamed 
lymphatic vessel on the penis. 
(2.) dlcute bubo at the groin generally affects only one gland, 
and pursues the course of an ordinary acute abscess. The cellular 
tissue between the gland and the skin is the seat of suppuration. 
(3.) Indolent or chronic bubo very commonly affects more than 
one gland. It occurs in weak, scrofulous habits, and especially in 
persons worn out by the improper administration of mercury. 
The glands slowly enlarge; suppuration is slow and imperfect, and 
commences at several points. The skin is long before it inflames, 
but when it does so, a large tract of it becomes of a dusky bluish 
tint; the matter spreads widely;-and at last large portions of the 
skin perish by ulceration or sloughing, leaving an extensive sore 
that may be months in healing. 
Diagnosis.-If a bubo at the groin affect one gland only, and 
that above Poupart's ligament, it is most probably caused by 
chancre on the penis, provided there be one. But if many glands 
are swelled, and they are below the level of Poupart's ligament, 
the swelling is probably caused by mere irritation. But the only 
diagnosis of a syphilitic bubo is, that if the matter taken from it be 
inoculated, it will produce a chancre;-or that the sore produced 
by opening the bubo presents the elevated edges and copper-co- 
loured margin of a chancre. As, however, every bubo is attended 
with some common inflammation of the cellular tissue, the surgeon 
should recollect that some of the matter taken when it is first opened, 
may not cause chancre by inoculation. 
It has been supposed by some surgeons, that the syphilitic 
virus, if applied to the skin of the penis, might be taken up by the 
absorbents and produce a bubo in the groin without having first 
caused a chancre. Such supposed cases are called bubon d'em- 
blbe by the French. But though it is very certain that the inguinal 
glands are apt to inflame and suppurate, if a person of bad 
constitution, who is disposed to such affections, indulges in immo- BUBO. 
201 
derate sexual intercourse; still there is not the slightest proof that 
such buboes are syphilitic, unless preceded by chancre; and the 
surgeon is not justified in administering mercury, unless decided 
secondary symptoms occur.* 
Treatment.-1. The acute, bubo must be treated as an acute 
abscess. The first indication is to produce resolution;-by rest, 
aperient and saline remedies, low diet, leeches, and warm or cold 
applications, according to the patient's choice. The applications 
to the chancre should be soothing, and mercury, if being adminis- 
tered, should be at once given up. Sometimes, it is true, a rapid 
exhibition of it causes a rapid disappearance of the bubo;-but 
more generally it hastens suppuration, and it certainly predisposes 
to subsequent ulceration. It may easily be resumed afterwards. 
Even if matter does form, the surgeon should be in no haste to 
evacuate it;-but should endeavour to procure its absorption by 
repeated leechings, and cold discutient lotions, with aperients, 
attention to the health, and change of air. When the case becomes 
chronic, frictions, bandages, &c., may be used to remove any swell- 
ing that remains. 
But if the matter increases, and the skin is inflamed and shining, 
a puncture should be made, and the case be treated as an acute 
abscess under the same circumstances. 
2. In treating the indolent bubo, the general health must be 
amended by every possible means; tonics, the acids, sarsaparilla, 
change of air, and especially a sea voyage ;-with occasional leech- 
ings and cold lotions, when demanded by an aggravation of heat 
and pain. If these measures fail, and matter forms, and the skin is 
becoming bluish and thin, a blister may be applied; -or the dis- 
eased skin may be rubbed with arg. nit.; which measures will 
either promote absorption, or at least stimulate the parts to a 
healthier action. But if the matter continue to increase, the swell- 
ing should be opened either by rubbing it with potassa fusa, or 
by applying the nitrate first, and then opening it with a lancet;- 
either plan having the advantage of causing diminution of the 
swelled glands, and preventing the spread of ulceration. Mercury 
should not be given;-except, perhaps, in alterative doses towards 
the close of the case. 
In treating the sore formed by opening a bubo, the first thing is 
to get rid of the loose red skin. This may be done (as soon as the 
part is becoming indolent and swelling is abated) by cutting it 
away with scissors, or by the potassa fusa. A solution of nitrate 
of silver is the best dressing afterwards. 
Sometimes there remain one or two indolent enlarged glands, 
projecting in the midst of the sore, denuded of skin, and incapable 
of forming healthy granulations. These may be destroyed by 
* An officer in the Rifles, young, tall, and eminently lymphatic in temperament, 
told the Author, that whilst serving in Canada in 1841, a large cluster of glands in 
the groin swelled and suppurated after immoderate sexual indulgence. He was 
attended by one civil and three military surgeons; and this surgical staff was 
equally divided in opinion, whether the complaint was syphilitic or not. 202 
SECONDARY SYPHILIS. 
caustic in the following way: An ounce of bread crumbs, two 
drachms of corrosive sublimate, and one drachm of red oxyde of 
lead, mixed into a paste with a little water, may be made into 
conical troches of the shape of bread-seals; and one of these may 
be inserted into a puncture in the diseased gland, which it will 
speedily cause to slough. 
Sinuses, if they are not soon healed by stimulating injections, 
may be slit up. 
If the ulcer become inflamed or irritable, spreading by ulcera- 
tion, or if it be attacked by sloughing, or phagedsena, (which may 
destroy the patient by exhaustion, or by laying open the femoral 
artery,) the same treatment must be adopted that has already been 
directed for similar ulcers in other parts. 
SECTION VII. OF SECONDARY SYPHILIS. 
The symptoms of secondary, or constitutional syphilis, generally 
occur about six weeks after the primary symptoms;-sometimes a 
fortnight, sometimes not for months. Before their appearance, the 
patient generally becomes thin and wan ;-he looks dispirited ;- 
his eyes are heavy;-and he complains of want of appetite and 
sleep, and of rheumatic pains. 
The effects of constitutional syphilis are usually first manifested 
upon the skin and mucous membrane of the throat, and then upon 
the bones. We shall first describe these several local affections, 
and then the treatment of secondary syphilis generally; but syphi- 
litic affections of the eye and testis, which generally accompany 
those of the throat, will be treated of in the chapters that are par- 
ticularly devoted to those organs. 
Syphilitic Eruptions vary in degree from the slightest dis- 
coloration to the most inveterate ulcers. 1. In the mildest form, 
the skin is mottled and stained in irregular patches of a brownish 
red colour; which are caused by a slight swelling and vascular 
injection. A greater degree of the same derangement will produce 
syphilitic psoriasis, in which the skin is raised in copper-coloured 
blotches, covered with scales of hypertrophied cuticle. Or there 
may be an eruption of papulse or pimples, varying in size from a 
pin's head to a pea. These eruptions are succeeded merely by 
scabs or exfoliations of the cuticle. 
2. Scaly Eruption {Lepra syphilitica} is an aggravated variety 
of the preceding. It begins with an eruption of copper-coloured 
blotches, which become covered with scales of enlarged cuticle ;- 
these are succeeded by scabs, and, when they fall off, by shallow 
ulcers with copper-coloured edges. 
3. Vesicular Eruption {Rapid). Large flattened bullse, filled 
with serum, which gradually become purulent, and finally dry 
into scabs, under which the skin is ulcerated. The ulcers spread 
under the scabs, and the latter become remarkably thick from suc- 
cessive additions. SECONDARY SYPHILIS. 
203 
4. Pustular Eruption (Ecthyma}. Large prominent pustules, 
with a copper-coloured base, leading to ulcers. 
5. Tubercular Eruption. Broad, red, copper-coloured tubercles, 
forming most frequently at the alae of the nose, or on the cheeks. 
They gradually suppurate, and are succeeded by deep irregular 
ulcers, terminating in puckered cicatrices, and more properly 
belong to the class of tertiary symptoms, in which mercury is 
almost inadmissible. 
This form of disease is most unfavourable, and usually appears 
at a considerable distance of time from the primary symptoms in 
persons whose constitution is originally weak, or has been shattered 
by privation, dissipation, or frequent unavailing courses of mer- 
cury. A patch of this kind of unhealthy inflammation is apt to 
form on the tongue, and after a time an abscess breaks, disclosing 
a ragged excavation, filled with orange-coloured sloughs, and 
exuding a copious fetid discharge. If it occurs on the palate, a 
probe will detect bare exfoliating bone;-which rapidly perishes 
and leaves a hideous chasm. 
Condylomata or mucous tubercles are soft red fungous eleva- 
tions of the surface of the skin, generally situated about the anus, 
or between the scrotum and thigh, or at other parts where two 
cutaneous surfaces are in contact. They are covered with a thin 
cuticle, like that of mucous membranes, and often exude a copious 
thin fetid discharge. They generally occur together with psoriasis 
or lepra. This affection is common in Ireland, where it is believed 
to be contagious; which M. Ricord denies, unless it occurs on the 
site of a chancre which is imperfectly healed. 
Syphilitic Sore Throat.-1. The mildest variety is a super- 
ficial excoriation of the mucous membrane of the tonsils or some 
other part of the mouth or fauces, corresponding to psoriasis on 
the skin. The parts affected are swollen and sore ; sometimes red 
and raw, and sometimes covered with a white secretion, or with a 
patch of thickened epithelium. This state may be succeeded by a 
superficial ulceration. 
2. The excavated ulcer looks as if a piece had been scooped out 
of the tonsil. Its surface is foul and yellow, its edges raised, and 
ragged, and swelled. There is remarkably little inconvenience 
from it, and very little constitutional affection, unless it be attended 
with eruption likewise. 
3. The sloughing ulcer begins as a small aphthous spot, which 
rapidly ulcerates, and is attended with great pain and fever. The 
surface of the ulcer is covered with an ashy slough, and the sur- 
rounding mucous membrane is dark, livid, and swollen. The 
lingual artery may be opened by the spread of the ulceration, and 
the patient may die of haemorrhage, unless the common carotid is 
tied. 
Syphilitic Ulcerations of the nose and palate commence with 
ulcerations of the mucous membrane, similar to those of the throat, 
which may denude the periosteum, and then produce exfoliation 
of the bones, with profuse fetid discharge and odious deformity. 204 
SECONDARY SYPHILIS. 
Ulceration of the nose generally begins with a sense of heat, and 
dryness, and snuffling. 
! Syphilitic ulceration of the larynx is mostly caused by an exten- 
sion of ulceration from the palate. It is characterized by tender- 
ness, great huskiness of voice (which frequently degenerates into a 
mere whisper), suffocative cough, and expectoration of bloody 
purulent matter;-there is great loss of flesh and strength, and life 
is often terminated by suffocation. 
Syphilitic Disease of Bone most frequently attacks the tibia, 
ulna, os frontis, clavicle, and other superficial bones. It commences 
with tenderness of the affected bone, and severe pain, which begins 
in the evening, and lasts almost all night, but ceases in the day- 
time. The pain is shortly accompanied with oblong swellings, 
called nodes, arising from infiltration of the periosteum with 
lymph and serum. These swellings are rather tender; they com- 
municate a doughy feeling, or obscure sense of fluctuation to the 
fingers; and the skin over them is at first pale and movable. If 
the disease is arrested at this stage, it causes merely a superficial 
deposit of rough porous bone, from the organization of the lymph 
effused ; or else a consolidation of the bone itself through the depo- 
sition of fresh osseous matter into its cancelli. If the disease pro- 
ceed one step further, a quantity of glairy serum is effused between 
the periosteum and bone, producing an exquisitely painful fluctu- 
ating tumour. If it advance still further, the bone becomes carious; 
matter forms between it and the periosteum; extensive exfoliations 
ensue; the patient suffers severely from the pain and discharge; 
and if the disease be seated on the head, (in which situation it is 
called corona veneris,') death 
may ensue from irritation of 
the dura mater, or protru- 
sion of the brain through 
apertures in the skull. Such 
aggravated cases are fortu- 
nately, however, now very 
rare; although common 
enough when mercury was 
supposed to be the only 
means of stopping the ra- 
vages of the disease. 
Diagnosis. - There is 
often some difficulty thrown 
into the surgeon's way, by 
the denial of patients that 
they have ever had any 
primary symptoms. If, how- 
ever, the patient has a cop- 
per-coloured eruption,a sore 
throat, falling off of the hair, 
Fig. n.* 
* This cut shows the ravages of syphlitic caries. From the King's College 
Museum. TREATMENT OF SECONDARY SYPHILIS. 
205 
and a general faded unhealthy look, and these disorders are of recent 
date, and cannot be attributed to any causes connected with diet 
or residence, the probability is that they are syphilitic. 
Treatment.-In the first place, if a venereal eruption and sore 
throat are ushered in with pain in the chest and other febrile or in- 
flammatory symptoms, it will be necessary to give aperients, and 
saline medicines with antimony, and to restrict the diet, and con- 
fine the patient to the house. The warm-bath will also be highly 
useful. 
When the febrile state has vanished, if the patient has never 
taken a course of mercury,-or if he has been subjected to an imper- 
fect course of it for the primary symptoms,-and his constitution is 
sound, he may take mercury after the manner directed in the fifth 
section. If, under its use, the strength and general appearances 
are improved, so much the better;-but if the patient gets thinner, 
weaker, and haggard, and suffers from chills or feverishness, or if 
his ulcers become irritable and phagedaenic, it must be given up. 
The corrosive sublimate in very small doses, and not carried to the 
extent of affecting the mouth, will often be of great service when 
a full course of the mineral is inapplicable, F. 30. 
The iodide of potassium is the remedy next in efficacy to mercury, 
and should be administered when the former is deemed inexpedient. 
F. 93, 106. Sometimes it is useful to combine it with iodine, F. 74. 
Sarsaparilla, F. 56, 57, is a remedy that may almost always be 
used with advantage. It may be combined with corrosive sublimate 
or the iodide of potassium ; or may be administered after a course 
of those remedies to restore the flesh and strength. The mineral 
acids, especially the nitric; F. 29 ;-sedatives, especially hyoscyamus 
and conium; F. 93 ;-tonics, F. 1, 2, 3, 26, 31;-and tartar emetic 
in minute doses, F. 103, will be all of service in protracted cases. 
In these the surgeon will find it necessary to change and vary his 
remedies repeatedly. The main object should be to improve the 
general look and condition of the patient,-to treat symptoms,- 
never to push a remedy, if it does manifest harm, under the vague 
idea that it is specific; and, never to attempt to produce sudden 
benefit by large doses of mercury, or other violent remedies, which 
may weaken or impair the constitution. 
Local Treatment.-For syphilitic eruptions, the warm, vapour, 
and sulphur baths will be often expedient. Obstinate patches of 
lepra or pimples may sometimes have their removal hastened by 
ung. hydr. nitratis diluted, or the ung. hydr. precipitati albi, or the 
ung. picis. Itching eruptions may often be relieved by a weak 
lotion of corrosive sublimate. Ulcers must be treated according to 
their condition-whether inflamed, irritable, or indolent. In general, 
weak mecurial applications, black wash, or weak red precipitate 
ointment, answer best. 
Condylomata are, according to Ricord, best treated by washing 
them with a solution of chloride of soda, and then sprinkling calomel 
over them, and applying dry lint. 
For the common excoriated sore throat, any soothing detergent 
gargle will do-F. 39, 40. When there are ulcers, it is advisable to 206 
TREATMENT OF SECONDARY SYPHILIS. 
use gargles of corrosive sublimate;-(gr. i. ad siv.;) and when the 
ulcers are indolent they may be touched with the liniment urn 
aeruginis. Mercurial fumigation is also occasionally of benefit. 
It is effected by putting a scruple of red sulphuret of mercury on a 
heated iron in a proper apparatus, and inhaling the vapour,-a 
heated pennypiece in a teacup will answer the purpose. 
Ulceration of the larynx is occasionally benefited by similar fumi- 
gation ; but of course mercury so as to affect the mouth is almost 
always injurious;-as it is in other cases of rapid ulceration. Sarsa- 
parilla and sedatives, blisters to the throat and occasional leechings, 
and the operation of tracheotomy, if the breathing becomes much 
embarrassed, are the necessary measures. 
The pain of nodes is often relieved by blisters, and so are rheu- 
matic pains of venereal origin. Sometimes it is useful to dress 
the blistered surfaces with strong mercurial ointment and opium. 
Acute inflammation of the periosteum or pericranium, is some- 
times relieved by a rapid administration of calomel and opium; 
although in disease of bone in general, the use of mercury requires 
the greatest caution, and is only admissible if the patient has a 
sound constitution, and has never taken a course of it. It is 
peculiarly noxious when there is caries of the bones of the nose. 
When nodes are very tense and full of fluid, it may be necessary 
to puncture them, but it should be avoided if possible. If during 
secondary syphilis, the nose becomes tender or painful, the greatest 
benefit will be derived from the application of one or two leeches 
twice or three times a week to the inside of the affected nostril. At 
the same time, the patient should take plenty of sarsaparilla, with 
small doses of iodide of potassium, and should have the benefit of 
country air, and a nutritious diet. By these means, any further 
mischief will sometimes be averted. If, however, ulceration does 
occur, it is of the utmost consequence to remove any loose or 
carious portions of bone, as soon as possible. 
Syphilis of children.-When a man labours under constitu- 
tional syphilis, it is probable that he may communicate it to his 
wife ; but, at all events, if the wife has it, she may communicate it 
to the foetus. The consequence is sometimes that the infant dies 
about the fourth or fifth month, and the woman miscarries repeat- 
edly. Sometimes a child is born weakly and shrivelled, with 
hoarse voice, discharge from the nostrils, and copper-coloured 
blotches or ulcers, especially about the anus and pudenda. Some- 
times, again, it is born healthy, but these symptoms appear a month 
afterwards. Lastly, a child may be infected with primary syphilis 
during its birth. 
The parents in these cases should take a course of mercury, and 
be treated in other respects for secondary syphilis. And for the 
children, the best plan is to rub ten grains of mercurial ointment 
daily into the axilla, or soles of the feet, or to administer half a 
grain or a grain of hyd. c. creta every night till the symptoms dis- 
appear. The prognosis is always favourable; and although- the 
symptoms are apt to recur once or twice, they are in general easily 
removed by a short repetition of the remedy. PART IV. 
OF THE INJURIES AND SURGICAL DISEASES OF 
VARIOUS TISSUES, ORGANS, AND REGIONS. 
CHAPTER I. 
OF THE DISEASES OF THE CELLULAR TISSUE. 
SECTION I. CARBUNCLE AND BOIL. 
Definition.-A carbuncle signifies an unhealthy inflammation 
and sloughing of a circumscribed portion of the cellular tissue. 
Symptoms.-It begins with a hard, circumscribed, livid red 
swelling, and with severe burning, smarting pain. Its most promi- 
nent part soon becomes soft and quaggy, and numerous small 
ulcerated apertures form on it, which give exit to a thin discharge, 
compared by Sir A. Cooper to flour and water. These ulcers 
gradually unite, and form a considerable opening, from which a 
slough of cellular tissue is slowly protruded; and when that is 
separated, the parts may granulate and heal. The most usual 
situations of carbuncle are the back, the nape of the neck, and the 
nates. The tumour may vary in size from that of half a crown to 
that of a small plate. 
Carbuncle is always an evidence of a vitiated state of the blood 
and disorder of the digestive organs; and it usually afflicts elderly 
people, whose health and spirits are impaired by intemperance, or 
by hard study, or anxiety of mind. It sometimes appears to be 
the means by which some poisonous matter is thrown out of the 
system ;* in corroboration of which idea, Sir B. Brodie mentions a 
case in which a carbuncle disappeared suddenly, and the patient 
began to sink and die at the same moment. It is often attended 
with considerable fever, and almost always with loss of appetite 
and flatulence. And it may be attended with great danger to life, 
if the patient is very old or weak-or if the carbuncle is very 
large, and seated on or near the head. 
Treatment.-The objects of the local treatment are, to afford a 
free exit to sloughs and discharge, and to excite the diseased tissues 
to healthy suppuration and granulation. In the first place, there- 
* Carbuncles, and unhealthy abscesses, are frequent consequences of what is 
called the water-cure,- and the Germans persuade themselves that they constitute a 
critical evacuation of diseased humours ; but it is far more probable that they are 
owing to the exhausted vitality of the skin, which is so inordinately taxed to relieve 
the blood of the immense quantity of water with which it is deluged. 208 
TUMOURS OF THE CELLULAR TISSUE. 
fore, a free incision should at once be made completely through the 
tumour;-and if the tumour is extensive, it should be scored across 
by a second incision at right angles to the first. Then warm poul- 
tices should be applied; and if there is much atony about the sys- 
tem, the yeast poultice, F. 46, or linseed meal poultice mixed with 
a little port wine, or beer-grounds, or unguentum resinae, will be 
advisable. Stimulating ointments and lotions, especially the nitric 
acid lotion, F. 17, will complete the cure. 
The indications for the constitutional treatment are, first, to eva- 
cuate and correct the secretions of the alimentary canal. This is 
to be effected by purgatives, which should be given in repeated 
doses, till the motions become light yellow and bilious, instead of 
dark, grumous, and offensive;-or, at all events, as long as the 
patient feels lighter and better under their use. If the patient is 
tolerably vigorous, calomel and the black draught will suffice; but 
in general it will be better to use a few doses of the blue pill, and 
the warmer aperients, such as rhubarb, and decoction of aloes, with 
ammonia, F. 8. Very often an emetic, composed of a scruple of 
ipecacuanha, followed by a cupful of warm chamomile tea, or F. 94, 
will be of service. If there is much fever and a pretty good pulse, 
the patient may take the liq. am. acet., or effervescing saline 
draughts;-but more frequently, bark with the mineral acids, or 
ammonia, or camphor, or small doses of opium, (F. 1, 2, 3, 26,) 
will be necessary to support the strength; together with wine, beef- 
tea, &c. 
Boils are miniature carbuncles. The best plan is to cut them 
through as soon as possible, poultice for a day or two, and then 
apply stimulating plasters; such as the empl. galbani, vel ammo- 
niaci. A few doses of mild aperient medicine should be given; 
and if they continue to come out in successive crops, a course of 
alteratives such as Plummer's pill, sarsaparilla, saline or sulphure- 
ous mineral waters, and sea-bathing;-but the liq. potassse, or 
sodae carb., in moderate doses three times a day, are generally con- 
sidered of most utility. " I was myself always troubled with boils," 
says Hunter, "until I took forty drops of the lixivium (of soda) 
night and morning in milk for two months, when all my boils dis- 
appeared, and I have since had no return of them."* 
SECTION II. TUMOURS. 
I. The Common Vascular Sarcoma, or simple fleshy tumour, 
is a yellowish-white, firm, fleshy, or fibrous mass;-with few blood- 
vessels ;-often surrounded with a coat of condensed cellular tissue ; 
-and somstimes containing irregular patches of bone or cartilage. 
Its formation is supposed to be owing to the organization of 
lymph. In external character, it is a firm, tabulated tumour, cir- 
cumscribed, movable, and free from tenderness, unless accidentally 
* Lectures in Palmer's ed., vol. i. p. 610. TUMOURS OF THE CELLULAR TISSUE. 
209 
inflamed. It is also free from pain, unless it press upon some sen-' 
sitive part. It grows slowly but steadily, and when it has attained 
considerable bulk, the veins on its surface become enlarged and 
tortuous. As to its consequences, first, it may last the whole life 
of the individual, without any ulterior consequences. Or (2) it may, 
by its enlargement, inflame the skin, and then slough out entirely. 
(3) It may produce sundry inconveniences, or even death, by pres- 
sure on various parts. Or (4) it may become the seat of malignant 
ulceration. It is known from abscess or inflammatory tumour by 
its slow, but steady, and painless enlargement. From scirrhus it 
is known by the absence of lancinating pain, and of the cancerous 
cachexia. But as it may degenerate into cancer, the proper treat- 
ment is extirpation with the knife. 
II. The Fatty Tumour consists of lobulated masses of fat, very 
slightly vascular, and contained in a cyst of cellular tissue. In 
external character, it is a softish, lobulated, painless tumour, feel- 
ing like fat. Its growth is slow, but progressive; and it may 
attain enormous bulk, even forty pounds. Its terminations may 
be the same as those of the last-named tumour, and its treatment 
should also be the same. 
Operation.-An incision-rather too long than too short-should 
be made along the tumour, and through its cellular cyst. If the 
skin adhere to it, (but not otherwise,) a portion may be removed 
by two elliptical incisions. Next, the tumour should be removed 
as rapidly as possible, partly by cutting its cellular adhesions, 
partly by tearing them with the finger. Then the wound should 
be examined to ascertain that extirpation is complete ;-and after 
bleeding has ceased it should be closed, and healed by the first 
intention. Sometimes fatty tumours may be removed by passing 
a seton through them, so that they may waste away in suppura- 
tion. This method is more tedious and painful than excision, but 
it may be adopted when it is an object to avoid a long cicatrix,- 
on the face for example. 
III. Encysted Tumours, or Wens, occur most frequently under 
the skin of the head. They consist of a sac, smooth on its external 
surface and containing various matters; sometimes like curd or 
rice, (such tumours being formerly called atheroma-sometimes 
like suet, (steatoma;}-sometimes like honey, (meliceris ;)-some- 
times mere water-sometimes hair, or matter like horn. These 
tumours are painless, rounded, elastic, circumscribed, movable, and 
they fluctuate indistinctly, according to the greater or less fluidity of 
their contents. They enlarge slowly and steadily. 
Treatment.-Extirpation is the only remedy. Punctures, setons, 
injections, or any means for obliterating them by exciting inflam- 
mation, are very hazardous;-because these cysts (like all new 
textures) are liable, if irritated, to take on malignant action. Oint- 
ments of iodine, or other substances for creating absorption, are 
perfectly useless, and may be mischievous. If, however, the 
tumour is small, and consist, as it occasionally does, of an enlarged 
and obstructed follicle of the skin, its aperture (a little black spot) 210 
SURGICAL DISEASES OF THE SKIN. 
Should be looked for, a probe may be passed into it, and the con- 
tents be squeezed out as often as necessary. Otherwise, a straight, 
double-edged, pointed bistoury should be thrust completely through 
the tumour, then the cut edge of the sac should be seized with for- 
ceps, and the whole of it be dissected out. 
IV. The Painful Subcutaneous Tumour is a small hard body, 
rarely larger than a pea or cofleeberry, seated immediately under 
the skin, liable to fits of excruciating pain, and supposed to be 
formed in the substance of a nerve. It must be extirpated. The 
removal of such a tumour from the breast has cured an obstinate 
hysteria.* 
CHAPTER II. 
OF THE SURGICAL DISEASES OF THE SKIN. 
1. General Hypertrophy.-The skin may grow into pendu- 
lous flaps or ridges, which, if inconvenient, are to be removed by 
incision. 
II. Warts or vegetations, consist of elongated papillae of the 
cutis vera, clothed with cuticle. When they are situated on an 
exposed part of the skin, the cuticle is thick, and they are generally 
dry, hard, and insensible; but when they are situated at the upper 
part of the thigh, where two surfaces of the skin are in contact, 
their cuticle is thin, and they exude a serous discharge, which is 
contagious. 
Causes.-They may be produced by the irritation of diseased 
secretions; and hence frequently follow gonorrhoea and syphilis, 
especially in women; but although their secretions are contagious, 
they have nothing of a syphilitic nature, and require no mercury. 
They often come on the hands of children, and disappear without 
any assignable cause. 
Treatment.-If their shape permit, they may be snipped off or 
tied;-or if in very inconvenient situations, (as about the finger 
nails) maybe cut out;-but the surface from which they grew 
requires some astringent to be frequently applied, in order to pre- 
vent their reproduction. If they cannot be removed in this man- 
ner, they may be destroyed by stimulants, of which the following 
are the most generally used: viz. one drachm of muriatic acid with 
three drachms of muriated tincture of iron ;-liquor plumbi diace- 
tatis;-liq. hydrarg. oxymur.;-liq. arsenicalis;-liq. aluminiscomp; 
-nitrate of silver;-equal parts of powdered savine and verdigris; 
* Wood in Edinburgh Med. Chir. Trans., vol. iii. Lon. Med. Gazette, vol. vi. 
p. 59. TUMOURS OF THE SKIN. 
211 
-one drachm of arsenic dissolved in half an ounce of nitric acid; 
and the juice of garlic, sponge, or sumach.* 
III. Corns.are growths of thick cuticle, and are produced when 
the skin, situated over some projecting point of bone, is irritated by 
frequent pressure or friction. It need scarcely be said that their 
usual seat is on the joints of the toes, and that tight boots or shoes 
are their usual cause. They are divided into two kinds, the hard 
and the soft. The hard are situated on the surface of the foot, 
where the cuticle can become dry and hard ;-the soft between the 
toes, where the cuticle is soft and spongy. We must observe, how- 
ever, that what are commonly called soft corns between the toes, 
are excessively irritable fungous warts, and consist of a growth 
from the cutis vera ; not of a mere thickening of the cuticle. More- 
over, according to Sir B. Brodie, when a corn is completely formed, 
a minute bursa is developed between it and the cutis vera.t 
Treatment.-The points to be attended to are, to have the boots 
or shoes properly adapted to the shape and size of the foot;-to 
bathe the feet frequently in warm water, and cover the corns con- 
stantly with a plaster composed of equal parts of soap-plaster and 
oil, spread on kid leather; or, if they are very tender, with a bit of 
linen thickly spread with spermaceti ointment, so that they may be 
kept soft and pliable, not hard and dry;-and to remove the 
growths of cuticle frequently with a blunt knife. If these direc- 
tions are attended to, a cure may be confidently promised in ordi- 
nary cases. But some feet are so misshapen originally, or the toes 
are so crowded together by wearing small low pointed shoes, that 
it is impossible to contrive any shoes that will not press somewhere, 
and create a corn. In some of these cases the application of several 
plasters of thick soft leather, each having a hole punched in it to 
receive the corn and relieve it from pressure, is a very useful device. 
But if the corn is on the sole of the foot, it must be covered with a 
piece of adhesive plaster spread on linen, before the circular plasters 
are applied, otherwise the weight of the body will cause the flesh 
to bulge into the holes, and occasion much pain in walking. Some- 
times it is useful to put a sole of felt into the shoe, with a hole in it 
to receive the corn. If the cuticle is excessively hard, its exfoliation 
may be hastened by rubbing it with nitrate of silver, or liniment of 
ammonia, or by touching it with a hair pencil dipped in strong 
nitric acid, or the chloride of antimony. For the soft corns between 
the toes, the nitrate of silver is the best application. When a corn 
inflames, and the bursa between it and the skin suppurates, the 
pain is often most excruciating, and only to be relieved by paring 
it down and letting out the fluid. 
IV. Horny Tumours are formed by an inspissation of the matter 
of the sebaceous follicles, and are easily removed by two small 
incisions. 
V. Cheloid Tumour.-Under this name is described a peculiar 
* Brodie, Leet, on Mortification, Med. Gaz. vol. xxvii. 
j- Brodie, Lecture on Corns, Med. Gaz. vol. xvii. p. 775; Key on Bunion, Guy's 
Hosp.'Rep. vol. i. p. 416. 212 
CANCEROUS ULCERS. 
tumour, consisting apparently of a thickened reddish patch of skin, 
partly covered with a thin wrinkled epidermis, and generally found 
in clusters on the neck and breast. This disease is rare ; and seldom 
or never leads to ulceration, although it is occasionally the seat of 
shooting pains.* 
VI. Tumours of Cicatrices.-The coloured races of mankind 
are occasionally liable to an hypertrophy of the skin at the site of 
some old cicatrix. Extirpation with the knife is the only remedy. 
There is another affection, which Mr. Caesar Hawkins has desig- 
nated the warty tumour of cicatrices, which occasionally appears 
on old scars. " There appears, in the first place, a little wart, or 
warty tumour in the cicatrix, which is dry and covered with a thin 
cuticle, but which soon becomes moist, and partially ulcerated, like 
the warts of mucous membranes, from which a thin and semi-puru- 
lent fluid is secreted. In this stage it gives no pain nor incon- 
venience." After a time the warts are converted into a more solid 
tumour like fungus haematodes, very vascular, and easily bleeding 
when touched. And this filially ulcerates or sloughs, forming a 
foul excavated ulcer, with fresh growths of warts around it, which 
may destroy the patient by its constant irritation and discharge. 
'Phis affection belongs to a class termed semi-malignant. The 
remedy is extirpation with the knife; or amputation of the affected 
limb, if the diseased growth is very extensive; and the patient may 
be confidently assured, that if thoroughly extirpated it will not 
return.! 
VII. Malignant Disease.-When the skin is affected with 
malignant disease it is generally found either near one of the natural 
orifices of the body in a part largely supplied with follicles, as the 
lip and glans penis; or else in the neighbourhood of some scirrhous 
gland from which the disease is propagated. But it occasionally 
commences independently, in any other situation, as a small, 
hard, indolent lump, which gradually degenerates into scirrhous 
ulceration. 
We have spoken of a class of morbid growths which may be 
called semi-malignant; which, although incurable if left to them- 
selves, destroying the tissues in which they are situated, spreading 
progressively and destroying the parts in their vicinity, and finally 
fatal to life from their constant irritation, still are not really malig- 
nant ;-because they do not attack the lymphatics, do not appear in 
several remote organs simultaneously, and do not return if effectually 
removed. To this class belong the following:- 
VIII. The Cancerous Ulcer (Lepoides} occurs on the face or 
neck of old people, especially below the under eyelid. It begins 
with a flat, brown, irregular crust, like a wart,-which falling off 
displays an ulcer with slightly elevated edges, but no hardened 
base. Its progress is slow; it is unaccompanied by haemorrhage, 
and it occasionally cicatrizes for a time. The tumours called moles; 
* Warren on Tumours, p. 40: Burgess's Translation of Cazenave, p. 305; 
Mayo's Pathology, p. 236. 
f Cassar Hawkins, Med. Chir. Trans., vol. xix. LUPUS. 
213 
-oblong patches of imperfectly organized skin, with black matter 
deposited in its interstices, together with warts, and other anoma- 
lous imperfections of the skin, sometimes degenerate into malignant 
ulcers, after existing in a quiescent state from birth for many years. 
Any such tumour of the skin, therefore, which appears inclined to 
increase or to become irritable should be removed by the knife, or 
by caustic. Sir B. Brodie prefers the caustic for these purposes, 
because he believes it less liable to be followed by erysipelas. 
IX. Lupus is a destructive ulceration of the skin commencing 
with tubercular inflammation. There are two forms; 1st, the 
genuine lupus, herpes exedens, or noli me t anger e; and 2dly, the 
herpes, or lupus non exedens. 
1. Lupus exedens.-A portion of the skin of the face (mostly on 
or near the alee nasi) inflames, swells, and becomes of a bright red 
tint. The swelling frequently occurs in the form of one or more 
tubercles. The inflamed surface sooner or later becomes excoriated, 
and secretes an ichorous matter which dries into a scab. After a 
time, a painful, foul, excavated ulcer forms;-variable in its pro- 
gress, sometimes stationary, or partially cicatrizing;-but, in the 
end, destroying the flesh of the nose and cheek; and causing caries 
and exfoliation of the bones:-till the patient, a horrid spectacle, 
dies worn out with pain;-his eye dropping from its socket into 
the chasm made by the destruction of the cheek. This affection 
mostly occurs to adults;-especially if of weakly scrofulous habits, 
vitiated by intemperance and gross feeding. 
2. The lupus non exedens is a milder form, and attacks scrofu- 
lous children. It begins with shining tubercles, which ulcerate; 
but the ulceration has a tendency to spread widely, rather than 
deeply;-causing prodigious deformity by the successive ulceration 
and puckered cicatrization of the face. 
Treatment.-The indications are, 1st. To correct the general 
health by opening the bowels, keeping up the secretions, promot- 
ing appetite and digestion, and regulating the diet. A course of 
Plummer's pill, with alkalis and sarsaparilla; or of the liq. arseni- 
calis in small doses, or in scrofulous cases of the iodide of potassium, 
will generally be of great service. 
2dly. To alter the diseased action by stimulants. If ulceration 
has not commenced, the part should be rubbed frequently with 
nitrate of silver, so as to keep it constantly covered with a black 
crust. If ulceration has commenced, the nitrate may be applied in 
the same manner;-or in the form of a lotion. But the best appli- 
cations for ulcerated lupus are the arsenical. Now, arsenical appli- 
cations should be either very weak or very strong; they should 
either produce mild stimulation or sphacelus. They should either 
be so weak as not to do any harm if absorbed into the blood; or 
so strong as immediately to kill the part they are applied to, and 
so render it incapable of absorbing them. The weak may be tried 
first-in the form of F. 68, in order to act as a mild stimulant and 
alterative. 
3dly. But if these measures do not speedily succeed, the diseased 214 
DISEASES AND INJURIES OF 
surface must be destroyed by escharotics, of which arsenic and the 
chloride of zinc are the best. The arsenic may be applied in the 
form of ointment or solution (5i. ad 3i) on lint, suffered to remain 
four or five hours. The chloride of zinc is a highly deliquescent 
salt, and is therefore ingeniously recommended by Mr. Ure, who 
introduced its use into this country, to be combined with two parts 
of fresh burned plaster of Paris. This may be made into a paste 
with a little water, and be spread on the diseased surface for four 
or five hours. It causes severe pain for eight or nine hours, which, 
however, may be relieved by opium. When a suspicious tubercle 
is increasing rapidly, but not ulcerating, it should also be destroyed 
with the chloride; but in this case, the cuticle should first be re- 
moved with the liquor ammonias. Caustic pastes may also be made 
with two parts of powdered potassa fusa, and one of soft soap ; - 
or of three parts of quick-lime, and two of dry soap, moistened 
at the time of using with spirits of wine;-or of three parts of 
caustic potass and two of fresh burned lime incorporated in a hot 
iron mortar. The last is called the Vienna paste ; the lime is useful 
in correcting the deliquescent and diffusive power of the potass. 
When either of these caustics is used, the neighbouring sound 
parts should be protected by layers of sticking plaster. After the 
sloughs have separated, which generally happens in from six to 
twelve days, according to their depth, the surface must be treated 
with a weak solution of nitrate of silver; but if there appears any 
return of the ulcerative process, the caustic must be applied again.* 
CHAPTER III. 
OF DISEASES AND INJURIES OF MUSCLES, TENDONS, AND BURS.E. 
I. Atrophy of Muscles.-Two forms of atrophy of muscles 
may come under the surgeon's observation. The first, which may 
be called rigid atrophy, is a state in which the muscles become 
short, rigid, and inextensible; and it generally, by its shortening, 
causes various displacements and deformities of the parts to which 
it is attached;-thus chibfoot is a consequence of this condition of 
the muscles of the calf. 
Causes.-This state of rigid atrophy may be a sequel of various 
circumstances. 1st. It may be induced by long inactivity of a 
muscle;-thus, after long-continued disease of the knee, the flexor 
muscles of the ham may become shortened and inextensible, keep- 
* Ure on Lupus and the Chloride of Zinc, Med. Gaz. vol. xvii. and xviii.; and 
Cyclop. Pract. Surg., Art. Cauterants; Earle, Med. Chir. Trans, vol. xii.; Travers, 
ib. vol. xv.; Burgess's Trans, of Cazenave, p. 250. MUSCLES, TENDONS, AND BURSAL. 
215 
ing the joint permanently bent, and often dragging the tibia off 
from the condyles of the femur. 2dly. It may be a sequel of a 
species of subacute inflammation, which occasionally affects 
muscles of their investing fasciae, and which is attended with pain, 
tenderness and spasm. 3dly. It may be a sequel of habitual 
spasm, by whatever cause produced. 4thly. It may arise from 
defective innervation; that is, from a want of nervous energy. It 
sometimes happens, that after a fever, one arm. or one leg, or both 
legs, are deprived of the power of motion. The affected member 
is always chilly; its skin is numb ; it is imperfectly nourished, and 
decreases in bulk; if the patient is young, it ceases to grow in pro- 
portion with the other parts of the body; and its flexor muscles 
become affected with this form of rigidity, so that the joints are 
immovably bent and contracted. 
Treatment.-In the earlier stages this affection may be relieved 
in various ways. By cupping, fomentations, or the steam bath, 
and subsequently blisters over the affected muscles, if there is any 
evidence of local inflammation. By purgatives and other consti- 
tutional measures, if spasm appears to arise from disordered bowels 
or any other sympathetic source. By stimulating frictions, affusion 
with cold water, passive exercise, shampooing, extension upon 
splints by bandages, and electricity or galvanism, if it arise from 
want of nervous energy, or if arising from any other cause it has 
become chronic. But in cases of long standing, the only remedy 
that can be relied on is division of the affected muscle or its tendon; 
by which means the divided parts will retract; they will unite by 
lymph, and will consequently be lengthened, and then extension 
and the other measures may be pursued with greater vigour and 
efficacy. (For further illustrations refer to Club-foot and Wry 
Neck.) 
Acute Atrophy.-In this affection, one or more muscles rapid- 
ly waste away, and their wasting is attended with severe pain, 
especially in the course of their nerves. It appears to depend on a 
rheumatic inflammation of the muscular nerves, and to be caused 
by exposure to cold.* 
II. Ruptures of Muscles and Tendons.-This is an accident 
which is frequently caused by violent muscular contraction ; espe- 
cially if, after illness or long inactivity, the muscles are subjected to 
sudden and severe exertion. The muscles which are most frequently 
ruptured are, the gastrocnemius and biceps flexor cubiti; but more 
frequently the tendons give way, especially the tendo-achillis, and 
flexor tendons of the wrist. " It occasionally happens," says Mr. 
Liston," to gentlemen of mature years, who, forgetting these, join 
in the sports of youth as they were wont to do ; suddenly they sup- 
pose that some one has inflicted a blow on the leg from behind-their 
dancing is arrested, the foot cannot be extended, and the nature of 
the case is forthwith evident to the most careless observer."! 
* Two cases of it are given in Mayo's Pathology, p. 117. The author has seen 
several, which all attempts have failed to cure. 
f Liston's Practical Surgery, 3d ed. A case of ruptured rectus femoris is related 
in the Med. Gaz., Oct. 10th 1841. It did not unite. 216 
DISEASES AND INJURIES OF 
The symptoms of this accident are, sudden pain, or sometimes an 
audible snap, loss of the motion peculiar to the muscle, and a depres- 
sion at the ruptured part, which may be felt with the fingers. The 
reparation is effected by the eff usion and organization of lymph like 
the callus of broken bone. 
Treatment.-The main point is to keep the injured muscle in a 
state of constant rest and relaxation, so that the severed ends may 
be in close approximation, and to pre- 
vent any violent extension till the 
union is firmly consolidated. Pain 
and inflammation must be counter- 
acted by leeches, and cold or warm 
lotions. When the tendo-achillis, or 
the gastrocnemius muscles are rup- 
tured, the knee may be kept bent by a 
string passing from the heal of the 
slipper to a bandage round the thigh. 
[See cut.] For ruptures of the exten- 
sors of the thigh, the limb must be 
placed in the same position as in frac- 
ture of the patella. If the biceps is 
ruptured, the elbow must be kept bent 
to its utmost;-if the tendons about 
the wrist or fingers, the forearm must 
be confined by a splint. After three 
or four weeks of this rest, the surgeon 
may use passive motion; that is, may 
bend and extend the joints of the in- 
jured limb with his hands several 
times successively. But the patient 
must be cautious in using the muscles 
for a long time; and (if it be the tendo- 
achillis) must walk with a high-heeled shoe for two or three 
months ; so that the recent callus may not be stretched and length- 
ened, which would cause permanent weakness. 
III. Strains.-A strain signifies a violent stretching of tendinous 
or ligamentous parts, with or without rupture of some of their fibres. 
It produces instant severe pain, often attended with faintness; and 
great tumefaction and ecchymosis; with subsequent weakness and 
stiffness. If the part is not kept at rest, or if the knee or some other 
large joint is affected, there will be great pain, inflammation, and 
fever, that may lead to serious or even fatal results. 
Treatment.-The most essential measure is perfect rest; and to 
ensure this, if the case is at all serious, the part must be confined 
by a pasteboard splint. Warm fomentations generally give more 
relief than cold lotions; but in this, as in similar cases, the patient's 
feelings are the safest •criterion. If inflammation runs high, or a 
large joint is affected, leeches, or bleeding, and general antiphlo- 
gistic measures, must be adopted. Subsequently the indications are 
to procure absorption of thickening and extravasation, by friction 
Fig. 12. TUMOURS AND BURSA:. 
217 
with stimulating liniments, moderate exercise, and bandages, espe- 
cially the flannel bandage. If the case is severe, it may be expedient 
to apply a succession of blisters, and the other remedies directed for 
chronic inflammation of joints. 
V. Acute Inflammation of Fascije.-Acute inflammation of 
fasciae is generally caused by punctured wounds;-especially by 
puncture of the fascia of the biceps during venesection :-and by 
punctures of the fingers, inflammation of the tendinous sheaths of 
what is called thecal abscess; paronychia grants, or tendinous 
whitlow. It is attended with severe, tensive, throbbing pain; exqui- 
site tenderness; slight, but tense and resisting swelling; and very 
great constitutional disturbance. It may lead to suppuration;-the 
matter extending itself along muscles and tendons-from the fingers 
to the forearm-causing sloughing of the tendons-severe irritative 
fever-life often obliged to be saved by amputation-or the limb, 
if preserved, stiff and useless. 
Treatment.-If the pain and tension increase, notwithstanding 
the employment of leeches, fomentations, and purgatives, free in- 
cisions must be made through the inflamed parts; in order to give 
vent to matter, if it have formed-or by creating a free discharge of 
blood, to prevent its fomentation.* 
VI. Subacute Inflammation of Fascia.-Subacute inflamma- 
tion sometimes affects the fasciae of the forearm, hand, or neck; pro- 
ducing pain and tenderness, with spasm in the subjacent muscles, 
which may degenerate into obstinate rigidity, producing one form 
of wry-neck, &c. 
Treatment.-Leeches, fomentations, blisters, mercurial cam- 
phorated liniments, F. 25 ; vapour bath; very small doses of col- 
chicum and Dover's powder at bedtime, with aperients in the 
morning; or blue pill administered so as to cause incipient ptyalism. 
VII. Tumours on Tendon and Ligament.-Small tumours 
about the size of a pea are apt to form on the tendons or fasciae. 
Sometimes they follow a strain; and they have been known to occur 
on the palmar fascia after a good day's work at the oar; but they 
often arise without any assignable cause. If indolent, as they often 
are, they maybe left to themselves, and they will probably disappear. 
If painful, leeches, blisters, and frictions with mercurial ointment or 
liniment, are the proper remedies. 
VIII. Chalkstone Tumours are composed of the lithate (or 
urate) of soda; a white insoluble substance, which in gouty sub- 
jects is frequently deposited into the texture of the bones, joints, 
and cellular tissue; -but most frequently into the cellular tissue 
that environs the tendons of the feet or hands. The tumours which 
this substance forms are not always inorganic, but may be per- 
meated by exquisitely sensible threads of cellular membrane. After 
remaining indolent for a variable time, they inflame the superjacent 
skin, and cause the formation of ulcers that are extremely obstinate, 
and discharge vast quantities of the concretion. They must be 
* Vide Whitlow, in Part iv. chap. 24. 218 
acute inflammation of bursje. 
treated with simple dressings. It is rarely expedient to meddle 
with these tumours with the knife; but if any one be very incon- 
veniently situated, and be perfectly indolent, it may be extirpated. 
The wound must be expected to heal very slowly. 
IX. Ganglion and Tumours of Bursa:.-The simplest affec- 
tion of bursae and of the synovial sheaths of tendons, is excessive 
secretion of synovia, and consequent tumefaction, to which the 
name of ganglion is given. A recently-formed ganglion is an indo- 
lent fluctuating tumour, transparent enough to per- 
mit the light of a candle to be seen through it. It 
contains a clear synovia; but tumours of those bursae 
which may be formed by friction-such as the bursa 
which forms the swelling of bunion, do not contain 
synovia, but a viscid, semi-fluid substance, like the 
crystalline lens. The ordinary situation of ganglion 
is, of course, that of the various bursae;-on(the 
patella, or olecranon; or on the inner side of the 
head of the tibia; or the angle of the scapula; but 
most frequently about the wrist and fingers. When 
the general sheath of the flexor tendons at the wrist 
is affected in this way, it forms a remarkable tumour, 
which projects in the palm of the hand, and also 
above the wrist, but is bound down in the middle by 
the anterior annular ligament of the carpus. When 
ganglion has lasted some time, or has been subjected 
to inflammation, the synovial membrane becomes 
thickened, the contained fluid turbid and mixed with 
flakes of lymph, and the tumour loses its softness and 
transparency. The ordinary cause of ganglion is a twist or strain 
of some kind, or irritation from pressure or friction.* 
Treatment.-The best plan of treating recent non-inflamed 
ganglion seems to be, either to puncture it with a grooved needle, 
or else to make a subcutaneous incision into the sac; that is, to 
introduce a needle with a cutting point, and to turn the point 
against the inside of the sac and divide it; without, however, 
making a larger wound in the skin than is necessary to introduce 
the needle. The object of these operations is to empty the sac, 
and form an aperture by which its contents may henceforth pass 
into the cellular tissue and be absorbed. As soon as it is emptied, 
constant, pressure should be applied by means of compress and 
bandage, which may be wetted with cold lotion if agreeable. 2. 
If this plan fails, recourse may be had to friction, with mercurial 
and other stimulating liniments; or Scott's ointment, F. 25, or tinc- 
ture of iodine, or blisters, with a view of exciting absorption. 3. 
In obstinate cases it is a good plan to dissect out the cyst of the 
ganglion-provided that it is formed of a mere bursa, (as over the 
patella or olecranon,) and has no connection with the sheaths of 
tendons. 4. But if the bursa is large or deeply seated, as over the 
Fig 13 
* The foregoing cut displays a ganglion formed by the synovial sheath of the 
flexor tendon of a finger. From the King's College Museum. DISEASES OF THE LYMPHATICS. 
219 
angle of the scapula, it should be punctured with a lancet, when 
it may probably inflame and suppurate, and heal up like an abscess. 
5. In obstinate cases, especially if the cyst is much thickened, Mr. 
Key recommends a puncture to be made, and a few threads of silk 
to be passed through the sac as a seton. This will create great 
suppuration and constitutional disturbance for a time, but it will 
destroy the secreting power of the sac, and effect a radical cure. 
The less, however, that the sheaths of the flexors of the wrist are 
meddled with, whether by puncture or seton, the better. Mr. 
Wickham strongly recommends the vapour bath, or local steam 
bath, as a means of getting rid of thickness and stiffness after these 
operations. Lastly, any rheumatic or gouty tendency should be 
corrected by proper medicines. 
X. Acute Inflammation of Bursae is most frequently exem- 
plified in the affection called the housemaid's knee,-which is 
an acute inflammation of the bursa, that intervenes between the 
patella and skin,-common enough in that class of females, from 
kneeling on hard damp stones. It causes very great pain, swelling, 
and fever; it may be distinguished from acute inflammation of the 
synovial membrane of the knee-joint, by observing that the swell- 
ing is very superficial, and in front of the patella, which is obscured 
by it; whereas, in inflammation of the synovial membrane of* the 
knee, the patella is thrown forwards, and the swelling is most pro- 
minent at the sides. 
Treatment.-Rest, leeches, fomentations, and purgatives; by 
which, if the pain and swelling are not relieved, it must be punc- 
tured, and treated as an acute abscess.* 
Loose Cartilages are sometimes formed in the synovial 
sheaths of the hand and foot. Their origin, symptoms, and treat- 
ment, are the same as when they are found in joints. 
CHAPTER IV. 
OF THE DISEASES AND INJURIES OF THE LYMPHATICS. 
I. Acute Inflammation of lymphatic glands has already been- 
exemplified when speaking of bubo. The inflamed gland enlarges 
rapidly, and forms a hard, tense swelling, with great pain and fever. 
If it suppurate, the matter is formed in the cellular tissue around it, 
or between it and the skin, and the case proceeds as an acute 
abscess. This affection may be caused, (1.) By constitutional dis- 
order, like acute abscesses. (2.) By local violence, such as blows 
or kicks. (3.) By the irritation or absorption of acrid matter from 
* Wickham, Cyclopaedia Pract. Surg. Art. Bursae. 220 
DISEASES OF THE LYMPHATICS. 
ulcers, venereal or otherwise. (4 ) By simple injuries, a clean 
prick, for instance, in persons whose health is deranged. (5.) By 
punctures inoculated with some irritant fluid, perhaps from a putrid 
body. 
When the disease arises from ulcers or punctures, the inflamma- 
tion generally begins in the absorbent vessels leading to the glands, 
which appear as red lines under the skin, and feel hard, cordy, and 
tender. 
Inflammation of the lymphatics, when a consequence of dissec- 
tion wounds, may be distinguished from the typhoid malady aris- 
ing from the same cause, (Part iii. chap, ix.) by the simple inflam- 
matory character of the constitutional symptoms. It begins with 
swelling and festering of the original wound, from which red lines 
extend up the arm. In trivial cases, these may stop at, or may not 
even reach the elbow; and there may be very little or no febrile 
disturbance. But, in severe cases, the glands in the axilla swell 
and become exquisitely painful;-there is great fever; the pulse is 
rapid, full, and hard;-matter is formed; and if it be confined by 
fasciae, and not evacuated by art, the nervous system may sink 
under the excruciating pain, and the patient may die. If the mat- 
ter is discharged, he recovers his health without much difficulty. 
A comparison of these symptoms with those of the other affection 
will readily show their intrinsic difference,-although, as was 
before said, it is very possible that both may be combined. 
Treatment.-Acute inflammation of the lymphaticsarising from 
local injury, from constitutional causes, or from the irritation of 
ordinary ulcers, must be treated by leeches, fomentations, purga- 
tives, and the other local and general antiphlogistic measures tnat 
require no comment. If it be produced by slight injuries, whether 
in dissection or otherwise, the original wound should be dilated, 
and then be assiduously fomented; lunar caustic should be applied 
to the skin over the inflamed lymphatic vessels, and the bowels 
should be cleared. If the axillary glands are affected, and the 
pulse is full and hard, venesection should be performed, and even 
repeated according to its influence on the pain and on the pulse;- 
calomel should be frequently administered, and the swelled parts 
should be covered with leeches and fomentations. Incisions should 
be made early wherever matter is suspected to exist, or is likely to 
be formed-and when fever abates, the patient's health should be 
recruited by tonics and change of air, and care must be taken to 
prevent the formation of sinuses. 
II. Chronic Glandular Tumours may arise from simple chro 
nic inflammation-from sarcomatous transformation-from deposit 
of scrofulous tubercle, and from scirrhus or other malignant disease. 
(1.) Chronic Inflammation causes a tender swelling, with 
aching pain, and slight redness of the skin. It may be caused by 
any slight irritation in the course of the lymphatics, but is more 
frequently constitutional. 
Treatment.-Repeated leechings, cold lotions, and aperients. DISEASES OF THE BONES. 
221 
followed by alteratives and tonics, and empl. hydrargyri, or ung. 
iodinii. 
(2.) Glandular sarcoma consists in the transformation of one or 
more glands (especially in the neck) into sarcomatous tumours, 
whose characters and treatment have been before described (p. 
208-9). These are to be distinguished from scrofulous tumours by 
the circumstance, that one or two glands only are enlarged, and 
that they grow slowly but steadily;-whereas in scrofula a whole 
cluster is enlarged, and they are subject to fits of swelling and sub- 
sidence, from constitutional changes or atmospheric vicissitudes. 
From scirrhus and fungus medullaris they may be distinguished by 
attention to the diagnostic signs of those maladies. 
CHAPTER V. 
OF THE DISEASES AND INJURIES OF BONE. 
SECTION I. - OF THE DISEASES. 
I. Simple Exostosis signifies a tumour formed by the hyper- 
trophy or irregular growth of bone. These tumours are hard, 
indolent, and irregular, and mostly situated on the upper part of 
the humerus, or on the lower part of the femur, near the inser- 
tion of the adductor magnus. Their shape, is sometimes broad 
and flat; sometimes rounded and prominent, with a narrow neck. 
Their structure, is that of ordinary bone, either dense like the cor- 
tical substance, or porous like the cancelli. They cause no pain, 
unless they happen to press on nerves or arteries; but they may by 
their bulk interfere with the functions of various important parts, 
and give rise to the most serious evils. When situated on the inner 
surface of the skull, they may cause epilepsy; in the orbit they 
may cause the eye to protrude on the cheek;-they may oblite- 
rate arteries, and impede the action of muscles, and the movements 
of joints. Sometimes they arise without any very obvious cause; 
although most probably they generally originate in a blow, or strain, 
or pressure, which produces a slight degree of inflammation. 
Treatment.-In the first place, an attempt may be made to pro- 
cure absorption of the tumour by means of blisters, friction with 
ointment of mercury or iodine, and mercurial plasters. F. 25. 
Sometimes (especially if the complaint follow a blow) a moderate 
course of mercury, so as barely to affect the mouth, will be effec- 
tual. If these measures do not succeed, the tumour must be re- 
moved by operation. If it is globular, with a narrow neck, it may 
be cut down upon, and be sawn or chiseled off, or cut off with a 222 
DISEASES OF THE BONES. 
gouge. But supposing that its base is broad, so that this cannot 
be done, its periosteum may be shaved off; after which it will pro- 
bably perish by necrosis, or else waste away. Inflammation must 
be guarded against after these operations; for it may possibly affect 
the whole bone, and the joints at either extremity, and lead to very 
disagreeable consequences. Exostoses of the clavicles of children 
almost always disappear of themselves. 
II. Rickets or Rachitis signifies a feeble state of the system, 
with atrophy and distortion of the bones ;* it is generally an accom- 
paniment of scrofula. The cortex of the bones is thin, and their 
internal structure very spongy; the cells large, and filled with gela- 
tinous fluid;-sometimes they are as soft as cartilage. Of course they 
are unable to support the weight of the body, without bending and 
producing deformity. In moderate cases, the ankles only may be 
a little sunk, or the shins bent, or the spine curved ; but in aggra- 
vated cases the physiognomy and general appearance are very 
peculiar. The stature is short; the head large, with a protuberant 
forehead; the face peculiarly triangular, with a very sharp-peaked 
chin, and projecting teeth; the chest narrow and prominent in front, 
whence the vulgar term pigeon-breasted;-the spine variously 
curved; the pelvis distorted in such a manner that the three points 
of support, viz. the promontory of the sacrum, and the two aceta- 
bula, are pressed together, rendering the cavity perilously small for 
child-bearing, and the limbs are crooked, their natural curves being 
increased. But after puberty it is astonishing how firm the bones 
become, and, in particular, how they are strengthened by strong 
ridges developed on their concave sides. 
Treatment.-The health must be invigorated by pure air, whole- 
some food, and the other measures prescribed for scrofula. With 
respect to irons and mechanical supports, they may perhaps be of 
service if the legs continue very weak and distorted at six or eight 
years old, provided that care be taken not to let them press injuri- 
ously on one part whilst supporting another. But at an earlier age 
they are of no use; they merely occasion fatigue and inactivity, 
and it is far better to trust to nature and good nursing. 
III. Mollities Ossium (Malacosteon} is a disease of adult age, 
and generally attacks females. In some cases the bones are reduced 
to a mere shell, thin as a wafer, and filled with fat; in others they 
are soft, reddish, and spongy. This malady is incurable. It is 
mostly connected with some palpable disorder; such as fetid 
sweats, enormous deposits in the urine, or cancer, of which it is a 
very frequent attendant.! 
* Atrophy of bone may be concentric or eccentric. In the former variety it is 
shrunk in size; in the latter it is feeble in tissue, and lighter in weight, but may 
preserve its original size. Atrophy, again, may be general, as in rickets and mol- 
lities ossium; or partial, when it depends on some local cause, as from want of 
exercise, deficient nervous influence, or insufficient supply of arterial blood, or 
sometimes after inflammation.-Vide T. B. Curling on Atrophy of Bone, Med. Chir. 
Trans, vol. xx. 
f Such bones contain only one-fifth or perhaps one-eighth of earthy matter 
instead of two-thirds, and their animal matter is so perverted that it yields no 
gelatine, which is the chief animal constituent of healthy bone. DISEASES OF THE BONES. 
223 
IV. Acute Inflammation of bone most frequently attacks the 
femur or tibia in children, and is usually attributed to cold. It fre- 
quently affects more than one bone, but is generally confined to the 
shafts, and does not often involve the articular extremities. 
Symptoms.-The patient is seized with violent shivering and fever, 
and with deep-seated severe pain, and great swelling of the affected 
limb, the skin of which displays a kind of erysipelatous redness. 
Matter soon forms, burrows among the muscles, and at last points 
in several places. Sometimes the patient is destroyed by the vio- 
lence of the constitutional derangement, or sinks under the profuse 
suppuration that follows; but more frequently life is preserved, 
and the bone left in a state of necrosis. On examination of cases 
that have proved fatal, or that have been subjected to amputation, 
the shaft of the bone is generally found separated from the epi- 
physes, and partially or entirely separated from its periosteum; and 
patches of newly-formed bone are deposited upon its surface, and 
between the layers of the periosteum. 
Treatment.-Aperient and febrifuge medicines, with leeches and 
cold lotions, should be assiduously employed at first. As soon as 
fluctuation can be detected anywhere, an opening should be made; 
and it is better to do so too soon than too late. When a free exit 
is provided for the matter, a bandage should be applied to prevent 
its accumulation. If the patient seem likely to sink, in spite of 
tonics and nutriment, from the extreme discharge, 
the affected limb must be amputated. 
V. Chronic Inflammation of bone is most 
frequently the result of some ■ constitutional dis- 
order, and generally attacks several bones simul- 
taneously. It is denoted by slow enlargement, 
tenderness, weight and pain. If caused by in- 
jury, it may lead to necrosis; but in general it 
produces no organic change, save irregular en- 
largement. 
Treatment.-The general health should be 
improved by change of air, alteratives, and tonics, 
especially Plummer's pill, or hyd. c. creta, in 
small doses every night, and the iodide of potas- 
sium, with sarsaparilla. F. 56, 57. The local 
measures are repeated leechings and fomenta- 
tions, as long as there is tenderness or much 
pain; with Scott's ointment, F. 25, or blisters 
subsequently. 
VI. Inflammation of the Periosteum gene- 
rally occurs on the subcutaneous aspect of thinly- 
covered bones; especially the tibia, ulna, clavi- 
cles, and os frontis. It produces oval swellings, 
called nodes, through an infiltration of lymph and serum into the 
periosteum, or between it and the bone. If acute or mismanaged, 
it may lead to suppuration, and caries or exfoliation of the bone; 
but more frequently it causes merely a superficial deposit of rough 
bone. It may sometimes be caused by mechanical injury, or ex- 
Fig- 14. 224 
DISEASES OF THE BONES. 
posure to cold; but far more frequently it is a consequence of dis- 
order of the health, especially of a scrofulous or venereal taint, or 
the too free use of mercury. 
Treatment.-For the acute, leeches, fomentations, purgatives, 
diaphoretics, and colchicum, in doses of xx. of the wine every 
six hours; or gr. ii. of the iodide of potassium at the same interval. 
Calomel may be given in doses of gr. ii., with half a grain of opium 
every night, if the constitution has not been injured by any previ- 
ous, profuse administration of it; but sometimes the disease will 
yield to nothing but the full influence of mercury, although the 
system has been enfeebled by repeated courses. For the chronic, 
the same treatment as for chronic inflammation of bone. The 
severe nightly pain is, after the application of leeches, best relieved 
by renewed blisters. An incision is sometimes necessary if matter 
form between the periosteum and bone, and no measures succeed 
in producing its absorption and allaying the pain; but it very often 
happens, especially in venereal cases, that mercury, (if not pre- 
viously administered to excess,) or the iodide of potassium, sarsa- 
parilla, and blisters, will accomplish those objects. 
VII. Abscess is a rare consequence of inflammation of bone. A 
cavity lined with a vascular membrane, and 
filled with pus, is formed in the substance of 
the bone, generally the tibia, which may or 
may not be unusually dense around it. Ab- 
scess may be suspected when, in addition to 
permanent inflammatory enlargement and ten- 
derness, (which may have lasted for years,) 
there is a fixed pain at one particular spot, 
aggravated at night, and unrelieved by any 
remedy. 
Treatment.-When there is good reason 
to suspect the existence of abscess, the bone 
must be laid bare by a crucial incision, and 
an opening be made with a trephine at the 
precise seat of pain; it may, if necessary, be 
deepened with a chisel. After the pus is evacuated, the wound 
must be left to granulate and cicatrize. 
VI1L Necrosis.-This term, although signifying the death or 
mortification of bone generically, is yet usually restricted to one 
form,-in which part of the shaft of a cylindrical bone dies, and is 
enclosed in a case of new bone. The term exfoliation signifies 
necrosis of a thin superficial layer, which is not encased in any 
shell of new bone. 
1. Necrosis is a frequent consequence of inflammation of the 
shafts of long bones in children, especially of the femur and tibia. 
Pathology.-The bone dies; but its periosteum and the sur- 
rounding cellular tissue become infiltrated with lymph, which 
speedily ossifies, forming a new shell around the dead portion, 
and adhering to the living bone above and below it. The dead 
portion, (technically called the sequestrvm,') generally consists of 
the circumference of the shaft only, and not of the entire thickness ; 
Fig 15. 225 
DISEASES OF THE BONES. 
for the interior of the shaft seems to be atrophied 
and absorbed after the death of the exterior. The 
inside of the sequestrum is usually rough, as if 
worm-eaten. In the majority of cases the epi- 
physes, or articular extremities, are fortunately 
unaffected. After a time, if the sequestrum is 
removed by art or accident, the newly-formed 
shell contracts, its cavity is abolished, and it gradu- 
ally assumes the shape and function of the former 
bone. 
Symptoms.-After acute inflammation, the bone 
remains permanently swelled; and the apertures 
which were made for the discharge of matter, 
remain as sinuses, from which many sensitive, 
irritable granulations shoot. These sinuous aper- 
tures in the skin correspond to holes in the shell 
of new bone, (technically called cloacsey,-and if 
a probe be passed into them, the sequestrum may 
be felt loose in the interior ; or at least the probe 
will strike against dead bone. 
Treatment.-The indication is to remove the 
sequestrum. Any hope of its being absorbed or 
extruded by any natural process is quite nuga- 
tory; and to permit it to remain, is but to condemn the patient 
to a perpetuance of disease and deformity. As soon, therefore, 
as the shell of new bone is sufficiently strong, a free incision 
should be made so as to expose its surface, and it should be made 
at a part where cloacse exist, or where the bone is nearest the skin. 
Then the new shell must be perforated with the trephine, or with 
Hey's saw, or with a pair of strong bone forceps ;*-and the 
sequestrum must be drawn out. If it cannot be extracted entire, it 
should be divided with strong forceps. If the sequestrum be small, 
or the cloacae large, the former may perhaps be extracted without 
any operation; and one way of enlarging the cloacae is to dilate 
the sinuses in the skin, and keep them open with tents of lint. 
Necrosis of the articular extremities, or of the tarsus or carpus, 
involves the joints, and requires amputation. 
2. Exfoliation signifies the mortification and separation of a 
superficial layer of bone, without the formation of a shell of new 
bone, as in necrosis. It is generally caused by some mechanical 
or chemical injury, or by stripping off the periosteum. Not, how- 
ever, that stripping off the periosteum is invariably followed by 
exfoliation; for the bone may remain red and moist, and throw out 
granulations; whereas, if it be about to exfoliate, it becomes white 
and dry. 
Treatment.-A lotion of weak nitric acid may be useful; and 
the exfoliating portion should be removed as soon as it can be 
detached. 
Fig. 16. 
* The chloride of zinc has also been used to make a hole in the new shell.- 
Vide p. 214. 226 
TUMOURS OF BONE. 
IX. Caries is an unhealthy inflammation of bone which essen- 
tially produces softening, and probably leads to ulceration and 
suppuration. 
Pathology.-The bone is soft and red; its cells are filled with a 
red serous or thick glairy fluid;-and in scrofulous cases there is 
also a deposit of more or less tubercular matter. The bone, when 
macerated and dried, looks soft and spongy; eaten into hollows, 
and thrown into irregular elevations, at the site of granulations. 
Symptoms.-" The external character of the limb," says Mayo, 
" is the same in necrosis and caries. The bone appears enlarged, 
and one or more sinuses open 
from it at points that are soft, and 
red, and sunken." If a probe is 
passed into these, it will readily 
break down the softened texture 
of the carious bone which yields 
a gritty feel. 
Causes.-1Caries most frequent- 
ly attacks bones of a soft, spongy 
texture; such as the vertebrae, 
the round and flat bones, • and 
the articular extremities of long 
bones. Its genuine cause is some 
constitutional disorder, scrofula, 
syphilis, or mercury. 
Treatment.-The indications 
are two fold;-to rectify consti- 
tutional disorder, and to remove 
the local disease. The former 
object must be accomplished by 
a change of air, tonics, and altera- 
tives, and the measures that have 
been directed for scrofula and sy- 
philis, supposing the caries to be 
connected with those maladies. 
If it can be done, the best local remedy consists in freely exposing 
and removing the whole of the diseased portion of the bone by the 
chisel or trephine. If this cannot be done, lotions of the dilute 
nitric or phosphoric acid may be used. Caries of the articular 
extremities of bones will be considered together with diseases of 
the joints. 
TUMOURS OF BONE. 
Of the various tumours of bone, some depend on an hypertrophy 
of its normal structure, or on the enlargements incident upon 
inflammation and its consequences. These have been sufficiently 
Fig. 17. 
Fig. 18.* 
* This cut displays a state formerly termed spina ventosa, in which the interior 
of a bone is hollowed out by caries, whilst fresh bone is deposited on the circum- 
ference. The bone most frequently so affected is the head of the tibia. TUMOURS OF BONE. 
227 
described in the preceding paragraphs. Others, which depend 
upon the development of adventitious tissues in or upon bone, 
remain yet to be noticed; and they are of two orders: the non- 
malignant, and the malignant; the former of which we shall treat 
of first. 
1. Tumours from extravasated blood.-Mr. Travers* describes 
a case in which, after a blow, the clavicle enlarged into a firm oval 
elastic tumour; which, when punctured by a grooved needle, 
yielded a few drops of dark grumous blood. The whole bone was 
extirpated. On examination, it was proved that the tumour had 
evidently originated in a rupture of the vessels of the bone, and an 
extravasation of blood into the cancelli. By the pressure of this 
blood, and a continuance of the extravasation, the bony tissue was 
expanded and absorbed; and the cancelli were converted into 
chambers filled with dark solid coagula. The tumour was invested 
by the periosteum. 
2. Osteo-aneurism. This consists in that disease of the capil- 
laries of the bone which is called aneurism by anastomosis, as 
will be described in the chapter on the arteries. The bone affected 
is generally the tibia just below the knee. The patient complains 
of a sudden pain in the part. This is followed by painful swelling, 
and all the veins of the leg are observed to be very tense and full. 
After a time, the whole limb becomes dark, red, and painful; and 
the tumour becomes distinctly pulsatory. On examination, it is 
found to be composed of a tissue filled with clots of blood in con- 
centric layers, and each clot communicating with a dilated artery; 
the bone of course expanded, thinned, and absorbed, as in the last 
case. This disease is rare. Ligature of the main arterial trunk 
of the limb, or amputation, are the remedies. 
3. Cartilaginous exostosis, enchondroma (Muller). This growth 
is described by Muller as a firm spheroidal tumour consisting of 
masses of true cartilage embedded in a fibro-membranous cellular 
structure. When boiled, it yields a variety of gelatine, termed 
chondrine. It may be developed in the centre of a bone, or on its 
surface. In the former case, it causes the bone to expand and be 
absorbed before it, till at last it is covered by a mere shell. This 
tumour ordinarily affects only one bone ; and is occasionally found 
in the glands, especially the parotid. It is not malignant; for 
although incurable, and although by its continued growth it may 
distend the skin, and cause ulceration, and wear out the constitu- 
tion by the irritation and discharge, still it does not return if 
thoroughly extirpated. 
4. di hard fibrous or fibro-cartilaginous tumour containing 
bony spiculse, may be developed in the substance, or on the sur- 
face of bone, especially of the superior or inferior maxillary. 
5. Hydatids or thin cysts, containing a clear water, are occa- 
sionally developed in the substance of bone ; causing it to expand 
and form a tumour, the diagnosis of which must be exceedingly 
difficult, until the part has been laid open by operation. One of 
* Med. Chir. Trans, vol. xxi. 228 
MALIGNANT TUMOURS. 
the best cases on record was described by Mr. keate, who treated 
it successfully by removing as much as possible of the cysts and 
of the bone containing them, and applying a solution of sulphate 
of copper to the diseased surface.* 
MALIGNANT TUMOURS. 
6. Osteosarcoma is described as a form of cartilaginous growth, 
containing numerous cysts filled with a 
reddish fluid, and having a kind of 
skeleton composed of thin papery plates 
and spiculse of bone, dispersed arbore- 
scently like coral through it.t This is 
malignant, because, after amputation 
of the tibia for this disease, it has 
appeared on the stump of the femur. 
7. Medullary sarcoma is perhaps 
the most frequent malignant disease of 
bone. I ts characters have been already 
described. "It generally," says Mr. 
Mayo, " arises in the cancellous struc- 
ture; it is therefore usually attended 
with considerable pain, for the growth 
of the tumour is rapid, and the shell of 
the bone has to be partly absorbed, 
partly mechanically forced open from 
within." 
8. Scirrhus in bone is generally a 
concomitant of the disease in the breast, 
or in some other part. The femur is 
the bone most frequently affected, and 
is often fractured in consequence of the 
scirrhous deposit and atrophy of its pro- 
per texture. 
The chief points which distinguish the malignant from the non- 
malignant tumours, are, their greater rapidity of growth; the greater 
pain with which they are accompanied, their greater softness at 
some points than others; their tendency to involve and become 
blended with the skin and other adjacent tissues, (a sure charac- 
teristic of malignant growth,) and the existence of the malignant ca- 
chexia. But as it is often impossible to distinguish these two classes 
of tumours from each other, or from inflammatory enlargements, it 
is satisfactory to know that the early treatment of them all is the 
same. The same measures that will cure the curable affections, will 
Fig J9 
* Vide Mr. Keate's case, Med. Chir. Trans, vol. x.; quoted also in Mayo's 
Pathology; case of hydatids growing on the tibia and causing absorption of the 
bone and fracture, in Wickham on Diseases of Joints; and case of hydatids in 
bones of pelvis, Med. Gaz. vol. xxx. p. 990. 
t This is well shown in the accompanying cut, from a preparation in the King's 
College Museum. FRACTURE. 
229 
check the incurable. They are, repeated leeching, mild mercurial 
alteratives, sarsaparilla with small doses of the iodide of potassium, 
and change of air and other general tonics. If these measures fail, 
the only recourse is amputation or extirpation; which may be per- 
formed with confidence of a cure as regards the non-malignant 
growths. But the extirpation of truly malignant growths, to be 
effectual, should be very early, and very complete, a partial removal 
being, to use Mr. Liston's words, an " unmeaning and utterly use- 
less cruelty."* 
SECTION II.-OF FRACTURE GENERALLY. 
The term fracture, with its varieties simple and compound, trans- 
verse, oblique, and comminuted, requires no definition. 
Exciting Causes.-The exciting causes of fracture are two: 
mechanical violence, and muscular action. Mechanical violence 
may be direct or indirect. It is said to be direct, when it produces 
a fracture at the part to which it is actually applied; as in the in- 
stance of fracture of the skull from a violent blow. It is said to be 
indirect when a force is applied to two parts of a bone, which gives 
way between. This is exemplified in the case of fracture of the 
clavicle from a fall on the shoulder. The sternal end of the bone 
is impelled by the weight of the body, and the acrominal end by the 
object it falls against; and the bone, acted upon by these two forces, 
gives way in the middle. 
The bones most commonly fractured by muscular action are the 
patella and olecranon; but the humerus, femur, or any other bone, 
may give way from this cause, if preternaturally weak. 
Predisposing Causes.-There are certain circumstances which 
render the bones more liable than usual to be broken. These are 
(1.) old age, which renders the bones soft and brittle; the earthy 
matter being deficient in quantity, and the animal matter having 
lost its elasticity. (2.) Disuse, as in bed-ridden people. (3.) Cer- 
tain diseases, as inollities ossium, and cancer. (4.) Original 
conformation; the bones of some people being exceedingly brittle, 
without any assignable cause. 
Reparation.-The reparation of fractures is produced by the 
effusion and organization of lymph. But this process varies con- 
siderably as it occurs in different bones. 
1. After fracture of ordinary bones, a quantity of lymph is 
effused into the cellular tissue around the broken part. This, in 
two or three weeks, becomes converted into a cartilaginous capsule, 
called a provisional callus, which completely surrounds the frac- 
ture, and adheres firmly to the bone above and below it. In two 
or three weeks more, the provisional callus ossifies;-and then the 
use of the bone is restored. But at this time the ends of the frac- 
* Vide Sir A. Cooper on Exostosis, in Cooper and Travers' Surgical Essays; 
Brodie on Abscess in Bone, Med. Chir. Trans, vol. xvii; Muller on Tumours, by 
West; Breschet sur des Tumeurs Sanguines; and Liston on Tumours of Mouth 
and Jaws, Med. Chir. Trans, vol. xx. 230 
FRACTURE. 
tured bones are not directly united; and if the provisional callus 
were removed, they would still be separable ;-in the course of five 
or six months, however, ossific matter is gradu- 
ally deposited between them, and the provisional 
callus is absorbed. 
There has been much dispute as to the source 
of the lymph which forms the callus. Some 
persons have asserted, that it is effused by the 
bone or its medullary membrane, others, by the 
periosteum, and others by the cellular or other 
tissues around. But the fact is, that it is effused 
indiscriminately from all the tissues around the 
fracture; and once effused, its conversion into 
cartilage and then into bone is the result of its 
own organic forces. Moreover, if one of the 
bones which unite by a provisional callus when 
fractured, be extirpated entirely, and its perios- 
teum with it, the lymph which is effused by the 
surrounding tissues will (especially in the lower 
animals) very probably form a new bone.* 
2. But after fracture of the cranium, acro- 
mion, olecranon, patella, cervix femoris, or of 
any bone invested with synovial membrane, no 
• provisional callus is formed. If the broken parts 
are kept in the very strictest apposition, bony union will certainly 
occur in two or three months. But if a portion of the skull be 
removed, so as to make a gap;-or if after fracture of it, or of the 
other bones in the same category, the divided parts be not kept 
in the closest apposition, the lymph effused will be converted into 
ligament, which very slowly ossifies, if at all. 
The reason for the absence of a provisional callus, in these cases, 
may be gathered from a consideration of the situation and function 
of the bones enumerated; and from the evil results that would 
ensue, if a hard lump of callus were liable to be thrown out on the 
interior of the skull, or into the cavities of the joints. That this is 
the true cause of non-union is plainly shown by an experiment of 
Sir B. Brodie's. He broke the tibia of a guinea-pig, just above the 
ankle joint, where it is entirely covered by synovial membrane. 
On examining the part some time afterwards, he found that there 
was no separation of the fragments, and no motion between them; 
the synovial membrane was scarcely torn, and the ligaments were 
uninjured; nevertheless there was no union, although there was a 
slight bony deposit into the cancelli.t 
Symptoms.-The essential symptoms of fracture are three. (1.) 
Deformity, such as bending, or shortening, or twisting, of the 
injured limb. (2.) Preternatural mobility,-one end of the bone 
moving independently of the other, or one part of it yielding when 
Ftg. 20. 
* Vide a paper by the author, containing an account of some experiments on 
the restoration of bone, by Dr. Heine, Med. Gaz. July 29, 1837; Troja, de novorum 
ossium regeneratione, Paris, 1775; Bransby Cooper, Guy's Hospital, Rep. 1837. * 
f Med. Gaz. vol. xiii. p. 55. FRACTURE. 
231 
pressed upon. (3.) Crepitus,-a grating noise heard and felt 
when the broken ends are rubbed against each other. But it must 
be recollected that if the broken parts are displaced, they must be 
drawn into their natural position, otherwise no crepitus will be 
detected. In addition to these symptoms, there will be more or 
less pain, swelling, and helplessness of the injured part. 
It is important in every case to know the causes which produce 
displacement and deformity after fracture, because it is necessary 
to counteract them carefully during the treatment. They are three. 
(1.) Muscular action; which produces various degrees of bending, 
shortening, or twisting in different cases. (2.) The weight of the 
parts below, which, for instance, causes the shoulder to sink down- 
wards, when the clavicle is broken. (3.) The original violence 
which caused the fracture, as when the ossa nasi are driven in. 
Treatment.-The general indications for the treatment of frac- 
ture, axe, first, to procure union, which is accomplished by keeping 
the parts at rest, and in apposition; and, secondly, to prevent 
deformity. For the latter purpose, certain appliances must be 
used, which will counteract the various causes of displacement that 
were enumerated in the preceding paragraph. Displacement from 
muscular contraction must be obviated by keeping the part (if pos- 
sible) in such a position that any offending muscle may be relaxed; 
and by using mechanical means of extension and support. 
The general method of treating fractures may be thus described: 
In the first place, the limb must, if possible, be put in a position 
that will relax the principal muscles that cause displacement. In 
fracture of the upper end of the radius, for instance, the elbow 
should be bent to relax the biceps; and in fracture of the olecranon 
it should be straight, so as to relax the triceps. 
Secondly, the fracture must be reduced or set; that is to say, the 
broken parts must be adjusted in their natural positions. For this 
purpose, the upper end of the limb must be held steadily,whilst the 
lower is extended, or drawn in such a direction as to restore the 
limb to its proper length and shape. The extension should be 
made firmly, but gradually and gently, otherwise it will aggravate 
the muscular spasm which it is intended to overcome. 
Thirdly, it is usual to bandage the whole of the fractured limb 
from its extremity. This is done for the double purpose of pre- 
venting oedema, and of confining the muscles, that they may not 
contract and disturb the fracture. 
Fourthly, it is necessary to use some mechanical contrivances to 
keep the limb of its natural length and shape, and prevent any 
motion of the fractured part. It is usual to employ for this purpose 
splints of wood, carved to the shape of the limb. The surgeon 
should measure the sound limb which corresponds to the injured one, 
and select splints that are long enough to rest against the condyles or 
other projecting points at its extremities. These must be padded, 
and pads are easily made of loose tow wrapped up in pieces of old 
linen. The splints, when ready, should be firmly bound to the 232 
FRACTURE. 
limb, with pieces of old bandage; leather straps and buckles are 
very inconvenient. 
Several substitutes for wooden splints have been brought into 
use of late years. One of the most popular and convenient of these 
is the gummed, or starched bandage, or appareil immobile; on 
which a Frenchman has written a large book. It consists merely 
of layers of bandage, lint, or linen imbued with a mucilage of starch 
or gum or arrowroot; which, when dry, form a remarkably light, 
firm, and unyielding support. Another contrivance of the same 
nature, invented by Mr. Alfred Smee, and called the moulding 
tablet, will often be found a very simple but efficacious auxiliary. 
It is composed of two layers of coarse old sheeting, stuck together 
with a mixture of gum arabic and whiting. It is easily prepared 
by rubbing very finely powdered whiting with mucilage of gum 
arabic till it acquires the consistence of thick paste, and then spread- 
ing this on the surface of the sheeting, which is to be doubled on 
itself; it dries without shrinking, and becomes remarkably hard and 
tough; and may readily be softened by sponging it with hot water, 
so that it may be adapted with the greatest accuracy.* 
Some practitioners, instead of applying splints immediately, place 
the limb on a pillow, and merely apply leeches or cold lotions for 
the first few days, or perhaps for a week, and resort to splints after 
the inflammatory stage has passed over. But it appears to be far 
better, in every case, at once to use measures, by splints or other- 
wise, for keeping the fracture immovable. " If," says Mr. Liston, 
" the limb is laid loosely on a pillow, in an easy position, as it is by 
some thought or said to be, and no efficient means are employed to 
prevent the spasmodic action of the muscles, the startings of the 
limb, the jerkings of the broken ends, the displacement of the frag- 
ments ; then assuredly, in spite of all local and general measures, 
there will arise frightful swelling, pain, tension, and heat; the inter- 
muscular tissue will be gorged with blood, and the circulation of 
the limb roused to a dangerous and alarming degree."! 
The remaining treatment of simple fracture must be conducted 
on general principles. Cordials to restore the patient from the 
shock of the injury; the catheter, if he cannot make water, which is 
common after fractures of the leg; opiates to allay pain and muscular 
twitching; aperients, if they can be given without disturbing the 
fracture ; cold lotion, if agreeable; and leeches and bleeding very 
rarely indeed, to allay excessive inflammation, must be employed 
at the discretion of the practitioner. 
The apparatus and bandages must be loosened when swelling 
comes on, and be afterwards tightened sufficiently, to keep the parts 
steadily in their place; and care must be taken to prevent painful 
pressure on any particular spot, and to rectify any displacement as 
soon as it may occur. 
If, through mismanagement, a fracture has united crookedly, an 
attempt may be made to bend the callus, and restore the right shape. 
* Lond Med. Gaz., Feb. 1839. * Practical Surgery, p. 65. NON-UNION OF FRACTURE. 
233 
Such a proceeding may easily be effected before the fourth week, 
and it has even been successful at the sixth month.* 
SECTION III. OF NON-UNION AND FALSE JOINT. 
There are some cases in which fracture of the shafts of bones 
does not unite by bone. This is liable to happen. 
1st. If the fractured part is subjected to frequent motion and dis- 
turbance ; in which case the effused lymph instead of ossifying, will 
either be converted into a ligament which unites the broken extre- 
mities, or else a false, joint will be formed; the ends of the bones 
being covered with synovial membrane, and surrounded with a 
ligamentous capsule. 
2dly. The reparative processes may be deficient if the vital pow- 
ers are exhausted by age and debility; or if the system is under 
the influence of gout, syphilis, or cancer; or if an acute disease or 
fever comes on; or if the patient becomes pregnant, and all the 
nutritive energies of the system are employed in the development 
of the foetus; or if the part be deprived of its nervous influence; 
thus Mr. Travers relates a case in which a patient had a fracture 
of the arm, and of the leg, and likewise an injury of the back, 
which palsied the lower extremities. The arm united readily 
enough, but the leg did not. But yet there are some cases which 
it is as difficult to account for as it is to remedy. 
Treatment.-There are three indications. 1st. To bind up the 
part in splints, or the starched bandages, or to envelope it in a 
mould of plaster of Paris, so as to insure perfect rest, perfect appo- 
sition, and pressure of the broken ends against each other. But, 
as Sir B. Brodie very justly observes, the bandage should not be 
put on so tightly as to impede the general circulation of the limb. 
2dly. Should this not succeed after a fair trial of six weeks or 
two months, means must be adopted to excite the adhesive inflam- 
mation around the fracture. This may be done by rubbing one 
end of the bone roughly against the other;-or by making the 
patient walk on the limb, which must be first well supported with 
splints; and then the apparatus should be again firmly applied for 
six or eight weeks.! If this also fail, the next thing to be tried is 
a seton; which may be passed through the limb, between the frac- 
tured ends;-although it is more safe, and quite as effectual to pass 
it through the flesh close to the fracture. If, however, there is any 
difficulty in doing this the surgeon may merely cut down on the 
fracture, and pass in a probe or a heated iron wire, between the 
broken extremities. Whatever is used for the purpose should be 
allowed to remain a week or ten days, after which the limb should 
be put up immovably in splints. If these measures also fail, the 
last resource is to cut down on the fracture, and saw or shave off 
the ends of the bone;-or sometimes it is found that a little piece 
* Syme, Ed. Med. and Surg. Jour., Oct. 1838. 
f Amesbury, Syllabus of Lectures on Fractures, &c. with plates of apparatus. 234 
COMPOUND FRACTURE. 
of muscle is wedged between them, which must be removed; but 
this is a most severe and dangerous operation, and not to be re- 
sorted to without absolute necessity. 
3dly. Care should be taken to detect and remedy any constitu- 
tional disorder to which the want of union can be attributed. 
Debility must be counteracted by tonics, nutritive food, and stimu- 
lants. Mr. Fergusson relates a case of fractured thigh in which no 
callus was formed for three weeks, until the patient was allowed a 
reasonable quantity of whiskey, to which he had been previously 
accustomed; and Sir B. Brodie relates similar instances. Mercury 
may be given if there is a syphilitic taint; and Mr. B. Cooper 
gives a case of non-union, in which, although the general health 
appeared perfectly good, mercury given to ptyalism effected a cure 
after the seton had failed.* 
A few instances are known in which the callus, after union was 
completed, inflamed and became absorbed, so that the fracture was 
disunited again. Leeches and blisters to the part proved effectual 
remedies.! A recent callus is also sometimes absorbed during 
fever; and it used to be common enough in the sea scurvy. 
SECTION IV. OF COMPOUND FRACTURE. 
Definition.-A simple fracture may be attended with a wound; 
but unless the wound communicates with the fracture, the latter is 
not compound. 
Causes.-Fracture may be rendered compound, (1.) By the 
same injury which broke the bone. (2.) By the bone being thrust 
through the skin. (3.) By subsequent ulceration or sloughing of 
the integuments. 
Dangers.-These are threefold. (1.) The shock and collapse of 
the injury, which may prove fatal in a few hours, especially if 
much blood has been lost. (2.) Inflammation, fever, and tetanus. 
(3.) Hectic or typhoid fever, from excessive suppuration. 
Question of Amputation.-In order to decide upon the neces- 
sity of this operation, the extent of the injury and the restorative 
powers of the patient must be most carefully examined. If the 
bone is very much shattered and comminuted;-if the fracture 
extends into a joint, especially the knee;-if the soft parts are 
extensively torn or bruised; if, in particular, the skin has been 
torn away, so that the wound cannot be closed; or if it is so 
injured that a large tract of it must slough;-if the patient is very 
old; or much enfeebled, either by previous disease, or present loss 
of blood ;-if the collapse of the injury is excessive and permanent; 
-amputation is probably requisite. Of course more may be 
hazarded with a young patient, or with an old person of a spare, 
firm habit, who has always been healthy and temperate, than with 
* Vide Sir A. Cooper on Dislocations and Fractures, p. 568; Brodie, in Med. 
Gaz. vol. xiii.; and Fergusson's Practical Surgery, p. 103. 
f James, Address in Prov. Med. Trans. 1840. COMPOUND FRACTURE. 
235 
one who is bloated and plethoric, and in the constant habit of 
enfeebling his vital powers by over-stimulation and animal indul- 
gence. 
Laceration of arteries is a dangerous complication both of 
simple and compound fracture. It is detected by the great flow of 
blood, if there be a wound; and if not, by a rapid, diffused, and 
dark-coloured tumefaction of the limb, with coldness and want of 
arterial pulsation in the parts below. If it be the femoral, ampu- 
tation will most probably be required, because the vein may have 
been injured also;-if any other, (the anterior or posterior tibial, 
for instance,) it may be secured;-provided that there is no other 
valid cause for amputation, and that the required incision will not 
too much aggravate the injury to the soft parts. But, caeteris pari- 
bus, this accident is always an additional reason for amputation, if 
there be other circumstances rendering it probably expedient. 
If amputation be decided on, it must be primary; that is, per- 
formed before the accession of fever and inflammation, as was 
observed in the chapter on gun-shot wounds. 
Treatment.-If it be determined to save the limb, it must first 
be placed in a proper position, and then the fracture must be re- 
duced. If a sharp end of bone protrude, and it cannot easily be 
returned or kept in its place, it should be sawn off. Any loose 
fragments or splinters of bone should be at once removed; and if 
necessary, the wound may be dilated for this purpose. If suffered 
to remain, they greatly aggravate the inflammation and danger of 
tetanus, and may produce long-continued disease of the bone. 
After reduction, the great object is to produce adhesion of the 
external wound, so as to convert the compound fracture into a 
simple one, and the best application is a piece of lint dipped in 
blood, or in warm water, and covered with oiled silk;-then 
bandages and splints are to be used; but, if possible, the splints 
should have apertures corresponding to the wound, so that it may 
be dressed without disturbance to the whole limb. When inflam- 
mation and swelling come on, the bandages must be loosened, and 
cold be applied if agreeable. Opium, with antimony and saline 
draughts;-laxatives or enemata, if they can be given without dis- 
turbance ;-and sometimes, though very rarely, bleeding, are the 
general remedies. The catheter should be used if required. The 
great object in the subsequent treatment is to prevent the lodgment 
of matter, by sponging and pressing it out carefully at each dress- 
ing, and applying compresses to prevent its accumulation, and, if 
required, by making openings for its discharge. But if, notwith- 
standing the employment of tonics, wine, and good diet, the patient 
seems likely to sink under the discharge and irritation, amputation 
is the last resource. 236 
FRACTURE OF THE JAW. 
SECTION V. OF PARTICULAR FRACTURES. 
I. Fractures of the Ossa Nasi, and of the Malar and 
Superior Maxillary Bones, may be produced by violent blows 
or falls on the face, or by gun-shot injuries. 
Treatment.-Any displacement of the fractured portions should 
be rectified as soon as possible, by passing a strong probe or female 
catheter up the nostril, and by manipulation with the fingers. A 
depressed fragment may often be conveniently raised by passing 
one blade of a dressing forceps up the nostril, and applying the 
other externally, so as to grasp the fragment between them. Some 
practitioners are in the habit of introducing tubes or plugs of oiled 
lint, in order to keep the fragments in their places; but this appears 
to be unnecessary, and is very irritating. A plug of lint may, 
however, be requisite to check profuse haemorrhage. If the frac- 
ture is compound, any loose splinters should be carefully removed. 
The great swelling, ecchymosis, bleeding from the nose, and head- 
ache, with which this injury is followed, will require to be com- 
bated by bleeding or leeches, purgatives, and cold lotions, and 
spoon diet; and if collections of matter form, they should be 
opened without delay. If there are symptoms of pressure on the 
brain, and the vomer seems depressed, it should be carefully drawn 
forwards. 
II. Fracture of the Lower Jaw may be caused by violent 
blows. Its most usual situation is at the middle of the horizontal 
ramus. Sometimes in children (though rarely) it occurs at the 
symphysis, and still more rarely 
at the angle, or in the ascending 
ramus. 
Symptoms.-It is known by 
pain, swelling, inability to move 
the jaw, and irregularity of the 
teeth, because the anterior frag- 
ment is generally drawn down- 
wards. On moving the chin, 
whilst the hand is placed on the 
posterior fragment, crepitus will 
be felt; and the gums are lace- 
rated and bleeding. The diag- 
nosis of fracture of the ascending 
ramus will often be obscured by 
the great swelling. Great pain 
and difficulty of motion are the 
chief signs. 
Treatment, 1st, by the four- 
tailed, bandage -A piece of 
pasteboard, softened in boiling 
water, should be accurately fitted to the jaw, and then a four-tailed 
Fig. 21. FRACTURE OF THE CLAVICLE. 
237 
bandage should be applied. This is made by taking a yard and a 
half of wide roller, and tearing each end longitudinally, so as to 
leave about eight inches in the middle, which should have a short 
slit in it. [See fig. 21.] The chin is to be put into this slit, and 
then two of the tails are to be tied over the crown of the head, 
so as to fix the lower jaw against the upper, and the other two are 
to be fastened behind the head. [See fig. 21.] The teeth on either 
side of the fracture may be fastened together with dentists' silk. It 
is useful to place a thin, wedge-shaped piece of cork between the 
molar teeth on each side, especially if any of the teeth at the frac- 
tured part are deficient. Sometimes a tooth falls down between 
the broken parts; a circumstance which should be looked to, if 
there is much difficulty in fitting them together. 
%dly, By apparatus.-If the above simple means do not suffice 
to keep the fractured parts in contact, Mr. Lonsdale's apparatus 
should be used;-and perhaps it would be well to adopt it in all 
cases, after the primary swelling and tenderness have subsided. It 
affords perfect support, and yet allows of free motion.* The patient 
for the first fortnight must be fed entirely with gruel, broth, arrow- 
root, &c. The cure generally occupies five or six weeks. 
III. Fracture of the Clavicle is most frequently situated 
at the middle of the bone, and it is generally caused by falls on the 
arm or shoulder; sometimes, however, by direct violence. 
Symptoms.-The patient complains of inability to lift the affected 
arm, and supports it at the elbow;-the shoulder sinks down- 
wards, forio ar ds, and inwards;-the distance from the acromion 
to the sternum is less than it is on the sound side ;-and the end of 
the sternal fragment of the bone projects as though it were dis- 
placed, although it is not so in reality, but merely appears to be so, 
in consequence of the sinking of the shoulder and of the outer 
fragment. 
Treatment.-The shoulder must be raised, and must be sup- 
ported in a direction upwards, backwards, and outwards. The 
broken parts may be reduced, either by putting the knee between 
the scapulae, and drawing the shoulders backwards; or by placing 
the elbow close to the trunk and a little forwards, and then pushing 
it upwards. To support the parts during the cure, the most com- 
mon apparatus is, 
The stellate, or figure of 8 bandage, represented in fig. 22. 
In the first place a thick wedge-shaped pad must be put into the 
axilla, with the large end uppermost. Then a long roller must be 
passed over each shoulder alternately, and be made to cross on the 
back. In the next place, the arm must be confined to the side by 
two or three turns of the roller; and lastly, the elbow should be 
well raised by a sling, which is also to support the forearm. It 
will be noticed, that the shoulder is kept up by the sling, out by 
* Lonsdale on Fractures. Lond. 1838. It consists of a grooved plate of ivory 
to fit the teeth: and a wooden plate adapted to the base of the bone. These two 
plates are fastened together by screws. See also Fergusson, op. cit. p. 425. 238 
FRACTURE OF THE SCAPULA. 
the pad, and back by the bandage. In ordinary cases the patient 
may be allowed to walk about 
in a week or ten days, and the 
cure will be completed in a 
month or five weeks. The pa- 
tient should be informed that 
some little irregularity is apt to 
remain. 
If, however, there is any diffi- 
culty in maintaining a proper 
position, the patient must be con- 
fined to bed, and some additional 
apparatus be employed. The 
simplest is a straight splint 
across the shoulders, to which 
they are to be bound by the 
figure of 8 bandage; or a splint 
shaped like a T, of which the 
horizontal part is bound to the 
shoulders; and the vertical part passes down the back, and is 
confined by a belt round the abdomen. 
Besides these there is the clavicle bandage, [Fig. 23,] which con- 
sists of two loops for 
the shoulders, attached 
to two pads, resting on 
the scapulas, which are 
drawn together by straps 
and buckles (it is little, 
if at all, better than the 
figure of 8 bandage)- 
and dlmesbury's appa- 
ratus, which, although 
very complex, seems con- 
structed in a manner that 
prevents all possibility of 
displacement. If nothing 
else will do, it should be 
procured at an instru- 
ment maker's. 
IV. Fractures of the 
Scapula.-The body of 
this bone may be broken 
across by great di red vio- 
lence. The symptoms are, 
great pain in moving the 
shoulder, and crepitus; which may be detected by placing one hand 
on the acromion or spinous process, and moving the shoulder or the 
inferior angle with the other. 
Treatment.-A roller must be passed round the trunk, and a 
few turns be made round the humerus, so as to fix the arm to the 
Fig. 22. 
Fig. 23. FRACTURE OF THE SCAPULA. 
239 
side, and prevent all motion. Bleeding, or at all events purging 
and low diet, will be required to avert inflammation of the chest. 
Fracture of the Neck of the Scapula, by which is meant 
an oblique fracture, detaching the coracoid process and glenoid 
cavity from the rest of the bone, is a rare accident, insomuch 
that some surgeons doubt its existence.* 
The symptoms described by Sir Astley Cooper, are the follow- 
ing :-The shoulder appears sunk, and the arm lengthened; the acro- 
mion is unusually prominent, and the deltoid dragged down and 
flattened; the head of the humerus can be felt in the axilla; and on 
placing one hand or one ear on the acromion, and moving the 
shoulder, crepitus may be detected. Crepitus may also be felt on 
pressing the coracoid process, which is 
situated deep below the clavicle, be- 
tween the margins of the pectoral and 
deltoid muscles. The accidents with 
which this fracture is most likely to be 
confounded are fracture of the neck of 
the humerus, and dislocation of the 
shoulder joint; the symptoms of which 
should be carefully studied and com- 
pared. The existence of crepitus, and 
the fact that the surgeon can move the 
shoulder freely, (although with great 
pain,) are the chief points of diagno- 
sis bet ween this accident and disloca- 
tion. 
Treatment.-The shoulder must be supported by the same sling, 
bandage, and pad, that are used for fracture of the clavicle; but a 
short sling from the axilla of the injured side to the opposite shoul- 
der, should be used in addition to the long sling from the elbow to 
the shoulder. Union may occur in seven 
weeks. Bleeding, leeches, purgatives, 
rest in bed, and warm fomentations, will 
be necessary for the contusion with 
which the fracture is accompanied. 
Fracture of the Acromion is 
known by a flattening of the shoulder, 
because the fractured portion is drawn 
down by the deltoid; and by an evident 
inequality felt in tracing the spine of the 
scapula. It may be distinguished from 
any dislocation, by noticing that the 
humerus may be freely moved in any 
direction, and that, on slightly raising 
the shoulder, the fragment is restored to 
Fig. 24. 
Fig. 25. 
* Mr. May, of Reading, relates a case of this fracture (Med. Gaz. Sth Oct. 1842,) 
happening to a young lady, and caused by her throwing her necklace over her 
shoulder. He ascertained that there was no dislocation, and no fracture either of 
the humerus or clavicle. 240 
FRACTURE OF THE HUMERUS. 
its place. This is also a rare accident; and Mr. Fergusson believes 
that, in some of the supposed cases of ligamentous union, the 
detached portion was never united by ossification to the rest of 
the bone from birth. 
Treatment.-The same bandages, &c. are to be applied as for 
fracture of the clavicle; but great care must be taken to raise the 
elbow thoroughly, so that the head of the humerus may be lifted 
up against the acromion, and keep it in its place. Moreover, no 
pad must be placed in the axilla; otherwise the broken part will 
be pushed outwards too much. Union is almost always ligament- 
ous, owing to the difficulty of keeping the parts in strict apposition. 
Fracture of the Coracoid Process is a rare accident, caused 
by sharp blows on the front of the shoulder. 
Symptoms.-The patient is unable to execute the motions per- 
formed by the biceps and coraco-brachialis, that is, to bring the arm 
upwards and forwards;-and motion and crepitus of the detached 
process may be felt by pressing with the finger between the pec- 
toralis major and deltoid, whilst the patient coughs or moves his 
shoulder. 
Treatment.-The humerus must be brought forwards and 
inwards, so as to relax the biceps and coraco-brachialis, and must 
be confined to the trunk. 
V. Fracture of the Humerus.-Fracture of the shaft will 
be known at a glance by the limb being bent, shortened and help- 
less, and by the crepitus felt when it is handled. 
Treatment.-The fracture may be reduced by drawing the 
elbow downwards, whilst the shoulder is steadied. Then the 
whole limb, from the hand upwards, is to be evenly bandaged. 
Next, a long padded splint should be placed on the inner side of 
the humerus, one end of it pressing against the 
axilla, the other against the inner condyle;-a simi- 
lar splint on the outside, resting against the acro- 
mion and external condyle; one in front, and ano- 
ther behind; and these are to be fastened by tapes; 
-lastly, the limb may be confined to the side for the 
sake of greater security, and the hand and forearm 
be supported by a sling; but the elbow must not be 
raised up; otherwise the fracture will be liable to 
be displaced. 
Fracture of the Neck of the Humerus is 
caused by great direct violence, and is attended with 
much swelling. It may occur either at the ana- 
tomical neck,-that is, above the tubercles;-or, at 
the surgical neck, or just below them. [Fig. 26.] 
The former form occurs sometimes to children, but 
the latter is by far more frequent. 
Symptoms.-The patient is unable to raise the 
arm. The shoulder seems flattened, but there is no 
hollow below the acromion, as there is in disloca- 
tion. The head of the bone may be felt in its 
Fig. 26. FRACTURES OF THE ARM. 
241 
socket, and the broken end of the shaft may be felt projecting either 
in the axilla, or else in front, near the coracoid process of the 
scapula. By grasping the head of the bone and rotating the 
elbow, the fractured shaft may be felt to move independently of 
the head. The natural position of the parts is restored when 
extension is made by drawing the elbow downwards, but the 
deformity returns immediately that the extension is discontinued; 
and during these movements, crepitus may be felt. There is greater 
mobility in the fracture below the tubercles, than in that above 
them. 
Treatment.-The same splints, bandages, &c., are to be used as 
in the last case ; and a pad to be placed in the axilla. The forearm 
should be lightly supported with a sling, but neither in this nor in 
the last case should the elbow be forcibly raised. The great secret 
in managing both is to get a good purchase against the axilla and 
the inner condyle with the innermost splint. 
It is a good plan in fractures of the upper 
part of the humerus, as soon as pain and in- 
flammation are abated and the patient is able 
to leave his bed, to apply a large piece of 
pasteboard, or of Mr. Smee's gummed sheet- 
ing, or of the soft leather sold for splints, all 
over the shoulder, and down the outer side 
of the arm to the elbow, instead of the outer 
splint; but the inner splint must in no case be 
dispensed with. 
Fracture with Dislocation.-Sometimes 
the head of the humerus is not only broken 
off from its neck, but dislocated also from the 
glenoid cavity. It can be readily felt in the axilla, and can also 
be felt not to move when the elbow is rotated. The broken end 
of the shaft must be 
brought into the gle- 
noid cavity, but it will 
be very difficult, if not 
impossible to restore 
the head of the bone 
to its place. The arm 
should be kept mo- 
tionless with a sling 
and figure of 8 band- 
age till inflammation 
has abated, and then 
passive motion be resorted to ; but the patient should be early 
informed that the power of raising the arm will be in a great mea- 
sure lost.t 
Fig. 27.* 
Fig. 28. 
* [This cut represents a fracture of the surgical neck of the humerus united.] 
f For cases, vide Sir A. Cooper on Fractures, and Fergusson's Pract. 
Surgery. 242 
FRACTURES OF THE ARM. 
Fracture of the lower extremity of the Humerus may 
present many varieties. 
(1.) There may be an 
oblique fracture above 
the condyles ; [fig. 29,] 
which usually happens 
to children. The radius 
and ulna, with the lower 
fragment, are drawn up- 
wards and backwards 
as in dislocation :-but 
the natural appearance 
of the parts is restored 
by extension. (2.) Either condyle may be broken off; and the 
fracture may or may not extend into the joint. (3.) There may 
be one fracture between the two condyles, and another separating 
Fig. 29. 
Fig. 30.* 
Fig. 31.* 
Fig. 32.* 
them both from the, shaft. All these injuries may be distinguished 
from dislocation of the elbow by noticing that the motions of the 
joint are free, and are attended with crepitus above the elbow; 
and that the length of the forearm, measured between the con- 
dyles of the humerus and the lower extremities of the radius and 
ulna, is the same as on the sound side. 
Treatment.-The fore and upper arm should be bandaged, and 
a piece of pasteboard, gummed sheeting, or leather softened in 
water, should be cut to a right angle, like the letter L, so as to fit 
* [Fig. 30 represents a fracture of the internal condyle of the os humeris. Fig. 
31, fracture of external condyle of os humeris. Fig. 32, transverse fracture of 
the extreme condyle within the capsular ligament.] FRACTURES OF THE FOREARM. 
243 
the elbow when bent, and should be applied on the inner and outer 
sides, and be retained by another bandage. Besides this, an 
angular splint may be employed. It is composed of two pieces 
joined at a right angle; one of which is placed behind the upper 
arm, and the other below the forearm. But if the injury was 
attended with much violence the patient must be confined to his 
bed for some days with the arm on a pillow, and leeches and 
lotions be employed to reduce the inflammation and swelling. 
Passive motion of the joint should be commenced in a fortnight or 
three weeks;-but the patient should be warned that it is very 
difficult to avoid all deformity and loss of motion. 
VI. Fractures of the Forearm. Fracture of the olecranon 
Fig. 33. 
may be caused \yy direct force, or by violent action of the triceps 
muscle. 
Symptoms.-The patient easily bends his limb, but has great 
pain and inability in straightening it. A hollow is felt at the back of 
the joint, because the broken part is drawn from half an inch to two 
inches up the arm; but sometimes, when the ligaments are not torn 
through, this displacement maybe very trifling,or altogether absent. 
Treatment.-The limb should be placed in a straight position, 
and leeches, and evaporating lotions, be used till swelling and ten- 
derness subside. Then the forearm having been bandaged, the 
olecranon should be drawn down as much as possible, and the roller, 
continued from the forearm, should be passed round above it, and 
then back again about the elbow in a figure of 8 form. Then the 
whole upper arm should be rolled in order to prevent contraction of 
the triceps; and a splint must be placed in front, so as to keep the 
arm straight. Passive motion should be commenced in three weeks. 
Union will be ligamentous. 
Compound fracture of the olecranon is far from an uncommon 
consequence of violent blows or falls on the elbow; and it is often 
followed by protracted disease of the joint. The part must be bathed 
and fomented; any loose fragments of bone be extracted; the wound 
be closed as it best may; the water dressing be applied, and the elbow 
be kept straight and motionless with a splint;-leeches, &c., must 
be used to reduce inflammation, and when the wound is healed, and 
the joint free from active disease, passive motion must be employed 
to restore it to its proper uses. If the bones are so excessively 
comminuted as to render it probable that the process of reparation 
will be tedious and exhausting, excision of the joint should be per- 
formed ; unless, indeed, the injury is so very severe as to render 
amputation indispensable. 
Fracture of the Coronoid Process is very rare. It is caused 
by the action of the brachialis muscle. Mr. Liston gives a case of 
it which occurred to a boy of eight years old, and was caused by his 
hanging with one hand from the top of a high wall. 244 
FRACTURES OF THE FOREARM. 
Fig. 34. 
Symptoms.-Difficulty of bending the elbow, and dislocation of 
the ulna,-the olecranon projecting backwards. 
Treatment.-The arm must be bandaged, and kept at rest in the 
bent position. Union will be ligamentous. 
Fractures of the shafts of the Radius and Ulna, together 
or singly, are known by the ordinary signs of fracture, especially 
by the crepitus felt on fixing the upper end, and rotating or moving 
the other. The objects in the treatment are to prevent the fractured 
ends of either bone from being pressed inwards towards the inter- 
osseous space, and to prevent the upper fragment of the radius from 
being more supinated or everted than the lower. 
Treatment.-The fracture is easily reduced by extension from 
the wrist and elbow. Then the elbow being bent, and the forearm 
placed in a position intermediate between pronation and supination 
(that is to say, with the thumb uppermost), one splint should be 
applied to the flexor side, from the inner condyle of the humerus to 
the palm of the hand; and another from the outer condyle of the 
humerus to the back of the wrist. Both splints should be well 
padded along their middle, so that they may press the muscles into 
the interosseous space, and prevent the bones from coming together. 
If the radius alone is broken, especially near its lower extremity, the 
hand should be permitted to drop downwards; but if the ulna alone, 
or if both bones be fractured, the splints should extend to the ends 
of the fingers, and the hand be kept in a line with the forearm; 
and, besides, a third slight splint may be applied to the ulna. Some 
practitioners, instead of placing the thumb uppermost, place the 
forearm quite supine, with the palm uppermost;-then having 
reduced the fracture, apply one splint below from the olecranon to 
the fingers' ends,-and another above from the bend of the elbow 
to the wrist. But this plan has no particular advantage, and does 
not allow the flexor and pronator muscles to be relaxed. 
After the first week, the splints maybe removed and the starched 
bandage be substituted. A dry roller is to be first applied from the 
hand to a little above the elbow. This is to be covered with several 
layers of roller imbued with starch ; but the part should still be sup- 
ported by a splint till the starched rollers become dry. The cure is 
generally complete in a month or five weeks. It must be recollected 
that the bandage must not be applied too tightly, so as to press the 
fractured extremities towards the interosseous space. 
Fracture of the lower extremity of the radius, about half 
an inch or an inch above the wrist is often caused by falls on the 
hand, and may be readily mistaken for dislocation of the wrist, as 
the hand with the lower fragment is drawn upwards and backwards 
by the extensor muscles. The distinction is, that if the hand be 
moved the styloid process of the radius will move with it, if there 
is a fracture;-but not if there is a dislocation. Sometimes the dis- FRACTURE OF THE RIBS. 
245 
Fig 35. 
tortion is so great, that the ulna is dislocated forwards on the carpus; 
-and sometimes the fracture is confined to the posterior rim of the 
articular surface of the radius, which is obliquely broken off, and 
the hand partially dislocated backwards.* 
Treatment.-These fractures must be treated as the other 
fractures of the forearm, but care must be taken to apply pads 
against the projecting points of the fractured bone, so as to keep 
them in their places. Passive motion must be commenced in three 
weeks or a month, but the patient should always be informed, that 
many months may elapse before the use of the wrist and fingers is 
restored, in consequence of the irritation which the lower extremity 
of the shaft of the radius produces in the sheaths of the flexor 
tendons : amongst which it is dragged by the pronator quadratus. 
VII. Fractures of the Hand.-The carpus is rarely fractured 
without so much other injury as to render amputation necessary. 
Fracture of the metacarpal bones, or of the phalanges, will be 
readily recognized. With respect to compound fracture of these 
parts we may observe, that no part of the hand should be ampu- 
tated unless positively necessary, and even one finger should be 
saved if it can be done. 
Treatment.-For fractures of the carpus, middle metacarpal 
bones, and first phalanges, it is a good plan to make the patient 
grasp a ball of tow or some other soft substance, and bind his hand 
over it; for fracture of the lateral metacarpal bones, it is better to 
support the hand on a flat wooden splint, cut into the shape of the 
thumb and fingers. If one finger only be fractured, it may be con- 
fined by a thin lath or pasteboard splint. It must be recollected 
that the palmer surfaces of the metacarpal and digital bones are 
concave. They must, therefore, be slightly padded before they are 
bound to any flat surface, or they will unite crookedly. 
VIII. Fracture of the Ribs is generally situated in their ante- 
rior half, and is commonly caused by direct violence, such as blows; 
the bone giving way at the point struck. Sometimes, however, it 
is caused by indirect violence; as for instance, when the chest is 
violently compressed between two points. In 1837, several people 
were crushed to death in a crowd in the Champ de Mars in Paris, 
and many of them were found to have several ribs broken in this 
manner. Sometimes, in old subjects, one or more ribs are broken 
by violent coughing.t 
* Barton, Philadelphia Med. Examiner, No. 7. 1838. 
f See an interesting paper on Fracture of the Ribs, by M. Malgaigne, in the 
Arch. Gen. de M£d. 1838, quoted in Forbes, Rev. vol. vii. p. 554. 246 
FRACTURES OF THE PELVIS. 
Symptoms.-Fixed lancinating pain, aggravated by inspiration, 
coughing, or any other motion. By tracing the outline of the 
bone, or by placing the hand or the stethoscope upon it, crepitus 
may be felt during the act of coughing or inspiration, and the patient 
is sensible of it likewise. If the fracture be situated near the spine, 
or if the patient be very corpulent, it may be difficult to detect it 
with certainty, but this is of little consequence; for in every case 
when a patient complains of pain on inspiration after a blow on the 
chest, the treatment is the same. 
Treatment.- The indications are, (1.) To prevent all motion of 
the ribs, by passing a broad flannel roller, or a towel fastened with 
tape round the chest so tightly, that respiration may be performed 
solely by the diaphragm;-(2.) to obviate inflammation of the 
chest, and diminish the arterializing duties of the lungs by bleeding, 
rest in bed, and low diet; to unload the bowels by purgatives, so as 
to enable the diaphragm to descend freely; and to administer opiates 
to prevent pain and cough. 
If several ribs are broken on each side, it may happen that no 
bandage can be borne, and the case becomes highly serious. Quiet- 
ude and depletion are the only remedies. 
Emphysema, a swelling caused by the presence of air in the 
cellular tissue, is an occasional complication of this fracture. It is 
produced in the following way: The extremities of the fractured 
rib perforate both pleurae, and wound the lung. In the act of in- 
spiration, air escapes from the lung into the cavity of the pleura, 
and from thence through the wound in the pleura costalis into the 
cellular tissue of the trunk. Emphysema forms a soft, puffy 
tumour, that crepitates and disperses on pressure. 
Treatment.-Provided the air escapes freely from the cavity of 
the chest, little inconvenience results, and if the skin merely be very 
much distended, it may be punctured. But if the air accumulates 
in the pleura and compresses the lung, which will be known by 
great dyspnma and a hollow sound on percussion,-and if the 
breathing is not relieved by free depletion, an aperture must be 
made into the chest to let the air escape.-See the chapter on the 
Injuries of the Chest. 
IX. Fracture of the Sternum. Symptoms.-Crepitus may 
be felt during inspiration or other movements of the trunk, and dis- 
placement (if any) can be detected by examination. 
Treatment.-The same as for fractured ribs. 
X. Fractures of the Pelvis can be caused only by most 
tremendous violence, and are often attended with some fatal com- 
plication ;-such as laceration of the bladder or rectum, or of the 
great arteries or veins. 
Treatment.-The only thing to be done is, to place the patient 
at perfect rest, and in as easy a position as possibleto keep a 
catheter in the bladder; to make incisions if urine is extravasated 
into the perineum, as it will be if the urethra is lacerated by frac- 
tured portions of the rami of the ischium and pubes, and to treat 
any symptoms that may arise. If it can be borne, a broad belt may FRACTURES OF THE FEMUR. 
247 
Fig. 36.* 
be passed round the pelvis; and another under the nates, which 
might be attached to a pulley over the bed, so that the patient may 
raise the pelvis, without exerting any of the muscles attached to it. 
There are some cases of fracture of the os innominatum passing 
through the acetabulum, and caused by falls on the hip, which might 
be mistaken for fracture of the cervix femoris. For instance, in 
some cases related by Mr. Earle,t the foot was everted, and there 
was loss of prominence of the trochanter; but there was no shorten- 
ing, and the limb could be turned freely outwards, which motion is 
highly painful after fracture of the neck of the femur. The diag- 
nosis will be guided chiefly by the crepitus felt on applying the 
stethoscope to the ilium, and by examination per anum. The 
patient must be kept on a fracture-bed. One of Mr. Earle's cases 
was cured in eight weeks. 
Fracture of the os coccygis, or of the lower extremity of the 
sacrum, may be caused by violent kicks or falls;-the former may 
occur during parturition to women who have children after the 
coccyx is united to the sacrum. The loose portions must be re- 
placed by introducing the finger within the rectum, and the bowels 
must be kept relaxed, so that no disturbance may be occasioned by 
hard stools. 
XI. Fractures of the Femur present many varieties, which 
must be carefully studied; because, as Pott observes, "they so often 
lame the patient, and disgrace the surgeon." We must, therefore, 
treat separately of fractures of the neck of the femur; of the shaft 
just below the trochanters; of the centre of the shaft, and of the 
condyles. 
* [This figure represents a fracture and dislocation of the bones of the pelvis. 
A fracture passes through the body of the pubes on the left side, and through the 
ramus of the left ischium, and the right os innominatum is separated from the 
sacrum at the sacro-iliac symphysis. The details of the case will be found in 
Cooper on Dislocations, p. 101, Philad. 1844.] 
f Earle on Fractures of the Pelvis. Med. Chir. Trans, vol. xix.; see also Case 
Ixxi. in the last ed. of Sir A. Cooper on Fractures and Dislocations. 248 
FRACTURES OF THE FEMUR. 
Fracture of the Neck of the Femur may occur either within 
the capsular ligament, or external to it. The fracture internal to 
the capsule is the more common, and is generally caused by indi- 
rect violence; that is, by a slight force acting on the lower extremity 
of the limb, as happens in slipping off the curbstone; sometimes, 
however, it is produced by falls or blows on the hip. It is very 
rare in persons under fifty; but very common in old people, espe- 
cially old women; because, in addition to the changes which all 
the bones experience in advanced life,-the thinness of the cortex, 
sponginess of the cancelli, deficiency of the bone earth, and loss of 
elasticity of the animal matter,-the neck of the femur is always 
peculiarly atrophied; it is shortened, and sunk from the oblique to 
the horizontal position;-changes that cannot fail to render it more 
easily fractured.* 
Fig. 37 + 
Fig. 38.: 
Symptoms.-After a blow or fall, the patient finds himself 
unable to stand, and complains of great pain, increased by motion, 
and principally seated at the upper and inner part of the thigh. 
The leg is from half an inch to two inches shorter than the other; 
* In old bed-ridden persons the neck of the femur is sometimes so shortened 
that the head is brought into contact with the shaft; and at the part where the cap- 
sular ligament is inserted, the bony texture is sometimes completely absorbed, and 
its place supplied with a ligamento-cartilaginous substance; irregular deposits of 
bone are formed also on the top of the shaft of the femur. These appearances 
have been mistaken for united fracture. 
f [This figure shows the greatest descent of the neck of the thigh-bone which 
Sir A. Cooper ever saw.] 
* [This figure shows the changes incident to the neck of the thigh-bone in old 
age, which might be mistaken for united fracture. The head of the bone is sunk; 
the neck shortened; the cancelli atrophied, and there is a line in which the bony 
texture is partially absorbed; and in the recent state, its place was filled by a liga 
mento-cartilaginous substance.] FRACTURES OF THE FEMUR. 
249 
the foot is turned outwards;-the heel rests in the interval between 
Fig. 39. 
Fig. 40. 
the ankle and tendo-achillis of the other leg; crepitus may be 
detected if the hand or the stethoscope be placed on the trochanter, 
whilst the limb is drawn to its proper length and rotated;-the 
trochanter generally projects less than on the other side; and the 
limb may generally be freely moved, although with great pain, 
especially if it is abducted. 
It may be mentioned, that the shortening very often does not 
occur till some days after the accident;-which may be accounted 
for by supposing that a part of the fibro-synovial investment of the 
neck of the bone was not entirely torn through at first, but gave 
way afterwards during the patient's movement in bed;-sometimes 
even the whole diameter of the bone is not completely fractured; 
and in this latter case the shortening will be altogether absent. 
Moreover in some few cases, the limb is turned inwards instead of 
outwards. The practical rule, however, is, that when an old person 
has tumbled down, and complains of pain in the hip, and is unable 
to stand, this fracture should be carefully looked for, although there 
may be no apparent shortening nor eversion.* 
* Three cases, in which the whole diameter of the cervix was not broken 
through, are narrated by Dr. Colles in the Dublin Hospital Reports, vol. ii. p. 339. 
Mr. Guthrie relates a case in which the limb at first was turned out as usual, but 
afterwards suddenly turned inwards ; giving him some annoyance lest he had mis- 
taken the nature of the injury. Med. Chir. Trans, vol. xiii. 250 
FRACTURES OF THE FEMUR. 
Fracture of the neck of the femur, internal to the capsular liga- 
ment, does not unite by bone, except in a few rare instances. The 
reason of this want of union appears to be, that it is contrary to 
the provisions of nature for the lymph which is effused after frac- 
ture within any joint whatever to be converted into a bony callus; 
because the motions of the joint would be completely annihilated 
by it. Besides this, it may be seen that bony union is very unlikely 
to occur; first. Because the inadequate nutrition of the upper frag- 
ment, which is supplied only by the small vessels of the ligamen- 
tum teres. Secondly. Because the fracture, being separated from 
the cellular tissue by the capsular ligament, cannot be assisted by 
a provisional callus, which is secreted by the tissues surrounding 
the fracture. Yet it is remarkable that bone is often deposited on 
the outside of the capsular ligament, both after this fracture and 
after disease of the joint; which bone is equivalent to the callus 
formed after an ordinary fracture; but is in this instance prevented 
by the capsular ligament from aiding in the work of reparation.* 
Thirdly. Because the fractured surfaces cannot be easily kept in 
apposition, or pressed against each other. Fourthly. Because the 
patients, being old, have neither time nor constitutional vigour suf- 
ficient to effect the cure. So that in general this fracture either 
unites by ligament, or, more commonly, does not unite at all; but 
the stump of the cervix becomes rounded and covered with a 
smooth porcellaneous deposit, and plays in a socket formed by the 
hollowing and absorption of the head. The capsular ligament 
becomes excessively thick, and so does the obturator externus 
muscle, so as to support the weight of the body. 
The few instances in which this fracture does unite by bone, are 
stated by Sir A. Cooper to be, 1st, those in which the periosteum 
is not torn through, so that the fractured surfaces are not separated, 
and the nutrition of the head of the bone continues; and, 2dly, 
those in which the fracture is partly internal to the capsular liga- 
ment and partly external to it. But it must be evident that in the 
former of these cases, there will be no shortening, crepitus, nor 
eversion; in fact, none of the distinctive symptoms of fracture; 
and that the real nature of the injury can be discovered only by 
dissection, t 
Treatment.-It is of no use to sacrifice the patient's little rem- 
nant of health and strength, and run the risk of producing sloughing 
of the nates, by long confinement to bed, in the hope of procuring 
union by bone. But he should be kept in bed for a fortnight, till 
pain and tenderness abate; with one pillow under the whole length 
of the limb, and another rolled up and placed under the knee. Then 
he may get up and sit in a high chair, and shortly begin to crawl 
about with crutches; and in time he will regain a tolerable use of 
* Instances of this may be seen in a preparation given by Mr. Earle to the 
Hunterian Museum, and marked 137-294 F.; and also in one in the King's College 
Museum, referred to in Mayo's Pathology. 
f Vide the last edition of Sir A. Cooper on Fractures and Dislocations of the 
Joints, 1842, pp. 129 et. seq. in which the whole subject is fully discussed. 251 
FRACTURES OF THE FEMUR. 
the limb, especially if not very corpulent. The sole of the shoe 
must be made thick enough to counteract the shortness of the limb. 
Fracture external to the capsular ligament resembles 
the last in many general fea- 
tures, but differs in the following 
points; 1. It is always caused 
by direct violence, such as severe 
blows or falls on the hip, by 
which the neck of the bone is 
driven into the cancelli of the 
trochanter major. [See Fig. 41.] 
2. It may occur to persons of 
any age; whereas the fracture 
internal to the capsule very 
rarely happens before fifty. 3. 
It is not attended with so much 
shortening and eversion. 4. 
Crepitus is much more easily 
felt, because the shortening is 
not so great. 5. It is caused by 
direct violence, and therefore is 
attended with great fever, pain, 
ecchymosis, and swelling; some- 
times enough to prove fatal;- 
whereas, in fracture internal to 
the capsule, caused by falls on 
the feet, there is very little local 
or constitutional disturbance af- 
ter the first week. 
Treatment.-This fracture will readily unite by bone, provided 
the patient's age or other circumstances do not prevent it; and 
measures should therefore be adopted to insure a constant and cor- 
rect adantation of the broken parts: and, we may observe, that in 
any case where there is a doubt whether the fracture is internal to 
the capsular ligament, or external to it, the treatment of the latter 
variety should be adopted, if the patient's strength is sufficient to 
enable him to bear the confinement. 
The indications are to preserve the length of the limb, and to 
keep the great trochanter pressed towards the acetabulum. The 
principal modes of treatment are the double inclined plane, or frac- 
ture-bed, and the long straight splint. 
The fracture-bed consists of four parts, something like a W. 
The body is placed on the first;-the second is appropriated to the 
thighs, and must be made a proper length for them;-the legs are 
to hang over the third, which must also be made of a proper 
length;-and the fourth is a footboard. There is a hole to admit 
of evacuations; and the patient can be so confined as to prevent 
any motion of trunk or body, together or singly. Both thighs must 
be bandaged;-the trochanter must be supported with a pad;-a 
band should be tightly buckled roittid the pelvis, so as to keep the 
fractured parts together-a splint should be placed on the outside 
Fig. 41. 252 
FRACTURES OF THE FEMUR. 
of the thigh-and the two limbs should be firmly fastened together 
at the knee and ankle by bandages. 
The object of the long straight splint is to overcome the resist- 
ance of all the muscles by extension, instead of averting it by re- 
laxing them by position. The common straight splint of Desault 
extends from the pelvis to the foot, and has a footboard with straps, 
&c., at the bottom. But the simple splint employed by Mr. Liston, 
and depicted in the adjoining cut, appears to be better. It is a 
simple deal board, of a hand's breadth for an adult, but narrower 
Fig 42. 
and slighter for a young person. It should reach from opposite the 
nipple to four or five inches below the foot. At its upper end it 
has two holes, and at its lower end two deep notches; with a hol- 
low for the outer ankle. " A pad of corresponding length and 
breadth is attached by a few pieces of tape; a roller is split at the 
end, and having been tied through the openings in the top part of 
the splint, is unrolled as far as the bottom, where it is fixed for a 
time. The limb must now be gently extended from foot and pelvis 
to its proper length, and must be bandaged from the foot to the hip. 
Fig. 43. 
The splint is next applied to the outside of the limb; and the roller 
before spoken of must be repeatedly passed round the instep and 
ankle, and through the notches, so as to secure the foot, and must 
then be carried up the leg. A perineal band, composed of a large 
soft handkerchief padded with tow and covered with oiled silk, 
must be put round the groin, and be fastened firmly to the holes at 
the top of the splint; and, lastly, a few turns of broad bandage are 
to be passed round the trunk."* The disadvantage of this plan, 
compared with the former, is supposed to be, that the perineal band 
tends to draw the fractured parts asunder. But more depends on 
the surgeon in every case than on the splint; and a man who 
watches his patient properly, and keeps him in a comfortable pos- 
ture, and corrects any deviation as soon as it occurs, will be suc- 
cessful with either. 
Oblique fracture through the Great Trochanter.-This 
accident may occur at any period of life, and is attended with the 
following symptoms:-The limb is everted, but very little short- 
ened; and the shaft of the bone can be felt widely separated from the 
* Liston, op, cit. p. 88. FRACTURES OF THE FEMUR. 
253 
trochanter. This fracture unites readily by bone; and the treat- 
ment required consists of extension of the limb, and a circular girth 
with a pad, to support the upper extremity of the shaft and keep 
the broken surfaces in apposition. 
Fig. 44. 
Fig. 45. 
Fracture of the Epiphysis of the Trochanter Major.-The 
trochanter is sometimes broken 
off from the femur, at the part 
where it is united by cartilage as 
an epiphysis in youth. The diag- 
nosis is generally obscure; but we 
allude to the accident in order that 
the surgeon may be aware of the 
possibility of such an occurrence. 
The part will unite by ligament. 
Fracture of the Femur just 
below the Trochanters is lia- 
ble to be followed by great de- 
formity and non-union, because 
the upper fragment is tilted for- 
wards by the psoas and iliacus 
muscles. [See fig. 46.] 
Treatment.-1The best plan is 
to place the patient on a fracture- 
bed, in a half sitting posture, so 
as to relax the offending muscles. 
Fracture of the shaft of 
the femur requires no observa- 
tions as to its causes or symptoms. 
Fig. 46.* 
* [This figure represents a fracture of the femur just below the trochanters, 
united, and exhibits the extreme shortening with the hideous projection forwards, 
which is the consequence of ill treatment.] 254 
FRACTURES OF THE FEMUR. 
The accompanying figure shows the influ- 
ence of the psoas and iliacus in tilting the 
upper fragment forwards; and of the ab- 
ductor muscles in drawing the lower frag- 
ment upwards and inwards. 
Treatment.-(1.) The first apparatus that 
we shall notice is the double inclined plane. 
It consists of two pieces like the letter A;- 
one for the thigh, the other for the leg, with a 
board to fasten the foot to. The whole limb 
must be bandaged ;-the thigh piece must be 
made accurately to correspond to the distance 
between the tuber ischii and the bend of the 
knee;-and then one splint is to be placed 
from the great trochanter to the outer con- 
dyle;-a second, from the ramus of the pubes 
to the inner condyle; and a third on the an- 
terior surface of the limb. Perhaps it is a 
good plan to apply a fourth splint, from the 
tuber ischii to the bend of the knee, before 
placing the patient on the plane. Both legs 
should be bandaged. The disadvantage of 
this plan is, that the patient's bottom sinks in 
the bed, and thus the upper fragment is tilted forwards. 
(2.) A second plan is that of Pott.* It consists in laying the 
patient on the affected side, the thigh at right angles to the trunk, 
and the knee bent-with a many-tailed bandage and four splints, 
applied between the different points of bone that have just been 
mentioned. The disadvantages of this plan are, first, that the 
patient soon turns round on his back, dragging the upper fragment 
away from its right place ; and, secondly, that the pressure on the 
great trochanter may cause sloughing. The first evil may be pre- 
vented simply by watching the patient, and telling him to turn 
round on his belly rather than on his back, if he wishes to shift his 
position. The second may be remedied by placing him on his back, 
at the end of a fortnight, with his knees bent up and supported by 
pillows. 
(3.) A third plan is that of the long straight splint before de- 
scribed, whose advantages are, that it keeps the foot, knee, hip, 
and pelvis immovable. Every surgeon must determine for himself 
what mode of treatment to adopt, but must never forget that care 
and attention are requisite for the success of either of them. 
Supposing a case of very oblique fracture of the thigh, with 
great difficulty in preventing overlapping of the fragments, it is a 
good plan to cover the whole limb from the foot to the hip with 
soap-plaster spread on calico ; then to extend it to its proper length 
with the pulleys, and to cover it with plaster of Paris; keeping up 
the extension till the plaster has become hard.! 
Fig. 47. 
• Pott, Chirurgical Works, vol. i. p. 365. 
f A case treated in this way by Dr. Bond of Glastonbury, will be found in Sir 
A. Cooper on Dislocations, p. 191. 255 
FRACTURES OF THE THIGH. 
li both thighs are broken, a iracture-bed should be employed;- 
or, if the surgeon has not one, the patient should be placed on his 
back, with four splints to each thigh, and his knees drawn up, and 
supported by pillows. 
When the lower end of the femur is fractured obliquely 
downwards and forwards, the sharp end of the upper fragment is 
apt to pierce the extensor muscles, and the lower fragment to be 
dragged down into the ham by the gastrocnemius. 
Treatment.-Firm extension must be kept up with the double 
inclined plane and splints;-and the knee must be well bent, to 
relax the gastrocnemius. 
Fracture of the Condyle into the 
Knee-joint mostly happens to old per- 
sons, and not unfrequently proves fatal. 
If much comminuted, or if compound, 
amputation will be necessary. Other- 
wise, the limb should be placed straight, 
so that the head of the tibia may keep 
the fractured parts in their places;- 
lotions and leeches should be used to 
prevent inflammation;-and afterwards 
a pasteboard splint. Passive motion 
should be commenced in five weeks. 
XII. Fracture of the Patella is 
generally transverse, and is caused by 
sudden contraction of the extensor mus- 
cles attached to it;-as, for instance, 
when a person who has his knee much 
bent under him, and is in danger of fall- 
ing, tries to save himself by throwing the body forwards. 
Symptoms.-Inability to straighten the knee, and separation of 
the fractured parts, which can be readily felt, and which is increased 
by bending the knee. 
Treatment.-The limb must be laid straight, with a well-padded 
splint behind the thigh and leg, in order to keep the knee quite 
motionless; and the patient's body should be raised to a half-sitting 
posture, in order to relax the rectus muscle. Evaporating lotions 
and leeches must be used, till pain and swelling abate;-then, and 
not till then, some apparatus may be employed to keep the broken 
surfaces as nearly in contact as possible. The most common con- 
sists of one pad, or strap, [see Fig. 49,] or bandage, placed above 
Fig. 48. 
Fig 49. 256 
FRACTURES OF THE LEG. 
the patella, and a similar one below it;-the two are then approxi- 
mated by longitudinal straps, or bandages, passing between them. 
But the best apparatus conceivable is that invented by Mr. Lons- 
dale ; for it causes no circular constriction of the limb whatever. 
If the parts can be kept in complete, apposition, 
the union may be bony;-if not, it may be liga- 
mentous, [see Fig. 50]; it is, however, a great 
object to have the ligament as short as possible. 
Passive motion should be begun in five or six 
weeks, the patient being made to sit on the edge 
of a high table, and desired to swing his leg 
backwards and forwards. 
Longitudinal or comminuted fracture of this 
bone is always caused by direct violence, and 
attended with great inflammation,-which being 
subdued, the parts must be kept in their places 
by bandages and pasteboard splints. Compound 
fracture will generally require amputation-unless 
the wound is very small-the skin not injured 
enough to slough or ulcerate-and the constitu- 
tion very good. 
XIII. Fracture of the Leg.-The ordinary 
fractures of the leg may be readily distinguished 
by careful examination. There are several me- 
thods of treatment. 
(1.) By the tailed bandage and splints.-The 
injured leg being laid on its outer side, the fracture 
is reduced by extension from the knee and ankle. 
Then a many-tailed bandage is applied after the manner repre- 
sented in the cut. This bandage is easily made, thus:-take a piece 
of roller, long enough to reach from the knee to the foot, and to 
overlap about one-third of the leg besides. Cut another roller into 
Fie. 50. 
Fig. 61. 
pieces, and lay them across the first at right angles, in such a man- 
ner that each shall overlap one-third of the preceding one; these 
transverse pieces (which should be half as long again as the cir- FRACTURES OF THE LEG. 
257 
cumference of that part of the leg which they are to encircle) are 
to be stitched to the longitudinal one, and then the bandage is 
ready for use. One splint, well padded, should be applied to the 
outer side of the limb; another to the inner side; and if there is 
any projection of either fragment, it should be kept in its place by 
a third slight splint to the shin. The outer splint should have a 
foot-piece, which should be carefully padded in such a manner 
as to prevent the foot from turning either inwards or outwards, 
especially the latter. There is a very useful rule, which should be 
attended to in all cases of injury below the knee: it is, to keep the 
great toe in a line with the inner edge of the patella. 
(2.) By the Macintyre's leg splint, [Fig. 52,] or some of the 
Fig. 52. 
numberless varieties of it in existence. The adjoining cut [Fig. 53,] 
represents it as applied to a patient of Fergusson's in the King's Col- 
lege Hospital, with a compound fracture, which is left uncovered by 
the bandages. It is straightened out by means of the screw under 
the knee, as Mr. Fergusson prefers the straight position in almost 
all cases of fracture of the lower extremity. Before its application, 
it must be made to correspond to the length of the sound limb, and 
must be well padded. 
Fig. 53. 
(3.) By the junk's. This very simple but efficient contrivance 
consists of a piece of old sheeting, with a bundle of reeds rolled 
together from either end. But it is more easy to comprehend it 
from seeing it once than from a page of description. 
(4.) By the starched bandage.-In simple cases of fracture of 
the leg, the patient may be permitted to leave his bed at the end 
of three weeks, with the fracture supported by the starched appa- 258 
FRACTURES OF THE LEG. 
ratus. First of all, a dry bandage should be applied from the foot 
half way up the thigh; then a piece of stout pasteboard, softened 
in boiling water, should be accurately adapted to the limb on each 
side; and the outer piece should be made to overlap the heel. In 
the next place, the hollows about the ancle and tendo-achillis 
should be well padded with tow; and then four or five layers of 
roller must be put on, thoroughly imbued with mucilage of gum 
or starch; and lastly a dry roller. When this has become dry, 
(which will be in a day or two,) the patient may get up, and move 
to his chair or sofa, but the foot must be suspended from his neck 
by a sling; and he must be particularly cautioned not to attempt to 
move it by its own efforts. 
For fracture of the head of the tibia into the knee- 
joint, the treatment is the same as for fracture of the condyles of 
the femur. The limb should be placed straight, so that the end of 
the femur may act as a splint, and keep the broken parts in their 
places. The whole limb should be raised, so as to relax the 
extensor muscles of the knee; and this should be done in all cases 
of fracture of the upper end of the tibia (for which, consequently, 
the treatment by splints, with the knee bent, is inapplicable.) Paste- 
board splints and starched bandages should be applied, to keep the 
joint motionless; but they should not cover the front of the knee 
so as to interfere with the leeches, fomentations, &c., that will be 
necessary to reduce the inflammation. Passive motion should be 
commenced in five weeks. 
Fracture of the lower end of the fibula, about three 
inches above the ankle joint, is not an uncommon accident, and 
may be caused by twists of the foot, or by jumping on uneven 
ground. 
Fracture of the internal malleolus may occur in the same 
way; and one or the other of these fractures commonly accompa- 
nies dislocation of the ankle. 
Treatment.-They may be treated either with the bandage and 
two splints, or with Macintyre's splint, or with Dupuytren's, which 
is a diminutive of the long straight splint, represented by fig. 42. It 
is to be well padded, and applied to the side opposite the fracture; 
but it is not so easy to keep the foot in a proper position with this 
as with the other apparatus. 
Fig. 54. 
Compound Fractures of the leg are to be treated on the princi- 
ples already laid down for the treatment of compound fracture in 
general. SYNOVIAL MEMBRANE. 
259 
XIV. Fractures of the Foot will often be attended with so 
much other mischief as renders amputation expedient. But an 
attempt should be made to save part of it;-especially the ball of 
the great toe. Pasteboard splints and other contrivances must be 
used to preserve the proper position;-and if matter forms, there 
should be no delay in freely dividing the dense fasciae of the foot, 
to let it escape. 
The tuberosity of the os calcis may be broken by the action of 
the muscles attached to it, in the same manner as the patella and 
olecranon, and will unite only by ligament. The treatment must 
be the same as that of ruptured tendo-achillis. 
CHAPTER VI. 
OF THE DISEASES AND INJURIES OF THE JOINTS. 
SECTION I.-OF THE DISEASES OF THE SYNOVIAL MEMBRANE. 
I. Acute inflammation of the synovial membrane (or syno- 
vitis} may be produced by local or by constitutional causes. The 
former are blows, strains, mechanical injuries, and especially pene- 
trating wounds, and cold. The latter are, the rheumatic and gouty 
diathesis, and the morbid state of the constitution produced by 
syphilis or the abuse of mercury;-sometimes, also, this disease is 
a sequel of gonorrhoea. It very seldom attacks young children. 
The joint most frequently affected is the knee. 
Symptoms.-In the most acute form, the symptoms are severe 
aching pain in the joint, aggravated by the slightest motion ; great 
swelling occurring very soon after the pain; redness and tender- 
ness of skin; and fever, which is often violent and alarming. 
The swelling is peculiar, and is distinctive of the disease. It is 
occasioned by a rapid effusion of fluid into the synovial cavity; 
and, consequently, if the joint is superficial, it fluctuates freely. It 
is always most prominent where the joint is least covered by liga- 
ment, and, consequently, the shape of the joint is always altered. 
When the knee is affected, the patella is protruded forwards, and 
there is a great fulness at each side of it, and at the lower and front 
part of the thigh. In the elbow, the swelling is most distinct above 
the olecranon, and in the hip and shoulder there is a general fulness 
of the surrounding muscles. 
Prognosis.-This disease is much more serious when it affects 
one joint solely, and more particularly when' it arises from local 
injury, (especially a penetrating wound,) than when it affects many 
joints, and arises from constitutional disorder. The danger to life, 260 
DISEASES OF THE 
in any case, will be proportionate to the severity of the febrile 
symptoms, and the rapidity and sharpness of the pulse ; delirium, 
or typhoid symptoms, show great peril. 
In severe cases, moreover, the membrane may suppurate, and 
the cartilage ulcerate, and the patient may often esteem himself 
lucky in recovering with the joint permanently anchylosed and 
immovable; whilst milder cases will be followed merely by a stiff- 
ness that may be gradually removed by treatment. 
Morbid dinatomy.-In recent cases, of great severity, the syno- 
vial membrane is found red, the joint filled with turbid synovia, 
mixed with flakes of lymph, or with pus, and portions of the mem- 
brane, and perhaps of the cartilage, ulcerated. 
Treatment.-In all cases arising from injury, the joint, or rather 
the whole limb, should be confined by a splint, so as to keep it 
perfectly motionless. This is indispensable; for the joint cannot 
be kept motionless without it. The other measures are, bleeding 
from the arm, if the patient is robust, and the joint important; if 
not, leeches in abundance to the joint, or cupping near it; ice, 
evaporating lotions, or warm poppy fomentations, according to the 
patient's choice; purgatives in moderation, and not given so as to 
disturb the part by frequent motions; tartar emetic in saline 
draughts; or calomel, with opium and antimony, in moderate 
doses every four hours, till the mouth begins to suffer, and opiates 
at night to relieve pain. A warm poultice of chamomile flowers, 
boiled till they are quite soft, will generally be found more soothing 
than cold applications. Blisters, it need scarcely be said, are inap- 
plicable during the acute stage. 
When the disease is manifestly connected with rheumatism- 
when it is attended with red sediment in the urine and acid perspi- 
rations, and affects several joints, and extends to the synovial sheaths 
of tendons, colchicum should be administered, F. 95, or the iodide 
of potassium with alkalis. But when only two or three joints are 
affected, or when there has been a manifest translation of the disease 
from some internal part, or from one joint to the another, Sir B. 
Brodie prefers the use of calomel and opium, in moderate doses, till 
the mouth is affected. When there is a tendency to gout, and the 
patient complains of grinding, excruciating pain, as if the joint were 
torn asunder, the colchicum is also the main remedy. In syphilitic 
cases, (which will be known by the patient's general history, by his 
wan, peculiar appearance, and most likely by the existence of papu- 
lar or other eruptions, vide p. 202,) mercury may be tried, if it has 
never before been given to excess; but if it has, or if the constitu- 
tion is broken down, recourse may be had to the iodide of potas- 
sium in doses of gr. iii. ter die, with a small dose of colchicum and 
opium at night; and sarsaparilla should be given in abundance. 
F. 56, 57. In all these cases, warm baths, in which a quantity of 
carbonate of soda or potass has been dissolved, will probably be of 
service. 
II. Chronic Inflammation of the synovial membrane is charac- 
terized by swelling of the joint, of the same nature that attends the SYNOVIAL MEMBRANE. 
261 
acute form, and by a dull aching pain, accompanied with a sense of 
weakness and relaxation, and not usually aggravated by pressing 
the articular surfaces against each other. The swelling always 
comes on in a few days after the pain; and sometimes, in cases of 
an indolent character, it is the only symptom present; these cases 
are called hydrops articuli,^ hydrarthus. If the disease proceed, 
the synovial membrane and surrounding tissue become thickened 
and gristly, and the swelling loses its softness and fluctuation; and, 
in neglected cases, the inflammation may lead to ulceration of the 
cartilages and destruction of the joint. The causes are the same as 
those of the acute form, of which it may be a sequel. 
Treatment.-The indications are, first, to correct constitutional 
disorder; secondly, to reduce inflammation ; and thirdly, to produce 
absorption of the effusion and thickening, and restore the part to 
its proper uses. 
In the first place, therefore, if the complaint is constitutional, and 
depends on gout, it must be treated by colchicum and warm ape- 
rients, especially the decoction of aloes and alkalis. F. 8, 9, 95, 
99. If the habit is rheumatic, colchicum, or the iodide of potassium, 
must be resorted to ; and in most cases, especially those following 
syphilis or gonorrhoea, warm bathing, change of air, sarsaparilla, 
and a most carefully regulated diet, avoiding all heavy, innutritions, 
acescent, or indigestible substances, will be indispensable. 
Secondly, in cases arising from local injury ; whilst there is any 
activity about the inflammation, (especially an increase of aching 
pain at night,) the part should be confined by a splint or starched 
bandage, and should be bathed with cold lotions, and blood should 
be repeatedly taken by leeches or cupping. 
The third indication is to be fulfilled by counter-irritation, 
beginning with blisters, which are as serviceable in the chronic as 
they are detrimental in the acute disease. They should be applied 
in succession, and be quickly healed up ; and should not be put too 
near the joint, if it is superficial, as the knee. The strong acetum 
cantharidis will often be found a very convenient substitute. After 
the blistering, when the activity of the disease has subsided, the 
tartar-emetic ointment, F. 38; the linimentum hydrargyri, or lini- 
ments of cantharides, ammonia, and turpentine, F. 14 ; the douche, 
or affusion with hot water; the vapour bath, and passive motion, 
will complete the cure. But all stimulating applications and passive 
motion must be at once abandoned, if they cause an aggravation 
of heat and pain. The ointment of Scott, F. 25, the ceratum 
hydrargyri comp, of the pharmacopoeia, is one of the most useful 
applications for the convalescent stage of this and other chronic 
diseases of joints. It is applied thus; the surface of the joint, having 
been first washed with camphorated spirit, should be covered with 
the ointment thickly spread on lint; next, adhesive plaster should 
be evenly applied in strips, so as to form a complete casing for the 
joint; and lastly, a bandage. The starched bandage may be substi- 
tuted for adhesive plaster. When the knee is bandaged in this way, 262 
DISEASES OF THE SYNOVIAL MEMBRANE. 
the adhesive straps should be arranged so as not to press too tightly 
on the patella. 
III. Abscess in Joints.-If, after acute or chronic inflammation, 
a joint becomes very much distended, and there is constant pain, 
unmitigated by remedies, and considerable constitutional excite- 
ment, suppuration of the synovial membrane may be fairly sus- 
pected. The first thing to be done under these circumstances is to 
make a puncture with a grooved needle, and examine the fluid that 
exudes. If it is serum, two or three more punctures may be made, 
and an exhausted cupping-glass be applied over them; and by these 
means the part may be very safely and expeditiously relieved of a 
considerable quantity of fluid. If it is pus, a free opening should be 
made with a lancet, in a depending position, so that the matter may 
run out easily; the joint should be placed on a splint in the most 
easy and convenient posture : the general health should be amended 
by tonics, alteratives, and proper diet; and then, in favourable cases, 
a cure will be effected by anchylosis. But if the suppuration and 
constitutional disturbance increase, the limb must be amputated. 
Purulent depots in Joints. - It has been mentioned in several 
previous chapters, that a rapid effusion of pus into the joints and 
other parts is a frequent occurrence in phlebitis, puerperal fever, 
erysipelas, dissection wounds, and other cases in which the blood is 
contaminated by a morbid poison. The part becomes red and 
painful, and very soon afterwards is found to be filled with pus. 
The only local treatment consists of a free incision in a depending 
position, and a splint, with a bandage to prevent accumulation of 
matter. 
IV. Pulpy Fungus consists in the conversion of the synovial 
membrane (generally of the knee) into a thick pulpy substance of a 
light brown or reddish-brown colour, intersected by white membra- 
nous lines. It produces, after a time, ulceration of the cartilages, 
caries of the bones, wasting of the ligaments, and abscesses in 
various places. 
Symptoms.-Gradually increasing stiffness and swelling of the 
joint, without pain;-the swelling less regular than that of chronic 
inflammation;-and not fluctuating, although so soft and elastic that 
it seems to do so. 
Treatment.-The progress of the disease may be retarded by 
rest and antiphlogistic measures; but, after a longer or shorter 
duration of the indolent stage, ulceration of the cartilage and hectic 
come on, and the patient can only be saved by amputation.* 
V. Loose Cartilages commence as little pendulous growths 
upon the synovial membrane, which become accidentally detached. 
They form in any joint, but most frequently in the knee. 
Symptoms.-They can be felt when they present themselves at 
the surface of the joint;-and when they get between the ends of 
the bones, which they are very apt to do during exercise, they 
cause sudden excruciating pain and faintness, followed by inflam- 
mation. 
* Brodie on Diseases of the Joints, 4th edit. p. 72. INFLAMMATION of the cellular tissue. 
263 
Treatment.-If possible, the cartilage should be fixed by band- 
ages, so as to prevent it from getting between the bones;-other- 
wise it must be removed ; taking care to prepare the patient by rest, 
low diet, and purgatives, and to use every precaution against in- 
flammation afterwards. 
The ordinary way of operating consists, first in pushing the carti- 
lage to the upper part of the joint on one side of the patella, and 
steadying it there against the condyle of the femur; then the skin 
having been drawn slightly upwards, an incision is made down to 
the cartilage of sufficient length to let it escape. But there is a plan 
of operating by subcutaneous incision, which seems to have been 
proposed almost simultaneously by Mr. Syme of Edinburgh, and 
M. Goyraud, and which avoids the danger of a direct wound into 
the joint. According to this plan, the cartilage having been pushed 
up as high as possible into one of the synovial pouches by the side 
of the patella, a long narrow knife is passed down upon it through 
the skin two or three inches above, and made to divide the synovial 
membrane to such an extent, that the cartilage may be squeezed 
through it into the subcutaneous cellular tissue, but without enlarg- 
ing the wound in the skin. There the cartilage must remain till the 
wound in the synovial membrane has had time to heal; and then 
it may, if desired, be easily removed by an incision through the skin; 
but if it causes no inconvenience it may be allowed to remain.* 
VI. Pendulous Fleshy or Gristly Tumours may produce 
many of the symptoms of loose cartilages. They may, perhaps, be 
distinguished by being less hard, and by being stationary. They 
have been extirpated from the knee, but of course with very great 
hazard to life. 
SECTION II. INFLAMMATION OF THE CELLULAR TISSUE. 
Inflammation of the cellular tissue around a joint is a peculiar 
affection, particularly described by Mr. Wickham, an author of 
great experience on the joints. It commences with a tolerably firm 
swelling, various in extent;-attended with slight obtuse pain, and 
caused by a deposition of lymph, which renders the tissue hard and 
brawny. As it increases, the skin becomes distended, white, and 
shining, and the pain and constitutional distress extreme. After 
this adhesive stage has lasted an uncertain number of months, sup- 
puration occurs at one or more points; and the abscesses burst 
through the synovial membrane, and cause irreparable disorganiza- 
tion of the joint. 
Treatment.-Leeches or cupping, and cold lotions, followed 
after a time by Scott's ointment (F. 25). Mr. Wickham deems 
counter-irritants and friction injurious.! 
• Vide B. & F. Med. Review, vol. xi. p. 526, and Fergusson's Practical Surgery, 
p. 321. 
j- Wickham on the Joints, p. 84, Winchester, 1833. See also Nicolai, quoted in 
Coulson on the Hip-Joint, p. 85. 264 
THE CARTILAGE. 
SECTION III. - THE LIGAMENTS. 
I. Inflammation.-Authors have described a form of inflam- 
mation of the ligaments of joints characterized by great pain from 
motions that shake, or twist them.* It must be treated like the 
subacute fascial inflammation. 
II. Relaxation.-Ligaments are liable to become relaxed and 
elongated, so as even to permit the dislocation of the joints to 
which they belong, if they have been long disused; and more 
especially if the innervation of the part is impaired likewise. Thus 
in a case of this kind related by Mr. Stanley, which followed an 
attack of hemiplegia, the ligamentum teres and capsular ligament 
of the hip were so elongated as to permit the head of the femur to 
slip out of the acetabulum. A similar result may ensue from long- 
continued chronic synovitis or rheumatism. Mechanical support, 
blisters, friction, cold affusion or sea-bathing, and electricity, are 
the only available remedies.! 
SECTION IV. THE CARTILAGE. 
The affections of cartilage in which the surgeon is interested, are 
its absorption or atrophy, and ulceration: of which there are seve- 
ral varieties. 
I. Senile Atrophy.-The cartilage of the joints of elderly per- 
sons is sometimes partially absorbed, so as even to denude the 
bone;-but both the cartilage itself and the exposed surface of 
bone are quite healthy. This state may exist without producing 
any symptoms, except, perhaps, a slight grating. Sometimes the 
place of the cartilage is partially supplied with a porcellaneous 
deposit. 
II. Articular cartilage is occasionally converted into a soft fibrous 
or villous structure. This change seems sometimes to be mere 
atrophy, sometimes the forerunner of ulceration. 
III. Acute Ulceration of cartilage is a frequent accompaniment 
of that acute inflammation and suppuration of the synovial mem- 
brane which follows compound dislocation and penetrating wounds. 
The cartilage rapidly disappears, but the exposed surface is healthy, 
and if the patient escape with life, it readily granulates and heals. 
Sir B. Brodie and Mr. Mayo relate several cases of acute idiopa- 
thic ulceration of cartilage "attended not with effusion into the 
joint, but with suppuration or oedema external to it," and rapidly 
followed by anchylosis; but such cases are rare. 
IV. Chronic Ulceration of cartilage is one of the most import- 
ant affections of joints, and ought to be carefully studied. It may 
be a consequence of previous caries of the bone, as will be described 
• Mayo's Pathology, p. 79. 
f Vide six cases of Dislocation from this source, narrated by Mr. Stanley in 
Med. Chir. Trans, vol. xxiv. ULCERATION OF CARTILAGE. 
265 
in the next section ;-and it may also follow the chronic inflamma- 
tion of the synovial membrane, if neglected; but generally speaking, 
the disease begins in the cartilage itself. It commonly affects per- 
sons of bad, scrofulous constitutions, between the age of puberty 
and thirty-five;-and is usually ascribed to cold, or to neglected 
injury. 
Symptoms.-For the first few weeks (or perhaps months) of this 
disease, the patient complains of only slight occasional rheumatic 
pains, and trifling lameness of the joint. After a time, the pain 
increases in severity, especially at night, and it is generally referred 
to one small spot, deep in the joint, and is compared by the patient 
to the gnawing of an animal. Moreover, it is usually accompanied 
by an aching of some other part of the limb;-thus, when the hip 
or elbow is affected, there is an aching of the knee or wrist;-but 
it is important to notice, that both the pain in the affected joint, 
and the sympathetic remote pain, are always aggravated by motion 
of the joint, and by pressure of the articular surfaces against each, 
other. As the disease proceeds, the suffering becomes most excru- 
ciating, and is attended with painful spasms and starting of the 
limb during sleep; so that the patient's rest is broken, his spirits 
exhausted, and his appetite and general health rapidly impaired. 
At first the pain is unaccompanied with any swelling; in fact, this 
symptom never appears in less than four or five weeks, and often 
not for as many months; and when it does appear, it is slight; and 
as it depends on an infiltration of the tissues around the joint, and 
not on effusion into it, the shape of the joint is unaltered. 
Terminations.-In fortunate cases that are subjected to judi- 
cious treatment at an early stage, the ulceration may be arrested, 
and the diseased surfaces will throw out lymph and heal; or very 
probably the lymph effused by two opposite ulcerated surfaces will 
unite, and anchylosis will be produced.* But, in unfavourable 
cases, the ulceration proceeds and lays bare the bone, which 
becomes carious, and can be heard to grate on the least motion;- 
suppuration occurs into the joint, and numerous tortuous abscesses 
form around it, so that the surrounding soft parts are disorganized; 
-the ligaments are destroyed, so that the flexor muscles, which 
have long kept the joint immovably bent, at last dislocate it;-if 
the knee is affected, for instance, the head of the tibia is drawn 
backwards into the ham;-and at last the patient, unless amputa- 
tion is performed, dies exhausted with hectic. 
The prognosis, in the first stage, that is, before swelling has 
occurred, may be favourable; but after swelling has existed for 
some time, the patient will be fortunate in recovering with anchy- 
* The ulcerated portion of cartilage is sometimes supplied by a dense mem- 
brane. "I cannot," says Brodie, "assert that this membrane is never ultimately 
converted into the true cartilaginous structure. In other cases a compact layer of 
bone is generated on the carious surface." In others there is found " a thin layer 
of hard semi-transparent substance of a gray colour, and presenting an irregularly 
granulated surface." Sometimes, lastly, the head of the bone is covered " with a 
crust of bony matter of compound texture, of a white colour, smooth, and like 
polished marble." Brodie on the Joints, 4th edit. p. 168. 266 
ARTICULAR CARIES. 
losis; and after suppuration, lie will (especially if an adult) be 
almost certainly compelled to suffer amputation. 
Treatment.-The first and most indispensable measure is per- 
fect rest; which must be insured by confining the joint with a 
starched bandage, or splint of undressed leather. The splint or 
bandage should have apertures in it to allow the application of 
counter-irritants. (2.) Occasional leechings, or small cuppings, in 
the early stages, when the pain is severe. But loss of blood is 
merely a palliative of accidental fits of inflammation, and must 
not be carried too far. (3.) Counter-irritation either by a seton, or 
caustic issue, or the actual cautery. If the knee is affected, an issue 
may be established on each side of the head of the tibia. Sir B. 
Brodie recommends, in these cases, that the issue should be kept 
open by rubbing the sore occasionally with caustic potass, or the 
sulphate of copper, rather than by peas. The actual cautery is 
exceedingly efficacious, and not half so painful in reality as might 
be imagined. The manner of applying it is described elsewhere.* 
For children, blisters answer Very well; and it is better to keep one 
blister open than to apply a succession of them. Sir B. Brodie has 
shown, that issues, when long established, sometimes irritate the 
constitution, bringing on a return of the pain which they relieved 
at first, and which will again depart if they are healed up. It is a 
practical rule, therefore, to give them up for a time, before con- 
demning a joint to amputation. The ointment of Scott, applied as 
described in a preceding page, will often be found an useful auxi- 
liary to time and quietude. (4.) The strength, if enfeebled, must 
be repaired by bark, steel, and the mineral acids, especially by sar- 
saparilla ; and pain must be relieved by opiates. Occasionally, a 
cautious course of Plummer's pill is of service. (5.) When abscess 
forms, there need be no haste in opening it; but if the skin becomes 
very much distended, it may be punctured, and the part be wrapped 
in a fomentation cloth, so that the matter may gently exude. No 
rough squeezing is admissible. If the puncture heals, another may 
be made when necessary-if it remains open, it should be made 
large enough to let the matter flow out freely as soon as it is 
secreted. The case must then be treated according to the directions 
for abscess in joints. 
SECTION V.-ARTICULAR CARIES. 
Caries of the head of a bone is not an uncommon cause of 
ulceration of the adjacent cartilage and disorganization of the joint. 
The affected bone is found to be soft, red, and vascular, and deficient 
in earthy matter, so that it is easily cut or crushed; its cancelli are 
filled with a reddish fluid, and in scrofulous cases a cheesy matter 
is deposited in them. Owing to this softened state of the bone, the 
cartilage peels off from it readily. This disease most frequently 
• Refer to the Index. ARTICULAR CARIES. 
267 
affects the knee, elbow, and small bones of the carpus and tarsus; 
-it is very common in scrofulous children, but rare after thirty. 
An advanced stage gives rise to what was formerly called .spina 
ventosa;-that is, the extremity of the bone becomes greatly 
enlarged, but is hollowed out into a mere shell by suppuration in 
its interior. 
The symptoms are nearly the same as those of ulceration of 
cartilage; -that is, fixed pain, extending to different parts of the 
limb;-aggravated by motion, and unaccompanied at first by 
swelling. But in scrofulous cases there is a remarkable absence 
of pain, except during the formation and bursting of abscesses. 
Treatment.-This is also nearly the same that is required for 
ulceration of cartilage. The chief dependence is to be placed on 
perfect rest; and on the various measures that have been directed 
for the constitutional treatment of scrofula. Issues are not advisa- 
ble in genuine scrofulous cases, as a general rule; but they are of 
great service when the pain is severe and continuous. Small leech- 
ings may be also occasionally expedient to relieve accidental fits 
of inflammation. Abscesses should in general be left to burst of 
themselves. ^Imputation need not be so hastily performed in 
general in this disease as in the last-both because the patient has 
a greater chance of recovery with anchylosis;-and because it 
seems probable that disease of the lungs or mesentery is sometimes 
suspended or averted by the continuance of a (not very severe) 
disease in the extremity. The author believes that it will agree 
with the experience of most surgeons, that those members of a 
scrofulous family are least likely to be consumptive at puberty, 
who have suffered from scrofulous affections of the skin or glands 
in early youth. If, however, the pain is so serious that it exhausts 
the strength and spirits, the part must be amputated; because the 
continuance of so severe an outward disease might induce the very 
same disease in the lungs or mesentery, which a more moderate 
degree might avert. Recovery without amputation is far more 
probable when one of the larger articulations is affected, than when 
the complicated joints of the tarsus or carpus are involved. 
General Diagnosis.-It may be useful to present a concise view 
of the differences of the three principal chronic diseases of joints, as 
regards their two principal symptoms-viz. pain and swelling. The 
pain in chronic synovitis is not very severe; it usually increases for 
ten or fourteen days, and then declines;-and it is not immediately 
aggravated by motion, or by pressure of the articular surfaces 
against each other. In ulceration of the cartilage, the pain is 
very severe, continuous, and exhausting, and increases as the dis- 
ease advances, becoming greater after the occurrence of swelling; 
moreover, it is attended with sympathetic pain of some other part 
of the limb, and is always aggravated by motion. "In articular 
caries in scrofulous children," says Brodie, "there is not that 
severe pain which exhausts the powers and spirits of the patient," 
as in ulceration of the cartilage;-but it must be confessed, that in 268 
ANCHYLOSIS. 
cases occurring to adults there is very little difference in this respect. 
The swelling in chronic synovitis comes on in the course of a 
few days; it fluctuates freely, and alters the form of the joint. In 
the other two affections it does not come on till after some weeks 
or months, and it does not alter the shape of the joint; but as it 
depends on a general infiltration of the tissues around the articular 
extremities, it seems as if it were caused by enlargement of the 
bones; the skin, moreover, is free from redness; hence the term 
white swelling, by which these two affections are commonly de- 
signated.* 
SECTION VI. ANCHYLOSIS. 
Anchylosis, or immobility, is a frequent consequence of serious 
injuries and diseases of joints; therefore, whenever it is likely to 
happen, the affected joint should be placed in the position which 
will be the least inconvenient for it to preserve. The elbow should 
be placed at a right angle ; the wrist straight; the hip and knee a 
little bent; and the ankle at a right angle to the leg. There are 
three varieties of anchylosis. 
(1.) The spurious or false anchylosis, which depends on thick- 
ening and deposits into the synovial membrane and ligaments, and 
rigidity of the muscles. The extensor muscles are apt, in almost 
all cases where the joint is diseased, to become paralyzed and 
wasted; and the flexor muscles to fall into the state of rigid atro- 
phy, becoming short, inextensible, and very probably dislocating 
the joint, by their continued traction. The form of anchylosis is 
very common after synovitis. 
Treatment.-Daily vigorous friction with stimulating liniments 
over the extensor muscles;-vapour baths or the local steam bath 
-shampooing-and passive motion-that is to say, the joint to be 
every day bent and extended with a gentle degree of force, not 
sufficient to cause much pain. If one or more right muscles seem 
to be the main obstacles, their tendons should be divided by subcu- 
taneous section. 
(2.) Ligamentous anchylosis signifies the union of two articular 
surfaces by ligament, and is an occasional consequence of com- 
pound dislocation, and of ulceration of cartilage. It admits of only 
very gentle treatment by passive motion, especially if it follow 
disease. 
(3.) Bony anchylosis is produced when the lymph that is effused 
after destruction of cartilage ossifies. It is incurable, except by 
sawing through the bone, and then employing frequent motion so 
as to prevent the consolidation of a callus and establish a false 
joint. This operation was successfully performed by Dr. Rhea 
Barton, of Philadelphia, on the hip, in 1827, and on the knee in 
• "Ulceration may be suspected," says Mr. Mayo, "when with little or no fluid 
in the synovial membrane, there is pain of the joint, accompanied with acute sensi- 
bility to pressure or motion of the articular cartilages on each other." DISEASE OF THE HIP-JOINT. 
269 
1838. It was also successfully performed by Dr. Gibson, of Phila- 
delphia, in a case of complete anchylosis of the knee, with not a 
vestige of ligament, cartilage, or synovial membrane remaining. 
Having laid bare the front of the joint by a V incision above the 
patella, he sawed out a wedge-shaped portion of the bone, and 
gently bent the rest so as not to endanger the popliteal vessels.* 
But of course this is so serious an operation, that it must not be 
undertaken inconsiderately. 
SECTION VII. OF DISEASE OF THE HIP-JOINT. 
This joint is exceedingly liable to chronic disease, and there are 
certain peculiarities in the symptoms which render it expedient to 
devote a section to it in particular. The usual forms of disease are 
the chronic ulceration of cartilage in the adult, and scrofulous caries 
of the head .of the femur in children. The symptoms and conse- 
quences of both are nearly the same. 
Symptoms.-The disease begins with slight occasional pain, and 
more or less lameness in the gait. As it advances, the pain becomes 
very excruciating in the cases of ulceration of cartilage, whilst in 
those of scrofulous caries it is comparatively trifling; but in both 
forms it is felt chiefly in the knee; and in the scrofulous caries, this 
pain in the knee may be the only symptom complained of; nay, 
there may even be some swelling there. The criterion, however, is, 
that if the surgeon moves the hip-joint, or if he jerks the femur 
upwards against the acetabulum, great pain will be felt in the hip, 
and the pain in the knee will be greatly aggravated. There is also 
tenderness in the groin, and behind the great trochanter, and some- 
times swelling of the inguinal glands ; and the nates of the affected 
side soon becomes wasted and flabby. 
But the chief characteristics of hip disease are certain alterations 
that occur in the length of the limb. In the first stage the limb 
acquires an apparent increase of length, which is accounted for in 
different ways by different authors. (1.) One opinion is, that it is 
produced by effusion into the cavity of the joint, and consequent 
protrusion of the limb outwards and downwards.! (2.) Mr. Wick- 
ham explains it by supposing that in the first stage of the disease 
there is a spasmodic action of the glutsei and rotator muscles, by 
which the limb is drawn a little away from its fellow. The sur- 
geon, in comparing their lengths, naturally approximates the sound 
limb to the diseased one, instead of disturbing the latter; and thus, 
as the sound limb is carried over the median line, it seems to become 
a little shorter, and the diseased one seems, by comparison, appa- 
rently lengthened. (3.) Sir B. Brodie explains it by showing that 
when the patient stands upright he rests his whole weight on the 
* Vide American Journ. Med. Sc. July, 1842. 
f This opinion is corroborated by the experiments of M. Parise on the influence 
of artificial injections into the hip-joint after death, in separating the bones, and 
dislocating the femur. Arch. Gen. de Med., Mai et Juin, 1842. 270 
DISEASE OF THE HIP-JOINT. 
sound limb, and stretches out the other in advance merely to steady 
himself; and that, in consequence of this repeated attitude, the 
pelvis on the diseased side becomes habitually depressed. But 
whatever explanation be adopted, it must be remembered that the 
lengthening is apparent, and not real; because the distance from 
the spine of the ilium to the patella is the same on both sides. 
In a subsequent stage of the complaint, the limb becomes appa- 
rently shortened, as shown in the adjoining cut, (fig. 55), which 
Fig. 55. 
Fig 56. 
gives a bird's eye view of a child, a patient of Mr. Partridge's in 
the King's College Hospital, in the second stage of hip disease. 
This shortening is attributed by Mr. Wickham to a preponderating 
action of the psoas and iliacus which draw the limb up across the 
other. And this explanation is rendered probable by the fact that 
spasmodic action of those muscles is capable of simulating disloca- 
tion of the hip. * But it is sometimes caused by the patient's atti- 
tude, as is explained in the quotation from Brodie in the next page. 
This shortening is functional, and is easily removed, if the disease 
is checked. 
But if the disease proceed, it is succeeded by another kind of 
shortening, caused either by the destruction of the neck of the femur 
* Kluyskiens, " 1'Experience," Oct. 29, 1840. Case of spasmodic affection 
simulating dislocation of the hip. DISEASE OF THE HIP. 
271 
by caries, or (as is more commonly the case) by the destruction of 
the acetabulum and capsular ligament, and dislocation of the bone 
upwards by the muscles. The deformed appearance caused by 
this dislocation is well exhibited in the preceding sketch (fig. 56), 
taken from a patient under the care of Mr. Fergusson, in the King's 
College Hospital; it also shows the apparently broad and large, 
but really wasted and flattened, form of the nates.* The effect of 
the altered length of the limb in distorting the spine is also seen. 
Sometimes the limb is turned inwards, as in dislocation on the dor- 
sum ilii; or outwards, as in fracture of the neck of the femur ; this 
is accidental. This organic shortening is usually soon followed by 
abscess, which may burst on the thigh or the groin; or the aceta- 
bulum may be perforated so that the matter passes into the pelvis 
and bursts into the rectum; and from this stage it is exceedingly rare 
for an adult to recover, although, in the case of children, the prog- 
nosis is not unfavourable, if the strength is pretty good. 
Diagnosis.-The ulceration of cartilage may be known from 
caries of bone by various distinctions, which have been before 
pointed out. The great pain caused by pressing the femur against 
the acetabulum will distinguish either disease from sciatica; and 
they may be distinguished from inflammation of the synovial mem- 
brane of the hip by the fact, that the pain in the latter complaint is 
referred to the upper and inner part of the thigh, and that it is not 
aggravated by standing on the limb. 
Treatment.-This must of course be the same in principle as 
the treatment of other diseased joints. Perfect rest must be 
enforced by a starched bandage, or leather splint, or by confining 
the patient to a fracture-bed; at all events he should not be per- 
mitted constantly to lie on the sound side, otherwise the distortion 
of the spine, and danger of dislocation, will be enhanced. When 
the stage of shortening has commenced, great comfort and advan- 
tage may often be derived from keeping up constant extension of 
the limb by means of a weight attached to the thigh above the 
knee, by a cord which passes over a pulley at the end of the bed. 
Cupping will be of great service in the early stages. But the prin- 
cipal dependence is to be placed on proper constitutional treatment, 
and on counter-irritation by means of an issue behind the great 
trochanter, or at the anterior edge of the tensor vaginse femoris, or 
by a seton in the groin ; and these measures should not be neglected, 
even though suppuration has commenced. When abscess forms, 
it should not be opened too soon, and when it is opened it should 
be done in the manner described in the section on chronic abscess, 
although, it must be added, that this is a plan of treatment which 
Sir B. Brodie does not believe to possess any particular advantage. 
* It also excellently illustrates the following passage from Brodie, relating to 
the cause of the apparent shortening which succeeds the lengthening in the early 
stage:-In "a few cases, where the patient is in the erect position, it may be 
observed that the foot which belongs to the affected limb is not inclined more for- 
ward than the other, but that the toes only are in contact with the ground, and the 
heel raised, at the same time that the hip and knee are a little bent." Op. cit. 
p. 134. DISLOCATION GENERALLY. 
272 
SECTION VIII. WOUNDS OF JOINTS. 
Symptoms.-A wound may often, but not invariably, be known 
to have penetrated a joint, by the escape of synovia, in the form of 
small oily globules. 
Treatment.-The object is to avert acute inflammation of the 
synovial membrane, which might prove fatal. If, therefore, the 
part wounded be the knee, and if the skin be torn or injured so 
that the wound cannot be closed, or so that it is certain not to unite 
by adhesion, and if the patient's constitution be bad, amputation 
should be performed at once. Otherwise, the wound should be 
carefully closed with a piece of lint dipped in blood;-the joint 
should be kept quite motionless on a splint;-and every local and 
constitutional measure be adopted to avert or subdue inflammation. 
SECTION IX. - OF DISLOCATION GENERALLY. 
Symptoms.-The symptoms of dislocation are two;-(1.) Defor- 
mity; there being an alteration in the form of the joint;-an unna- 
tural prominence at one part and a depression at another, together 
with lengthening or shortening of the limb. (2.) Loss of the pro- 
per motions of the joint, which is most frequently rendered stiff 
and motionless. 
Causes.-Dislocation maybe caused by external violence, or bv 
muscular action. And the circumstances that enable muscular 
action to produce it are,-a peculiar position (as when the jaw is 
very much depressed);-paralysis of an antagonist set of muscles; 
-elongation of ligaments;-or fracture or ulceration of some pro- 
cess of bone. Thus ulceration of the acetabulum permits the head 
of the femur to be dislocated upwards, and fracture of the coronoid 
process permits the ulna to be dislocated backwards. 
Morbid Jinatomy.-Dislocation is generally attended with rup- 
ture of ligaments, which may readily unite and heal by the adhe- 
sive inflammation. If the dislocation be left unreduced, the lymph 
thrown out around the head of the bone in its new situation 
becomes converted into new ligaments, and a new socket, which is 
lined with a smooth ivory substance, and not with cartilage ; and 
a very useful degree of motion is often acquired. Meanwhile the 
old socket gradually becomes filled up. 
Diagnosis.-Dislocation maybe distinguished from fracture, 1, 
by the absence of crepitus. For although a slight crackling is 
often perceptible, owing to an effusion of serum into the cellular 
tissue, it can hardly be mistaken for the grating of fracture. 2. 
By the circumstance, that mobility is increased in fracture, dimi- 
nished in dislocation. 3. By measurement of the bone supposed 
to be broken, which, if broken, will be most probably shortened. 
4. By the patient's age;-for fractures near joints are most com- 
mon in the very young, and the aged-dislocations in the adult.* 
* This, like all other general rules as to frequency, is not worth much without a DISLOCATION GENERALLY. 
273 
Treatment.-The reduction of dislocations may be effected by 
fixing the part from which the bone lias been dislodged, and 
extending the dislocated limb in such a manner as to draw the 
head of the bone into its socket, and in such a position as to relax 
as many of the opposing muscles as possible. After reduction, 
leeches, cold, and purging, must be used to prevent inflammation, 
and the joint should be kept at rest till any laceration of its liga- 
ments may have healed, otherwise the dislocation may be perpetu- 
ally recurring. But it will be necessary, before attempting reduc- 
tion, to diminish the resistance offered by the muscles, if those 
which surround the affected joint be large, or if the patient be 
robust and plethoric. Bleeding to faintness; immersion in a hot 
bath (100 to 106 F.) for half an hour, and the exhibition of»half- 
grain doses of tartar emetic, are the requisite measures. But they 
may be often avoided, if the reduction can be effected before the 
patient has recovered from the faintness consequent on the injury. 
Compound Dislocation is a dangerous accident, because of the 
acute synovial inflammation, rapid ulceration of cartilage, and vio- 
lent constitutional disturbance, with which it is liable to be fol- 
lowed. The necessity of amputation will depend on precisely the 
same contingencies as in compound fracture ;-old age ;-bad con- 
stitution;-shattering of the bone;-extensive bruising or lacera- 
tion of the integuments, so that the wound cannot be closed;- 
laceration of large blood-vessels;-or if it be the knee-joint. If 
the limb is to be saved, the dislocation must be reduced;-if the 
end of the bone protrude through the skin, and render reduction 
difficult, it must be sawed off, or the aperture must be slightly 
dilated;-the wound must then be closed, and covered with a piece 
of lint dipped in blood; and the case be treated as a wounded 
joint. 
Dislocation and Fracture.-Supposing the femur or humerus 
to be dislocated and fractured also, Sir A. Cooper directs the frac- 
tured part to be first well secured in splints and bandages, and then 
the dislocation to be reduced without delay. Because, if the dis- 
location is not attended to till after the fracture has united, the 
difficulty of reducing it will be very much increased through the 
lapse of time; and, perhaps, the bone may be broken again during 
the forcible extension that will be necessary.* 
definite numerical estimate. Thus, supposing an injury to the hip attended with 
deformity, the prima facie probability is that it will prove to be a fracture, if the 
patient is old: but a dislocation if middle-aged;-but, there may be exceptions 
either way. Again, dislocations of the elbow-joint are quite as common in children 
as fractures. 
* [Dislocations especially of the large joints, sometimes occur from elongation 
of their capsules and ligaments, the consequence either of impaired nervous 
power, or of a mild kind of inflammation, whether rheumatic or not, by which, 
without any evident change in the organization of tissues, their property of resist- 
ance becomes so much impaired that they will yield considerably to an extending 
force.-See remarks and cases by Mr. Stanley, in a paper " On dislocations of the 
Hip Joints, accompanied by elongation of the Capsules and Ligaments." F.] 274 
DISLOCATIONS OF THE CLAVICLE. 
SECTION X. OF PARTICULAR DISLOCATIONS. 
I. Dislocation of the Jaw may be caused by a blow on the 
chin, when the mouth is wide open, or by spasm of the pterygoid 
muscles, by which the articular condyles are drawn over the trans- 
verse root of the zygomatic process. 
Symptoms.-The mouth 
fixedly open;-the chin 
protruding forwards;-and 
a prominence felt under 
the zygomatic process. If 
one side only is dislocated, 
the chin will be turned to- 
wards the opposite. 
Treatment.-The sur- 
geon should wrap a napkin 
around his thumbs, and 
place them at the roots of 
the coronoid processes be- 
hind the molar teeth;- 
then he should press them downwards and backwards, elevat- 
ing the chin at the same time with his fingers. Or he may place 
Ihe handle of a fork on the last molar teeth, and depress them 
with it, using the upper teeth as a fulcrum. Or a piece of cork 
may be put between the molar teeth in order to act ast* fulcrum, 
whilst the chin is elevated. After reduction, the chin must be con- 
fined for a week or two by a four-tailed bandage. 
II. Dislocations of the Clavicle.-The sternal extremity of 
Fig. 57. 
Fig. 58.* 
* [This figure is intended to represent dislocation of the sternal extremity of the DISLOCATIONS OF THE SHOULDER. 
275 
this bone may be dislocated forwards by blows on the shoulder. 
It can readily be felt on the anterior surface of the sternum. The 
treatment is in all respects the same as for fractured clavicle. Dis- 
location of this end of the bone backwards has been caused by 
curvature of the spine. It produced so much pressure on the oeso- 
phagus as to threaten starvation, and was in consequence extirpated 
by Mr. Davie of Bungay. There is also one case on record of 
dislocation of this end of the clavicle backwards by violence. It 
did not cause so much inconvenience as might have been expected, 
and was reduced by fixing the elbow, and drawing the upper 
end of the humerus outwards.* 
The outer extremity of the clavicle may be dislocated upwards 
on the acromion. The shoulder is sunken and flattened, and on 
tracing the spine of the scapula, the end of the clavicle can be 
felt upon the acromion. The outer extremity of the clavicle has 
also been known to be dislocated under the acromion by a kick 
from a horse on the shoulder.t The treatment is the same as for 
fracture of the clavicle. 
Dislocation of the Shoulder-Joint may occur in three prin- 
cipal directions. The head of the humerus may be thrown down- 
wards, forwards, and backwards; besides which it may be partially 
dislocated forwards and upwards. 
(1.) In the dislocation downwards, or into the axilla, which is 
the most common, the head of the bone rests on the axillary plexus 
of nerves, between the subscapularis muscles and the ribs. 
Fig 59. 
Fig 60. 
clavicle, and dislocation forwards of the shoulder-joint on its left side; and disloca- 
tion of the acromial end of the clavicle, and dislocation of the shoulder downwards 
on its right side.] 
* Vide a case by M. Pellieux in the Revue Medicale, Aug. 1834, p. 151. 
j- Forbes's Rev. vol. vi. 276 
DISLOCATIONS OF THE SHOULDER. 
Symptoms. - The arm is lengthened;-a hollow may be felt 
under the acromion, where the head of the bone ought to be;-the 
shoulder seems flattened;-the elbow sticks out from the side; - 
and the head of the bone can be felt in the axilla, if the limb be 
raised; although such an attempt causes great pain and numbness. 
Diagnosis.-There are three fractures liable to be mistaken for 
this dislocation: viz. fracture of the acromion;-of the neck of the 
scapula;-and of the neck of the humerus. The first two may 
be known by the facility with which the form of the joint is re- 
stored by raising the limb, and by the crepitus felt on doing so. In 
fracture of the cervix humeri, the limb is shortened, instead of 
being lengthened as it is in dislocation;-there is not so much 
vacuity under the acromion ;-and the rough angular end of the 
shaft may be felt in the axilla, instead of the smooth head of the 
bone. 
(2.) In the dislocation forwards, the head of the humerus is 
thrown on the inner side of the coracoid process, and may be felt 
under the clavicle. [See figs. 61, 62.] Symptoms.-The arm is 
shortened;-the elbow projects backwards; the acromion seems 
pointed, and the head of bone cannot be felt under it. 
Fig 61. 
Fig 62. 
(3.) In the partial dislocation forwards, the head of the bone is 
thrown partly off from the gleAoid cavity against the coracoid pro- 
cess. The symptoms are, projection of the acromion and a hollow 
under it, at the back of the joint, whilst the head of the bone is 
prominent in front, and may be felt to move on rotating the elbow: 
cramps of the hand, and difficulty of raising the elbow, because the 
head of the bone strikes against the coracoid process. 
(4.) In the dislocation backwards, the head of the bone may be 
felt on the dorsum scapulas; and the elbow projects forwards. DISLOCATIONS OF THE SHOULDER. 
277 
Fig 63. 
Fig. 64. 
(5.) The partial dislocation upioards is attended with a dis- 
placement of the biceps tendon from its groove, as we shall mention 
more particularly presently. 
Fig. 65. 
Treatment.-There are five methods of reducing the first or 
downwards form of dislocation. 
(1.) By simple extension. A jack-towel is to be passed round 
the chest, both above and below the shoulder, so as to fix the sca- 
pula well; this should be held firmly. Another should be fastened 
round the arm, above the elbow. Extension should then be made 
by the latter;-the patient sitting on the floor, his elbow being bent, 
and the humerus being raised and caried forwards, so as to relax 
the deltoid, supra-spinatus, and biceps muscles. When extension 
has been made for some minutes, the surgeon should lift the head 
of the bone, and it will frequently return with a snap. 
(2.) The extension may be performed in the same direction with 
the aid of the pulleys;-recollecting always that they are not to be 278 
DISLOCATIONS OF THE SHOULDER. 
used in order to exert greater force, but to exert it more equably. 
A damp bandage should be applied round the elbow to protect the 
skin before the strap of the pulleys is attached. 
Fig. 66. 
(3.) By the heel in the axilla. The patient lies down on a bed, 
and the surgeon sits on the edge. He puts his heel (without his 
boot) into the axilla, to press the head of the bone upwards and 
outwards, and at the same time pulls the limb downwards by means 
of a towel fastened round the elbow. 
Fig. 67. 
(4) According to the method invented by Air. White of Man- 
chester, and revived by Malgaigne, the patient lies down, and. the 
surgeon sits behind him. The scapula is well fixed, by placing 
one hand upon the shoulder, or by passing a jack-towel over the 
shoulder, and fixing it to the opposite corner of the bed ; -the arm DISLOCATIONS OF THE SHOULDER. 
279 
is raised from the side, and drawn straight up by the head, till the 
bone is thus elevated into its socket. 
Fig. 68. 
(5.) By the knee in the axilla. The patient being seated in a 
chair, the surgeon places one 
of his knees in the axilla, 
resting the foot on the chair. 
He then puts one hand on 
the shoulder to fix the 
scapula, and with the other 
depresses the elbow over his 
knee. 
The dislocation forwards 
may be reduced by the heel 
in the axilla, or by exten- 
sion with the jack-towel or 
pulley. But the extension 
must be made in a direction 
downwards and backwards. 
For the dislocation back- 
wards, extension should be 
made forwards. The partial 
dislocation forwards may be 
reduced by simple extension. 
After reduction a pad 
should be placed in the 
axilla, and the arm and 
shoulder supported for some days with a figure of 8 bandage, 
a few turns of which should confine the arm to the trunk. Warm 
fomentations -perhaps leeches-and subsequently frictions, will 
relieve the pain* and swelling. The more weak and flabby the 
patient, or the oftener the dislocation has occurred, the longer will 
confinement be necessary, in order to allow of a complete con- 
solidation of the ruptured ligament. In fact, when the dislocation 
Fig. 69. 280 
DISLOCATIONS OF THE ELBOW. 
has occurred more than twice, an apparatus consisting of a clavicle 
bandage, with a broad band round the head of the humerus, should 
be worn for some months so as to restrain the motions of the joint. 
It has been before directed that this and all other dislocations 
should be reduced as soon as possible after the injury. If the 
reduction has been delayed till the muscles have fixed the part, 
and the patient is robust, it will be necessary to bleed or administer 
tartar emetic, and to make a long, slow, and gentle, but unremitting 
extension by the pulleys. When the extension has been continued 
some time, the surgeon may gently rotate the limb by the forearm, 
or lift the head of the bone; and during the whole operation, the 
patient's attention should be diverted as much as possible to other 
objects. If the dislocation has lasted some time, there will be still 
greater necessity for a preparatory bleeding, purging, and the warm 
bath, and for a tedious operation. Sir A. Cooper's opinion is, that 
a reduction ought not to be attempted after three months. Although 
the criterion which Mr. B. Cooper has proposed is a better one; 
and that is, the degree in which the arm has been exercised and 
the amount of useful motion which it has acquired in its new 
situation; for, in proportion as the head of the bone has formed 
for itself a new socket, so most likely will the old socket have 
become unfit for its reception again. There are numerous in- 
stances on record of the most disastrous and even fatal results that 
have ensued from attempts at reduction at a later period; the 
integuments and muscles have been lacerated; abscess has formed, 
and been followed by anchylosis of the joint; nay, even the whole 
side has been palsied from injury to the cervical vertebrae, and the 
axillary artery has been torn across. 
Injuries of the shoulder-joint are liable to be followed by various 
obstinate and intractable affections. Sometimes the deltoid muscle 
wastes away, owing probably to injury of the circumflex nerve. 
Violent spasms and neuralgic pains of the arm sometimes occur 
from injury to the other nerves; and there are some cases in which 
rupture or displacement of the long tendon of the biceps is the 
source of continued impairment of motion; and, together with 
displacement of this tendon, the head of the humerus has been 
known to be partially dislocated upwards * 
IV. Dislocation of the Elbow presents six varieties. Both 
radius and ulna may be dislocated, (1) simply backwards; or, 
(2) backwards and inwards; or (3) backwards and outwards. 
(4) The ulna by itself may be dislocated backwards;-and the 
radius by itself either (5) backwards, or (6) forwards. 
(1) When both radius and ulna are dislocated buckwards, the 
elbow is bent at a right angle, and is immovable. The olecranon 
projects much behind;-a hollow can be felt at each side of it, cor- 
responding to the greater sigmoid cavity;-and the trochlea of the 
* See a paper by Mr. Stanley on Rupture of the Biceps Tendon in the Lond. 
Med. Gaz. vol. iii.; and case of partial dislocation of the humerus upwards, by Mr. 
Soden, in Med. Chir. Trans, for 1841. DISLOCATIONS OF THE ELBOW. 
281 
Fig. 70. 
Fig. 71. 
humerus forms a hard protuberance in front. The coronoid process 
rests in that fossa of the humerus which naturally contains the ole- 
cranon. 
(2.) In dislocation of both bones backwards and outivards, the 
coronoid process is thrown behind the external condyle; and in 
addition to the preceding symptoms, the head of the radius can be 
very plainly felt on the outer side of the joint. 
(3.) The dislocation backwards and inwards is known by a 
great projection of the outer condyle, in addition to the symptoms 
of the first variety. 
(4.) In dislocation backwards of the ulna solely, the olecranon 
is much projected backwards;-the elbow is immovably bent at 
right angles, and the forearm is much twisted and pronated. 
Fig 72 ♦ 
Fig. 73 * 
* Opposite views of same bones 282 
DISLOCATIONS OF THE WRIST. 
The treatment of these four varieties is the same. Reduction 
may be effected, first, by fixing the lower end of the humerus 
whilst the fore-arm is drawn forwards; or secondly, the surgeon 
may bend the elbow forcibly over his knee; or thirdly, (if the case 
be quite recent,) he may forcibly straighten the arm, so as to make 
the tendon of the biceps pull the trochlea of the humerus back into 
its place. 
(5.) The head of the radius alone may be dislocated forwards, 
being thrown against the external condyle. The elbow is slightly 
bent, and in bending it more, the head of the radius can be felt to 
strike against the front of the humerus. 
Fig. 74. 
Treatment.-Simple extension from the hand, the elbow being 
straight. 
(6.) Dislocation of the radius backwards is very rare. The 
head of the bone can be felt behind the outer condyle. Reduced 
by simply bending the arm, which should be kept bent for three 
weeks. 
Fig 75. 
Diagnosis.-These dislocations of the elbow may be distin- 
guished from fractures of the lower extremity of the humerus, (1) 
by the impaired mobility of the joint, and by the absence ot crepitus; 
(2) by measuring the length of the humerus from its condyles to 
the shoulderwhich, in dislocation, will be equal to that of the 
sound limb, but will be diminished in fracture ot the lower extre- 
mity of the humerus. But when it is considered that these six 
dislocations may be combined with various fractures of the con- 
dyles of the humerus and of the bones of the fore-arm, it will be 
admitted that the injuries of the elbow present a sufficiently wide 
and complicated field of study- . . . 
V. Dislocations of the Wrist may readily be distinguished by 
the altered position of the hand, which is thrown either backv aids DISLOCATIONS OF THE RIBS. 
283 
or forwards if both bones be dislocated, or twisted if only one be 
displaced,-and by the alteration of the natural relative position of 
the styloid processes of the radius and ulna with the bones of the 
carpus. They are reduced by simple extension.* 
VI. Dislocations of the Hand.-The os magnum and os 
cunei for me are sometimes partially dislocated through relaxation 
of their ligaments, and form projections at the back of the hand, 
which must not be mistaken for ganglia. Mr. Fergusson has also 
known the os pisiforme dislocated by the action of the flexor carpi 
uInaris muscle. 
Treatment.-Cold affusion, friction, and mechanical support. 
Dislocations of the thumb, fingers, and toes, are difficult of 
reduction in consequence of the strength and tightness of their 
lateral ligaments, and the small size of the part from which exten- 
Fig. 76. 
sion can be made. A firm hold may be obtained by means of a 
piece of tape fastened with the knot called the clove, hitch, repre- 
sented in this figure. But it is a good plan to place a part of the 
tape round the head of the dislocated bone, so as to pull it straight 
forwards into its place. Extension should be made towards the 
palm, so as to relax the flexor muscles. But " before the reduction 
has been effected," says Mr. Liston, " it has been in some cases 
even found necessary to divide one of the ligaments; the external 
is most easily reached; it is cut across by introducing a narrow- 
bladed and lancet-pointed knife through the skin at some distance, 
and directing its edge against the resisting part." 
In compound dislocation of the first phalanx of the thumb, on 
the metacarpal bone, the head of the phalanx should be sawn off, 
before attempting reduction; and in compound dislocation of the 
second phalanx, it is better to saw off the head of the first. 
VII. Dislocations of the Ribs.-The costal cartilages maybe 
torn from the extremity of the ribs, or from the sternum;-and the 
posterior extremity of the ribs may be dislocated from the spine by 
falls on the back; but these accidents are very rare. A case is 
related in which the heads of the last two ribs were driven forwards 
* Dupuytren taught that these dislocations are extremely rare, or, in fact, almost 
impossible; and that fractures of the lower extremity of the radius were generally 
mistaken for them. But the experience of English surgeons shows that real dis- 
location, without any fracture, is not by any means uncommon. See a very care- 
fully reported case in the Lond. Med. Gaz. June 17th, 1843. 284 
DISLOCATIONS OF THE HIP. 
from the spine, in a boy of eleven, by a violent blow on the back; 
abscess formed, and the case terminated fatally.* The body of the 
sternum has also been dislocated in front of the manubrium, and 
the ensiform cartilage is sometimes separated. In all these cases, 
the same local and constitutional treatment must be adopted that 
was prescribed for fracture. 
VIII. Dislocations of the Hip-Joint.-There are four prin- 
cipal varieties of this dislocation. 1st. The dislocation upwards; in 
which the head of the bone is thrown on the dorsum ilii. 2dly. 
The dislocation backwards on the sciatic notch; 3dly, downwards, 
on the obturator externus muscle; and 4thly, forwards, on the os 
pubis. Besides which there are two or three others that are ex- 
ceedingly rare. 
1. Dislocation vpivards on the dorsum ilii is the most frequent. 
Symptoms.-The limb is from an inch 
and a half to two inches and a half shorter 
than the other;-the toes rest on the oppo- 
site instep ;-the knee is turned inwards, 
and is a little advanced upon the other;- 
the limb can be slightly bent across the 
other, but cannot be moved outwards;- 
the trochanter is less prominent than the 
other, and nearer the spine of the ilium;- 
and if the patient is thin, and there is no 
swelling, the head of the bone can be felt 
in its new situation. 
Diagnosis.-Fracture of the cervix fe- 
moris may be distinguished from this dis- 
location by the circumstance that the limb 
can be freely moved in any direction, al- 
though with some pain; that it is turned 
outwards instead of inwards;-and that it 
can be drawn to its proper length by mo- 
derate extension, but becomes shortened 
again as soon as the extension is discon- 
tinued: whereas, in dislocation, it requires 
a forcible extension to restore the limb to 
its proper length and shape; but when 
once the head of the bone is replaced in its 
socket, it remains there.! 
Fig. 77. 
* Dublin Med. Press, 3d Feb. 1841. 
f There are a few cases on record of fracture of the upper extremity of the 
femur, in which a portion of the great trochanter was broken off, and drawn by the 
muscles backwards on the dorsum ilii, into the position usually occupied by the 
head of the bone when dislocated; so that the nature of the accident was obscure. 
It suffices to notice the possibility of such cases, in order to put surgeons on their 
guard. Vide a paper by Mr. Stanley, Med. Chir. Trans, vol. xiii. When one leg 
also has been shortened by previous disease or injury, the surgeon is puzzled if 
the other is dislocated; as he has no criterion by which to estimate its proper 
length. 285 
DISLOCATIONS OF THE HIP. 
Fig 78. 
Treatment.-In the first place, it will most likely be requisite to 
diminish the force of the muscles by a moderate bleeding; by immer- 
sion in a hot bath of 100° to 110°; and by the exhibition of half a 
grain of tartar emetic every ten minutes, continued till the patient 
feels nauseated and powerless. Then he should be wrapped in a 
blanket, and placed on his back on a table; a leathern girth or 
strong towel should be passed round the upper part of the thigh, so 
as to bear firmly against the perinaeum and crista ilii, as represented 
in the foregoing cut, fig. 78 ; and this should be attached to a ring 
or hook securely fastened into the wall or floor. A linen roller 
should next be applied to the lower part of the thigh, and over it 
the strap belonging to the pulleys;-which last are to be fixed to 
Fig. 79. 
Fig. 80. 286 
DISLOCATIONS OF THE HIP. 
the wall or some other.firm object. Then extension is to be made 
in such a direction as to draw the thigh across the opposite, a little 
above the knee. After a little time, the surgeon should gently rotate 
the limb, or lift the upper part of it, and the head of the bone will 
probably return to the acetabulum. The patient should then be 
carefully moved to bed with his thighs tied together. 
2. The dislocation backwards (in which the head of the femur 
is thrown into the sciatic notch, [see Figs. 79, 80,] or on the pyri- 
formis} is known by the following symptoms. The limb is shortened 
from half an inch to an inch;-the toes rest on the ball of the great 
toe of the other foot;-the knee is advanced and turned inwards, but 
not so much as in the last case;-the trochanter is rather behind 
its natural position, and the head of the bone can scarcely be felt. 
Treatment.-Pulleys are required, as in the last case; but the 
patient should be placed on his side, and the limb be drawn across 
the middle of the opposite thigh. After a little while the upper 
part of the limb should be lifted by means of a napkin, so as to 
raise the head of the bone over the edge of the acetabulum. 
Fig. 81. 
3. In the dislocation downwards, the head of the bone is thrown 
into the thyroid foramen, or on the obturator externus. The 
.symptoms are as follow :-the limb is lengthened one or two inches; 
-it is drawn away from the other;-the toes point downwards 
and directly forwards;-and the body is bent forwards, because 
the psoas muscle is on the stretch. [See Fig. 82.] 
Treatment.-The object is to draw the head of the bone out- 
wards, and rather upwards. There are two methods of effecting 
this. In the first place, the patient may be laid on his back on 
a bed, with one of the bed-posts between his thighs, and close up 
to the perinaeum. Then the foot may be carried inwards, across 
the median line ;-so that the bed-post, acting as a fulcrum, may 
throw the head of the femur outwards. But the foot must not 
be raised, otherwise the head of the femur may slip round under 
the acetabulum into the sciatic notch. (2.) Or the pelvis may be 
fixed by straps, and the pulleys be applied to the upper part of DISLOCATIONS OF THE HIP, 
287 
Fig. 82. 
Fig. 83. 
the thigh, to draw it outwards: whilst the knee is at the same 
time pulled downwards and inwards. [See Fig. 83.] 
Sir Astley Cooper has decided that eight weeks is the latest 
period after which it is justifiable to attempt the reduction of a 
dislocated hip, except in persons of extremely relaxed fibre or of 
advanced age ; and numerous instances are on record of death from 
abscesses or phlebitis, occasioned by violent extension at a later 
period. 
4. In the dislocation upivards and forwards, (on the pubes,) the 
limb is shortened about an inch ;-it is drawn away from the other, 
and the foot points directly outwards; the head of the bone may 
be plainly felt below Poupart's ligament; and by this circumstance 
this dislocation may be distinguished from fracture of the cervix 
femoris. [See Figs. 84, 85.] 
Treatment.-The patient is to be laid on the sound side;- 
extension should be made with the pulleys in a direction back- 
wards and outwards;-and after it has been continued a little time, 
the head of the bone should be lifted over the edge of the acetabulum 
by means of a napkin. [See Fig. 86.] 
With respect to the relative frequency of these dislocations, 
Sir A. Cooper believed that out of twenty cases, twelve would 288 
DISLOCATIONS OF THE HIP. 
Fig. 84. 
Fig. 85. 
Fig. 86. 
be on the dorsum ilii, five in the ischiatic notch, two in the foramen 
ovale, and one on the pubes.* 
Unusual Dislocations.-Besides the above four varieties, a 
dislocation directly downwards on the tuberosity of the ischium; 
* These dislocations generally happen to adults. In very old people it is more 
common for the cervix femoris to give way. They are also rarely met with in 
children, although Sir A. Cooper relates one case which happened to a boy of 
seven ; and Mr. Place, of Wimborne, was good enough to communicate to the 
author the particulars of a case of dislocation on the dorsum ilii happening to a 
boy of ten. DISLOCATIONS OF THE KNEE. 
289 
one directly backwards on the spine of the ischium; and one directly 
upwards on the space between the anterior spinous processes of the 
ilium, [see Fig. 87,] have 
been known to occur, al- 
though very rarely. In a 
case of dislocation directly 
downwards, recorded by Mr. 
Keate, the limb was length- 
ened three inches and a half, 
and was fixed and everted ; 
the trochanter was sunk ; and 
the head of the bone, close to 
and on a level with the tube- 
rosity of the ischium, where 
it was capable of being 
moved under the finger. In 
a case of dislocation on the 
spine of the ischium, which 
happened in the practice of 
Mr. Earle, at St. Bartholo- 
mew's, the limb was length- 
ened about half an inch; it 
was neither everted nor inverted, but if any thing the latter; there 
seemed to be a great vacuity in front of the hip : the edges of the 
sartorius and tensor vaginae femoris could be plainly felt, and a 
cavity behind them; and the trochanter was further back, and not 
so prominent as usual. But the dislocation directly upwards is the 
most common of these unusual forms. In a case that was examined 
by Mr. Travers, jun., some time after the accident, the limb was 
completely everted and slightly movable ; and the neck of the bone 
lay between the two anterior spinous processes of the ilium; so that 
when the patient was erect, the limb seemed to be slung or sus- 
pended from this point. The diagnosis must in such cases be 
guided by an attentive examination of the deformity that is present, 
and by the absence of any symptoms of fracture. The reduction 
must be effected by extension, made in such a direction as seems 
most likely to bring the head of the bone into its socket.* 
IX. Dislocations of the Knee.-Dislocation of the tibia from 
the, femur is not very common; and, when it does occur, is rarely 
complete. In most cases the tibia is thrown backwards towards 
the ham. The deformity and impediment to motion will enable 
the practitioner to distinguish the accident;-and if there be no 
Fig. 87. 
* Vide a paper on Rare Dislocations of the Hip-Joint, in the Med. Chir. Trans., 
vol. xx. by Mr. Travers, jun. Sir A. Cooper, op. cit. and Guy's Hosp. Rep. vol. i.; 
Keate, Med. Gaz., vol. x.; a case of dislocation directly upwards, in the Lancet, 
May 15th, 1841; and Mr. Earle's case, Lancet, vol. xi. p. 159. [See also the im- 
portant observations by Prof. J. C. Warren, on Dislocations of the Hip-Joint, in the 
American edition of Cooper's Treatise on Dislocations and Fractures of the Joints, 
p. 92. Philada. 1844. Several cases of a kind of dislocation downwards and 
backwards, not noticed by Mr. Druitt, are there related.] 290 
DISLOCATION OF THE PATELLA. 
complication requiring amputation, the displacement must be recti- 
fied by simple extension, and the knee be kept at rest till inflam- 
matory symptoms have subsided. 
Fig. 88. 
Dislocation of the Patella may occur either inwards or out- 
wards ; more frequently in the latter direction. The symptoms are, 
that the knee cannot be bent, and that the bone can be felt in its 
new situation, This dislocation may be caused either by mechani- 
cal violence, or by a sudden contraction of the extensors of the 
thigh. It generally happens to knock-kneed, flabby people. There 
is, in genera], no difficulty in reducing it by means of the finger 
and thumb, if the knee is straight and the leg raised. There is 
one variety of this dislocation, however, in which the patella is 
turned round on its long axis, so that its inner edge rests on the 
outside of the trochlea of the femur, and its outer edge lies imme- 
diately under the skin. In one instance, the surgeon was unable 
to reduce it by any means, even although he divided the liga- 
mentum patellas, and cut through the quadriceps at its insertion 
into the patella; and the patient died in eleven months inconse- 
quence of his wounding the joint. Mr. Mayo relates a similar 
case, in which he succeeded in overcoming the difficulty by bend- 
ing the knee to the utmost, so that the patella was drawn out of 
ihe groove in which it was lodged.* 
The patella is dislocated upwards after rupture of its tendon by 
the extensor muscles. This must be treated as fracture of the 
patella; but it is very rare. 
Partial Dislocation of the Semilunar Cartilages.- 
During sudden twists of the knee-joint, the semilunar cartilages 
may slip out of their proper position, and become wedged in 
between the tibia and femur. The symptoms are sudden, extreme 
sickening pain, and inability to stand, or to straighten the limb. 
This accident generally happens to people of relaxed habits, and 
when it has once happened is very liable to recur. In a case dissected 
by Mr. Fergusson, the external semilunar cartilage was found to 
be torn from its connection with the tibia, except just at its extre- 
* These cases are related in Sir A. Cooper; and a similar one in Sir G. Balling- 
all's Military Surgery. DISLOCATION OF THE ANKLE. 
291 
mities. The best way of restoring the part to its 
place, is to bend the joint to the utmost, and 
then extend it: and the patient should wear an 
elastic knee-cap. 
Dislocation of the Head of the Fibula 
is of very unfrequent occurrence; except as a 
consequence of relaxation of the ligament from 
weakness, which must be treated by blisters 
and bandages, with a pad to press on the head 
of the bone. There are two cases of it, caused 
by violence, in Sir Astley Cooper's work; the 
head of the bone could be felt to pass more 
backwards than natural, and could be moved 
by the finger. The pad of a tourniquet was 
employed to keep it in its place. 
X. Dislocation of the Ankle may occur 
in four directions. (1.) Dislocation of the tibia 
inwards is the most common. It is attended 
with fracture of the lower third of the fibula, 
and may be easily known by the sole of the 
foot turning outwards;-its inner edge turning 
downwards; and great projection of the internal 
malleolus, [see Fig. 89]. (2.) Dislocation of the 
tibia and fibula outwards is attended with frac- 
ture of the internal malleolus, and may be known 
by the sole of the foot turning inwards. (3.) In 
the dislocation forwards, the foot appears shortened, and the heel 
lengthened, and the toes pointed downwards. There is also a 
Fig. 89. 
Fig. 90. 
Fie. 91. 292 
DISLOCATIONS OF THE FOOT. 
partial dislocation forwards, in which the tibia is only half dis- 
placed from its articulation with the astragalus, the fibula being 
also broken; the foot appears shortened and immovable, and the 
heel cannot be brought to the ground, [see Figs. 90, 91]. (4.) A 
dislocation backwards has been described; but it must be excessively 
rare, as Sir A. Cooper never saw it. There is a case of it described 
by Mr. Colles, which, however, was probably one of transverse frac- 
ture of the tibia and fibula just above the joint, with displacement 
backwards. The fracture of the fibula about three inches above 
the outer malleolus, which accompanies the dislocation inwards, is 
commonly called Pott's fracture. 
Treatment.-The patient must be laid on the affected side, and 
the knee must be bent, (to relax the gastrocnemius,) and be firmly 
held by an assitant. The surgeon must then grasp the instep with 
one hand, and the heel with the other, and make extension, (aided 
by pressure on the head of the tibia,) till he has restored the natural 
shape and mobility of the parts. Then the limb must be put up 
with a splint on each side, in the same manner as a fracture of the 
lower part of the leg, taking care to keep the great toe in its proper 
line with the patella. 
Compound Dislocation of the ankle-joint is by far the most 
frequent example of that kind of injury. If the wound in the. 
integuments does not heal by the first intention, the joint inflames; 
suppuration occurs in about five days;-much of the cartilage is 
destroyed by ulceration; at last the wound is filled with granula- 
tions, and the patient recovers a tolerably good use of the foot in 
from two to twelve months. The first thing to be done is, to wash 
away all dirt with warm water; to remove any shattered pieces of 
bone gently with the finger, and then to reduce the bone to its 
place; slightly enlarging the wound in the skin if necessary, in 
order to effect this without violence. If it is very difficult to return 
the end of the tibia, or if it is fractured obliquely, or much shat- 
tered, it is better to saw it off, as the patient will have quite as 
good use of the limb afterwards. Then the external wound should 
be closed with a bit of lint dipped in the patient's blood, and the 
leg be secured with a tailed bandage and splints, and be wetted 
with an evaporating lotion. Care must be taken not to let the foot 
be pointed, nor be turned to either side. The remaining treatment 
is the same as that of compound fracture; and the rules which are 
given as to the necessity of amputation, are the same in both cases. 
XI. Dislocations of the Foot.-The most important of these 
are the dislocations of the astragalus, which may be separated from 
its connection with the os naviculare and os calcis in various ways. 
Sometimes it is thrown inwards, so as to rest on the inner surface 
of the os calcis; and in this case there appears an unusual pro- 
jection below the inner ankle, and a corresponding depression 
below the outer one, and the whole foot seems displaced out- 
wards. Sometimes it is thrown outwards, and then the foot 
seems to be displaced inwards. If these dislocations are simple, 
reduction should be immediately attempted by extension, and the WOUNDS OF ARTERIES. 
293 
pulleys and tartar emetic will be 
needed; although the attempt will 
often be unsuccessful. If the dislo- 
cation is compound, and the bone 
cannot be replaced, or if it is much 
shattered, it may be dissected out. 
In these two dislocations, the astra- 
galus is separated from the other 
tarsal bones, but preserves its con- 
nections with the tibia and fibula, so 
that they may be regarded merely as 
varieties of dislocation of the ankle- 
joint, in which the tibia and fibula 
carry the astragalus with them in 
their displacement. It may, how- 
ever, be completely shot out from 
under the tibia, and lie under the 
skin of the outer side of the foot. 
And lastly, it may in the same way 
be dislocated backwards; projecting 
behind the ankle-joint, and pushing 
the tendo-achillis backwards. This 
displacement, if only partial, will be 
extremely difficult to rectify, and, if complete, it will most likely be 
impossible.* 
Besides these, the five anterior tarsal bones may be dislocated 
from the os calcis and astragalus. The cuneiform bones may be 
dislocated upwards from the navicular; the metatarsal bones from 
the tarsal, and the toes from the metatarsal. In any of these cases, 
the proper position of the parts must be restored as much as pos- 
sible by pressure and extension, and be preserved by bandages; 
but reduction will often be very difficult, if not impossible. 
Fig. 92. 
CHAPTER VIL 
OF INJURIES AND DISEASES OF ARTERIES. 
SECTION I.- OF WOUNDS OF ARTERIES. 
Symptoms.-An artery may be known to be wounded by the 
flow of blood,-which is profuse ;-of a florid colour,-and ejected 
per saltum;-that is to say, in repeated jets, corresponding to each 
beat of the pulse. 
* For cases of the dislocation of the astragalus backwards, see a paper by Mr. 
B. Phillips, Med. Gaz. vol. xiv. p. 596, and Fergusson's Practical Surgery. 294 
WOUNDS OF ARTERIES. 
Pathology.-It must be evident that the bleeding from wounded 
arteries must necessarily be profuse and dangerous, because from 
the nature of their coats they remain open and patulous, and do 
not collapse as the veins do; and because of the perpetual current 
of blood impelled by the heart. Hence it is important to study 
the means by which arterial haemorrhage is at first arrested, and 
those by which the wound is afterwards permanently closed; as 
well as the different effects of different kinds of wounds. 
There are four processes employed by nature for the temporary 
suppression of arterial haemorrhage. In the first place, the divided 
orifice contracts more or less; and secondly, it retracts into its 
cellular sheath; 3dly, the blood coagulates in the sheath of the 
artery and in the wound, and thus obstructs the further exit of it; 
and 4thly, the faintness induced by haemorrhage, both checks the 
current of blood from the heart, and gives it an increased disposi- 
tion to coagulate. 
Now if a very large artery, such as the femoral or subclavian, is 
wounded, and if the aperture in it is large, and the flow of blood 
is in no manner opposed, the loss of blood will be so rapid as to 
occasion death almost instantaneously. But if the wound in the 
artery is very small, it may be closed firmly by coagulated blood 
during syncope, and the patient may survive.* 
If the artery is of the second order, as the humeral or tibial, the 
bleeding will most probably cease for a time through the influence 
of the four processes that we have just spoken of. But in the 
course of some hours, when the faintness has passed off, and the 
heart beats strongly again, the coagula in the orifice of the vessel 
will most probably be dislodged, and the bleeding will recur again 
and again, so that the patient will very likely die of it, unless it be 
checked by art. In some cases, however, the orifice of the vessel 
may become permanently closed in the way that we shall mention 
directly. 
If the wounded artery is small, as the digital or temporal, the 
haemorrhage, though pretty brisk for a time, will generally soon 
cease spontaneously and permanently in the following manner: 
Supposing the artery to have been completely divided, its orifices 
will contract, and will retract into the sheath, which also will be 
plugged with coagula. Thus then the bleeding is checked for a 
time. But shortly the adhesive inflammation is set up ;-a yellowish 
green, tough lymph is effused, and fills up the concentrated orifice 
of the vessel;-that part of the artery which intervenes between 
the wound and the nearest branch, gradually contracts in the shape 
of the neck of a champagne bottle;-the blood coagulates within it, 
adheres to its internal surface, and becomes organized into a cellulo- 
fibrous tissue;-and, finally, the impervious portion of the artery 
degenerates into a fibrous cord, and is gradually absorbed. 
It must be evident that a puncture or partial division of an 
artery, is much more dangerous than complete division;-because 
the two principal natural means of arresting hasmorrhage,-namely, 
• A case is quoted in Forbes' Rev. vol. vii. p. 254, in which a patient lived a 
year after a wound in the ascending aorta. TREATMENT OF WOUNDS OF ARTERIES. 
295 
the contraction and retraction, are prevented;-and the bleeding 
can only be obstructed by the coagulated blood in the wound. 
Under these circumstances, three things may happen. In the first 
place, the aperture, if longitudinal or very small, may in favourable 
cases be closed by the adhesive inflammation, the artery remaining 
pervious. The uniting lymph, however, is very liable to be dilated 
into a false aneurism. Or, secondly, the channel of the artery may 
be obliterated by lymph or coagulated blood. Or, thirdly, bleeding 
may recur perpetually, till the undivided part of the vessel ulcerates, 
or is divided by art. From these details may easily be gathered the 
reason why, when a small artery has been partially divided, (as the 
temporal in arteriotomy,) it is judicious to divide it completely. 
When an artery is torn across, it contracts almost immediately, 
and becomes quite impervious, so that an arm or leg may be torn 
off by a shot or by machinery, without any loss of blood from the 
axillary or tibial arteries. For this reason, there is no haemorrhage 
from the umbilical cord of young animals, which is either torn or 
bitten through by the mother. Lastly, it will be readily seen that 
division of arteries which are diseased, or which are situated in 
condensed and inflamed tissues, so that they cannot contract or 
retract, will be followed by profuse bleeding. 
Treatment.-The first indication is to stop the flow of blood, 
until measures can be adopted for arresting it permanently. This 
may be done by placing a finger on the orifice of the bleeding vessel, 
or by grasping it between the finger and thumb, if the wound is 
large and open;-or, by making pressure on the wound itself;-or 
by pressing the trunk of the artery above, against a bone;-or by 
applying the tourniquet f or in default of that, a handkerchief may 
be passed round the limb, and be twisted tightly with a stick. The 
permanent measures are, ligature-torsion-pressure-cold, and 
styptics. 
Ligature.-When a ligature is tied tightly upon an artery, it 
divides the middle and internal coats, leaving the external or cellular 
coat enclosed in the knot. Then the following series of phenomena 
occurs. The cut edges of the internal coats unite by adhesion;- 
the blood between the point tied and the nearest collateral branch 
coagulates and adheres to the lining membrane;-the ring of the 
cellular coat enclosed in the ligature ulcerates;-the ligature comes 
away in from five to twenty-one days, (sooner or later, according to 
the size of the vessel;)-and, finally, that portion of the artery which 
is filled with coagulum shrinks into a fibrous cord. 
Now it must be observed that the efficacy of the ligature depends 
on two things. (1st,) On the adhesion of the cut surfaces of the 
internal coats of the artery;-and in order to promote this the 
ligature should be small and round, (dentists' silk is the best 
material,) so as to divide them smoothly and evenly.t 
^2dly,) On the adhesion and organization of the blood in the 
artery between the part tied and the nearest branch. Now, although 
* The tourniquet is described in the chapter on Amputations. 
f J. F. D. Jones, M. D., Treatise on Haemorrhage and the Ligature. Lond. 1805. 296 
TREATMENT OF WOUNDS OF ARTERIES. 
the adhesion of the internal coats alone may be sufficiently strong 
to resist the current of blood, and prevent bleeding when the external 
coat ulcerates and the ligature comes away;-still it must be recol- 
lected that the place of this adhesion is close to the ligature;-that 
the ligature is necessarily removed by ulceration of the cellular coat; 
-that this ulceration is attended with suppuration that owing to 
this suppuration the adhesion might be broken up,*-and that con- 
sequently it will be expedient to have a long coaguhim of blood 
above the ligature, and to make its adhesion to the artery as firm 
as possible. 
Hence the rule is generally given, never to tie an artery imme- 
diately below a branch, if it can be avoided ;t and in tying it to 
disturb it as little as possible;-in order not to tear through the 
vessels which it receives from its sheath, and on which the nutrition 
of its coats, and their capacity for adhesion, depend. 
The manner of tying an artery is simple enough. If the wound 
is large and open, as after an amputation, the orifice will generally 
be readily seen, and very likely will project a little. It should be 
taken hold of with a forceps, and be gently drawn out, and then 
an assistant should tie the ligature round it as tightly and smoothly 
as possible in a double or treble knot. If the bleeding orifice 
cannot be drawn out with the forceps, it may be transfixed with 
the tenaculum;-but in some cases, where it is deeply seated or 
cannot be found, or is contained in a dense consolidated tissue, it is 
necessary to pass a curved needle and ligature through a consider- 
able thickness of the flesh, and tie it up altogether. This, however, 
should never be done if it can be avoided. In all cases where it 
is possible, the artery alone should be included in the ligature. 
After tying, one end of the ligature should be cut off, and the other 
made to hang out of the wound. 
When an artery is completely divided, it is necessary to tie both 
orifices;-or if it is wounded, but not divided, a ligature must be 
placed by an aneurism needle both above and below the wounded 
part; after which the intermediate part may be cut through. But 
this is not of much consequence. It is necessary to observe, that 
in all cases, when it is possible, a wounded artery must be tied at 
the wounded part;-3.m\ not in the trunk above. When the 
wound is not large enough to expose the artery, it should be 
lengthened by an incision upwards and downwards; and it is 
better, as Mr. Guthrie insists, to cut even through thick muscles 
than to tie the trunk of the artery above the wound.f When the 
artery is diseased and brittle, the ligature should be large, and not 
tied so tightly,-otherwise it may cut through entirely. 
* Manec says it is always so. On the Ligature of Arteries, translated by Garrick 
and Copperthwaite. Halifax, 1832. 
j- The author does not believe this circumstance to be of such great importance 
as it is sometimes thought; and agrees with Mr. Porter that when secondary haemtn-- 
rhage occurs, it is more frequently owing to some morbid state of the artery or of 
the system, which has prevented the health}' process of obliteration, than to the 
place or mode of application of the ligature. Vide Porter on Aneurism. 
| Guthrie on Diseases and Injuries of Arteries, p. 254. Lond. 1830. GENERAL TREATMENT OF HEMORRHAGE. 
297 
2. Torsion is performed by drawing out the vessel, fixing it by 
a pair of forceps a quarter of an inch from the end, and then twist- 
ing the end round and round till it will not untwist itself. There 
is no English authority for applying this method to large arteries, 
but it may be useful enough when many minor vessels bleed after 
the extirpation of a tumour. 
3. Pressure is a means of suppressing haemorrhage that may 
be resorted to either when the ligature is deemed unnecessary, or 
when it cannot be applied. Thus it is applicable to wounded 
arteries of small size situated immediately over bones; as the tem- 
poral ;-or to arteries that cannot be tied because they lie very 
deeply; as the external carotid in the parotid glandor to arteries 
that are so diseased that a ligature will not hold. The pressure 
must be confined as much as possible to the bleeding orifice, and 
should be effected by a graduated compress; i. e., one composed 
of several pieces gradually decreasing in size, the smallest being 
on the wound. It is also a good plan to apply pressure to the 
course of the trunk, above the wound. Moreover, when pressure 
is to be relied upon, the whole limb should be securely bandaged 
from its extremity, in order to diminish its entire circulation, and 
it should be placed in a raised position. When the palmar arch is 
wounded, one compress may be placed on the wound, and another 
on the back of the hand;-a paper knife or strong slip of wood 
may then be laid on each compress transversely across the hand, 
and their ends be firmly tied together. 
4. Cold is applicable to cases of bleeding from numerous small 
vessels. If there is a general oozing from a stump after amputa- 
tion, a cloth dipped in cold water may be twisted over the face of 
it. Hemorrhages from the vagina and rectum may sometimes be 
checked by dilating them with the speculum and exposing them 
to the cold air. 
5. Styptics are of various kinds. 1. Some of them check hemor- 
rhage by opposing a mechanical obstacle to the exit of blood;-as 
the agaric, and other porous substances which entangle it;-2, 
others act by coagulating the blood;-3, or by causing contraction 
of the bleeding vessels;-4, or by exciting the adhesive inflamma- 
tion and formation of granulations. The tinct. ferri mur.; a satu- 
rated solution of alum;-turpentine, creosote, and nitrate of silver, 
are the best. They are applicable to the same cases as cold and 
pressure;-that is, when the bleeding vessels are very numerous 
and small. The actual cautery, which is^the most potent styptic 
of ail, has two operations. If the iron be red hot, it stops bleeding 
mechanically by burning up the orifices of the vessels, but the 
bleeding is liable to return when the eschar separates. It is better, 
therefore, to use the iron at a black heat, for it then excites the 
adhesive inflammation, and is very efficacious for arteries that 
either cannot be tied, or that are too diseased to hold the ligature. 
A pinch with the forceps will often cause small vessels to cease 
bleeding. There are certain other methods that have been pro- 
posed for obliterating arteries, which act by causing effusion of 298 
GENERAL TREATMENT OF HEMORRHAGE. 
lymph on their inner surface, and coagulation of blood in them:- 
such as applying a ligature for a few hours, and then removing it; 
-or passing needles through them;-but these are not to be 
depended on.* 
Medical Treatment. In cases of arterial heemorrhage, which 
there is any difficulty in restraining by ligature or otherwise, it 
will be necessary to keep the patient in the recumbent posture, and 
on low diet; and to keep down the heart's action by lead, F. 60, 
henbane, or opium. 
Secondary Hemorrhage may occur under the following seven 
circumstances: 1. It often happens that in a few hours after a 
wound has been bound up, and the patient put to bed and become 
warm, sundry small arteries bleed. This case is easily managed. 
The wound must be opened; any vessels must be tied that require 
it;-the surface sponged with cold water, and then be exposed to 
the air for a few hours. 2. There may be a general exudation 
of blood from a wound, owing to some disorder of the circulation. 
Its causes and treatment are described in the chapters on Haemor- 
rhage, and on Gun-shot Wounds. The surgeon must recollect its 
liability to occur in the female from the menstrual nisus. 3. Haemor- 
rhage may occur from sloughing of an artery; and 4. From ulcer- 
ation spreading through the arterial tunics. 5. It may occur from 
imperfect closure of an artery when a ligature separates;-through 
the influence of a diseased state of the artery, or of the constitution, 
which prevents the healthy process of adhesion;-and this form of 
haemorrhage will be more likely to occur, if the ligature was coarse, 
thick, and ill-applied, so as to bruise the internal coats instead of 
cutting them evenly;-or if the artery was much disturbed in its 
sheath during the operation. In the last three cases the only 
remedy is to cut down upon and tie the bleeding orifice;-or if 
that cannot be done, or the vessel be too diseased to hold the liga- 
ture, and pressure and styptics fail, the trunk must be tied above. 
6. Haemorrhage is apt to come from the lower orifice of a divided 
artery, if only the upper one has been tied. In this case the blood 
wells out in a continuous stream, but not with the arterial saltus; 
-and it is not quite so florid as that which conies from the other 
end. 7. Haemorrhage is very likely to occur if the operation for 
aneurism is applied to a wound of an artery;-that is, if the vessel 
be tied at a distance above instead of at the wounded parts.t For 
these two cases the ligature is the remedy. 
The Hemorrhagic Diathesis is a peculiar constitutional defect, 
which sec.ms to consist in a want of contractility of the arteries, and 
of coagulability of the blood; so that the slightest wound bleeds 
almost uncontrollably, and life may be lost through the most trifling 
injury or surgical operation. If the existence of this diathesis be 
ascertained, surgeons would do well to refrain from operations with 
* When the lining membrane of an artery or vein is wounded, or is inflamed in 
a moderate degree, the blood always has a tendency to coagulate or to deposit 
adhesive lymph upon it. 
f Guthrie, op. cit. p. 248. INFLAMMATION OF ARTERIES. 
299 
the knife on the individuals possessing it. In a case of congenital 
phymosis, in a person of this kind, which fell under Mr. Liston's 
care, he very judiciously employed the ligature instead of the knife. 
The history is recorded of four children who possessed this dia- 
thesis. They were born of healthy parents; their skins were 
white and complexions fair;-they were very subject to fever 
with ecchymosis; their blood was very fluid, but coagulated in the 
usual manner; violent coughing easily produced hsemoptysis or 
epistaxis, and any slight injury caused ecchymosis of the skin. 
One died at twenty months from biting his tongue; another at 
eight years from general mucous heemorrhage, and a third at 
twelve from epistaxis. In a case of obstinate bleeding of this kind, 
pressure and the nitrate of silver locally, and a nutritious diet with 
iron or the acetate of lead and opium, seem to be the most hopeful 
remedies.* 
SECTION II.-OF INFLAMMATION OF ARTERIES.t 
This is rather an uncommon and obscure disease. There are 
three forms of it. 1. Subacute Arteritis (Phlegmonous Arteritis, 
Guthrie) is a local form of inflammation, not extending any great 
distance. It produces redness and thickening of the artery, with 
effusion of lymph into its cavity, and coagulation of the blood 
within it. The symptoms are, tenderness of the affected artery, 
with violent pain, numbness, absence of arterial pulsation, and 
tendency to gangrene, in the parts supplied by it. Treated by 
local and general antiphlogistic measures;-taking care to support 
the circulation of any part that threatens to slough. 
2. Acute Arteritis (Erysipelatous or diffused Arteritis') has a 
tendency to spread, and involve the arterial system generally, and 
to produce rapid suppuration, and it is almost invariably fatal. It 
may be idiopathic, or it may be caused by a wound. It is known 
by very violent fever, and great throbbing of the arteries; suc- 
ceeded by symptoms of irritative or typhoid fever; with livid vesi- 
cations on different parts of the body. If the disease originate in 
a wound there will probably be gangrene. Treatment must be 
antiphlogistic, without reducing the patient too low. 
In a case of severe and rapidly fatal inflammation of the chest, 
the aorta was found to participate in the inflammation, and .there 
was an effusion of adherent lymph on its inner surface, nearly 
blocking up the left subclavian artery. This is believed to be not 
* Vide B. and F. Med. R. Jan. 1840; and two valuable papers by Dr. Allan of 
the Haslar Hospital, and Mr. Miller of Edinburgh, in Dr. Cormack's Journal for 
June and July 1842. 
[Creosote is one of the best styptics we have. I have known it to be applied to 
a wound of the finger on a person of the haemorrhagic diathesis-with the effect of 
arresting an alarming bleeding which nothing else would staunch. F.] 
f Guthrie, op. cit. Mayo, Pathol., p. 447. Copland, Diet., Art. Arteries; and 
Hodgson on Diseases and Injuries of Arteries, Lond. 1815, p. 5. 300 
ANEURISM. 
an uncommon cause of embarrassed circulation towards the close 
of acute inflammation in the chest. 
A curious case is recorded by Mr. Crisp, (Lancet, 1835-6, vol. i. 
p. 534,) of what seems to be rheumatic arteritis. A girl, aged 22, 
suffered from violent fever, fainting, profuse perspirations, great 
pain in the limbs, and tenderness in the course of the arteries. 
After some days, no pulse could be felt in the axillary from an 
inch below the clavicle, or in the popliteal. Both feet became gan- 
grenous, especially the left, which was amputated below the knee 
eight months afterwards; at the time of the operation no pulse 
could be felt in any of the extremities. Very little blood came 
from the larger arteries, and that not per saltum, but the smaller 
vessels bled profusely. On examination of the leg, the arteries 
seemed smaller than natural, but not otherwise diseased. In a 
somewhat similar case, recorded in the Provincial Medical Journal, 
23d April, 1842, sudden obliteration of the left axillary artery, with 
intense pain and numbness of the arm, and sloughing of the end 
of one finger, followed the haemorrhage of abortion in a young 
lady of 24.* 
3. Chronic Sir ter it is may be supposed to be an occasional cause 
or accompaniment of thickening, softening, ossification and other 
forms of degeneration of arteries. 
SECTION III. OF ANEURISM. 
Definition.-An aneurism is a sac filled with blood, and com- 
municating with an artery, by the rupture or dilatation of which it 
has been produced. 
Varieties.-In the first place, a distinction must be made 
between aneurism, which consists of a dilatation of an artery, for 
a part only of its circumference, and the general dilatation, 
which consists of a bulbous expansion of all the arterial tunics for 
the whole of their circumference, and which differs from true aneu- 
rism in containing no laminated coagula. 
Then there are three kinds of aneurism. First, the true aneu- 
rism, which consists of a sac formed by one or more of the arterial 
tunics.t Secondly, the false aneurism, which is formed after a 
puncture of an artery, by a dilatation of the adhesive lymph by 
which the puncture was united. Thirdly, the diffused aneurism; 
which is formed when an artery is lacerated by a fractured bone, 
or ruptured by a blow, without a wound in the skin; or when an 
artery is punctured, and the wound in the skin heals up speedily. 
In either of these cases, the blood escapes into the cellular tissue, 
which forms the sac of the aneurism. Besides these kinds, authors 
speak of a sacculated aneurism; that is, one which is formed into 
* See also Sir B. Brodie's Lecture on Gangrene, Med. Gaz. vol. xxvii. for two 
cases of dry gangrene from arteritis. 
f It may be remarked that some authorities call all aneurisms false which do 
not consist of all three arterial tunics. 301 
ANEURISM. 
pouches by an unequal dilatation of its parietes;-and of a dissect- 
ing aneurism, that is to say, one in which the blood finds its way 
between the arterial tunics, and may even open into the artery at 
another part. 
Pathology.-The formation of aneurism is preceded by some 
disease of the artery. Sometimes the middle or fibrous coat becomes 
opaque, yellow, and as thin as paper;-sometimes it degenerates 
into a fatty substance; and a soft, pultaceous, or as it is called, 
setheromatous matter is deposited upon it; this, according to Mr. 
Gulliver, displays under the microscope earthy and albuminous 
particles, oily globules, and crystalline plates and scales; and is 
principally composed of cholesterine. At the same time the lining 
membrane often acquires considerable thickness and hardness; in 
consequence apparently of an effort to compensate for the weak- 
ness of the middle coat; and Dr. Davy believes that these changes 
must terminate either in aneurism, or in obliteration of the artery.* 
Or, lastly, there may be a deposit of a brittle calcareous substance 
(composed of phosphate of lime) in the substance or on the outer 
surface of the inner tunic. This earthy matter may be deposited 
in spots, or scales, or rings, or projecting spiculee ; and in the arte- 
ries of elderly people it is very common. But the earthy degene- 
ration of old age does not appear to be so common a cause of 
aneurism as the soft aetheromatous deposit. 
The prevailing opinion is, that aneurism generally commences 
by a laceration of the internal and middle tunics of the artery, 
when diseased and brittle; but that it may also commence by a 
dilatation of all three of the tunics at some diseased spot. This is 
the opinion of Hodgson. Scarpa, however, asserts, " that there is 
only one form of this disease;-that, namely, caused by a rupture 
of the proper coats of the artery, and an effusion of arterial blood 
into the cellular sheath which surrounds the ruptured artery."t 
Sometimes it commences by the blood finding its way into small 
cysts or abscesses that are developed between the coats of the 
artery. Sometimes again, as in a case that happened to Mr. 
Liston, an aneurism commences by an artery ulcerating and open- 
ing into the sac of an abscess. Let the aneurism, however, com- 
mence as it may, it gradually dilates under the constant pressure of 
the heart's impulse, and forms a sac, communicating with the trunk 
of the artery by a distinct rounded opening. It soon becomes lined 
with coagulated blood, deposited in distinct concentric laminae, of 
which the outer ones are the palest and firmest;-and whether it 
was originally formed or not of all the three tunics, certain it is, 
that the two internal ones soon become absorbed and disappear. 
Symptoms.-If an aneurism be seated in the neck or limbs, it 
appears as a tumour in the course of an artery, and pulsating with 
it. If it be small, and not filled with coagulum, pressure on the 
artery above will render it flaccid, so that it may be emptied by 
* Vide Davy's Researches, and Gulliver on Fatty Degeneration of the Arteries, 
Prov. Med. Jour., March 18th, 1843. 
j- Scarpa on Aneurism, by Wishart, Edin. 1808, p. 113. 302 
ANEURISM. 
pressure;-and the blood returns into it afterwards with a peculiar 
vibratory thrill or bruissement. The patient will very often say 
that it commenced after some violent strain, when something 
appeared to give way. In the chest, aneurism will be principally 
known by an unnatural pulsation felt by the patient, and detect- 
able by the stethoscope;-together with symptoms of disordered 
circulation and respiration. In the abdomen, an aneurismal tumour 
may be felt through the parietes. 
Diagnosis.-Tumours situated over arteries, and receiving pulsa- 
tion from them, may be distinguished from aneurism by noticing, 
1st, That they do not pulsate at first, when they are smallwhereas 
aneurisms do so from their earliest formation. 2dly, That a tumour 
may often be lifted up from the artery, and that then it will cease 
to pulsate. 3dly, That aneurisms are generally soft at first, and 
become hard subsequently; tumours are generally the reverse. 
4thly, That tumours cannot be emptied by pressure;-and that no 
alteration is made in their consistence by compressing the artery 
above. 5thly, Enlarged lobes of the thyroid gland x\YAy be dis- 
tinguished from aneurism of the carotid by their slipping up out of 
the fingers, along with the larynx, in the act of deglutition. 6thly, 
Psoas abscess may be known from aneurism by the precursory 
pain and weakness in the back, and by its disappearance when the 
patient lies down. 
Progress.-As an aneurism enlarges, its coats become thinner, 
but are strengthened by the adhesion of the parts around. As the 
enlargement proceeds, these are gradually absorbed;-bone offers 
no resistance, but is absorbed as well;-and at last the tumour 
reaches the skin and distends it. Inflammation succeeds;-the skin 
becomes red, then livid and vesicated;-and sloughs. When the 
slough separates, a fatal bleeding ensues;-sometimes in a gush 
enough to destroy life at once, although more frequently the blood 
oozes away slowly. But an aneurism may burst into a mucous 
canal;-or into a serous cavity; (although then the aperture is 
formed by a laceration, and not by sloughing;)-or into a vein, 
with, of course, a fatal disturbance of the circulation if the vein is 
large ;-or into the cellular tissue of a limb;-or it may cause death 
through its pressure on the trachea or oesophagus;-or through the 
pain and irritation created by its compressing nerves or interfering 
with the abdominal viscera, without bursting. 
Spontaneous Cure.-In some fortunate cases a spontaneous 
cure occurs. 1st, It may occur in consequence of the coagulation of 
the blood contained in the sac, and the conversion of the aneurism 
into a firm tumour. In some cases, however, the sac does not 
become quite obliterated, but the coagula become thick and firm 
enough to resist further distension. Nature generally endeavours 
to aid this process by enlarging the collateral-circulation, and by 
setting up the adhesive inflammation so as to thicken the artery 
and obstruct its current. It has happened that a portion of clot has 
been detached from the interior of the sac by some accidental vio- 
lence, and has effected a cure by blocking up the opening into the ANEURISM. 
303 
aneurism. 2dly, The aneurism has sometimes sloughed, or has 
been involved in a large abscess; and the artery participating in 
the inflammation has become obstructed by effusion of lymph, or 
by coagulation of the blood in it. 3dly, The artery has become 
obliterated by an accidental pressure of the aneurism upon it;-or 
by the pressure of blood escaping from it on its bursting into the 
cellular tissue. 
Causes.-The predisposing cause of aneurism is some constitu- 
tional tendency to arterial disease, which may perhaps be created 
by intemperance, syphilis, or the abuse of mercury. The exciting 
cause may be, strong emotion of the mind,-violent exertion of the 
body, or local injury. Men are very much more subject to it than 
women;-and it is a disease of middle life, being most frequent 
between the ages of thirty and fifty, although it has occasionally 
been met with even in children. 
Treatment.-The indications are to stop the circulation through 
the aneurism, and to produce coagulation of the blood within it. 
Surgical Treatment.-If the aneurism throbs painfully, and is 
rapidly on the increase, and the patient is plethoric, a moderate 
quantity of blood may be abstracted once or twice; and then, if it 
can be done, the great measure is, to tie the artery between the 
aneurism and the heart. The operation should be performed 
neither too near the aneurism, so as to place the ligature on a 
portion of the vessel that is diseased;-nor too far from it, lest the 
circulation through it be kept up by means of collateral branches. 
After the operation, the temperature of the limb falls two or three 
degrees;-but in a few hours it rises rather higher than that of the 
opposite limb, because the blood is forced to circulate through the 
superficial capillaries. Subsequently it sinks again rather below 
the natural standard. Therefore, the patient should be placed in 
bed, with his limb in an easy position; wrapped up, to preserve its 
circulation; and though it become rather swelled, (which is not 
unlikely,} cold must on no account be applied. 
When a ligature cannot be applied between the aneurism and 
the heart, it has been proposed to tie the vessel on the distal side; 
and this operation has been performed with success in cases of 
carotid aneurism, by Mr. Wardrop and others. But Mr. Guthrie 
shows that this operation does not act as the (Hunterian, or) liga- 
ture between the aneurism and the heart does, by stopping the 
circulation through the aneurism; but by " giving rise to inflamma- 
tion in the aneurism, and in the artery both above and below it, 
and that unless it does this, it fails." It is therefore a dangerous 
and uncertain operation, and should be performed only where the 
tumour increases rapidly, and cannot be checked by any other 
means. 
After the operation the limb may become gangrenous, in the 
same manner as described at p. 229. If the gangrene spread 
beyond the fingers or toes, amputation should be performed above 
the level of the ligature. • 
Any other local measures, such as the application of pressure to 304 
ANEURISM. 
the aneurism, or to the trunk above it,-or of ice, may have done 
good in some cases, but more frequently the reverse. 
The medical treatment that must be resorted to when no opera- 
tion can be performed, consists in measures that reduce the heart's 
action, without lowering the vital energies too much. Bleeding 
may be performed occasionally, if the patient is plethoric, and the 
tumour increases rapidly, with violent pulsation;-but it should 
never be carried to faintness. The diet should be light. Bodily 
or mental exertion and fermented liquors should be rigidly ab- 
stained from. Much benefit may be derived from digitalis in mode- 
rate doses. But the most useful remedy is the acetate of lead given 
in doses of gr. |-i ter die, with half that quantity of opium, and a 
draught containing acetic acid, F. 60, 61. This medicine seems to 
have the faculty of rendering the blood coagulable, and of dimin- 
ishing the calibre of the arteries. It used to be mentioned in terms 
of commendation by Mr. Green in his lectures at King's College, 
who gave some instances of its efficacy.* But it must be recollected 
that frequent bleeding and too rigid starvation will increase the 
irritability of the heart and arteries, and render the systeqi incapable 
of forming healthy lymph; and that consequently they will prevent 
the desired changes in the aneurismal sac. Particular care should 
be taken not to administer drastic purgatives; because they inva- 
riably cause a great excitement and throbbing of the arteries. 
Diffused Aneurism is caused, when an artery is lacerated-by 
a broken bone for instance-without any wound of the skin; or 
when the wound in the skin has healed quickly, that in the artery 
remaining open; in either of which cases the blood escapes into the 
cellular tissue. It is known by a rapid dark-coloured swelling of a 
limb soon succeeding an injury; perhaps fluctuating, and sometimes 
pulsating,-together with coldness, numbness, and absence of pulsa- 
tion in the parts below. For this, as well for the false aneurism, 
formed by dilatation of the cicatrix of a wounded artery, the opera- 
tion for ordinary aneurism is inadmissible; but the wounded part 
must be exposed, and a ligature be placed above and below it, as 
was directed in a former page. 
Aneurismal Varix is produced when an artery is punctured 
through a vein,-the brachial artery through the median basilic vein 
at the bend of the elbow for instance;-and they adhere together, 
the communication between them remaining permanent. The conse- 
Fig. 93. 
• See also a case of aneurism of af>rta caused by acetate of lead in large doses, 
Arch. Gen. de Med., Sept. 1839. ANEURISM BY ANASTOMOSIS. 
305 
quence is, that blood passes from the artery into the vein at each 
beat of the pulse; causing it to become enlarged and tortuous, and 
to present a vibrating thrill at each pulse. 
Varicose Aneurism is said to exist when an artery has been 
punctured through a vein, and a false aneurism has formed between 
them, opening into both, and formed of lymph that was effused 
between them. These two cases need not be interfered with, unless 
they enlarge rapidly, or cause inconvenience. If they do, a ligature 
must be placed both above and below the wounded part of the 
artery. 
Fig. 94. 
SECTION IV. OF ANEURISM BY ANASTOMOSIS AND N^JVUS. 
Aneurism by Anastomosis is a pulsating tumour, generally situ- 
ated in the subcutaneous tissue of the head or neck, or sometimes in 
the extremities. It is formed of several enlarged and tortuous 
arteries, whose coats are excessively thin ; and which are accom- 
panied with many dilated veins, which feel like a bundle of worms. 
Fig. 95. 
N^svus is a similar affection, consisting apparently in an enlarge- 
ment of very many small arteries, which form a kind of erectile 
tissue. It appears soon after birth as a small red shining spot in 
the skin. This in many cases remains stationary, and gives no 
further trouble; but more commonly it enlarges, and forms a soft, 
dusky red, and pulsatory tumour, the skin covering which is so 306 
NJEVUS. 
exceedingly thin, that profuse bleeding may occur from the slightest 
abrasion. Naevus may, however, like aneurism by anastomosis, be 
seated under the skin, which may not be implicated. 
The symptoms of large naevi, and of aneurism by anastomosis, 
are the same. "Some of these tumours," says Mr. Liston, "com- 
municate a thrill to the fingers; they can be emptied to a certain 
extent by uniform and continued pressure, or by interrupting the 
circulation, and are instantly filled on permitting the blood again to 
flow into or towards them. The large ones pulsate synchronous with 
the heart's action. They are much increased in size by any thing 
that increases the activity of the circulation; as the cries of chil- 
dren, and the violent exertion of adults. On the application of the 
stethoscope, pulsation is heard as in common aneurismal tumours, 
and a sound which differs from that of the common aneurism, being 
loud, rough, and whizzing, and which being once heard can never 
be mistaken." 
Their course and termination are also the same. Sometimes they 
remain for a long time stationary; but, in general, gradually enlarge, 
and distend the skin, and at last ulcerate or slough, and cause the 
patient's death by repeated haemorrhage. 
Treatment.-The cure of these diseases may be effected either 
by exciting the adhesive inflammation in the diseased structure, so 
as to obliterate the distended vessels, or by extirpation with the 
ligature or knife; the former class of remedies being best adapted for 
naevi under the skin, the latter for those which implicate the skin 
itself. 
Of the former class, the best remedy is the seton; and the best 
way of using it, is to pass two or three threads in different direc- 
tions across the tumour, withdraw them as soon as they have excited 
suppuration, and then pass others through other parts of the tumour. 
The needle should be straight and flat, with sharp edges, and should 
be made to drag through as much silk as it can possibly carry, so 
as to fill the wound, and prevent haemorrhage. On a similar prin- 
ciple the naevus may be punctured with the point of a lancet, and 
a fine probe which has been dipped in melted nitrate of silver, or 
a needle heated to a black heat, may be passed through it in various 
directions; or its substance may be simply broken up with a cataract 
needle. Pressure by means of a smooth surface of ivory or sheet- 
lead, confined by strips of plaster and a bandage, is a good remedy 
if the naevus is small, and situated over a bone, so that it can be 
applied uniformly and effectually. The injection of an astringent 
fluid by means of Anel's syringe, has been proposed, but has caused 
the death of a child by convulsions. Vaccination has also been 
used for this disease; but it requires that the whole surface of the 
tumour and some of the skin around should be inoculated, so as to 
cover it with a confluent vesicle, which excites great fever, and the 
opportunity of doing so must be rare. A very small naevus may 
also be destroyed by puncturing it, and inserting into the puncture 
a glass pen dipped in nitric acid; this is also a good method of 
removing little red spots on the face, formed by a distended vessel NJEVUS. 
307 
with radiating branches; but immediately after applying the acid, 
the part should be sponged with a solution of carbonate of soda, 
to prevent any scar on the skin. Mr. Fergusson sometimes passes 
a needle through a small naevus, and twists a thread over it, as in 
inserting the twisted suture, allowing it to remain for forty-eight 
hours or longer. 
Extirpation of these tumours is practicable only when they are 
of the cutaneous variety, or when they can be lifted up from the 
parts beneath, so that their whole extent can be ascertained. If 
it is done with the knife, two elliptical incisions should be made, to 
include the whole of the diseased growth, and a little of the sound 
tissues around. For, to use Mr. Guthrie's words, " it cannot be too 
forcibly impressed on the mind of the surgeon, that if the diseased 
part be cut into, the bleeding will be terrific and difficult to stop." 
But it is generally considered that the ligature is the safest and 
best method. The most convenient form of using it is to pass two 
or three needles crucially 
through the base of the 
tumour, and then twist a 
strong silk ligature firmly 
round beneath them. Or in- 
stead of this, two or more 
double ligatures may be pass- 
ed through the base of the 
tumour, with a curved needle 
which has its eye at its point- 
ed extremity, and then the 
tumour may be strangulated 
by tying the adjacent threads 
together.* [See cut.] The 
tumour may be punctured 
before the threads are finally 
tightened, but in every case 
the constriction should be 
made as tight as possible. If 
Fig. 96. 
* [The method of extirpating erectile tumours described in the text, is borrowed 
from Liston's Practical Surgery, and it is strange that its essential faultiness-not 
to say impracticability-did not occur to one so accomplished in the details of our 
art as the distinguished author of that excellent work. I had marked it for cor- 
rection in our first edition, but overlooked it in the preparation of my notes. 
When the surgeon has transfixed the tumour in both directions, and knotted 
the " adjacent threads," he will find it impossible to tighten them so as to compress 
the included portion of it, inasmuch as the other extremities of the threads, having 
no support or counter-strain, will be drawn through, and his undertaking frus- 
trated. I have found the following a very convenient and satisfactory process for 
the same purposes. 
Carry a double thread through one of the diameters of the tumour, at its base, 
either by means of the instrument described in the text, or a common suture 
needle, and transfix it again in the diameter at right angles to that occupied by the 
threads, with a polished steel needle of suitable dimensions. Having divided the skin 
by a semicircular sweep with a narrow bistoury, passing through the point of exit of 
the needle, the operator seizes the two extremities of the same cord, carries them 
behind the extremity of the needle, and draws them, in a single knot, as tightly as 308 
INJURIES AND DISEASES OF VEINS. 
the skin is not implicated, it may be dissected back in flaps before 
the ligatures are passed. 
Another method analogous to extirpation, is the division of all 
the soft parts around the tumour. This was once done successfully 
by Mr. Lawrence, in an aneurism by anastomosis on the finger. 
He divided all the soft parts, except the tendons and thecae. But 
in other cases it has been unavailing. 
If the disease is inacessible to any of these means, (as in the 
orbit,) and increases rapidly, ligature of the common carotid (or of 
all the large trunks supplying it) is the only resource; but it is dan- 
gerous and not often successful.* 
CHAPTER VIII. 
OF INJURIES AND DISEASES OF VEINS. 
I. Wounds.-The haemorrhage from wounded veins is not in 
general dangerous, unless from some large and deep-seated trunk, 
or from a large varicose vein on the leg. It may in ordinary cases 
be restrained by pressure and a raised position. But if there is any 
difficulty in the matter, it will be necessary either to apply a liga- 
ture, (which, however, should always be avoided, if possible,) or to 
keep up unremitting pressure on the bleeding point with the finger. 
The latter practice was resorted to " in the case of his Excellency 
William Prince of Orange, who, in his hurt by the Spanish boy, as 
my Lord Bacon relates, when the internal jugular was opened, 
could find no way to stop the flux of blood, till the orifice of the 
wound was hard compressed by men's thumbs, succeeding for 
their ease one after the other, for the space of forty-eight hours, 
when it was hereby stanched."! 
II. Inflammation of Veins, or Phlebitis, is a very important 
disease, of which there are two forms, the subacute, (or as it might 
more properly be called, the circumscribed,') and the acute, or 
diffused. 
The Subacute Phlebitis is not a very serious disease, and 
generally affects the veins of the leg, especially if varicose. The 
possible. The textures readily glide towards the centre on the smooth needle, and 
one-half of the morbid mass is secured. A similar manoeuvre being practised 
on the other half, the whole tumour is effectually strangulated. The projecting 
extremities of the steel needle are nipped off, and the operation is finished. F.] 
* Vide Curling's Pathological Lectures in Med. Gazette, July 1838. Lawrence, 
Med. Chir. Trans, ix. 216. A fatal case of convulsion during the operation for 
nsevus by injection, Med. Gaz. vol. xxi. p. 529. J. Adair Laurie on Cricoid Aneu- 
rism, Med. Gaz., 21st Oct., 1842; the author has also borrowed from a lecture 
which he heard delivered by Sir B. Brodie, at St. George's Hospital, in Nov. 1842. 
f Turner, op. cit., vol. i. p. 346. 309 
ACUTE PHLEBITIS. 
symptoms are, tenderness and hardness of the affected vein, more 
or less swelling around it, oedema of the parts below, and painful- 
ness of the limb generally. After it has subsided, the vein is usu- 
ally felt hard as a cord; because, as was explained in a previous 
page, inflammation of a blood-vessel causes the blood within to 
coagulate, which, with the lymph that is effused, renders it im- 
pervious. It sometimes, although rarely, causes a circumscribed 
abscess in the vein, or in the cellular tissue around it. 
Treatment.-Rest, with the limb in an elevated position ;- 
leeches;-fomentations, or cold lotions, according to the patient's 
choice;-and purgatives;-subsequently, friction with camphorated 
oil, and bandages. 
III. Acute Phlebitis is a most dangerous, and generally a 
fatal disease. It may be caused by wounds of veins,-as in vene- 
section, for example-if irritated andmot permitted to heal;-or by 
tying veins;-or even by bruises and other injuries unattended 
with an open wound, if the patient be subjected to the influences 
that produce erysipelatous disease. It is a frequent concomitant of 
malignant puerperal fever, phlegmonous erysipelas, and diffused 
cellular inflammation; with which diseases it appears to be identi- 
cal in its type, and in the form of constitutional affection which 
attends it. 
Symptoms.-The symptoms are, repeated shiverings, rapidity 
of the pulse, anxiety of the countenance, and depression of spirits, 
and more or less swelling and tenderness over the course of the 
affected veins. In many cases, the tongue soon becomes furred, 
brown, and dry, or black ; the pulse exceedingly rapid and weak ; 
the prostration of strength and spirits extreme; the skin sallow ;- 
then bilious vomiting and low delirium come on, and are followed 
by death, perhaps in two or three days from the commencement 
of the attack. In other more protracted cases, great swelling and 
redness occur over the inflamed veins, and abscesses form, which, 
if punctured, are found to contain clots of blood mixed with pus. 
But the most characteristic termination of this disease is the forma- 
tion of consecutive abscesses. The patient remains low, with an 
anxious sallow countenance, rapid pulse, and yellow tongue ; and 
suddenly complains of excruciating pain in the shoulder, knee, or 
some other joint, which is rapidly succeeded by a copious forma- 
tion of pus ;-and this abscess is followed by others in the other 
joints, or in the lungs or liver, which ultimately cause death. 
Pathology.-At an early period of the disease, the lining mem- 
brane of the affected vein is found deeply red, and a little lymph is 
effused at the seat of injury. Subsequently, the vein is plugged 
with coagulated blood and lymph,mixed either with real pus, or with 
a pus-like fluid formed of softened coagulum. In cases which do 
not terminate very early, some portion of the vein is formed into 
an abscess, by the effusion of lymph above and below the inflamed 
part; and this abscess soon communicates with the cellular tissue 
by ulceration. The extreme malignity of the constitutional affec- 
tion which accompanies this disease, used to be accounted for by 310 
VARICOSE VEINS. 
supposing that the inflammation travelled along the great veins to 
the heart. Mr. Arnott,however,has shown that this is a mistake; 
because the inflammation is generally found to stop abruptly at 
the juncture of some collateral branch with the inflamed v.ein. 
The more probable supposition is, that the whole of the blood is 
contaminated by the secretions of the inflamed part; and that this 
contaminated state of the blood is the source of the great constitu- 
tional depression, as well as of the consecutive abscesses that are 
so often formed. 
Treatment.-The principal things to be done in this almost 
hopeless malady are-to apply numerous relays of leeches and 
fomentations to the part affected-to open all abscesses early-to 
open the bowels moderately-to allay restlessness and pain;-and 
to support the strength by nutriment, such as beef-tea and arrow- 
root. Relief is also generally afforded by a flannel bandage. As 
to any other measures, stimulating or lowering, they must be 
employed according to the exigencies of each particular case. 
Bleeding may occasionally be of service when the patient has a 
robust, unimpaired constitution; but in many cases it would only 
accelerate the fatal issue ; nay, excessive bleeding seems occasion- 
ally to be a main cause of the disease. Mercury may be resorted 
to in genera], unless there is very great depression indeed. Wine 
and bark should be used, if the pulse is very feeble. 
IV. Varix signifies an enlarged and tortuous state of the veins, 
which are generally thickened, rigid, and divided into irregular 
pouches, with their valves incapable of preventing the reflux of 
blood. This state may be caused by any thing that retards the 
venous circulation;-such as occupations that require a standing 
posture; or pressure from loaded bowels or the gravid uterus. But 
there must be an original weakness of structure besides; because 
varix often occurs when there is no pressure on the veins to account 
for it; and if produced by temporary pressure in healthy people, 
always subsides of itself when that pressure is removed ; a fact 
that is familiar to practitioners in midwifery. It is most frequently 
seated, in the lower extremities, scrotum, and rectum. 
Varicose veins on the leg produce several troublesome conse- 
quences. (1.) In the first place, they occasion great pain, weight 
and fatigue upon taking much exercise, or remaining long in an 
erect posture. (2.) They frequently cause ulcers or excoriation of 
the skin. (3.) Sometimes a vein becomes exceedingly thin, and 
bursts; causing a profuse or even fatal haemorrhage, inasmuch as 
there might be no valves between the part ruptured and the heart. 
(4.) Occasional inflammation occurs, with clotting of the blood in 
the affected vein ;-which may, perhaps, give rise to abscess. 
Treatment.-This may either be palliative or radical. The 
palliative consists of measures adapted to prevent further enlarge- 
ment, and induce contraction of the distended veins. If one or two 
trunks only are affected, it may be sufficient to apply pieces of 
leather spread with soap plaster firmly over them;-but if many 
smaller veins are enlarged, the whole limb should be well supported VARICOSE VEINS. 
311 
with a calico or caoutchouc bandage, or laced stocking, which 
should be applied in the morning, before the patient rises. Friction 
with lin. hydrargyri;-or with iodine ointment;-the application of 
tincture of iodine, repeated blisters, and electric sparks, have been 
supposed to accelerate the cure. Constipation should always be 
provided against; and when the patient is not taking exercise, the 
leg should be placed in a raised position. 
But if these means fail, and the patient is subject to urgent incon- 
venience, the radical cure must be resorted to ; that is to say, the 
diseased veins must be obliterated ; a proceeding which will have 
some prospect of success if only one or two large trunks are affected; 
but not if all the minor cutaneous veins are enlarged also. There 
are several ways of effecting this. Some years ago, Sir B. Brodie 
recommended division of the vein by subcutaneous section in the 
following way. A long curved narrow-pointed knife, like a bis- 
toury, but cutting on the convex edge, was introduced by the side 
of the vein, and carried horizontally with its flat surface between it 
and the skin. Then the convex edge was turned towards the vein, 
in order to cut through it, as the knife was withdrawn. Mr. Watson, 
Fig. 97. 
of New York, recommends, in some cases, excision of a portion of 
the affected vein. Then there is the method which was introduced 
by Mr. Cartwright, and improved by Mr. Mayo, of destroying a 
narrow slip of skin across the vein by a paste of potassa fusa and 
quicklime, in order to cause slight inflammation of the vein with 
coagulation of the blood in it, and obliteration of its cavity. Pressure 
by means of a firm pad and bandage has been used for the same 
purpose. 
But the newest and safest treatment is that by means of the 
twisted suture. The surgeon pinches up the vein between his left 
fore-finger and thumb, and passes a needle behind it;-it is a good 
plan also to pass another at right angles, which should be made to 
transfix the vein twice, and should go behind the first; a thread is 
then to be twisted around them tightly enough to stop the circulation; 
and this may be done at as many places as the surgeon thinks 
requisite. The points of the needles should be cut off. They should 
be allowed to remain till they have begun to create slight ulcera- 
tion; and it is better, unless the irritation is too great, to permit one 
or two of them to separate by ulceration quite through the vein. 312 
INJURIES AND DISEASES OF THE NERVES. 
Because, if they only remain long enough to cause coagulation of 
the blood between the needles, the coagulum will soon be absorbed 
again, and the circulation be re-established, as has been conclusively 
shown by M. Bonnet. 
Both before and after these operations, care must be taken to 
avoid every cause of inflammation. Because any of them-even 
the last-may be followed by abscess or diffused phlebitis, if pre- 
caution be neglected.* 
CHAPTER IX. 
OF INJURIES AND DISEASES OF THE NERVES. 
I. Complete Division of a nerve produces palsy and loss of 
sensibility in the parts to which it is distributed. The nerve, how- 
ever, will readily unite in the same manner as bone or tendon, and 
sensibility and motion will return. Sensibility has been known to 
return in three weeks, and the power of motion in four weeks after 
division. A nerve may also recover its functions after a small piece 
of it has been removed. Sometimes, however, the divided ends, 
instead of uniting, shrink and become bulbous, as they do in a stump 
after amputation.! 
II. Partial Division.-If a nerve is partly divided, leaving 
some fibres on the stretch, as sometimes happens in venesection, 
very disagreeable consequences may ensue; such as intermediate 
severe pain, recurring in paroxysms, and shooting in the course of 
the nerves; violent spasms, or palsy of the limb ;-fits of epilepsy; 
-and great disorder of the digestive organs. The same symp- 
toms may also ensue if a nerve has been bruised, or compressed, 
or stretched;-or if it has been divided, and its extremity has 
become implicated and compressed in a cicatrix. This not unfre- 
quently happens after amputation, and produces excruciating pain, 
with spasm and retraction of the muscles of the stump, causing it 
to become conical. 
Treatment.-If these symptoms come on immediately after a 
wound, so that it is probable that a nerve has been partly divided, 
an incision may be made so as to divide it completely. If, how- 
ever, they appeared whilst a wound was healing, it is the best plan 
* Vide Arnott in Med. Chir. Trans., vol. xv. Lee, ibid. Mayo, Pathol.; Cope- 
land and others in Med. Gaz., July and August 1838. Bonnet, quoted in Brit, and 
For. Med.-Rev. Jan. 1840. Dodd, Med. Gaz., 20th Dec., 1839; and valuable papers 
bjr Dr. Norris and Dr. Watson in American Journ. Med. Sc., Jan. 1843. 
fThe bulbous ends of a nerve which had not united have been cut out, but with- 
out avail. Vide Sir G. Ballingall's Mil. Surg. p. 249. NEURALGIA. 
313 
to remove the cicatrix entirely. But it unfortunately happens, that 
neuralgic pains, when once established, do not always cease, even 
when the cause which produced them at first is removed. Very 
disagreeable consequences, in the shape of palsy, or numbness, or 
spasm, are sometimes caused if a nerve is subjected to pressure- 
as for instance, the pressure of crutches on the axillary nerves-or 
from a blow, such as people often meet with on the ulnar nerve 
above the elbow;-or from a violent stretch. Leeches, blisters, 
and the application of mercurial or tartar emetic ointment, or of 
opiate, or belladonna plasters, or inoculation of a concentrated 
solution of morphia under the cuticle, are the chief remedies. 
III. Inflammation of Nerves is known by pain and tender- 
ness, with fever if acute. Sciatica is an example of rheumatic 
inflammation of the sciatic nerve. Purgatives, alkalis, colchicum, 
the iodide of potassium, and other anti-rheumatic remedies, must 
be used according to circumstances. 
IV. Tumours in nerves may produce every local and general 
symptom of nervous irritation. The painful subcutaneous tumour 
is one instance.* Iodine, counter-irritation, and the other means of 
exciting absorption, may be tried;-but if they fail, as they most 
likely will, the tumour must be extirpated, provided that it be not 
intimately embedded in the substance of a large nerve such as the 
sciatic, the division of which would paralyze a limb. 
V. Neuralgia, or Tic Douloureux.-This affection may be 
defined to be severe pain affecting the nerves, not necessarily pro- 
duced by organic lesion. It occurs in paroxysms of very severe 
pain, mostly of a plunging, lancinating character, shooting in the 
course of the nerves. It most frequently attacks persons of middle 
age, female sex, and comfortable circumstances. 
Causes.-The exciting causes may be of two orders. (1.) There 
are some which act upon the nerve that is the seat of pain. Thus 
neuralgia may be produced by wounds and other injuries, as before 
related;-by tumours;-by spiculae of bone pressing on the nerve, 
(which is a frequent cause of facial neuralgia;) or by some disease 
in the brain or spinal cord at its origin. 
(2.) It may be caused sympathetically by influences that act 
upon distant parts, or on the system at large ; as, for instance, by 
loss of blood and debilityby wet and coldby irritation of the 
skin from eruptions or wounds;-by carious teeth;-by disorders 
of the alimentary canal;-sometimes by diseases of the urinary or 
other internal organs;-lastly, by malaria. When arising from 
malaria, it is generally intermittent, like other diseases arising 
from the same source, and occurs at regular intervals. But all 
intermittent neuralgia is not necessarily caused by malaria; because 
this, as well as other nervous affections, may occur only at stated 
periods, although caused by a local source of irritation that is per- 
manent. 
The nature of the complaint is apparently functional derange- 
* Vide p. 210. 314 
NEURALGIA. 
ment. The suddenness of its accession and departure,-and the 
absence of the organic change in nerves that have been affected 
for years, prove that it is not essentially inflammatory;-although 
inflammation of*a nerve, when existing, may doubtless be an 
exciting cause. 
The most common forms of neuralgia are,-the Supraorbital 
Neuralgia, Brow digue, or hemicrania, which is usually caused 
by malaria;-neuralgia of the superior and inferior maxillary 
nerves, which is often caused by diseased teeth, or disease of the 
bony canals through which those nerves pass ; -and neuralgia of 
the ear, mamma, and testicle, which will be treated of elsewhere; 
it may also attack the extremities, or any internal organ. 
Treatment.-The indications are three. First, to remove all 
local sources of irritation; secondly, to amend any disorder of the 
constitution that can be detected; thirdly, to alleviate pain. 
In the first place, therefore, the whole course of the affected 
nerve should be thoroughly examined, and if there is a cicatrix, or 
tumour, or wound,-or a carious tooth; or an abscess, or ulcer, or 
hernia, or aneurism, to which the pain can be attributed, measures 
should be taken for their removal. In cases of neuralgia of the 
extremities, if there is any tenderness, or other reason for suspect- 
ing inflammation of the nerve or its sheath, leeches and blisters, 
followed by liniments, (especially F. 24,) or tartar emetic ointment 
applied in the course of the nerve, combined with proper constitu- 
tional remedies, may effect a cure. The head, and particularly the 
spine, should be well scrutinized; and if any pain or tenderness, 
or other genuine sign of congestion or disease, is detected, it should 
be removed by cupping, the warm bath, and blisters, or the tartar 
emetic ointment. 
Secondly. The state of the constitution must be regulated in the 
same manner as was directed in the treatment of chronic inflamma- 
tion. If there are paleness of the lips, emaciation, and debility, 
iron, bark, and other tonics may be given with advantage. Inquiry 
should always be made in these cases for piles, menorrhagia, or 
other weakening ailments. On the other hand, bleeding and low 
diet have cured cases attended with hard full pulse and plethora. 
In all cases, the appetite, the tongue, the biliary and alvine secre- 
tions, and the state of the uterine system, should be investigated. 
In the brow ague and other cases arising from malaria, quinine 
should be freely administered; and if it fails, the liq. arsenicalis, or 
the extract of nux vomica, in doses of gr. i ter die, may be tried. 
In cases of a rheumatic or gouty character, colchicum, F. 96, may 
be of service. Assafostida with aloetic purgatives and valerian may 
be given if there are hysterical symptoms, and sarsaparilla with 
iodide of potassium, and perhaps with small doses of mercury if the 
malady has followed syphilis, or if there is any reason to suspect 
thickening of the bone of the skull. But all lowering remedies, 
and especially mercury, should be used with the utmost care and 
hesitation. 
Thirdly; but if no cause whatever can be detected; or, if detected, NEURALGIA. 
315 
it cannot be removed ;-or if, as frequently happens, even though 
removed, its removal fail to cure the disease, an empirical and 
palliative plan of treatment is the only resource. A course of 
purgatives, especially the croton oil, in doses of ttf 1 ter die; tonics, 
especially the carbonate of iron, and oxide or sulphate of zinc; any 
remedies, in fact, that have been known to do good, may be tried 
in succession; taking care, however, not to impair the constitution 
by giving them at random. Opium, morphia, hyoscyamus, bella- 
donna, conium, stramonium, or prussic acid, given internally; fric- 
tion with ointments, or alcoholic solutions of veratria, strychnia, or 
aconitina (3ss ad oi.)-sprinkling gr. i-5 of morphia or strychnia, 
on a newly blistered surface ; or making a dozen punctures in the 
course of the nerve and inoculating a concentrated solution of these 
alkaloids under the cuticle-galvanism, acupuncture, issues, and 
the moxa, generally afford some relief, and sometimes completely 
cure. Division of the nerve, with or without excision of a portion, 
is the last resource. It produces instant ease,-which, however, 
lasts but a short time; and the oftener it is repeated, the more tran- 
sient are its effects. Sometimes, after repeated divisions, the pain 
is as severe as ever, although the part may become quite numb 
and insensible. The infraorbital and mental nerves, (which may 
be divided from within the mouth just as they escape from their 
foramina,) the frontal, the radial, just after it has passed between 
the supinator tendon and the bone, and the digital, are those which 
have been most frequently operated upon. 
VI. Anomalous Nervous Affections.-The same local and 
constitutional causes that give rise to neuralgia, may also occasion 
every other symptom that can be produced by functional nervous 
disorder; such as rigid and permanent spasm, (as in wry neck,) or 
twitching and convulsion of muscles;-difficulty of swallowing and 
performing evacuations, owing to spasm of the oesophagus, of the 
sphincter ani, or of the perineal muscles; -sneezing, dumbness, 
stammering, thirst, and affections of the sight and hearing. The 
treatment must be conducted on the same principles. 
VII. Hysterical Neuralgia.-Hysterical females are liable 
to suffer from various obstinate maladies which simulate serious 
organic diseases. In particular they are exceedingly subject to 
severe and permanent pain and tenderness of the joints; (especially 
the knee or hip;) with weakness of the limb, and inability to use 
it;-or to pain and tenderness of the spine, with perhaps spasms, 
or weakness of the legs, tympanites of the belly, and palsy of the 
bladder;-symptoms, in fact, of ulcerative disease of the joints or 
spine, that might mislead careless practitioners; more particularly 
as they are often attributed to some injury. These cases may be 
known by observing that the patients are young females, perhaps 
newly married, most likely (but not invariably) subject to irregular 
menstruation, torpid bowels, and coldness of the extremities:-or 
perhaps to well marked fits of hysteria. Not uncommonly some 
intimate friend has laboured under a similar complaint just pre- 
viously. The pain is greatly aggravated by motion or pressure;- 316 
NEURALGIA. 
but it seems to be principally seated in the skin; and the patient 
shrinks from the least touch;-whilst, if her attention be engaged 
elsewhere, a somewhat rude examination may be made without 
complaint. The pain often prevents the patient from sleeping, but 
once asleep, she may continue so for hours. There may be some 
degree of swelling, but it is puffy and diffused,-and comes and 
goes capriciously. These complaints may last many years in 
defiance of all treatment, and then may vanish suddenly without 
assignable cause;-or perhaps from some strong impression on the 
nerves,-fright or fanaticism. Sometimes the patient labours under 
an obstinate contraction of some joint; perhaps the hip, or the 
finger; which very likely goes off quite suddenly, and transfers itself 
to another joint. 
Treatment.-Any detectable disorder of the digestive or uterine 
systems should be removed. The patient should have fresh air, 
generous living, and plenty of occupation for body and mind; she 
should be encouraged to take exercise, notwithstanding pain and 
weakness; and to resume as far as possible the habits of a healthy 
person. The shower bath;-the mistura ferri, or the ammonio- 
chloride in doses of gr. ii.; the sulphate of zinc in small doses with 
ext. anthemidis-or the ammonio-sulphate of copper in doses of gr. 
s ter die, may be given with benefit if the circulation is languid; 
and quinine may be of use if the pain is periodic. The bowels 
should be kept open by nightly doses of the warmer aperients, such 
as aloes, or colocynth, with assafoetida, cajuput oil, or the compound 
galbanum pill. Acidity of the stomach must be counteracted by 
soda or magnesia; and inaction of the liver by occasional doses of 
the blue pill. Deficiency or excess in menstruation should be pro- 
perly looked after. " Sometimes," observes Sir B. Brodie, " the 
symptoms have abated under the use of active purgatives; or of 
valerian combined with bark and ammonia, or of injections of 
assafoetida." F. 96 is one of his prescriptions for these cases. He 
also recommends warm fomentations, especially one composed of 
sp. rosmarin. siss and mist, camph. 3 viss, or of lin. camph. 3iv, with 
ext. belladon. 5ii. Occasional leeching may be of service, but 
counter-irritants should be avoided. If the limb at any time become 
very hot, it should be sponged with tepid lotions;-but if cold, it 
should be wrapped up warmly in flannel and oiled silk.* Ampu- 
tation in these cases is useless and cruel. 
• Vide Brodie on the Joints, 4th ed. p. 311. Brodie on Local Nervous Affec- 
tions, Lond. 1837. Rowland on Neuralgia, Lond. 1838. INJURIES OF THE HEAD. 
317 
CHAPTER X. 
OF INJURIES OF THE HEAD. 
SECTION I.-WOUNDS OF THE SCALP. 
Wounds and contusions of the scalp, be they ever so slight, are 
not to be neglected. For they may be followed by erysipelas;-or 
by inflammation and suppuration under the occipito-frontalis, or 
within the cranium, that might easily prove fatal. It may be 
observed, that sutures are generally inexpedient; that although 
there be considerable arterial haemorrhage, ligatures should be 
avoided, if it can be restrained by pressure ;-that if a flap of the 
scalp is nearly or even quite detached, it should be carefully 
washed, and returned to its place, avoiding sutures and pressure 
by bandages and plasters; that if a blow on the head causes an 
extensive and increasing extravasation of blood under the scalp, 
rendering it evident that an artery has been divided by the blow, 
the exact situation of the injured vessel should, if possible, be ascer- 
tained, and pressure be applied there; that early and free incision 
must be made in the event of suppuration, and that punctures must 
be made if there is great effusion of serum under the occipito- 
frontalis ;-but that if blood is extravasated there, its absorption is 
to be promoted by bleeding, cold, and low diet; and no incision is 
to be made, unless positively necessary. 
SECTION II. CONCUSSION OF THE BRAIN. 
Definition.-Concussion (commonly called stunning) signifies 
sudden interruption of the functions of the brain, caused by a blow, 
or other mechanical injury to the head, and not necessarily attended 
with visible organic lesion of the brain. 
Symptoms.-There are two degrees of it. (1.) In ordinary 
cases, the patient lies for a time motionless, unconscious, and insen- 
sible ; if roused and questioned, he answers hastily, and instantly 
relapses into insensibility; after a time, he moves his limbs as if 
in uneasy sleep, and vomits, and frequently recovers his senses 
instantly afterwards; remaining, however, giddy, confused, and 
sleepy for some hours. (2.) In the more severe degree the patient 
is profoundly insensible, the surface pale and cold, the features 
ghastly, the pulse feeble, and intermittent, or perhaps insensible, 
and the breathing slow, or performed only by a feeble sigh, drawn 
at intervals. 
Vomiting is an important symptom. It is not present in very 
slight cases, nor in very severe ones -and its occurrence is mostly 
an indication of approaching recovery. 318 
CONCUSSION OF THE BRAIN. 
Consequences.-(1.) In cases not attended with fracture or 
lesion of the brain, the patient suffers from some degree of head- 
ache and feverishness for a few days, which might easily be 
aggravated into a fatal inflammation of the brain. (2.) If the 
concussion be very severe, it may be followed by death, although 
this is not often the case, unless there is also a fracture of the skull, 
or extravasation of blood within the brain. The degree of danger 
in any case may be estimated by the degree in which the spinal 
and ganglionic systems appear to be implicated. If, therefore, the 
pulse and respiration continue feeble for many hours; if the eyelids 
do not move when irritated, and the legs are not drawn up when 
the soles of the feet are tickled, the prognosis will be serious. 
(3.) Concussion is occasionally succeeded by a peculiar state of 
insensibility, which may last some days. The patient lies as if in 
a tranquil sleep ; his pulse is regular; but on the slightest exertion 
it rises to 130 or 140, and the carotids beat vehemently;-when 
roused he answers questions, but immediately relapses into uncon- 
sciousness. Some patients in this state resemble somnambulists; they 
may get out of bed, bolt the door, shave, or make water, but still 
are insensible to what passes around. (4.) It may leave a very 
infirm state of the health and intellect;-impairment of the memory, 
or of the senses, especially of smell and hearing; and a constant 
tendency to inflammation, and to extravagant actions after drink or 
any other excitement. 
Pathology.-The brain is often found bruised, or ecchymosed, 
or lacerated; but still concussion may be fatal, without any injury 
that can be detected by dissection. 
Treatment.-The indications are: (1) to recover the patient 
from insensibility and collapse; (2) to prevent inflammation ; (3) to 
restore any faculties that may remain impaired. 
1. In order to fulfil the first indication, friction of the surface with 
the hand, and the application of warmth to the feet, may be resorted 
to, if the depression is very great, and the pulse very low; but it is 
better in most cases to leave the patient to recover by himself, than 
to be officious in administering stimulants, as they would increase 
the effusion of blood, supposing the brain to be lacerated. Mr. 
Guthrie's sentiments on tins point are very decisive. " It is useless 
to open the patient's veins," he observes, " for they cannot bleed 
until he begins to recover, and then the loss of blood would pro- 
bably kill him. It is as improper to put strong drinks into his 
mouth, for he cannot swallow; and if he should be so far recovered 
as to make the attempt, they might probably enter the larynx and 
destroy him. If he be made to inhale strong stimulating salts, 
they will probably give rise to inflammation of the inside of his 
nose and throat to his subsequent great distress."* 
2. After reaction has taken place, the patient (unless too young 
or feeble) should be bled ;t at all events the bowels should be 
• Guthrie, G. J. on Injuries of the Head affecting the Brain. Lend. 1842, p. 11. 
f Whether the patient has recovered his consciousness or not, he should be 
bled if the pulse become hard, and the skin hot. But bleeding is not a remedy for COMPRESSION FROM EXTRAVASATED BLOOD. 
319 
freely acted on, and perfect rest and low diet should be observed. 
If the pulse becomes hard and frequent, and if the patient com- 
plains of pain or tightness in the head, the bleeding and purgatives 
should be repeated as often as may be necessary, with saline and 
antimonial draughts in the intervals; and the head should be shaved 
and kept wet with evaporating lotions. As a general rule, after 
any severe blow on the head, the patient should observe a cautious 
antiphlogistic regimen for a month or six weeks-carefully keeping 
himself free from all fatigue, intemperance, and excitement. If 
violent delirium or convulsions come on after an injury to the head 
which has been treated by copious venaesection, and if they are not 
relieved by further depletion, or if that seems inexpedient, they 
will probably yield to acetate of morphia. 
3. In order to remove headache, deafness, giddiness, squinting, 
loss of memory, tinnitus aurium, and other remote consequences of 
concussion, a course of mild alterative mercurials;-repeated 
blisters, or an issue or seton;-the shower-bath, change of air, 
general friction of the surface, and a most regular diet, are the 
remedies. 
SECTION III. COMPRESSION FROM EXTRAVASATED BLOOD. 
Symptoms.-The symptoms of compression of the brain are 
those of apoplexy. They are insensibility; general palsy, (some- 
times, but rarely, confined to one side;) dilated and insensible 
pupil; slow, labouring pulse ; skin often hot and perspiring; reten- 
tion of the urine, through palsy of the detrusor urinx; involuntary 
discharge of faeces through palsy of the sphincter ani; and ster- 
torous breathing, owing to palsy of the velum pendulum palati. 
Sometimes, however, the pupils are contracted, and sometimes one 
is contracted and the other dilated. 
Causes.-Compression (surgically considered) may be produced 
by three causes. (1.) By extravasation of blood. (2.) By frac- 
ture of the skull, with depression. (3.) By suppuration within its 
cavity. 
The symptoms of compression from extravasated blood gene- 
rally show themselves in the following manner: The patient 
receives a blow, and becomes stunned and insensible from the con- 
cussion, with extremely feeble pulse and cold skin. After awhile 
he recovers his senses ;-but again in an hour or two he becomes 
sleepy, confused and insensible ; with slow stertorous breathing, 
slow pulse, and dilated pupils. These symptoms closely correspond 
with those.of one form of apoplexy, called the ingravescent; in 
which the patient suddenly feels an acute pain in the head, caused 
by the bursting of a blood-vessel, and becomes sick and faint-in 
concussion itself:-it merely removes its consequences; and if employed during 
a depressed state of the circulation, may induce epileptic convulsion, or perhaps 
death. In every case of sudden insensibility, whether from disease or accident, 
the vulgar clamorously demand that the patient should be bled; but the-surgeon 
must be very ignorant or very weak if he yields to their wishes. 320 
COMPRESSION FROM EXTRAVASATED BLOOD. 
fact, suffers from concussion. Then he recovers his senses-but 
shortly afterwards, as the extravasation from the ruptured vessel 
increases, becomes quite comatose.* 
On the other hand, if a large quantity of blood is extravasated 
rapidly, the symptoms of compression may immediately succeed 
the insensibility of concussion, without any interval of con- 
sciousness. 
The blood may be situated, (1) between the dura mater and 
skull; and if in large quantity, it proceeds from laceration of a 
branch of the middle meningeal artery; (2) between the mem- 
branes; (3) in the substance of the brain. 
Diagnosis.-The insensibility arising from compression may be 
distinguished from that which arises from concussion of the brain, 
by observing, 1st, that the symptoms of concussion always follow 
the accident immediately; those of compression from effusion of 
blood may come on after an interval. " The first stunning or 
deprivation of sense," says Pott, " may be from either; no man 
can tell from which; but when these first symptoms have been 
removed, or have spontaneously disappeared, if such patient is 
again oppressed with drowsiness or stupidity, it then becomes 
most probable that the first complaints were from concussion, and 
that the latter are from extravasation." 2dly. In concussion, the 
pulse is feeble, and the skin pale ; and the greater the insensibility 
the feebler will the pulse be. In compression, on the contrary, 
when reaction is thoroughly established, the pulse will be slow and 
full, and the skin hot and perspiring. 3dly. Stertorous breathing 
and muscular palsy are rare in mere concussion, common in com- 
pression. 4thly. The pupil in concussion is variable: sometimes 
contracted, sometimes dilated, and not always insensible to light; 
in compression, it is almost always dilated and insensible. 
Treatment.-The head should be shaved and examined, and if 
there is no sign of fracture, the case must be treated as one of apo- 
plexy ; the indications being to avert inflammation, and procure 
absorption of the blood by bleeding, cold applications to the head, 
purgatives, and calomel in repeated doses. Frequently a puffy 
swelling arises after a day or two, and points out the seat of the 
blow. If, in spite of the above measures, the insensibility continues, 
and the lungs become clogged with mucus, and the breath escapes 
from the corner of the mouth with a peculiar whiff during expiration, 
which are very perilous symptoms, the last resource is trephining, 
-which operation should be performed at the seat of the injury, if 
that is known,-or if that is not known, it should be done where 
any puffy swelling arises;-or lastly, if there is no puffy swelling, 
it should be done over the middle meningeal artery;-and if one 
side is more palsied than the other, it should be done on the other, 
because, as is well known, injury of one side of the brain produces 
palsy of the opposite side of the body. The trephine should be 
rather large. Perhaps the inner table may be found extensively 
* Copland, Diet. Art. Apoplexy. FRACTURE OF THE SKULL. 
321 
fractured, with only a mere fissure of the outer table. The skull is 
said always to bleed very little when scraped at the seat of effusion 
between it and the dura mater, because it is deprived of its supply of 
blood from that membrane. This, therefore, is an important diag- 
nostic sign; and in a desperate case it might be advisable to cut 
through the scalp, and examine the bone at any part where mischief 
is suspected to exist. 
When a piece of bone has been removed, the dura mater, in its 
normal state, is found to be level, and of a reddish silvery colour, 
and it rises and falls synchronously with the motions of respiration; 
but if there is fluid underneath, it bulges up tightly into the aper- 
ture made by the trephine, and its motions are very indistinct or 
entirely lost. In this latter case a puncture should be made to let 
the fluid escape.* 
SECTION IV. FRACTURE OF THE SKULL. 
Fractures of the skull are divided, (1) into those which consists of 
a mere crack or fissure without displacement; (2) into fractures 
with extravasation of blood, which generally accompanies fracture 
of the anterior inferior angle of the parietal bone, and which was 
spoken of in the last chapter; and (3) into fractures with depression. 
Fracture of the base of the skull is the most dangerous kind. It is 
caused when the patient falls from a height, and pitches on his head; 
the basilar process being snapped through by the weight of the whole 
body, which tells upon it through the spinal column. In these cases 
there is frequently a copious venous haemorrhage from the ears, in 
consequence of laceration of the sinuses at the base of the brain. 
This is a most unfavourable symptom; although a slight haemor- 
rhage from the ears, or nose, or mouth, may depend on an insignifi- 
cant rupture of the membrana tympanij or of the mucous membrane 
of those parts. These cases mostly terminate fatally, although there 
is one instance of recovery on record. 
1. Simple fissure requires no treatment apart from that of the 
concussion, compression, or scalp wound, with which it may be ac- 
companied. 
2. Fracture with depression may be simple or compound ; the 
compound being that which is attended with a scalp wound exposing 
the fracture. 
(«.) Simple fracture with depression maybe ascertained by a 
careful examination of the shaved scalp, when, if it exist, there will 
be felt a depression at one part, with a corresponding edge or pro- 
jecting ridge near it. Sometimes a coagulum of blood under the 
* Guthrie, op. cit. pp. 39, 125. 
f The author was informed by his friend and pupil, Mr. T. W. Houchen, that Mr. 
Tatum mentioned a case in the course of some Clinical observations at St. George's 
Hospital, in which the membrana tympani was ruptured by a fall on the head, and 
the saliva flowed copiously from the ear; passing, of course, through the Eustachian 
tube. Mr. Guthrie mentions a copious discharge of a thin watery fluid from the 
ear as a dangerous symptom, as it comes, most likely, from the sac of the arachnoid. 322 
FRACTURE OF THE SKULL. 
scalp conveys the feeling of a sharp elevated ridge of bone;-it may 
be known, however, by its yielding to firm pressure with the finger, 
and by observing that no part of the bone is below its natural level. 
But although there may be a real fracture with depression, still 
there may be no compression of the brain; because the outer table 
may merely have been driven into the diploe, or the outer wall of 
the frontal sinus may have been broken in. The former accident 
(i. e. fracture of the outer table only) can only happen to a patient 
of middle age, because the diploe neither exists in infancy nor old 
age;-the latter will be known by the escape of air, when the nose is 
blown forcibly, either into the cellular tissue of the forehead, or out 
of the wound if there be one. 
Treatment.-In a case of simple depressed fracture, if there are 
symptoms of compression of the brain, the scalp should be divided, 
and the bone be raised by trephining. But if there are no symp- 
toms of compression, (and there sometimes are not,) and if the 
patient is conscious and rational, there is a difference of opinion as 
to the plan to be pursued. Sir A. Cooper and Abernethy direct 
that no incision should be made through the scalp, nor should the 
trephine be immediately resorted to, which they contend must 
necessarily aggravate the amount of the injury, and the patient's 
danger:-but that the patient should be bled, purged, and kept 
under the strictest antiphlogistic regimen; and then, perhaps, re- 
covery may be completed without the slightest appearance of com- 
pression, and inflammation be averted. Even if there be slight 
symptoms of compression, the same plan is to be adopted, in the 
hope that they may be removed by free depletion. 
The practice however of Pott and his predecessors was to tre- 
phine in every case of depression; alleging that the operation should 
be performed in order to prevent ill symptoms, and that if it were 
delayed till they came on, it would be too late. And this latter 
doctrine is supported in some degree by Mr. Guthrie; who says, 
that if fracture with marked depression exists, in an adult, it is the 
best plan to divide the scalp, and ascertain the nature and extent of 
the depression. If it is probable that portions of bone are sticking 
into and irritating the dura mater, it is better to trephine at once, 
even although no symptoms of compression should be present.* 
In children, whose bones are soft and thin, great indentations and 
depressions may be produced without fracture. They are to be 
treated antiphlogistically; and if the bowels are kept well open, 
they may not cause any bad symptom whatever, and the bone may 
rise in time to its proper level. 
(b.} In the case of compound fracture of the skull with depres- 
sion of bone, whether there are symptoms of compression of the 
brain or not, the bone must be elevated. If possible, it should be 
done with the elevator ; but if one piece of bone is wedged in under 
another, a small aperture should be made with the trephine, in 
order to make room for employing the elevator. If any pieces of 
bone are perfectly loose and detached, they must be removed; but 
* This question is admirably discussed in Sharp's Practical Treatise on Injuries 
of the Head. Lond. 1841. WOUNDS OF THE BRAIN. 
323 
not if they have a pretty good adhesion to the pericranium and 
dura mater. 
Sabre Cuts.-Cuts inflicted by a sword or sabre, if they do not 
quite penetrate the skull, are to be treated as simple fissures; but if 
produced by a blow which descended perpendicularly, the inner 
table of the skull is apt to be extensively splintered; and if on 
examination with a blunt probe this is found to be the case, re- 
course should be had to the trephine. 
SECTION V. WOUNDS OF THE BRAIN, HERNIA CEREBRI, &C. 
Wounds of the dura mater add very considerably to the 
danger of compound fractures of the skull, both from the risk that 
inflammation may spread over the surface of the arachnoid, and 
from the greater chance of hernia cerebri. Hence this membrane 
should never be indiscreetly wounded. 
Wounds of the sinuses are of no great consequence, provided the 
blood does not accumulate within the skull; and the haemorrhage is 
easily restrained by pressure. 
Wounds of the brain, whether incised or lacerated, are not of 
necessity attended with any mental or bodily disorder, besides that 
which arises from the concussion, compression, or inflammation 
that may accidentally be present. Instances are numerous in which 
portions of the brain have been lost without any ill consequences at 
the time or afterwards. But yet Sir B. Brodie has observed in 
some cases a greater degree of mental confusion than usually attends 
concussion, and in others spasmodic twitchings of the muscles. 
If foreign bodies are embedded in the brain, the danger will be 
materially augmented. Sir B. Brodie says, that no foreign body, 
whether a portion of the skull or not, is to be removed, if the 
removal will add in the least to the irritation or injury; but the 
practice of most surgeons is, that they should be removed without 
delay, but with as little disturbance as possible. 
The treatment of these wounds consists in the preventing of 
inflammation;-and in causing the wound to cicatrize without the 
formation of hernia cerebri. 
Hernia Cerebri.-When a portion of the skull has been re- 
moved, the brain is liable to protrude through the aperture in the 
form of a rounded tumour, styled hernia or fungus cerebri. Mr. 
Guthrie describes two varieties of it. In the first, which occurs 
within two days, the tumour is composed of coagulated blood, and 
is caused by haemorrhage into the brain near its surface. It is 
accompanied with delirium and phrenitis, and is generally fatal. 
The best treatment is to shave it off level with the surface, so as to 
permit a free discharge of blood. The other kind of tumour con- 
sists of brain itself, infiltrated with lymph from inflammation; which, 
if the dura mater is still entire, causes it to slough by its constant 
pressure, and then protrudes through the aperture in the skull. As 
it increases in size, it suffers constriction from the aperture through 324 
INFLAMMATION OF THE BRAIN. 
which it passes, and sloughs; but is speedily succeeded by a growth 
of brain and of fungous granulanon, which undergoes the same 
processes, till the patient dies of the irritation. 
Treatment.- In order to prevent this variety, a well regulated 
pressure, just sufficient to afford a natural support, should be made 
upon the brain by means of compresses of soft lint oiled, in all cases 
when the skull is perforated. If the fungus has already protruded, 
the best application is liq. calcis, with which the lint may be wetted. 
If this fail, and the degree of pressure requisite to prevent increase 
cause symptoms of cerebral oppression, the part should be shaved 
off level with the scalp, and any further growth be prevented by 
the liq. calcis and lint, and pressure, as before. 
SECTION VI.-INFLAMMATION OF THE BRAIN. 
General Description.-Inflammation of the brain rarely makes 
its appearance till a week after an injury, frequently not till three 
weeks, or even later. Its symptoms and progress are very various; 
sometimes sudden, violent, and soon terminating in destructive 
suppuration ;-sometimes slow, insidious, and unsuspected, till sud- 
denly manifested by fatal coma or palsy. 
Symptoms.-First stage. The patient complains of pain in the 
head, aggravated by heat, motion, and any thing that causes excite- 
ment of mind or body, together with a disagreeable sense of languor 
or weakness, confusion of ideas, quick pulse, disturbed sleep, 
nausea, and want of appetite, and alternate flushing and paleness. 
Second stage. These symptoms having lasted a day or two, there 
comes on a violent rigor, followed by burning heat of the skin;- 
the pulse is hard and frequent;-the carotid and temporal arteries 
pulsate vehemently;-the headache becomes most intolerable and 
throbbing, the pupils are contracted ;-light is insupportable to the 
eyes, and sound to the ears ;-the tongue is dry, the bowels obsti- 
nately costive, and the stomach rejects every thing with frequent 
retching. Besides these symptoms, violent delirium or convulsions 
come on at intervals, or perhaps coma. If they are unrelieved, the 
third stage soon follows. The pulse loses its force, and becomes 
either slow and oppressed, or excessively rapid; and squinting, 
low delirium, convulsions, or palsy, soon usher in death. Rigors, 
followed by squinting, dilated pupil, stertorous breathing, coma, 
and palsy, are indications of suppuration. 
Certain changes on the outside of the head, also accompany the 
mischief that is going on within. Supposing the injury, which is 
the cause of the inflammation, to have been accompanied with a 
wound which up to the occurrence of the inflammation has been 
going on well-to use the words of Pott,-"the sore loses its 
florid complexion and granulated surface, and becomes pale, flabby, 
glassy, and painful; instead of good matter, a thin gleet is dis- 
charged from it; the lint with which it is dressed sticks to all parts 
of it; and the pericranium, instead of adhering firmly to the bone, INFLAMMATION OF THE BRAIN. 
325 
separates all round from it to some distance from its edges." The 
bone, moreover, becomes white, dry, and bloodless; because the 
nutrient vessels that naturally pass from the dura mater to the skull 
are cut off, in consequence of the intlammation or incipient suppu- 
ration of that membrane. If there be no wound, still the scalp 
presents the puffy swelling that has been before spoken of. If the 
dura mater is exposed, it at first appears of " a dull, sloughy cast, 
and smeared over with something glutinousand subsequently is 
covered with matter. 
Pathology.-It is believed that if the membranes and surface 
of the brain be inflamed, there will be greater pain, and a greater 
disposition to delirium and convulsions ;*-but that in inflamma- 
tion of the cerebral substance there will be an early tendency to 
coma and palsy. 
Prognosis will be unfavourable if the malady have advanced to 
its second stage, and is not promptly relieved by depletion. 
Treatment.-Upon the first appearance of the symptoms, bleed- 
ing should be performed, (perhaps from the temporal artery or 
jugular vein,) to the approach of faintness ; the bowels should be 
most freely opened, and the head be shaved and kept cool and 
elevated. If they do not yield, the bleeding should be repeated as 
often as may be necessary; leeches should be freely employed, and 
from two to six grains of calomel, with a quarter of a grain of 
tartar emetic, (not enough to cause vomiting,) should be given 
every two or three hours. The remedies for the third stage are 
blisters to the head or its vicinity; -mustard cataplasms to the feet; 
-terebinthinate or stimulant enemata;-and trephining, if suppu- 
ration is indicated by symptoms of compression, or by the above- 
mentioned state of the wound. The trephine should be large, and 
if the matter be seated between the dura mater and skull, it may 
afford relief, although it rarely does. 
•Abscess in the brain, or that form of disorganization which is 
called softening or ramollissement, may be very remote conse- 
quences of injury; not occurring perhaps for years. Their symp- 
toms are very obscure and insidious. Occasional headache ; general 
loss of health and strength; impairment of the memory or other men- 
tal faculties; quick pulse, and furred tongue ; disorder of the eyes or 
ears; sense of constriction, or of coldness in the scalp, or of creep- 
ing in the limbs, with numbness, are the most frequent. But these 
are succeeded by sudden convulsions, or palsy, or coma, from which 
the patient soon dies, although he may perhaps recover for a time. 
Treatment.-Blisters, issues, setons, or the tartar emetic oint- 
ment ;-mercurial alteratives ;-purgatives;-occasional depletion ; 
-shower-baths;-the most regular diet, and avoidance of every 
kind of excitement of mind or body, are the remedies in case mis- 
chief is suspected. After the occurrence of palsy or other decided 
symptoms, blisters;-leeches, if the pulse is strong enough, and 
* Dr. Marshall Hall ascertained that lacerations of the dura mater of frogs gave 
rise to spasmodic motions, of the eye, eyelids, and head; probably through the 
reflex influence of the small branches of the fifth nerve which supply that mem- 
brane. 326 
TREPHINING. 
there is pain or heat in the head-purgatives, and enemata. But 
if the patient is low and feeble, he must be supported by mild 
nutriment and stimulants of the diffusive kind, especially the pre- 
parations of ammonia. 
SECTION VII. TREPHINING AND PARACENTESIS. 
I. Trephining.-The apparatus requisite for this operation com- 
prises a large and small trephine, a straight and curved Hey's saw, 
and an elevator-besides a good scalpel, and the other instruments 
which every surgeon is supposed to have in his pocket. 
There are four cases which may require this operation. 1. Frac- 
ture of the skull with depression of bone. 2. Extravasation of 
blood under the skull. 3. Suppuration of the dura mater. And 
lastly, occasional cases of epilepsy arising from the irritation of a 
diseased spot of the skull. For the first and last cases, the trephine 
should be quite small, so as not to sacrifice more bone than is abso- 
lutely necessary; but when the operation is intended for the relief 
of suppuration or extravasation, the trephine should be large, so as 
to afford a free exit to the fluid. 
Supposing it to be a case of depressed fracture. In the first place, 
the bone, if not already laid bare by a scalp wound, must be ex- 
posed by an incision in the shape of a V, or T. Then perhaps 
some loose fragment may be picked out, or a projecting point may 
be sawn off with a Hey's saw, that will enable the surgeon to raise 
the depressed portion with the elevator. But if this cannot be done, 
a circular piece, consisting of the edge of the depressed bone, and 
of the adjoining bone under which it has been wedged, must be 
removed. The pericranium being shaved off from the part which 
is to be perforated, the surgeon applies the trephine, and works it 
with an alternate pronation and supination of the wrist, and when 
it has made a circular groove deep enough to work in steadily, he 
takes care to withdraw the centre pin. He saws on steadily and 
cautiously, pausing frequently and examining the groove with a 
probe, to ascertain whether it has reached the dura mater, and 
when it has, he introduces the elevator to raise the circular piece of 
bone. He must be particularly careful to fix the centre pin, and 
the greater part of the circumference of the instrument, on firm 
bone,-and by no means to press heavily, whilst sawing, on any 
piece that is loose or yielding. The saw will be known to have 
reached the diploe by the escape of blood with the bone-dustbut 
it must be recollected that the diploe exists neither in children nor 
in the aged. The trephine should not be applied in the course of 
the sutures, nor over the lower part of the frontal or occipital bones, 
if it can be avoided; but if necessary there is no objection. 
II. Paracentesis Capitis, or puncture of the head, is an opera- 
tion that sometimes is resorted to in hopeless cases of hydrocephalus 
in children, when all medicine fails of checking the effusion of 
water, or of causing it to be absorbed. It has been particularly DISEASES OF THE SPINE. 
327 
recommended by Dr. Conquest, who has performed it in nineteen 
cases, out of which he succeeded in saving ten. The operation 
consists merely in introducing a very fine trocar or grooved needle 
perpendicularly to the surface, through the anterior fontanel, as far 
as possible from the longitudinal sinus. When two or three ounces 
of fluid have escaped, the puncture should be carefully closed, and 
moderate support be applied to the head by bandages. If the child 
becomes faint, it must be kept in the recumbent posture, and have 
a few drops of sal volatile. The operation may be repeated at 
intervals of two or three weeks.* 
CHAPTER XL 
OF THE DISEASES AND INJURIES OF THE SPINE. 
I. Lateral Curvature.-Curvature of the spine presents many 
varieties, some of which arise from mere debility, whilst others are 
caused by the destruction of portions of the spinal column by dis- 
ease. We shall first describe that distortion which arises from 
debility of the bones, ligaments, and muscles, and which is so 
exceedingly common in this country in young females of the middle 
and upper classes, from about the age of ten to sixteen. 
Symptoms.-The first thing that attracts attention is a projection 
of one scapula, or of one side of the bosom, or an elevation of one 
shoulder, (most commonly the right,) which are popularly, but 
erroneously, supposed to be growing out. On examination, the 
spine is found to be curved like an italic /;-the right shoulder 
projecting, and the right side of the chest and the left hip being 
unnaturally convex;-whilst the chest on the left side and the loins 
on the right are correspondingly curved inwards. This affection is 
readily caused by occupations or postures that tax one side of the 
body more than the other,-if at the same time the patient be sub- 
jected to want of exercise, or other influences that deprive the 
muscles and ligaments of their natural elasticity and vigour. 
Treatment.-Attention must be paid to the following circum- 
stances;-viz. position, exercise, and rest. (1.) In the first place, 
the patient must be watched, in order to find out from what par- 
ticular attitude or habit the distortion takes its rise. Standing on 
the right leg is the most frequent, for in this posture the left side of 
the loins is thrown upwards, and the patient is obliged to raise the 
right shoulder to keep the body perpendicular. A habit of raising 
the right shoulder whilst writing, or drawing, or playing the harp, 
* Vide Dr. Watson's Lectures on the Practice of Physic. 328 
DISEASES OF THE SPINE. 
or riding on horseback,-or of sleeping constantly on one side with 
too high a pillow,-or the abominable custom of wearing dresses 
made low on the chest, so that the patient hitches her frock up on 
one shoulder and lets it fall off the other, are also occasional causes. 
And all these, and every other one-sided posture, should be vigi- 
lantly prohibited. (2.) The patient should take free exercise in the 
open air, whether walking or riding, or indulging in any games or 
sports, such as the dumb-bells, the skipping-rope, drawing a light 
garden roller, hopping, or carrying weights in the hands. The club 
exercise, introduced by Mr. Angelo into the regular cavalry training, 
is extremely advantageous.* It consists in a series of exercises for 
the arms, whilst a club or loaded stick about two feet long, and 
from two to seven pounds in weight, is held in each hand. In this, 
as well as in using the dumb-bells, or other exercises performed in 
a standing posture, the patient should stand with the heels close 
together, the feet at an angle of 60°, the knees straight, the belly 
thrown back, (so that it may not be strained,) the chest forwards, 
and the shoulders square; and whilst both sides are duly exercised, 
the weaker one should be principally brought into play. (3.) 
These exercises should never be carried so far as to fatigue; and 
after using them the patient should lie down on her back on a flat 
inclined plane, although any easy posture on a bed or sofa, or on 
the floor, will do as well. She should never be forced to stand 
longer than is perfectly agreeable, and when sitting should rest her- 
self well against the back of the chair. Her seat should be wide 
enough to reach to the knees, and the feet should be well supported, 
These measures, combined with tonics, especially steel, F. 63, good 
diet, country air, bathing, friction of the back with horsehair gloves, 
and attention to the health, may be sufficient to cure incipient cases,' 
and to mitigate severer ones. 
Curvature from Rickets.-There is another form of curvature 
from debility, which chiefly affects young children of the lower 
orders, and arises from rickets. It is readily distinguished by the 
general rickety aspect of the patient, (vide p. 222,) and by the dis- 
tortion of the limbs that is also present, as well as by the circumstance 
that the spine is not simply curved laterally as described above, but 
is often curved directly forwards;-the seat of this curvature being 
the upper part of the back;-or perhaps it may be curved back- 
wards. 
There are four other measures which are occasionally resorted to 
for the cure of these and the other severer degrees of spinal distor- 
tion, viz. the recumbent position-mechanical support-mechanical 
extension-and division of some of the spinal muscles. 
1. The recumbent position, continued for a length of time, is a 
measure which has been most disgracefully abused by certain spine- 
quacks ; insomuch that poor wretches who have applied to them to 
be cured of a mere distortion of the back, have, after many months 
of confinement, been sent away broken in health, and incapable 
* Vide proposed Regulations for the instruction &c. of the Cavalry. Part I. 
Published by Authority. Lond. 1832, p. 11. diseases of the spine. 
329 
almost of moving a limb. In slight cases the patient need lie down 
only for a short time after taking exercise, in order to relieve the 
spine from the weight of the body while its muscles are fatigued. 
In severer cases, the patient should never be permited to sit or stand 
upright; she should, however, walk out daily in the open air; but 
when not ivalking, should lie down. She should, moreover, be 
provided with some exercises for the arms, which may be used 
whilst lying down. But a continuance in the recumbent position, 
without rising at all, is only necessary under one circumstance- 
and that is, when the curvature increases very fast, and is so abrupt 
at one point that it begins to compress and irritate the spinal cord, 
and produce spasms or palsy of the legs. 
2. Mechanical support by means of stays or other contrivances 
made to receive the weight of the trunk at the axillae, and transmit 
it to the hips, is of service in many cases; but all circular constric- 
tion of the body, as with the common female stays, is an evil. 
3. Extension of the spine longitudinally, may be effected by 
fixing the pelvis or feet to the bottom of an inclined plain or couch, 
and the armpits to the upper part of it; then there must be some 
contrivance by which the couch may be very gently lengthened. 
Or something may be done by pulling at the arm on the convex 
side of the chest, whilst one foot of the operator is pressed against 
that side of the chest, and the other against the pelvis. These mea- 
sures may do good if not abused. 
4. Division of spinal muscles*-Lastly, there are some cases, 
in which the difficulty is supposed to be either entirely caused, or 
chiefly kept up, by over-action of the muscles on one side, and which 
have been attempted to be relieved by dividing those muscles, by 
subcutaneous section. It will readily be seen that the muscles to be 
divided are the transverse ones, (the trapezius, rhomboids, and 
levator anguli scapulas,) on the convex side of the curvature, and 
the longitudinal ones, (sacro-lumbalis and longissimus dorsi,) on the 
concave side. But the author can give no opinion as to the merits 
of this operation. 
II. Angular Curvature (Pott's curvature) is produced, as the 
adjoining cut shows, by caries of the bodies of the vertebras, or 
ulceration of the intervertebral substance-a disease which gene- 
rally affects scrofulous children or adults. It begins with symptoms 
that indicate irritation of the spinal cord; the patient complains 
of weakness, coldness, and numbness of the legs, and incapability 
of taking exertion; and these symptoms are followed by twitchings 
and spasms of the legs, and afterwards by palsy. The bowels are 
costive, and there is difficulty sometimes of passing, sometimes of 
retaining the urine, which is generally pale and akalescent. Chil- 
dren rarely complain of much pain in the back; but if the patient 
* [The operations noticed in this paragraph and equivocally sanctioned by Mr. 
Druitt, deserve to be characterized as he has justly done those barbarous ones which 
have lately been performed for the cure of stammering. This " may truly be styled 
muscle-cutting gone mad." F.] 330 
DISEASES OF THE SPINE. 
is an adult, there is generally a heavy, dull, aching pain, aggravated 
by motion, together with great tenderness on pressure ; and a pecu- 
liar dead, sickening sensation like that of a carious tooth, if a smart 
blow be struck on the diseased part 
with the knuckles. If the disease is 
situated in the dorsal vertebrae, it 
will moreover be accompanied with 
tightness of the chest, and difficulty 
of breathing; and if in the cervical, 
one or both arms will be palsied, 
and there will be a difficulty of sup- 
porting the head. As the disease 
advances, the back becomes curved 
forwards, and the spinous processes 
of the diseased vertebrae project 
backwards; so as to cause great 
deformity; abscesses form, and the 
patient exhibits great constitutional 
derangement and hectic. 
Consequences.-1. In favourable cases, abscesses, if they form, 
are healed, or their matter is absorbed; the diseased bones collapse; 
and the patient recovers with more or less deformity, which is of 
course incurable. 2. In some fatal cases the patient dies suddenly 
from two or three of the diseased vertebrae giving way and crushing 
the spinal cord,-or from dislocation of the odontoid process, owing 
to ulceration of its ligament,-or from the bursting of abscesses into 
the spinal cord, or into some visceral cavity; but more frequently 
death is caused by slow irritation and exhaustion, consequent on 
the formation and bursting of psoas or lumber abscesses. 
Diagnosis.-This affection must not be confounded with its 
hysterical counterfeit spoken of in the ninth chapter. It may readily 
be distinguished from the distortion which arises from debility by 
noticing that the curvature is abrupt and angular, whereas in the 
latter affection it is gradual and rounded, and implicates nearly the 
whole spine. It may be distinguished also by the tenderness and 
pain; and by the symptoms of irritation of the spinal cord; which 
latter symptoms are present in cases of vertebral caries from their 
very commencement, but exist only in very severe degrees of curva- 
ture from debility. 
Treatment.-(1) Rest in the horizontal posture is absolutely 
necessary. A water-bed or fracture-bed may be used, if easy or 
convenient. But the patient must not be taught to lie on his back, 
nor must any means be used with a view of straightening the spine, 
as they would merely impede the natural process of recovery, by 
preventing the remains of the diseased vertebrae from falling to- 
gether. A bandage, containing strips of whalebone, and reaching 
from the head to the hips, is of use in keeping the trunk at perfect 
rest. (2) Issues should be made and kept open with caustic on 
each side of the spinous processes of the diseased vertebrae. (3) 
Fig. f8. INJURIES OF THE SPINE. 
331 
At the same time, the constitution must be throroughly supported 
by sarsaparilla and steel, and other tonics and alteratives, as directed 
for scrofula. 
III. Lumbar and Psoas Abscess.-These are abscesses arising 
from that diseased condition of the spine which has just been de- 
scribed. Sometimes they point in the back, (constituting lumbar 
abscess if low down,)-sometimes the matter makes its way between 
the abdominal muscles,-sometimes it enters the sheath of the psoas 
muscle, passes downwards in its sheath, causes absorption of that 
muscle, and points below Poupart's ligament;-forming a tumour 
which diminishes or disappears when the patient lies down, and 
receives an impulse on coughing. This is called psoas abscess. Its 
diagnosis is alluded to in the chapters on Aneurism and Hernia. If 
these abscesses enlarge in spite of the issues and other measures 
directed against the vertebral disease, they must be treated in the 
manner directed for large chronic abscess, p. 73. 
IV. Concussion.-Violent blows or bendings of the spine are 
liable to produce very serious injury to the spinal cord. Sometimes 
they cause an immediate paralysis of the parts below the seat of the 
injury, which gradually passes off, and thus resembles the effects of 
concussion of the brain; sometimes they are followed by inflamma- 
tion, which requires prompt antiphlogistic measures, in order to 
avert permanent paraplegia or death. 
V. Extravasation of Blood.-A severe blow on the back 
sometimes causes an extravasation of blood into the spinal canal, 
which as it increases causes compression of the cord, and paraplegia. 
VI. Dislocation and Fracture.-Dislocation of the spine is 
rare except in the cervical region, but it occasionally does occur even 
in the lumbar and dorsal without any accompanying fracture. When 
fracture occurs, it generally passes transversely across the body and 
Fig. 99. 
Fig. 100. 
arch of the vertebras. The ill consequences of these accidents will 
of course be proportioned to the amount of injury inflicted on the 
spinal cord; and if that escapes compression, the consequences may 332 
INJURIES OF THE SPINE. 
not be serious. Thus it may happen that one or more spinous 
processes may be broken off;-or that the cervical vertebrae may 
be twisted round;-and the last dorsal and first lumbar vertebrae 
have been displaced backwards, the patient recovering with per- 
manent deformity, but nothing worse.* 
But it more frequently happens in fracture and dislocation of the 
vertebrae, that the spinal cord is compressed or lacerated, and the 
parts below the seat of injury deprived of their nervous influence: 
and in these cases the symptoms vary, according to the level of the 
injury. 
If the injury affect one of the lumbar or lower dorsal vertebrae, 
the legs and lower part of the trunk are palsied and insensible,- 
the penis is erect,-the faeces are discharged involuntarily, owing to 
palsy of the sphincter ani,-but the urine cannot be voided volun- 
tarily, owing to palsy of the muscular coat of the bladder. Im- 
mediately after the injury, the secretion of urine is diminished, but 
in a few days it becomes copious, ammoniacal, and offensive, and 
the mucous coat of the bladder inflames and secretes a quantity of 
viscid adhesive mucus. The bowels are distended with wind, and 
obstinately costive;-in protracted cases the evacuations become 
black, treacly, and extremely offensive. The temperature of the 
palsied parts at first rises,-in one case so high as 111° F., but after- 
wards sinks to the natural level, or below it. In some few cases, 
in which the spinal cord is not entirely compressed or lacerated, the 
patient may retain some degree of sensation or motion, or may 
suffer from painful spasms of the legs; but in general the loss of 
feeling and motion is complete. 
If the fracture or dislocation be high in the back, or at the lower 
part of the neck, there will, in addition to the above symptoms, be 
palsy of one or both arms, and great difficulty of breathing, espe- 
cially of expiration, because the intercostal and abdominal muscles 
are palsied, and the diaphragm has no antagonist. 
If the injury be above the origin of the phrenic nerve, (fourth or 
fifth cervical,) the diaphragm will be palsied, and death instanta- 
neous. The most frequent example of this is the dislocation of the 
odontoid process, which is sometimes caused by ulceration of its 
transverse ligament, sometimes by blows on the back of the head, 
or by lifting a child up by the head. 
VH. Softening is a frequent consequence of concussion or 
laceration of the spinal cord. The affected part becomes pulpy and 
diffluent, without, however, any traces of inflammation. 
VIII. Acute Inflammation of the spinal cord is a very rare 
consequence of injuries, except penetrating wounds, which gene- 
rally prove speedily fatal in consequence. It is known by rigors, 
delirium, opisthotonos, or general convulsions, followed by palsy 
and coma. 
Prognosis.-If a fracture is situated high up, so as to affect the 
respiration, the patient rarely survives more than a day or two. If 
* Guerin, L'Experience, Dec. 3, 1840; Shaw, Med. Gaz. vol. xvh. p. 936. INJURIES OF THE SPINE. 
333 
it is situated in the lower part of the back or loins he may live two 
or three weeks or a month; and in some rare cases recovery has 
even occurred, of course with permanent paraplegia. The manner 
in which death occurs after these injuries, is from general exhaus- 
tion and debility. The appetite and digestion fail; a weakening 
diarrhoea comes on, and then the nates slough, and the patient soon 
sinks. The prognosis is very uncertain after severe blows; some- 
times the patient has recovered the use of his limbs even after 
complete paraplegia,-sometimes recovery occurs with permanent 
paraplegia,-sometimes, on the other hand, the patient having 
appeared to recover from the ill effects of the injury, most unex- 
pectedly becomes paralytic, and dies from slow disorganization of 
the cord. 
Treatment.-1. If there be any displacement, an attempt may 
be made to reduce it by extension. In partial dislocations of the 
neck, however, the attempt should be very cautious indeed, since 
although it has succeeded (in the case of M. Guerin for instance), 
it has also been known to produce instant death. 2. The patient 
must be kept at perfect rest in the horizontal posture, and the 
greatest care must be taken to prevent or delay gangrene of the 
nates, by arranging pillows, or Macintosh's air-cushions, half filled 
with water. 3. The urine must be drawn off by the catheter, and 
the bowels be kept open by clysters and purgatives, to which Sir 
B. Brodie recommends ammonia to be added. Tonics and the 
muriatic acid may be given to support the strength, and obviate the 
derangement of the urine. The tympanitic state of the belly may 
be relieved by rubbing it with the compound camphor liniment. 
4. Bleeding or cupping may occasionally be employed if there are 
inflammatory symptoms and the pulse is firm. But in the majority 
of cases, if fracture has occurred and the cord is injured, loss of 
blood is contra-indicated by the pulse, and would hasten a fatal 
issue. 5. If the patient reco ver with his life, any remaining weak- 
ness or palsy may perhaps be attempted to be removed by the 
cautious use of blisters or issues, friction, warm bathing, and the 
internal use of strychnine, but they will very rarely do any good.* 
IX. Spina Bifida, or hydrorachitis, is an affection depending 
on want of development of the spinous processes and laminae of 
some of the vertebrae, generally the lower dorsal or lumbar. The 
spinal membranes, deprived of their ordinary support, yield to the 
pressure of the fluid which they contain, (which also is secreted in 
unusual quantity,) and bulge out, forming a fluctuating tumour in 
the middle line of the back. The legs are often palsied. The ordi- 
nary course of the case is, that the tumour enlarges, the skin be- 
comes distended, inflames, and ulcerates,-the fluid is discharged, 
-the spinal membranes inflame, and the patient dies. Sometimes, 
however, when it happens that the skin and membranes are strong 
* Vide Cooper on Dislocations, and Brodie on Injuries of the Spinal Cord, in 
Med. Chir. Trans., vol. xxi. 334 
INJURIES OF THE EYE. 
enough to support the distension, the patient may live out his three- 
score years and ten.* 
Treatment.-Moderate support by properly adjusted trusses and 
bandages, and occasional punctures with a grooved needle when 
the tumour i§ much distended, seem to be the best established reme- 
dies. A cure is said to have been accomplished by cutting away 
the loose skin, and bringing the divided edges together by the 
twisted suture.t But unless the tumour is palpably enlarging fast, 
the surgeon had better leave it alone, since it cannot even be punc- 
tured without some risk. 
X. Malignant Disease of the Spinal Column. When severe 
and continued pain in some part of the spine, with more or less 
derangement of the nervous functions, and perhaps some perceptible 
tumour, occurs in a patient affected with malignant disease, the 
probability is, that some of the same morbid growth is deposited in 
or near the vertebrae.^ 
CHAPTER XII. 
OF THE INJURIES AND DISEASES OF THE EYE. 
SECTION I.-OF WOUNDS AND FOREIGN BODIES. 
I. Wounds of the eyelids or eyebrows should be most carefully 
adjusted by means of small sutures, introduced with a very fine 
sewing needle. A linen rag wetted with cold water should then 
be laid on the part,-inflammation should be counteracted, and the 
patient be kept at rest till the wounds are healed. Wounds of the 
forehead are sometimes liable to be followed by amaurosis, in con- 
sequence of injury to the frontal nerve. 
II. Blows on the eye are generally followed by a disreputable 
looking ecchymosis, which is inconvenient enough. But sometimes 
a blow on the naked eyeball causes permanent blindness from con- 
cussion of the retina. Antiphlogistic measures are the only re- 
source. 
III. When a patient complains of a foreign body in the eye, the 
surgeon should first examine the inside of the lower eyelid and 
lower part of the globe, telling the patient to look up. If nothing 
is discovered there, the patient should turn the eye downwards, so 
• Two or three cases of persons who have lived to maturity with spina bifida, 
are given in Cooper's Surgical Dictionary, and one case has come under the 
author's observation. 
f Dubourg, B. & F. Med. Rev., vol. xii. 
i Caesar Hawkins, Med. Chir. Trans., vol. xxiv. DISEASES OF THE EYELIDS. 
335 
as to expose the upper part of the globe, and the surgeon should 
turn the upper eyelid inside out, which may easily be done by 
taking the eyelashes between the finger and thumb, and turning 
them upwards over a probe. If any substance stick in the cornea, 
so that it cannot be removed by a probe, or silver toothpick, or fine 
forceps, the point of a cataract needle or lancet should be carefully 
passed under it so as to lift it out. If, however, the removal cannot 
be effected without considerable difficulty, it is better to leave it to 
be detached by ulceration. Every means must be taken to obviate 
inflammation, and if the wound in the cornea is painful or irritable, 
it should be touched with nitrate of silver. To remove particles of 
lime or mortar, the eye should be well syringed or sponged with 
weak vinegar and water, or with oil, or with pure water if neither 
be at hand. 
IV. Prolapse of the Iris, in consequence of penetrating 
wounds of the cornea, may be attempted to be reduced (provided 
the pupillary margin is not prolapsed) by closing the eye, and very 
gently rubbing the lid against the cornea, so as to press on the pro- 
lapsed portion, and by exposing it to a strong light, so as to cause 
the pupil to contract. But if the pupil is prolapsed, belladonna 
should be applied to cause dilatation. If, however, the prolapsed 
part cannot be returned, it should be snipped off, in order to avoid 
the irritation which it would otherwise cause; and if the wound 
does not soon heal, it should be touched with a pencil of lunar 
caustic. 
SECTION II. - DISEASES OF THE EYELIDS. 
I. Hordeolum, or sty, is a small painful boil at the edge of the 
eyelid. 
Treatment.-Poultices and early puncture, subsequently ung. 
hydr. nitrat. dilut., to remove any remaining hardness. Aperients, 
tonics, and alteratives, are always necessary. 
II. Ophthalmia Tarsi is an inflammation of the edge of the eye- 
lids, with disordered secretion of the meibomian glands-so that 
the eyelids stick together and become encrusted with inpissated 
mucus during sleep. It may be acute-attended with great pain 
and soreness, and requiring leeches-but in general it is chronic 
and obstinate, and attended with violent itching. It occurs to 
weakly persons with disordered digestive organs. It may lead to 
ulceration of the eyelids, loss of the lashes, and subsequent thick- 
ening or inversion of the lids. 
Treatment.-In the first place, the health, which is always out 
of order, must be remedied by aperients, alteratives, tonics, change 
of air, bathing, and whatever other measures may be suitable for 
each particular case. Whilst there is much heat and swelling, the 
eyes should be bathed with an anodyne collyrium, F. 97, and the 
lids be smeared with lard at bedtime to prevent them from sticking 
together. But as soon as the bowels have been well cleared, an 336 
DISEASES OF THE EYELIDS. 
astringent collyrium (F. 36, 37) may be used during the day, and 
the undiluted unguentum hydrargyri nitratis be applied in very 
small quantity to the edges of the lids at bedtime for three nights 
successively. A weaker ointment of the same sort may be used 
habitually afterwards if necessary, F. 73. The lashes should be 
plucked out if there is any ulceration about their roots. 
III. Syphilitic Ulcers of the eyelids, if primary, will be known 
by their sudden appearance and rapid progress in a patient other- 
wise healthy, and by their not having been preceded by a wart or 
tubercle, like malignant ulcers. Secondary ulcers will be known 
by their coppery colour and the general cachectic look of the patient. 
Treatment.-Mercury, and the treatment of syphilis generally. 
IV. Trichiasis signifies a growing inwards of the eyelashes.- 
Districhiasis, a double row of eyelashes, one of which grows 
inwards. The misplaced hairs must be perpetually plucked out, 
or if that do not suffice, their bulbs must be extirpated with a fine 
knife; or each bulb may be punctured, and destroyed by introduc- 
ing a very fine probe dipped in melted nitrate of silver. 
V. Entropion, permanent inversion of the eyelid, may (1) be 
caused by contraction of the ciliary margin of the lid, after pro- 
tracted ophthalmia tarsi-the remedies for which are, either to 
make two perpendicular cuts with scissors quite through the lid, 
near each angle-or rather to dissect off the edge of the lid with 
the lashes and their bulbs. (2) Sometimes it is caused by a thick- 
ening of the conjunctiva at the line of its reflection from the lid to 
the globe, so that the orbitar margin of the lid is pushed outwards, 
and the tarsal margin consequently turned inwards. This must 
be counteracted by leeches, and astringent applications. (3) If 
there is no disease of the margin of the lid, and the patient is old, 
with the skin of the cheek loose and flabby, a transverse flap of 
the loose skin, and of the orbicularis beneath, should be cut out 
of the eyelid, and the edges of the wound be brought together with 
fine sutures, in order that the inversion may be counteracted by the 
contraction of the cicatrix. Sometimes for the same purpose a por- 
tion of the skin is destroyed by drawing transverse lines on it with 
a wooden point, dipped in the concentrated sulphuric acid; but 
this method is more painful and uncertain. Care must be taken 
not to remove too much, else this disease will be converted into 
ectropion, which is still worse. 
VI. Ectropion, or eversion of the eyelid, may be caused by 
a fleshy thickening of the conjunctiva, owing to long-continued 
inflammation. The weak ung. hydr. nitric, oxyd., or lotion of arg. 
nit. (gr. ii. ad si.) may be tried first in order to bring the conjunc- 
tiva into a healthy state-but if they do not succeed, a portion of 
the thickened conjunctiva must be removed by scissors. This 
failing, it may be necessary to cut out a triangular slip from the 
tarsus. If caused by a cicatrix on the cheek, the cicatrix must, if 
possible, be divided or dissected out. 
VII. Lagophthalmos (hare eye) signifies an inability to close 
the palpebras. Sometimes it arises from the contraction of cica- DISEASES OF THE EYELIDS. 
337 
trices, and requires the same treatment as ectropion when arising 
from the same cause. But it sometimes depends upon inaction of 
the orbicularis muscle, through palsy of the portio dura. This may 
be caused by exposure to cold; on the outside of a coach for 
instance; in which case it is attended with numbness of the cheek, 
and generally subsides in a few days with aperients, nursing, and 
perhaps a blister behind the ear. But it may be caused by a tumour 
in the course of the nerve; by disease of the temporal bone;-or 
by congestion within the head, like the following disease. 
VIII. Ptosis signifies a falling of the upper eyelid from palsy of 
the third nerve. Sometimes it is a precursor of apoplexy, and is 
attended with headache, giddiness, and other signs of congestion in 
the head, which should be treated by bleeding, purgatives, mer- 
cury, and blisters. Sometimes it is an accompaniment of that form 
of amaurosis which arises from organic cerebral disease; and is 
attended with dimness of sight; a sluggish dilated pupil; and more 
or less strabismus; the eye being turned outwards and downwards 
because the external rectus and superior oblique are the only 
muscles unparalyzed. If it occurs without any assignable cause, 
and persists notwithstanding the employment of every measure 
calculated to improve the health, a portion of skin must be snipped 
out from the eyebrow, so that the lid may be brought into contact 
with the occipito-frontalis muscle, and be elevated by it. 
IX. Ancyeoplepharon.-Union of the edges of the lids, when 
complete and congenital, (which is very rare,) may be removed by 
an incision; when partial, and consisting of a junction of the lids 
near one angle, which is sometimes caused by cicatrizing ulcers, it 
is incurable. 
X. Symblepharon signifies an union of the lid to the globe, fol- 
lowing some accident that has caused ulceration of both-the in- 
troduction of lime, for instance. It is irremediable, if the adhering 
surfaces are extensive. Very slight adhesions (frsena) may be 
divided ; but the raw surfaces are too apt to adhere again. 
XI. Tumours, vascular or encysted, occurring outside the eyelids, 
are to be treated the same as elsewhere. Sometimes thin cysts, or 
hydatids, containing a watery fluid, grow beneath the loose fold of 
conjunctiva which passes from the lid to the globe. If that fold be 
divided longitudinally, they may be extracted by a hook or forceps. 
A small encysted tumour, containing a gelatinous fluid, sometimes 
grows within the substance of the tarsal cartilage, about its centre. 
It feels at first like a small pin's head under the skin; and on evert- 
ing the lid it may be seen to cause a slight prominence. It should 
be punctured from within when it has acquired some little size, and 
when it begins to look bluish about its centre; and the cyst should 
be lacerated with the pointed end of a probe. 
XII. Pediculi.-These loathsome insects sometimes lodge about 
the roots of the eyelashes, and produce an obstinate itching. They 
are easily killed by any mercurial preparation; but the surgeon 
ought to be aware of their existence, as they might be mistaken for 
crusts of dried mucus. 338 
DISEASES OF THE LACHRYMAL APPARATUS. 
SECTION III. - DISEASES OF THE LACHRYMAL APPARATUS. 
I. The Lachrymal Gland is very rarely the seat of disease. 
It is, nevertheless, occasionally subject to acute and chronic inflam- 
mation-(the symptoms and treatment of which will be obvious). 
It is also liable to morbid growths, for which it has occasionally 
been extirpated. 
II. Xerophthalmia signifies a dryness of the eye from deficiency 
of the tears, or rather of the mucous secretion of the conjunctiva. It 
may be palliated by frequently bathing the eye with tepid water 
by means of an eye-cup. 
III. Epiphora signifies a redundancy or over secretion of tears, 
so that they run over the cheeks. It should be distinguished from 
the stillicidium lachrymarum, or overflow of tears in consequence 
of an obstruction in the channels that convey them to the nose. It 
may depend on general irritability of the eye, and is not unfrequent 
in scrofulous children. When arising from this cause, it should be 
treated by aperients and alteratives, with tonics .and antacids (F. 28, 
or quinine, with small doses of sodas carb.). An emetic may be 
given if the stomach is foul. The same local applications may be 
used as are prescribed for scrofulous ophthalmia. Search should 
be made for foreign bodies or inverted eyelashes. 
IV. Closure of the Puncta Lachrymalia may be congenital, 
in which case it is quite incurable, or it may be a consequence of 
inflammation of the lachrymal sac and its appendages. Of course 
it produces a stillicidium lachrymarum. When a consequence 
of inflammation, the openings must first be restored by a fine gold 
pin, and then one of Anel's gold probes should be frequently passed 
through them into the sac. The probe must be introduced, first 
perpendicularly upwards for the superior punctum and downwards 
for the inferior; then horizontally inwards towards the nose. 
V. Obstruction of the Nasal Duct is known by watering of 
the eye, dryness of the corresponding nostril, and distension of the 
lachrymal sac, which forms a small tumour by the side of the nose, 
from which tears can be squeezed upwards through the nuncta, or 
downwards into the nose, if the obstruction be not quite complete.* 
It mostly leads to 
VI. Chronic Inflammation of the Lachrymal Sac-tender- 
ness of the sac, perhaps redness of the superjacent skin; irritability 
and constant tendency to inflammation of the conjunctiva;-and if 
the sac be squeezed, glairy mucus escapes with the tears. 
VII. Acute Inflammation of the sac is known by great red- 
ness, swelling, pain, and tenderness at the side of the nose, impli- 
cating the eye, and attended with fever and headache. If it be not 
soon relieved, the sac will suppurate and burst. 
VIII. Fistula Lachrymalis signifies an ugly fistulous aperture 
at the inner corner of the eye, communicating with the lachrymal 
* A case is related in Forbes's Rev. xii. 641, of congenital absence of the nasal 
duct, in which M. Berard succeeded in establishing a communication with the nose. FISTULA LACHRYMALIS. 
339 
sac. It is the ordinary consequence of the three preceding affections 
if unrelieved, and may be said to have five stages. First, it begins 
with obstruction of the nasal duct; the most prominent symptom of 
which is a perpetual watering of the eye. Secondly, this is followed 
by inflammation; which, thirdly, gives rise to abscess; and this, 
fourthly, by its bursting causes the fistulous aperture from which 
the name of the affection is derived ; whilst, fifthly, in old neglected 
cases, the lachrymal or inferior turbinated bone may become carious; 
but this is not very common. The fistulous aperture is generally 
crowded with fungous granulations, and the skin around is red and 
thickened from the perpetual irritation of the tears that escape 
from it. 
Treatment.-Acute inflammation of the sac must be treated by 
leeches, purgatives, and cold lotions or poultices. If the pain in- 
crease in severity, and become throbbing, the sac should be opened 
in the manner shown in the next figure. 
Chronic inflammation of the sac should be treated by an occa- 
sional leech, and attention to the digestive organs. When the sac 
becomes distended, the patient should press its contents down into 
the nose; and he should also frequently draw in his breath strongly 
whilst his mouth and nostrils are closed, so as to draw the tears 
down the duct. The secretions of the eyelids should be corrected 
with the ointments of the nitrate, or nitric oxyde of mercury, and 
a few drops of some astringent collyrium (F. 36) should be put 
twice a day into the inner angle of the eye, so that it may be 
absorbed by the puncta, and carried into the sac. By these means 
the thickening of the duct may perhaps be removed ; or at all 
events the patient may go on pretty comfortably. 
Treatment by the style.-But if there is constant irritability 
of the eye, or if there is a fistulous orifice between the sac and the 
cheek, measures should be adopted to restore the obstructed duct. 
Supposing that there is a fistulous aperture, the fungous granula- 
tions, or thickening of the skin about it, should be first removed by 
nitrate of silver and poultices. If there is no aperture, the sac 
should be opened by a bistoury, or cataract knife; introducing it 
just below the tendo oculi, and carrying it downwards and out- 
wards for one fifth of an inch. The place of the tendo oculi may 
easily be found by gently drawing the eyelids outwards; when it 
is seen as a small rounded cord, passing inwards from the inner 
canthus of the eye. The escape of tears and mucus shows when 
the sac is opened. Then a common probe should be pushed 
through the duct into the nose. In order to make sure of getting 
it into the sac, it may as well be introduced by the side of the bis- 
toury before that is withdrawn. It should be pushed downwards, 
but a little backwards and inwards. When in the right direction, 
its upper part lies in the situation of the supra-orbital notch. It 
will be known to have reached the nose by the escape of a little 
blood. When inflammation has subsided, a style should be intro- 
duced, i. e. a silver-gilt probe about an inch or an inch and a quarter 
long, with a head like a nail, which lies on the cheek, where it 340 
INFLAMMATION OF THE EYE. 
passes unnoticed like a black patch. The constant presence of this 
instrument causes the duct to dilate, so that the tears flow by its 
side. It should be occasionally cleaned, and then be replaced; and 
it causes so much comfort, and the duct is so likely to close if it be 
left off, that it generally is worn for life. The above is the plan of 
treatment which the author has generally seen adopted; and the 
results have been on the whole satis- 
factory; but, it follows of necessity, 
that in so common a complaint many 
other plans of treatment are followed 
by different surgeons. Short pieces 
of catgut bougie, or silver tubes are 
sometimes employed instead of the 
style. Sometimes attempts are 
made to retore the nasal duct to its 
proper calibre, by introducing in- 
struments from below; either a com- 
mon silver probe, with its blunt end 
at a right angle, or else a steel probe 
made for the purpose,-whichever 
is employed, should be passed along 
the inferior meatus of the nostril till 
its point is under the anterior extremity of the inferior turbinated 
bone; and then by a little manipulation it will pass into the duct. 
SECTION IV. - OF INFLAMMATION OF THE EYE GENERALLY, AND OF 
THE DISEASES OF THE CONJUNCTIVA. 
I.. Common acute Ophthalmia consists of inflammation of the 
conjunctiva. Symptoms.-Smarting, heat, stiffness, and dryness 
of the eye, with a feeling as if dust had got into it; the conjunc- 
tiva of a bright scarlet redness; the redness superficial, so that 
the enlarged vessels can be moved by pulling the eyelids; slight 
intolerance of light and flow of tears on exposure of the eye, and 
more or less headache and fever. Causes.-Slight local irritation, 
disorder of the digestive organs, or cold and damp. 
Catarrhal Ophthalmia is a variety of this inflammation, caused 
by cold and damp, and attended with a thin mucous discharge,- 
which in severe cases becomes thick, purulent, and doubtless con- 
tagious. 
Treatment.-A few leeches to the temples, an emetic if the 
stomach is foul, a dose of calomel, followed by a black draught;- 
the eye to be frequently bathed with dec. papav., or F. 97, or the 
weaker forms of F. 36, lukewarm or cold, according to the patient's 
choice ;-the edges of the eyelids to be smeared at night with fresh 
lard, and with weak ung. hydr. nit. ox. after the first day or two; 
-a green shade to be worn over both eyes, whilst there is much 
intolerance of light; but the patient not to be confined to the house 
too long, unless the case is very severe, or the weather bad. In 
Fig. 101. INFLAMMATION OF THE CONJUNCTIVA. 
341 
the catarrhal variety, a large drop of solution of arg. nit. (gr. ii.- 
iv ad 5i.) may be put into the eye twice or thrice a day. If the 
patient is plethoric, and there is much pain, headache, and fever, 
bleeding and calomel in repeated doses will be required. But it is 
a great mistake to treat common inflammation of the eye, when it 
occurs to delicate subjects, by lowering measures. After the bowels 
are cleared, a good diet, and exposure to moderate light and cool 
air, will do more good than black draughts, leeches, and green 
shades. 
II. Inflammation of the whole Eye is a rare disease. It 
may be caused by severe injuries, or may be a consequence of the 
common ophthalmia if neglected. The symptoms are great redness 
and swelling of the conjunctiva; pain, both burning, aching, and 
throbbing; intolerance of light, dimness of vision, and severe head- 
ache and fever. It may lead to suppuration of the whole globe; or 
to opacity of the cornea and lens, adhesions of the iris, insensibility 
of the retina, and atrophy of the whole globe. The treatment must 
be decidedly antiphlogistic; and if it be clear that suppuration within 
the eyeball has occurred-there being rigors-the cornea yellow 
and distended, and excruciating pain unrelieved by further deple- 
tion, a free incision should be made into the cornea to let the matter 
escape. 
III. Chronic inflammation of the Conjunctiva may be a 
sequel of the acute,-or may be caused by some local irritation, 
such as inverted eyelashes,-or by some derangement of the health. 
Treatment.-(1.) All local sources of irritation should be re- 
moved. (2.) The general health should be amended, in the same 
manner as directed for chronic inflammation generally. (Vide 
p. 55). (3.) The distended capillaries must be unloaded by occa- 
sional local bleedings, and be excited to contract by stimulants and 
astringents, such as the various collyria in F. 36 and 37, which 
should be used with an eye-cup; or the vinum opii, of which a few 
drops may be put into the eye daily. The edges of the eyelids 
should be smeared every night with weak ung. hydr. nit., and 
blisters should be applied behind the ears if the case is obstinate. 
IV. Purulent Ophthalmia, or purulent conjiinctivitis^ is the 
most violent form of inflammation of the conjunctiva, and is attended 
with a thick purulent discharge, which supervenes in from twenty- 
four to forty-eight hours after its commencement. There are three 
varieties of it: (1.) the purulent ophthalmia of children; (2.) the 
common purulent ophthalmia of adults; and (3.) the gonorrhoeal 
ophthalmia. 
The Purulent Ophthalmia of Children, or ophthalmia neo- 
natorum, always begins to appear a few days after birth; gene- 
rally, on the third day. 
Symptoms.-At first the edges of the lids appear red, and glued 
together; their internal surface is red and villous, and the eye is 
kept closed. Then the conjunctiva of the globe becomes intensely 
scarlet and much swelled, often so much so as to cause eversion of 
the lids;-it secretes a thick, purulent discharge, and the child is 342 
purulent ophthalmia. 
very restless and feverish. If neglected, this disease may occasion 
opacity or ulceration, or, perhaps, sloughing of the cornea; but it 
generally yields to early and proper treatment. 
Causes.-The contact of gonorrhoeal or leucorrhoeal secretions 
from the vagina during birth, neglect in washing the natural cheesy 
secretion of the skin away from the eyes; together with exposure to 
cold and damp, and bad nursing. 
Treatment.-The eye should be frequently but gently washed 
out with a weak astringent collyrium (F. 36, or 37); and a large 
drop of a solution of two grains of nitrate of silver to an ounce of 
distilled water should be put between the lids once a day with a 
camel's hair pencil. The eye should be opened with very great 
delicacy; because, if the cornea is beginning to suppurate, it might 
easily be burst, and the lens be squeezed out. Moreover, it is better 
to wash out the eye by everting the lids and using a bit of sponge, 
than by injecting with a syringe; which would create a risk of 
splashing some of the discharge into the operator's eyes. The 
bowels should be cleared, with a grain of calomel or gray powder 
followed by a little castor oil or rhubarb; and if the disease has been 
neglected, and there is great tumefaction, a leech may be applied 
to the upper eyelid, and half a grain of calomel be given every 
eight hours. If the insides of the lids become thickened they must 
be scarified, and touched afterwards with sulphate of copper. The 
lids should be smeared at night with weak citrine ointment; and a 
few threads of cotton, spread with blistering plaster, may be laid 
between the external ear and the head, so as to create a discharge. 
If the cornea ulcerate or slough, or if the discharge be obstinate, 
tonics are required, (quin, sulph. gr. ss.-vel ext. cinchon. gr. iii. ex 
lacte,) and the astringent collyria should be persevered in. 
V. Purulent Ophthalmia in Adults-(Contagious or Egyp- 
tian Ophthalmia). Symptoms.-This disease begins with stiff- 
ness, itching, and watering of the eye, with a sense of dust in it, and 
slight swelling of the lids, which stick together during sleep-and 
on examination of their internal surface, the palpebral conjunctiva 
is found to be intensely red, thick, and villous, like a foetal stomach 
injected. As the disease advances, the conjunctiva covering the 
globe becomes also intensely red, swollen, and villous, and dis- 
charges a copious secretion of pus. The swelling of the ocular con- 
junctiva is called chemosis. It is produced by a secretion of blood, 
lymph, and serum into the cellular tissue which connects the con- 
junctiva to the sclerotic; and it elevates the conjunctiva into a kind 
of roll around the margin of the cornea, which sometimes overlaps 
it entirely. These symptoms are accompanied with severe burning 
pain, extending to the cheek and temple, and great headache and 
fever; the palpebrne also are swollen, tense, and shining, so that the 
patient cannot open the eye. 
Consequences.-This affection may lead to ulceration or opacity, 
or perhaps sloughing of the cornea; or to adhesion of the iris; or to 
impairment of vision, from extension of inflammation to the internal 
parts of the globe. GONORRHfEAL OPHTHALMIA. 
343 
Causes.-It may be produced by severe local irritation, as the 
introduction of lime, for instance. It is endemic in Egypt, owing 
to the glaring sunshine and the particles of sand with which the 
air is loaded;-it may also be produced by the close damp atmo- 
sphere loaded with animal vapour that results from crowding many 
persons together in a confined space, and from the neglect of clean- 
liness and ventilation; hence its prevalence amongst the military in 
barracks; in schools; and on board ship; especially amongst the 
wretched inmates of slave-ships. But when once produced by any 
cause whatever, it is most probably both contagious and infec- 
tious-,- that is, capable of being propagated both by contact with 
the purulent secretion, and by exposure to its vapour, if many per- 
sons affected with this disease are crowded together. 
VI. Gonorrhce al Ophthalmia is the most violent form of puru- 
lent conjunctivitis. The symptoms are essentially the same as those 
of the last species; but the chemosis is greater, the discharge thicker 
and more abundant, and constitutional disturbance more severe, and 
the cornea much more apt to slough. 
Cause.-This disease arises without doubt from the application 
of gonorrhoeal matter from the urethra to the eye. 
Prognosis.-This is very unfavourable. The sight of the affected 
eye will either be lost, or excessively impaired, unless treatment be 
very early and efficacious. 
Consequences.-The most frequent and detrimental is sloughing 
of the cornea, which is said to be caused by the constriction of its 
vessels by the chemosis. The sloughing generally occurs quite 
suddenly; the cornea may be clear in the morning-cloudy and 
flaccid in the evening-and by the next morning it may have burst; 
-and this change may supervene at any time from the second day 
of the disease till the last. After this has occurred, the swelling of 
the lids subsides, the discharge diminishes and becomes thinner, 
and the pain greatly abates. If the slough is very small, the iris 
may protrude, and close the aperture, imperfect sight remaining,- 
but generally the greater part of the cornea perishes, and all useful 
sight is lost. 
Treatment.-The indications are, (1) to mitigate inflammation; 
(2) to alter the action of the inflamed part by certain stimulants. 
1. A full bleeding should be performed from the arm or jugular 
vein ;-the bowels should be well cleared;-calomel and antimony 
(F. 6) should be administered in repeated doses, and Dover's powder 
at bedtime, to allay pain. The patient must be kept in bed in a 
darkened room, with the head elevated, and on low diet. But if 
these measures do not arrest the disease, and the chemosis is evi- 
dently extending round the cornea, and the cornea is becoming 
hazy, Mr. Tyrrell's plan of dividing the chemosis should be put in 
practice ; that is to say, six or eight incisions should be made com- 
pletely through the swollen conjunctiva, beginning at the margin 
of the cornea, and radiating towards the. circumference of the eye. 
By this means, Mr. Tyrrell believes that the tension of the conjunc- 
tiva will be relieved without cutting through the vessels that supply 344 
SCROFULOUS OPHTHALMIA. 
the cornea. The incisions should be fomented with warm water, 
that they may bleed. Leeches should be repeatedly applied; the 
forenoon is the best time, in order to anticipate the exacerbation of 
pain which generally supervenes in the evening. The eye may 
be covered with a poultice, or with poppy fomentation, or with 
any warm or cold application that is agreeable. Cold affusion of 
the head has been much recommended when it is heavy and pain- 
ful. Blisters should be applied to the neck, or behind the ears, 
after the abstraction of blood. 
2. From the beginning of the disease, the eye should be fre- 
quently but gently washed out, by means of a piece of fine sponge, 
or syringe, with warm water or poppy decoction, containing a grain 
of alum to an ounce, in order to get rid of the purulent secretion. 
But as soon as the chemosis is lessened-(or as soon as the cornea 
has perished)-the proportion of alum should be increased, or F. 
37, or the weaker preparations of F. 36, may be used instead. The 
diet also should be improved, and the edges of the lids should be 
smeared at night with weak ung. hyd. nit. ox. If the strength 
becomes impaired, and the cornea has given way, tonics (especially 
F. 1) or sarsaparilla should be administered; which, with repeated 
blisters, and a continuance of the astringent applications, are the 
measures for removing the reliques of the disease. 
We have given precedence to Mr. Tyrrell's plan of treatment,* 
because it is the most recent, and apparently the most successful; 
but before it was introduced, it was the custom to attempt to check 
the inflammation by the application of powerful stimulants and 
astringents. Some persons employed liq. plumbi acet, undiluted, 
or the ol. terebinth, but a strong solution or ointment of nitrate of 
silver (gr. iv-x-ad si aquae) was generally preferred. Mr. 
Guthrie in particular recommended an ointment of arg. nit. gr. x. 
liq. plumbi nt xv. adipis 5i, the nitrate to be very finely powdered, 
and the lard well washed. A piece of ointment the size of a pea, 
or a large drop of the solution on a hair pencil, to be thoroughly 
diffused between the lids and globe twice a day at the least. The 
ointment should turn the membrane white. 
VII. Scrofulous Ophthalmia {phlyctenular ophthalmia) gene- 
rally attacks children under eight years of age. 
Symptoms.-Extreme intolerance of light,-the lids spasmodi- 
cally closed,-the head turned obstinately away from the light,- 
no general vascularity of the conjunctiva, but one or two enlarged 
vessels running towards the cornea, and terminating at one or more 
phlyctenulae^ or small opaque pimples, (or sometimes pustules,) on 
the cornea. This, like other scrofulous diseases, is extremely obsti- 
nate, and liable to recur perpetually. Its most frequent conse- 
quences are ulceration of the cornea at the seat of the phlyctenulae, 
and opacity from the effusion of lymph between its layers. 
Treatment.-The firstand chief point is to look after the general 
health. The alimentary canal, therefore, should be cleared by an 
* Med. Chir. Trans, vol. xxi. part 2; and Tyrrell on the Eye, vol. i. p. 73. PTERYGIUM. 
345 
emetic and dose of calomel and jalap, and, after feverishness has 
subsided, recourse must be had to steel, sarsaparilla, and alkalis, 
and to the various combinations of tonics, aperients, and antacids, 
and to the other general remedies directed for scrofula. Quinine 
is particularly recommended by Mackenzie. Secondly, the dis- 
tressing intolerance of light must be relieved. This is sometimes 
effected by cold lotions applied to the outside of the eye, and to the 
forehead and temples; such as poppy decoction with a little spirit; 
or water to which a little vinegar or spirit, or nitric aether, has been 
added; or the white of egg curdled with alum. But warm poul- 
tices, or dec. papav. vel anthemid., or exposing the eye to the 
vapour of warm water, or to the vapour of laudanum or sp. camp., 
which may be put into a teacup and be held in warm water-or 
warm lotions of ext. belladon. vel hyoscyami (9i ad 5j aquae), or 
those extracts smeared on the brow, are of more efficacy. Small 
doses of extract of conium are also of service. Moreover, both eyes 
should be protected by a shade. Thirdly, if the insides of the lids 
are turgid, they may be scarified;-any enlarged vessels running 
from the conjunctiva to the cornea may also be scarified across; 
and blisters or the tartar emetic ointment may be applied behind 
the ears, or to the nape of the neck. Lastly, in the advanced stage 
of the disease, benefit will be derived from dropping in a few drops 
of vin. opii or lotion of nitrate of silver (gr. i. and 5i) once a day. 
VIII. Granular Conjunctiva signifies a thick, rough, fleshy 
state of that membrane, (especially of that part of it which lines the 
eyelids,) and is a frequent consequence of severe and long-continued 
ophthalmia. It does not depend, as its name would seem to imply, 
on the formation of granulations, but on an hypertrophy of the 
villous surface of the mucous membrane. It causes great pain and 
disturbance to the motions of the eye, and, if it continues, will ren- 
der the cornea opaque by its friction. 
Treatment.- In the first place, the thickened part should be 
scarified, then, after one or two days, it should be touched with 
lunar caustic or sulphate of copper, and the scarification and caustic 
should be repeated alternately at intervals of two or three days. 
The dilute citrine ointment should be smeared at night on the edges 
of the lids, blisters should be applied behind the ears, and the general 
health be attended to. But if these measures prove fruitless, the 
thinnest possible layer of the granular 'surface must be shaved off 
with a fine knife or scissors. 
IX. Pterygium is a peculiar alteration of the conjunctiva, a 
triangular portion of which, with the apex towards the cornea, be- 
comes thickened and elevated,-sometimes transparent, sometimes 
red and fleshy It may spread over the cornea and obstruct vision; 
but it does not give much inconvenience besides, and is not essen- 
tially an inflammatory affection, although it sometimes follows pro- 
tracted ophthalmia. 
Treatment.-If it does not disappear under the use of vin. opii 
or caustic lotion, it must be completely scarified across; and if that 346 
DISEASES OF THE CORNEA. 
fail, it must be seized with a hook and be extirpated with curved 
scissors. 
SECTION V. OF THE DISEASES OF THE CORNEA. 
I. Acute Inflammation of the Cornea, or acute corneitis, is 
generally a consequence of neglected injury. The part becomes red 
and opaque,-the sclerotic around highly vascular, and ulceration of 
the cornea, or suppuration between its layers, or abscess of the ante- 
rior chamber, may ensue. Local and general bleeding, mercury 
and antimony, or turpentine in the dose of one drachm three times 
a day in an emulsion with carbonate of soda and mucilage, and 
fomentations, are the remedies. Stimulating applications are pre- 
judicial. 
II. Scrofulous Corneitis most frequently occurs between the 
ages of eight and eighteen. 
Symptoms.-The cornea opaque, rough and red, and unusually 
prominent,-the surrounding sclerotic also red,-pain and intole- 
rance of light are generally trivial,-there is considerable tendency 
to inflammation of the iris and retina,-the pulse is frequent, and 
the skin dry. 
Treatment.-For the acute, leeches, emetics, purgatives, calomel 
and antimony, fomentations, and belladonna smeared on the eye- 
brow. For the chronic, quinine should be perseveringly admi- 
nistered; blisters should be repeatedly applied to the nape of the 
neck, and behind the ears, and the health should be treated after 
the manner directed for scrofula. The vin. opii,and ung. hydr. nit. 
ox. to the eyelids are almost the only local applications admissible. 
III. Opacity of the cornea may be divided into two kinds. 1st. 
The opacity which results from the Adhesive Inflammation, and 
effusion of fibrine between its layers, or between it and the con- 
junctiva, which is a very common consequence of inflammation of 
the cornea, and of scrofulous ulcers during their healing stage; - 
and, 2dly, the opacity, or leucoma, which is produced by a loss of 
substance and its resulting cicatrix-that which follows a pustule 
of the small-pox, for example. The former kind is in most cases 
curable : the latter not so. 
When an opacity of the former kind is slight and diffused, it is 
called nebula;-when denser and of a firmer aspect, albugo. 
Sometimes the lymph forming an albugo becomes vascular, and one 
or more vessels run to it from the circumference of the eye, and the 
cornea becomes red and fleshy; this state of things is called pannus. 
Treatment.-(1) All sorts of irritation about the eye or lids, (in- 
verted hairs, granular conjunctiva, &c.) must be removed, and any 
existing degree of inflammation be counteracted by proper measures. 
Then (2) absorption of the lymph may be promoted by counter-irri- 
tants ; such as blisters and the tartar emetic ointment-by alteratives 
and measures calculated to improve the health-and by the applica- 
tion of stimulants to the eye. The ordinary applications are caustic DISEASES OF THE CORNEA. 
347 
lotion (gr. ii-x ad gj) or hydr. bichlor, gr. i-ii ad aq. gj;-vin. 
opiiung. hydr. nit. ox.;-or a powder composed of hydr. nit. ox. 
3j, sacchari 3j, very finely powdered, a little of it to be blown into 
the eye. Whichever is selected should be applied regularly, and 
should not excite long-continued pain or active inflammation. Any 
enlarged vessels running from the circumference of the eye to the 
opacity should be divided. Gooch used to cure opacity of the cor- 
nea, even of long standing, and, in fact, other forms of chronic in- 
flammation of the eye, by the administration of corrosive sublimate, 
in doses that would now be considered hazardous. He gave gr. £ 
twice a day; and in a few days' time increased the dose to gr. i, 
and then to gr. i. It caused feverishness, purging, slight sweating, 
and headache. 
IV. Leucoma signifies an opaque cicatrix of the cornea. If recent, 
it may be partially removed by the measures just indicated for the 
cure of the opacity arising from adhesive inflammation. If of long 
standing, it is irremediable. 
V. Onyx signifies a suppuration between the layers of the cornea, 
and is an occasional result of acute ophthalmia, especially of the 
catarrho-rheumatic. It derives its name from its resemblance in 
shape to the white spot at the root of the finger nail. It mostly 
disappears with proper antiphlogistic treatment. If it extend very 
fast, it may be necessary to puncture the external layers of the cor- 
nea to relieve the great pain, but the sight will be lost. 
VI. Ulcers of the cornea are most frequently the results of the 
phlyctenulae of scrofulous ophthalmia, but they may arise from 
mechanical injury, or from any form of conjunctival inflammation. 
When a consequence of the scrofulous phlyctenulae, they are gene- 
rally deep, and tend to perforate the cornea, and leave an opaque 
cicatrix;-when arising from other causes, they are often superficial, 
and heal with a semi-transparent cicatrix which gradually becomes 
clear. 
These ulcers may, as Mr. Tyrrell observes, exist in three states. 
"First, that which we may term healthy, when the surface and 
circumference exhibit a degree of haziness or opacity of a whitish 
or gray aspect, which is owing to the effusion of adhesive matter on 
the surface, and in the surrounding texture, which is essential to the 
healing of the part." In this state, the case merely requires to be 
watched, to prevent injurious increase of action. 
Secondly, an ulcer may be inflamed-when its hazy circumfer- 
ence will be observed to be highly vas- 
cular. Leeches and counter-irritation, 
with soothing applications, are the 
remedies. 
Thirdly, an ulcer may be indolent; 
clear and transparent, looking as if a 
little bit had been cut out of the cornea; 
without any vascularity or effusion of 
Fig. 102.* 
* This figure exhibits the healing stage of an ulcer of the cornea. It is copied 
by Mr. W. Bagg from a drawing for which the author has to thank Mr. Partridge. 348 
DISEASES OF THE CORNEA. 
lymph. This state requires stimulating applications (arg. nit. gr. i. 
ad aq. $i). 
Again, ulcers may form on a surface that is already rendered 
opaque and nebulous by scrofulous inflammation. However, in any 
case, counter-irritation-and measures to improve the health-to- 
gether with weak caustic lotion or vin. opii used twice a day, are 
the chief remedies. The pupil should be dilated with belladonna, 
if the ulcer is near the centre of the cornea. 
When an ulcer is very irritable, keeping up constant pain and 
intolerance of light, in spite of soothing applications, the best plan 
is to touch its surface with a finely-pointed pencil of nitrate of silver, 
so as to produce an insensible film on the surface; this is to be 
repeated at intervals of three or four days. 
VII. Hernia Corneal When the cornea is nearly or quite per- 
forated by an ulcer, a thin transparent vesicle is apt to protrude 
from the aperture, consisting either of the membrane of the aqueous 
humour, or of a thin lamella of the cornea ; or else of an imperfectly 
organized cicatrix protruded by the aqueous humour. It may be 
snipped off if large, and the place be touched with caustic; but it is 
apt to be reproduced very rapidly. 
VIII. Staphyloma is a term employed to signify any protrusion 
on the anterior surface of the eye. There are several varieties of 
it. 1. Staphyloma iridis signifies a protrusion of the iris, which 
occurs when the cornea is perforated by ulcers or wounds. The pro- 
truded part should be punctured, or be snipped off if large, and be 
subsequently touched with arg. nit. The term myocephalon is 
applied to the protrusion of a very small piece of the iris through 
an ulcerated opening in the cornea. 
2. Staphyloma of the cornea is said to exist when a portion or 
the whole of the cornea is opaque, white, and prominent, the in's 
adhering to it-a consequence of severe inflammation. If partial, 
the nitrate of silver or butter of antimony may be applied to the 
apex of the staphyloma, so that the inflammation excited may 
thicken the cornea, and enable it to resist further protrusion. The 
caustic should be well washed off with milk before the lids are 
closed. If general, the staphyloma should be shaved off, for, as it 
is not covered by the eyelids, it is a source of constant irritation and 
pain. 
IX. Conical Cornea. In this curious affection, the cornea 
seems to become weak in its structure, so as to bulge out under an 
increased secretion of aqueous humour. It gradually becomes thin 
and exceeding convex, but remains transparent, and it often gives 
a peculiarly brilliant appearance to the eye. As it increases, it 
causes almost total deprivation of vision, which, however, can be 
partially remedied by looking through a minute aperture in a piece 
of blackened wood. It is incurable, although its progress may be 
retarded by tonics, counter-irritants, and mild stimulating applica- 
tions. Fide Artificial Pupil, p. 353. 
Caution.-If the acetate of lead is used as a collyrium when 
there is any abrasion of the conjunctiva or cornea, a white precipi- DISEASES OF THE SCLEROTIC. 
349 
tate is formed, which is liable to become fixed in the cicatrix as a 
dense white spot. The film may, however, sometimes be removed 
by a needle. The nitrate of silver, if applied too long, is apt to 
turn the conjunctiva to a deep olive hue. 
SECTION VI. DISEASES OF THE SCLEROTIC. 
I. Acute Inflammation of the Sclerotic is commonly called 
Rheumatic Ophthalmia ; because the structure affected is similar 
to that which is attacked by rheumatism; but it is not certain that 
the kind of inflammation present is always the genuine rheumatic. 
Symptoms.-It is known by redness of the sclerotic,-no great 
intolerance of light,-severe stinging pain of the eye, and aching of 
the bones around, which is greatly aggravated at night,-and fever. 
It may be caused by cold, and sometimes, like other rheumatic in- 
flammations, is a sequel of gonorrhoea; but it is a rare disease. It 
may lead to opacity of the cornea, or to iritis. 
Diagnosis.-This form of ophthalmia may be distinguished from 
inflammation of the conjunctiva, 1st, by the character of the pain; 
which is a severe aching, principally felt in the eyebrow, temple, 
and cheek; and is greatly aggravated every evening; being exces- 
sively severe during the night, but remitting towards morning. 
Whereas in conjunctivitis, the pain is of a scalding nature, and ac- 
companied with a sensation as if sand was in the eye. 2dly, By 
the character of the redness; which is deep-seated, and of a pale 
pink; and by the vessels running in straight lines from the circum- 
ference of the eye towards the cornea; whereas in conjunctivitis the 
redness is scarlet and superficial, and more vivid; the vessels are 
tortuous, and freely anastomose, and can be moved about with the 
finger. 
Treatment.-In severe cases, it will be necessary to bleed and 
purge, and administer colchicum, F. 95; or perhaps calomel and 
opium till the gums begin to suffer. The other measures are, fric- 
tion of the forehead every afternoon, with extract of belladonna 
dissolved in warm laudanum (3j ad 3j), or with mercurial ointment 
and opium;-warm pediluvia, or warm bath,-blisters behind the 
ears,-and Dover's powder at bedtime. Subsequently tonics will 
be useful, especially F. 31, or a combination of dried carbonate of 
soda and powdered bark, five grains of each of which may be given 
every four hours. Dry warmth, by means of muslin bags, filled 
with chamomile flowers and heated on a hot plate, is the most 
soothing local application. 
II. Catarrho-rheumatic Ophthalmia is a combination of in- 
flammation of the sclerotic with that of the conjunctiva. The symp- 
toms of conjunctivitis, that is to say, roughness and sense of dust in 
the eye,-muco-purulent discharge and superficial scarlet redness, 
-are combined with the deeper-seated, straight-lined redness, and 
with the zone around the cornea, and fits of nocturnal aching, that 
characterize inflammation of the sclerotic. This disease is very apt 350 
DISEASES OF THE IRIS. 
to lead to onyx, and to ulceration of the cornea, and suppuration in 
the anterior chamber. 
Treatment.-Nitrate of silver, astringent collyria, scarifications, 
weak citrine ointment, and the other topical applications for con- 
junctival inflammation, must be used in addition to bleeding, 
calomel, and opium, and the other remedies prescribed for simple 
inflammation of the sclerotic. 
SECTION VII.-INFLAMMATION OF THE ANTERIOR CHAMBER, OR 
AQUO-CAPSULITIS. 
This affection is generally the consequence of some other form of 
ophthalmia, but it may occur by itself. 
Symptoms.-The iris dull, the cornea mottled, the eye very tense 
and painful, and fever. The most peculiar consequence of this dis- 
ease, whether primary or consecutive of some other inflammation 
of the eye, is hypopyon; i. e., an effusion of an albuminous (or per- 
haps purulent) fluid into the anterior chamber. It is distinguished 
from onyx by the white fluid moving in different positions of the 
head, and by its upper margin being straight, not convex. 
Treatment.-Calomel and opium, and belladonna, and the 
general treatment of iritis, will remove the inflammation, and cause 
absorption of the hypopyon. 
SECTION VIII.-OF THE DISEASES OF THE IRIS. 
I. Inflammation of the Iris, or Iritis. The iris being mus- 
cular in its structure, and covered with a serous membrane, is ex- 
ceedingly liable to inflammation of an adhesive character, which 
frequently involves also the sclerotic, the anterior capsule of the 
lens, and the deeper structures in the eyeball. 
Symptoms.-In the first stage, the fibrous texture of the iris 
appears confused, and it loses its colour; if dark, it becomes reddish; 
if blue, it becomes greenish. The pupil, also, is contracted and 
irregular. In the next stage, lymph begins to^e effused; some- 
times in the form of a thin layer, causing the surface to appear rusty 
and villous,-sometimes in small nodules;-sometimes the pupil is 
filled with a film of it,-sometimes it is poured out in such abun- 
dance as to fill the whole cavity of the aqueous humour. The eye 
displays that kind of redness which arises from vascularity of the 
sclerotic; that is to say, a pink redness, with vessels running in 
straight lines from the circumference of the eye, and terminating in 
a vascular zone around the cornea; but in very acute cases the 
conjunctiva becomes injected likewise. The patient complains of 
intolerance of light and dimness of vision, and of more or less burn- 
ing, stinging pain in the eye; but besides this, there is also a severe 
aching of the brow and parts around the orbit, coming on in noc- 
turnal paroxysms, as in the rheumatic ophthalmia, and depending DISEASES OF THE IRIS. 
351 
probably on an affection of the orbitar periosteum and surrounding 
fasciae. f 
Causes.-Iritis may be caused by injuries, or by over-exertion 
of the eye; but it more frequently depends on constitutional taint, 
syphilis, or gout. 
Prognosis.-Favourable, if the disease is recent and confined to 
the iris, although the impairment of vision may be considerable;- 
but doubtful, if it be of long duration (i. e., more than a fortnight); 
-if there be much deep-seated pain, and especially, if there be 
great effusion of lymph behind the iris. 
Varieties.-Iritis may vary in the degree of acute inflammation 
which attends it; being active and rapid, attended with bright red- 
ness, great pain and fever if it occurs in a 
robust plethoric subject; but in other 
cases, slow and insidious. It is also di- 
vided into several species, according to 
the nature of the cause producing it. 
Thus, 1. The traumatic iritis is that 
which arises from penetrating wounds of 
the eye. 2. The rheumatic iritis arises 
from cold; although, like the rheumatic 
sclerotitis, it does not necessarily occur in 
persons who have suffered from rheumatism previously. 3. Syphi- 
litic iritis.-This is the most frequent variety. It is said to be dis- 
tinguished by the pupil being displaced upwards and inwards, and 
by the effusion of lymph in little nodules of a reddish or dirty 
brown colour, which cause the pupil to become angular. There 
is great pain at night, and but little by day, and secondary venereal 
affections of the throat and skin are usually present at the same time. 
4. The arthritic or gouty iritis, is an asthenic form, generally 
occurring to elderly dyspeptics and sots. It is said to be distin- 
guished by the atonic dusky hue of the redness; and the varicose 
state of the blood-vessels; and there is also sometimes a narrow 
white ring or interval of sclerotica between the red vascular zone 
and the cornea; but Mackenzie says, that the same is seen also in 
the other varieties of iritis if occurring to old people. There is 
great pain round the eye; and the patient will generally be found to 
have laboured under irregular gout, and various forms of asthenic 
dyspepsia. 5. Scrofulous iritis.-This is generally an extension 
of disease from the external tunics in neglected cases of strumous 
ophthalmia; but iritis sometimes, although rarely, occurs in young 
scrofulous subjects as a primary affection. 
Treatment.-The indications are, 1, to subdue inflammation; 
2, to arrest the effusion of lymph, and cause absorption of what is 
already effused; 3, to preserve the pupil entire; 4, to allay pain. 
1. If the patient be strong, and the disease acute, with much 
pain and fever, bleeding should be performed, and be repeated 
according to the pulse. In chronic cases, cupping will be prefer- 
Fig. 103 * 
* From a drawing in the possession of Mr. Partridge. It represents the nodules 
of lymph effused in syphilitic iritis. 352 
DISEASES OF THE IRIS. 
able. The bowels must be well cleared, the antiphlogistic regimen 
generally be observed, and blisters be applied after the most acute 
stage has subsided. 
2. To fulfil the second indication, the principal remedy is mer- 
cury; given in such a manner as to affect the mouth speedily;- 
such as gr. i-iii of calomel with gr. i -of opium at intervals of 
from four to eight hours. And when the mouth becomes sore, the 
lymph will generally be found to break up and gradually disap- 
pear, leaving the pupil clear. If it is judged inexpedient to admi- 
nister mercury because the patient's constitution has been broken 
down by repeated salivations, the remedy to be tried is the turpen- 
tine, in the dose of a drachm thrice daily, as prescribed for the 
rheumatic sclerotitis. When given in these small doses, it enters 
the circulation and often acts severely on the kidneys, without 
opening the bowels; but it may also be given sometimes in a larger 
dose, F. 18, during the exhibition of mercury, so as to purge copi- 
ously. 
3. The pupil should be kept well dilated by means of extract of 
belladonna, a thick solution of which should be painted on the eye- 
lids during the acute stage ; and a filtered solution of one scruple 
in an ounce of distilled water may be dropped into the eye after- 
wards. Stramonium or hyoscyamus may be substituted if preferred. 
4. The pain must be relieved by nightly doses of opium, and the 
application of poppy fomentation to the eye. 
In gouty iritis, calomel is only to be used in order to evacuate 
the bowels and amend the secretions, and it is highly injurious if 
given to the extent of affecting the system. But colchicum in doses 
of Tt[xx of the wine, (F. 95,) with turpentine purgatives, (F. 18,) 
must be used instead. Bleeding, local and general, must be em- 
ployed as the strength permits, and pedihivia containing mustard 
should be used every night. 
II. Synechia Posterior-adhesion of the uvea to the capsule 
of the lens;-Synechia Anterior-adhesion of the iris to the 
cornea;-and Atresia Iridis, or closure of the pupil-three con- 
sequences of organization of lymph from protracted iritis-may be 
partially removed by mercury if recent, but are irremedial, except 
by operation, if the lymph has become organized. But belladonna 
should always be applied; because, if a very small portion of the 
pupil is by chance unadherent, it may be dilated so as to afford a 
very useful degree of vision. 
III. Myosis-a preternaturally contracted pupil-is sometimes 
met with in persons accustomed to look at minute objects, and is 
attended with great obscurity of vision, especially in a feeble light, 
because the iris is unable to dilate. To give repose to the eyes, and 
attend to the health, are the only available indications of treatment. 
Mackenzie says, that belladonna is hurtful. 
IV. Mydriasis signifies a preternatural dilatation of the pupil, 
which does not contract on exposure to light. This state, as is well 
known, is readily produced by belladonna and many other nar- 
cotico-acrid poisons;-it is caused also by any injury or compres- DISEASES OF THE IRIS. 
353 
sion of the brain affecting the tubercula quadrigemina;-and is an 
attendant of confirmed amaurosis. But sometimes it depends simply 
on a derangement of the nerves supplying the iris, without any 
diminution of the sensibility of the retina; and this form of it may 
also be attended with ptosis; as a further evidence of paralysis of 
the third nerve. If the retina is sound, which will be known by 
the perception of light, and by vision being improved by looking 
through a small round aperture in a piece of blackened card, the 
best remedy is the application of lunar caustic to the margin of the 
cornea; this was proposed by M. Serres, and has been found 
useful in England by Mr. Ure.* Electric sparks and other stimu- 
lants have also been used with benefit; and one case is recorded! 
which was cured by ergot of rye, in scruple doses four times a day. 
V. Tumours or Cysts growing upon the iris must be removed if 
they become large, so as to interfere with vision, or to inflame the 
eye by their pressure. A section of the cornea must be made as 
for extraction of cataract, and the diseased part of the iris, having 
been drawn out, must be snipped off. 
VI. Artificial Pupil.-There are certain cases in which it 
becomes expedient to alter the shape and position of the pupil, or 
to form a new papillary aperture in the iris. 
1st. In cases of conical cornea, or of permanent opacity of the 
centre of the cornea, it is advisable to bring the pupil opposite to a 
transparent part of it; and Mr. Tyrrell observes that, if the position 
and extent of the opacity do not forbid, the pupil should always be 
brought downwards and outwards. This is done in the following 
way: A broad needle is carefully passed through the cornea, close 
to its junction with the sclerotic. Through the puncture thus made, 
Tyrrell's hook, a fine blunt hook with a long bend, is passed into 
the anterior chamber, with the bent limb forwards. As soon as it 
has reached the pupillary margin, the hook is turned backwards so 
as to catch it; and then the hook is withdrawn, through the corneal 
puncture, bringing out the iris with it, and of course rendering the 
pupil oblong. The piece of the iris that protrudes should be snipped 
off with a fine pair of scissors. 
2dly. In cases where the pupil has been nearly or altogether lost 
in consequence of prolapse of the iris through wounds or ulcers, or 
slough of the cornea;-or where vision is obscured by opacity of 
the cornea, with adhesion of the iris to it;-or by partial staphyloma 
of the cornea, with adhesion of the iris;-a new pupillary aperture 
may be made;-or the old pupil (if not quite abolished) may be 
extended opposite to that part of the cornea which remains trans- 
parent, by the same operation which we have just described. But 
if the old pupil is quite lost, it will be necessary to make a little 
puncture of the iris with the needle which is employed to puncture 
the cornea;-into which puncture of the iris the hook is to be in- 
serted. Supposing, moreover, that after either of these operations 
the new pupil degenerates' into a mere slit, this slit must be en- 
* Vide Lond. Med. Gaz., 19th May 1843. 
f L'Experience, Sept. 1839. 354 
CATARACT. 
larged, by another operation of the same kind-that is, by making 
another puncture of the cornea at a little distance above the first, 
and dragging up the upper margin of the slit with the hook. 
3dly. In cases where the pupil has closed after the removal of a 
cataract-whether in consequence of prolapse of the iris, or of in- 
flammation and organization of lymph, an artificial pupil may be 
made by making an opening at the margin of the cornea, about a 
quarter of an inch in extent. Through this, a small pair of scissors 
(Maunoir's) is introduced, and a V shaped cut is made in the iris. 
Or in cases where part of the cornea is opaque, a new pupil may 
be made with the needle and hook as above described.* 
But before resorting to any of these operations, it must be ascer- 
tained, 1st, whether the adhesions of the iris cannot be removed 
by mercury or belladonna, or opacity of the cornea by external 
applications; 2dly, that the retina is perfectly sound; 3dly, that all 
tendency to inflammation (syphilitic or otherwise) has ceased. It 
is not advisable to operate if one eye be quite sound;-and sup- 
posing one eye to be irrecoverably lost, it is not advisable to form 
an artificial pupil in the other, provided the patient find his way 
about with it. Moreover, the new pupil should be made large, 
because it will always contract somewhat afterwards. 
SECTION IX.-INFLAMMATION OF THE CAPSULE OF THE CRYSTAL- 
LINE LENS. 
This is a very rare affection, and always chronic. Vision is con- 
fused,-objects looking as if they were seen through a fine gauze. 
On examining the eye with a strong lens in a good light, and the 
pupil being well dilated with belladonna, a number of minute red 
vessels are seen in the pupil. If the anterior capsule be affected, 
the vessels form a circular wreath of vascular arches with the centre 
clear;-if it be the posterior capsule, they are central and arbor- 
escent. The iris is always slightly discoloured and sluggish. 
Treatment.-Local or general bleeding;-mercury,counter-irri- 
tation, change of air, and alteratives. 
SECTION X. OF CATARACT. 
Definition.-An opacity of the crystalline lens or its capsule. 
Symptoms.-Before examining any patient with suspected cata- 
ract, the pupil should be dilated with belladonna, and then, if there 
be cataract, there will be seen an opaque body of a gray, bluish 
white, or amber colour, behind the pupil. The patient usually 
gives as his history, that his vision has become gradually impaired ; 
* This operation, when performed by means of an incision in the iris, is techni- 
cally called coretomia,■ when performed by the excision of a little piece, it is called 
corectomia,- and when effected by detaching the iris from the ciliary ligament, it is 
called coredialysis. papilla. CATARACT. 
355 
that objects appear as if surrounded with a mist, or as if a cloud 
was interposed between them and the eye; and that the sight is 
better in the evening, or when the back is turned to the window ; 
or after the application of belladonna,-obviously because the pupil 
being dilated under those circumstances, permits more light to pass 
through that part of the lens which is yet transparent. In the most 
confirmed cases, the patient is able to distinguish day from night. 
There is also the catoptric test, that is, the mode of examining 
the eye by the reflection of light, which was proposed by M. San- 
son. When a lighted taper is moved before the eye of a healthy 
person, three images of it may be observed. 1st. An erect image, 
that moves upwards when the candle is moved upwards; and that 
is produced by reflection from the surface of the cornea. 2dly. 
Another erect image, produced by reflection from the anterior sur- 
face of the crystalline lens, which also moves upwards when the 
candle is moved upwards; and, 3dly. A very small inverted image, 
that is reflected from the posterior surface of the crystalline, and 
that moves downwards when the candle is raised upwards. Now, 
in cataract, this inverted image is from the first rendered indistinct, 
and soon abolished; and the deep erect one is soon abolished also. 
Diagnosis will be spoken of under Amaurosis and Glaucoma. 
Causes.-Cataract (especially of the capsule) is sometimes attri- 
butable to inflammation, and may be caused in a short space of 
time by wounds or other injuries of the lens. But the ordinary 
cataract of the old seems to be a mere effect of impaired nutrition. 
Varieties.-1. Hard cataract. This is the form that is gene- 
rally met with in elderly people. The lens is shrunk and hard, 
amber yellow in the centre, gray towards the circumference. There 
is an appreciable interval between the lens and iris. 2. Radiated 
cataract. In this form the opacity commences in streaks at the 
circumference, which, as the disease advances, slowly converge 
towards the centre. In this variety there is of course some little 
diversity from the ordinary symptoms. For instance, the patient 
sees best in a bright light, when the pupil is contracted; and, more- 
over, he is apt to see objects double, or distorted, in consequence 
of irregular reflection of light from the opaque streaks. Soft cata- 
ract,-the lens of the consistence of soft cheese or cream, and of a 
gray or bluish, or pure white colour, without any amber tint. This 
variety is generally met with in congenital cases, and in fact in all 
persons under forty; it causes a greater degree of blindness than 
the hard variety,-moreover, the lens being swelled projects against 
the iris, and interferes with its motions. 4. Capsular cataract. 
Opacity of the capsule is said to occur in spots or streaks, with less 
opaque intervals. It is not unfrequently the result of a slow inflam- 
mation, which may be accompanied with pain in the eye, and 
signs of congestion in the head;-it may be produced also by 
inflammation extending from the iris or conjunctiva. Opacity of 
the anterior portion may be seen immediately behind the iris, and 
has a glistening, chalky, or pearly white appearance. That of the 
posterior appears at some little distance behind the pupil, and pre- 356 
CATARACT. 
sents a concave striated surface, of a dull yellowish appearance. 
5. Capsulo-lenticular cataract is very common.-in fact, opacity 
of the capsule is always followed by opacity of the lens. 
Treatment.-The cataract must be removed by operation. No 
other treatment is of any avail to get rid of the disease, although 
perhaps its progress may be retarded by counter-irritation, and 
stimulating applications to increase the flow of tears, and sternuta- 
tories, and measures calculated to lower vascular action. It is, 
however, a general rule not to operate till the cataract is mature; 
-that is, not whilst the degree of vision is sufficient for ordinary 
purposes; more particularly if the patient is very old and feeble, 
or if one eye is already lost;-because, under these circumstances, 
a failure of the operation would entail utter blindness. Therefore 
the patient should assist his vision by dropping into the eye one or 
two drops of a carefully-filtered solution of extract of belladonna 
(9i ad $i) in distilled water night and morning, so as to dilate the 
pupil, and defer the operation till, despite of that aid, his blindness 
is complete. 
Prognosis.-This will be favourable if the patient is in good 
health, of a spare frame and temperate habits; if the iris moves 
freely, and if the retina seems perfectly sensible to light. On the 
other hand, it will be doubtful if there are signs of vascular dis- 
turbance in the eye or head-if the iris is motionless or altered in 
colour, or if it is adherent to the capsule ;-or if the cataract is com- 
plicated with amaurosis, synchysis, or glaucoma. 
Preparation.-Before operating, the patient should be put into 
as perfect a state of health as possible. The bowels should be 
cleared, the secretions be regulated, and bleeding and low diet be 
enjoined if the habit is inflammatory. Moreover, the operation 
should always be performed in mild weather. 
There are three methods of operating;-1, extraction, 2, depres- 
sion, (or couching,} and, 3, the operation for causing absorption. 
1. Extraction.-The object of this operation is, to make an in- 
cision through rather more than one half of the circumference of the 
cornea, almost close to the sclerotic; to lacerate the capsule of the 
lens; and then to extract the cataract entire, through the pupil. Its 
advantage is, that it effectually removes the cataract;-its dis- 
advantage, that in the event of a failure sight is almost irretriev- 
ably lost. It is best adapted for hard cataracts in elderly people. 
But it should not be attempted, 1st, if the patient is very old and 
feeble, in which case the wound of the cornea might not unite. 2dly. 
If the anterior chamber is very small and the cornea very flat, so that 
a sufficiently large opening cannot be made in it. 3dly. If the iris 
adheres much to the cornea, or if the cataract is large and pushes it 
forwards, or if the pupil is habitually contracted. 4thly. If the eye 
is sunken, or if the fissure of the lids is preternaturally small. 5thly. 
If the eyes are very unsteady, or if the patient is subject to habitual 
cough or asthma, or is unmanageable in consequence of infancy or 
idiocy. Some practitioners direct that one eye only should be CATARACT. 
357 
operated on at a time, the other being kept as a reserve, whilst others 
are not afraid to operate on both together. 
Preliminaries.-The patient should be seated in a low chair 
with a high back, opposite a window that admits a good clear light, 
but no sunshine, and the eye to be operated upon should be turned 
somewhat obliquely to the window, so that the operator may not 
see the image of it on the cornea. The surgeon should sit imme- 
diately before him on a higher chair; and should have a stool, so as 
to raise one knee to a proper height for steadying the elbow of the 
operating hand upon it. Behind the patient an assistant should stand, 
whose duties are, 1st, to steady the head against the back of the 
chair, or against his own breast. 2dly. To elevate the upper eyelid, 
and to fix it against the margin of the orbit, with one forefinger. 
3dly. To drop it at a preconcerted signal from the surgeon. 
Operation.-The surgeon, 1st, depresses the lower eyelid, and 
steadies the globe with the fore and middle fingers of one hand, but 
without exerting any pressure on it. He particularly endeavours 
to prevent it from rolling inwards during the operation. 2dly, 
holding the cornea-knife* like a pen, (in the right hand for the left 
eye, and vice versa,') and resting the other fingers on the patient's 
cheek, he touches the cornea once or twice with the flat part of the 
blade, in order to take off the patient's alarm. 3dly. He punctures 
the cornea close to its outer margin, pushing the point of the blade 
perpendicularly towards the iris, and not obliquely; otherwise it 
would pass between the laminae of the cornea instead of entering 
the anterior chamber. 4thly. He must push it steadily across 
parallel to the iris, till it cuts its way out, making a semicircular flap 
of the lower half of the cornea; immediately upon which the eyelid 
should be dropped. 5thly. Waiting a few seconds, the surgeon 
takes a curette,-introduces the pointed end with the convexity 
upwards, and freely lacerates the capsule with it; and then with- 
draws it with the convexity downwards. 6thly. He makes very 
gentle pressure on the under part of the globe, and on the upper 
eyelid, till the lens rises through the pupil and escapes. Lastly, 
the eye should be opened after a minute or two, to see that the 
flap of the cornea is rightly adjusted, and that the iris is not pro- 
lapsed :-if it is, the eyes should be exposed to a bright light, so as 
to make the pupil contract, and the prolapsed portion should be 
gently pressed upon the spoon of the curette. Then the operation 
is finished. 
It follows, as a matter of necessity, that there must be many 
variations in the manner of performing an operation comprising so 
many minute and delicate manoeuvres as the one under considera- 
tion. Thus, if the surgeon be ambidexter, he may sit before his 
* The knife called Beer's is most used. It has a triangular blade,-the point 
sharp,-the back straight and blunt, the edge slanting obliquely, and the blade in- 
creasing in breadth and thickness as it approaches the handle. The advantages of 
this shape are, that it fills up the incision which it makes, and prevents the escape 
of the aqueous humour; and that the flap of the cornea is made by one simple 
motion, that is, by pushing the knife inwards. 358 
CATARACT. 
patient, when operating on either eye; but, if he can use his right 
hand only, he must sit behind his patient when operating on the 
right eye. Many surgeons make a flap of the upper instead of the 
lower half of the cornea. " The 
advantages of this operation," 
says Mr. Lawrence, " are, that 
the operator has a more complete 
control over the globe ; he can fix 
it very perfectly; that the aque- 
ous humour does not escape so 
readily, and consequently, that 
the section of the cornea is more 
readily accomplished; that there 
is less chance of prolapsus iridis; 
and that the upper lid keeps the 
flap of the cornea in exact apposition." Some operators again, dis- 
pense entirely with an assistant, and fix the globe with the left hand. 
Mr. Guthrie also objects to making the puncture of the cornea with 
the knife perpendicular to the eye. Some operators use belladonna 
to dilate the pupil; others are averse to it. 
Complications.-(1.) Sometimes, in consequence of the prema- 
ture escape of the aqueous humour, the iris falls forwards under 
the edge of the knife. The best way of inducing it to retract, is to 
press on the cornea with the forefinger over the protruding part of 
the iris. If this fails, the knife must be withdrawn, and the operation 
be completed with Guthrie's double knife, which has a sharp blade 
sliding on a blunt one; the sharp being pushed out when the knife 
has reached the inner side of the cornea. But sometimes the point 
of the knife is so completely entangled in the iris, that it is necessary 
to withdraw the instrument, heal the wound, and repeat the opera- 
tion afterwards. If, however, a little bit of it should get under the 
edge of the knife, when the section is nearly complete, the operator 
may push on boldly, since if a little piece of it be cut, it will be of 
no great consequence. (2.) If the opening of the cornea is not large 
enough, it must be enlarged with a small knife. (3.) If a portion of 
the lens remain behind, it should be left to be absorbed-unless it 
has passed into the anterior chamber, and can be removed very 
easily indeed. (4.) If the vitreous humour seem disposed to escape, 
the cataract should be hooked out with the curette. But the escape 
of a little is of no consequence. 
Alfter Treatment.-The patient should be put to bed, with the 
shoulders raised, the room darkened, and with a very soft dry linen 
rag over both eyes. No food should be allowed which requires 
mastication, the bowels should be kept open, and every thing be 
avoided which is likely to provoke coughing, sneezing, or vomiting. 
If he goes on comfortably, the eyelid may be raised on the fifth day, 
and then if there be no prolapse of the iris, and the cornea be united, 
he may get up occasionally, wearing a shade, sitting in a darkened 
room, and walking about a little. After a fortnight the eye may be 
opened in a weak light, and be gradually brought into use. But 
Fig. 104. CATARACT. 
359 
inasmuch as it remains weak and irritable, the patient must take the 
greatest care to avoid exposure to cold, excess in diet, over-exertion 
of the eye, or exposure of it to too strong a light. Gray spectacles 
are the best protectors against wind, or too glaring a light. The 
patient will require convex spectacles for exact vision, but they 
must be used very sparingly at first. He should have two pairs, 
one with a short focus for near objects, and another of long focus 
for distant objects. 
The inflammation which may come on after the operation may 
be of two kinds. If the eyelids are swollen, and florid, and tender, 
and there is a thick yellow secretion about the lids, and the conjunc- 
tiva is red, swollen, and chemosed, the inflammation is acute, and 
requires to be treated by bleeding and purging. But if, as Mr. 
Tyrrell shows, the palpebrae are not much discoloured, and are 
rather oedematous than tinged with blood;-and if the secretion is 
light-coloured, and the conjunctiva oedematous, the patient will be 
benefited by good broth, carbonate of ammonia, and opium. 
II. Depression.-The object of this operation is to remove the 
cataract from the axis of vision. It is adapted only to those cases 
of hard cataract, of which the extraction would be unad visable, for 
reasons mentioned in a preceding page (356). The disadvantages 
of it are, that the pressure of the lens on the ciliary processes and 
retina is liable to be followed by protracted inflammation or amau- 
rosis ; and that the lens may rise again to its old place, and obstruct 
vision as before. The preparation of the patient, his position during 
the operation, as well as that of the surgeon, and the duties of the 
assistant, are the same as required for the operation of extraction. 
The pupil should be dilated with belladonna. There are four ways 
of operating. 
Operations.-(1.) A couching-needle is passed through the outer 
side of the sclerotic, about two lines behind the margin of the cornea, 
and a little below the transverse diameter of the eye, so as to avoid 
the long ciliary artery. It is carried upwards and forwards behind 
the iris, and in front of the cataract, and then is steadily and gently 
pressed upon it till it has carried it downwards and backwards out 
of sight. It should be held for a few moments to fix it, then should 
be lifted up, and if the lens rise also, it must be again depressed for 
a short time. Then the needle is withdrawn. 
(2.) According to Scarpa's plan, a curved needle is used instead 
of a straight one. It is to be introduced with its convexity forwards, 
and the lens is to be depressed in the manner just described-but 
before withdrawing the needle, its point is to be turned forwards, 
and made to lacerate the capsule freely. 
(3.) King's operation.-A curved needle is passed perpendicu- 
larly through the sclerotic, as low down as possible; and if the 
patient's eye is directed upwards and inwards, it can be made to 
enter almost perpendicularly below the centre of the cornea, and 
one-eighth of an inch from its margin. It should then be passed 
onwards with a slight rotatory motion of the pupil, having its 
convexity forwards, i. e., towards the back of the iris. When it 360 
CATARACT. 
reaches the pupil, these rotations are to be increased, so that the 
point may cut the anterior capsule into small pieces. The needle 
is then slowly withdrawn, and the lens follows it, so that it is left 
at the bottom of the eye close to the puncture made by the needle. 
If the lens should not immediately follow the needle downwards, 
the latter is to be stuck into it again.* 
(4.) The method of reclination, which consists of turning the 
lens backwards from an upright to an horizontal position is not 
much in vogue, although some surgeons recline the cataract before 
they depress it. 
HI. The Operation for producing Absorption is very easily 
performed, and excites very little inflammation. Its disadvantages 
are, that it requires to be repeated several times, and that the cure 
is very slow, occupying several weeks or months. It is well adapted 
for soft cataracts, especially the congenital, but very seldom if ever 
answers with the hard cataracts of old people. 
Operations.-(1.) The needle may be introduced behind the iris 
in the same manner as for depression. Then the anterior layer of 
the capsule is to be freely divided, and the needle, having been 
passed once or twice through the substance of the lens, is to 
be withdrawn. Care must be taken not to dislocate the lens in 
this first operation. The cataract will be more or less dissolved 
by the aqueous humour, and be absorbed. After the lapse of a 
few weeks, the operation may be repeated, the capsule may be 
lacerated more extensively, and the lens be cut up into fragments, 
which, if perfectly soft, may be pushed through the pupil into the 
anterior chamber, where absorption is more brisk. The operation 
may be repeated again and again if necessary. But if a hard frag- 
ment be pushed into the anterior chamber, it may probably excite 
great inflammation, and require to be removed by operation; so 
that the surgeon had better avoid attempting to do too much at once. 
(3.) Some recommend the needle to be introduced through the 
cornea, an operation styled keratonyxis. The pupil must be well 
dilated. Then the needle is passed through the cornea about an 
eighth of an inch from its margin, and is made to lacerate the cap- 
sule to the extent of the pupil. It should be of such a shape as to 
prevent the escape of the aqueous humour. The method is liable 
to induce iritis, and does not enable the surgeon to act upon the 
body of the lens. It should therefore be merely employed as a 
first operation, to divide the capsule. 
(3.) There is a third modification of this operation, which Mr. 
Tyrrell terms the operation of drilling. It is particularly adapted 
for cases of capsular or capsulo-lenticular cataract which have been 
caused by extension of inflammation from the iris. It is performed 
by introducing a fine straight needle through the cornea, near its 
margin, and passing it through the pupil to the lens. It is then to 
be made to enter the substance of the lens to the depth of about 
one-sixteenth of an inch, and to be freely rotated. This operation 
• Lond. Med. Gaz., vol. xxii. pp. 701 and 1009. GLAUCOMA. 
361 
may be repeated at intervals of three, four, or five weeks; and if 
the puncture be made in a fresh place at each operation, that portion 
of the capsule which is behind the pupil will become loosened and 
detached, and the lens absorbed. This operation may also be occa- 
sionally resorted to in order to diminish the size of the lens, pre- 
viously to depression or extraction. 
Operations on Infants.-Congenital cataracts should be ope- 
rated on early-within four months, if possible, lest the eye, which 
when born blind habitually oscillates from side to side, may never 
acquire the power of being directed to one particular object. The 
pupil being well dilated, the child should be placed on a table- 
the head on a pillow, and rather hanging over it-one assistant 
holding the legs and trunk, a second the arms and chest, a third 
fixing the head between his two hands, and a fourth, depressing 
the lower eyelid with one hand, and steadying the chin with the 
other. The operator then, seated behind the patient, performs the 
operation for absorption as before described; at the same time 
elevates the upper lid, and fixes the globe with an elevator. Care 
must be taken not to dislocate the lens, and not to wound the pos- 
terior capsule or vitreous humour. This operation on children, and 
in fact on persons under twenty, generally excites so little inflam- 
mation, that both eyes may be operated on at once; but the bowels 
must be kept open, and leeches should be applied if there be pain. 
Capsular Cataract.-When congenital cataract is left to itself, 
the lens becomes absorbed, and the capsule remains tough and 
opaque. And it sometimes happens that an opaque capsule is 
left, or that it becomes opaque after one of the operations for cata- 
ract. There are three plans of treatment. (1.) A needle with 
cutting edges may be introduced, as for depression; and then may 
be made to cut crucially through the opaque capsule, which then 
may shrink and leave the pupil clear. (2.) The upper part of the 
capsule, for four-fifths of its circumference, may be detached by the 
needle from the ciliary processes, and then be pushed down below 
the pupil. (3.) If no other plan succeed in removing a detached 
piece of capsule, an opening may be made in the cornea, through 
which it may be extracted by means of a small hook or forceps. 
Mr. Middlemore has recently proposed a plan for removing such 
bodies through the sclerotic.* 
SECTION XI. OF GLAUCOMA. 
Glaucoma signifies a state of impaired vision, accompanied with 
a greenish discoloration of the pupil. It was formerly supposed 
to be dependent on a turbidity of the vitreous humour; dissection, 
however, has shown that this opinion is not correct; but that the 
organization of all the central portions of the eye is impaired. The 
lens is found still transparent, or nearly so, but yellowish or reddish 
* Med. Gaz., April 7, 1838. 362 
DISEASES OF THE CHOROID. 
in colour;-the vitreous humour, yellowish, but nearly pellucid 
and quite fluid, owing to an atrophy of the hyaloid membrane; - 
the choroid membrane of a light brown colour, from a deficiency 
of the black pigmentand no remains of the central spot in the 
retina. The greenish discoloration which appears deep in the eye, 
is owing partly to a deficiency of black pigment, partly to the change 
of colour in the lens which reflects the light of a greenish colour, 
and absorbs the other rays. 
Symptoms and Diagnosis.-The patient complains of gradually 
increasing dimness of sight attended with more or less rheumatic 
pain over the eyebrow, and visions of black spots, and flashes of 
light. The pupil is dilated, and moves sluggishly ; the eye feels 
hard ; and its blood-vessels often appear dilated and varicose. The 
patient is generally from forty to sixty years of age, and the disease 
appears to partake of the nature of senile degeneration. It may be 
distinguished from cataract, by the greenish colour, and indistinct 
nature of the opacity ; which resembles, as Mr. Tyrrell observes, 
the reflection of the sun's rays from a muddy pool; and by its being 
seen deep in the eye; whereas in cataract, a definite whitish opaque 
body is seen immediately behind the pupil. The opacity disap- 
pears, moreover, in glaucoma when looked at sideways, which is 
not the case in cataract. Vision is assisted by a strong light in 
glaucoma; but the reverse in cataract. If the eye be examined by 
means of the reflection of a lighted candle, as was shown in the 
section on cataract, the inverted image, which is soon obliterated 
in cataract, is distinctly perceptible in the earlier stages of glaucoma; 
although not in the later stages; yet it continues to be formed by 
the circumference of the lens after it is imperceptible at the centre.* 
The deep erect image, however, continues more distinct even than 
in the healthy eye ; whereas it is absent in cataract. 
Treatment.-It is of no use to adopt any other treatment for the 
ordinary chronic glaucomatous degeneration of age, beyond absti- 
nence from exertion of the eye ; and from any thing likely to disorder 
the health. But if the affection begin suddenly with acute symp- 
toms of a gouty character, as it does sometimes, they must be com- 
bated by cupping, counter-irritation, and the other remedies pro- 
posed for the arthritic iritis. 
SECTION XII.-OF THE DISEASES OF THE CHOROID; AND OF 
SYNCHYSIS AND IIYDROPHTHALMIA. 
I. Inflammation of the Choroid, or Choroditis, is not a 
common disease, and is apt to be overlooked in its early stages; Dr. 
Mackenzie has generally met with it in strumous females. 
Symptoms.-It commences with more or less intolerance of light, 
and dimness of vision, together with pain in the eye, eyebrow, and 
* When the candle is held in the axis of the ejre, the inverted image is obscure, 
both in incipient cataract and in incipient glaucoma; but when it is moved to one 
side, it becomes distinct in glaucoma, but remains obscure in cataract. DISEASES OF THE CHOROID. 
363 
forehead, and lachrymation. The conjunctiva is not uniformly red, 
but one or more enlarged vessels are seen to proceed from the back 
of the eye, and to terminate in a vascular zone partially surrounding 
the cornea. The pupil is often displaced, and brought towards the 
affected side of the choroid. If it proceed, the sclerotic becomes 
thin and blue, showing the choroid through it-a watery fluid is 
effused between the choroid and retina, causing the thinned part of 
the sclerotic to bulge out (staphyloma scleroticx,) and finally the 
cornea may become opaque, the eye protrude from the socket, and 
the whole globe suppurate. The digestive organs are generally 
much deranged from the first, and hectic and emaciation come on 
when the eye becomes much distended and painful. 
Treatment.-1. Repeated and profuse local bleeding, by cup- 
ping on the temples, and afterwards by many leeches to the eye ;- 
purgatives of calomel and black draught, followed by daily doses 
of blue pill (gr. v.) and aloes (gr. iv.), the tartar emetic ointment to 
the nape of the neck, and the vapour bath to excite the secretion of 
the skin, are the remedies for the first stage. Ptyalism is not con- 
sidered useful. Afterwards tonics, such as the oxide of iron and 
quinine, but especially the liq. arsenicalis, in doses of n^iv. ter die, 
are of service. When the sclerotic becomes much distended, it 
should.be punctured with a needle-the instrument being intro- 
duced for one-eighth of an inch towards the centre of the eye, so as 
not to wound the lens. 
II. Weakness of Sight; Muscle Volitantes. Persons of 
delicate constitutions and sedentary habits, especially if they are in 
the habit of writing much, or otherwise exerting their eyes on 
minute objects, are liable to suffer from dimness of sight; uneasiness 
on exposure to a strong light; and the vision of floating black specks 
or streaks, which from their resemblance to flies, have acquired the 
name of muscse volitantes. These symptoms evidently depend on 
weakness of organization, either original, or produced by over-exer- 
tion ; the principal measures to be adopted are tonics, aperients, 
shower-bathing; and care never to use the eyes too long at a time. 
Weakness of sight, with intolerance of light, is very commonly an 
accompaniment of short sight; it may always be recognized by an 
uneasy bashful look about the patient's eyes, the lids of which are 
half-closed, and perpetually winking, and the brow contracted. 
The muscse volitantes are supposed to depend on a distension of 
the vessels of the choroid;-if there is a permanent black spot, it 
probably depends on a permanent varicosity of some branch. 
III. Synchysis is an unnatural fluidity of the vitreous humour, 
which may or may not be also discoloured. The eye feels soft and 
flaccid, the iris is peculiarly tremulous, shaking backwards and for- 
wards like a rag in a bottle of water, the retina becomes insensible, 
and the lens opaque. This affection is sometimes the result of 
wounds, and sometimes comes on without obvious cause. It is 
supposed to depend on a slow inflammation. It is irremediable. 
IV. Dropsy of the vitreous humour, or Hydrophthalmia, pro- 
bably depends on a slow inflammation of the inner tissues of the 364 
amaurosis. 
eye. It causes enlargement of the globe, with loss of sight and 
constant excruciating pain, only to be relieved by puncturing the 
sclerotic with a needle. 
SECTION XIII.-OF RETINITIS. 
The Retina must of necessity be more or less involved in any 
inflammatory process which affects the deeper structures of the eye- 
ball ; but sometimes it appears to be the original seat of inflamma- 
tion, of which authors describe three forms; the acute, subacute, 
and chronic. 1. In the acute form the symptoms are-severe, 
deep-seated and throbbing pain in the eye, extending to the temples 
and head; vision rapidly impaired, or even altogether lost; frequent 
sensations of flashes of light, with great fever and delirium. The 
pupil gradually closes-the iris loses its brilliancy, and the sclerotic 
is highly vascular and rose-red. If unrelieved, the whole globe 
may suppurate. 2. Subacute.-Dimness of sight, headache or 
giddiness, flushed countenance and fever, the pupil soon becoming 
motionless, and the iris turbid. 3. Chronic.-Gradually increasing 
dimness of sight-visions of black spots or flashes of light,-irrita- 
bility of the eye, and intolerance of light-tenderness of the eyeball, 
and of the parts around;-but the patient, though he may shade 
the eye, does not always shut it. These affections are distin- 
guished by the circumstance that dimness of sight and intolerance of 
light occur before redness, or any external sign of inflammation. 
Causes.-Exposure to vivid light, flashes of lightning, strong 
fires, the reflection of the sun from snow, and the like-or habitual 
exertion of the eye on minute objects, together with, neglect of 
exercise, confinement of the bowels, and over-indulgence in food 
and spirituous liquors. 
Prognosis.-If, in the acute or subacute form, vision is not much 
impaired, nor the iris altered, nor the pupil much contracted, the 
prognosis may be favourable. 
Treatment.-General and local bleeding, purgatives, mercury, 
administered so as to affect the mouth-belladonna, and the anti- 
phlogistic treatment generally, according to the urgency of the 
symptoms and the strength of the patient. 
SECTION XIV. OF AMAUROSIS. 
Definition.-Imperfection of vision, depending on some change 
in the retina, optic nerve, or brain. 
Symptoms.-1. Of course the first and most prominent symptom 
is impairment of vision; the mode and degree of which, are, how- 
ever, subject to very great variety. Sometimes, the sight becomes 
suddenly dim, and is soon extinguished altogether; more frequently 
it becomes impaired by slow degrees; and at first is only so at inter- 
vals ; after the eyes have been fatigued, for instance, or when the AMAUROSIS. 
365 
spirits are low, or the stomach disordered. Sometimes it com- 
mences as indistinct vision, or amblyopia,-or as diplopia, objects 
appearing doubled-or as hemiopia, one half only of the objects 
looked at being seen;-or objects may appear crooked, disfigured, 
or discolouredor they may be seen covered with patches;-or 
the affection may commence as near-sightedness or far-sightedness. 
The patient finds himself unable to estimate distances, and misses 
his aim when trying to snuff a candle, or pour beer into a glass. 
The flame of a candle generally appears split, lengthened, or broken 
into an iridescent halo. 
2. Ocular spectra, sometimes in the form of floating black spots, 
(musew volit antes,} sometimes as flashes of light, or as a coloured 
cloud or network.* 
3. Sometimes incipient amaurosis is attended with great intole- 
rance of light-sometimes, on the contrary, with a constant thirst 
for liqht, or feeling as if objects were not illuminated enough. 
4. The patient walks with a peculiar uncertain gait, and his eyes 
have a vacant stare;-the eyelids move imperfectly and seldom- 
the pupil is generally dilated (unless it be an incipient case, attended 
with intolerance of light);-the iris moves sluggishly, and in con- 
firmed cases is totally motionless. But if one eye be sound, and be 
exposed to light during the examination, the iris of the affected eye 
will often move in sympathy with that of the sound one. 
Diagnosis.-Amaurosis may be distinguished from cataract by 
noticing, 1. that in cataract, an opaque body can be seen behind 
the pupil, and that the impairment of vision is in proportion to the 
extent of that opacity; whereas, in pure amaurosis, the pupil either 
shows its natural colour, or else a deep-seated greenish discolora- 
tion. 2. That, in cataract, (with the exception of the radiating 
variety,) vision is simply clouded, and that a lighted candle appears 
as if enveloped in a mist; whereas, in amaurosis, objects are seen 
^coloured or perverted in shape; and that a lighted candle seems 
split, or lengthened, or iridescent; and that muscae volitantes, and 
flashes of fire when the eyes are shut, are not present in pure cata- 
ract. 3. That in cataract, vision is better in a dull light, whereas, 
it is generally the reverse in amaurosis. 4. That a patient with 
cataract is always able to discern light from darkness, and that he 
looks about him and moves his eyes as though conscious that vision 
still exists, although he may be unable to discern particular objects; 
whereas in confirmed amaurosis there is a peculiar fixed vacant 
stare, and the eyeball is protruded and motionless. 5. That in pure 
amaurosis the three images of a candle are as distinct as in the 
healthy eye, which is not the case in cataract. 
Prognosis.-This is generally unfavourable-unless the disease 
depends on some palpable cause which admits of removal, and 
unless the remedial measures employed very soon produce good 
effects. 
Varieties.-Amaurosis has been divided into the functional 
* The Student will do well to read Milton's account of his own blindness, as 
given in Dr. Johnson's Lives of the Poets. 366 
AMAUROSIS. 
and organic: the former depending on some sympathetic or other 
disorder which does not primarily affect the structure of the nervous 
apparatus of the eye. 
Causes.-The usual causes of amaurosis are circumstances that 
over-stimulate and exhaust the retina;-such as long-continued 
exertion of the eye on minute objects;-or exposure to glaring 
light, especially if combined with heat-and these exciting causes 
are particularly aided by intemperance, stooping, tight neckcloths, 
too much sleep in bed, and any other circumstances capable of pro- 
ducing determination of blood to the head. Amaurosis may also 
be a consequence of organic change, inflammation, concussion, 
compression from extravasated blood, fractured bone, morbid effu- 
sions, tumours or aneurisms-whether affecting the brain, optic 
nerves, or eye. 
Treatment.-The indications in every case are, 1. To rectify 
any palpable disorder-inflammation or plethora by depletion;- 
debility by tonics. 2. To neutralize determination of blood to the 
eye or head by counter-irritation. 3. To stimulate and restore the 
excitability of the retina. For practical purposes, it will be conve- 
nient to classify the disease under the five following heads, viz. 1. 
Inflammatory; 2. Atonic; 3. Sympathetic cases; 4. Those pro- 
duced by poisons; and 5. By organic disease. 
1. Inflammatory.-(a.) If amaurosis be attended with any of 
the symptoms of retinitis that have been before enumerated ; 
(6.) Or if it suddenly follow some injury to the eye, such as a 
punctured wound, or blow on the naked eyeball, or exposure to a 
flash of lightning; or if the patient has been engaged in occupations 
that necessarily tax the eye severely, such as reading and writing 
much by candle-light; exposure to the intense light reflected from 
snow; staring at an eclipse of the sun, and so forth; 
(e.) Or if there are plethora, headache, giddiness, red turgid coun- 
tenance, with a hot skin and a hard pulse,-and if there are fre- 
quent flashes of light, or streams of red-hot balls seen before the 
eyes, (especially when stooping, or undergoing some active exer- 
tion) ; 
fl.) Or if the complaint has followed a suppression of any accus- 
tomed evacuation, such as bleeding from piles ; or the translation of 
erysipelas or gout; or the suppression of the menses from exposure 
to cold; or the sudden suppression of perspiration; or the drying 
up of an habitual ulcer or eruption ; or if it accompanies the inflam- 
matory hydrocephalus that sometimes follows scarlatina; in all 
these cases the antiphlogistic treatment must be adopted, and should 
be pursued with vigour. 
Bleeding, or cupping, from 1he temple or mastoid process, should 
be performed at intervals. The bowels should be well cleared, the 
diet should be low, and all employment of the affected organ and 
all violent bodily exertion should be desisted from. Mercury should 
be administered-rapidly if the case be sudden in its attack, and 
present urgent inflammatory symptoms-but more slowly if it pre- 
sents a more chronic aspect-but in either case it should be given AMAUROSIS. 
367 
so as to bring the system under its influence, and its effects should 
be kept up for some time. Small doses of tartarized antimony may 
sometimes be conveniently combined with the mercury (calomel 
gr. ii. ant. tart. gr. J,) or may be given according to F. 34and 35. 
Counter-irritants of all sorts are beneficial; blisters, or the tartar- 
emetic ointment applied behind the ears, or to the nape of the neck 
-immersion of the feet in hot water and mustard-or an issue in 
the arms in chronic cases. 
2. Jltonic amaurosis may come on at the close of some long and 
exhausting illness, or may be produced by great loss of blood, 
menorrhagia, immoderate suckling, leucorrhoea, excessive venery, 
or other debilitating circumstances. It may be distinguished by its 
being attended with general debility, pallid lips, frequent trembling 
pulse, dilated pupils, and despondency of mind;-and the patient 
generally sees best after a meal or a few glasses of wine, and in a 
strong light. The practitioner must carefully examine into the 
causes of debility-whether they consist in some disorder of the 
system, or in depraved and unhealthy habits of life. The treatment 
consists, first, in suppressing any habitual discharge, or other source 
of exhaustion. Secondly, in strengthening the system by change 
of air, tonics, quinine, steel and zinc, and especially by good living. 
At the same time the abdominal secretions should be well regulated 
by aperients, (such as aloes and rhubarb,) that act copiously, but 
not drastically; and the cutaneous and general circulation be pro- 
moted by exercise and bathing, especially the shower-bath. Cam- 
phor, or arnica, assafoetida, and other fetid stimulants, or strychnine 
in very small doses (gr. may be of service. It is in this form, if 
in any, that local stimulants are applicable-such as exposing the 
eye to the vapour of aether, or sal volatile, (a teaspoonful of either 
being held in the hand,)-taking electric sparks from the eye; 
stimulating snuff, (F. 32, 33,) cataplasms of capsicum to the temples; 
strychnine applied to the temples after the skin has been denuded by 
a blister, beginning with gr. j, and gradually increasing it to gr. i; 
-friction of the forehead with cajeput or croton oil, or with an 
alcoholic solution of veratria.* 
3. Sympathetic.-(a) Amaurosis not unfrequently supervenes 
on an attack of jaundice. If there be evidence of congestion in 
the head, as there frequently will be, blood should be taken by 
cupping, whilst the abdominal disorder should be removed by 
appropriate measures. 
(6) If there be headache, vertigo, foul tongue, disagreeable eruc- 
tations, tumid belly, and other evidence of abdominal congestion 
and disorder, emetics, repeated once or twice a week, blue pill or 
hyd. c. creta, in small doses every night; and purgatives such as 
senna, aloes, and rhubarb, with soda, magnesia, and ipecacuanha, 
till the secretions are set to rights, followed by tonics and counter- 
irritants, are the requisite measures. In similar cases, some foreign 
authors recommend the use of Schmucker's or Richter's resolvent 
* The dose of arnica is, f§i of an infusion, made with ^ss of the dried leaves, 
to Oj of boiling water. It should be combined with aromatics. 368 
SHORT AND LONG SIGHT. 
pills, F. 34, 35. Turpentine should be given both as a purgative 
and enema, if there be signs of worms. 
(c) Amaurosis sometimes arises from irritation of the fifth pair of 
nerves. If it follow a wound on the forehead, the latter should be 
dilated, or if it have healed, the cicatrix should be cut out. Tumours 
of all sorts near the eye, and carious teeth, should be removed. 
4. From poisons.-Amaurosis is liable to be induced by certain 
narcotico-acrid poisons, such as belladonna, and especially by to- 
bacco, whether administered in poisonously large doses by acci- 
dent, or used slowly and frequently in the form of snuff or smoke. 
If the amaurosis persists after the ordinary effects of the poison 
have been got rid of by the usual measures; the cold shower bath, 
counter-irritation, electricity, and small doses of mercury are the 
remedies most likely to be of service. Amaurosis is also one of the 
set of paralytic affections which lead may induce. The treatment 
must be conducted on the same principles. 
5. Organic.-These cases are the most hopeless. If the disease 
has followed an injury of the head, or fit of apoplexy, or syphilis, 
or if there be reason to suspect a tumour in the brain, or in the 
course of the optic nerve,-a moderate course of mercury, with 
alkalis, and sarsaparilla, and with counter-irritants, and attention 
to the general health, should be tried, and sometimes may effect a 
cure. For other cases of amaurosis arising from organic disease, 
especially if there be fixed pain in the head, palsy, or epilepsy, or 
idiocy, the best thing that the surgeon can do will be to prevent con- 
gestion in the head by occasional depletion, and counter-irritation; 
-to maintain the secretions of the liver and bowels;-to keep up 
the strength by a nutritious but not stimulating diet, and to guard 
the patient from every excess or exertion, mental or bodily, that is 
capable of accelerating the cerebral circulation. 
SECTION XV. OF SHORT AND LONG SIGHT. 
I. Short Sight or Myopia.-This affection appears to depend 
either on an increase in the refractive power of the eye, or else on 
an elongation of its axis, so that in either case the rays of light 
are brought to a focus before they reach the retina. The cornea is 
generally exceedingly convex, and the secretion of aqueous humour 
abundant; and the crystalline lens is also probably too convex, all 
of which circumstances would cause the refractive power of the 
eye to be increased. It is most frequently congenital, and is per- 
ceived in early childhood; but doubtless, if not congenital, it may 
be brought on during youth by too close attention to study and by 
habits of looking at minute objects, which irritate the eye, and 
cause the secretion of aqueous humour to be increased, and render 
the cornea more convex. It is a popular error to imagine that the 
sight improves as the individual grows older. 
Treatment.-The eyes should be exercised and accustomed to 
look at distant objects. When children display any tendency to SQUINTING. 
369 
short sight, their studies should be abridged, and they should have 
plenty of exercise in the open air. Shooting, archery, cricket, and 
field sports in general, are highly beneficial. It is worth while also 
to try a plan of treatment invented by Berthold, and consisting in 
the use of an instrument which has received the sesquipedalian 
title of myopodiorthoticon. This is really nothing more than a 
support for the chin, to prevent the patient stooping forwards, 
whilst he reads from a book with large print. And the book is 
every day to be placed at a slightly greater distance from the eyes, 
till the patient has acquired the faculty of reading at the ordinary 
focal distance-that is to say, at about fifteen inches. The glasses 
which are adapted for shortness of sight are concave ; since they 
tend to disperse the rays of light, and prevent their coming to a 
focus so soon. They need not be resorted to, however, if the 
patient can go on pretty comfortably without them; or at all events 
should only be worn when required to prevent him from stooping 
awkwardly whilst reading or playing music. But if the myopia 
is very decided, or if the eyes feel fatigued after any ordinary use 
of them, it well be better to wear the glasses continually. Spec- 
tacles should always be used in preference to a single glass. The 
patient should choose a pair that enables him to see objects within 
forty feet as distinctly as other people,-the names on the corners 
of the street for instance ; but should not have them so concave as 
to make objects appear dazzling, or smaller than usual. 
II. Presbyopia, or longsightedness, depends apparently on a 
diminished quantity and density of the humours of the eyeball, 
through which it becomes flatter, and its refractive powers are 
diminished. It needs scarcely be said that it is one of the earliest 
signs of impaired nutrition in old age. The patient's sight must be 
remedied by convex glasses; but he should not resort to them at 
first-nor change those first selected for stronger ones before he is 
absolutely compelled; and the sight should be spared by candle- 
light as much as possible. The glasses should cause minute objects 
near the eye to appear bright and distinct, but not larger than natu- 
ral. If they do, they are too convex.* 
SECTION XVI. OF SQUINTING. 
Squinting, or Strabismus, may be defined to be a want of paral- 
lelism in the position and motion of the eyes. 
The essential cause of the affection appears, in most instances, to 
be some weakness of sight, or some want of adjustment in the 
visual axis of the affected eye, in consequence of which it is invo- 
luntarily turned aside, in order to avoid the double or distorted 
* An elderly gentleman, who had been some time presbyopic, met with a vio- 
lent fall and contusion of the eyes; which doubtless produced an increased secre- 
tion of aqueous humour, and restored his power of seeing at the ordinary focal 
distance. Presbyopia occurring in young persons generally arises from intestinal 
irritation, and may be a precursor of amaurosis. 370 
SQUINTING. 
vision that would result from looking at objects with two eyes of 
different powers. The immediate mechanism by which the squint 
is produced, is most probably a relaxed or inactive state of the 
external rectus muscle, so that its antagonist muscle, the internal 
rectus, preponderates in force, and draws the eye inwards.* Some- 
times, although more rarely, it may be supposed that the affection 
commences by an original spasm of the internal rectus. 
The ordinary form of squint is the convergent, or that in which 
the eye is turned inwards; the divergent, or that in which the eye 
is turned outwards, is more rare. It occasionally happens that both 
eyes squint; but it must be remarked that they do not both squint 
at the same time, but alternately. When one eye is distorted and 
fixed, the affection is called luscitas. 
Causes.-1. Squinting may be caused by congenital malforma- 
tion. 
2. It may be induced by bad habits; such as the imitation of 
parents, nurses, or schoolfellows, if they happen to squint;-or by 
constantly looking at spots and pimples on the nose; or it may 
follow affections (such as hordeolum) which render motion of the 
eye painful; and during which the patient turns the eye inwards, 
and keeps it motionless. 3. It may be caused by using one eye 
constantly to the neglect of the other. It may be observed, that all 
shortsighted persons have more or less tendency to squint, for the 
following reason. They never use both eyes whilst they are read- 
ing or examining small objects near the eye; but sometimes use 
the right eye, and sometimes the left. If, however, they were by 
accident to persist in using one only, it would become stronger by 
use, and the other weaker by disuse ; and the weaker might squint. 
In this manner, squinting has been known to occur after one eye 
has been for a long time shaded in consequence of an inflammatory 
attack ; which shows the expediency of always covering both eyes 
when a shade is necessary. 4. If there happens to be an opacity 
on the cornea of one eye, and that eye is the better one, the patient 
will sometimes continue to use it for ordinary vision, but for that 
purpose is obliged to distort it so as to remove the corneal opacity 
from the visual axis. 5. Squinting, like almost every other con- 
ceivable consequence of defect of nervous influence, is sometimes 
a relic of fevers and the exanthemata. 6. It may be induced by 
irritation or disorder of the stomach and bowels, teething, worms, 
constipation, and so forth;-it may, moreover, be caused by fright 
or violent fits of passion; and in some children it always appears 
when the health is out of order, and disappears when it is restored. 
Lastly, it may be caused by some disorder of the circulation in the 
brain. Thus it is pretty frequently the precursor of acute hydro- 
cephalus or convulsions in children ; and when it is associated with 
• This is shown by the results of the operation of dividing the internal rectus, 
after which the eye is merely drawn by the external rectus into its natural posi- 
tion; whereas, when (in various accidents) one of the recti of a sound eye has 
been severed, its antagonist has drawn it completely over to its own side. Vide 
Sir C. Bell, Practical Essays, 1841. SQUINTING. 
371 
dropping of one or both eyelids, and with unusual sleepiness, or 
torpor of the intellect, or faltering in the gait, some mischief within 
the head may fairly be anticipated. 
Treatment.-If the affection be recent, it may perhaps be re- 
moved by judicious medical treatment. The patient should be 
secluded from the society of every squinting person who might be 
imitated. Any disorder in the stomach or bowels should be re- 
moved by purgatives, antacids, and tonics; and if the patient is a 
weakly child, and if the squinting has followed a severe illness, a 
course of steel wine, or small doses of sulphate of zinc, may be of 
service. An endeavour should be made to strengthen and exer- 
cise the squinting eye, by covering the sound one with a light shade 
for one or two hours every day; but this must be done with mode- 
ration ; because it has happened, that whilst a squinting eye has 
been cured by this means, the sound one has been weakened by 
seclusion, and has been made to squint instead. It is a useful plan 
to make the patient exercise his eye before a glass in the following 
manner. He should be told to close the sound eye, and look at a 
particular point with the squinting one. Then let him open the 
sound eye. Upon this, the squinting eye will immediately diverge; 
but by perseverance the patient may educate it, till he can com- 
mand it, and keep it parallel with the other. If a child is begin- 
ning to squint, it should be carefully watched, and be told to 
endeavour to correct it; close application to study should be inter- 
dicted ; plenty of exercise should be taken in the open air; and if 
the sight is short, a pair of shallow concave spectacles should be 
used. Lastly, cases are related of recent squinting cured by very 
small doses of strychnia, and by taking electric sparks from the 
eye, or by passing slight galvanic currents between the frontal and 
infraorbital nerves. 
But if the squint is of long standing and is habitual, very little 
good can be done unless the internal rectus muscle is divided; or 
the external rectus, if the squint is divergent. This operation (the 
rationale of which will be alluded to in the chapter on Club Foot) 
will be of equal efficacy, whether the squint is produced by spasm 
of one muscle, or by weakness of its antagonist. It is easily per- 
formed in the following manner. 
The patient, if an adult and 
manageable, sits in a low chair; 
if an unruly child, he should be 
rolled up in a sheet, and be placed 
on a table, with the head sup- 
ported by a pillow. The sound 
eye should of course be ban- 
daged, and an assistant should 
place two fingers on it to keep 
it steady during the operation. 
Then the upper lid of the squint- 
ing eye being held up by the as- 
sistant's finger, or by a wire spe- 
Fig. 105. 372 
MALIGNANT DISEASES OF THE EYE. 
culum, and the lower lid being held down by another assistant's 
finger, or by a small catch or bulldog forceps, (which may be 
made to seize the conjunctiva inside the lid, and will hold it down 
by its weight,)-these preliminaries being arranged, the surgeon 
introduces the fine double hook into the conjunctiva just inside 
the cornea, and having drawn the eye outwards, gives it to an 
assistant to hold steadily. Then he raises the conjunctiva on the 
inner side of the eyeball with a forceps, and divides it perpendicular- 
ly with the curved scissors. Next, he raises some reddish cellular 
tissue, and cuts through it in the same manner: and thirdly, he cuts 
through the muscle; which being divided will expose the clear 
white sclerotic. He should be careful to divide perpendicularly 
every fibre which covers the sclerotic for the extent of half an 
inch; and if he does so he will find that the patient can move the 
eye more freely than before in all other directions, but that he 
cannot move it directly inwards. This is a sign that the operation 
is complete. 
After the operation the eye should be protected from cold and 
light, and any inflammatory symptoms be checked by appropriate 
measures. But it is very rarely succeeded by any untoward symp- 
toms, although the author knows more than one case in which the 
eyeball suppurated and burst. 
This operation may be performed for two purposes. The first 
is, to get rid of the deformity'of the squint. And this purpose is 
generally answered effectually; although it must be confessed that 
the inner side of the eyeball is apt to project somewhat, and the 
eye to look large and goggled. But the patient must make his own 
choice between this and the squint. 
The second purpose is that of strengthening the eye, and enabling 
the patient to bring it into use. And this purpose is no doubt an- 
swered in some measure, so that both eyes are used for the vision 
of remote objects, and the patient says that the eye feels stronger 
and clearer; but it is not likely to be useful in near vision till after 
a long time, if at all. Moreover, after the operation, it is very 
common for some degree of double vision to be complained of. 
This will be perfectly intelligible when it is considered that objects 
are viewed by two eyes of different powers and adjustments. But 
this inconvenience soon passes off, because the patient learns to 
neglect the image presented by the weaker eye. 
SECTION XVII. - OF MALIGNANT DISEASES OF THE EYE. 
I. Scirrhus.-After years of supposed inflammation, the eye 
becomes shrunk and hard, and the conjunctiva tuberculated, thick- 
ened, and red. The eye is exquisitely tender; there is much 
burning or lancinating pain, and severe hemicrania. After a time, 
ulceration occurs, and spreads to the neighbouring parts, and the 
patient sinks. MALIGNANT diseases of the eye. 
373 
Treatment.-Extirpation, if it can be adopted before the lids are 
affected ; if not, the local and general employment of narcotics. 
IL Fungus Me dull arts is not unfrequent, especially in children. 
Its most frequent seat is the termination of the optic nerve. The 
eye is accidentally discovered to be blind, and a small tumour of a 
peculiar metallic lustre can be detected very deep behind the pupil. 
This gradually advances, and generally appears whitish or yellow- 
ish, and lobulated, and more or less streaked with blood-vessels. 
In a space of time, varying from a few months to two or three years, 
the cornea bursts before the enlarging tumour, a bleeding fungus 
protrudes, the cervical glands enlarge, and the patient perishes. 
There is not usually much pain before the cornea begins to be 
distended. Melanosis is sometimes combined with this disease. 
Treatment.-Much may be hoped from a light nutritious diet, 
fresh air, occasional leechings, and a gentle course of mercury, which 
should be kept up for some weeks. By these means the disease, if 
malignant, may be checked; if not malignant, may be cured. Ex- 
tirpation is scarcely ever deemed advisable in children, (1) because 
the disease, if really malignant, is sure to return; (2) because there 
are sundry scrofulous tumours which cannot be distinguished from 
the malignant, and which either disappear, or give no trouble. The 
diagnosis may be considered doubtful, if such tumours follow an 
evident wound or injury; if there be scrofulous disease in other 
parts, and if the eye shrink and become atrophic. 
III. Extirpation of the Eye.-The operator first passes a liga- 
ture through the anterior part of the globe in order to steady it, or 
else seizes it with a hook or vulsellum, and slits up the external 
commissure of the lids. Then he raises the upper eyelid, cuts 
through the fold of conjunctiva reflected from it to the eye, and 
dissects backwards, so as to separate all the soft parts from the roof 
of the orbit. The same process is repeated below and on the sides 
-taking care to cut close to the bone, and to remove the lachrymal 
gland. Then a curved knife is introduced on the outer side to cut 
through the optic nerve and origin of the muscles, and so the eye is 
detached. The patient must then be put to bed, with a cloth dipped 
in cold water laid over the face. If there is a very great haemor- 
rhage from the ophthalmic artery, it may be restrained by pressure 
with a piece of lint,-which should be removed as soon as it is sup- 
pressed ; but it is better not to stuff the orbit with lint if it can be 
avoided. 
After staphyloma or any other disease which has rendered the 
eyeball shrunken and sightless, if the patient objects to the trouble 
and expense of an artificial eye, it may be convenient to divide the 
levator palpebrae, in order that the lids may remain permanently 
closed. This may be effected by making a transverse incision in 
the upper eyelid just below the orbit, and seizing the belly of the 
muscle as far back as possible. Then a piece should be snipped 
out of it with scissors. 
IV. Encanthis is an enlargement of the caruncula lachrymalis, 
and semilunar fold of the conjunctiva, which may be easily extir- 374 
diseases of the ear. 
pated by curved scissors. Sometimes, however, it assumes a 
malignant action, becoming dull red, very hard, and subject to lan- 
cinating pain; and finally it degenerates into a cancerous ulcer. 
Sir A. Cooper thinks that in this case extirpation is inadmissible.* 
CHAPTER XIII. 
OF THE DISEASES AND INJURIES OF THE EAR. 
I. Foreign Bodies may be removed from the ear by syringing 
it violently with warm water-or by a pair of small forceps-or by 
a small scoop, or curette, or bent probe, which may be introduced 
behind the intruding substance, so as to draw it forwards. Insects 
may be removed by similar means, or by introducing a piece of 
cotton fastened to the end of a probe, and smeared with honey, or 
some other viscid substance. 
II. Acute Otitis.-Acute Inflammation of the external ear 
is known by violent pain in the part, which is increased by pressure, 
and by noise, as well as by the motions of the head and of the lower 
jaw, and by exposure to cold air. Hearing is confused, and there 
are noises in the ear {tinnitus aurium}. The meatus is swelled, 
and highly vascular, and secretes a thin serous fluid. Inflammation 
of the internal ear is attended with much severer pain, and constant 
ringing, throbbing sounds. Both are accompanied with severe head- 
ache and fever, and may prove fatal. They are generally caused 
by cold, or foreign bodies, or by gastric derangement, and are most 
frequent in children. 
Treatment.-Leeches behind the ear, or bleeding, if the patient 
is old enough to bear it, and if it is demanded by violent fever and 
delirium;-subsequently, an emetic, followed by a dose of calomel 
with antimony, purgatives, and salines. The ear may be very 
gently syringed with poppy decoction, or milk and water, or may 
be poulticed. All foreign bodies, or hardened wax, should be 
gently removed. Blisters should be applied to the nape of the neck, 
or behind the ear, when the acute stage is subsiding. If the cavity 
of the tympanum have suppurated, which will be known by an 
* Vide Lectures by Professor Green, in Sir A. Cooper's Lectures, Renshaw's 
edit.; Lawrence on Diseases and on Venereal Diseases of the Eye; Copland Diet., 
Art. Eye, Amaurosis, &c.; Middlemore on Diseases of the Eye; Guthrie on the 
Operative Surgery of the Eye, and in Lond. Med. and Surg. Journal; Littell's Com- 
pendium ; Foot's Ophthalmic Memoranda; Morgan on the Eye, Lond. 1839; Tyrrell 
on the Eye, Lond. 1840 ; and especially Mackenzie on Diseases of the Eye, 3d edit., 
Lond. 1840, a work of the greatest erudition and practical utility. Much informa- 
tion and amusement may also be derived from Hull on the Morbid Eye, Lond. 1840, 
which contains much sterling sense under a vein of pleasantry and affectation of 
pedantry. CARIES. 
375 
aggravation of the throbbing pain and headache, and by a sense of 
weight and bursting in the ear, and by the membrana tympani* 
appearing white and convex externally, it should be opened with 
a long slender knife, to save the pain and delay of its ulcerating or 
bursting. But this operation should not be hastily performed ; and 
if early and free antiphlogistic measures are employed, it will rarely 
be required. , 
III. Otorrhiea-that is to say, a mucous or muco-purulent dis- 
charge from the ear, is a very common complaint in scrofulous 
chil<^fen, and may last for a long term of years. It generally begins 
with feverishness, headache, intense pain in the ear, and swelling 
of the glands of the neck; all which acute symptoms subside when 
a copious thin yellow discharge appears, which becomes fetid if 
great attention is not paid to cleanliness. 
Treatment.-Mild aperients should be given frequently, to- 
gether with tonics, such as iron, bark, and iodine, in the manner 
directed for scrofula. Sulphur is much praised as a laxative in 
these cases. It is well known that sundry dangerous affections of 
the brain, or disorders of the eye, or of other parts, are liable to 
supervene upon the suppression of this discharge. Therefore, till 
the constitution is set to rights, no other local applications should 
be used save mild injections to cleanse away the discharge ; such 
as warm milk and water, or dec. papav.;-avoiding oily matters, 
lest they become rancid and irritating. If, under the employment 
of these measures, the discharge diminishes, without any ill conse- 
quences, mild astringent injections may be tried, beginning with 
lime-water, or inf. rosae, and afterwards the different lotions in F. 
36, 37, 21, 22, taking care to increase their strength very cautiously, 
especially if the membrana tympani has been perforated by pre- 
vious ulceration or suppuration. If the discharge ceases suddenly, 
and there is pain in the ear or head, hot poultices or fomentations, 
and the remedies for acute inflammation, should be adopted. If 
the discharge .continues very obstinately, blisters may be applied 
to the nape of the neck; but great care should be taken not to let 
the discharge come in contact with the blistered surface, for which 
reason they should not be applied behind the ears; because the dis- 
charge is liable to produce a porrigo, or impetigo larvalis;-that is 
to say, a superficial inflammation of the skin, producing a profuse 
secretion of a yellowish nauseous discharge which dries into scabs.! 
IV. Caries of the temporal bone, especially of the mastoid pro- 
cess, may be a consequence of extension of inflammation from the 
mucous membrane of the ear, particularly if the cavity of the tym- 
panum has suppurated, and matter has lodged and become putrid, 
after the membrana tympani has burst, or has been opened. There 
* In order to bring this part into view, the auricle requires to be drawn out- 
wards, upwards, and forwards; if necessary, the meatus must be dilated with a 
speculum. 
. j- Although the impetigo larvalis, or porrigo larvalis, is generally said not to be 
contagious, the author has witnessed numerous cases which have convinced him 
that it is so; and he has seen a wide spreading impetigo larvalis produced on the 
throat from the contact of the discharge from the ear of a scrofulous child. 376 
DISEASES OF THE EAR. 
is constant otorrhoea, and the discharge is sanious and fetid, and 
stains silver probes. This is a most serious disease. Death may 
be caused by extension of the caries to the cranial cavity and sup- 
puration on the dura mater, or by inflammation of the brain or its 
membranes, through contiguous irritation,-or the side of the face 
may be palsied through compression of the portio dura. Some- 
times an abscess bursts behind the ear, or burrows amongst the 
muscles of the neck and points low down. 
Treatment. - Tonics, alteratives, counter-irritants, and mild 
astringent injections, frequently repeated, to wash away the^fetid 
discharge. Abscesses near the ear should be opened as soon as 
possible. Injections of weak nitric acid lotion (F. 17) may be 
employed to correct the disease of the bone, provided there is no 
fear that it may have reached the dura mater. If the patient be 
labouring under secondary venereal symptoms, sarsaparilla may be 
given with advantage. If inflammation, or symptoms of compres- 
sion of the brain supervene, they must be treated as was detailed 
in Chapter X., recollecting that depletion and mercury must be 
used with the greatest moderation, as they cannot remove the ex- 
citing cause. 
V. Earache-(otalgia}.-(1.) Genuine neuralgia of the ear,- 
occurring in fits of excruciating pain, shooting over the head and 
face,-may be distinguished from otitis by the sudden intensity of 
the pain, which is not throbbing,-does not increase in severity,- 
is not attended with fever,-and comes and goes capriciously. Its 
causes are the same as those of neuralgia generally, but particu- 
larly caries of the teeth ; and its treatment principally consists in 
removing carious teeth, or stopping them, and giving large doses of 
carbonate of iron. 
(2.) Common earache, which is frequently produced (in children 
especially) by decay of the posterior teeth, or by cold, although a 
sympathetic affection, is generally somewhat inflammatory. 
Treatment.-An emetic and purgative will mostly be of service. 
Carious teeth should be extracted, and gum-boils be opened. The 
pain may be relieved by filling the meatus with a warm mixture 
ofol. oliv. 5i, tinct. opii 5i, the concha being plugged with cotton, 
to keep it in; or by exposing the ear to the vapour of sp. aether, c. 
oiii aq. f$iv, which may be put into a phial, immersed in hot water, 
-or by the crumb of a hot loaf applied to the head;-or by spong- 
ing the head with hot water, and wrapping it up in a cap of oiled 
silk; together with pediluvia and enemata, and, in obstinate cases, 
blisters. An examination for hardened wax, or foreign bodies in 
the meatus, should never be omitted. 
VI. Warts and excrescences in the meatus are not uncommon 
consequences of chronic inflammation, and may be snipped off, if 
they are not removed by the various injections before mentioned. 
VII. Hypertrophy of the External Ear.-Dr. Graves men- 
tions a case in which the pendent lobes of the ears became thick- 
ened and elongated through a deposit of fat into their cellular tissue, 
in a patient who died of fatty degeneration of the liver. The author DEAFNESS. 
377 
has seen one or two cases in which the whole external ear was 
excessively enlarged and thickened; but he would not have in- 
cluded them in this chapter, had not Dr. Graves appeared to con- 
sider the affection as an uncommon one.* 
VIII.-(1.) Deafness may be a consequence of very many 
pathological conditions; but the researches of Mr. Toynbee have 
shown that in the majority of instances it depends on an inflamma- 
tion and thickening of the membrane that lines the cavity of the 
tympanum, and not on any change in the nervous apparatus of the 
ear. . He divides the changes in the tympanic cavity into three 
stages. In the first stage, the membrane retains its natural deli- 
cacy of structure, but its vessels are enlarged and tortuous ; blood 
is sometimes effused into its substance, or on its attached surface, 
or sometimes between it and the membrane of the fenestra rotunda; 
and sometimes lymph is effused on its free surface. In the second 
stage, the membrane is thickened and flocculent; and occasionally 
covered with cheesy, tuberculous, or fibro-calcareous concretions; 
but the morbid change most frequently observed consists of fibrous 
bands, which are sometimes numerous enough to occupy nearly 
the whole of the cavity. In some instances they connect the inner 
surface of the membrana tympani to the inner wall of the tympanic 
cavity ; or to the incus and stapes ; but by far most frequently they 
extend from the crura of the stapes to the adjoining wall of the 
tympanum. In the third stage the membrana tympani is ulcerated; 
the ossicles discharged, and the whole middle ear disorganized.! 
Mr. Toynbee's researches, show that a very small proportion of 
cases of deafness can be considered as nervous, and that a few 
leeches close behind the ear, followed by blisters, is a course of 
treatment much more likely to be beneficial than the stimulating 
injections into the meatus which are too frequently resorted to by 
ear doctors and quacks. 
(2.) Deafness is sometimes caused by chronic inflammation of 
the external meatus, or membrana tympani, with thickening, or 
excrescences of the membrane, and purulent discharge. These cases 
must be treated by blisters behind the ear, attention to the health, 
and the cautious use of injections. If the cuticle of the meatus and 
membrana tympani is much thickened, injections of arg. nit. or of 
ung. hydr. nit. $j, ol. oliv. 5iii. are much recommended. The internal 
ear may have suppurated, and the ossicula may have sloughed 
away, but still deafness is not total unless the stapes has perished, 
-the loss of which lays open the fenestra ovalis, and permits the 
escape of the fluid in the labyrinth. 
(3.) .Accumulations of hardened wax are an occasional cause 
of deafness, and depend on a diseased state of the meatus. They 
should be frequently removed with the syringe. In syringing the 
ear, the water mostly requires to be rather hot, and a little wool 
* Graves's Clinical Medicine, p. 581. 
f As a proof of the small number of persons whose hearing is quite perfect, Mr. 
Toynbee found in 120 dissections, 29 healthy; 20 in the first stage of tympanic dis- 
ease ; 65 in the second stage, and 6 in the third stage. 378 
DISEASES OF THE EAR. 
should be introduced afterwards to prevent cold.* Combinations 
of oxgall jii vel ol. terebinth fsj with ol. oliv. fjvii, or tinct. cas- 
torei, are occasionally dropped into the ear in these cases; and they 
are also sometimes used when it is conceived that there is a defi- 
ciency of wax; but such applications quite as frequently do harm 
as good. 
(4.) Deafness is sometimes caused by tumours of the tonsils 
obstructing the eustachian tubes, or by relaxation of the mucous 
membrane of the throat, with secretion of viscid mucus in the 
tubes-or by contraction, or by obliteration of the tubes consequent 
upon ulcers,-a thing not uncommon after scarlet fever or venereal 
sore throat; and these morbid conditions of the throat are probably 
accompanied with a diseased condition cf the membrane lining the 
tympanic cavity. These cases will be known by the patient's his- 
tory, and by an examination of the throat. 
Treatment.-Chronic sore throat, or swelling of the tonsils, must 
be removed by stimulating and astringent gargles, or by touching 
the parts with a hair pencil dipped into a strong solution of nitrate 
of silver; as well as by the use of tonics, counter-irritants, and 
attention to the general health. If these measures fail, the enlarged 
tonsils must be abridged by the knife. The eustachian tubes may 
be known to be pervious if the shock of air can be heard against 
the membrana tympani, by means of the stethoscope applied to 
the mastoid process, whilst the patient closes his mouth and nostrils 
and makes a strong expiration. These tubes or the cavity of the 
tympanum may be known to be clogged with mucus, when loud 
crackling or gurgling noises are heard by the patient, (or by the 
surgeon with the stethoscope,) when he expires strongly with the 
mouth and nose closed. For this state, it is useful to wash out 
the tube and tympanum with warm water. A bent silver catheter 
(of the size of a common probe) is introduced along the floor of 
the inferior meatus of the nostril into the pharynx. It should be 
introduced with its convexity uppermost; and when it has reached 
the pharynx, if its point be turned upwards and outwards, it will 
slip into the tube. Warm water may then be gently injected by a 
syringe, and if the tube be pervious, it will be heard and felt to 
strike against the membrana tympani. If the tube be not pervious, 
a catgut bougie (made of the small E string of a harp) may be 
very gently passed through the catheter to dilate it. But this 
bougie should never be introduced more than an inch and a half 
into the tube, and should on no account be passed quite into the 
tympanum. Moreover it is quite fruitless to perform this operation 
if the patient cannot hear a watch tick when it is nut between his 
teeth. Perforation of the membrana tympani may be resorted 
to when the eustachian tube is known to be quite impervious. It 
is best accomplished by means of an instrument that cuts out a 
little circular piece. 
(5.) Deafness is often caused by blows on the head, which either 
* It is never justifiable to put wool or cotton into the meatus,- it should merely 
be put loosely into the cavity of the concha. SALIVARY FISTULA. 
379 
produce concussion or rupture of the auditory nerve, or else extra- 
vasation of blood into the tympanum or labyrinth. Depletion, if 
any inflammatory symptoms are present, with alteratives and 
counter-irritants afterwards, are the only remedies; but if deafness 
immediately succeed the injury, they will scarcely relieve it. 
(6.) It may be produced by organic alterations in the brain, 
tumours or the like, and may be attended with epilepsy or idiocy, 
or may be a consequence of apoplexy or convulsions. The treat- 
ment must be the same as for amaurosis arising from similar causes 
(p. 368). 
(7.) It is sometimes connected with general plethora, or with 
suppressed menstrual or haemorrhoidal discharge, and attended 
with giddiness, tinnitus and flushings of the countenance. To be 
treated antiphlogistically. 
(8.) Deafness is said to be nervous when it depends on general 
torpor and debility, and is better at some times than at others, 
especially in fine weather, and when the patient is cheerful or 
excited, and the stomach in good order. 
Treatment.-Aperients and alteratives, with diffusible stimu- 
lants, especially ammonia, aether, and valerian, taken occasionally, 
and the employment of excitants locally; such as stimulating gargles, 
(tinct. capsici f^ss ad inf. rosae Oss,) masticatories of pellitory; 
snuffs, (F. 32.) the introduction of ox gall or turpentine, or the 
vapour of aether or of sp. am. ar. into the meatus, and the applica- 
tion of garlic, mustard, and other counter-irritants behind the ear. 
Electricity may be mischievous.* 
CHAPTER XIV. 
OF THE DISEASES AND INJURIES OF THE FACE AND NOSE. 
I. Salivary Fistula signifies a communication between the 
stenonian duct and the skin, so that the saliva dribbles out on the 
cheek. It may be caused by wounds or ulcers. 
Treatment.- In the first place, a good passage must be estab- 
lished from the duct into the mouth. This may be done by 
* Vide Copland Diet., Art. Ear and Hearing; Kramer on Diseases of the Ear, 
translated by Bennett; Pilcher on the Structure and Diseases of the Ear, Lond. 
1838; Essay on the Ear, by Joseph Williams, M.D. Lond. 1840; a paper by Mr. 
Toynbee in Med. Chir. Trans, vol. xxiv; and a notice of another paper read before 
the Med. Chir. Society, in Med. Gaz. 7th July, 1843. The last named gentleman 
gives an account of 120 dissections of the ear, and no doubt will succeed in 
rescuing the treatment of its diseases from the hands of the mercenary ignorant 
quacks who at present monopolize it almost entirely. 380 
epistaxis. 
puncturing the mouth through the fistula in two places, passing a 
small skein of silk, or, still better, a piece of very flexible wire, 
through the apertures, and securing the two ends in the mouth by 
a knot. After a few days the edges of the fistula must be pared, 
and be brought into contact by sutures, in order that they may 
unite by adhesion. When there has been a loss of substance, it 
may be necessary to apply the actual cautery to the margin of the 
aperture, in order that the fungous granulations succeeding the 
burn may supply the deficiency; or to cover it with a flap of skin 
raised from the adjoining parts. 
11. Lipoma is a term employed to signify an hypertrophy, or 
sarcomatous tumour, of the cellular tissue and skin of the nose, 
which is particularly liable to affect persons who have been 
addicted to the pleasures of the table. These tumours are very 
inconvenient and unsightly, but not malignant. They grow slowly 
-are indolent and painless-the sebaceous follicles are much 
enlarged, and secrete profusely, and the skin is more or less mottled 
with veins. 
Treatment.-If the patient desires it, the tumour may be re- 
moved with the knife ; but he must observe rigid abstemiousness, 
and have his bowels well cleared for a fortnight previously. An 
incision may be made in the median line nearly down to the 
cartilage. Then an assistant distends the nostrils with his fore- 
finger, whilst the surgeon seizes the morbid growth, and shaves it 
clean off-, close to the cartilage. After the operation, there will be 
considerable hsemorrhage from numerous vessels. Some of these 
may be tied, some may be pinched with a forceps, some may be 
secured with a very fine cambric needle and thread; and any 
general oozing may be restrained by the application of a cloth 
dipped in cold water, or if it be obstinate, by plugging the nostrils, 
and making pressure with strips of plaster. 
III. Foreign Bodies may be removed from the nose by a small 
curette, or scoop, or bent probe. If they cannot be brought through 
the nostrils, they may be pushed back into the throat. The removal 
should be effected as early as possible. 
IV. Epistaxis, or hsemorrhage from the nose, may, like other 
haemorrhages, be produced, 1st, by injury;-2dly, It may be an 
active haemorrhage of arterial blood through general excitement and 
plethora, or determination of blood to the head, or the suppression 
of some other discharge. 3dly, It may be a passive draining of 
venous blood, owing to obstruction of the circulation by disease of 
the heart or liver, or to a morbidly thin state of the blood, together 
with relaxation of the vessels, as happens in scurvy, purpura, and 
the last stage of fevers. 
Treatment.-(1.) If the patient be redfaced, plethoric, and sub- 
ject to headache and giddiness, the hsemorrhage should be regarded 
as salutary, and should not be restrained too suddenly. If it be very 
profuse, and attended with much headache, venesection may be per- 
formed, and at all events purgatives and low diet should be pre- 
scribed. Epsom salts in small doses, with dilute sulphuric acid, NASAL POLYPUS. 
381 
form an useful medicine. (2.) But the haemorrhage requires to be 
stopped, either if it have continued so long that the patient will be 
injuriously weakened,-or if it arise from injury,-or if it be a 
passive haemorrhage depending on visceral disease, or general ca- 
chexy. If an upright posture, cold applied to the head, and a piece 
of cold metal to the back, with a draught of any cold liquid, and 
compression of the nostrils, do not stop it; the patient may snuff up 
powdered gum, or gall nuts ; and, that failing, the nostril must be 
plugged with lint, or with putty. In very urgent cases, the posterior 
orifice of the nostril must be plugged also. This is easily done by 
passing a bougie, with a long piece of silk fastened to its end, through 
the nostril into the pharynx. The end of the silk is then brought 
through the mouth with a pair of forceps, and a piece of soft sponge, 
less than an inch in diameter, is tied to it. Then, by pulling the 
silk back through the nose, the sponge is drawn into the posterior 
opening of the nostril. The plugs, or coagula, in severe cases, 
should not be disturbed for three days. Nitre and other salines; 
or pills of plumbi acet., with draughts containing vinegar, F. 60, 61, 
may be given with advantage in inflammatory cases-and the 
nitric or sulphuric acids, opium, alum, quinine, small doses of tur- 
pentine, (n[xv.) and the ergot of rye, in those of atony and debility. 
V. Nasal Polypus.- There are four varieties of this affection. 
1. The common gelatinous poly- 
pus is a tumour of the consistence 
of jelly, pear-shaped, yellowish, 
slightly streaked with blood-ves- 
sels, attached by a narrow neck to 
the mucous membrane, especially 
that on the turbinated bones, and 
apparently consisting of organized 
lymph. The patient has a constant 
feeling of stuffing and cold in the 
head, which is increased in damp 
weather. If he force his breath 
strongly through the affected nos- 
tril, whilst he closes the other, the 
polypus may be brought into view. 
There are very often more than one of these tumours, and they are 
very liable to return when removed. If polypus be permitted to 
remain, it continually increases in size, blocks up the nostril, dis- 
places the septum, and obstructs the other nostril, causes prodigious 
deformity of the cheek, prevents the passage of the tears, and may 
even cause death by pressure on the brain. 
Treatment.-A probe should be introduced to feel for the neck 
of the polypus, which should then be seized with forceps, and be 
gently twisted off. If, as sometimes happens, it projects backwards 
into the pharynx, it must be extracted through the mouth with 
curved forceps. After the operation, the nostril should be plugged 
to restrain bleeding. 
2. The hydatid polypus is a rare species, consisting of a number 
Fig. 106. 382 
DISEASES OF THE ANTRUM. 
of thiii vesicles filled with a watery fluid, and attached by a pedun- 
cle. The vesicles burst upon the slightest pressure, and their repro- 
duction may be prevented by touching the peduncle frequently with 
a hair-pencil dipped in butter of antimony. 
3. The carcinomatous polypus is nothing more than a scirrhous 
tumour in the nose. It may be known by its occurring to elderly 
persons-by the cancerous cachexia, the hardness of the tumour, 
and lancinating pain. 
3. The fungoid polypus is a soft red tumour, growing with 
great rapidity, frequently bleeding, and pursuing the ordinary course 
of fungus hsematodes. This, like the last, admits only of palliative 
treatment. 
VI. Chronic Inflammation, and tumefaction of the Schneide- 
rian membrane, produces a constant feeling of weight and stuffing, 
as from a bad cold in the head, and more or less discharge, which 
is very apt to be fetid. It is very common in young persons of 
scrofulous constitutions, and if neglected may lead to a very obsti- 
nate ozama. It is to be treated, by applying one or two leeches to the 
inside of the nostrils, once or twice a week;-by keeping the bowels 
open with mild purgatives, and occasional doses of hyd. c. creta; 
and by administering sarsaparilla with alkalis, F. 56,57. Sometimes, 
in young children, the membrane swells into little red fleshy emi- 
nences, which may be touched with nitrate of silver, but must not 
be mistaken for polypi, nor be meddled with by the forceps. 
VII. Oz^na signifies an obstinate fetid discharge from one or 
both nostrils, depending on ulceration of the membrane, with or 
without disease of the bones. It is most frequently a venereal 
affection, and when so, must be treated accordingly. But it some- 
times occurs in scrofulous children, and in others who are perfectly 
free from venereal taint. Astringent injections-of nitrate of silver, 
sulphate of copper, &c.-and of the chlorides of soda and lime, or 
creosote to correct the fetor,-the citrine ointment applied by means 
of a camel's hair pencil, with attention to the health, are the only 
remedies. 
VIII. The nostrils are sometimes imperforate, owing to con- 
genital malformation. The passage may (if the parents wish it) be 
restored by a cautious incision, and must be kept open with bougies. 
If, however, the obstruction be seated far back, it ought not to be 
meddled with. 
DISEASES OF THE ANTRUM. 
IX. Abscess of the Antrum may be caused by blows on the 
cheek, but it more frequently results from the irritation of decayed 
tegth. The symptoms are permanent aching and uneasiness of the 
ohcBk, preceded probably by acute throbbing pain and fever and 
rigors, and followed, if an opening is not made soon, by a slow, 
general enlargement of the cheek, and loosening of the subjacent 
teeth. The parietes of the cavity sometimes become so thin from FUNGUS MEDULLARIS OF THE ANTRUM. 
383 
distension that they crackle on pressure like parchment. Sometimes 
(though rarely) the matter makes its way into the nostril; and 
sometimes the abscess points externally, or bursts into the mouth. 
Treatment.-A free aperture must be made into the cavity. If 
either of the molar teeth is loose or carious, it should be extracted; 
and a trocar be pushed through the empty socket into the antrum. 
But if the teeth are all sound, or if they have been all extracted 
before, an incision should be made through the membrane of the 
mouth above the alveoli of the molar teeth, and the bone be pierced 
by a strong pair of scissors or trocar, as represented in the following 
figure. The instruments should not be made of too highly tempered 
steel, lest they might break. The cavity should be frequently 
syringed with warm 'water, in order to clear away the matter, 
which is sometimes thick and lardaceous. If the discharge con- 
tinues profuse and fetid, search should be made with a probe for 
loose pieces of bone, which should be removed without delay, the 
aperture being enlarged if necessary. 
Fig. 107. 
X. Dropsy op the Antrum.-The antrum may become enor- 
mously distended, and its parietes thin and crackling on pressure, 
in consequence of an accumulation of its natural clear mucous 
secretion, if the aperture into the nostril has become obliterated. 
An opening must be made in the manner just described. 
XI. Fungus Medullaris may commence in the lining mem- 
brane of the antrum, or in the sockets of the adjoining teeth. In 
its first stage it forms a hard tumour in the cheek, with a constant 
sense of pain and uneasiness. After a time, some portion of it feels 384 
NON-MALIGNANT TUMOUR. 
soft and pulpy, and then bleeding fungous tamours project from 
the cheek, or into the mouth, or into the orbit, causing horrid pain 
and deformity, protruding the eye from its socket, and leading to 
the inevitable fatal results of fungus haematodes. 
Treatment.-The only remedy is extirpation of the superior 
maxillary bone; but, to be of any use, it must be performed before 
the diseased growth has burst from the cavity, and before the skin 
and lymphatic glands have become implicated. 
XII. A Non-Malignant Tumour is sometimes developed in 
the antrum, or on the external surface of the superior maxillary 
bone. On a section it appears a dense, homogeneous, fibrinous 
mass, containing spiculae of bone. Its origin is generally ascribed 
to external injury, or to disease of the teeth. It may be distinguished 
from malignant disease by noticing that its growth is slow, that its 
surface is lobulated, that it feels hard and elastic, like brawn inter- 
spersed with bony particles; that although the superjacent skin may 
become turgid and purple with distended veins, still that it does not 
become incorporated with the tumour; and that although ulceration 
may accidentally occur on its surface, still that the ulcers are 
superficial, furnish no fetid discharge, and may heal on the removal 
of the exciting cause.* These tumours may, if suffered to remain, 
destroy by suffocation or starvation. 
Treatment.-The tumour must be extirpated entirely. If of 
moderate size, and situated towards the front of the bone, the aper- 
ture of the mouth may be enlarged by an incision from the ala of 
the nose to the margin of the lip; if very small, this may not be 
necessary. At all events,11 the mucous membrane and cheek must 
be dissected off the tumour as far upwards and backwards as its 
bulk renders necessary; then an incisor tooth and bicuspid or molar 
must be extracted, and the point of the knife be carried through the 
mucous membrane of the hard palate, and every soft texture which 
it can reach, where it is intended to effect the separation:" then the 
bone on either side of, and above the tumour, must be grooved 
with small saws, of various sizes, after which its separation must be 
completed with the cutting forceps. 
If, however, the tumour is of larger dimensions, so that it not 
only protrudes in front, but also encroaches on the nostril, and 
pushes the eyeball upwards, it will be necessary to remove the 
whole of the superior maxillary, and perhaps the malar bone also. 
An incision must be made with a straight bistoury from the nasal 
process of the superior maxillary bone to the mouth. It must go 
quite down to the bone-must detach the nasal cartilages, and cut 
* " Softness and rapidity of growth are," says Mr. Fergusson, " most indicative 
of malignancy in such cases; and if combined with these, the limits are indistinctly 
defined, and there are constitutional indications of such a growth, the disease is 
evidently one of a serious character. If, on the other hand, the swelling is hard and 
slow of increase; if the distinctions between it and the surrounding parts are 
apparent; if the person seems otherwise in good health, and in nowise disturbed 
by the swelling excepting by the inconvenience resulting from its bulk, then there 
may be every reason to suppose that it is benign in its character.-Practical 
Surgery, p. 483. 385 
RHINO-PLASTIC OPERATIONS. 
through the lip in the median line. A second incision must be 
made from the external angular process of the frontal bone to the 
corner of the mouth; and if the malar bone is to be removed, a 
third, at right angles to the second, must be made along and down 
to the zygoma. The flap is then dissected up, the infraorbital nerve 
divided, the inferior oblique muscle and other parts separated from 
the floor of the orbit, and supported with a narrow bent copper 
spatula; the nasal process of the superior maxilla, and its junction 
with the malar, are divided with strong bone forceps, (or if the 
malar is to be removed, its junction with the frontal and zygoma 
must be divided instead,)-a notch must be made with strong scis- 
sors in the alveolar process of the middle incisor tooth, (which 
should be extracted before the operation)-then the anterior half of 
the roof of the mouth must be divided with a pair of strong cutting 
forceps, one blade being put into the nostrils, the other into the 
mouth. The tumour being thus loosened is then to be forcibly 
moved, and its remaining attachments are to be divided with the 
knife, carefully preserving the velum palati. If the floor of the 
orbit is not implicated, it should be permitted to remain; and for 
this purpose, instead of cutting through the nasal process of the 
superior maxilla, the bone must be sawn horizontally just below 
the orbit. During the operation, the common carotid is to be com- 
pressed to prevent haemorrhage. After it, the facial, and any other 
arteries that require it, are to be tied, the chasm to be filled with 
lint, and the wound closed with sutures.* 
XIII. Rhino-plastic, or Taliacotian Operations.-When a 
portion or the whole of the nose has been destroyed by disease or 
accident, the deficiency may be restored by a transplantation of skin 
from an adjoining part, the operation being varied according to 
the extent of the deformity. 
(1.) When the whole, or greater part of the nose has perished, a 
triangular piece of leather should be cut into the shape which it 
formerly presented, and be spread out flat on the forehead, with its 
base uppermost, and its boundaries should be marked out on the 
skin with ink. Then the remains of the old nose (if any) are to be 
pared, and the margins of the nasal aperture are to be cut into deep 
narrow grooves. When the bleeding from these wounds has 
ceased, the flap of skin marked out on the forehead is to be dis- 
sected up, and all the cellular tissue down to the periosteum with 
it, so that it may hang attached, merely by a narrow strip of skin 
between the eyebrows. When all bleeding has ceased, the flap is 
to be twisted on itself, and its edges are to be fitted into the grooves 
made for their reception, and to be fastened with sutures. The 
nose thus made is to be supported, but not stuffed, with oiled lint; 
-it should be wrapped in flannel to support its temperature, and 
if it become black and turgid, owing to a deficiency in the return of 
blood from it, a leech may be applied. When adhesion has tho- 
roughly taken place, the twisted strip of skin, by which its connec- 
* Vide Liston on Tumours of the Face, Med. Chir. Trans., vol. xx.; and Fergus- 
son's Practical Surgery, p. 486: also Lancet, Feb. and March, 1842. 386 
RHINO-PLASTIC OPERATIONS. 
tion with the forehead was maintained, may be cut through, or 
a little strip may be cut out of it, so that it may be laid down 
smoothly. 
(2.) The septum or columna nasi is often restored by the same 
operation with the nose itself, by means of a flap from the forehead; 
but it is better, as Mr. Liston proposes, to form it out of the upper 
lip at a subsequent operation. A strip is cut out of the centre of 
the upper lip, a quarter of an inch in breadth, and of its whole 
thickness. The fraenulum having been divided, this strip is turned 
up, but not twisted; and its labial surface having been pared off, 
and the inside of the apex having been made raw, the two latter 
surfaces are united by the twisted suture, and the wound of the lip 
is also united by the same. During the cure, the nostrils must be 
kept of their proper size by introducing silver tubes occasionally. 
(3.) When one ala nasi alone is destroyed, a portion of integu- 
ment may be measured out on the cheek, and be raised to supply 
the deficiency. But if both alas are lost, or if the cheek is spare 
and thin, it is better to supply their place with skin brought from 
the forehead. The slip which connects the engrafted portion with 
the forehead will of course be long and thin; and in order to main- 
tain its vitality, a groove may be made to receive it on the dorsum 
of the nose. But when union has occurred, this connecting slip 
may be raised and cut off, and the groove which contained it be 
united by sutures. 
(4.) Depression of the apex of the nose is to be remedied by 
raising the parts, dividing any adhesions that may have formed, 
making, if necessary, a new columna, in the manner described 
above, and supporting the parts carefully with plugs of lint, till 
they have acquired firmness. But it may be done still more com- 
pletely by a method which was proposed by Dieffenbach, and a 
modification of which has been practised with great success by Mr. 
W. Fergusson. "The point of a small scalpel," says Mr. Fergus- 
son, " was introduced under the apex, and the alas were separated 
from the parts underneath; next the knife was carried on each side 
between the skin and the bones, as far as the infraorbital foramen, 
taking care not to interfere with the nerves, when by passing the 
point of my finger below the nose, I caused the latter organ to be 
as prominent as could be wished. I now passed a couple of long 
silver needles, which had been prepared for the purpose, with 
round heads and steel points, across from one cheek to the other, 
having previously applied on each side a small piece of sole leather, 
perforated with holes at a proper distance; then I cut off the steel 
points, and with tweezers so twisted the end of each needle, as to 
cause the cheeks to come close to each other, and thus to render 
the nose prominent. Thus by bringing the cheeks more into the 
mesial line, a new foundation, as it were, was given to the organ. 
Adhesion occurred in some places, granulations in others, in the 
lapse of ten days the needles were withdrawn, and in the course 
of a few weeks, when cicatrization was complete, the nose pre- 387 
HARE-LIP. 
sented as favourable an appearance as could reasonably have been 
desired."* 
(5.) Depression of the ridge, owing to the loss of the ossa nasi, 
may be remedied by paring the surface, and covering it with a 
flap of skin from the forehead; or by making a longitudinal incision, 
and engrafting a small portion of skin from the forehead into it; 
or, if the case is slight, by cutting out one or two transverse slips, 
and bringing the cut edges together by sutures, so that thus the 
surface may be stretched to its proper level. 
XIV. Hare-Lip signifies a congenital fissure of the upper lip. 
It may exist only on one side, [Fig. 109,] or 
there may be a double fissure with a small 
flap of skin between. Sometimes there is also 
a fissure in the bony palate,-sometimes in the 
soft palate also,-and sometimes the upper in- 
cisor teeth and their alveoli project through the 
fissure,-all which conditions give rise to con- 
siderable deformity and impediment in speaking 
and feeding. 
Treatment.-The edges of the fissure, which are red like the 
lip, are to be pared, and then made to unite by adhesion. Sir A. 
Cooper recommended that the operation should not be undertaken 
till the child is about two years old, and has cut its teeth; because 
of the great liability of young infants to be carried off by diarrhoea 
or convulsions; Mr. Fergusson believes this risk to be exaggerated, 
and prefers operating shortly after the child has ceased to suck; 
provided however it is in good health, and not suffering from its 
teeth at the time. If the patient is a child, his body should be 
entirely wrapped in a cloth, to prevent struggles; and the surgeon 
sits behind him, taking the head between his knees. Then seizing 
the lip by the corner of the fissure with his left forefinger and 
thumb, he pierces it with a bistoury at the top of the fissure just 
under the nose, and carries the instrument downwards, so as to 
shave off the edge of the fissure, and the rounded corner at the 
bottom ; and it is better to remove too much than too little. This 
process is repeated on the other side, and the two strips are next 
detached from the upper angle. When bleeding is checked, the 
edges are to be brought into most exact union, and to be transfixed 
by two or more hare-lip pins, or long slender needles, over which a 
twisted suture is to be made. The pin should be inserted near 
the angles of the fissure; and if the labial artery bleed, another 
should be placed so as to transfix and compress it. The pins should 
penetrate full two-thirds of the thickness of the lip. They may be 
removed on the fourth or fifth day; and a slip of adhesive plaster 
may be drawn from one cheek to the other instead. 
If the hare-lip is double, both sides should be operated on at 
once, the middle flap being transfixed by the pins. But care shoud 
be taken to push up the middle flap towards the nose so as to render 
Fig. 109. 
* Op. cit. p. 454. 388 
CANCER OF THE LIP. 
the latter organ more prominent, as it is in general very flat in cases 
of hare-lip. 
If one or more teeth project in the fissure, so as to offer any 
impediment to its union, they should be extracted ; and if the bone 
project much, it may be necessary to remove a small portion of it 
with the cutting pliers, the soft parts on it having been first divided 
with the knife; but sometimes (as in a case related in Cooper's 
Dictionary) the projecting bones may be pushed so far backwards 
by means of a kind of spring truss worn for several hours, that the 
soft parts may be brought over them without any difficulty; and 
when this can be done it is far better not to sacrifice any of the teeth. 
XV. Fissure of the Palate, when extending through the 
bones, and forming a wide aperture into the nose, cannot be cured. 
The parts, however, become slightly ap- 
proximated during growth;-and at 
puberty the defect may be palliated by 
means of a metallic or ivory plate. But 
when the velum pendulum palati 
alone is fissured-and the fissure not 
very wide, it may be remedied by the 
operation of staphyloraphe-which, 
however, must necessarily be deferred 
till puberty, or it would be defeated 
by the patient's struggles. The edges 
of the fissures are first pared-then 
they are united by three interrupted 
sutures, which may be very easily 
introduced by means of Mr. Beau- 
mont's instrument described in the 
twentieth volume of the Med. Chir. 
Trans., or with a port aiguille, and the 
threads may be drawn together by pull- 
ing them through a perforated bead of lead or some other soft metal, 
which must be pushed upon the thread till it has drawn the edges 
of the incision close together, and then should be pinched with pliers 
to make it hold tightly.! Before the sutures are tightened, a shal- 
low incision may be made in the velum on each side near the 
alveolar border, in order to diminish the tension. The patient must 
fast for twenty-four hours, and on the succeeding days must take 
very small quantities of thick fluids. 
XVI. Cancer of the Lip commences as a small scirrhous tu- 
mour, or wart, or as a small fissure caused by the irritation of 
smoking, which gradually degenerates into foul ulcer, with hardened 
base and ragged surface. 
Treatment.-The disease must be extirpated by a V incision- 
taking care to include the whole of it-and uniting the wound after- 
wards like that made in the operation for hare-lip. If, however, the 
Fig. no.* 
* From a preparation of Mr. W. Fergusson's in the King's College Museum. 
f This was suggested by Mr. Maclean of Dublin. Vide Cusack, Dub. Journ. 
Med. Sc., Jan. 1843. CANCRUM ORIS. 
389 
whole or greater part of the lip be implicated, the diseased parts 
should be freely removed without any attempt to unite the edges 
of the incision. The extirpation cannot be expected to be effectual 
unless performed before the glands are implicated-but it is justifi- 
able at any stage-in order to avoid for a time the horrible pain and 
fetor of the ulcerative process. It has been very clearly shown by 
Mr. Earle, that any ulcers, if subjected to perpetual irritation, (and 
especially ulcers near the outlets of the body,) may assume a malig- 
nant appearance, which ceases on the removal of the source of irri- 
tation. When therefore there are foul ulcers on the lips, cheeks, or 
tongue, the teeth should be well examined in order to remove any 
roughness, or collections of tartar, and the secretions of the skin, 
bowels, and kidneys should be carefully attended to. 
XVII. Cancrum Oris.-(Phagedaena oris, gangrenous erosion 
of the cheek')- is a phagedceno-gangrenous affection of the lips 
and cheeks, occurring almost exclusively amongst the ill-fed squalid 
children of large towns. It appears to be a disease of debility, and 
to be induced by want of proper food and of fresh air, and by 
neglect of cleanliness. Like other disorders of a similar character, 
it is very liable to follow the measles or scarlatina, or any other 
severe and weakening illness. 
Symptoms.-In the instances which have fallen under the 
author's observation, it has commenced as a shallow ulcer on the 
lip, or inside of the cheek; with a peculiar dirty gray or ash- 
coloured surface, and black edges. Sometimes it is said to com- 
mence with an exudation of a pale yellow fibrinous matter, like that 
which is exuded in croup and some forms of putrid sore throat. At 
the same time the face is swollen, the breath exceedingly fetid, and 
there is a dribbling of fetid saliva mixed with blood. If the disease 
proceeds, the ulcer becomes gangrenous, and destroys the cheek 
and gums; the teeth drop out, typhoid symptoms supervene, and 
the patient dies exhausted. The swelling which accompanies this 
disease, shpws nothing like active or healthy inflammation. It is 
moderately firm, or what may be called semi-oedematous, and is 
either pale, or else of faint pink colour. In the most rapid form of 
the disease, it commences at once as a black spot of gangrene, 
which slowly spreads, and is not accompanied by any inflammation 
whatever; all the parts around being quite pale and wax-like. The 
constitutional symptoms are at first those of weakness, and disorder 
of the stomach and bowels, and afterwards the rapid feeble pulse, 
and stupor of typhus. 
Diagnosis.-The diagnosis of this affection is of some importance, 
because when a child has died of it, the parents, through ignorance 
or malice, are liable to bring the surgeon into trouble, by accusing 
him of having caused death through profuse mercurial salivation. 
The chief points of distinction are, that in this disease the ulceration 
or gangrene is circumscribed, and is generally confined to one side; 
and that it commences usually in the cheek, and that it only affects 
that part of the gums which is in close contiguity, and that the 
tongue is untouched. Whereas in severe mercurial salivation, the 390 
DISEASES OF THE TONGUE. 
ulceration is diffused; the whole of the gums, and the lining mem- 
brane of the cheeks, and the tongue, as well as the palate, being 
affected from the first. 
Treatment.-The indications are threefold. 1st, To evacuate 
and correct the secretions of the stomach and bowels by mild but 
efficient purgatives-especially rhubarb and magnesia, which 
should be administered daily. The author believes that one or 
two grains of calomel may be advantageously added to the first 
dose, although the practitioner may deem it prudent to avoid the 
risk of being accused of causing the disease by this remedy. 2dly, 
To keep up the strength by wine, beef-tea, and other nutritious 
articles, and by bark or quinine in sufficient doses. 3dly, To 
excite a healthy action in the diseased part by stimulating lotions 
-especially solution of nitrate of silver, alum, sulphate of copper, 
or the chloride of lime; and, lastly, if these means fail to arrest 
the disease, the strong nitric acid should be applied so as to destroy 
the whole of the diseased part, in the same manner as was directed 
for hospital gangrene.* 
XVIII. Small Tumours, semi-transparent and fluctuating, con- 
taining a glairy matter, and probably consisting of obstructed 
mucous follicles, are often met with on the inner surface of the 
cheeks and lips. 
XIX. Ranula is a tumour of the same nature, situated under 
the tongue. It may consist either of one of the Whartonian ducts, 
or of a follicle obstructed. This and the foregoing tumours are 
best treated by snipping out a small piece of the sac, and rubbing 
the interior with lunar caustic;-or by passing a small seton 
through the sac. 
XX. Tongue-tie-a prolongation of the fraenum linguae, con- 
fining the apex of the organ to the lower jaw-is by no means so 
common as is often supposed. If it does really exist, and the child 
cannot suck, the fraenum may easily be divided for an eighth of an 
inch with a blunt-pointed pair of scissors-taking care to direct 
their points downwards, and to keep as close to the lower jaw as 
possible, so as to avoid the lingual artery. 
XXL Wounds of the tongue are liable to be attended with severe 
haemorrhage from the lingual artery. If the bleeding orifice cannot 
be tied, one or more ligatures must be introduced with curved 
needles, so as to include and constrict the bleeding parts-or a 
heated iron may be applied through a tube. 
XXII. Inflammation of the tongue-known by great swelling, 
tenderness, and difficulty of speaking and deglutition, must be 
treated by bleeding and leeches, purgatives, slight incisions, and the 
antiphlogistic regimen generally. Inquiry should be made whether 
the patient has been taking mercury. If abscess form, the fluc- 
tuating part should be opened.t 
* Vide James on Inflammation, p. 527; Marshall Hall in Lancet for 1839-40, p. 
409; P. H. Green, ibid.; and also in Cycl. Prac. Surg. Art. Cancrum Oris,- and 
Willis on Cutaneous Disease. 
f Sometimes the tongue enlarges suddenly to an immense size, so as almost to DISEASES OF THE TONGUE. 
391 
XXIII. Hypertrophy.-Slow enlargement, without tenderness 
or structural disease, sometimes affects the tongue, causing it to 
protrude permanently from the mouth. The superfluous portion 
may be removed by ligature-a needle armed with a strong double 
ligature being passed through the centre of the tongue, and one 
thread being then tied very tightly round each half. But if it be 
not very considerable a a shaped portion may be cut out from its 
anterior extremity-the cut surfaces being united by suture after 
the bleeding vessels are tied, and oozing has ceased. 
XXIV. Cancer.-A foul excavated ulcer, with extremely har- 
dened base, and prominent edges, with burning and lancinating 
pain, and preceded by nodular scirrhous enlargement. The con- 
stitutional symptoms are those of the cancerous cachexia. 
Treatment.-The diseased part should be early extirpated with 
the knife-or if extensive, with ligatures, in the manner before 
described. 
XXV. Ulcers on the Tongue, presenting very formidable 
characters, are often attributable to local irritation, (from diseased 
teeth, &c.,) or to some derangement of the health-perhaps a 
venereal taint.-The obvious indications are, to remove irritation 
from rough teeth-to keep up the secretions of the liver and bowels 
-to regulate the diet-and support the strength. Plummer's pill 
-sarsaparilla-or F. 29 and 30-hyoscyamus and conium-per- 
haps iodine-and the local and general treatment of irritable ulcers 
will be of service. 
XXVI. Stammering.-This affection requires to be noticed here, 
because of two operations which have been recently introduced for 
the cure of it. The first operation, which is intended to divide the 
muscles of the tongue, is performed by drawing the tongue as far 
as possible out of the mouth, and then making a very deep incision 
completely across the base of it. In addition to this, a triangular 
notch is cut out from the anterior edge of the transverse incision. 
This operation is necessarily attended with so much haemorrhage, 
and danger to life, that the author believes it to be utterly unjusti- 
fiable for the relief of a mere inconvenience. It may truly be 
styled muscle-cutting gone mad. The other operation, which is 
also of quite recent invention, is performed on the supposition that 
stammering may be caused by an obstruction to the passage of air 
from the pharynx into the mouth, in consequence of an enlargement 
of the tonsils, or a contraction of the arch of the palate. This 
latter operation consists in cutting off the uvula, and in removing 
part or the whole of the tonsils, so as to enlarge the passage of the 
mouth into the fauces. There are many doubts as to the success 
of this plan; but as the author has yet had no experience of it, he 
cause suffocation, but without any symptoms of inflammation properly so called. 
A case which proved fatal in spite of bleeding, leeching, calomel, and incisions, is 
related by Mr. Lyford, of Winchester, in the Lancet for 1828, p. 16; a similar case, 
cured by purgatives and incision, by Mr. Taynton, Med. Gaz. vol. xii.; who speaks 
of it as the only case he had seen in a practice of forty years; and one by Mr. 
Collins (ib. p. 642) in a pregnant woman, cured by an incision in the raphe on the 
under surface. 392 
DISEASES OF THE TEETH. 
will pronounce no opinion. At all events, it is not liable to the 
objections that may be urged against the former, on the score of 
danger, and it certainly is not impossible that the kind of obstruction 
which it is intended to remove may possibly exist in some cases ; 
whereas there is certainly never such a state of organic rigidity of 
the tongue, as to render the division of its muscles even probably 
expedient.* 
XXVII. Lancing of the Gums.-If at any time during denti- 
tion a child is feverish and restless, with its stools slimy and clay- 
coloured, or if there are any symptoms of disorder in the head or 
chest, the gums should be examined; and if any part, especially 
where a tooth is soon expected, appears red and swollen,-a free 
incision should be made with a gum lancet quite down to the tooth. 
This affords instant relief by removing the tension and pain. The 
edge of the lancet should be turned outwards, so as to avoid the 
sacs of the permanent teeth. 
XXVIII. Irregularity of the permanent Teeth is a fre- 
quent consequence of injudicious haste in extracting the temporary 
set-an operation which not only permits the arch of the jaw to 
become contracted, but disturbs the nutrition of the permanent 
teeth, hurries their appearance, and insures their early decay. The 
temporary set should therefore always be suffered to remain as 
long as possible. The only ones that there need be any haste in 
extracting, are the upper incisors, in order to prevent their succes- 
sors from growing behind their natural position, which would 
render the mouth under hung. If either of the canine teeth, or of 
the incisors of either jaw, project much, the patient should be taught 
perpetually to endeavour to push it back into its proper situation 
with his fingers. But if at the age of fourteen or fifteen this method 
has not succeeded, and the teeth are much crowded, the projecting 
tooth may be removed-although in many cases it is better to 
sacrifice one of the bicuspides to make room for it. If one or more 
of the superior incisors project backwards, it must be drawn for- 
wards by means of ligatures attached to a gold bar worn in front 
of the teeth-for the manner of applying which the reader is re- 
ferred to Bell on the Teeth. 
XXIX. Fracture and dislocation of Teeth.-If a portion 
cd a tooth is broken off, the exposed surface should be filed smooth, 
and then no immediate inconvenience will probably follow. If, 
however, the greater part of the tooth is lost, and considerable pain 
and swelling should arise, extraction should be performed-but if 
a useful portion remain, leeches, &c. should be first tried, in order, 
if possible, to remove inflammation. If a tooth is loosened by a 
blow, it should be fastened by silk to its neighbours. If a tooth is 
entirely driven out, it should be replaced as soon as bleeding has 
* These operations are described in the Med. Gaz. March 12th, and the Athe- 
nseum March 13th, 1841; and the Med. Gaz. for March 19th, 1841. Mr. Brain of 
Manchester speaks of an operation for dividing the frenum epiglottidis. The 
author believes that the experience of the last two years has been any thing but 
confirmatory of the value of these operations. TOOTHACHE. 
393 
ceased, and be fastened in by silk; no food should be allowed that 
requires mastication, and inflammation should be combated by 
repeatedly leeching the gum. 
XXX. Caries of Teeth signifies a successive softening and 
decay;-strictly corresponding to ulceration. It generally begins 
at the surface of the bone of the tooth, and appears as a dark spot 
underneath the enamel, which after a time gives way and exposes 
a cavity. The disease gradually spreads and reaches the central 
cavity of the tooth, which from that time is subject to fits of tooth- 
ache. This disease may be caused, (1.) by original weakness of 
the teeth, which is often hereditary, and appears to be connected 
with the strumous diathesis-the teeth being remarkably white and 
pearly. The profuse administration of mercury during early child- 
hood is justly conceived to be another predisposing cause. (2.) 
Injuries to the teeth-the abrasion of their enamel-the use of 
very hot or very cold drinks-and especially of ices, are exciting 
causes. 
Treatment.-If the caries be slight and recent, the whole of the 
decayed portion should be removed by proper instruments, and the 
cavity be filled up with gold. This operation should not be per- 
formed indiscriminately, however, if the decay has advanced so far 
as to lay open the central cavity of the tooth,-or if the introduction 
of an instrument causes the peculiar pain arising from pressure on 
the nervous membrane. Such a proceeding might very probably 
cause excruciating agony, and induce suppuration in the centre of 
the tooth and in the socket. Under these circumstances, the indi- 
cations are to remove the diseased part of the tooth, and to protect it 
from the irritation of contact with food and saliva, and to diminish 
its sensibility. For these purposes the best plan is, to fill the cavity 
with a composition of powdered chalk, with a very little tannin, 
mixed up into a paste with a solution of mastic in alcohol;-or else 
with a little bit of cotton wool dipped in a solution of one scruple 
of tannin, and the same quantity of mastic in half an ounce of 
Eether, F. 115; or frequently to introduce a drop of some narcotic 
or stimulating solution;-such as a solution of acetate of morphia; 
or of alcohol, or sp. camph., or nitrate of silver (gr. x. ad oi). By 
these means the tooth may very probably be brought into a state 
to bear stopping with gold. The patient should avoid exposure to 
cold-or drinking very hot, or cold, or sweet, or acid fluids-and 
should be careful not to induce feverishness by any errors in diet. 
A peculiar fungous excrescence occasionally grows from the lining 
membrane when exposed by caries. Sometimes it is indolent- 
sometimes acutely sensible; but it always gives more or less an- 
noyance in mastication. A strong solution of the nitrate of silver 
is the best application. 
XXXI. Toothache.-This disagreeable infliction may be 
caused by four circumstances. 1st, by caries; 2dly, by inflam- 
mation of the lining cavity; 3dly, by neuralgia; and 4thly, by a 
deposit of bone on the root of the tooth. 
(1.) The most common form is that which arises from caries- 394 
TOOTHACHE. 
the lining membrane being rendered irritable by exposure, and 
being liable to nervous or inflammatory pain from local irritation 
or disorder of the health. 
Treatment.-We may arrange the multifarious remedies for this 
form of toothache in the following order, (a.) Purgatives and low 
diet are indicated if the pain followed exposure to cold or excess at 
table, and if it is attended with foul tongue, hot skin, and headache. 
(b.') Scarification of the gums, or leeches to them or to the cheek, 
may be supposed useful if the tooth is tender and the gums swollen, 
(c.) Derivatives.-Pediluvia of hot water and mustard-and rube- 
facients to the cheeks-especially ammonia and asther applied in 
the palm of the hand, or mustard poultices, are generally of service; 
and (d.) Sialagogues, especially ginger, cloves, and pellitory, or 
steaming the mouth with hot water, are equally so. (e.) Ano- 
dynes.-A small quantity of laudanum, or a solution of morphia, 
or a paste made with opii gr. j. camph. iv.-or of morphia, chalk, 
and solution of mastic;-or a drop of tincture of aconite-inserted 
into the tooth, are often of great benefit; but it is not generally of 
use to administer large doses of opium internally-they disorder 
the system without adequately relieving the pain. A drop of the 
hydrocyanic acid inserted into the hollow of the tooth, and two 
minims of the same, given every four hours in a saline draught, are 
the best remedies of this class. (J?) Stimulants-such as the 
essential oils of cinnamon, origanum, cloves, and the like,-creosote, 
-solution of the nitrate of silver,-alcohol,-diluted hydrochloric 
acid (3ss ad 3ii aquae)-very hot or very cold water,-are popular 
remedies, whose efficacy is supposed to depend on their exhausting 
the sensibility of the nerve. When the lining membrane is exposed, 
and there is severe toothache, some dentists introduce either a drop 
of a strong solution of nitrate of silver, or else a little fragment of 
it, and stop up the cavity with wax, or diachylon plaster, softened 
between the fingers. (#.) Astringents.-A solution of half a 
drachm of alum in half an ounce of nitric aether is one of the 
popular remedies that sometimes succeeds; but of all antiodon- 
talgic remedies whatever, the author believes the best to be tannin, 
in the form of an aetherial solution, F. 115; the use of which he 
gratefully acknowledges to have learned from his friend Mr. Tomes. 
This is particularly beneficial if the tooth looks soft, or the gum 
flabby; and especially if, as frequently happens, a bit of the gum 
grows into the cavity of the carious tooth. When a patient com- 
plains of severe toothache, let him have an aperient dose ; let him 
wash out the mouth with a solution of carbonate of soda in water; 
let the gum around the tooth, and between it and its neighbours, 
be scarified with a fine lancet; then let the cavity be filled loosely 
with a little bit of cotton dipped into the solution of tannin ; and if 
the toothache is curable at all, this plan, with a little patience, will 
be almost sure to succeed. If the pain is very violent, half a grain 
of powdered acetate of morphia may be taken up with the cotton 
imbued with the tannin; which should be warmed before it is put 
into the cavity. Or a little piece of wax may be softened and EXTRACTION OF TEETH. 
395 
formed into a roll by the fingers, and some of the powdered tannin 
may be taken up on one end of the wax and be inserted into the 
tooth. Much more good is to be effected in general by the repeated 
application of mild stimulants, than by using them in too concen- 
trated a form. (A.) Alkalis.-It sometimes happens that tooth- 
ache arises from disorder of the stomach, and an acid state of the 
secretions of the mouth ; and may be relieved almost immediately 
by rinsing the mouth with a solution of carbonate of soda. (/.) 
Cauterants.-It has been proposed to introduce the concentrated 
sulphuric or nitric acids, or a red hot wire, into the carious cavity, 
in order to disorganize the nervous pulp. One author has recom- 
mended it to be broken up by a sharp steel punch. But these 
remedies can scarcely ever be applied with a certainty of accom- 
plishing their object-if they do not cure the toothache, they will 
be sure to aggravate it,-and in the hands of a bungler they might 
be productive of very great mischief. The chloride of zinc is the 
most useful of this class of substances. It was recommended by 
Mr. James, and has been extensively used by Mr. Tomes, in the 
following manner: He dilutes it with ten parts of powdered plaster 
of Paris, and then dips the end of a little roll of softened wax in 
this powder, and stops it into the cavity. 
(2.) Inflammation of the lining membrane sometimes affects a 
tooth that is apparently sound. It occasions severe, heavy, throb- 
bing pain extending to the head, and considerable tenderness of 
the tooth and of the gum around. It may lead to suppuration of 
the pulp, or to abscess in the alveolus, and death of the tooth in 
consequence. 
Treatment.-Leeches, low diet, and purgatives. 
(3.) Neuralgic toothache, whether it occurs in teeth that are 
entirely sound, or partially carious, is to be distinguished by its 
occurring in paroxysms which come and go suddenly, in more or 
less regular intervals. It is very common in the earlier months of 
pregnancy. 
Treatment.-Quinine or the carbonate of iron in large doses, 
together with aperients and alteratives, are the most successful 
remedies. 
(4.) It sometimes happens that the fang of the tooth is thickened 
by a deposit of bone; in which case the tooth becomes affected 
with severe pain that can hardly be distinguished from that of neu- 
ralgia. It sometimes occurs on teeth that are perfectly sound, but 
more generally on carious teeth, or stumps. The excessive pain of 
this affection is in general only to be relieved by extraction. 
XXXII. Necrosis of Teeth.-A tooth is said to be necrosed 
when it has become black and unsightly, and loose in its socket. 
This affection may be caused by blows, which have torn across the 
nutrient vessels,-or by inflammation of the pulp (perhaps from the 
abuse of mercury). Extraction must be performed, if the tooth 
cause inflammation or other inconvenience. 
XXXIII. Extraction of Teeth.-The instruments for extract- 
ing teeth are the forceps, the elevator, and the key. 396 
EXTRACTION OF TEETH. 
(1.) The forceps is the instrument that is now generally employed 
by dentists. It should be made with sharp edges, so that it may be 
pushed up between the tooth and the gum, and should seize the 
tooth by its neck, close to the alveolus. For this purpose also, the 
Fig. 111. 
jaws of the instrument should be made to incline towards each 
other in such a way, that they may slip up and embrace the neck 
of the tooth accurately when the handles are pressed together; and 
they should be ground in such a manner that they may be adapted 
accurately to the shape of each tooth. 
For this purpose, the surgeon will 
require several sets of instruments. 
Two are required for the upper 
molars-one for each side, because 
of the third fang which projects in- 
wards. The adjoining figure shows 
the manner in which they fit the 
depressions and elevations of the 
tooth. One will suffice for the lower 
molars, both right and left, because 
they have only two fangs. One in- 
strument will be necessary for the 
bicuspides and canines of the upper 
jaw, and another for those of the 
lower jaw; and two sets will be 
necessary for the incisors of either 
jaw. 
In extracting teeth by the forceps, 
there are two things to be done; first 
to loosen the tooth, and then to pull it straight out. In extracting 
the incisors and canines of the upper jaw, they may first be loosened 
by giving them a gentle twist, combined with a slight rocking 
motion, and then may be pulled perpendicularly downwards with 
a slight inclination backwards. The incisors and canines of the 
lower jaw are to be loosened by giving them a firm but gentle 
motion backwards and forwards, and then may be pulled straight 
up. The bicuspides and molars are to be loosened by moving 
them from side to side, so as to make the alveolar process yield a 
little, and then they may be pulled perpendicularly, upwards or 
downwards, as the case may be. The operator should grasp the 
forceps firmly, in such a manner that it may move altogether with 
his hand; but yet not so forcibly as to run the risk of crushing the 
Fig. 112. EXTRACTION OF TEETH. 
397 
tooth. The two preceding figures were sketched by Mr. W. Bagg 
from the hand of Mr. Tomes. 
(2.) The. elevator is highly useful for stumps, and for old strag- 
gling teeth. The point is to be thrust firmly down between the 
tooth and its socket, and then by bringing the instrument into a 
horizontal position, and making a fulcrum of the edge of the alveolar 
process, or of the adjoining tooth, or of the operator's fingers, the 
tooth may be lifted out. 
(3.) The key is an instrument that is very generally employed 
for the extraction of the bicuspides and molars; but it is more 
painful than the forceps, and every one must know instances of 
laceration of the gum, and splintering of the alveoli, followed 
perhaps by tedious exfoliation, that have been produced by the 
clumsy use of this instrument; not to mention the risk of the 
claw slipping from the decayed tooth and dragging out a sound 
neighbour instead. If, however, it is preferred, care should be 
taken to select an instrument of proper size, and to place the 
fulcrum in a proper position. If the key is too small, and the fulcrum 
too high, very probably the crown of the 
tooth will be snapped off. If the key is too 
large, and the fulcrum too low, either the claw 
of the instrument may be snapped across, or 
the alveolar process be extensively splintered. 
The adjoining figure is intended to show the 
right position, which will draw the tooth more 
or less perpendicularly from its socket. The 
fulcrum ought to be placed on the inner side, 
for the bicuspides of the lower jaw, and mo- 
lars of the upper; and on the outer side for the 
molars of the lower jaw. The dentes sapien- 
tix of the upper jaw should never, according 
to Bell, be extracted with the key, because of the delicate texture 
of the bone on which the fulcrum must rest. 
Before extracting teeth with the key, it is usual to cut away the 
gums from their necks by means of a gum lancet;-a practice which 
some authorities consider unnecessary. It certainly is unnecessary 
in the majority of cases, especially for the extraction of the tem- 
porary teeth, and of the teeth of old persons;-yet it may be per- 
formed either if the gum has been subject to repeated inflammation 
-which renders it adherent to the tooth, and liable to be lacerated 
on its removal; or secondly, in order to afford room for the claw, 
if the tooth has decayed down to the gum. Some persons, instead 
of using a lancet, separate the gum by means of a small tenaculum, 
and it certainly is less painful and equally efficacious. 
Hxmorrhage after Extraction of Teeth.-This operation may 
be followed by very severe and dangerous haemorrhage, which 
sometimes appears to come from the dental artery at the bottom of 
the socket: sometimes from the gums when they have been long 
diseased. A strong solution of nitrate of silver may be tried first; 
but if that does not suppress it, the alveolus must be plugged in the 
Fig 113. 398 
DISEASES OF THE GUMS.-INFLAMMATORY ABSORPTION. 
following way: It is first to be cleansed from coagulum,-then one 
end of a long thin strip of lint is to be firmly pressed into it, so as 
to come into contact with its very bottom, and the remainder in 
successive portions is to be forced in till the socket is filled up to the 
level of the gum. A compress should then be placed on the part, 
thick enough to be pressed upon by the antagonist teeth, and the 
mouth should be kept firmly closed by a bandage passing from 
under the chin to the vertex. Sometimes the alveolus is plugged 
with putty; or by inserting again the tooth which has been extracted. 
XXXIV. Tartar, or salivary calculus, is an earthy matter de- 
posited on the teeth from the saliva. It is found most abundantly 
on the superior molares and inferior incisors-obviously because 
those teeth are nearest the orifices of the salivary ducts. If suffered 
to accumulate, it causes inflammation and absorption of the gums, 
and gradual loosening of the teeth. 
Treatment.-The deposit of this substance is to be prevented by 
taking care not to disorder the stomach, and by the strictest cleanli- 
ness. The teeth should be cleansed at least twice a day, with a soft 
toothpowder (camphorated chalk is the best) and a little soap. The 
hairs of the toothbrush should be soft, and not too closely set;-so 
that they may penetrate the better into the interstices of the teeth. 
When any quantity of the tartar has accumulated, it should be re- 
moved by the scaling instrument. The edge or point of the in- 
strument is to be introduced between the concretion and the gum, 
so as to detach the former in flakes,-in the meanwhile a finger or 
thumb, guarded with a towel, should be pressed firmly on the cut- 
ting edges of the teeth, so that they may not be loosened by the force 
necessarily employed. Sometimes a small portion of this substance 
is found sticking in the orifice of one of the salivary ducts, and 
creating great discomfort by its irritation. It may be easily removed. 
XXXV. Inflammatory Absorption, vulgarly called scurvy of 
the gums, generally affects middle-aged or elderly people, and may 
be a consequence of the accumulation of tartar, but more fre- 
quently depends on a congested state of the liver and bowels. The 
gums are swollen, spongy, exceedingly tender and subject to con- 
stant aching pain, and they bleed on the slightest touch. If the 
disease proceeds, they separate from the teeth;-the alveoli gradu- 
ally become absorbed, and the teeth loosen, and at last fall out. 
These consequences are sometimes speedy, and are attended with 
suppuration in the alveoli, but more frequently they are slow- 
the teeth dropping out one by one in the course of years. 
Treatment.-The gums should be unloaded by deep and free 
scarifications and repeated leechings,-the bowels should be well 
cleared by a course of purgatives and mercurials,-and gargles 
should be employed to correct the secretions of the mouth, and ex- 
cite the vessels to contract. Whilst there is much pain and soreness, 
dec. papav. vel anthemid., or three drachms of nitre dissolved in a 
pint of barley-water, will answer best. Subsequently, recourse 
may be had to F. 39, or to gargles of dec. cinchon. with alum or TUMOURS OF THE LOWER JAW. 
399 
dilute sulphuric acid and tinct. myrrhae, or of liq. calcis chlorid. f3j 
to half a pint of brandy and water. 
XXXVI. Gum Boil [alveolar abscess, purlins') is a small abscess 
commencing in the socket of a tooth, and bursting through the gum, 
or sometimes through the cheek. It is usually caused by the irri- 
tation of a dead or carious tooth. 
Treatment.-Leeches and fomentations,-removal of the tooth, 
-and a puncture as soon as matter can be detected. If the tooth 
is extracted soon, the sac of the abscess very often comes away 
with it. 
XXXVII. Epulis signifies a tumour formed by an hypertrophy 
of the gum, without any apparent alteration in its structure. It gene- 
rally commences between two teeth, which it gradually separates, 
then loosens, and finally displaces,-and may spread so as to involve 
several of them. This tumour is indolent, painless, and of slow 
growth, but it ought always to be extirpated without delay; be- 
cause it is sure to increase, and might become the seat of offensive 
ulceration, or even of malignant disease. 
Treatment.-The tooth on either side must be extracted, and 
the tumour entirely cut out. A portion of the alveolar process must 
be removed likewise, if necessary, in order to render the extirpation 
complete. 
A similar tumour is sometimes formed when a dead portion of the 
roof of a tooth remains in its socket, and the gum has healed over 
it. The tumour should be entirely removed with the knife, and the 
extraneous body should be sought for, and be extracted if possible. 
Malignant tumours of the gums are exceedingly rare; they will, 
however, be recognized by their rapid growth and tendency to 
haemorrhage. 
XXXVIII. Tumours of the Lower Jaw may, like those of the 
upper, be either simple or malignant. Their distinctive characters 
have been before alluded to. Free extirpation is the only remedy. 
If the tumour is large, and situated near the middle of the bone, it 
must be exposed by making an incision from each angle of the 
mouth down to the bottom of the chin ;-a tooth must be extracted 
on each side of the tumour; -next the bone maybe sawn half 
through perpendicularly on each side, and then be divided com- 
pletely by the straight cutting forceps, one blade being passed up 
on the inner side of the bone, and the other placed in the groove 
made by the saw ;-and, lastly, the parts attached to the inner side 
of the bone must be cautiously divided-namely, the digastric, 
mylo-hyoid, genio-hyoid, and genio-hyo-glossus muscles. When 
the attachments of these muscles are divided, care must be taken 
not to let the tongue retract into the throat, which might push back 
the epiglottis and cause suffocation. To prevent this a ligature 
may be passed through the tip of the tongue, by which it may be 
held forwards during the operation, and which may be fastened to 
the twisted suture by which the wound is afterwards to be closed. 
If, however, the disease is not so very extensive, it may not be 
necessary to sacrifice the whole thickness of the bone, but a hori- 400 
CLOSURE OF THE JAWS. 
zontal portion of the base of the bone may be saved; which will 
prevent the chin from falling in after the operation. In order to 
effect this, the bone may be sawn downwards for half its depth on 
each side of the tumour, and a horizontal cut be made below it; 
and then the diseased portion be separated completely with the cut- 
ting pliers. 
If a lateral portion is to be removed, an incision should be made 
from the lower lip to the chin, and along the basis of the bone, to 
its posterior angle. Thus a flap is formed, which may be turned 
up so as to furnish a good view of the tumour, and then the bone 
is to be divided as before described. 
If the extent of the disease renders it necessary to remove the 
entire side of the bone, and to separate it from its articulation with 
the temporal,-the operator must begin by making a curved inci- 
sion from beneath the ear, along the basis of the jaw, to the chin. 
The flap so formed is to be dissected up, and the masseter with it; 
-an incisor tooth is to be removed, and the bone to be sawn verti- 
cally throughthe end is next seized and depressed, and the 
temporal muscle dissected from the coronoid process,-the ptery- 
goid muscles and other internal attachments are then to be divided, 
and finally the ligaments of the joint. Whilst effecting the dis- 
articulation of the condyle, the point of the knife should be kept 
close to the bone, so as to avoid all risk of wounding the external 
carotid artery. After bleeding has been restrained, the wound is 
to be closed by sutures, excepting at the middle, where an aper- 
ture should be left for the ligatures, and to permit the escape of 
discharge.* 
XXXIX. Closure of the Jaws, with more or less inability to 
open the mouth, and to masticate solid food, may be a result of 
disease of the bone implicating the joint; or of rigid cicatrices 
within the mouth produced after sloughing;-whether caused by 
drinking boiling water, or by the profuse administration of mer- 
cury. The division of any rigid bands of cicatrices,-the division 
of the masseter muscle by subcutaneous section, thrusting a narrow 
knife from the mouth between the muscle and the skin, an opera- 
tion which has been successfully performed by Mr. W. Fergusson ; 
-and the use of a screw dilator, are the only available remedies. 
• Vide Liston's Elements of Surgery, and Practical Surgery, 2d ed.; Copland's 
Diet. Art. Haemorrhage; Sir A. Cooper's and Lawrence's Lectures; Guthrie in 
Med. Gaz. vol. xvii.; Brodie, ibid, vol xv.; Liston on Tumours of the Face, in Med. 
Chir. Trans, vol. xx.; Bell on the Teeth; Jobson on the Teeth; and Fergusson's 
Practical Surgery. Disease of the lower jaw requiring amputation has been caused 
by a projection anteriorly of the coronoid process, which hindered the evolution of 
the wisdom tooth. Forbes's Rev. vol. viii. DISEASES OF THE TONSILS. 
401 
CHAPTER XV. 
ON THE SURGICAL DISEASES AND INJURIES OF THE NECK. 
I. Acute Inflammation of the Tonsil, is known by rapid 
swelling of the part, great pain in deglutition, and fever. It must 
be treated by leeches or bleeding, purgatives, gargles calculated to 
promote the secretion of saliva, (F. 39,) and the ordinary antiphlo- 
gistic routine. If the gland continue to swell, or if it occasion any 
embarrassment to the breathing, an incision should be made into it, 
to unload the vessels, and give exit to matter. The tongue should 
be depressed with one forefinger, whilst a straight bistoury, wrap- 
ped round with lint, except an inch and a half of its point, is 
plunged directly into the tumour, and made to cut its way out 
towards the median line. 
II. Chronic Enlargement of the Tonsil is a frequent sequel 
of repeated inflammation of the tonsils, especially in scrofulous 
children. It causes sundry inconveniences. The parts are liable 
to repeated inflammation-deglutition is impeded-the voice is 
rendered hoarse-respiration is noisy and laborious, especially 
during sleep-there is more or less deafness from the obstruction of 
the eustachian tubes-and suffocation has even been caused by 
viscid mucus entangled between the swollen glands. 
Treatment.-In the first place, the system must be strengthened, 
and the secretion be kept up by proper tonics and alteratives. The 
iodide of iron, the combination of corrosive sublimate with tinct. 
cinchonas, and other remedies mentioned at p. 109, may often be 
administered with benefit. At the same time absorption of the 
tumour must be promoted by astringent gargles (of dec. cinchon. 
with alum, or F. 92)-by washing it once a day with strong lotions 
of arg. nit., or cupri. sulph. on a hair pencil-by applying stimulat- 
ing, or mercurial, or ioduretted liniments and ointments to the skin; 
-and by lancing the gums over the wisdom teeth if tumid, and 
removing any decayed teeth that cause irritation. But if these 
measures fail, part of the gland should be removed with the knife 
-a much more expeditious and cleanly method than the ligature. 
The surgeon seizes the tumour with a hook, or vulsellum, (depress- 
ing the tongue with its handle,) then introduces a blunt-pointed 
curved bistoury, and shaves it off-cutting upwards, parallel to the 
isthmus faucium. The nearest half of the blade of the bistoury 
should be wrapped in l,int to prevent the lips from being cut; and 
in operating on the right side, the surgeon will find it most conve- 
nient to cross his hands; the left, holding the vulsellum, being 
undermost. There are certain other instruments occasionally used 
for this operation, such as a kind of guillotine instrument, consisting 
of a ring with which the tonsil is encircled, and a blade moving in 
a groove; but the simple knife and forceps answer every purpose. 402 
DISEASES OF THE (ESOPHAGUS. 
III. Enlargement of the Uvula produces tickling cough and 
expectoration by irritating the larynx. If it does not yield to the 
treatment directed for enlarged tonsil, it should be stretched and 
steadied with forceps, and be cut through in the middle with a pair 
of long scissors. 
IV. A Polypus growing from the Epiglottis has been known 
to produce fits of suffocative spasm of the muscles of the glottis, 
which have proved fatal.* Any such tumour, if ascertained to 
exist, must be removed. A case is on record also of a polypous 
tumour growing in the trachea; the diagnosis of such a case from 
chronic inflammation or thickening, must be very difficult.! 
V. Spasm of the (Esophagus {spasmodic stricture} is known 
by its generally occurring in sudden fits-the patient at a meal 
finding himself altogether incapable of swallowing-and the at- 
tempt to do so producing spasmodic pain and a sense of chok- 
ing. The diagnosis between this and the organic or permanent 
stricture is founded on the suddenness of its accession; it being 
much better at some times than at others; and the fact that the 
bougie, if passed, either meets with no obstruction, or with one that 
very easily yields. 
Treatment.-This affection always depends on a weakened or 
hysterical state of the system, or on the presence of some other dis- 
order, as has been mentioned whilst treating of neuralgia. Brodie 
relates a case that ceased on the removal of bleeding piles; and 
Mayo, another that was cured by relieving chronic disease of the 
liver. Tonics, antispasmodics, and alteratives-especially the car- 
bonate of iron thrice a day, with pills of aloes and galbanum at bed- 
time,-exercise in the open air, the shower-bath, and other forms of 
warm and cold bathing-great attention to the diet-care not to 
swallow any thing imperfectly masticated or too hot, and the occa- 
sional passage of a bougie, are the remedies. 
VI. Palsy of the (Esophagus occasions inability of swallow- 
ing, but without pain or other symptoms of spasm; and a bougie, 
when passed, meets with no obstruction. It generally depends on 
organic disease of the brain or spinal cord, which must be ex- 
amined into and cured if possible. The patient should be fed 
by the stomach-pump, by nutrient enemata, and by pushing soft 
food occasionally down the oesophagus with a pro bang. The palsy 
has sometimes been temporarily relieved by electrifying the patient 
on an insulating stool. Nutrient enemata should be composed of 
very strong beef or mutton broth, without salt or spice, and with 
ten or twenty drops of laudanum. The quantity injected at one 
time should not exceed four ounces. 
VII. Dilatation and Sacculation.-The oesophagus has been 
found after dpath exceedingly dilated. The symptoms during life 
were, great dysphagia,-food, when swallowed, never seemed to 
reach the stomach, and was vomited in a few minutes. If this con- 
* A preparation exhibiting this, is in the King's Coll. Museum, from Mr. Mayo's 
collection. 
f Vide Case published by Mr. Stallard, Med. Gaz., 19th May, 1843. DISEASES OF THE (ESOPHAGUS. 
403 
dition should be ascertained during life, the patient should be fed 
as in palsy. Sometimes a blind pouch is connected with the oeso- 
phagus, and occasions great distress in swallowing by intercepting 
the food. It may be formed either by a protrusion of the mucous 
membrane through the muscular fibres, or by the sac of an abscess 
which has burst into the tube. The only remedy is, to feed the 
patient constantly with the stomach-pump, so that the pouch may 
be allowed to close. 
VIII. Permanent Stricture of the oesophagus signifies a 
narrowing produced by an inflammatory thickening of its mucous 
and submucous coats, which form a firm ring, encroaching on the 
canal. It is generally found just below the termination of the 
pharynx ; that is, opposite the cricoid cartilage :-and is most fre- 
quent in females. The symptoms are, difficulty of swallowing- 
noticed probably for years-gradually increasing-never absent- 
and occasionally aggravated by fits of spasm. The act of swallow- 
ing frequently produces pain in the chest, which shoots between 
the shoulders, and up to the head. When a bougie is passed, it 
meets with an obstruction, and displays the impression of the stric- 
ture on its extremity. The causes of this affection are generally 
unknown-sometimes, however, it appears to be a sequel of re- 
peated quinsy, or to be caused by swallowing boiling or corrosive 
liquids;-in one case it appeared to be induced by violent retching 
in sea-sickness. The prognosis is always serious; especially if the 
complaint is of long duration. If unrelieved, its consequences will 
be ulceration of the oesophagus, either above or below the stricture; 
with salivation, vomiting of purulent matter, and impossibility of 
deglutition-which in no long time will be followed by death. 
The fatal termination may be owing either to sheer starvation, or 
to the irritation of the local disease, or the extension of ulceration 
to the lungs. 
Treatment.-A mild course of mercury, so as just to affect the 
gums,-combined with hyoscyamus or conium, if there be much 
irritability-a seton between the scapulae-and the occasional 
passage of a bougie, or of a ball probang-an ivory ball attached 
to a piece of whalebone or flexible wire-or of a piece of sponge 
moistened with a weak solution of nitrate of silver, and attached 
to a stout copper wire, as recommended by Sir C. Bell, are the 
remedies. The method of introducing the bougie is as follows: 
The patient sits upright, with the head thrown as far back as pos- 
sible, and the mouth wide open. The bougie, which should be 
previously warmed in the hand and oiled, and gently curved, is 
passed down into the pharynx in such a manner that its point may 
slide along the vertebrae. In order that it may not excite cough by 
interfering with the epiglottis, the patient should be directed to pro- 
trude the tongue from the mouth as far as possible;-or to perform 
the act of deglutition just when the bougie is entering the pharynx. 
If it meets with an obstruction to its descent, the surgeon should 
slightly withdraw it,-then again press it gently against the obstruc- 
tion, increasing the pressure for a few minutes if it gives no pain. 404 
DISEASES OF THE (ESOPHAGUS. 
If it fail to pass, it should be taken out, and its point be examined; 
and if it bear the impress of a stricture, a smaller one should be 
tried. 
IX. Scirrhus of the oesophagus produces at its commencement 
the same symptoms as stricture, and must be traced in the same 
manner, as it will be impossible to distinguish them. 
X. Ulceration of the oesophagus is generally situated at its 
upper part, and on its posterior surface. It causes great dyspha- 
gia, and burning pain on the passage of food. If a bougie is 
passed, it meets with an obstruction just above the ulcer, and with 
another just below it,-and its point returns marked with bloody 
pus, and presenting the ragged impression of the ulcer. 
Treatment.-Alteratives, counter-irritants, and nutrient ene- 
mata. The burning pain is sometimes relieved by swallowing 
small quantities of iced cream. 
XI. Tumours pressing on the oesophagus-whether abscesses, 
aneurisms, bronchocele, or enlargement of the bronchial lymphatic 
glands, will produce all the symptoms of organic stricture. Aneu- 
risms and abscesses have been burst by the passage of bougies- 
with, df course, instant death in the former case, and relief in the 
latter. Before performing this operation, therefore, the chest ought 
to be well scrutinized by auscultation, to detect any unnatural pul- 
sation or bruit; and any signs of embarrassed circulation or respira- 
tion should not be overlooked.* 
XII. Foreign Bodies, when fixed in the pharynx, or about the 
aperture of the larynx, or in the oesophagus, produce a sense of 
choking, and fits of suffocative cough. This accident, if unre- 
lieved, may prove fatal in two manners. The patient may either 
be suffocated at once, by spasm of the glottis;-or if the foreign 
substance remains impacted, it may produce a final ulceration of 
the parts-attended with exhausting cough and dyspnoea, and pro- 
fuse fetid expectoration. 
Treatment.-The patient should be seated in a chair, with the 
head thrown back, and the mouth wide open. The surgeon should 
then introduce his finger-regardless of attempts to vomit-and 
should pass it swiftly into the pharynx, and search the whole of it 
thoroughly. When the substance is felt, it may perhaps be en- 
tangled in the point of the nail-or curved forceps may be guided 
to it by the finger. Pins or fish-bones are often entangled about 
the velum, or in the folds of mucous membrane between the epi- 
glottis and tongue. 
If the body has passed into the oesophagus, and it is small and 
sharp, (a fish-bone for instance,) it may be got rid of by making 
the patient swallow a good mouthful of bread. If large and soft, 
(as a lump of meat,) it may be pushed down into the stomach with 
the probang. But large hard bodies, especially if rough and an- 
* Vide Sir E. Home on Stricl«res, vols. i.and ii.; Monro on the Morbid Anatomy of 
the Gullet, &c.; Brodie on Local Nervous Affections, Spasmodic stricture;') Mayo's 
Pathology; Stokes in Cyclop. Pract. Med., vol. ii.; and Sir C. Bell's Institutes of Sur- 
gery, vol. i. LARYNGOTOMY AND TRACHEOTOMY. 
405 
gular, (such as pieces of bone or glass, &c.,) should be brought up 
if possible. A pair of long curved forceps, or a piece of whalebone 
armed with a flat blunt hook, or with a skein of thread, so as to 
form an infinite number of nooses, are convenient instruments. If 
the stomach is full, a dose of tartar emetic dissolved in a very small 
quantity of water may be administered, in the hope that when the 
contents of the stomach are vomited, they may bring up the offend- 
ing substance with them. One case is on record in which a 
chicken bone lodging in the oesophagus was dissolved by making 
the patient swallow large quantities of dilute acid. If all means 
fail, however, and the substance can neither be brought up nor 
down, and if it be lodged in the cervical portion of the tube, it 
must be extracted by the operation of oesophagotomy in the follow- 
ing manner. 
XIII. CEsophagotomy.-This operation should be performed on 
the side towards which the foreign substance projects. Its situa- 
tion having been ascertained, an incision of sufficient length must 
be made through the skin and platysma between the sternomastoid 
muscle and trachea. The cervical fascia must next be divided on 
a director. The surgeon must then divide the cellular membrane 
with a blunt knife, or lacerate it with his fingers, avoiding the caro- 
tid and thyroid arteries, and the recurrent nerve. A common silver 
catheter may then be passed down the throat, and be made to pro- 
ject in the wound, so that the oesophagus may be opened by cutting 
on it. This small wound in the oesophagus should be dilated with 
forceps, in order to avoid haemorrhage, and the foreign body should 
then be extracted.* This operation has occasionally been performed 
for the purpose of conveying food into the stomach in cases of 
stricture of the oesophagus, but with no very satisfactory results. 
XIV. Foreign bodies in the Larynx and Trachea.-It some- 
times happens that a person who is busily laughing and talking dur- 
ing a meal, suddenly rises from table, attempts to put his finger into 
his throat, speedily turns blue in the face, and then drops down dead. 
This arises from a piece of food getting into the rima glottidis. It 
rarely happens that the surgeon arrives in time to do any good; but 
if he should be promptly on the spot, he ought to search the 
pharynx with his fingers, and to pass a probang down the oeso- 
phagus, to ascertain whether the obstruction can be removed;- 
and if not, he ought to perform laryngotomy or tracheotomy imme- 
diately;-and to pass a probe up into the larynx through the 
wound, so as to push the foreign substance up into the mouth. 
When a foreign substance has passed the rima glottidis, and 
has got into the trachea, it will produce different symptoms 
according to different circumstances. For, in the first place, it may 
become impacted in the ventricles of the larynx or upper part of 
the trachea; in which case it will probably produce violent spas- 
modic cough and difficulty of breathing, together with a fixed pain 
referred to one particular spot-a croupy sound during respiration, 
* Vide Arnott on CEsophagotomy, Med. Chir. Trans., vol. xx. 406 
LARYNGOTOMY AND TRACHEOTOMY. 
which may be heard by the stethoscope most distinctly at the seat 
of that pain; and loss of voice. 
In the second place, the foreign substance may be loose in the 
trachea. In this case, the violent coughing and sense of suffocation 
produced by its first introduction generally subside for a time;- 
but every now and then there are violent fits of coughing and of 
spasmodic difficulty of breathing, during which the substance may 
be heard by means of the stethoscope, or perhaps may be felt by 
the finger to be forcibly impelled against the upper part of the 
larynx. 
Thirdly, the foreign substance may have passed into one of the 
bronchi, (generally the right,) where perhaps it may be detected 
by causing a whistling or murmuring sound; and it will very 
probabty be dislodged and driven upwards, when the patient 
coughs. 
It is sometimes difficult to distinguish the symptoms produced by 
a foreign body in the larynx or trachea from those of croup or 
laryngitis. But the surgeon may generally pretty confidently decide 
that a foreign body is present, if the symptoms come on suddenly 
during a meal; or perhaps the history will be that the patient was 
playing with a button, or cherrystone, or some similar body in his 
mouth, and that he chanced to fall down, when the button dis- 
appeared, and the symptoms came on directly afterwards. More- 
over, in these cases, expiration is generally more difficult than 
inspiration, whereas it is usually the reverse in croup. Besides, 
when there suddenly occurs a fixed pain, and a fixed whistling 
sound in the larynx or bronchi, without any other symptoms of 
croup, the case must almost of necessity arise from a foreign body.* 
Treatment.-For the removal of any foreign substance from the 
air-passages, recourse must be had to one of the two operations 
next described. 
XV. Laryngotomy and Tracheotomy.-The former of these 
operations is most quickly and easily performed, and is to be pre- 
ferred in sudden emergencies, but the latter most readily admits of 
the removal of foreign bodies, and is always to be chosen in cases 
of suffocation from disease. 
Laryngotomy is performed by cutting at once, through the 
cricothyroid membrane, which may be felt as a soft depression, an 
inch below the pomum dldami. 
Tracheotomy is thus performed: The head being thrown back, 
an incision, an inch and a half to two inches long, must be made 
exactly in the median line from the cricoid cartilage to the top of 
the sternum. The skin, superficial fascia,and fat, are then divided; 
the sternohyoid muscles are separated with the point of the knife; 
the loose cellular tissue and veins are cleared from the front of the 
trachea with the fingers or handle of the scalpel; the thyroid gland, 
if in the way, is pushed up; then the patient being told to swallow, 
* Vide an interesting paper by Mr. C. Hawkins, and another by Mr. Travers, jr. 
on this subject. Med. Chir. Trans., vol. xxiii., and a notice of a paper read by Sir 
B. Brodie on Mr. Brunel's case, Med. Gaz., July 7th, 1843. SCALDS OF THE GLOTTIS. HANGING. 
407 
the surgeon seizes the moment, and whilst the trachea is stretched, 
sticks in his knife, with a slight jerk,* at the bottom of the wound, 
and carries it upwards, so as to divide three or four of its rings. 
The operator must take great care to keep in the middle line, and 
must be very cautious not to cut downwards at the bottom of the 
wound, for fear of the large veins. Haemorrhage may be arrested, 
if arterial, by the ligature ; if venous, by nicely adapted pressure; 
which must be kept up with the point of the fingers if nothing else 
suffices. As soon as an opening is made, the foreign body is 
usually expelled with a strong gust of air; but if not, it must be 
searched for with a probe, and be removed by forceps or by a blunt 
hook. If there is any difficulty, the plan may be tried, which has 
recently been practised with success, of turning the patient with his 
head downwards, in order to let the foreign substance fall through 
the rima glottidis; and it may be remarked that as soon as an 
artificial passage is made for the patient to breathe through, the 
great irritability of the natural aperture subsides, so that it permits 
the body to pass. The wound may be closed by plaster when 
bleeding has ceased, but not before. 
If the operation were performed for the relief of dyspnoea, a 
conical curved tube should be introduced for the patient to breathe 
through. From its shape, it fits tightly into the 
aperture, and prevents the entrance of blood into 
the trachea. It should be of such a size, as 
Trousseau has remarked, that the air may pass 
through it in respiration without any whistling 
noise.t When the patient wishes to cough or 
speak, he must be taught to close its orifice with 
his finger. It should be frequently cleared of any mucus that may 
lodge in it. 
XVI. Scalds of the Glottis, through swallowing boiling 
water or corrosive fluids, produce the ordinary symptoms of laryn- 
gitis-suffocative cough, and dyspnoea. 
Treatment.-Leeches, ice to the throat, calomel in large doses, 
so as rapidly to affect the system, and tracheotomy if required. 
XVII. Hanging may destroy life in three ways. (1.) By dis- 
locating the neck. (2.) By compressing the trachea, and suspend- 
ing respiration. (3.) By compressing the jugular veins, and inducing 
apoplexy. 
Treatment.-Artificial respiration, bleeding from the jugular 
vein if the face be turgid, dashing cold water on the face and chest, 
and a current of galvanism passed from the nape of the neck to the 
pit of the stomach, so as to excite the diaphragm.^: 
Fig. 114. 
* The trocar is, as Mr. Fergusson justly observes, a most clumsy and inefficient 
instrument for opening the trachea; which being an elastic tube, yields and bends 
before the pressure necessary to introduce the point of it. The author once saw a 
surgeon fruitlessly endeavour to use it; and he seemed in great danger either of 
running it through both trachea and oesophagus into the vertebrae, or else of letting 
it slip sideways into the jugular vein. 
■[ Trousseau de la Tracheotomie, L'Experience, Nov. 5,1840. 
t For the manner of applying galvanism in these cases refer to Part v. chap. ii. 408 
STOMACH-PUMP. 
XVIII. Drowning, Treatment of.-If respiration has ceased, it 
should instantly be commenced artificially; at the same time the 
body should be wiped dry, and be assidulously rubbed with hot 
cloths. Hot bricks and bottles of hot water should be put into the 
axillae, between the thighs, and to the feet; the head should be 
raised, the nostrils irritated with a feather, or with the fumes of 
hartshorn, and a warm enema of turpentine may be thrown up. 
Galvanism should be resorted to, if respiration is not quickly 
restored. It need scarcely be said that enemata of that filthy nar- 
cotic, tobacco, must not be thought of. As soon as the patient can 
swallow, he should have some weak wine and water; and soon 
afterwards an emetic of mustard, to clear the stomach of the water 
which he has swallowed, and to restore the circulation by the 
impetus of vomiting. After some hours he will suffer from severe 
headache and fever, which must be relieved by bleeding or leech- 
ing, purgatives, and other remedies, according to the exigencies of 
the case. A case is related in which life was restored by the most 
persevering friction, which was kept up for eight hours before the 
humanity of the surgeon, Dr. Douglass of Havre, was rewarded by 
a return of respiration.* 
XIX. Artificial Respiration is required in all cases of sus- 
pended animation,-whether from external injury, noxious gases, 
or narcotic poisons, including alcohol. It may be performed by 
passing a pipe through the mouth, or a male catheter through the 
nostril, into the glottis; or by simply putting a pipe into one nos- 
tril, and closing the mouth and the other nostril, and blowing 
through it. But it is a better plan to use a small pair of bellows, 
putting its muzzle into one nostril. The operator should be careful 
to force the air into the lungs with very great gentleness, and to 
press the larynx against the spine, so that it may not go down the 
oesophagus. If the larynx has been crushed by a rope, or by a 
violent blow, it may be necessary to perform tracheotomy, so as to 
impel a current of air directly into the trachea-but not otherwise. 
XX. Stomach-pump.-The tube of this instrument is to be intro- 
duced in the same manner as the oesophagus bougie. It is usual 
to place a gag into the patient's mouth, having a hole for the tube 
to pass through, in order that it may not be compressed by the 
teeth. Before pumping out the contents of the stomach, one or 
two pints of water should be injected into it, and care should be 
taken not to withdraw quite as much as was injected. More 
water should then be thrown in, and the process should be repeated 
till it returns colourless. 
The stomach-pump is by no means so universally efficacious as 
is popularly supposed. It ought only to be employed in those 
cases of poisoning by opium, or alcohol, or other narcotics, in which 
the stomach and nervous system are rendered so insensible that 
vomiting cannot be excited. For, in the first place, the operation 
is not free from danger. It is a well-established fact, that a tube 
* Med. Gaz., 23d December, 1842. WOUNDS OF THE THROAT. 
409 
may sometimes be passed into the trachea of a sensible person 
without creating any peculiar sensation, or exciting cough ; but if 
the patient be insensible, that accident will be much more liable to 
happen. In fact, a case is on record in which a meddling surgeon, 
with more zeal than knowledge, did actually pass the tube down 
the trachea, and inject the lungs with chalk mixture, which he had 
far better have permitted his luckless patient to have swallowed 
quietly; and Sir C. Bell tells us, that he has seen on dissection 
both lungs filled with broth, which was intended to have been 
injected into the stomach. Again, it is known that in one case the 
mucous membrane of the stomach was sucked into the holes of the 
tube, and torn into strips,-a thing likely to happen if the stomach 
is pumped too empty. Besides, this artificial evacuation of the 
stomach is by no means so efficacious as free vomiting, assisted by 
plenty of diluents. Lumps of arsenic were left in the stomach, in 
the very case just cited, in which the mucous membrane was torn. 
But yet surgeons have been reprimanded by attorney coroners and 
"respectable" juries for not using this instrument, even in cases 
where it must have been either useless or injurious. These are 
the fruits of permitting the office of coroner to be filled by men who 
have no knowledge of the subjects that they are required to sit in 
judgment on.* 
XXI. Wounds of the Throat are generally made with inten- 
tion of suicide, and are extremely dangerous, no less from the 
importance of the parts injured, than from the despondency of the 
patient. 
Treatment.-The general indications are, 1st, to arrest haemor- 
rhage ; 2dly, to obviate difficulty of breathing; 3dly, to prevent 
inflammation of the trachea or chest. 
In the first place, any arteries that are wounded must be tied, and 
haemorrhage from large veins must be restrained by pressure with 
the finger, kept up as long as may be necessary. The patient should 
be put to bed in rather a warm room; and as soon as all oozing has 
ceased, but not before, his shoulders should be raised by pillows, 
and the head be bent forwards, and be confined by a bandage 
passing from each side of the nightcap to the shoulders. Plasters 
are inadmissible, and so are sutures, except in the cases that will 
be alluded to presently. If the wound penetrates the trachea or 
larynx, it should be covered with a loose woollen comforter, or, 
after the first week, with one of Jeffrey's respirators, if it can be 
nicely adapted. The patient should not be kept too low; and if 
the pharynx or oesophagus is wounded, a common, large-sized, 
elastic catheter may be passed, through which nutritive fluids 
can be injected by means of an elastic bottle. But if during the 
inflammatory stage the attempt causes great irritation, it may be 
necessary to employ nutrient enemata merely. At all events no 
tubes should be passed through the wound for that purpose. The 
* Vide an amusing Clinical Lecture on the Abuse of the Stomach-pump, by 
Professor Watson, in Lond. Med. Gazette, vol. xvii.; and Roupell's Illustrations of 
the Effects of Poisons. 410 
BRONCHOCELE. 
great thirst and dryness of the fauces, experienced in these cases, 
may in some measure be mitigated by sucking a wet rag. If the 
patient finds great difficulty in expectorating through the wound, 
he must be taught to close it partially by leaning his head forwards 
and placing his fingers on it, whilst he makes an expiratory effort, 
so that he may expel the air with a sudden gust. 
In every stage of the cure, difficulty of breathing should be viewed 
with suspicion. It may arise from several causes. (1) If the wound 
is above the larynx, it may be caused by the epiglottis being de- 
tached from the tongue, and hanging down upon or irritating the 
rima glottidis,-ox by clots of blood collecting in the pharynx. 
(2) It may be caused by an irregular and jagged division of the 
larynx or trachea, so that some pieces of the cartilage hang into the 
tube; or supposing the trachea to have been completely cut through, 
it may be caused by the aperture of the lower portion being over- 
lapped by the upper. In these cases it may be requisite to employ 
sutures, but they should be passed merely through the cellular tissue 
around the cartilage, and neither through the cartilage nor the skin. 
(3) It may be caused by swelling of the mucous membrane of the 
larynx and trachea in the acute inflammatory stage immediately 
after the injury-or by chronic thickening of that membrane from 
the continued irritation of cold air, if the wound is very slow in 
closing. In the former of these cases, free antiphlogistic measures 
must be used;-the latter must be prevented by using a proper 
position, so as to promote the approximation of the wound whilst 
it is healing. In either case it may be necessary to make a longi- 
tudinal division of the trachea to relieve the dyspnoea. (4) Another 
frequent cause of dyspnoea is the passage of blood into the trachea, 
if the wound is prematurely closed, and especially if it is sewn up 
or covered with plasters. Even supposing the trachea not to be 
opened, great danger may result 
from closing a wound of the 
throat before bleeding has ceased, 
for the blood may accumulate in 
the cellular tissue, and coagulate, 
and compress the trachea. 
XXII. Bronchocele (Goitre, 
Derbyshire neck} is an hyper- 
trophy of the thyroid gland. 
Symptoms.-A soft, project- 
ing, elastic, tumour occupies the 
front of the neck, in the situation 
and of the shape of the thyroid 
gland. It is rarely tender, and 
the skin is not discoloured. Fre- 
quently one lateral lobe is larger 
than the other;-and occasion- 
ally the middle lobe or isthmus is 
solely or principally affected. 
Fig. 115 * 
* From the King's College collection. The oesophagus is seen to be pushed to 
the right side by the tumour. BRONCHOCELE. 
411 
Consequences.-When of moderate bulk, it rarely causes any 
inconvenience;-except occasional headache, and difficulty of 
breathing in a stooping posture. But when very large, it may pro- 
duce a most dangerous difficulty of swallowing and breathing, and 
congestion in the head by its pressure on the trachea, oesophagus, 
and jugular veins ;* or it may induce thickening and disease of the 
trachea, with most obstinate cough, which may end in consump- 
tion. 
Diagnosis.-It is to be distinguished from encysted and other 
tumours by its shape, by its want of fluctuation, and by its mostly 
affecting both sides. 
Prognosis.-If it be soft and recent, and occur in a young 
patient, it will most likely be cured; but probably not, if it be old, 
hard, and the patient advanced in life. 
Anatomical Characters.-The cells of the gland are found en- 
larged ;-of various sizes from that of a pea downwards;-and 
filled with a viscid fluid, which becomes gelatinous if immersed in 
alcohol. Hence it has been presumed that the disease consists 
essentially of an increased secretion of the matter contained in the 
cells of the gland. Sometimes they are filled with blood. In old 
cases, the tumour becomes hard, resembling a sarcomatous forma- 
tion ; and may contain ossific deposits.! 
Causes.-Bronchocele is what is called an endemic disease ; that 
is, one extremely prevalent in certain localities; amongst which 
may be mentioned Derbyshire, Nottingham, and the chalky parts 
of England generally; and various Alpine and mountainous dis- 
tricts, especially the Tyrol and valley of the Rhone. The use of 
melted snow or of water impregnated with calcareous or earthy 
particles, to which the inhabitants of all those places are more or 
less habituated, although not perhaps the invariable cause, is the 
most probable that can be assigned.^ In England it most frequently 
affects females about the age of puberty, and in many cases is ob- 
viously connected with uterine derangement. Patients so often 
refer its origin to some twist or strain of the neck, that there is 
some reason for believing that such an accident may be an exciting 
cause. There are some persons who always have more or less 
enlargement of the thyroid gland, and who invariably find it in- 
crease in bulk when their health is out of order, or their strength 
lowered. 
Treatment.-The best remedy for this disease is iodine. The 
dose should not be large enough to cause pain or disorder of the 
stomach, or any diminution of the general health. The tincture of 
* Mr. Howship gives a case of bronchocele with the jugular vein passing 
through its substance. The patient suffered greatly from congestion in the head. 
f Vide Baillie's Morbid Anatomy, by Wardrop, 2d ed. p. 84, and Turner's Art of 
Surgery, vol. i. p. 198. 
t Capt. Alexander Gerard, in his account of Korrawur in the Himmalayas says, 
that " although the Korrawurrees can get nothing but snow for some months in 
the year, they are not so subject to goitres as the people that live in the damp 
grounds in the forest at the foot of the hills, where there can never be any snow 
water." 412 
BRONCHOCELE. 
pure iodine is objectionable, because it is not miscible with water, 
and is apt to cause pain in the side. But the iodine should be com- 
bined with an alkali, or with the iodide of potassium, or with iron ; 
and an aromatic or a little hyoscyamus often makes it sit more 
lightly on the stomach. (F. 41, 74.) Before administering the 
iodine, however, it is useful, if the complaint is of recent origin, to 
apply leeches, and purge the patient freely. An ointment or lini- 
ment of iodine, or of the iodide of potassium, may also be rubbed 
into the tumour, but it must be remembered that the swelling gene- 
rally enlarges, instead of decreasing, if the skin be irritated. The 
patient, if possible, should remove from a district in which the ma- 
lady is prevalent, and should drink boiled or distilled water. A 
residence on the coast and warm sea-bathing are mostly advanta- 
geous. If the iodine does not succeed, the burnt sponge, in doses 
of gfs ter die, is the best substitute. Any disorder in the digestive 
or uterine organs should be carefully removed. Pills composed of 
aloes, soap, and assafoetida (aa gr. ii-iii.) may be given at bedtime 
with advantage. Other remedies which were in vogue before the 
discovery of iodine, and which may be resorted to if that fails, are 
as follows-mercury, iron;-potass and soda;-chlorides of barium 
and calcium;-digitalis, hyoscyamus, and belladonna;-and sea 
water. 
If medicines prove ineffectual, and the tumour enlarges rapidly 
so as to threaten suffocation or apoplexy, surgical operations must, 
be resorted to. There are three which have been proposed and 
practised viz. the introduction of setons;-ligature of the arte- 
ries which supply the gland;-and extirpation. The general re- 
sults of these operations may be stated thus: All three of them 
have at different times succeeded; all of them are hazardous to life, 
and have proved fatal; and the first two have in some instances 
failed to remove the disease, although the patient has recovered 
with his life. 
If a seton be passed, it should be of silk, and large enough to 
fill the wound made by the needle, so that there may be no fear of 
bleeding. The needle should be long and narrow. The utmost 
precaution must be taken, both before and after the operation, to 
avoid inflammation. If after the seton has remained for some time, 
it. ceases to produce a diminution of the gland, it should be with- 
drawn, and be reintroduced in another place. 
Extirpation of the gland is performed by making an incision in 
the mesial line of the neck;-the skin and muscles must then be 
dissected from the tumour;-and every artery be tied as soon as it 
is divided. Then (as it is mostly enlargement of the isthmus, or 
middle lobe, that requires this operation) a strong double ligature 
should be passed through it, and should be firmly tied on each side 
of it before it is cut out. 
Encysted tumours.-Sometimes cysts are formed in this gland, 
which contain a glairy matter or blood. If necessary, they may be 
punctured,-when they will most likely inflame, suppurate, and 
contract, If bleeding prove troublesome, the wound must be filled WRYNECK. 
413 
with lint. Similar cysts are liable to form in other parts of the neck, 
and connected with the thyroid gland. Their treatment is the same.* 
This gland may further be effected with acute and chronic in- 
flammation, and tubercular deposit; either of which may lead to 
abscess. Their treatment must be conducted on general principles. 
XXIII. Hernia Bronchalis (Bronchocele vera, Goitre aerien) 
is a very rare tumour, formed by a protrusion of the mucous mem- 
brane through the cartilages of the larynx, or the rings of the tra- 
chea, and caused by violent exertions of the voice. Larrey met 
with sundry instances of it in French officers, and in the muezzin 
or priests that call the people to prayer from the top of the minarets 
in Mohammedan countries. The tumour is soft and elastic,-can 
often be made to disappear by pressure,-and is increased by any 
exertion. The only available treatment is moderate support.t 
XXIV. Parotid Tumours.-The parotid gland is occasionally, 
although rarely, the seat of malignant disease, and perhaps sarco- 
matous enlargement. But the tumours behind the ramus of the 
jaw (commonly called parotid tumours') generally depend on dis- 
ease of the lymphatic glands, which are embedded in the parotid, 
and which cause the natural texture of the latter to be displaced or 
absorbed, so that they may extend inwards to the pterygoid and 
styloid processes, and be intimately connected with the branches of 
the portio dura. " If there be reason to suspect," says Mr. Liston, 
" that the disease is of malignant nature, and not thoroughly limited 
by a cellular cyst, no interference is admissible. If, on the contrary, 
it be at all movable, has advanced slowly, possesses a smooth sur- 
face, and is firm, (neither of stony hardness, nor pulpy,) then an 
operation may be contemplated." 
XXV. Tumours in the side of the Neck, arising from enlarge- 
ment of the lymphatic glands, if subjacent to the skin merely, and 
freely movable on the subjacent tissues, may be readily removed,- 
but if they lie deep, and are bound down by the platysma and 
fascia, they require some consideration. If a tumour be of slow 
growth, defined in its outline, and movable, so that it is probably 
not malignant,-or if it interferes with deglutition or respiration, its 
extirpation may be attempted. The patient should always be 
warned of the probability of facial palsy after removal of a parotid 
tumour. See the remarks on the removal of tumours in Part V. 
XXVI. Wryneck is a peculiar distortion in which the head is 
bent down towards one shoulder, (generally the right,) and the face 
is turned to the opposite. The right eyebrow and right corner of 
the mouth generally become elevated, so as to preserve their hori- 
zontal position, notwithstanding the distortion of the neck. 
Varieties.-This affection presents many varieties. It may per- 
haps be only a part of general lateral curvature of the spine. Or 
(2) it may depend on caries of the cervical vertebrae. (3) It may be 
caused by contraction of the cicatrix of a burn or ulcer; or (4) by 
* Vide a paper by Mr. B. Phillips in Med. Chir. Trans., vol. xxv., on Tumours in 
the neck not involving the Thyroid Gland. 
f Larrey, Clinique Chirurgicale, tom. ii. p. 81. Paris, 1829. 414 
WRYNECK. 
glandular enlargement on one side of the neck;-the treatment of 
which cases requires no observation in this place. 
But the genuine wryneck is produced by permanent contraction 
of one sterno-mastoid muscle,-which may depend (1) on inflam- 
matory spasm of that muscle, with or without subacute inflamma- 
tion of the cervicle fascia. This form generally occurs somewhat 
suddenly to weakly children with disordered digestive organs. The 
skin over the muscle is often hot and tender, and any motion causes 
pain. 
Treatment.-Perfect rest in the horizontal posture,-leeches,- 
and poultices or hot fomentations, so as to keep the skin constantly 
moist and perspirable,-with purgatives and alteratives.* 
(2.) It may depend on rigid atrophy of the muscle, which may 
be a sequel of the state of inflammatory spasm last described, or 
may be congenital. 
Treatment.-Long-continued friction with mercurial ointment, 
or with lin. hydrargyri,-or Scott's ointment (F. 25) worn as a 
plaster,-with blisters behind the ears, and to the nape of the neck, 
-and the use of a machine to keep up extension,! may be of ser- 
vice in cases that are of no very long duration. If they fail, or if 
the case is congenital, division of the sternal origin of the muscle 
(or perhaps of the clavicular also) is the last resource. It is best 
performed thus:-The skin covering the muscle at about an inch 
from the sternum is to be pinched up between the left forefinger and 
thumb. A narrow curved bistoury is then to be thrust under the 
muscle, and is to be made to divide it as it is being withdrawn,- 
but the wound in the skin must only be large enough to admit the 
instrument. The aperture may be made at the anterior border of 
the right muscle, and between the sternal and clavicular portions of 
the left. As soon as the division is complete, the ends of the mus- 
cle retract with a dull snap, and the thumb should be pressed on 
the part to prevent effusion of blood under the skin. When the 
wound has healed, but not before, an apparatus should be applied 
to elongate the callus, and restore the neck to its proper position. 
A stiff collar to the diseased side is the simplest and best apparatus. 
(3.) Lastly, this distortion may be caused \yy palsy of one sterno- 
mastoid muscle, in consequence of which the other muscle, being 
uncontrolled, drags the neck permanently to its own side. If the 
administration of remedies calculated to remove any existing dis- 
ease in the head or back, and to improve the health,-and if 
strychine, blisters, issues, and electricity fail,-division of the sound 
muscle has been recommended f 
* For further information respecting this form of wryneck, consult Abernethy, 
Leet, xxxii., Renshaw's ed.; James on Inflam.; 2d ed., p. 484; and Brodie on Local 
Nervous Affections. 
j- See a plate in Cooper's First Lines. 
I Vide Cases of Wryneck, &c. by Dieffenbach, in the Lancet for Sept. 1838. 
Gooch gives a case of wryneck and distortion of the jaw caused by contraction of 
the platysma myoides, and cured by division of that muscle, in the year 1759. HYDROTHORAX. 
415 
CHAPTER XVI. 
OF THE SURGICAL DISEASES AND INJURIES OF THE -CHEST. 
I. Pneumothorax signifies a distension of the cavity of the 
pleura with air, and collapse of the lung. It is known by the 
following symptoms: On the affected side there is an absence of 
the respiratory murmur, with an exceedingly clear sound on per- 
cussion, and immobility of the ribs-and there is puerile, respiration 
on the other side. It may be caused (1) by a fractured rib which 
has lacerated the lung-and in this case it is attended with emphy- 
sema,-as has been detailed at page 245. (2.) It may be caused 
by the bursting of an abscess of the lung into the cavity of the 
pleura. This case will be indicated by succussion^xA by metallic 
tinkling, in addition to the signs mentioned above. Succussion 
simply consists in making the patient shake himself, when (inas- 
much as both air and fluid have escaped from the lung into the 
pleural cavity) the fluid will be heard to splash, if the ear is applied 
to the chest. The metallic tinkling is a clear sound, like the 
dropping of water into a cask. It is produced when the patient 
coughs,-by which means a drop of fluid is shaken from the orifice 
in the lung, and made to fall to the bottom of the chest. 
Treatment.-As far as the mere surgical treatment of pneumo- 
thorax is concerned, if the breathing become very difficult a grooved 
needle or small exploring trocar may be introduced between the 
fifth and sixth ribs, to let the air escape. 
II. Hjemothorax, which signifies the presence of blood in the 
pleural cavity, may be suspected if great dyspnoea and dulness on 
percussion follow a fractured rib. The blood may proceed either 
from the intercostal artery, or from the lung. 
Treatment.-If the difficulty of breathing be very urgent, para- 
centesis must be performed, to let the blood escape. 
III. Hydrothorax, or water on the chest, is indicated by great 
difficulty of breathing, especially when lying down-livid counte- 
nance-disturbed sleep-dulness on percussion-and if the effusion 
be confined to one side of the chest, there is very great difficulty in 
lying upon the other. 
Treatment.-If the hydrothorax were merely an inflammatory 
effusion from pleurisy,-a local affection,-paracentesis might be 
advisable for the dyspnoea; but if (as it is generally) it is a mere 
effect of organic disease of the heart or lungs, the operation would 
do no good. At all events, both sides of the chest must not be 
punctured. 
It has been suggested to the author by Dr. Ferguson, that it 
might be advantageous to employ the needle for the cure of serous ' 
effusion into the pleura, in the same manner as it is employed for 416 
HYDROPS PERICARDII. 
the cure of hydrocele and ganglion. That is to say, half a dozen 
punctures might be made with an acupuncture needle or grooved 
needle through one of the intercostal spaces; and thus the serum 
might pass through the punctures into the cellular tissue outside the 
pleura, whence it might be absorbed. The same plan might also 
be adopted in cases of hydrops pericardii and ascites. 
IV. Empyema signifies abscess of the chest, or suppuration of 
the pleura. It is an effect of acute inflammation, whether idiopathic 
or caused by injury. It is known by dulness on percussion- 
gradually increasing enlargement of the side of the chest-separa- 
tion of the ribs-dyspnoea-difficulty of lying on the sound side 
-and more or less oedema of the parietes of the chest. If left to 
itself, the abscess may point and burst between the ribs. Para- 
centesis is decidedly required, if the case be clear;-if it be not, two 
or three punctures may be made with a grooved needle, or a small 
exploring trocar, and a cupping-glass be applied over them to 
extract some fluid. 
V. Paracentesis Thoracis, or puncture of the chest, is an 
operation sometimes required for the foregoing affections, and espe- 
cially for empyema, and may be performed by making an incision 
an inch and a half long on the upper edge of the sixth rib, at or a 
little behind its middle. -The intercostal muscles are then to be 
cautiously divided, and the point of the bistoury to be passed 
through the pleura. If fluid escapes from this puncture, it may be 
slightly enlarged. When performed for the relief of empyema, this 
operation is liable to be followed by many of the mischiefs that 
result from the opening of large chronic abscesses. The pleural 
cavity is incapable of contracting as the pus escapes;-air conse- 
quently enters to supply its place, and causes irritation of the cyst, 
and putrefaction of its contents. The discharge becomes profuse 
and fetid, and the patient suffers severely from irritative fever, 
under which he may sink. It is therefore advisable to place the 
patient on the diseased side immediately after the puncture, so that 
the matter may flow out without the ingress of air-to close the 
wound with lint and plaster before too much has escaped-to 
bandage the chest-and to repeat the operation in a few days, if 
necessary, instead of leaving the wound open. 
VI. Hydrops Pericardii may occur under the same pathologi- 
cal conditions as hydrothorax, and may be combined with it. Its 
diagnosis is obscure. It may be suspected to exist if the patient 
complain of constant weight in the praecordia, great dyspnoea, espe- 
cially when lying on the back, and faintness upon exertion;-if 
there is great dulness on percussion, and manifest fulness over the 
region of the heart-if its pulsations are tremulous-and the circu- 
lation embarrassed. The operation of paracentesis pericardii has 
been practised, although it can rarely be of much benefit. It has 
been attempted in sundry cases of hydrothorax, which were mis- 
taken for hydrops pericardii; but by a second lucky mistake the 
pleura was opened instead. It may (if thought advisable) be per- 
formed, either by making an incision opposite the heart's apex, and WOUNDS OF THE CHEST. 
417 
dividing the muscles and pericardium with the same precautions as 
in paracentesis thoracis-or by first making an opening into the 
pleura, opposite the junction of the fifth or sixth rib with its car- 
tilage-and then introducing the finger, feeling for the distended 
pericardium, and cutting into it with curved scissors. 
VII. Wounds and Contusions of the Parietes of the chest 
require the same treatment, whether the ribs are fractured or not. 
A firm bandage (having an aperture to admit of the dressing of 
any wounds) must be applied to prevent motion of the ribs. Free 
vensesection must be employed to prevent inflammation; the 
bowels must be opened, the diet low, and cough and irritation be 
allayed by opiates. 
VIII. Penetrating Wounds of the thorax, unattended with 
wound of the lungs, are exceedingly rare. In some cases when 
the chest is laid open, the lung collapses, just as it would in a dead 
body; in others, on the contrary, it does not recede from, or it even 
may protrude out of the wound. 
Treatment.-Bleeding must be restrained; foreign bodies and 
splinters of bone must be removed, and the wound be closed; then 
the surgeon must employ free bleeding, and the other measures 
spoken of above. The intercostal artery, if wounded, must, if 
possible, be tied, with a curved needle or tenaculum, the wound 
being enlarged for that purpose if necessary. If this cannot be 
done, pressure must be kept up on the bleeding orifice by the finger. 
If the lung protrudes, the rule generally given is, to return it as 
quickly as possible, unless it is injured or beginning to mortify; but 
Mr. Guthrie recommends that it should be permitted to remain, as 
it closes the aperture into the pleura, and speedily granulates and 
heals over. 
IX. Wounds of the Lung are known by the following symp- 
toms : Great dyspnoea and sense of suffocation; the countenance 
pallid and extremely anxious-and expectoration of blood,*- 
which is coughed up in florid arterial mouthfuls, mixed with occa- 
sional clots. The dangers of these wounds are threefold. 1st. The 
great haemorrhage, which may destroy the patient by exhaustion, 
or may fill up the air passages and induce suffocation. 2dly. In- 
flammation, which is sure to supervene from the injury, and may 
be aggravated by the irritation of clots of blood, or of other extra- 
neous bodies. 3dly. Profuse and exhausting suppuration, with 
cough, debility, hectic, and all the symptoms of phthisis. 
Prognosis.-This of course must be extremely guarded. But 
there may be good hopes of recovery after the third day is passed. 
Death is seldom caused after the first forty hours. 
Treatment.-The first indication is to check the haemorrhage. 
This can only be done by abstracting a large quantity of blood 
* [Expectoration of blood is far from being a constant phenomenon in these 
lesions. In the course of the last eighteen months, I have treated three cases of 
wounded lungs-in one of which the injury was inflicted by a pistol-shot, and in 
the others by dirk-knives-where there was no spitting of blood among the pri« 
mary symptoms of the affection.-F.] 418 
WOUNDS OF THE CHEST. 
from the arm, provided the patient be not already faint. Then the 
wound should be examined, and if it be of large size, or a gunshot 
wound, the finger should be introduced into it, to remove clots of 
blood, splinters of bone, or any other foreign substances that it may 
find. If it is not sufficiently large for this purpose, it may be dilated 
by a probe-pointed bistoury. At the same time, an intercostal 
artery, if wounded, should be secured. The wound should then be 
accurately closed with lint and plaster, and the patient should be 
suffered to lie as quiet as possible. He should have plenty of cool 
air, and a very light covering. It is a general rule, in all injuries 
of the thorax and abdomen, to place him on the wounded side. In 
the course of a few hours the pulse will probably rise, and the pain, 
and cough, and spitting of blood return. Upon the first appearance 
of such symptoms, venaesection must be repeated, and it must, 
without hesitation, be resorted to again and again if they recur. 
The diet must be rigorously low; nothing but cold acidulated drinks 
-lemonade,or barley-water with lemon-juice-can be allowed for 
several days; the bowels must be opened, and opiates be given to 
allay cough and pain. 
Secondary haemorrhage, after wounds of the lung, may (1) be 
caused by inflammatory excitement; or (2) (if the wound be gun- 
shot) by the separation of sloughs from the lung; or (3) by the 
sloughing of an intercostal artery that may have been brushed by 
the ball. Venajsection is the remedy for the first two cases, and 
the ligature, or pressure, for the third.* 
If, after the primary dangers of haemorrhage and inflammation 
have ceased, and the wound has closed, there are rigors, dyspnoea, 
and other signs of empyema, paracentesis is requisite. And if 
these symptoms come on soon after the injury, the paracentesis 
should be performed at the site of the wound; but if they come on 
at a distant period, the paracentesis should be done at the usual 
place, in order to avoid the adhesions that are sure to be formed 
near the wound. 
Foreign bodies in the chest add greatly to the danger of ex- 
hausting suppuration, although patients have recovered for years 
with balls, or pieces of cloth, encysted in the lung or pleural cavity. 
In some cases, a ball has remained rolling loosely about in the 
pleural cavity. If any foreign body is detected, it should, if pos- 
sible, be removed, and part of the upper border of a rib may be 
sawn away with Hey's saw, if necessary, in order to get at it. 
Some sufgeons direct penetrating wounds of the chest not to be 
closed; or they even recommend tents or canulae to be inserted, to 
provide for the escape of blood or matter. But it must be evident 
that there will be much less liability to severe inflammation if the 
wound is closed,-just as in wounds of joints and compound frac- 
* [There is no means of suppressing traumatic haemorrhage from the thorax, 
more effectual and safe than the application of large bladders filled with pulverized 
ice, to the parietes of the cavity, provided the patient have not become too much 
exhausted already m tolerate an agency so depressing to the vital powers, as pro- 
tracted and intense cold.-F.] DISEASES AND INJURIES OF THE ABDOMEN. 
419 
tures. Besides, " if the patient," says Hennen, " is placed with the 
wound in a dependent posture, the exit of effused fluids is not 
necessarily impeded. If they exist in large quantity, the wound is 
effectually prevented from closing; if the flow is so minute as to 
admit of the union of the wound, the quantity effused is within the 
power of the absorbents to remove." 
After wounds of the chest, there is a constant susceptibility of 
inflammation from slight causes, so that the patient should be cau- 
tious to avoid over-fatigue, intemperance, and atmospheric vicis- 
situdes. 
X. Wounds of the Heart generally prove fatal from haemor- 
rhage. Numerous instances, however, are on record, in which 
stabs or musket wounds of this organ healed, both in man and 
animals, without any remaining ill effects. The diagnosis and prog- 
nosis will of course be extremely doubtful. The only available 
treatment is free depletion and opiates, in order to prevent haemor- 
rhage, and keep the circulation as quiet as possible, so that the 
blood may coagulate in the wound, and the coagulum become 
adherent and organized. 
CHAPTER XVII. 
OF THE SURGICAL DISEASES AND INJURIES OF THE ABDOMEN. 
I. Paracentesis Abdominis is an operation performed in ascites 
and ovarian dropsy, when the abdomen has become so distended 
that the breathing and the circulation of the lower extremities are 
seriously impeded. 
Diagnosis.-Ascites is known by the abdomen being equably 
enlarged and fluctuating-not feeling harder at one part than at 
another,-whilst in ovarian dropsy, the swelling fluctuates less 
distinctly,-and is evidently composed of distinct cysts, some of 
which feel more distended than others. Another means of distin- 
guishing the two affections is afforded by percussion. In ascites, 
the bowels, as they contain air, float up through the serum; and, 
in whatever position the patient may be placed, they tend to occupy 
the uppermost part, and the serum the lowest; and a clear sound 
may be elicited by percussion over the bowels, but a dull sound 
over the serum. Thus, if the patient be placed on his back, a clear 
sound will be produced over the anterior surface of the abdominal 
parietes, but a dull sound towards the sides and back. In ovarian 
dropsy, on the contrary, the abdomen is distended by a tumour 
which is stationary; and which occupies its front part, the bowels 420 
OVARIAN DROPSY. 
being behind and on either side of it. Consequently, when the 
patient lies on her back, percussion of the anterior surface produces 
a dull sound; whilst a clear sound may be produced towards the 
back part and sides. 
Operation.-The patient must be seated in a chair. A broad 
towel must then be passed round the lower part of the abdomen, 
and its ends be crossed behind and entrusted to two assistants, who 
are to be instructed to draw it tight and support the belly as the 
fluid escapes; otherwise, the removal of the compression to which 
the abdominal veins have been habituated would cause the blood to 
gravitate into them from the heart, and induce syncope,-or perhaps 
they might burst, and occasion a fatal haemorrhage. A piece of 
flannel broad enough to cover the whole abdomen, and having a 
notch cut out of it above and below, (and the edges sewn together 
afterwards,) is a good substitute for the towel. The surgeon then 
plunges the trocar and canula through the linea alba, two inches 
below the umbilicus, (or perhaps it is better to make a cautious 
puncture with a lancet, and introduce a blunt trocar and canula,) 
-then he draws out the trocar, and receives the fluid into a proper 
vessel-the assistants drawing the towel tight as it escapes. The 
aperture is afterwards to be closed with lint and plaster,-and the 
patient to be put to bed, with the towel fastened round the loins. 
A broad flannel roller should be substituted for it before she rises. 
If a patient with ascites happens also to have an old irreducible 
hernia, and the sac is much distended, and preserves a free com- 
munication with the abdomen, it is a good plan to puncture the sac 
instead of the linea alba. 
II. Ovarian Dropsy.-This disease consists apparently in the 
conversion of the ovary into a large tumour, composed of one or 
many cysts, filled with a serous or glairy fluid. Its diagnosis from 
ascites has been spoken of in the preceding paragraph. It need 
scarcely be said, that this form of dropsy is very little if at all under 
the influence of medicine, and that it generally continues to increase, 
and fill up the abdomen, till it proves fatal by interfering with the 
functions of the stomach, and exhausting the powers of life;-a 
termination which is seldom very far postponed by the ordinary 
operation of paracentesis. Extirpation of the tumour has, therefore, 
been proposed and practised; and there are two modes of operating 
which require to be spoken of here. 
The first is the extirpation of the cyst by means of a short inci- 
sion, which has lately been brought into notice by Mr. Jeaffreson, 
and is performed thus:-An incision, an inch and a half long, is to 
be made into the abdomen below the umbilicus. As soon as the 
ovarian cyst is exposed, it is to be punctured, and the edges of the 
puncture being seized with forceps, the whole of the cyst is to be 
dragged out of the wound, as it gradually collapses on the fluid 
escaping;-then the pedicle of the cyst is to be tied tightly with a 
single silk ligature, and cut off. An estimate may be formed whe- 
ther the tumour consists of one cyst or many, by the quantity of 
fluid which escapes when the puncture is made; and if a second OVARIAN DROPSY. 
421 
cyst is discovered, it may be punctured and dragged out as well. 
The objections to this operation are-the probability that the tumour 
may be composed of many cysts;-or that part of it may be solid; 
-or that it may have contracted numerous adhesions;-and, lastly, 
that out of the number of operations performed, about one half 
have proved fatal.* 
The second is the extirpation of the tumour by means of a long 
incision from sternum to pubes; which was practised some years 
ago by Mr. Lizars, and has of late been revived by Dr. Clay of 
Manchester. The manner of operating, and the previous and sub- 
sequent treatment which Dr. Clay adopted were as follows:-The 
night before the operation he gave ten grains of inspissated oxgall, 
and repeated it in the morning, believing it to have the power of 
evacuating the alimentary canal and of dispelling flatulence with 
the least possible amount of irritation. The patient being placed 
comfortably on a table, he severed the integuments from sternum 
to pubes with one stroke-an incision 24 inches long;-then having 
carefully cut through the peritoneum at the upper part, sufficiently 
to introduce two fingers of his left hand, he passed in a probe- 
pointed bistoury, and, under the protection of his fingers, divided 
the peritonaeum to the extent of the first incision. The pedicle of 
the tumour, one of the broad ligaments, was then firmly tied and 
cut through; but as it was excessively thick, some of the vessels in 
it continued to bleed and required separate ligatures. The hands 
were now passed round the tumour in search of adhesions; some 
that were soft and recent gave way readily to the slightest touch; 
but an extensive omental adhesion required to be divided by the 
scalpel, and a vessel that bled freely was secured. The tumour 
was then lifted up and removed. When all bleeding had ceased, 
the integuments were brought together with nine stitches, and 
straps of adhesive plaster; and a broad bandage was passed round 
the body. The subsequent treatment consisted in giving small 
doses of henbane and morphia when necessary; opening the bow- 
els by clysters; relieving flatulence by introducing a gum elastic 
tube ; and nourishing the patient with as simple a diet as possible. 
It may be remarked further, that at the time of performing such an 
operation care ought to be taken to have the air of a temperature 
of 65° or 70°;-the incision should be made to diverge a little so as 
not to cut through the umbilicus;-and if on examining the tumour 
it is found either to be of a different nature from what was antici- 
pated, or to have contracted excessively numerous and wide adhe- 
sions, it is better to close the wound quietly, without attempting to 
extirpate it. In order to bring the sides of the abdomen evenly 
together, a number of lines may be marked across the linea alba 
with nitrate of silver before the operation. This gigantic operation, 
as it may be called, has of late been performed several times with 
success; although its results were rather infelicitous when it was 
* Vide Jeaffreson, Lancet, 7th January, 1839 ; King, Lancet, 21st January, 1837; 
West, Lancet, 25th November, 1837 ^.also Med. Gaz., November 24th, 1838; and 
case by Mr. B. Phillips, which proved fatal, Med. Gaz., October 10th, 1840. 422 
WOUNDS OF THE ABDOMEN. 
attempted by Mr. Lizars some years ago; for, out of his four 
patients, one died; one recovered; in one, after the abdomen was 
laid open, there was found to be no tumour at all; and in the fourth 
there was discovered an enormous mass of convoluted vessels look- 
ing like a placenta, which proceeded from the omentum to the 
tumour, and of course rendered extirpation quite out of the ques- 
tion, so that the incision was quietly closed again. But this, vexa- 
tious as it may be, every operator must consent to do under similar 
circumstances; for the mere incision into the abdomen cannot 
possess half the danger that must attend the severing of extensive 
adhesions to the omentum or viscera.* 
III. Violent Blows on the Abdomen from obtuse substances, 
-the passage of cartwheels, spent shot, and so forth, may produce 
various results. (1) They may cause severe concussion and col- 
lapse, which may either speedily prove fatal,-or may pass off 
without further ill consequences, or may be succeeded by inflam- 
mation. 
(2) They may produce laceration of the bowels, or of the solid 
viscera;-with effusion of blood or of their secretion into the peri- 
tonseal cavity. This may be suspected if the patient complains of 
excruciating pain radiating over the whole bellyif the features 
are pinched, the belly soon swells, and the pulse is very small and 
tremulous. 
Treatment.-1The patient must be suffered to lie quietly during 
the stage of collapse, without any officious administration of stimu- 
lants : and as soon as pain or vomiting comes on, he should be bled. 
Subsequently, bleeding, leeches, and fomentations to the belly, to 
abate inflammation; and large doses of opium to support the sys- 
tem under the irritation, are the only available remedies. The 
bowels should not be disturbed either with purgatives or enemata 
for the first three days,-nor should any nutriment be taken, save 
very small quantities of the mildest fluids at intervals. 
IV. Abscesses between the abdominal parietes occasionally 
result from contusions or punctured wounds, and sometimes occur 
idiopathically. According to the principles laid down in the chap- 
ter on abscess, they should be opened early, both because of the 
tendinous structures by which they are covered, and of the possi- 
bility that they might burst into the peritonaeum. 
V. Penetrating Wounds of the abdomen may be divided into 
four species; namely, 1st, simple wounds of the parietes; 2dly, 
wounds of the viscera; 3dly, wounds of the parietes with pro- 
trusion of the viscera; and 4thly, wounds in which some of the 
viscera are protruded and wounded likewise. 
(1.) In the case of a simple wound of the parietes, the surgeon 
must first (if it be large enough) gently introduce his finger, to 
ascertain that no part of the intestines is beginning to protrude;- 
* Vide Lizars on the Extirpation of Diseased Ovaria, Edinburgh, 1825; account 
of Dr. Clay's operations in Braithwaite's Retrospect, vol. vii.; and of two suc- 
cessful operations by Mr. Walne, Lond. Med. Gaz., 23d December, 1842, and 7th 
July, 1843. WOUNDS OF THE ABDOMEN. 
423 
then the wound must be closed by sticking plaster; or by suture 
if it is extensive. If the epigastric artery is divided, it must be 
cut down upon and tied. The surgeon must recollect that when 
any part of the abdominal parietes has been wounded or severely 
bruised, it is almost certain afterwards to become the seat of hernial 
protrusion. 
(2.) Wounds of the viscera. - In the case of small wounds of 
the abdomen without protrusion, it will be often impossible to say 
whether the bowels are wounded or not, but the treatment must 
be altogether the same, whether they are or not. 
(a) Wounds of the stomach may be known by the situation and 
depth of the sound,-by vomiting of blood,-by the very great 
depression and collapse,-and by the nature of the matters (if any) 
that escape from the wound. 
(6) Wounds of the bowels may perhaps be known by the pass- 
age of blood with the stools,-or by faecal matter escaping from 
the wound,-or by the symptoms of extravasation of their contents 
into the abdominal cavity-that is to say, excruciating pain, radiat- 
ing over the whole belly from the seat of the injury, and attended 
with signs of great collapse. Fortunately, however, as Mr. Travers 
has shown, wounds of the stomach and intestines, unless very large, 
are not so liable to be attended with extravasation as was formerly 
thought. For, in the first place, the mucous membrane protrudes 
through the muscular,so as to fill up a small aperture; and second- 
ly, any tendency to extravasation is counteracted by the constant 
equable pressure of all the abdominal viscera against each other. 
Moreover lymph is soon effused, and glues the neighbouring parts 
together, and thus the aperture is circumscribed, and any future 
extravasation is prevented. 
(c) Wounds of the liver, if extensive, are, from its great vascu- 
larity, nearly as fatal as those of the heart. Small wounds may be 
recovered from. There will at first be symptoms of great collapse, 
which, if the patient survive, will be succeeded by severe sickness, 
pain in the liver, yellowness of the skin and urine, great itching, 
and a glairy, bilious discharge from the wound. 
(</) Wounds or rupture of the gall-bladder are almost invaria- 
bly fatal, although there are one or two instances of recovery on 
record. 
(e) Wounds of the spleen, if deep, are also fatal from the great 
haemorrhage that follows, although the whole organ has been re- 
moved from animals (and it is said from man) without much con- 
sequent evil. 
(/) Wounds of the kidneys are attended with bloody urine. 
They are exceedingly dangerous, first from haemorrhage, next from 
violent inflammation with excessive vomiting; and lastly, from 
profuse suppuration, kept up by the passage of urine through the 
wound. Venaesection, very mild laxatives, the warm bath, avoid- 
ance of too much drink, very light dressings so as to admit of the 
flow of urine through the wound, and some unctuous application 424 
WOUNDS OF THE ABDOMEN. 
to prevent excoriation of the surrounding skin, are the necessary 
measures. 
(g) Wounds of the bladder, if communicating with the perito- 
naeum, are extremely dangerous, owing to extravasation of urine. 
In fact, unless there is an external wound through which it can 
escape, they are almost uniformly mortal. The catheter must be 
worn constantly. 
(3.) If the intestines protrude, and are neither wounded nor 
gangrenous, they should first be freed from any foreign particles 
that stick to them, and then be returned as soon as possible. The 
patient should be placed on his back, with his shoulders raised, 
and his knees drawn up. If absolutely necessary, the wound must 
be a little dilated with a probe-pointed bistoury. Then the surgeon 
should return the bowel portion by portion, passing it back with his 
right forefinger and thumb, and keeping his left forefinger on that 
which is already replaced, to prevent it from protruding again. He 
should be careful to replace intestine before omentum, and the part 
that protruded last should be returned first. 
(4.) If the stomach and Intestines, when protruded, are found 
to be wounded, the wound should be sewn carefully up with a fine 
needle and silk by the continuous or glover's suture, (p. 123,) in 
such a manner as to bring the edges into apposition, and prevent 
all extravasation between them. Then the part should be replaced, 
and the external wound be closed. The aperture in the bowel 
will be united, as in other cases, by the adhesion of contiguous sur- 
faces; and the silk employed in the suture will be detached by 
ulceration, and fall into its cavity. If, however, any part of the 
bowel that is protruded be bruised or lacerated, or be gangrenous, 
it should not be returned, but be left hanging out, that an artificial 
anus may be formed. 
The symptoms of inflammation of the peritonaeum or abdo- 
minal viscera, which is of course exceedingly likely to follow these 
wounds and injuries, may readily be recognized. The patient lies 
on his back with his knees drawn up; he breathes solely with the 
thorax and not with the diaphragm, or abdominal muscles; the 
countenance is anxious; the pulse small, wiry and resisting, but 
becomes fuller after bleeding;-there is severe throbbing pain with 
great tenderness, more or less widely diffused ;-a dry tongue, con- 
stant nausea or vomiting, and obstinate constipation, complete the 
catalogue. If the case proceeds to a fatal termination, the belly 
swells, partly from serous effusion, partly from tympanites; and 
the pulse becomes more frequent and weak; the patient retaining 
his senses to the last. 
The after treatment of all these cases is the same. The patient 
must be kept at perfect rest, and should lie on the wounded part, 
if such a posture be easy. Venaesection and leeches must be sedu- 
lously employed to avert haemorrhage and inflammation, and the 
indication for bleeding must be taken rather from the stomach than 
from the pulse. The pulse will, from the nature of the parts 
inflamed, be small and perhaps weak-but if there be vomiting. ARTIFICIAL ANUS. 
425 
bleeding may be performed without fear. After the bleeding, large 
doses of opium should be given, and should be repeated so as to 
keep the system under its influence. Nothing but water, or thin 
arrowroot, should be given for three days, when the stomach or 
intestines are probably wounded. 
The author hopes that it is unnecessary to warn his readers 
against the fatal and abominable custom of giving purgatives in 
cases of inflammation of the bowels arising from wounds of the 
abdomen. It is quite true that the bowels will be obstinately 
costive ; but this costiveness arises from their being inflamed and 
unable to propel their contents onwards; and the proper remedies 
for it, are such as will relieve the inflammation-that is, bleeding, 
leeches, fomentations, and calomel and opium. But if, in spite of 
common sense, the surgeon attempts to overcome the costiveness by 
colocynth pills and black draughts, he will soon induce an obstinate 
vomiting, that will render all his other remedies nugatory. If in 
any case of inflammation of the bowels it is probable that they are 
loaded with faeces, the proper remedy is the repeated injection of 
warm water as an enema.* 
VI. Artificial Anus signifies a preternatural communication 
between the intestine and skin. It may be a consequence of 
penetrating wounds-of abscess or ulceration of the intestines-or 
of mortification of intestine in strangulated hernia, and it is some- 
times purposely made by the surgeon in cases of imperforate anus, 
in order to afford an exit for the faeces. The external opening is 
irregular, everted, and red-and the surrounding skin excoriated. 
The aperture in the intestine adheres by its margin to the perito- 
naeum, so that extravasation into the abdomen is prevented. That 
portion of intestine which is immediately above the aperture, and 
that portion which is immediately below it, meet at the artificial 
anus at a more or less acute angle-and present two orifices-one by 
which matters descend from the stomach, and another which leads 
down to the rectum. These two orifices are separated by a sort of 
crescent-shaped septum, formed by a projection of the mesenteric 
side of the bowel opposite to the aperture. Now it may readily be 
understood, that the greater the aperture in the bowel, the more 
acute will be the angle at which the upper and lower portions 
meet-and the greater will the septum also be-and that, if the 
septum is large, it will act as a valve, and close up the orifice of the 
lower portion of bowel-causing any matters that come down 
through the upper portion to escape externally, instead of passing 
into the lower, t 
The consequences of this affection may be, 1st, that the patient 
may die of starvation from the escape of the chyle, if the aperture 
is near the duodenum. 2dly, that a portion of the intestine may 
* Vide Travers on Wounds of the Intestines, Lond. 1812; Hennen's Military- 
Surgery; the observations on the treatment of Enteritis in Ferguson on Puerperal 
Fever; Griffin's Medical Problems; and Dr. Holland's Notes and Reflections. 
f Vide the chapter on Artificial Anus in Lawrence on Hernia, and Dupuytren in 
Diet, de Med. tom. iii. 426 
HERNIA. 
protrude and form a hernia;-besides the constant disgusting 
annoyance occasioned by the escape of faecal matter and flatus. 
Treatment.-If the affection is of recent origin, and especially 
if it is consequent upon strangulated hernia, the patient should 
remain in bed, and great care should be taken to keep the parts 
clean ; and then, perhaps, the external aperture may contract and 
cicatrize. If the latter is very small, and if the passage between it 
and the bowel is of some length, (a state of parts termed feecal 
fistula,} something may perhaps be done by compression, and by 
engrafting a piece of skin over the aperture. 
But if the loss of substance in the bowel is considerable, and the 
projecting septum large, the chance of recovery is not great. A pad 
of simple linen or lint may be worn to compress the aperture and 
prevent discharge from it-or sometimes a hollow truss with a 
leathern or horn receptacle may be used with advantage. Enemata 
are useful in all cases. Moreover, a tent may be thrust into both 
internal orifices in order to enlarge the lower one, and repress the 
septum, as proposed by Dessault. As a last resource, a small 
Fig. 116. 
portion of the septum may be nipped and strangulated by the 
forceps invented by Dupuytren for that purpose. 
CHAPTER XVIII. 
OF HERNIA. 
SECTION I. OF THE NATURE AND CAUSES OF HERNIA GENERALLY. 
Definition.-Hernia signifies a protrusion of any viscus from 
its natural cavity. But the term, employed singly, is restricted to 
signify protrusion of the abdominal viscera. 427 
HERNIA. 
Causes.-The formation of hernia may be readily understood by 
considering that the abdominal viscera are subject to frequent and 
violent pressure from the diaphragm and other surrounding muscles 
-a pressure which tends to force them outwardly against the 
parietes of the abdomen. Consequently, if any point of the parietes 
be not strong enough to resist this pressure, some portion of the 
viscera may be forced through it, and form a hernial tumour 
externally. 
The predisposing cause of hernia, therefore, is a weakness of the 
parietes of the abdomen, which may be produced by various circum- 
stances. Thus (1) some parts of the parietes are naturally weaker 
than others; especially the inguinal and crural rings, and the umbili- 
cus ; and it is at these parts that hernia most frequently occurs. (2.) 
The abdominal parietes may be weak from malformation, or con- 
genital deficiency. (3.) They may be weakened by injury or dis- 
eases, such as abscesses, wounds, and bruises-or by distension by 
the pregnant uterus, or by dropsy. 
The exciting cause is compression of the viscera, by the action of 
the muscles that surround them. Hence hernia is so frequent a 
result of violent bodily exertion-lifting heavy weights and the like 
-especially if the patient have been previously weakened by ill- 
ness. Moreover, it is not uncommon in persons afflicted with stone 
or stricture, from the immoderate straining that they employ in 
passing their urine. 
The viscera most liable to hernial protrusion are the small intes- 
tines, omentum, and arch of the colon. But every one of them has 
occasionally been found protruded, partially or entirely-especially 
in cases of congenital deficiency of the abdominal parietes. 
The Sac of a hernia is a portion of the parietal or reflected layer 
of peritonaeum which the protruding viscera push before them in 
their escape, and which forms a pouch containing them. It very 
soon contracts adhesion to the surrounding cellular tissue, and con- 
sequently does not return into the abdomen when the viscera are 
replaced. Although it must be observed, that a hernia may be 
pushed back en masse, sac and all, when great force is used in 
reducing a strangulated hernia. As the hernia increases in size, the 
sac also increasespartly by growth; partly by distension, and 
slight laceration or unravelling; partly by fresh protrusion of peri- 
tonaeum. Sometimes it diminishes in thickness whilst increasing 
in capacity - sometimes, on the contrary, it becomes thick, indurated, 
and divisible into layers. Its neck (the narrow part which communi- 
cates with the abdomen) always becomes thickened, rigid, and more 
or less puckered, in consequence of the pressure of the muscular or 
ligamentous fibres which surround it. Sometimes the sac has two 
necks-either because (as in oblique inguinal hernia) it passes 
through two tendinous apertures-(the external and internal ab- 
dominal rings)-or because the original neck has been pushed down 
by a fresh protrusion. Some herniae, however, are destitute of a 
sac-or at least of a complete one. This may happen, (1) if the 
protruded viscus is not naturally covered by peritonaeum; as the 428 
REDUCIBLE HERNIA. 
coecum. (2.) If the hernia occur in consequence of a penetrating 
wound. (3.) In some cases of congenital umbilical hernia. (4.) 
Hernia may be considered virtually without a sac, if the sac lias 
been burst by a blow, or if it has become entirely adherent to its 
contents. 
Division.-Hernia is divided into several species (1st) according 
to its situation-as the inguinal, femoral, and so forth; (2dly) 
according to the condition of the protruded viscera ;-which may 
be reducible, (or returnable into the abdomen); (b} irreducible; 
(c) strangulated; that is, subject to some constriction which not 
only prevents their return into the abdomen, but interferes with 
the passage of their contents, and with their circulation. 
SECTION II. OF THE REDUCIBLE HERNIA. 
Symptoms.-A soft compressible swelling appears at some part 
of the abdominal parietes. It increases in size when the patient 
stands up ; if grasped, it is found to dilate when he coughs or makes 
any exertion-and it diminishes or disappears when he lies down, 
or when properly directed pressure is made upon it. If the sac con- 
tains intestine, (entero-cele,} the tumour is smooth, rounded, and 
elastic;-borborygmi (or flatulent croakings) are occasionally heard 
in it,-and when pressed upon, the bowel returns in the abdomen 
with a sudden jerk and gurgling noise. If, however, it contains 
omentum, (epiplo-cele,') the tumour is flattened, inelastic, flabby and 
unequal to the touch, and when pressed, it returns without noise, 
and very slowly,-the pressure requiring to be continued till it has 
entirely disappeared. But very often one hernia contains both in- 
testine and omentum (entero-epiplo-cele\* 
Treatment.-The indications for the treatment of reducible 
hernia are, to replace the hernia, and to prevent its return. The 
replacement of the hernia is to be effected by the taxis, that is, 
properly directed pressure, in the manner described when speaking 
of each particular species. The second object is to be accomplished 
by the use of a truss ; an instrument consisting of a pad placed on 
the seat of protrusion-and of a steel spring which passes round the 
body, and causes the pad to press with the requisite degree of force. 
In order to take the measure for a truss, the patient should lie down, 
and the hernia should be replaced-then he should stand up and be 
told to cough-whilst the surgeon ascertains with his fingers the 
exact spot at which the protrusion commences. The distance from 
this spot round the hip to an inch on the other side of the spine 
gives the required admeasurement. If the hips are very flat, or 
peculiarly formed, the measure should be taken with a piece of wire, 
stiff enough to keep its shape, so that it can be taken to the instru- 
* From xnXn, tumour; intestinum', and swiwXoov, omentum. The word x«x« 
is frequently used in the older surgical terminology; ex. gr. hydrocele, a tumour 
containing water; hxmatocele, a tumour containing blood; bubonocele, a hernial 
tumour in groin. REDUCIBLE HERNIA. 
429 
ment-maker's for a pattern. The pad should not be too large, nor 
the spring too weak, or the instrument will be loose and inefficient; 
-nor should the spring be too forcible, or the pad too small, other- 
wise it will cause pain. But the patient must expect to find it 
rather irksome for the first week. The truss should be constantly- 
worn by day; and if the patient will submit to wear it at night also, 
so much the better. If he will not do this, he should at all events 
apply it in the morning before he rises from the recumbent posture. 
Thousands of trusses, with every possible complication and variety 
of spring and pad, are daily advertised by their inventors; but any 
one who has had much practical knowledge of the subject, will not 
fail to agree with Mr. Liston, that " the simple truss well con- 
structed, made for and fitted to the particular individual, with or 
without a thigh strap, is to be preferred" in most cases; yet it must 
be acknowledged that there are instances in which the trusses of 
Coles, Salmon, Williams, and other patentees, are found to answer 
when the common ones fail. 
Radical Cure.-If the patient is below the age of puberty, or 
not much above it, and if the hernia has not existed very long, it is 
probable that the truss, if constantly worn, may effect a permanent 
cure. The herniary aperture, no longer subject to distension, may 
become firmly closed, and the neck of the sac obliterated. This 
cure may perhaps occur in two or three years, but as a measure of 
precaution, the truss should be worn for two or three years more. 
As for the old-fashioned attempts to obtain a radical cure by cut- 
ting out the sac-or by including its neck in a wire or other liga- 
ture-or by making a large slough of the superjacent skin-or M. 
Belmas's scheme of poking little bladders of goldbeater's skin upon 
sticks of gelatin into the neck of the sac for the same purpose*- 
the less that is said about them the better. One or two measures 
for the radical cure of inguinal hernia will be mentioned in their 
proper place.! 
* Vide Lancet, 1829-30, vol. ii. p. 390. 
f [The truss of Stagner, with the various modifications it has received from Dr. 
Chase and others, has been thoroughly tested by the most competent surgeons in 
the country, and, on all hands, pronounced one of the most valuable contributions 
of mechanical, to the healing art. 
When fitted and applied by a person of adequate professional knowledge and 
skill-and no others are entrusted with these duties, by the proprietors, who are 
themselves eminent medical men,-these instruments are harmless and comfort- 
able supports, and, in a large proportion of cases, favour the contraction of the 
ring, or promote adhesions about it-which result in a permanent cure of the com- 
plaint. It would seem that Mr. D. has not become acquainted with the merits of 
these American instruments. Dr. Chase would do well to send him a copy of his 
expose. 
Dr. Dodson, of this city, deserves to be mentioned among those who have con- 
tributed to the perfection of these instruments, by important improvements in their 
construction. F.] 430 
IRREDUCIBLE HERNIA. 
SECTION III. OF THE IRREDUCIBLE HERNIA. 
Definition.-Hernia is said to be irreducible when the pro- 
truded viscera cannot be returned into the abdomen, although there 
is no impediment to the passage of their contents, or to their cir- 
culation. 
Causes.-Hernia may be rendered irreducible (1) by an adhe- 
sion of the sac to its contents, or of the latter to each other, or by 
membranous bands formed across the sac. (2.) By enlargement 
of the omentum or mesentery-whether from simple deposition of 
fat, or from sarcomatous or other organic change. (3.) Omental 
hernia may be rendered irreducible by a contraction of that portion 
which lies in the neck of the sac, so that it is not stiff enough to 
stand against the pressure intended to push it back into the abdo- 
men, but doubles up under it. 
Consequences.-Irreducible hernia may produce sundry incon- 
veniences. In the first place, the patient is often liable to dragging 
pains in the abdomen, or perhaps attacks of vomiting, which come 
on after food, or when he assumes the erect posture-because the 
protruded omentum or intestines, being fixed, resist all distension 
or upward movement of the stomach. These inconveniences will 
be greatly aggravated, if the patient increase in corpulency, or 
become pregnant. Moreover, the protruded bowels being deprived 
of the support naturally afforded them by the abdominal muscles, 
their faeculent contents are apt to lodge in them, and frequently 
cause colic or constipation. Lastly, the bowel is greatly exposed 
to external injury, and in constant hazard of strangulation. 
Treatment.-This may be either palliative or radical. (1.) 
The palliative treatment consists in applying a hollow bag truss, 
or else a truss with a hollow pad that shall firmly embrace the 
hernia, and prohibit any additional protrusion. The patient should 
avoid all violent exertion or excess in diet, and should never let his 
bowels be confined. 
(2.) Radical Cure.-It has occasionally happened, after confine- 
ment to bed for several weeks with fever or some other emaciating 
ailment, that a hernia, irreducible before, has been replaced with 
ease, owing to an absorption of the fat of the omentum or mesen- 
tery, and relaxation of the abdominal apertures. The same result 
has also in some cases been effected by art-by keeping the patient 
in the recumbent posture and on very low diet for six weeks or 
two months, and by the frequent use of glysters and laxatives, at 
the same time keeping up a constant equable pressure on the 
tumour by means of a bag truss made to lace over it. This plan is 
very uncertain as to its results, and will be effectually defeated if 
there are any adhesions; and besides, there are not many patients 
who will submit to it. It will be more likely to succeed if the 
hernia is omental, than if it contains intestine. But several instances 
are known, in which, after the contents of old hernias had been 
replaced, they produced so much irritation in the abdomen, that STRANGULATED HERNIA. 
431 
the patients were glad to compound for their life by keeping the 
hernia. Any surgical operation with the view of opening the sac, 
dividing adhesions, and returning the parts into the abdomen, is 
scarcely justifiable, as it would be exposing life to too great a 
hazard for the removal of a mere inconvenience.* 
SECTION IV. OF STRANGULATED HERNIA. 
Definition.-Hernia is said to be strangulated, when it is con- 
stricted in such a way, that the contents of the protruded bowel 
cannot be propelled onwards, and the return of its venous blood is 
impeded. 
The causes of strangulation may be (1.) A sudden protrusion of 
bowel or omentum through a narrow aperture, in consequence of 
violent exertion,-(a thing not unlikely to happen if a truss has 
been worn for some time, and then is carelessly left off.) (2.) 
Swelling of the neck of the sac, or spasm of the muscular fibres 
around it. (3.) Distension of the protruded intestines by flatus or 
faeces,-or tumefaction and congestion of the omentum or mesen- 
tery.! 
The seat of stricture is generally at the neck of the sac, but in 
some rare cases the bowel has been constricted by membranous 
bands, or by fissures in the omentum, or in the sac itself. 
The symptoms of strangulated hernia are, first, those of obstruc- 
tion of the bowels;-secondly, those of inflammation. The patient 
first complains of flatulence, colicky pains, a sense of tightness 
across the belly, desire to go to stool, and inability to evacuate. 
(It is true that stools may be passed if there be any faecal matter in 
the bowel below the hernia, or if the hernia be entirely omental, 
but with very transient relief.) To these symptoms succeed vomit- 
ing of the contents of the stomach,-then of mucous and bile,-and 
lastly, of matters which have acquired a stercoraceous smell by 
being delayed in the small intestines. Meanwhile the tumour is 
uneasy, tense, and incompressible. If this state of things continue, 
the inflammatory stage comes on. The neck of the sac becomes 
tender, and tenderness diffuses itself over the tumour and over the 
abdomen, both of which become very painful and much more 
swelled. The countenance is anxious;-the vomiting constant;- 
the patient restless and despondent;-and the pulse small, hard, 
and wiry. After a variable time, the constricted parts begin to 
mortify. The skin becomes cold,-the pulse very rapid and tremu- 
lous,-and the tumour dusky red and emphysematous, but the pain 
ceases, and the patient, having perhaps expressed himself altogether 
relieved, soon afterwards dies. 
* A case in which Velpeau practised subcutaneous incisions for the relief of an 
irreducible hernia, is related in Bull. Gen. de ThtSrap, 15 & 30 August, 1840. 
f Mr. T. Wilkinson King, Med. Gaz., 5th May, 1843, shows that the duration of 
hernia before strangulation in above half the number of cases, is from fifteen to 
twenty-five years; and attributes the production of strangulation in old cases to 
tumefaction of the bowel from defective circulation. 432 
STRANGULATED HERNIA. 
Varieties.-There is often considerable diversity in the rapidity 
and violence of these symptoms. If the patient is a strong adult, 
and the strangulation has commenced suddenly with a fresh pro- 
trusion during strong exertion, the inflammatory stage may come 
on instantly, and be followed by death in a very few hours. On 
the other hand, if the patient is old,-if the hernia has been long 
irreducible, and has a large neck,-and if the strangulation is pro- 
duced by distension of the protruded bowel with flatus or faeces- 
the symptoms of mere obstruction may last many days before those 
of inflammation come on. To this latter class of cases the term 
incarcerated is applicable. Again, if the hernia be omental, the 
symptoms will be less acute than if it be intestinal. 
Diagnosis.-If the patient with irreducible hernia be attacked 
by colic, or enteritis, or peritonitis, the case will present many of 
the features of strangulation. Yet it may perhaps be distinguished 
by noticing that the pain and tenderness did not begin at the neck 
of the sac, and are not more intense there than elsewhere. The 
diagnosis will be very obscure if the inflammation commences on 
the omentum or intestine in the sac. But the general rule is, when 
in doubt, operate. In every case of sudden and violent vomiting 
and colic, the bend of the thigh should be well examined, and in- 
quiry should be made for any tumours about the abdomen-because 
the patient may have been labouring under hernia for years, and 
yet from ignorance or mauvaise honte may not mention it. 
Morbid Appearances.-After death from strangulated hernia, 
the bowels are found reddened,-the upper portion of them much 
distended,-and there are effusions of turbid serum and lymph. 
Around the sac the tissues are oedematous or emphysematous. 
The strangulated intestine is dark, claret-coloured, and turgid with 
blood,-roughened in patches by a coating of lymph,-and dis- 
playing patches of gangrene, in the form of greenish or ash-coloured 
spots, which break down under the finger. The omentum is dark 
red-if gangrenous, it feels crispy and emphysematous, and the 
blood in its veins is coagulated. The sac also contains bloody turbid 
serum. 
Treatment.-The indications are, 1st, to return the intestine, or 
any portion of it that may not be irreducible; 2dly, to divide any 
constricting part, if necessary; 3dly, to obviate inflammation. 
The Taxis.-In the first place, an attempt should be made to 
return the protrusion by a manual operation-technically called 
taxis* The bladder having been emptied, the patient should lie 
down, with his shoulders raised; and both his thighs should be bent 
towards the belly and be placed close to each other, so that every 
muscle and ligament connected with the abdomen may be relaxed. 
He should be engaged in conversation to prevent him from straining 
with his respiratory muscles. Then the surgeon, if the tumour be 
large, grasps it with the palms of both hands,-gently compresses 
it in order if possible to squeeze a little of the flatus into the ab- 
* From 'taa-c-K, I set in order. STRANGULATED HERNIA. 
433 
domen,-pushes it in the axis of the neck of the sac, and at the 
same time with his fingers gently kneads and sways the parts at 
the neck of the tumour, or perhaps tries to pull them very gently 
downwards, in order if possible to dislodge them. This operation 
may be continued for a quarter or half an hour or longer if the 
tumour is indolent, but not so long if it is tender,-and at last, per- 
haps, the surgeon will be delighted to hear a gurgling sound ac- 
companying the return of a portion of intestine. The operator 
should recollect that too much force may bruise or rupture the 
viscera,-or drive sac and all into the abdomen,-or push them 
between the layers of abdominal muscles,-and that he must not 
be satisfied with a partial reduction of the volume and tension of 
the tumour, if the vomiting remains unrelieved,-because, as Mr. 
Mayo has shown, such a diminution might be caused by merely 
forcing the serum contained in the sac into the abdominal cavity.* 
If the taxis do not succeed, certain auxiliary measures may be 
resorted to, in order to relax the muscles, reduce the heart's action, 
and diminish the size of the tumour. These we must treat of in 
succession. 
(«) Bleeding to the approach of syncope should be tried if the 
patient is robust, the hernia small and of recent date, and if there 
is much tenderness of the sac or the abdomen, in which latter case 
it should be employed before trying the taxis. 
(6) The hot bath (96°-100° F.) continued long enough to pro- 
duce great relaxation is useful in similar cases; but it must be 
recollected that a delicate person will not be very likely to bear the 
shock of an operation, if bled or boiled to death's door first of all. 
(c) A large dose of opium or morphia, is a remedy that is now 
much in vogue in cases of acute strangulation, after bleeding; 
especially if the pain and vomiting are violent. 
(d} The tobacco enema (gj ad Oj aq. ferv. allowed to stand ten 
minutes, and half to be used at a time) has certainly been suc- 
cessful in many cases, especially of inguinal hernia,-but it requires 
great caution. It has proved immediately fatal to some patients, 
and has rendered others incapable of surviving the shock of the 
operation. 
(e) Cold applied to the tumour by means of pounded ice or a 
freezing mixture (F. 12) in a bladder, is useful by reducing inflam- 
mation, condensing flatus, and constringing the skin. It is most 
applicable to large scrotal herniae. It, too, is not without its hazards, 
* [I have repeatedly profited by a suggestion of the late Dr. Parrish, of Phila- 
delphia, in effecting the return of an incarcerated hernia. There is probably some 
peculiarity in the mechanical relations of the parts concerned, in every case of 
hernia, and the patient, in his habitual management of it, has usually ascertained 
this peculiarity, and conducted his daily, or frequent taxis accordingly. But when 
strangulation occurs, he becomes alarmed, distrusts his own efforts, or is deterred 
from making them by pain, and abandons himself to the surgeon. He should be 
reassured, advised to take the same position, and practise the same measures he 
has found effectual on occasions of less difficulty, and he will often be able to do 
better for himself, than the science and dexterity of the best surgeon can do for him, 
in the way of the taxis.-F.] 434 
STRANGULATED HERNIA. 
for it may cause gangrene of the skin if applied too long, or if hot 
applications are incautiously used after it. 
(f) Tartar emetic, given as in dislocation, is said to have been 
employed with benefit, but it might cause a very troublesome 
vomiting. 
(,g) Purgatives and enemata are irritating and mischievous in 
sudden acute strangulation, but vastly beneficial if the patient is 
aged, the hernia large and long irreducible, and if the attack has 
been preceded and caused by constipation. Large doses of calomel 
and colocynth are the best purgatives, and the enemata should con- 
sist of as much salt and water as can be injected without causing 
very much pain or distension. They should be injected with a 
pumping syringe, and not with those filthy, inefficient, and now 
obsolete instruments, the bladder and pipe, or old-fashioned pewter 
syringe. Moreover, Dr. O'Beirne has fully shown that greater 
benefit is to be derived in cases of incarcerated hernia and obstinate 
constipation from passing up a long tube-(the tube of a stomach- 
pump answers very'- well)-into the colon, than from the use of the 
ordinary short enema pipe. The long tube relieves the bowels of 
their flatus; and of course by diminishing the bulk of the contents 
of the abdomen, renders the return of the hernia more easy.* In 
the old standing cases, occurring to aged people with large hernias, 
the surgeon may be justified in waiting some time to try the effect 
of his remedies; but in the acute cases occurring to young people, 
it may be laid down as a general rule that, if the taxis, bleeding, 
warm-bath, and opium do not succeed, it is the safest plan, on the 
average, to perform an operation for dividing the stricture without 
further delay,-using the other remedies only if the patient will not 
consent to the operation. 
The operation generally performed consists in opening the sac, 
dividing the stricture, and returning the intestine. The manner of 
doing which for each variety of hernia, will be found in the follow- 
ing sections. When the sac is opened, the intestine should be well 
examined, and especially that part of it which has be6n actually 
compressed by the stricture, and which should be gently drawn 
down for that purpose. If it be merely dark claret-coloured from 
congestion,-or slightly roughened with lymph,-or if it exhibit a 
few black patches of ecchymosis, it should be returned-the opera- 
tor being careful to replace it bit by bit-intestine before omentum 
-and those parts'first which protruded last. The wound may 
then be closed with one or two sutures, and a firm compress be 
placed upon it. 
If the hernia were irreducible long before it was strangulated, 
and if its contents are united to the sac by firm broad adhesions, 
they should not be disturbed. But if the adhesions are recent, or 
very thin and slight, they may be divided and the bowel be re- 
turned. 
If the intestine is mortified, which will be known by the softened 
* Vide Lancet, July 6 and 27, 1839; also James's Retrospective Address, in 
Prov. Med. Trans., 1840; and O'Beirne on Defecation. STRANGULATED HERNIA. 
435 
green or ashy spots, the mortified part should be slit open, the stric- 
ture be divided, and the patient left to recover with an artificial 
anus. Again, if a large portion of the intestine, which has been 
long irreducible in an elderly person, appear extremely dark and 
advanced towards sphacelus, so as to render it doubtful whether it 
would be capable of performing its functions when returned,-the 
safest plan is to make an opening into it, and so afford an outlet for 
its contents; although the inconvenience of an artificial anus must 
of course be considered. 
If the omentum is gangrenous, or if it is thickened and indu- 
rated, it would, if returned, excite dangerous irritation of the peri- 
tonaeum. In this case some surgeons advise it to be left to gra- 
nulate in the sac,-or to cut it off close to the neck of the sac, 
and leave it there as a plug to prevent further protrusion. Mac- 
farlane and others, on the contrary, recommend it to be cut cleanly 
off, and all the vessels to be tied with fine silk ligatures, and the end 
to be then passed quite into the abdomen-breaking up any adhe- 
sions about the neck of the sac, if necessary;-thus avoiding the 
dragging pains and colic which are liable to occur if a portion of 
the omentum or intestine is fixed. 
Division of the Stricture external to the Sac.-Some surgeons 
recommend that the stricture should be released by dividing the 
parts surrounding the neck of the sac, without opening the sac 
itself. The argument in favour of this proceeding is, that the 
danger of inflammation of the peritonaeum is greatly diminished; 
-the arguments against it, are, that the stricture may be in the 
sac itself, or at its thickened neck; and that it is desirable to exa- 
mine the state of the intestine before returning it into the abdomen. 
The circumstances under which this mode of operating seems most 
advisable, are when the hernia is of very great size, and has been 
long irreducible, so that the idea of returning its contents could 
not be entertained; and when the hernia is small, and of quite 
recent date, so that there is no chance of gangrene, or of great 
thickening of the neck of the sac. In a similar case, M. Guerin 
has divided the stricture by means of a subcutaneous incision.* 
Hernia reduced en masse.-When the taxis is used forcibly for 
the reduction of a strangulated hernia, the tumour, sac and all, 
may be forced through the herniary aperture, and lie between the 
abdominal muscles and the peritonaeum; or, rather, between the 
muscles and the fascia transversalis. In such a case, all the symp- 
toms of strangulation continue, although the tumour disappears. 
The first thing to be done is to make the patient stand up and 
cough, in order if possible to bring the hernia down again, when 
it should be operated on without delay;-but if this does not suc- 
ceed, a cautious incision should be made through the abdominal 
* Mr, Luke informed Mr. Fergusson that he had lost only two out of nearly 
forty patients since he had operated without opening the sac; although previously 
he had lost about one in three. Vide Fergusson's Practical Surgery, p. 526. 
Guerin, Gaz. Med. de Paris, 7th Aug., 1841, and Mr. Key's Memoir, on dividing 
the Stricture external to the sac. 436 
INGUINAL HERNIA. 
parietes, over the suspected seat of the disease; and if found, the 
sac should be opened, the stricture divided, and the case be then 
treated according to the ordinary rules.* 
Jlfter Treatment.-After the hernia has been returned, whether 
by taxis or operation, the patient should be put to bed-all exertion 
being strictly forbidden. Vomiting must be treated by large doses 
of calomel and opium, and by effervescing draughts containing one 
or two drops of prussic acid,-tenderness and pain by bleeding, 
leeching, calomel and opium, and fomentations. If- the bowels do 
not act in six or eight hours, they may be solicited by injections; 
but salts and other purgatives administered by the mouth can 
scarcely fail to be mischievous; for as the intestine that was con- 
stricted remains for some time inflamed, weakened, and incapable 
of propelling its contents, they will but irritate it uselessly. Mr. 
Travers has very satisfactorily shown, that the great danger after 
the return of the hernia arises from palsy, and not from inflamma- 
tion of the bowels.t Castor oil, or rhubarb and magnesia, may 
be resorted to after twelve hours. A truss should be applied before 
the patient gets up again. 
SECTION V.-OF INGUINAL. HERNIA. 
Definition.-Inguinal hernia is that which protrudes through 
one or both abdominal rings. 
Varieties.-There are four varieties. 
The oblique,-direct,-congenital,-anti 
encysted. 
(1.) The oblique inguinal hernia is 
the most common. It takes precisely 
the same route as the testicle takes in 
its passage from the abdomen into the 
scotum. It commences as a fulness 
or swelling at the situation of the in- 
ternal abdominal ring, that is to say, a 
little above the centre of Poupart's liga- 
ment,- next passes into the inguinal 
canal,-(and in this stage is called bubo- 
nocele,')-and if the protrusion increase, 
it projects through the external ring, and 
descends into the scrotum of the male, or 
labium of the female. The coverings 
of this hernia, are, 1, Skin. 2, A strong 
layer of condensed cellular tissue, de- 
rived from the superficial fascia of the 
abdomen, in which the external epigas- 
tric artery ramifies. With this is mostly 
incorporated, 3, the fascia spermatica- 
Fig 117. 
Common oblique ingui- 
nal hernia. The intestine 
in a distinct sac of perito- 
neum; 1, hernial sac; 2, 
tunica vaginalis; 3, testi- 
cle; 4, spermatic chord. 
* See a report of a paper read by Mr. Luke at the Royal Med. Chir. Soc., in 
Med. Gaz., 5th May, 1843. 
f Travers, case of Hernia, &c., Med. Chir. Trans., vol. xxiii. INGUINAL HERNIA. 
437 
a tendinous layer, derived from the inter-columnar bands, a set of 
semicircular fibres, which connect the two margins of the external 
ring. Under this lies, 4, the cremaster muscle,-sometimes called 
tunica communis. 5. Next confes the fascia propria, a cellular 
layer continuous with the fascia transversalis of the abdomen; 
and lastly, 6, the sac. The internal epigastric artery is always 
internal to the neck of the sac. The spermatic cord is generally 
behind the sac; but, in old cases, the parts which compose the 
spermatic cord are separated by the tumour, so that the vas defe- 
rens and spermatic artery lie sometimes in front, sometimes on either 
side of it. 
2. The direct inguinal hernia bursts through the conjoined ten- 
don of the internal oblique and transversalis muscle, just behind 
Fig. 118. 
[Reference to Fig. 
a. Spinous process of ilium. 
b. Tendon of the external ob- 
lique muscle, reflected 
from Poupart's ligament. 
c. Pubic attachment of the 
tendon of the external 
oblique. 
d. Internal oblique, partly 
raised to show the trans- 
versalis muscle. 
e. Transversalis muscle. 
ff. Tendon of the transversa- 
lis muscle and the fascia 
transversalis, elongated 
by the pressure of the 
hernial tumour, and pro- 
truded through the ex- 
ternal ring. The tendon 
and the fascia transver- 
salis were so blended as 
not to be distinguished. 
This bag is cut open to 
show the peritoneal sac. 
g. Peritoneal sac, connected 
to the tendinous bag 
by cellular membrane. 
There is frequently a 
considerable quantity of 
fat found between the 
fascia transversalis and 
peritoneum, which in 
some cases of direct 
hernia is protruded be- 
fore the peritoneum, and 
in the operation may 
lead to the supposition 
of omentum being ex- 
posed. 
h. Testicle. 
i. Fascia detached from the 
edge of the external 
ring, left adhering to the 
cremaster, which was attached to the outer side of the tumour, while the cord 
was at the outer and back part-C. A. Key.] 438 
INGUINAL HERNIA. 
the external ring. Its coverings are the same as the oblique variety, 
except the cremaster, for it has no connection with the cord. The 
epigastric artery runs external to the neck of the sac. It may, 
however, push the conjoined tetidon before it, instead of bursting 
through it. The spermatic cord generally lies on its outer side. 
3. The congenital hernia is a variety 
of the oblique, and is so called because 
that state of parts which permits of it 
only exists at or soon after birth. A 
portion of omentum or intestine accom- 
panies the testicle in its descent, and 
passes down with it into the very pouch 
of peritonaeum which forms the tunica 
vaginalis refiexa, before its communica- 
tion with the general peritoneal cavity 
has become obliterated. The sac of 
hernia is consequently formed by the 
tunica vaginalis,-its coverings in other 
respects are the same as of the oblique 
variety-and the protruded bowel lies 
in immediate contact with the testicle, 
and if not replaced, generally adheres 
to it. 
4. The encysted (or hernia infan- 
talis) is a sub-variety of the congenital. 
The protruding bowel pushes before it 
a sac of peritonaeum either into or close 
behind the tunica vaginalis, and this 
tunic and the sac adhere very closely 
Fig. 119* 
Fig. 120. 
Fig. 121. 
* This figure represents a congenital omental hernia of the right side, from a 
preparation in King's College Museum. INGUINAL HERNIA. 
439 
together. This hernia, therefore, (as may be seen in the adjoining 
diagram of Mr. Liston's, Fig. 120,) has, as it were, two sacs, viz. one 
proper sac, and another anterior, composed of the tunica vaginalis, 
which in these cases is very liable to be the seat of hydrocele? 
The adjoining figure, [fig. 121,] which was copied from a pre- 
paration in the King's College Museum, shows another variety 
ol this hernia, in which the sac is apparently formed of tunica 
vaginalis, but its communication with the testicle is closed. 
Diagnosis. - (1.) The difference between the oblique and direct 
inguinal kernite, and their relations to the epigastric artery, are 
shown in the accompanying figure, which is taken from Tiedemann. 
In the oblique, the neck of the tumour inclines upwards and out- 
wards, and causes a fulness extending up to the middle of Poupart's 
ligament. In the direct it inclines (if at all) rather inwards; and 
when the hernia is reduced, the finger, carrying integument before 
Fig. 122. 
it, can be passed straight back into the abdominal cavity. But in 
old cases of oblique hernia, the neck of the sac is dragged down 
towards the mesial line, so that all distinction is lost. 
(2.) Hydrocele, may be distinguished from hernia by its begin- 
ning at the bottom of the scrotum-by its being semi-transparent 
and fluctuating, and preventing the testicle from being clearly felt, 
(whilst the cord can be distinctly felt above it,) and by not dilating 
on coughing. Whereas, hernia begins at the top of the scrotum ; it 
is not transparent; does not fluctuate; does not prevent the testicle 
from being clearly felt, although it obscures the cord; and dilates 
* This kind of hernia was first described by Hey of Leeds, in a letter to Gooch. 
(Vide Gooch's Chir. Works, vol. ii. p. 217.) He says, "The intestine in this case 
had forced its way into the scrotum before the tunica vaginalis had formed its 
adhesion to the cord, but after its abdominal orifice was closed; under which cir- 
cumstance it brought the peritonaeum down with it, forming the hernial sac; con- 
trary to what happens in the hernia congenita, where the intestine descends before 
the orifice in the tunica vaginalis has closed, and consequently has no hernial sac 
but that tunic." 440 
INGUINAL HERNIA. 
on coughing. But hernia may and does often co-exist with hydro- 
cele, the former beginning from above, the latter from below. 
(3.) Hydrocele of the cord, if low down, may be distinguished by 
its transparency and fluctuation ; but if high up, it may extend into 
the abdominal ring, and receive an impulse on coughing, and the 
diagnosis be very difficult. But as a hernia may be concealed 
behind this kind of tumour, the rule, when in doubt, operate, 
should be acted upon in case of symptoms of strangulation. 
(4.) Varicocele, (or cirsocele,') which signifies a varicose enlarge- 
ment of the spermatic veins, resembles hernia, inasmuch as it 
increases in the erect posture, and perhaps dilates on coughing; but 
it may be distinguished from hernia by its feeling like a bag of 
worms; and although, like hernia, it disappears when the patient 
lies down, and the scrotum is raised, still it quickly appears again, 
if pressure be made upon the external ring, though that pressure 
would effectually prevent a hernia from coming down again. 
(5.) Lastly, a testicle that has not come down through the 
external abdominal ring into the scrotum, has been frequently con- 
founded with a bubonocele, or small hernia in the inguinal canal; 
and has been compressed with a truss, to the great pain and 
detriment of the patient. A little care and attention will prevent 
this mistake. 
Treatment.-(1.) Inguinal hernia, if reducible, must be kept up 
with a truss, of which the pad generally requires to press on the 
internal abdominal ring, and the spring should pass round midway 
between the trochanter and crest of the ilium. Care must be taken 
not to let the pad slip down, and bear against the spinous process 
of the pubes. In fact, it should be made to press accurately 
against the internal ring, where the protrusion begins, and not be 
permitted to slip down so as to bear against the spermatic cord. 
Malgaigne found that out of two hundred cases in which a com- 
mon truss was applied, there was disease of the cord or testicle in 
sixty-five.* 
Various plans have been proposed for the radical cure of this 
hernia. One (which is useless) consists of transfixing the root of 
the scrotum with a number of pins, and making pressure at the 
same time with corks, (through which the pins are passed,) so as 
to create the adhesive inflammation in the sac. 
A second plan which is more feasible, consists in pushing a fold 
of integument as far up as possible into the neck of the sac, securing 
it in this inverted or invaginated position by means of two sutures, 
(both ends of a ligature being passed from within the invaginated 
skin,) and then denuding the pouch of invaginated skin of its 
cuticle by means of liquor ammonias; so that the surfaces of skin 
and peritonaeum thus opposed to each other may adhere, and the 
neck of the sac be effectually plugged. 
This operation, which was proposed by M. Gerdy, has been 
practised by Mr. Bransby Cooper, and with some benefit. For the 
herniary aperture was so large before the operation, that it was 
• Malgaigne, Bull. Gen. de. Th^rap. 1839. INGUINAL HERNIA. 
441 
impossible that the bowel could be kept up by a truss; whereas, 
after the operation, a common truss enabled the patient to pursue a 
laborious occupation with safety and comfort.* 
Another plan which has been proposed by M. Guerin, consists in 
scarifying the neck of the sac with a convex blunt-pointed knife, 
rather less than an inch in the length of its blade, such as is used in 
the division of tendons. This is introduced through a mere punc- 
ture, so that the incisions are subcutaneous.! 
(2.) The irreducible must be supported with a bag truss. If it 
contain only omentum, a common truss may perhaps be applied in 
the usual manner, so as to make it adhere to and plug the neck of 
the sac. But this cannot often be borne, and is liable to induce 
swelled testicle. 
(3.) In performing the taxis for the relief of strangulated oblique 
inguinal hernia, the patient should be placed in the position de- 
scribed in a foregoing page (432), with his thighs as close together 
as possible, (although the surgeon must put one arm between them), 
and the pressure must be made upwards and outwards. 
The operation for this hernia is performed thus-The parts 
being shaved, and the skin made tense, an incision three or four 
inches long must be made through the skin, along the axis of the 
tumour, beginning from above its neck. This will be quite long 
enough even for the largest hernia; because the object is to bring 
the seat of stricture fully into view, without exposing too much 
of the sac. Then the successive coverings before enumerated are 
to be divided in the following manner-a little bit of each is to be 
pinched up with forceps, and to be cut into with the knife held 
horizontally; a director is to be passed into this little aperture, and 
the layer is then to be divided on it to the extent of the incision in 
the skin. Cautious operators will find (or make) many more layers 
than those usually enumerated-which are, in fact, easily subdi- 
visible, especially in old hernias. When at last the sac is reached, 
which will be known bv its bluish transparency-it is to be opened 
to the like extent-a little bit of it being first pinched up and cut 
through so as to admit the director. If possible, it should be done 
at a part where there is some serum, or omentum, between it and 
the bowel. Then the left forefinger should be passed up into the 
neck of the sac to seek for the stricture, which will generally be at 
the internal ring. It may be at the external ring, (or at both,) but 
wherever it may be, it must be dilated so as to allow the finger to 
pass into the abdomen. A curved blunt-pointed bistoury or hernia 
knife-not cutting quite up to the point-should be passed up flat 
on the finger through the stricture, and its edge be then turned up 
so as to divide it; and in every case the division should be made 
directly upwards-parallel to the linea alba; and then, whether 
the hernia be direct or oblique, the epigastric artery will not be 
wounded. If no stricture be discovered in the neck, it must be 
sought for in the body of the sac. 
* Bransby Cooper, Guy's Hosp. Rep. Oct. 1840. 
+ See in a case in Provincial Med. Journ., 16th Oct. 1841. 442 
FEMORAL OR CRURAL HERNIA. 
The subsequent proceedings-the return or otherwise of the 
intestine, and the after treatment-are detailed in the preceding 
section. 
SECTION VI. - OF FEMORAL OR CRURAL HERNIA. 
Definition.-Femoral hernia is that which escapes behind Pou- 
part's ligament. 
It passes first through the crural ring-an aperture bounded 
internally by GimbernaVs ligament-externally by the femoral 
vein-before, by Poupart's ligament-and behind by the bone. It 
Fig. 123 * 
Fig. 124.f 
* [A section of the structures which pass beneath the femoral arch. 1. Pou- 
part's ligament. 2. 2. The iliac portion of the fascia lata, attached along the 
margin of the crest of the ilium, and along Poupart's ligament, as far as the 
spine of the os pubis (3.) 4. The pubic portion of the fascia lata, continuous at 3 
with the iliac portion, and passing outwards behind the sheath of the femoral ves- 
sels to its outer border at 5, where it divides into two layers; one is continuous 
with the sheath of the psoas (6) and iliacus (7;) the other (8) is lost upon the cap- 
sule of the hip-joint (9.) 10. The femoral nerve, enclosed in the sheath of the 
psoas and iliacus. 11. Gimbernat's ligament. 12. The femoral ring, within the 
femoral sheath. 13. The femoral vein. 14. The femoral artery: the two vessels 
and the ring are surrounded by the femoral sheath, and thin septa are sent between 
the anterior and posterior wall of the sheath, dividing the artery from the vein, and 
the vein from the femoral ring.] 
f The cut, taken from a preparation of Mr. Fergusson's in the King's College 
Museum, shows a femoral hernia with its relation to the other parts which pass 
under Poupart's ligament. Externally are seen sections of the iliacus and psoas 
muscles, with the crural nerve between them; then the femoral artery and vein; 
next the hernia, which passes through a small aperture occupied by an absorbent 
gland in the normal state, and is bounded by Gimbernat's ligament on its inner 
side. The hernia passes downwards in the sheath of the femoral vessels, sepa- 
rated. however, from the vein, as that is from the artery, by a process of cellu- 
lar tissue. The sheath of the vessels is continuous above with the fascia trans- 
versalis. FEMORAL OR CRURAL HERNIA. 
443 
next descends behind the falciform, process of the fascia lata- 
thirdly, it comes forwards through the saphenic opening of that 
fascia-and, lastly, as its size increases, it does not descend down 
on the thigh, but turns up over the falciform process, and lies on 
the anterior surface of Poupart's ligament. The coverings of this 
hernia are-1. Skin. 2. The superficial fascia of the thigh-loaded 
with fat, and divisible into an uncertain number of layers. 3. Fas- 
cia propria, a layer of cellular tissue derived from the sheath of 
the femoral vessels-or, according to others, from the fascia cri- 
briformis which closes the saphenic aperture. It is in general 
pretty dense about the neck of the hernia, but thin, or even defi- 
cient, on its fundus. 4. The sac. Between the last two there is 
often found a considerable layer of fat, which might be mistaken 
for omentum. This hernia rarely attains a very large size. It is 
much more frequent in the female than in the male-obviously 
from the greater breadth of the pelvis.* 
Diagnosis.-(1.) Femoral hernia maybe distinguished from the 
inguinal by observing that Poupart's ligament can be traced over 
the neck of the sac, and that the spinous process of the pubes lies 
internal to it; whereas, it is the reverse in the inguinal hernia. 
Besides, the femoral is generally much smaller and is more frequent 
in women. 
2. Psoas abscess resembles this hernia in its situation-in dilating 
on coughing, and diminishing when the patient lies down. The 
points of distinction are, that it is generally more external, that it 
fluctuates, but does not feel tympanitic, and that it is attended with 
symptoms of disease of the spine. 
3. Varix of the femoral vein also resembles this hernia, inas- 
much as it dilates somewhat on coughing, and diminishes when 
the patient lies down; but then, if pressure be made below Pou- 
part's ligament, the swelling quickly reappears, although it must 
be evident that under such circumstances a hernia could not come 
down. 
4. Bubo and other tumours of the groin may in most cases be 
recognized by their general character and history, and by their 
being unattended with abdominal disorder. But if there be any 
such swelling, and symptoms of strangulation as well, an incision 
should certainly be made to examine it. The very best surgeons 
have been known to fail in the diagnosis of these cases. 
Treatment. - (1.) The reducible femoral hernia should be sup- 
ported by a truss; the pad of which requires to be bent downwards 
at an angle with the spring. Its pressure should tell against the 
hollow which is just inferior and external to the spinous process of 
the pubes. This hernia is very seldom, if ever, cured radically. 
(2.) The irreducible should be supported by a truss with a 
hollow pad ; or perhaps (if it be omental) the pressure of a common 
pad may be borne. 
* Mr. Partridge informed the author that he had met with a case of femoral 
hernia, protruding below Poupart's ligament, external to the vessels. 444 
umbilical hernia. 
(3.) The femoral hernia, when strangulated, gives rise to much 
severer symptoms than the inguinal does, because of the denser 
and more unyielding nature of the parts which surround the neck 
of the sac. In performing the taxis, the patient should be placed 
in the usual position, with the thigh of the affected side much 
rolled inwards, and crossed over towards the other side. The 
tumour should first be drawn downwards, from the anterior part of 
Poupart's ligament, and then be pressed with the points of the 
fingers backwards and upwards. If, however, the taxis (with 
bleeding and the warm-bath if the tumour is tender) does not soon 
succeed, the operation should be resorted to. No good will be 
done by any other measures. 
Operation.-In the first place, the skin must be divided. Some 
surgeons make one simple perpendicular incision. Sir A. Cooper 
directs one like an inverted j ; Mr. Liston prefers making one inci- 
sion along Poupart's ligament, and another falling perpendicularly 
from its centre over the tumour, thus,. The skin may be very 
safely and expeditiously divided by ^pinching it up into a 
fold, and running the knife through it with its back to- 
wards the sac. Nir. Fergusson some- times makes one like 
an inverted so that the skin can be turned back in three flaps; 
after which the succeeding layers may be divided by a simple 
longitudinal incision. Then the different cellular layers down to 
the sac must be divided by the bistoury and director, as in the 
inguinal hernia, and the sac must be opened with very great care, 
because it is generally very small, and embraces the bowel tightly, 
and seldom contains any serum or omentum. Then the finger 
should be passed up to seek for the stricture, which, according to 
Sir A. Cooper and Mr. Liston, will be generally found to be the 
inner edge of the falciform process. This must be gently divided 
for a line or two, the incision being directed upwards and a kit- 
tle inwards, towards the spinous process of the pubes. It must 
be recollected, that if this incision were carried too far, the sperma- 
tic cord in the male, or round ligament in the female, would be 
injured. If, however, the stricture is not released by that incision, 
a few fibres of Gimbernat's ligament must be divided; although it 
must be recollected that the obturatrix artery not unfrequently runs 
round behind that ligament, and would be infallibly wounded. 
SECTION VII.-OF THE UMBILICAL, VENTRAL, AND OTHER REMAIN- 
ING SPECIES OF HERNIA. 
I. Umbilical Hernia-(exomphalos)-is, for obvious reasons, 
most frequent in children soon alter birth. It is also not uncom- 
mon in women who have been frequently pregnant, although, in 
many of the so-called umbilical herniae in adults, the hernial aper- 
ture is really not at the umbilicus, but a little on one side of it. 
The coverings of this hernia are skin, superficial fascia, and sac ; UMBILICAL HERNIA. 
445 
they are always very thin, and not unfrequently the sac is adhe- 
rent to its contents. 
Treatment.-If reducible, and the patient an infant, the best 
plan is to place a hemisphere of ivory with its convex surface on 
the aperture, and retain it there with cross stripes of plaster, and a 
bandage round the belly. A pad of linen, covered with sheet lead, 
will do as well. But the belly should by no means be bound up 
too tightly, otherwise there will be danger of producing inguinal 
hernia. An adult should wear a truss or broad belt, with some 
contrivance to prevent it from slipping down below its proper level. 
For the irreducible umbilical hernia, a large hollow pad should be 
worn. The reduction of this hernia is effected by the ordinary 
manual taxis; but if it be very large, Sir A. Cooper recommends it 
to be compressed by a wooden platter. If it becomes strangulated, 
and the patient is aged, and the strangulation was preceded by con- 
stipation, purgatives and copious enemata should have a fair trial. 
If the operation is necessary, an incision three inches in length 
should be made at the upper part of the tumour through the skin, 
fascia, and sac, in succession. The stricture should then be dilated 
directly upwards in the linea alba with the knife recommended in 
other cases. But perhaps it is better to make the incision so as to 
divide the under side of the neck of the sac, as advised by Mr. 
Liston. 
II. Ventral Hernia is that which protrudes through the linea 
alba, or through the lineze semilunares or transversx, or in fact 
through any other parts of the abdominal parietes, save those which 
are the ordinary seats of hernia. It may be a consequence of 
wounds or bruises. Its treatment requires no distinct observations; 
but if it should ever be necessary to operate for the relief of stran- 
gulation, care must be taken to avoid the epigastric artery.* 
III. Perineal Hernia descends between the bladder and rec- 
tum, forcing its way through the pelvic fascia and levator ani, and 
forming a tumour in the perinaeum. 
IV. Vaginal Hernia is a variety of the preceding;-in which 
the tumour projects into and blocks up the vagina, instead of 
descending to the perinaeum. 
V. Labial or Pudendal Hernia descends between the vagina 
and ramus of the ischium, and forms a tumour in one of the labia. 
It is to be distinguished from inguinal hernia by the absence of 
swelling at the abdominal rings. These three hernias must be 
replaced by pressure with the fingers, and be kept up by pads made 
to bear against the perinaeum, and by hollow caoutchouc pessaries 
worn in the vagina. 
* Mention is made in the Lond. Med. Gaz., 21st Oct. 1842, of an adipose tumour, 
situated between the peritonaeum and abdominal muscles, and projecting through 
an aperture in the linea alba, through which it could be pushed back, so that it 
completely simulated a hernia. Such a case, if complicated with peritonitis, 
might render the diagnosis very obscure; but an incision would clear up the 
mystery. 446 
DISEASES OF THE RECTUM AND ANUS. 
VI. Obturator or Thyroid Hernia projects through that 
aperture in the obturator 
ligament which gives exit 
to the artery and nerve. 
In a fatal case related by 
Mr. Howship, in which a 
very small piece of intes- 
tine was strangulated in 
this opening, the patient 
complained of great pain 
down the leg in the course 
of the obturator nerve. 
This might be an aid in 
the diagnosis. 
Vil. Ischiatic Hernia 
protrudes through the sci- 
atic notch. This and the 
preceding are exceedingly 
rare;-and the tumours are of necessity small. If discovered to 
exist during life, they must be returned and supported by proper 
apparatus-and if strangulated, the stricture must be divided by 
operation. 
VIII. Diaphragmatic Hernia is generally a result of congenital 
deficiency, or accidental separation of the fibres of the diaphragm. 
But it may also be caused by violent falls on the abdomen, or by 
violent pressure of any kind, capable of lacerating the diaphragm, 
and driving some of the bowels into the thorax.t This form of 
hernia, if strangulated, will produce the ordinary symptoms- 
vomiting, constipation, and pain;-which are not in any manner to 
be distinguished from the symptoms of ileus or intus-susception- 
or from those produced when a fold of bowel is entangled in a rent 
in the omentum, or mesentery; or when the bowel is constricted 
by membranous bands resulting from previous inflammation of the 
peritoneum. 
Fig. 125 * 
CHAPTER XIX. 
OF THE SURGICAL DISEASES AND INJURIES OF THE RECTUM AND 
ANUS.* 
I. Foreign Bodies in the rectum sometimes require to be re- 
moved by surgical art. They may either consist of small bones or 
* From a preparation of Mr. Fergusson's in the King's College Museum. 
t Reid on Diaphragmatic Hernia, Ed. Med. and Surg. Journ., Jan. and July, 1840. 
i [Nothing has been more remarkable, in my surgical experience in the west, than 
the disproportioned frequency of diseases of the rectum and adjacent textures- DISEASES OF THE RECTUM AND ANUS. 
447 
the like that have descended from above, or of pins, glyster pipes, or 
other bodies introduced from below. Substances of very extraor- 
dinary dimensions (a blacking-bottle, for instance) have been forced 
into the anus. The grand point is first to dilate the bowel well, by 
passing in several fingers (oiled) or by means of a speculum;-and 
then a proper forceps, or a lithotomy scoop, may generally be used 
with success. 
II. Imperforate Anus (atresia ani} signifies a congenital 
closure of the rectum, and may occur in various degrees. The gut 
may terminate in a blind pouch at any point from the sigmoid 
flexure downwards, the anal aperture being altogether wanting-or 
the anus may be open for an inch or two, with an obstruction beyond. 
Treatment.-If the end of the intestine can be felt protruding 
when the child cries, a crucial incision may be made into it without 
delay-if it cannot be felt, a day or two should be waited, so that it 
may become distended with meconium, and then a cautious incision 
should be made with a double-edged bistoury, in the direction of 
the curve of the sacrum. If it succeed in reaching the bowel, the 
aperture should be kept open by tents. 
But if this operation should fail in reaching the bowel, or if the 
rectum appears to be altogether deficient, so that it is useless to 
attempt it, the only resource is the formation of an artificial anus; 
a measure which it is the surgeon's duty to propose to the parents, 
and to perform if they wish it; although it really appears more 
humane to let the child die quietly, than to subject it to the pain of 
the operation, and the perpetual misery and filth of an artificial 
anus if it survives. The best operation for this purpose is one that 
has been performed successfully by Amussat in cases of obstruction 
fistula, piles, prolapsus, &c., and I advert to the fact chiefly for the purpose of add- 
ing a cautioning remark respecting the causes of it. Doubtless it is partly to be 
referred to the > chafing and contusions incident to horse-back riding which is a 
much more common mode of travelling here, than at the east; but it is mainly 
attributable to the habit of indiscriminate and excessive purgation, so prevalent both 
as a remedial and prophylatic measure. 
A large portion of the practitioners of the valley of the Mississippi have been 
educated under a system of medicine whose theory regards portal congestion and 
hepatic derangement as the essential elements of all diseases, and whose practice 
consists, almost exclusively, in the exhibition of drastric purgatives. 
It is natural that the people should imitate the therapeutics of their medical ad- 
visers, when so simple and easily applied, and accordingly they are very much in 
the habit of drenching themselves, and teasing the alimentary canal on every occa- 
sion of illness, with some concentrated purgative, in the form of pills. 
Under one of the most constant laws of irritation in mucous canals, the termi- 
nating portions of the apparatus of defecation, is thus perpetually suffering under 
propagated as well as direct stimulation, and reacts in the various forms of disease 
under notice. 
Besides these direct mischiefs, and others involving the health in other ways, 
occasioned by the pernicious doctrines referred to-which are, indeed, themselves 
essentially empirical-they encourage the grossest species of quackery, by pro- 
moting the consumption of vast quantities of patent pills and other purgative 
nostrums. 
In proportion as a more rational pathology shall prevail among physicians, the 
habits of the population will undergo a corresponding change, and the preponderance 
of diseases of the rectum in the duties of the surgeon, may be expected to disappear 
accordingly. F.] 448 
DISEASES OF THE RECTUM AND ANUS. 
of the rectum by disease. A transverse incision is made in the left 
lumbar region, just above the crista of the ilium, so as to come upon 
the descending colon at the outer edge of the sacro-lumbalis and lon- 
gissimus dorsi muscles, where it is not covered by peritonaeum. As 
soon as the gut is reached, a loop of thread should be passed through 
it to fix it, and then it may be opened with a bistoury. The con- 
stant prolapsus, which is such a source of distress when artificial 
anus is situated in the groin, is not so likely to occur when an aper- 
ture is made in this situation.* 
III. Spasm of the Sphincter Ani is known by violent pain 
of the anus, with difficulty of evacuating the faeces. On examina- 
tion, the muscle feels hard, and resists the introduction of the finger. 
This affection may be caused by constipation of the bowels, or dis- 
order of the health. It may occur in sudden paroxysms which soon 
go off,-or may last permanently, and lead to an organic thickening 
and stricture of the anus. 
Treatment.-In recent cases, a dose of calomel and Dover's 
powder, followed by castor oil, and by enemata of warm water 
with a little laudanum, will relieve the paroxysm. In more obsti- 
nate cases, a bougie or mould candle should be passed daily- 
alteratives and enemata of warm water should also be administered 
daily ; but if they fail, the sphincter must be divided and made to 
heal by granulation. Division of the sphincter is easily performed 
by introducing the forefinger into the anus, and a straight, narrow, 
blunt-pointed bistoury by its side-and then making an incision of 
sufficient extent towards the tuberosity of the ischium. 
IV. Hemorrhoids, or Piles, are small tumours situated near the 
anus. 
Pathology.-They commence as varicose enlargements of some 
of the haemorrhoidal veins; the irritation of which causes various 
morbid changes in the mucous membrane and cellular tissue ad- 
joining. Sometimes there is a little varicose knot with the cellular 
tissue around thickened. Sometimes the blood in a dilated vein 
coagulates, forming a solid tumour with the thickened cellular tissue 
around. Again, if piles are situated within the rectum, the mucous 
membrane covering them is liable to become excessively vascular 
and sensitive, resembling an erectile tissue. They are divided into 
two species, the internal and external, according as they are situated 
within the rectum, or external to the anus. 
Internal Piles are generally firm tumours, varying in size from 
that of a pea to that of a walnut, of a pale reddish-brown colour 
when indolent, but dark or bright red when congested or inflamed. 
They generally cause great inconvenience by protruding at each 
motion, and the hypertrophied vascular mucous membrane covering 
them is exceedingly liable to bleed from the straining and pressure. 
External Piles may be met with (1) in the form of round hard 
tumours just at the margin of the anus, and covered half with skin 
* This operation is described in the Brit, and For. Rev., Jan. 1840, and cases of it 
have since been published in the Prov. Med. Journ., by Mr. Teale of Leeds, and 
others. HEMORRHOIDS. 
449 
and half with mucous membrane; or (2) of oblong ridges of skin 
external to the sphincter. These are commonly called mariscx, or 
blind piles, because they do not bleed. 
Symptoms.-Piles may be met with in two states-indolent or 
inflamed. When indolent, they merely produce the inconveniences 
that necessarily result from their bulk and situation. When in- 
flamed, they occasion the following symptoms: Pain, heat, itching, 
fulness, and tension about the anus-a sensation as if there were a 
foreign body in the rectum-pain and straining in passing evacua- 
tions-with perhaps more or less bleeding. These symptoms may, 
in violent cases, be complicated with irritation of the bladder, fre- 
quency of micturition, pain in the back, pain and aching down the 
thighs. The young surgeon should be aware, that a patient with 
piles may not be aware of the nature of his complaint, or through 
delicacy may abstain from mentioning it. Whenever, therefore, a 
patient complains of unusual irritation of the bladder, or of symp- 
toms of dysentery-that is to say, frequent, painful, and unsatisfac- 
tory efforts to pass motions, the surgeon should always make 
inquiries after piles. The haemorrhage from piles will be treated 
of more particularly at p. 451. 
Causes.-The predisposing causes are any circumstances that 
produce fulness of the abdominal vessels, or that impede the return 
of blood from the rectum-such as luxurious and sedentary habits 
of life-pregnancy, constipation, disease of the liver or lungs retard- 
ing the passage of blood through them, and tight stays. The ex- 
citing causes may be any thing that irritates the lower bowels,- 
particularly large doses of aloes-ascarides-horse exercise, or the 
application of cold and damp to the posteriors. Piles are most fre- 
quent in women, and are rare under puberty. 
General treatment.-The grand objects are to remove the pre- 
disposing and exciting causes. The patient, if stout, plethoric, and 
of sedentary habits, ought to live abstemiously, and take plenty of 
exercise. The bowels should be regulated by some mild aperient, 
capable of producing daily copious soft evacuations without strain- 
ing or griping. Senna, sulphur, castor oil, cream of tartar, and 
magnesia, in the form of electuaries (F. 42), injections of cold 
water, and pills of soap and rhubarb, are the best; and blue pill, or 
hydr. c. creta should be added if the liver is inactive. It is worth 
knowing that the nauseous greasy taste of castor oil is pretty effectu- 
ally disguised by mixing it with milk, and adding a little nitric 
aether and oil of cinnamon. In cases of long standing, Ward's 
paste, or the confect, piperis comp, may be given with great benefit 
in doses of $j ter die. In similar cases, especially if the patient is 
advanced in years, and the piles are attended with a flow of mucus, 
copaiba may be given in the dose of thirty or forty drops every 
morning in milk; and a scruple of common pitch may be taken in 
pills every night at bedtime. Old people rarely dislike the taste of 
copaiba. The bowels should act once daily-and Dr. Burne says, 
that the evening is a much better time for that purpose than the 450 
DISEASES OF THE RECTUM AND ANUS. 
morning. Tire seat of the water-closet should shelve inwards at 
its margin. 
If the piles are inflamed, leeches to the anus, or cupping on the 
sacrum, a dose of calomel and opium at bedtime, followed by 
castor oil in the morning ; low diet, rest in bed, warm fomentations 
and poultices; and enemata of warm water, if the anus is not too 
tender to bear the introduction of the pipe, are the requisite mea- 
sures. Cold lotions of lead (with a little laudanum) may be sub- 
stituted for the warm applications, if more comfortable. If there is 
a tense bluish solid tumour, evidently containing coagulated blood, 
it may be punctured. 
Local treatment.-(1.) The first and most essential measure is 
perfect cleanliness. Mr. Mayo directs the anus to be well washed 
with yellow soap and water after each motion-and if the piles are 
internal, and protrude during evacuations, they should be washed 
before they are returned. Moreover great comfort will be derived 
from the custom of washing out the rectum with an enema of cold 
or tepid water after each dejection. (2.) Astringents -the zinc 
lotion (F. 15)-or unguentum gallae, to which latter a little of the 
liq. plumbi diac, may be advantageously added, (F. 43,) are gene- 
rally of benefit. Dr. Burne recommends an ointment composed of 
pulv. hellebori nigri 5j adipis sj, which he says never fails of 
affording great relief, although exceedingly painful for a time. (3.) 
Pressure by means of a bougie introduced occasionally-or a pad 
of ivory with or without a spring, made to bear against the anus 
with a T bandage, are often of service. There is an instrument 
consisting of a short egg-shaped ivory bougie, which is introduced 
into the anus, and which is attached by a slender neck to an ivory 
pad-so that pressure is thus made both internally and externally, 
that is extremely useful in cases of internal piles with prolapse. 
Extirpation.-If the preceding constitutional and local measures 
fail to afford the patient the requisite degree of relief, extirpation 
must be resorted to. But the surgeon must bear in mind that it is 
highly dangerous to operate upon internal piles if the health is 
broken, or if there is any organic disease of the liver or kidneys; 
and the operation must be both preceded and followed by a course 
of the most regular diet, and medicines to maintain the secretions, 
and remedy any disorder in the health. 
The piles, if external, may be removed by excision with the 
knife or scissors; if internal, they should be removed by ligature, 
for excision of them might occasion a fatal haemorrhage * 
The operation is performed as follows: The bowels having been 
previously well cleared, the patient must be told to protrude the 
piles; and if he cannot do it easily, he should sit over a vessel of 
warm water, or have an enema of warm water. Then the piles 
• If the surgeon is determined to excise internal piles, the only safe way of 
doing so is as follows: When the tumour is protruded, the base of it should be 
transfixed by a long needle, which will prevent it from returning into the anus. 
Then it may be cut oil'; and the cut surface being exposed to the air, will not 
bleed so profusely; or if it does, it is easy to apply cold, astringents, or ligatures. HEMORRHAGE FROM THE RECTUM. 
451 
should be drawn out with a tenaculum, and a ligature (not too fine) 
to be tied as tightly as possible round the base of each. If one of 
the tumours is large, a double ligature may be passed through its 
base with a needle, and either half be tied separately. Before 
finally tightening the ligatures, the piles should be slightly punc- 
tured. After the operation, the ends of the thread should be cut 
short, and be returned into the rectum. The patient should remain 
in bed, and the bowels should not be disturbed for forty-eight hours 
after the operation. Pain is to be relieved by an opiate, or by 
leeches; and if it persist, the piles should be examined to see 
whether the ligatures remain as tight as possible, and if not, they 
should be reapplied. 
We must also mention the use of nitric acid, which has been 
recommended by Dr. Houston in order to destroy the tender, tumid, 
and bleeding surface of mucous membrane which covers internal 
piles, and which is the source of their excessive irritability and 
haemorrhage. The pile having been protruded, its surface is to be 
smeared with a smooth wooden stick dipped in the concentrated 
acid; and then pure olive oil is to be applied in order to prevent 
the caustic being too widely diffused. The subsequent treatment 
is the same as after extirpation by the ligature ; and when the 
slough caused by the acid separates, the surface generally cicatrizes 
speedily, and leaves the part braced up by the contraction.* 
V. Warts, Condylomata, and other excrescences around the 
anus, that arise from local irritation, are to be removed with the 
knife, and the surface from which they grew should, during the 
granulating stage, be treated with astringent lotions. 
VI. Hemorrhage from the rectum is a very frequent concomi- 
tant of piles, and may be of two kinds. In the first place it may 
be caused by the bursting of a varicose vein; in which case the 
blood is venous; and the haemorrhage in general occurs only at 
unfrequent intervals. But far more frequently it proceeds from the 
vascular surface of internal piles; which gives way under the 
straining which accompanies defecation. In the latter case the 
blood is arterial: it is squirted from the anus in jets, when the 
patient is straining at the water-closet, and the bleeding occurs very 
frequently, especially when the body is feverish, or the piles in- 
flamed. Haemorrhage from the rectum may be distinguished from 
that which has its source higher up, by noticing that the blood is 
generally of a florid hue, and that it covers the faeces, but is not 
intimately mixed with them. 
Treatment.-(1.) If the haemorrhage is moderate in quantity- 
if it has been of habitual or periodic occurrence-if it induces no 
weakness-and if it brings relief to pain in the head, or any other 
feeling of disorder-before suppressing it the patient must be made 
to adopt a course of exercise, temperance, and alterative and ape- 
rient medicines, with the view of removing the state of plethora 
that occasions it. (3.) But if the patient is weak and emaciated; 
if the lips are pale, and the pulse feeble, the bleeding should be at 
* See an account of Dr. Houston's method in Dublin Med. Journ., March, 1843. 452 
diseases of the rectum and anus. 
once suppressed. (We may observe here, that whenever a patient 
applies for relief in consequence of violent palpitations and short- 
ness of breathing; or giddiness and swimming in the head, if the 
lips are pale, and the extremities tend to swell, the surgeon should 
always inquire for piles, because, as we before observed, some 
patients, through false delicacy, will not mention them.) Or if the 
bleeding, as sometimes happens, instead of relieving symptoms of 
heat and fulness in the rectum, aggravates them, the bleeding should 
also be stopped, whatever the patient's complexion may be ; and 
if he is of a full habit, he should live abstemiously, and keep the 
bowels open with Seidlitz powders. The means of checking 
haemorrhage from the rectum are, (1.) That piles, if any exist, 
should be tied. (2.) Astringent applications, such as injections of 
dec. quercus, or infus. catechu, used cold. (3.) The internal reme- 
dies most likely to be of service are salts of iron, or bark with sul- 
phuric acid, or the balsams of copaiba and Peru, or oil of turpen- 
tine (in the dose of ^Ixx in mucilage) F. 60, 61, 69. 
VII. Discharge of Mucus-clear and viscid-without faecal 
odour, may be caused by piles, ascarides, the use of aloes, or any 
other causes of irritation to the rectum. To be treated by mild 
aperients, astringent injections, and copaiba. F. 8, 9, 42, 20. 
VIII. Abscesses near the rectum may be caused by the irritation 
of foreign bodies, or by caries of an adjacent bone, but they are 
much more frequently the result of the various causes of disordered 
circulation in the hajmorrhoidal vessels that were mentioned as 
producing piles, and especially of tubercles in the lungs. They 
may either be large or deep-seated, or small and superficial. (1.) 
Deep-seated abscesses are attended with great aching and throb- 
bing,-difficulty and pain in evacuating the faeces,-and fever,- 
and on internal examination, a fulness or fluctuation may be felt. 
If these abscesses are left to themselves, a vast quantity of matter 
may accumulate in the loose cellular tissue of the pelvis, and severe 
irritative fever result from its confinement. (2.) Superficial ab- 
scesses are attended with more or less pain, tenderness, and throb- 
bing, and swelling around the anus. They are often chronic, and 
often occur in the consumptive. 
Treatment.-Leeches and fomentations may be tried at first- 
but if they do not very soon remove the pain and tenderness, or if 
there is the least suspicion that matter is forming, a bistoury should 
be pushed home into the inflamed part,-and if it be at all exten- 
sive, two or three punctures should be made. 
IX. Fistula in Ano signifies a fistulous track by the side of the 
sphincter ani. It is extremely difficult to heal, both because the 
constant contractions of the sphincter and levator ani interfere with 
the union of its sides, and because of the passage of fascal matter 
into it from the bowel. There are three kinds spoken of in books. 
(1.) The complete fistula, which has one external opening near the 
anus, and another into the bowel above the sphincter. (2.) The 
blind external fistula, which has no opening into the bowel, 
although it mostly reaches its outer coat. (3.) The blind internal FISTULA IN ANO. 
453 
fistula, which opens into the bowel, but not externally, although 
its situation is indicated by a redness and hardness near the anus. 
This affection is a common result of abscess by the side of the rec- 
tum. Sir B. Brodie's opinion is, that it always commences with an 
ulceration of the mucous membrane of the rectum, and an escape of 
faecal matter into the cellular tissue ; which gives rise to abscess, 
and the abscess to fistula. This opinion is corroborated by the cir- 
cumstance, that fistula is so common in consumptive persons, who 
are also very subject to ulceration of the bowels. It also accounts 
for the fetor of the discharge.* 
Treatment.-The grand remedy for this affection is division of 
the sphincter ani, so as to prevent contraction of that muscle for a 
time, and cause the fistula to heal from the bottom. The digestive 
organs and secretions must first be put in good order, and the 
bowels be well cleared by castor oil and an injection, so that they 
may not want to be disturbed for two or three days. Operation. 
-The patient being placed on his knees and elbows on a bed, or 
being made to kneel on a chair and lean over the back of it, and 
the nates being kept asunder by an assistant, the surgeon introduces 
his left forefinger into the anus, and at the same time explores with 
a probe the whole extent and ramifications of the fistula. If it is 
of the blind internal kind, its situation must be ascertained, and a 
puncture be made into it by the side of the anus. Perhaps a probe 
bent at an acute angle may be passed into it from the bowel, and 
serve as a guide for the puncture. Then, one forefinger being still 
in the anus, the surgeon passes a strong curved probe-pointed bis- 
toury up to the further end of the fistula. Next (if the internal 
opening cannot be found) he pushes it through the coats of the 
bowel, so that its point may come in contact with his forefinger. 
Then he puts the end of his forefinger on the point of the bistoury, 
and draws it down out of the anus; and as soon as it is fairly 
emerged, he pushes the handle towards the orifice of the fistula, so 
as to divide skin, sphincter, and bowel, at one sweep. Sir B. Bro- 
die recommends that the bistoury should always be passed through 
the internal opening of the fistula, and says that the affection will 
very likely return if this is not divided;-he also condemns the 
practice of cutting through the bowel higher up than this opening. 
A few threads of oiled lint are then to be placed in the wound, and 
the patient to be kept in bed for three days. The subsequent treat- 
ment consists in the use of perfect cleanliness, and the daily intro- 
duction of a very little slip of lint (which may be dipped in some 
stimulating lotion if necessary) between the edges of the wound for 
the first few days, so as to prevent its premature union, and cause 
it to granulate from the bottom. If haemorrhage prove violent, 
after this operation, and does not yield to the application of cold, 
the anus must be well dilated with a speculum, so as to expose 
the bleeding surface to the air,-and any artery discernible may 
be tied. 
* This was also the opinion of Mr. Ribes, who held that the internal orifice of 
the stricture might always be found at about an inch and a quarter from the anus. 454 
DISEASES OF THE RECTUM AND ANUS. 
If the patient will not submit to this operation, or if he is labour- 
ing under disease of the lungs or liver in an advanced stage, so 
that it would be unsafe,-the confec. piperis, or copaiba and tonics, 
may be administered internally, and stimulating injections and 
ointments be applied to the fistula; but they will rarely be of any 
avail. 
X. Rhagades-fissures and excoriations about the anus-pro 
duce the utmost pain during the passage of evacuations, and if ne- 
glected may .lead to spasm and permanent stricture of the sphincter. 
Treatment.-Aperients and alteratives,-regular diet,-astring- 
ent applications, such as decoction of rhatany, zinc lotion, borax 
and honey,-or mercurial ointment, or ung. hydr. nitrat. dilut., to 
which a little ext. belladon. should be added if there be much pain 
or spasm of the sphincter, and the strictest cleanliness. But if a 
fair trial of these measures is unavailing, the sphincter must be 
divided. 
XI. Prolapsus Ani consists in an eversion of the lower por- 
tion of the rectum, and its protrusion through the anus. Some- 
times a little fold of the mucous membrane only protrudes; but in 
ordinary cases the muscular coat, and whole thickness of the bowel, 
come down. This affection is most common in infancy and old 
age. It may depend on a natural laxity and delicacy of structure, 
or be caused by violent straining, in consequence of costiveness, or 
of the existence of stone or stricture. 
Treatment. - Whenever 
the protrusion occurs, the 
parts should be carefully 
washed, and then be re- 
placed by pressure with the 
hand. If there is any diffi- 
culty in doing so, the fore- 
finger oiled should be push- 
ed up into the anus, and it 
will carry the protruded 
part with it. If, however, 
as sometimes happens, a 
larger portion than usual has 
come down, and it is so 
swelled and tender from 
the constriction of the sphincter, and from being irritated by the 
clothes, that it cannot be returned, leeches, fomentations, a dose of 
opium, and rest in the horizontal posture for some hours, will re- 
move the difficulty. To cure this affection, the bowels should be 
regulated by gentle aperients, (F. 42,) so as to prevent costiveness 
and straining,-the stools should be passed whilst the patient is in 
the horizontal posture,-injections of dec. quercus, or of a lotion 
Fig 126.* 
* This cut, from a preparation in the King's College Museum, shows a section 
of a prolapsed rectum-the whole substance of the bowel being everted and com- 
ing down. The mucus membrane is excessively thickened from the irritation of 
exposure. STRICTURE OF THE RECTUM. 
455 
composed of a drachm of muriated tincture of iron to a pint of 
water;-dashing cold water on the part-tonics, especially steel 
wine-the occasional passage of a bougie, and support by padsand 
T bandages, may be used to give tone and firmness to the parts- 
and piles or any other source of irritation must be removed by 
appropriate remedies. Dr. MacCormac of Dublin recommends 
that when the stools are passed, the skin near the anus should be 
drawn to one side with the hand, so as to tighten the orifice ; this 
the author believes to be a very valuable suggestion. But if the 
diligent employment of these measures is of no avail, certain ope- 
rations may be resorted to. (1.) The mildest consists in pinching 
up two or three folds of mucous membrane on the protruded bowel 
with forceps, and tying them tightly with ligatures. (2.) Or liga- 
tures may be passed by needles through several folds of skin just 
at the margin of the anus, which are then to be tied up tightly. 
Either of these operations may be repeated as often as necessary. 
Their effect in producing adhesion and consolidation of the relaxed 
tissues must be obvious. There is a French operation, which con- 
sists in excising a portion of the sphincter ani; but when this ope- 
ration used to be performed (as it commonly was sixty years ago), 
for fistula, it was often followed by inability to retain the faeces. 
XII. Internal Prolapsus.-Sometimes the upper part of the 
rectum becomes prolapsed and invaginated within the lower, giving 
rise to most of the symptoms of stricture. On examination with 
the finger, the canal of the rectum is found obstructed by a tumour 
with a capacious cut de sac around it, and with the natural passage 
of the bowel in its centre. 
Treatment.-Aperients, mild astringent injections, and the bou- 
gie, the point of which should be carefully guided into the orifice 
in the centre of the prolapsed portion. 
XIII. Spasmodic Stricture of the rectum-known by great 
difficulty in evacuating the bowels, with spasmodic pain on doing 
so-is an affection about which but little is known. " It generally 
depends," says Mr. Mayo, " on a vitiated state of the secretions; 
and is more frequently relieved by a regulated diet and alterative 
medicines, and the use of injections, than by the employment of the 
bougie." 
XIV. Permanent Stricture.-In this affection there is a 
chronic thickening and contraction of the mucous coat of the rec- 
tum, so as to form a ring encroaching on its canal. It is generally 
situated at from two inches and a half to four inches from the anus. 
More rarely it is met with higher up, or even in various parts of 
the colon. The symptoms are great pain, straining and difficulty 
in voiding the faeces, which are passed in small, narrow, flattened 
fragments;-and on examination the stricture may in ordinary 
cases be readily felt. Irritation of the bladder and uterus, and 
pains or cramps in the leg, with headache and dyspepsia, are occa- 
sional additional symptoms. If this affection be unrelieved, it 
leads to ulceration of the rectum above the stricture, with a con- 
sequent aggravation of all the symptoms, and death from irritation. 456 
diseases of the rectum and anus. 
Treatment.-The remedies are aperients and injections so as to 
produce daily soft unirritating stools,-and the bougie. A soft 
bougie, capable of being passed with moderate facility through the 
stricture, should be introduced once in three or four days, and be 
allowed to remain fifteen or twenty minutes; and its size should be 
gradually increased when a larger one admits of being passed. 
The best bougie is a short one, made of India rubber, which may 
be received altogether within the sphincter; and it may be with- 
drawn by means of a ribbon at one end. Instruments of every 
sort introduced into the rectum should be handled with the utmost 
gentleness. Nothing is gained by forcing a large bougie through a 
stricture. The cure is to be effected by the repeated and gentle 
stimulus of pressure,-so as to excite absorption,-not by mere 
mechanical dilatation. There are numerous fatal instances on re- 
cord in which the bowel has been torn by bougies, and by that 
most dangerous and loathsome instrument the common clyster 
syringe, in the hands of careless or ignorant people. For the admi- 
nistration of enemata, the pipe should be only an inch and a half 
in length, with a large bulbous extremity. Or if in cases of stric- 
ture, or of obstinate costiveness with great accumulation of fasces, 
or of incarcerated hernia, it is desirable to introduce a tube farther, 
it should be quite flexible like that of a stomach pump. But the 
natural sharp fold at the junction of the rectum with the sigmoid 
flexure, and the fact shown by Mr. Earle that the bowel not unfre- 
quently makes a horizontal curve to the right before descending 
into the pelvis, render the introduction of bougies into the sigmoid 
flexure a very blind, hazardous proceeding, and one that is not 
often to be justified. Moreover, the surgeon must be on his guard 
lest he fall by inadvertence into an error, which some vile merce- 
nary men daily commit on purpose. That is to say, he must not 
pronounce his patient to have a stricture because the point of the 
bougie catches in a fold of the mucous membrane, or is obstructed 
by the promontory of the sacrum. 
XV. Simple Ulcer of the rectum is generally situated on its 
posterior surface, just above the sphincter, where it may be felt 
with a slightly indurated edge. It generally begins as a small 
crack or fissure of the mucous membrane, caused by straining to 
get rid of hardened fasces. It produces great pain and difficulty 
of defecation;-more or less discharge, occasionally tinged with 
blood, and irritation of the bladder. 
Treatment.-Laxatives, enemata of warm water, to which a 
little laudanum may be added when there is much pain,-and the 
application of a solution of arg. nit. to the ulcer, or the introduction 
of tents of lint smeared with mercurial ointment,-which failing, 
the sphincter must be divided and made to heal by granulation. 
XVI. Scirrhous Ulcer of the rectum presents, according to 
Mr. Mayo, the following appearances: The mucous membrane 
disappears for a certain extent; and the muscular coat which is 
exposed is pale, hard, and gristly like cartilage. The symptoms 
are great pain, tenesmus, fetid discharge, and irritation of the blad- DISEASES of the urinary organs. 
457 
der. The treatment consists in the use of aperients, astringent and 
opiate injections,-and the very occasional passage of a bougie. 
XVII. Fungus Medullaris occasions all the symptoms of per- 
manent stricture. It is known by the projecting fungous masses. 
The bowels must be kept loose,-pain and irritation must be allayed, 
-and the bougie be passed occasionally, to delay contraction of 
the passage. It is sometimes advisable to cut through the morbid 
growth, to provide for a time for the passage of the faeces,-but 
any attempt at extirpation is hardly to be thought of. The fatal 
result may, perhaps, be delayed by the formation of an artificial 
anus in the left lumbar region. 
XVIII. Pruritus Ani, a very violent itching of the anus, is a 
very troublesome affection. The best plan is, to keep the bowels 
open with sulphur, Seidlitz powders, or castor oil, with occasional 
doses of blue pill;-to put the stomach in proper order ;-to bathe 
the part very frequently with water as hot as can be borne; 
and to apply some stimulating or astringent substance-such as 
nitrate of silver, weak solution of corrosive sublimate, the citrine 
ointment, or lemon-juice. 
CHAPTER XX. 
OF THE DISEASES OF THE URINARY ORGANS. 
SECTION I. OF RETENTION OF URINE FROM SPASMODIC STRICTURE 
OF THE MALE URETHRA. 
The urethra in the male is liable to be obstructed or strictured 
through several circumstances. (1.) It may be contracted through 
a thickening and condensation of its texture from chronic inflam- 
mation ; a condition commonly called permanent stricture. Or 
(2) it may be obstructed through spasm of the muscular fibres which 
surround the membranous portion; which state is called spasmodic 
stricture; and (3) this in certain cases is combined with some 
degree of acute inflammation, whence the term inflammatory 
stricture. The canal may also be obstructed by cicatrices, abscesses, 
tumours, or fractured bones external to it; but in the present section 
we shall treat merely of that sudden obstruction which arises from 
spasm. 
Spasmodic Stricture depends on spasm of the muscular fibres* 
which surround the membranous portion of the urethra. It gene- 
rally affects persons who are labouring under some degree of per- 
manent stricture,-or whose urethra has been rendered irritable 
by repeated attacks of gonorrhoea, or by a diseased condition of 
* Particularly described by Mr. Guthrie in his work on the Urinary and Sexual 
Organs, 3d ed. Lond. 1843. 458 
SPASMODIC STRICTURE. 
the urine (especially a tendency to phosphatic deposits);-these, 
therefore, are the predisposing causes. The usual exciting causes 
are, exposure to cold and wet,-and indulgence in punch or cham- 
pagne, or similar acid liquors, which disorder the stomach and 
render the urine unusually irritating. Hence an attack of spas- 
modic stricture generally comes on about four hours after dinner. 
It may also be caused by cantharides, whether taken by the mouth, 
or absorbed from blisters applied to the skin. 
The symptoms are,-sudden Retention of Urine ; that is to 
say, the patient finds himself suddenly unable to pass his water, 
although he has a great desire and makes repeated straining efforts 
to do so. The bladder soon becomes distended, and can be felt as 
a tense round tumour above the pubes, and unless relief is given, 
the countenance becomes anxious, the pulse quick, and the skin 
hot. The straining efforts at micturition also become more fre- 
quent and violent, and the distress and restlessness are extreme. In 
this way, if unrelieved, the patient may perhaps go on for three or 
four days; a little urine passing occasionally when the spasm is 
less urgent, but the bladder still remaining loaded; till at last either 
the bladder bursts into the peritonaeum;-or as more frequently 
happens, the urethra behind the stricture, (which of course becomes 
dilated and weakened under the pressure of the urine impelled by 
the whole force of the abdominal muscles,) bursts into the peri- 
naeum, and gives rise to extravasation of urine, as will be de- 
scribed in the third section. 
The inflammatory stricture is a variety of the preceding, in 
which great pain and tenderness of the perinamm, and fever, are 
combined with spasm. It is generally caused by abuse of injec- 
tions, or by exposure and intemperance during acute gonorrhoea. 
The treatment of this and of the spasmodic variety must be the 
same. 
Treatment.-In the first place the bladder must be relieved if 
possible. A silver catheter may first be introduced. But if that 
fails to pass, the surgeon may try a gum catheter of the smallest 
size, which lias been kept for some time on a curved wire, so that 
it retains its curve when the wire is withdrawn. If that also fails, 
a catgut bougie, or a common bougie, may be tried in succession, 
the surgeon endeavouring to get them within the gripe of the stric- 
ture ; after which if they are withdrawn, a stream of urine will 
generally follow. In introducing either of these instruments, the 
surgeon should be careful, 1st, to draw the penis well forwards on 
it, so as to stretch the urethra, and prevent the instrument from 
becoming entangled. 2dly. To make the point slide along the 
upper surface of the urethra. 3dly. On meeting with the obstruc- 
tion, to press against it steadily, but very gently. And by one or 
other of these means, used with delicacy and perseverance for five 
or ten minutes, the stricture will in most cases be made to yield. 
The size of the instruments employed should vary according to the 
duration of the disease ; being small if that is of long standing; but 
larger if it is only of recent formation. DISEASES OF THE URINARY ORGANS. 
459 
If, however, they all fail, certain remedies for relaxing the spasm 
must next be resorted to. 
(a) Venesection, or cupping from the perineum-if the patient 
is of an inflammatory habit, or complains of much pain; (6) An 
enema or some purgative of speedy operation-if the attack is 
caused by excess at table;-followed by (c) an enema of solution 
of starch fgiii with tinct. opii fsi,-or by repeated doses of opium 
or Dover's powder;-together with (d) immersion of the whole 
body in a hot bath (104° F.) till faintness supervenes,-are the 
most useful. But there are many others that are often of very great 
service; especially (e) the tinct. ferri sesquichloridi in doses of 
nix every ten minutes-(/) affusion of cold water on the genitals 
-(^) large draughts of lime-water-(A) and belladonna smeared 
on the perinasum. (?) A slight touch with the caustic bougie some- 
times produces immediate relief, when there is some degree of 
permanent stricture, which is exceedingly irritable, and liable to 
frequent spasm. (A) Quinine has cured cases in which spasmodic 
stricture occurred periodically. 
But the most generally useful remedy of all, is opium ; which 
allays the extreme anxiety of the patient, and stops his repeated 
strainings; for the stricture generally relaxes when it is relieved 
from the constant pressure of the urine against it. 
Puncture of the bladder-If none of these means succeed, and 
the bladder has become exceedingly distended, it must be punc- 
tured. But this operation, although sometimes necessary to save 
life, is not very frequently performed. The time at which it must 
be done must be decided by the surgeon's judgment; sometimes, 
as Sir B. Brodie observes, it is necessary within thirty-six hours, 
sometimes not for three or four days. The puncture may be made 
in three places, viz. 1, by the rectum,-2, above the pubes,-or 3, 
the urethra may be opened in the perinaeum. The first operation 
is to be preferred in cases of retention of urine by stricture,-the 
second when the prostate is enlarged,-and the third when urine is 
extravasated. 
Puncture of the Bladder by the Rectum is performed by 
Fig. 127. 460 
PERMANENT STRICTURE. 
placing the patient on his hands and knees, or placing him on his 
back with his knees drawn up, and bringing him close to the edge 
of the bed,-introducing the right fore-finger into the anus, and a 
long curved trocar and canula, by its side,-then feeling for the 
distended bladder just behind the prostate, and exactly in the mid- 
dle line, and plunging the trocar into it-leaving the canula for 
four-and-twenty hours. 
SECTION II.-PERMANENT STRICTURE. 
Permanent Stricture signifies a contraction of the urethra, 
caused by chronic inflammation. At first, a small portion of the 
mucous membrane, perhaps only a line or two in extent, is found 
thickened and deprived of its natural elasticity; but in old neglected 
cases, the canal with the corpus spongiosum around may become 
converted into a thick, gristly, cartilaginous mass several inches in 
extent. Its most frequent situation is just at the commencement of 
the membranous portion of the urethra; but it is also very com- 
monly found in the anterior portion of the canal, especially at the 
distance of four inches from the orifice. The causes are repeated 
gonorrhoea, intemperance, and unhealthy conditions of the urine. 
Symptoms.-In what may be called 
the first stage, the patient finds that 
he wants to make water oftener than 
usual, and that he has more or less 
uneasy sensation in the perinaeum 
after doing so; he also notices that a 
few drops hang in the urethra, and 
dribble from him after he has button- 
ed up. Then he observes that the 
stream of water is smaller than usual, 
and forked, or scattered, or twisted, 
and that he requires a longer time and 
greater effort than usual to pass it. 
Itching of the end of the penis and 
gleety discharge are not unfrequent 
concomitants if the stricture is near the 
anterior extremity of the urethra. 
If the disease proceeds to its second 
stage, the bladder becomes irritable,- 
obliging the patient to rise in the night 
to void his urine. He is liable to at- 
tacks of spasm with complete reten- 
tion, as was described in the preceding 
section. In one of these, the urethra may ulcerate or burst,-giving 
rise to urinary abscess, or to extravasation of urine, as will be 
described in the next section. Rigors occurring in paroxysms like 
ague fits are not uncommon. 
Finally, if the complaint is permitted to continue, the health suf- 
Fig. 128. 461 
DISEASES OF THE URINARY ORGANS. 
fers from the constant irritation and want of sleep; the bladder and 
kidneys become diseased; the complexion becomes wan; the ap- 
petite fails; the patient complains of chill and flushes, of aching and 
weakness in the back, and of great languor and depression of 
spirits; and the urine is constantly loaded with fetid mucus. After 
death, the urethra behind the stricture is found greatly dilated; the 
prostate, with its ducts dilated, and in a state of suppuration, or 
perhaps containing small circumscribed abscesses; the bladder, 
sometimes dilated, but more frequently contracted and having its 
muscular coat enormously thickened; sometimes sacculated from a 
protrusion of its mucous coat between the fibres of the muscular; 
-the ureters dilated, and converted into subsidiary receptacles for 
the urine, and the kidneys either greatly dilated or disorganized 
Treatment.-In the first place, any disorder of the general health, 
or of the digestive organs, and any derangement of the urine, must 
be corrected by proper remedies. (Vide Gleet, Chronic Inflamma- 
tion of the Bladder, and Urinary Deposits.) The patient also must 
avoid violent exercise, especially on horseback. But the stricture 
can only be cured by mechanical means. And these are five : 1, 
The bougie,-2, the catheter kept in the urethra,- 3, the caustic 
bougie,-4, puncturation with the stilet,-and 5, division from the 
perinaeum. 
1. The bougie. -In order to ascertain with precision the existence 
of stricture, the urethra should be examined with a common plaster 
bougie of full size, i. e., one that will readily enter the orifice, and 
that will fill the urethra without stretching it. The surgeon takes 
the corona glandis in his left hand, and introduces the bougie (pre- 
viously oiled and bent to the shape of the urethra) with his right- 
holding it loosely like a pen. If it meets with an obstruction, it 
should be slightly withdrawn,-then tried again. If it now seem 
to pass, the surgeon should relinquish his hold,-and then if it 
recoils, it is a sign that it has bent against the stricture;-whereas if 
it has entered the stricture it will be held, and will require a gentle 
force to dislodge it. If after all it does not pass, a metallic sound or 
catheter may be tried, because a slight obstacle to the instrument at 
its first introduction must not be set down at once as stricture. The 
patient generally suffers somewhat from sickness and faintness on 
the first trial. When the stricture is clearly made out, the surgeon 
should mark and lay by a bougie that will just pass through it. In 
three or four days' time he introduces the same bougie again,-lets it 
remain a few minutes,-then withdraws it, and introduces another 
of a size larger, which he suffers to remain for ten or fifteen minutes. 
After three more days the process is repeated,-first using the in- 
strument that was passed on the former occasion,-then one of a 
size larger ; and this process repeated a sufficient number of times 
affords in most cases an easy, painless cure. 
Metallic bougies or sounds made of silver, or steel plated, are to 
be preferred to those of the ordinary soft materials, 1st, if the stricture 
is old and very hard and gristly; 2dly, in cases of very irritable 
urethrae, because their smooth polished surface is not so apt to cause 462 
STRICTURE. 
spasm; 3dly, in cases where a false passage has been formed, which 
these instruments, as they can be directed with greater precision, 
can be better made to avoid. They should be eight or nine inches 
long, and not very small, slightly curved, and mounted on a firm 
wooden handle, and their point should be made to slide along the 
upper surface of the urethra, as it is at the bottom that false pas- 
sages generally exist, and are most easily made. These instruments 
may also be used for the cure of old impassable strictures in the 
following way :-A sound of moderate size, about one-fifth or one- 
sixth of an inch in diameter, may be introduced once in three or 
four days, and be firmly pressed against the stricture for from five 
to fifteen minutes, taking care to keep its point against the upper 
part of the urethra. This will cause the anterior part of the stricture 
to relax a little ; and if the process is repeated often enough it will 
at last clear the way to the bladder.* 
2. If a small catheter is retained in the bladder for two or three 
days, the passage suppurates and dilates remarkably; just as the 
lachrymal duct does from the presence of a style. This method of 
cure is extremely speedy and efficient. It may therefore be em- 
ployed, 1st, when time is of much value; 2dly, when the stricture 
is very gristly and cartilaginous; 3dly, when the urethra is irregular, 
or has had a false passage made in it; 4thly, when the urethra is so 
irritable that severe rigors and fever are occasioned by the passage 
of the urine after the use of the common bougie-a circumstance 
common enough with patients who have lived in hot climates. 
The catheter should be retained by means of two strings, which 
may either be fastened to the penis with sticking-plaster, or may 
be tied to the thighs, or may be passed backwards between the 
thighs, and be fastened to a band round the waist. It should be 
removed in three or four days, and a larger catheter should be 
passed after twelve or four-and-twenty hours, and should be intro- 
duced often enough subsequently to keep up the dilatation. In 
cases of stricture which will not suffer any instrument to pass, Air. 
Guthrie recommends a bougie to be kept in the urethra, and to be 
made to press constantly against the anterior surface of the stricture. 
He says that this plan " has never failed in his hands to clear the 
urethra, and to effect a passage into the bladder." Mr. Liston, 
however, describes it as "a very futile and unsurgical proceeding," 
and one "not likely to be called for in the practice of a man with 
hands to act and head to guide them." 
3. The caustic bougie is a powerful agent in diminishing the 
irritability of strictures, and is advisable in cases where there is a 
perpetual tendency to spasm. The modus operand! is that of a 
stimulant, not of an escharotic; it is employed to take away the 
irritability of the urethra; not mechanically to burn a fresh passage 
through an old stricture. Yet it may sometimes be employed to 
destroy very firm strictures of small extent. But it should never 
be used till other means have failed, and never should be repeated 
* Vide Sir B. Brodie on the Urinary Organs, 3d ed. 1842. DISEASES OF THE URINARY ORGANS. 
463 
more than three or four times about the same period,-for it is 
liable, if misused, to induce inflammation, abscess, spasm, haemor- 
rhage, or false passage. The manner of using it is this :-the dis- 
tance of the stricture is measured by a common bougie,-then the 
caustic bougie is passed down to the same distance, and is to be 
pressed firmly and heavily against the stricture for a quarter or half 
a minute. The process should not be repeated in less than three 
days. 
4. Puncturation, or division of the stricture by means of the 
lanceted stilets invented by Mr. Stafford, may be resorted to with 
advantage in some cases of old stricture, especially if at the anterior 
part of the urethra. But if the stricture is far back, it is a blind, 
dangerous proceeding; and, if any instrument whatever can be 
passed, it is unnecessary. 
5. The operation of Opening the Urethra from the Peri- 
naium is absolutely requisite in all cases of rupture of the urethra 
with extravasation of urine,-and it may also be expedient in cases 
of very old stricture with extensive urinary fistulas. It is performed 
thus:-the patient is placed in the lithotomy position; agrooved 
staff is passed down to the stricture, and the left forefinger, intro- 
duced into the rectum, is to feel for the urethra, and serve as a 
guide to the incisions. Then a straight bistoury is to be plunged in 
just above the anus to the depth of an inch, and made to cut its 
way out upwards in the middle line of the perinaeum. The end of 
the sound should next be felt for and cut upon,-and the knife is 
then to be carried backwards through the stricture into the urethra 
beyond it, which is always more or less dilated. A gum catheter 
should then be passed into the bladder, and be retained there, so 
that the wound may heal over it, and form a new passage. It 
should, however, be changed once in three or four days. 
There is a modification of this operation which Sir B. Brodie 
adopted in a case of old stricture, so hard, narrow, and extensive, 
that no instrument could be passed through it, and complicated with 
urinary fistulae. He cut down through the perinaeum into the 
dilated part of the urethra behind the stricture. Then, having 
introduced the finger, he pressed with it against the back part of 
the stricture, and having passed down an instrument similar in prin- 
ciple to Mr. Stafford's, made the lancet cut through the stricture. 
A catheter then passed into the bladder, and retained there; the 
wound in the perinaeum healed, and the patient recovered the 
facility of making water in a tolerable stream. The advantage of 
this method is, that the free opening in the perinaeum prevents all 
risk of extravasation of urine. 
In whatever manner a stricture has been cured, the bougie should 
still be used at intervals, to prevent a fresh contraction. 
Contraction of the Orifice of the urethra may be a con- 
genital affection, or may be caused by the cicatrization of ulcers. 
It must be counteracted by the daily passage of a short bougie, 
otherwise it may produce all the evil consequences of stricture 464 
URINARY ABSCESS. 
further back. If the contraction is very great, and causes retention 
of urine, one of Anel's probes, a common probe, and a director 
may be introduced in succession, and then when the bladder is 
emptied, the orifice must be dilated by a slight incision downwards; 
any subsequent contraction being obviated by the bougie. 
SECTION III. OF URINARY ABSCESS, EXTRAVASATION OF URINE, AND 
FISTULA IN PERINJEO. 
I. Urinary Abscess is a frequent consequence of stricture. It 
signifies an abscess in the cellular tissue of the perinaeum, and is 
caused in the following way: One or two drops of urine escape 
into the cellular tissue, in consequence of a slight ulceration or 
laceration of the weakened or dilated part of the urethra behind the 
stricture; and this small quantity of urine produces inflammation, 
so that an abscess forms, filled with dark-coloured putrid pus.* 
Symptoms.-A patient with old stricture complains of rather 
more difficulty of micturition than usual-he is seized with shiver- 
ing, the skin becomes hot, the tongue brown, and the pulse faltering; 
-and on examination, a deep, hard, and painful but not prominent 
swelling will be detected in the perinaeum. Perhaps the scrotum 
is oedematous. 
Treatment.-The abscess should be opened immediately, and 
the patient will soon be brought from the gates of death to com- 
parative health. It will also be expedient to cut through the 
stricture as directed in the last section, and pass a catheter into the 
bladder. 
II. Rupture of the Urethra and Extravasation of Urine. 
-This is another consequence of old stricture, and it generally 
happens in the following way: The patient, who has long been 
labouring under difficulty of micturition, has a fit of spasmodic 
retention more obstinate than usual. He is repeatedly getting out 
of bed, and straining with all his might to pass his water. At last, 
during one violent effort, he plainly feels that something has given 
way;-his painful sense of distension becomes immediately less, 
and he is very well pleased, and thinks himself better. And 
perhaps he is now able to make a little water by the natural 
passage, because the stricture generally relaxes, when, by any 
means whatever, it is relieved from the former pressure. But at the 
time when something seemed to yield, the urethra burst;-the 
urine was forced by the whole power of the abdominal muscles 
into the cellular tissue of the scrotum, perinaeum, and groins;- 
the patient soon complains of a smarting or tingling about the anus 
and perinaeum;-the urine, which has become putrid and concen- 
* In the same manner, a little urine may escape from a minute aperture in the 
bladder, and give rise to abscess behind the pubes, or between the bladder and 
rectum; which may point above the pubes; or in the groins, or may burrow 
amongst the muscles of the thigh. FISTULA IN PERINJSO. 
465 
trated by long confinement in the bladder, speedily causes inflam- 
mation and sloughing;-the skin over the infiltrated parts displays 
a reddish blush, which is soon succeeded by black spots of gangrene; 
-low typhoid symptoms appear; the tongue is black, the pulse 
begins to falter, the skin is clammy; low muttering delirium and 
hiccup come on;-and the patient soon departs this life, unless 
proper measures are taken for his relief. A black spot on the glans 
penis, indicating that the urine has penetrated the corpus spongi- 
osum, is a very fatal sign. 
Treatment.-A staff'or catheter must be passed as far as possible, 
and it may sometimes be passed quite into the bladder, because, as 
was observed above, the stricture generally relaxes after the 
bladder is unloaded, be it how it may. Then the urethra must be 
opened and the stricture be divided in the manner described in the 
last section, and a catheter be passed through the wound into the 
bladder, and be allowed to remain several days. At the same time 
free incisions must be made into any parts that are swelled or 
emphysematous-showing that they have been pervaded by the 
urine. 
The urethra may also be ruptured by blows or kicks on the peri- 
naeum, or by accidents that fracture the bones of the pelvis. The 
symptoms will be pretty evident. The patient will be unable to 
make water; or if he attempts it, the urine will be extravasated into 
the perinaeum and scrotum. The treatment consists in retaining a 
catheter in the urethra, and incising the perinaeum if urine has been 
extravasated. 
III. Fistula in Perinjeo, or Urinary Fistula, signifies an 
opening from the perinaeum into the urethra, through which the 
urine dribbles when the patient makes water. It is a frequent 
consequence of urinary abscess and extravasation. 
Treatment.-1The first and most essential measure is, to restore 
the urethra to a healthy state, and to dilate any strictures that may 
happen to exist, by the bougie. When this has been done, the 
fistula should be stimulated to granulate by injection of arg. nit. or 
by passing a heated wire into it;-and the external orifice should 
be occasionally touched with potass, so as not to allow it to heal 
before the whole track is closed-otherwise fresh abscesses will 
form. Sir B. Brodie thinks it is not a good plan either to introduce 
the catheter every time the patient makes water, nor yet to keep 
a catheter in the urethra, as some have recommended with the 
view of preventing the urine from passing through the stricture, 
as the irritation does more harm than good. 
Sometimes there is a blind fistula in perinaeo; that is, a small 
narrow fistula, opening into the urethra, but not externally. It is 
occasionally inflamed and tender; and may be felt as a small 
tumour in the perinaeum; perhaps the size of a horse-bean. It 
is attended with more or less discharge from the urethra. The 
treatment consists in laying the tumour open, and dilating any 
strictures that exist. 
Sometimes a fistulous communication forms between the urethra 466 
CONTRACTION OF THE URETHRA. 
and rectum. This may be known by air passing through the 
urethra. It is to be treated by dilating the urethra, and then per- 
haps a heated wire may be introduced into the fistula. 
SECTION IV. OF SOME OTHER AFFECTIONS OF THE MALE URETHRA. 
I. Contraction of the Urethra following injuries, such 
as blows on the perinamm, must be treated in the same way as 
permanent stricture: that is, bougies should be regularly passed to 
keep the canal dilated ; but if it has become contracted and impene- 
trable, Sir B. Brodie's plan of opening the canal, described at the 
end of the second section, should be adopted, and a catheter be 
passed into the bladder and be kept there till the wound heals 
over it. 
II. False Passage.-This may be produced by using too small 
a sound, and pushing it out of the urethra, or by the misuse of 
caustic bougies. There is nothing to be done for the false passage, 
but the stricture which was the origin of it must be treated either 
with the metallic sound, or by keeping in a small catheter. When 
the surgeon suspects that he has pushed an instrument out of the 
right passage, he ought to leave the urethra untouched for at least 
a week. 
III. Hemorrhage from the Urethra may be caused by the 
rude introduction of bougies, or by injuries from without, or by the 
separation of a slough formed by the caustic bougie;-or, lastly, 
by a rupture of blood-vessels during acute chordee. If the appli- 
cation of cold does not check it, pressure may be tried. A flat 
piece of cork should be pressed by the patient against the peri- 
naeum far back, and be gradually moved forward till it lights on 
the right spot, and the dripping of blood ceases. 
IV. Solid Tumours in the course of the urethra, composed of 
indurated follicles, torment the patient by keeping up a perpetual 
gleet and chordee. The mercurial ointment with camphor exter- 
nally; and the passage of a bougie; or keeping a small catheter in 
the bladder for a few days at a time, are the chief remedies. 
V. Acute and Chronic Inflammation of the urethra from 
whatever cause arising, differ in no respect, in their symptoms, 
consequences, or treatment, from gonorrhoea and gleet. 
VI. Foreign Bodies in the urethra may consist of calculi, or of 
small bodies introduced from without. They may perhaps be 
pushed forwards by means of the fingers, aided by the patient's 
strainings,-or may be seized by forceps, and be brought out 
through the orifice, which must be slightly dilated if necessary. 
Or, it is a very good plan to press the thumb on the urethra behind 
the foreign body, and then to inject a good stream of water from a 
large syringe, so as to dilate the passage. But if these means fail, 
the substance must be pushed back into the membranous portion, 
(if not there already,) and be extracted by an incision in the peri- 
naeum. Incisions into the front of the urethra should be avoided, DISEASES OF THE PROSTATE GLAND. 
467 
for they are liable to leave irremediable fistulas; or if near the 
scrotum, may occasion infiltration of urine into its loose cellular 
tissue. 
SECTION V. OF THE DISEASES OF THE PROSTATE GLAND. 
I. Acute Inflammation of the prostate is generally a conse- 
quence of acute gonorrhoea. The symptoms are, great weight, 
pain, and throbbing at the neck of the bladder-and tenderness of 
the perinaeum;-the gland feels swelled and tender on examination 
by the rectum-and there are frequent, violent, and exceedingly 
painful efforts to make water. ' ■ i -■ 
Treatment.-Rest in bed-cupping or leeches to the perinaeum 
-or general bleeding if the patient is strong-hip-baths and ene- 
mata of starch $ii, laudanum 3ss every night. If the urine cannot 
be passed without it, a very small gum catheter may be introduced; 
-but it should be avoided if possible. 
II. Abscess of the prostate may be suspected if rigors and 
obscure swelling in the perinaeum follow the symptoms of acute 
inflammation. In any such case, the swelling should at once be 
freely punctured with a bistoury. If left to itself, the abscess may 
burst into the rectum or the urethra, which latter circumstance will 
be indicated by a sudden discharge of pus with the urine. If the 
abscess should burst into the urethra, the catheter should be used 
every time the patient passes his urine, in order to prevent it from 
entering and irritating the cyst. If the case is chronic and the habit 
scrofulous, quinine and tonics, and small doses of cubebs, to act as 
a gentle stimulus on the parts, will be of service. 
III. Chronic Enlargement of the prostate is extremely fre- 
quent in advanced life, and seems to depend on the decay of age 
rather than on any disease; or perhaps it may be said to resemble 
the enlargement of the thyroid gland in bronchocele. It generally 
commences, as Sir B. Brodie observes, about the time that the hair 
turns gray, and when earthy specks begin to be deposited in the 
coats of the arteries. The gland increases from two to fourteen 
times its natural bulk, and becomes hardened. The middle lobe 
generally forms a projecting tumour at the neck of the bladder, 
and, in consequence of the alteration of the shape and size of the 
gland, the prostatic portion of the urethra becomes lengthened, and 
curved abruptly upwards. 
The first symptoms are slowness and difficulty in making water, 
sense of weight in the perinseum, and tenesmus. In the next place, 
the bladder becomes irritable, and the calls to make water are 
oftener than before. Then, as the patient cannot empty the organ 
completely, in consequence of the projection formed by the tumour, 
a portion of urine always remains behind, and decomposes, and 
becomes ammoniacal. Sometimes a fit of complete retention 
ensues, and it may be brought on by exposure to cold or excess in 
venery. Next, the mucous coat of the bladder, irritated by the fre- 468 
ENLARGED PROSTATE. 
quent strainings, and by the alkaline urine, inflames and secretes a 
viscid mucus. Finally, the obstacle continuing to increase, the 
bladder is constantly distended-the urine perpetually dribbles 
away-the ureters become dilated into subsidiary receptacles; 
the kidneys become disorganized, the patient's little remaining 
strength is exhausted, and he dies. Abscess in the gland, or ulcer- 
ation of that surface which projects into the bladder, sometimes 
adds to the patient's misery, and hastens his death.* 
Treatment.-Medicines are of no avail to remove senile enlarge- 
ment of the prostate, although they may very likely be required 
for accompanying disease of the bladder or kidneys.t The only 
thing to be done is to introduce the catheter two or three times a 
day, so that the bladder may be completely emptied. The instru- 
ment will meet with an obstruction just at the entrance of the blad- 
der, occasioned partly by irregularity of the urethra, partly by the 
projection of the third lobe. To avoid the latter, the instrument 
(commonly called prostate catheter} should be long, and have its 
point well turned up. In introducing it, the point should be made 
to glide as close as possible round the pubes, and the handle should 
be well depressed as it is entering the bladder, in order that the 
point may ride over the projection. The finger also should be 
introduced into the rec- 
tum to guide it. The 
7' ■ best catheter, if it can be 
/ used, is a small gum, 
z which has been kept a 
- . long while on an iron 
' wire of considerable 
, curve; but a silver one 
* of proper shape is more 
• z z -easy of introduction. 
If the bladder has 
been long distended to 
' w^the utmost, and the kid- 
neys have become or- 
ganically 'diseased in consequence, the sudden withdrawal of all 
Fig. 129. 
* [There is a certain form of chronic irritability of this gland, occurring in young 
Then, attended with little or no enlargement of it, and with inconsiderable tender- 
ness on examination per rectum. 
Generally speaking, the subjects of this affection have abused the genital organs 
by venereal excess, or by protracted medication for gleet or fancied loss of virility. 
After relieving the despondency of such patients by assurances of probable 
restoration, and persuading them to abandon their leazing nostrums and meddle- 
some anxiety, I have generally succeeded in allaying the morbid sensibility of the 
affected parts, and restoring their tone, by the introduction of a small seton in the 
perinaeum, and the daily application of the cold-water dash to the whole external 
genito-urinary apparatus. 
I have seldom resorted to the fashionable process of cauterization, but the result 
of my limited experience of it has fallen far short of its pretensions.-F.] 
f Sir B. Brodie gives a case in which enlargement of the prostate in a man aged 
31, following gonorrhoea, was cured by the iodide of potassium; and the same 
remedy has been used as a local application in the senile form. DISEASES OF THE BLADDER. 
469 
the urine will be liable to be followed by irretrievable sinking. 
The urine should therefore be drawn off in small quantities at a 
time, and the strength be well supported with tonics, wine, and 
plenty of nutriment. 
IV. Complete Retention of the Urine from enlargement of 
the prostate. In this case, if there are inflammatory symptoms, 
cupping from the perinseum and the hip-bath are indicated. The 
catheter should be passed, if possible, and when passed, it should 
be retained, because the bladder does not regain its contractility 
for two or three days, and the frequent introduction of the instru- 
ment would be irritating. If, however, the catheter cannot be 
passed by the natural route, it should be thrust through the pro- 
jecting part of the gland, so as to make a new passage into the 
bladder-(or perhaps one of Stafford's lanceted stilets may be 
advantageously employed for that purpose. But if this cannot be 
done, the last resource is 
Puncture of the Bladder above the Pubes. This is easily 
performed by making a small incision through the linea alba just 
above the pubes, and then thrusting a long trocar and canula down- 
wards and backwards into the bladder, where it is not covered by 
the peritonaeum. The canula must be retained, and the patient be 
kept on his back to prevent extravasation;-and no time should be 
lost in restoring the natural passage. 
V. Calculi of the prostate are small reddish-brown concretions 
of phosphate of lime formed in the ducts of the gland. They 
cause obscure irritation of the neck of the bladder, and difficulty of 
micturition. They may perhaps be felt by the finger in the rectum. 
Sometimes it may be possible to remove some of them with the 
urethral forceps-or if there are many contained in one cyst, to cut 
upon them from the perinseum: but in general the only thing to be 
done is, to keep the urethra well dilated with bougies, so as to 
favour their spontaneous escape. 
VI. Scirrhus of the prostate is a disease of very rare occur- 
rence. In one or two cases which occurred in Sir B. Brodie's prac- 
tice, the gland was enlarged, and of a stony hardness; there was 
great pain referred to the groins and perinseum, and irritability of 
the bladder, and the real nature of the disease was shown by the 
cancerous cachexia manifest in the patient's whole appearance. 
SECT. VI. OF THE DISEASES OF THE BLADDER. 
I. Acute Inflammation of the bladder or {cystitis') is rarely a 
primary idiopathic affection. Most frequently it is a consequence 
of neglected or ill-treated gonorrhoea, or else an aggravation of the 
chronic inflammation. The symptoms are pain, referred to the 
perinseum and sacrum-tenderness of the lower part of the abdo- 
men-micturition exceedingly frequent, attended with great strain- 
ing, and followed by an aggravation of the pain-a mucous or 
muco-purulent sediment in the urine, and fever. 470 
DISEASES OF THE BLADDER. 
Treatment.-Bleeding-leeches or cupping on the lower part of 
the abdomen or perinaeum-hip-baths and warm fomentations- 
castor oil, so as to keep the bowels open without much straining- 
opiate glysters at night. If, moreover, the urine is acid, (turning 
blue litmus paper red,) and if the sediment in it is yellowish and 
not adhesive, F. 6 may be given three or four times a day, with 
saline draughts containing excess of alkali, (or F. 19,) in the inter- 
vals. But if the urine be alkaline, (turning red litmus paper blue,) 
and if it deposit a dark-coloured adhesive mucus, vin. colchici n^xx 
-xxx should be given three or four times a day instead of the 
calomel and alkalis. 
II. Chronic Inflammation of the bladder (catarrhiis vesicae) 
is a very frequent consequence of irritation from stricture, diseased 
prostate, or stone. 
Symptoms.-The bladder irritable-micturition very frequent 
and painful-the urine loaded with mucous-which is sometimes 
tinged with blood, sometimes yellowish and puriform, but more 
generally grayish, streaked with white, highly alkaline, and exces- 
sively viscid, so as to stick to the bottom of the chamber-pot when 
turned upside down. In the early stages there is but little mucus, 
and the urine may remain acid; but as the disease advances, the 
quantity of mucus becomes enormous, and the urine is voided of a 
brownish hue, and of a most offensive ammoniacal odour. More- 
over, it may clog the urethra, and cause retention of urine;-a kind 
of retention difficult to manage, because the mucus clogs up the 
eyes of the catheter. In this stage there is very frequent desire to 
make water, and constant pain above the pubes. In general, the 
mucus contains phosphate of lime, which may be seen in it in white 
streaks, and which is apt to collect and form a stone in the bladder. 
Perhaps the mucous membrane of the bladder may ulcerate, and 
after death it may be found as cleanly dissected from the muscular 
coat, as if it had been done with a knife. This will be attended 
with an intense aggravation of the pain in micturition, and with a 
dark colour of the urine;-owing to the admixture of a little blood 
which exudes from the ulcerating surface, and which, after the 
urine is passed, sinks to the bottom like coffee grounds. But more 
frequently the bladder throws out flakes of lymph, which become 
encrusted with patches of phosphate of lime. Moreover, the blad- 
der, by the constant exercise of its muscles in straining, becomes 
hypertrophied and exceedingly thick;-and portions of its mucous 
membrane are apt to be forced between the intervals of its muscular 
fibres, and form pouches which are soon filled with mucus, or with 
phosphatic calculi. Finally the mucus becomes purulent, disease 
of the kidneys ensues, and the patient dies. Dr. Prout says that, 
in the last stage of all kinds of bladder disease, the urine not unfre- 
quently becomes acid suddenly, and the mucus and pus disappear, 
immediately before death. 
Treatment.-In the first place, if there is a stricture, or enlarged 
prostate or stone in the bladder, proper measures should be taken 
for their removal or relief. In the next place, if the symptoms DISEASES OF THE BLADDER. 
471 
are at all severe, the patient should keep himself in the recumbent 
position as much as possible, with the pelvis elevated. Thirdly, if 
there is at any time a great aggravation of pain, and the strength is 
pretty good, a few ounces of blood may be taken by cupping on the 
sacrum or perinaeum; but, as a general rule, all lowering measures 
are injurious. Stimulating or opiate plasters to the sacrum are 
sometimes of use. Pain and irritation are to be allayed by the hip- 
bath, and by enemata or suppositories of opium-(F. 48,) or by 
the internal administration of opium. The bowels should be kept 
properly open by mild aperients, such as castor oil or rhubarb; but 
griping or purging are inexpedient. The diet should consist of 
boiled mutton, white fish, rice, arrowroot, and other substances 
that are nutritious, easily digestible, and not apt to turn sour;- 
with cold weak brandy and water, or gin and water, or sound 
sherry. Mercury and alkalis are of course, as a general rule, inex- 
pedient ; yet if the urine is still acid (not being yet made alkaline 
by the mucus) and the strength is good, small doses may be given, 
if required for the state of the stomach; -as will be shown when 
treating of the phosphatic diathesis. 
Besides these remedies, the bladder may be acted on by certain 
medicines, and by injections. Of medicines, the most useful, accord- 
ing to Brodie, is the root of the pareira brava, an ounce of which 
should be boiled in three pints of water down to a pint, and the de- 
coction be administered in doses of 5iv ter die-or the extract of 
pareira in doses of gr. xxx ter die may be substituted. Uva ursi, 
or buchu, in doses of an ounce or two of a strong infusion or decoc- 
tion, F. 91; or oil of turpentine, (^Ixv.) or chian turpentine, (gr. 
ii) or cubebs (gr. xv.) ox copaiba, (itlxx.) or tinct. ferri mur. (lUxv.) 
-in small doses three times a day, are also remedies of similar 
virtues. Hyoscyamus or opium, and small doses of mineral acids, 
if the urine is highly alkaline, may be added to any of them, F. 98. 
The sulphate of zinc may also be highly useful, F. 53. 
Injections into the bladder are not to be thought of when there 
is acute inflammation of the bladder and blood mixed with the 
mucus, but they are highly serviceable in chronic cases, by relieving 
the irritability of the bladder, and washing out the organ, getting 
rid of the decomposed stinking urine and mucus. Injections of 
simple warm water are very useful; the best way of effecting them 
is that employed by Mr. W. Fergusson; it is, to have a catheter 
with a double passage, and to throw in the water in a continuous 
stream by means of a syringe like that of a stomach pump. Three 
or four pints of water may thus be passed through the bladder 
daily. Decoction of poppies or laudanum may be added in some 
cases. Moreover, injections of very dilute nitric acid (Uli - ii-ad 
5iss aq. destil.) thrown into the bladder not oftener than Qnce a day, 
through a double gold catheter, and allowed to remain thirty 
seconds, are of great service when the urine is highly ammoniacal. 
III. Irritable Bladder.-Many cases described under this title 
are cases of chronic inflammation. Simple irritability,-that is, a 
frequent'disposition to pass the urine without any disease,-maybe 472 
DISEASES OF THE BLADDER. 
caused by an irritating state of the urine ; or it may be the effect of 
mere nervousness, which is not uncommon in elderly people; or it 
may be sympathetic of disease of the kidney, as will be described 
in the next section; or of irritation of the rectum. 
IV. Paralysis of the bladder may occur under many circum- 
stances. It may be caused by injury or disease of the head or spine 
-it is often present in typhus fever-it may be caused for a time 
by any severe injury, especially of the legs-it generally remains 
for a few days after the bladder has been long distended, whether 
from prostatic disease or stricture-and it sometimes occurs sud- 
denly to nervous sedentary people, who, if they let their bladder get 
filled beyond a certain point, find that they cannot empty it. The 
symptoms of it are, either retention of urine;-i. e., that the patient 
cannot make water;-or else incontinence of urine; that is, the 
water dribbles away without his being able to hold it. The diagnosis 
of retention through palsy, from retention through stricture, is easy. 
The retention from palsy comes on suddenly, and there is no obsta- 
cle to the introduction of a catheter. 
A strong decoction of parietaria officinalis; cantharides, and 
tinct. ferri mur. are the remedies for simple palsy. 
V. Incontinence and Dribbling of Urine.-This is a symp- 
tom that requires particular notice; because in nine cases out of ten 
it happens, not because the patient cannot hold his water, but be- 
cause he has retention of urine, either from stricture or enlarged 
prostate, or palsy of the bladder. For it must be noticed, that, in 
either of these cases, as soon as the bladder becomes full, a little urine 
begins to dribble away through the urethra-and besides the patient 
may perhaps be able to squeeze out a little by straining with his 
abdominal muscles, and may believe his bladder to be empty, 
although all the while it is enormously distended. No surgeon will 
fail to put his hand on the pubes when he sees the urine dribbling 
away. The obvious remedy is the catheter. 
VI. Hysterical Retention of Urine.-There is one form of 
palsy of the bladder which is not unfrequent in hysterical women, 
and which consists in a deficiency of volition rather than of power. 
They are not unable to empty the bladder if they try-but they are 
unable to try. These cases must be treated with purgatives, and 
fetid medicines both internally and as enemata, F. 105, 49. If the 
catheter is not employed, the patient will generally begin to make 
water as soon as she suffers much from distension; but the bladder 
must not be allowed to go unrelieved too long. 
VII. Puerile Incontinence.-Incontinence of urine during the 
night is common enough in delicate children; but the surgeon may 
be consulted on account of its continuing to an age at which such 
an infirmity becomes very troublesome and degrading. The best 
plan of treatment is, to administer quinine or steel, and other tonics; 
F. 1, 2, 53, 63, 69, &c.; to prevent the patient from sleeping on his 
back; to have him awakened at a certain hour, so that he may 
empty the bladder of his own accord ; and to adopt some means of 
rendering the habit so disagreeable to him, that he may be induced DISEASES OF THE KIDNEY. 
473 
to correct it by exercising that degree of volition which remains 
during sleep. Assafoetida glysters; nauseous medicines; and in the 
female cauterizing the orifice of the urethra with nitrate of silver, so 
that the flow of urine may cause severe smarting, are amongst the 
remedies worth adopting. 
VIII. Fungus Hjsmatodes.-This form of malignant disease 
sometimes affects the bladder, and generally commences in the 
mucous membrane near its neck. The ordinary symptoms are, 
frequent desire to make water, and uneasiness in the region of the 
bladder, aggravated after micturition, and often extending to the 
glans penis, perinaeum, and groins. The urine is generally turbid, 
and deposits an adhesive mucus, and it is very frequently mixed 
with-blood, in irregular clots; and with these, portions of medullary 
substance are sometimes intermingled. These symptoms, combined 
with the absence of a calculus, and the possibility perhaps of detect- 
ing a tumour with the sound, are the chief means of diagnosis. 
Treatment can only be palliative. 
SECTION VII. OF DISEASE OF THE KIDNEYS, HEMATURIA, AND SUP- 
PRESSION OF URINE. 
I. Acute Inflammation of the Kidney [Acute Nephritis} is 
sometimes caused by blows on the loins, or by the irritation of renal 
calculi, but is very rarely an idiopathic primary affection. The 
symptoms are, burning pain and tenderness in the loins; colicky 
pains in the belly; the urine scanty and high coloured, and the 
bladder irritable, so that there are constant attempts at micturition; 
-fever and great thirst, and violent vomiting. The remedies are 
-bleeding, cupping, and leeches-castor oil-repeated doses of 
calomel, opium, and antimony, with colchicum if the habit is gouty; 
-warm baths, or warm fomentations to the loins, and barley water 
and other demulcent drinks. 
II. Chronic Disease of the Kidneys, when it cbmes under the 
surgeon's care, is generally a consequence of long standing disease 
of the urethra or bladder. When the bladder has been subject to 
frequent distension through stricture or enlarged prostate, and its 
mucous membrane inflamed, the ureters are liable to become dis- 
tended and converted, as it were, into subsidiary receptacles for the 
urine, so that all the violent strainings to evacuate it tell upon the 
kidneys; and these become diseased, partly from the mechanical 
irritation, partly from sympathy, partly from an extension of 
inflammation from the bladder, and partly through participating in 
that general degeneration of the functions and structures of the 
body, which is sure to ensue when any one important function is 
long and seriously impeded. 
Symptoms.-A person who has long been labouring under some 
chronic affection of the bladder, begins to complain of general 
weakness and langour, both bodily and mental. The sleep is 
unrefreshing, and the appetite impaired. There is frequent pain of 474 
DISEASES OF THE BLADDER. 
a weak aching character in one or both loins; occasionally shooting 
down to the testicles or groins. The urine is almost invariably 
albuminous,* it is generally pale-coloured and opaquish when 
passed; sometimes it is tinged with blood, and sometimes it dis- 
plays shreds or flakes of lymph, moulded probably into the shape 
of the ureters. As the disease proceeds, it becomes yellowish and 
purulent, and deposits a quantity of pus after standing, the globules 
of which may be detected by examination with the microscope. 
These cases are almost sure to end fatally. Sometimes the patient 
dies of exhaustion and obstinate vomiting; sometimes of sup- 
pression of urine and coma: sometimes in a sudden fit of severe 
shivering; and sometimes of a rapid attack of acute inflammation. 
The kidneys are found after death to be soft and disorganized; 
readily separating from their capsule, which, however, adheres 
firmly to the fat and cellular tissue of the loins; and most likely 
they are dilated into cysts; the secreting tissue being spread out 
over the dilated pelvis and infundibula. 
Strumous Disease of the Kidneys, chiefly affecting the Blad- 
der.-There is one form of disorganization of the kidney which is 
apt to be unsuspected for some time, because it is principally 
manifested by great irritability of the bladder. The patient is of a 
pale, unhealthy, scrofulous appearance ; he complains of very fre- 
quent and urgent desire to pass his water, and the act of micturition 
is followed by considerable burning pain at the neck of the bladder 
and in the perinamm. " The urine," says Dr. Prout, "is generally 
acid; of a pale-greenish, whey-like colour, opalescent from the 
presence of minute flocculi, or diseased particles of epithelium or 
mucus; of low specific gravity, (that is, below 1-020); often albu- 
minous, but rarely bloody." It sometimes contains small worm- 
like masses of coagulated lymph, moulded to the shape of the 
ureters. The patient complains of weakness and loss of flesh and 
strength; of occasional pain and swelling of the testicles, and of 
irritation or gleet from the prepuce or orifice of the urethra (male 
or female); and also occasionally of pain in the back. But the 
principal symptoms are referred to the bladder, so that the surgeon 
might be led to suspect the existence of stone. But if in any such 
case the urine is albuminous, but free from the ropy mucus of 
chronic cystitis, the origin of the mischief may fairly be referred to 
the kidneys. After death, the kidneys are found enlarged, soft, 
dark red, and vascular, and speckled with minute deposits of 
lymph, or perhaps small abscesses. 
Pyelitis.-This is the name given by M. Rayer to inflammation 
of the mucous lining of the pelvis and infundibula of the kidneys. 
It may accompany the catarrhus vesicas, or mismanaged gonor- 
* Urine may be known to contain albumen if it become cloudy and opaque when 
exposed to a heat of 170 degrees or upwards, a little nitric acid being also added. 
Heat alone, without the acid, might cause a white deposition of the phosphates that 
might be mistaken for albumen;-and the corrosive sublimate, that is sometimes 
recommended as a test, might produce a deceptive precipitate of the lithate of 
mercury. DISEASES OF THE BLADDER. 
475 
rhoea, or may be caused by renal calculus. The symptoms are, 
low fever, heat and pain in the back, irritation of the stomach and 
testicles, and the presence of flakes of epithelium, and of mucus in 
the urine. 
Abscess in the Kidney.-This may be suspected if dull pain in 
the loins and repeated shivering follow the symptoms of nephritis. 
Sometimes the abscess bursts into the ureter, and an immense 
quantity of pus is discharged with the urine. Abscess of the 
kidney also sometimes bursts on the loins, and the patient has been 
known to recover. 
Treatment.-In treating chronic disease of the kidney, the diet 
should be made a matter of chief importance;-all acescent and 
indigestible substances, acid wines, and hard water, being carefully 
avoided. Blisters or issues to the loins, or plasters of the emp. 
ammoniaci cum hydrargyro, with extract of belladonna, may be of 
service if the pain is severe. The skin should be kept warm, and 
flannel should be constantly worn. The infusions of buchu, with 
carrot-seed or uva ursi, and very small doses of tinct. ferri muriatis, 
are sometimes beneficial. If there is a calculus in the kidney, 
proper measures should be taken for removing the state of urine 
which gave rise to it. 
III. Hjematuria, or Bloody Urine.-1The seat of the haemor- 
rhage may be either the kidneys, or the prostate or bladder. (1.) 
Haemorrhage from the kidney is generally caused by the irritation 
of renal calculi, or by blows on the loins; but it may also depend 
on a diseased state of the whole system, as in typhus fever or 
scurvy. The blood is rarely in large quantity, and it is equally 
diffused through the urine ; although, perhaps, there may be some 
long shreds of coagulum formed in the ureter. If the urine is boiled, 
the blood will coagulate, and leave the fluid of its natural colour. 
(2.) Haemorrhage from the prostate or bladder may be caused 
by the rude introduction of instruments, or by the irritation of stone ; 
or by the existence of an ulcer or fungoid tumour, of which in fact 
it is often the earliest manifestation. When the blood is derived 
from the bladder, some portion of it often flows pure after the urine 
is discharged, and it is in much greater quantity, and often in larger 
and more irregular clots than when derived from the kidneys; 
moreover, the pain in the back, and other signs of renal irritation 
that accompany bleeding from the kidney, will not be present. 
Treatment.-When haemorrhage from the kidneys is attended 
with inflammatory symptoms, bleeding and the acetate of lead are 
indicated;-when with symptoms of debility, the dilute sulphuric 
acid, alum, tinct. ferri muriatis, or pulvis gallae; and when with 
symptoms of gout, alkalis and colchicum are indicated. In haemor- 
rhage from the bladder, a catheter should be passed and be retained, 
in order to prevent both accumulation of blood in tire bladder, and 
straining efforts at micturition. If the haemorrhage is obstinate, the 
bladder may be injected with cold water containing a scruple of 
alum to each pint;-and if much blood have coagulated in the 476 
URINARY DISEASES. 
bladder, it will be necessary to break it down by repeated injections 
of water. 
IV. Suppression of Urine, ischuria renalis.-When the kid- 
neys have been long abused by inordinate indulgence in strong 
drink, and are falling into disease,-or when they have become 
diseased through the irritation of stricture or enlarged prostate, they 
are liable suddenly to lose their functions of secreting the urine. 
The consequence of this is, that the urea and other elements of the 
urine accumulate in the blood; the patient complains of great un- 
easiness in the head and loins; he becomes first drowsy, and then 
comatose, and dies in four or five days of effusion into the brain. 
This affection is alluded to here, in order to hint at the diagnosis 
between it and retention of urine. In suppression, if the catheter 
is introduced, the bladder will be found empty; whereas, in reten- 
tion, whether from stricture, or from diseased prostate, or from 
palsy of the bladder, it may be felt full and distended above the 
pubes.* 
SECTION VIII. - OF URINARY DEPOSITS AND GRAVEL; AND OF THE 
DIATHESIS, OR STATES OF CONSTITUTION WHICH GIVE RISE TO 
THEM.t 
Under particular diseased conditions of the system, certain sub- 
stances are precipitated from the urine. If they are not precipitated 
from it till it has cooled, they are commonly called sediments;-if 
they are precipitated whilst the urine is yet in the bladder, they 
constitute gra vel,and lastly, they may lodge in some part of the 
urinary apparatus, and concrete into stone. They may be divided 
into three classes; the lithic; the oxalic; and the phosphatic. 
1. Lithic Deposits.-The lithic or uric acid, is an animal sub- 
stance, containing much nitrogen. It is insoluble, unless combined 
with an alkali; and in the urine it is combined with ammonia, with 
which it forms a salt, the superlithate of ammonia, the acid being 
in excess. This salt is held in perfect solution in the healthy urine ; 
but if it is secreted in unnatural quantity, it will be thrown down 
in the form of an impalpable powder, constituting the amorphous 
lithic sediment;-and if there is any free acid existing abnormally 
in the urine, the lithic acid will be separated from its ammonia, and 
will be thrown down in a crystalline form, constituting lithic or red 
gravel. 
1. dimorphous Lithic Sediments may appear in three forms. 
(«) The first is that yellowish sediment, which appears in the urine 
of almost every person, when the digestive organs are out of order. 
* See retention from stricture, p. 458; retention from enlarged prostate, p. 4G9, 
and retention from palsy of the bladder, p. 472. 
j- For information on the subject of this and the following sections, consult Prout 
on Stomach and Urinary Disease; Dr. Golding Bird's Lectures in Med. Gaz., Feb. 
and March 1843; Dr. Bence Jones on Gravel, Calculus, and Gout; Dr. Willis on 
Urinary Diseases, and on Stone in the Bladder; Sir B. Brodie's Lectures on Dis- 
eases of the Urinary Organs, 3d edition. LITHIC DEPOSITS. 
477 
It consists almost entirely of the lithate of ammonia mixed with the 
colouring matter of the urine, and a little of the phosphates, whose 
quantity will be proportioned to the whiteness of the sediment. 
This form of sediment is so common and well known, that little 
more need be said about it. The urine is always acid, and clear 
when passed. The sediment is deposited when it cools ; but it may 
be dissolved again by heating a little of it in a watch-glass. 
(6) A second variety is the red or lateritious sediment, which is 
deposited in fever, and especially in gout and rheumatism. This is 
composed of the lithate of ammonia, combined with the colouring 
matter of the urine, and, according to Dr. Prout, with a little of the 
purpurate of ammonia. 
(c) A third variety is the pink sediment, which is very rare, and 
is deposited in some cases of organic disease of the liver and spleen, 
and in hectic from strumous suppuration. It consists, according to 
Prout, of the lithate and purpurate of ammonia, without any of the 
colouring matter of the urine.* Of these three sediments, and the 
states of constitution that give rise to them, it does not fall within 
the scope of this chapter to speak further. 
2. Crystallized Lithic Deposits.-The most common form of 
these is the red gravel; which consists of minute crystals of lithic 
acid like cayenne pepper. They do not dissolve by the application 
of heat, like the lithate of ammonia.! The urine from which they 
are precipitated is generally acid, high-coloured, and scanty, but 
clear. Sometimes the lithic acid is secreted in a semi-fluid state, 
which soon concretes into stone in the kidney. The symptoms at- 
tending the deposit of a large quantity of this acid, constitute what 
is called a fit of the gravel. They are, feverishness; pain in the 
loins, shooting down to the bladder; aching of the testicles and 
hips; and micturition exceedingly frequent, and attended with 
severe scalding. 
Causes.-The diathesis or state of constitution in which lithic 
acid gravel is precipitated from the urine, is very frequently heredi- 
tary. It is intimately connected with the gout, (of which it will be 
recollected that deposits of the lithate of soda are highly charac- 
teristic,) and with the sanguine variety of scrofula. It may also be 
induced by errors in diet, and especially by inordinate indulgence 
in animal food, wine, and malt liquors. It is, therefore, generally 
speaking, a sign of an inflammatory habit. The ages at which it is 
most strongly marked, are before puberty, and between forty and 
sixty. 
Pathology according to Prout and Liebig.-With regard both 
to the source of the nitrogenized principles of the urine in health,. 
and to the causes of their occasional excess in disease, it seems 
* Berzelius contends that the pink colour depends on a peculiar colouring ex- 
tractive principle; which latter view is supported by Drs. Brett and Golding Bird, 
who give the name of purpurine to the colouring matter. 
f The lithic acid when pure is white; and it is white in the urine of serpents 
and birds; but when deposited from the urine of man it is tinted reddish or yellow 
by the colouring matter always present in that fluid. 478 
LITHIC DIATHESIS. 
agreed generally that they are derived from the albuminous and 
gelatinous constituents of the body. Dr. Prout's theory is, that the 
lithate of ammonia is derived not only from the materials of tissues, 
which, having answered their purpose in the economy, have be- 
come effete and excrementitious, but also from alimentary matters 
imperfectly digested, which have passed into the blood, but are not 
sufficiently assimilated to entitle them to become component parts 
of that fluid, or to be laid down in the normal structure of the body. 
He supposes " that the healthy kidney possesses the power of se- 
lecting and disorganizing such imperfectly developed chylous mat- 
ters, and of converting them into the lithate of ammonia. Such is 
the presumed origin of most of the common yelloio amorphous 
sediments occurring to healthy individuals from slight errors in 
diet." The crystallized lithic gravel is supposed to be precipitated 
when the urine contains a free acid either introduced in the food, or 
derived from the organs of digestion; or pent up within the system 
through a deficiency of action in the skin. 
Liebig's theory is briefly as follows: He believes that the tissues, 
when their vitality is exhausted, combine with the oxygen carried 
by the arterial blood, in order to be removed from the system, in 
the form of excrementitious products. He shows that the elements 
of fibrine or albumen (in other words blood and muscle) combined 
with oxygen and water, form exactly the elements of choleic acid, 
the chief principle of the bile, and lithate of ammonia. If a further 
supply of oxygen be combined with the lithic acid, it is converted 
into urea and oxalic acid-if a larger quantity still, it will be con- 
verted into urea and carbonic acid. Gelatine, by giving up some 
of its oxygen forms the elements of lithate of ammonia, and fat. 
Now it follows from these data, that if oxygen be abundant in the 
system, the lithic acid will be converted into urea, a highly soluble 
substance contained in the urine. If oxygen is less abundant, the 
lithic may undergo conversion into the oxalic acid; if less abundant 
still, it will remain undecomposed, and liable from its insolubility 
to be precipitated in crystals from the urine. The grand principle 
to be attended to, therefore, in the treatment of the lithic acid dia- 
thesis, according to this theory is, to promote the action of oxygen 
on the lithic acid: which is to be effected, 1st, by taking in much 
oxygen by exercise, cold air, and medicines, such as iron;-2dly, 
by diminishing the quantity of other substances on which oxygen 
acts more readily than it does on the lithic acid;-by abstaining 
from them in food, that is, from fat, starch, &c., and by removing 
them in purgation, and perspiration;-3dly, to keep the lithic acid 
in solution by water and alkalis. 
Treatment of the Lithic Diathesis.-In the first place, the diet 
should be plain and temperate; consisting chiefly of meat, bread, 
and cruciferous vegetables, such as greens; peas appear to be un- 
objectionable ; but fat, and substances abounding in starch and 
sugar, such as apples, pears, rice, potatoes, and pastry, should be 
avoided. Fermented liquors should be taken as sparingly as pos- 
sible; a little good sherry, or weak gin or brandy and water, are the OXALIC DEPOSITS. 
479 
best; but beer and sweet wines, in fact all acescent substances, 
should be rigidly prohibited. .Ripe pulpy fruits, such as straw- 
berries, do not appear to be injurious. But Dr. Prout's rule should 
never be lost sight of, that moderation in quantity is quite as im- 
portant as attention to quality. Secondly, the action of the skin 
should be promoted by warm clothing; by exercise not carried to 
the extent of fatigue ; and by vapour, hot air, or sulphur baths, 
if there is any difficulty in procuring perspiration, or if the skin is 
diseased. For the skin naturally eliminates a considerable quan- 
tity of acid. Baths may also be made the vehicles of introducing 
water and alkali into the blood; but for this purpose they must be 
used before meals, when the blood-vessels are empty. Thirdly, 
the bowels must be freely acted on; the best remedies being mer- 
curials, aloes, colocynth, colchicum, and salines, F. 9, 42, 95, 99, 
116. Fourthly. The lithic acid must be kept in solution by the 
administration of alkalis, with plenty of water. The bicarbonate 
of potass in doses of gr. xv-xx in distilled water may be given 
between meals. If there is acidity of the stomach, F. 54 may be 
given after meals. The liquor potassse, although valuable as an 
alterative in skin disease, does not appear to be so efficacious in 
these cases as the carbonate. Dr. Prout recommends five grains of 
nitre to be added to each dose of alkali;-and soda water, and 
alkalis combined with vegetable acids, such as soda and Seidlitz 
powders, are highly useful, for the vegetable acid is digested in the 
stomach, and the alkali passes to the kidneys. We may add that 
common salt should be taken freely, and that small doses of steel 
when the system can bear them, are of service in promoting the 
oxygenation of the blood. 
II. Oxalic Deposits.-We have already given Liebig's theory 
of the formation of this acid. He considers it a step nearer health 
than the formation of lithic acid. According to Dr. Prout, it is de- 
rived either from the imperfect assimilation of vegetable matter in 
the stomach, or from an abnormal change in the gelatinous tissues 
of the body. Hence individuals who possess the oxalic acid dia- 
thesis, have generally a dry, irritable skin, are exceedingly liable 
to boils, and in advanced age to carbuncles, and often suffer from 
dyspepsia, with flatulence and palpitations. But the train of con- 
stitutional symptoms belonging to this diathesis is of an irritable 
or nervous, rather than of a congestive or inflammatory character, 
as in the lithic diathesis. Dr. Golding Bird also states, that a ner- 
vous exhaustion and despondency always accompany this dia- 
thesis. The urine is generally transparent, of a pale greenish yel- 
low, or citron hue; and of moderate specific gravity. It is also 
remarkably free from visible sediments, but it contains numerous 
minute crystals of the oxalate, octohedral in shape, and formed of 
two pyramids, with a rhombic base placed base to base. These 
may be detected if some of the urine passed at bedtime is exa- 
mined under the microscope. It also sometimes contains small 
grayish concretions, known as hemp-seed gravel. When Stone is 
formed, it appears to be owing to an accidental secretion of unu- 480 
URINARY DISEASES. 
sual quantities of phosphate or carbonate of lime from the urinary 
organs; which, combining with the oxalic acid, form the oxalate 
of lime, or mulberry calculus. 
Causes.-The oxalic diathesis, according to Drs. Prout and 
Golding Bird, is very common. It may be supposed to be caused 
partly by the same causes as the lithic diathesis, combined with cir- 
cumstances that occasion nervous debility, and hypochondriasis; 
partly by residence in damp malarious situations, and by a diet of 
unwholesome saccharine or farinaceous matters. It may also be 
supposed to be induced or aggravated by partaking too freely of 
vegetables in which the oxalic acid exists; such as rhubarb stalks 
and sorrel; although these substances in moderate quantity are 
readily digested by the healthy stomach. 
Treatment.-The general rules are the same as those laid down 
for treating the lithic diathesis. Distilled water should be used, in 
order to avoid the introduction of lime into the system. The medi- 
cinal treatment must be adapted to each individual case. If there 
are acidity and flatulence, small doses of alkalis with ammonia, F. 
54, may be given after meals, whilst the system must be strength- 
ened by tonics, and the mineral acids may be given before meals. 
III. Phosphatic Deposits, white gravel. Of these there are 
three varieties; viz. 1. the triple phosphate, or phosphate of ammo- 
nia and magnesia; or ammoniaco-magnesian phosphate; 2. the 
phosphate of lime; and 3. the mixed or fusible phosphates, con- 
sisting of the first two varieties combined. 
1. Triple Phosphate.-The source of phosphatic salts in the 
urine is partly from the food, partly from the oxydation of the phos- 
phorus contained in the tissues. When in excess, they are not only 
abundantly present in the urine, but are also thrown out by the 
mucous membranes; of the mouth for example. They are naturally 
held in solution by the acid of the urine; but if through debility, 
or some other cause, the urine is insufficiently acid; or if it be- 
comes alkaline through decomposition of its urea,* the triple phos- 
phate will be deposited. The urine in these cases is pale, more 
copious than natural, and of low specific gravity;-sometimes it is 
slightly opaque when passed ;-it is very feebly acid, and scarcely, if 
at all, reddens litmus paper ;-it has a faint nauseous smell, which 
soon becomes ammoniacal and offensive;-and it exhibits the pecu- 
liar minute white brilliant crystals of the triple phosphate, which 
often float on the surface and look like an iridescent film of grease. 
2. Phosphate of Lime.-This salt is deposited from the urine in 
the form of an impalpable powder, which is generally white, but is 
occasionally tinged with the colouring matter of the urine. The 
general characters of the urine are the same as those of the last 
variety. This salt is not, strictly speaking, deposited from the 
urine, but is secreted by the mucous membrane of the kidneys and 
bladder when chronically inflamed or otherwise degenerated. We 
have shown in a preceding section, that it is contained in the viscid 
* Urea is a cyanate of ammonia,- and by a transposition of its elements is con- 
vertible into carbonate of ammonia. PHOSPHATIC GRAVEL. 
481 
mucus of cystirrhoea (p. 470); in fact, it is sure to be secreted if the 
urinary organs are subjected to long-continued irritation, whether 
from the too long retention of a catheter, or from a stone or other 
foreign body in the bladder, or from diseased urine. 
3. Mixed Phosphates.-The phosphate of lime is very seldom 
deposited alone, but in by far the greater number of cases is asso- 
ciated with the triple phosphate;-an association that is easily 
accounted for;- for if the triple phosphate is secreted by the kid- 
neys, the mucous membrane will also throw out phosphate of lime; 
or, on the other hand, if the phosphate of lime is secreted with 
mucus in unusual abundance, through irritation of the mucous 
membrane, the presence of the mucus soon causes the urea to be 
decomposed, and ammonia to be evolved, which precipitates the 
triple phosphate from the urine. The urine in these cases is copious, 
pale, and stinking, and deposits a thick mortar-like sediment, mixed 
with more or less of the crystallized triple phosphate. 
Causes.-The phosphatic diathesis offers a remarkable contrast 
to the lithic, both in the qualities of the urine, and in the characters 
of the constitution, and in the causes which engender it. Persons 
whose urine deposits the triple phosphate are of a pale, bloodless 
appearance, and complain of exhaustion and debility, and of an 
aching weak pain in the loins;-and Dr. Prout has very ingeni- 
ously attempted to show, that the great consumption of phosphorus, 
which is an essential constituent of all the nervous tissues, may be 
a cause of great nervous irritability and exhaustion which accom- 
pany phosphatic deposits from the urine. This diathesis may be 
induced by inordinate bodily fatigue, or mental anxiety; hard 
study; night watching; insufficient and unwholsome food, and by 
lowering medicines, and especially by mercury, alkalis, and saline 
purgatives, (especially Seidlitz powders, and others containing vege- 
table acid,) given in excess. Injuries of the spine also produce 
alkaline phosphatic urine (vide p. 332); and we need not again 
mention stricture, cystirrhosa, and other local causes. 
Treatment.-The indications are, to strengthen the system, and 
acidify the urine. The diet should be generous, but plain, and 
should include sound malt liquor, or port, or sherry.* The import- 
ance of good air and exercise needs scarcely be hinted at. Nothing 
can be more injurious, however, than fatigue, bodily or mental. 
The other remedies are tonics, acids, and opium. Bark, quinine, 
or steel, may be given in combination with the mineral acids, F. 
3, 98, 26, 1, 69, and with opium; which in confirmed cases of phos- 
phatic deposits in adults agrees remarkably well; allaying pain and 
nervous irritation without impairing the appetite or inducing cos- 
tiveness. Benzoic acid in doses of gr. x. twice daily appears, from 
the observations of Mr. Ure, to be of great value.! Buchu and uva 
ursi, F. 91, are also of service. If the mucous membrane of the 
* Soda water is injurious if it contain soda, which as a mere article of luxury 
it ought not to do. But simple water impregnated with carbonic acid is grateful 
to the stomach and wholesome. 
f See an interesting case by Mr. Ure, Prov. Med. Journ., Feb. 11, 1843. 482 
VARIOUS KINDS OF CALCULI. 
bladder is diseased, recourse must be had to the remedies mentioned 
at p. 471. AH diuretics are, as a general rule, injurious; and mer- 
cury and alkalis are unadvisable, except perhaps in small occa- 
sional doses when required by the state of the stomach. It must 
be observed, in conclusion, that although phosphatic deposits are 
attended with an alkalescent state of the urine, and although they 
are as a general rule to be treated by acids, still acescent sub- 
stances, sugar, pastry, hard beer or cider, and especially the thin 
acid French wines which are sometimes recommended, are highly 
injurious. The author has had constant opportunities of observing 
the urine loaded with the triple phosphate and highly ammoniacal, 
when the stomach has abounded in acidity; the simple fact being, 
that when the health is disordered by any means whatever, whether 
acidity in the stomach or not, the phosphates will be deposited if 
the diathesis exists. On this account small doses of alkalis, F. 54, 
may occasionally be given in these cases with the greatest benefit 
after meals, if the stomach is disordered; whilst the tonics and 
acids may be given an hour or two before meals. 
SECTION IX. OF THE VARIOUS KINDS OF CALCULI. 
The various deposits spoken of in the preceding section may, as 
we observed, lodge in some part of the urinary organs, and con- 
crete into stone. There are altogether fourteen species, many of 
which are excessively rare. The principal ones are the lithic, 
phosphatic, and mulberry. 
I. Lithic Acid calculi are generally oval, flattened, fawn or 
mahogany coloured, and on a section are seen to be composed of 
concentric laminae. Tests.-This acid maybe dissolved by boiling 
in liquor potassae;-it burns away almost entirely before the blow- 
pipe, and if digested in a small quantity of nitric acid and evaporated 
at a very gentle heat, it leaves a scarlet residue {purpuric acid} 
which becomes purple on the addition of ammonia. 
II. Lithate of Ammonia rarely forms a calculus, because it is 
tolerably soluble in warm urine, fests.-It may be known by the 
same tests as the preceding,-and, besides, it evolves ammonia 
when treated by liq. potassas. 
III. Phosphate of Lime or bone earth calculi are rare. They 
are pale brown, friable, and laminated. Tests.-Soluble in nitric 
or muriatic acids, and precipitated by liq. ammonias; infusible 
except at a very intense heat. 
IV. Triple Phosphate {of ammonia and magnesia) forms 
white or pale gray calculi, composed of small brilliant crystals. 
Tests.-Soluble in acetic or muriatic acid; evolves ammonia 
when treated with liq. potassse. 
V. The Fusible Calculus is formed of the phosphate of lime 
and triple phosphate mixed. It forms a white friable mass like 
mortar, and is very fusible. 
VI. The Mulberry Calculus is composed of oxalate of lime. STONE IN THE KIDNEY AND URETER. 
483 
It is dark red, rough and tuberculated. Tests.-Soluble in nitric 
acid, and if exposed to the blow-pipe, the acid is burned off, and 
quick lime is left, which if moistened, reddens turmeric paper. 
VII. Besides the above, calculi are sometimes composed of car- 
bonate of lime, cystic oxy de, (a peculiar animal substance, soluble 
both in alkalis and dilute mineral acids, and containing much 
sulphur,) fibrine of the blood, and xanthic or uric oxyde, a pecu- 
liar animal matter allied to uric acid. The lithate of soda, the 
lithate and carbonate of magnesia and silica are also rare ingre- 
dients in calculi. 
Alternating Calculi. Sometimes stones are composed of alter- 
nate layers of lithic acid and oxalate of lime ; and very commonly 
the outer layers of a stone are phosphatic, the nucleus lithic or ' 
mulberry. The phosphates commonly succeed the other deposits, 
being surely produced after a time by the irritation of the mucous 
membrane; but the lithic and mulberry never coat the phosphates. 
SECTION X. OF STONE IN THE KIDNEY AND URETER. 
Symptoms.-The symptoms of stone in the kidney are, pain in 
one or both loins;-irritation and retraction of the testicles ;-the 
urine bloody after violent jolting exercise ;-and occasional fits of 
inflammation of the kidney. Stones in the kidney are most fre- 
quently composed of lithic acid, which will be known from the 
deposit of red sand from the urine. The mulberry calculus is more 
rare; it may be suspected, if the urine is free from sediment either 
lithic or phosphatic, and if dark-coloured blood is frequently mixed 
with it. Crystals both of this substance and of lithic acid have 
been detected in the tubuli uriniferi. Phosphatic stone in the 
kidney is still more rare. When it does exist, it is generally 
composed of the phosphate of lime, and indicates incipient disease 
of the organ. 
Treatment.-When a stone is ascertained or suspected to exist 
in the kidney, the indications are, first, to determine the peculiar 
diathesis, and take measures to counteract it, as detailed in the last 
section; secondly, to endeavour to expedite its expulsion through 
the ureter, by diluents and diuretics; and by the cautious use of 
exercise so as to dislodge it; and thirdly, to remove inflammation 
and pain by cupping on the loins, (if the habit is inflammatory,) by 
mild aperients, and copious enemata of warm water, by opium or 
henbane, and by warm baths or fomentations. Pounded ice 
applied to the loins gives great relief when much burning pain is 
complained of; but it must be used with caution. 
The ordinary and most favourable event of renal calculus is, that 
it descends through the ureter into the bladder. In some cases, 
however, it remains in the kidney, increases in size, completely 
fills up the pelvis and infundibula, and causes the organ either to 
waste away or to suppurate;-the abscess bursting either into the 
colon, or on the loins. 484 
STONE IN THE BLADDER. 
The Passage of a Stone through the Ureter causes the 
following symptoms: The patient complains of sudden and most 
severe pain, first in the loins and groin, subsequently in the testicle 
and inside of the thigh. The testicle is also retracted spasmodically. 
At the same time, there are violent sickness, faintness, and collapse, 
which may last two or three days, and are only relieved when the 
stone reaches the bladder. Treatment.-The warm bath, large 
doses of opium, emollient enemata, and plenty of diluents, are the 
obvious remedies,-and an active purgative may perhaps be tried 
if the process is slow. 
Sir B. Brodie has shown that there is a set of symptoms which 
frequently affect gouty people-consisting of pain in the loins 
* reaching to the groin and neck of the bladder; and scanty, high- 
coloured urine-which very much resemble those caused by the 
passing of a stone through the ureter. They may be distinguished 
by the absence of faintness and vomiting, and readily yield to 
purgatives and colchicum. 
SECTION XI. OF STONE IN THE BLADDER. 
Stone in the bladder produces the following symptoms:-1. 
Irritability of the bladder,-frequent irresistible desire to make 
water. 2. Occasional sudden stoppage of the stream of water 
during micturition, from the stone falling on the orifice of the 
urethra;-the stream probably flowing again if the patient throws 
himself on his hands and knees. 3. Occasional pain at the neck of 
the bladder-always severest after micturition. 4. Pain in the 
glans penis. If the patient be a child, he is always attempting to 
alleviate this pain by pulling at the fraenum, which becomes 
extremely elongated. 5. Sounding. But none of the above symp- 
toms must be depended on alone. The existence of the stone 
must be made sensible to the ear and fingers by means of the 
sound, a solid iron rod like a catheter, but not so curved, and with 
a polished handle. This should be introduced-the patient lying 
on his back, the pelvis raised on a pillow, and the bladder nearly, 
but not quite, full. It should be carefully moved about, to examine 
every part of the bladder, and if there is a stone of any size it will 
most probably be heard to strike and felt to grate upon it. If 
nothing, however, is discovered, the patient may be made to turn 
on one side, or to sit upright, or the finger may be passed into the 
rectum; or a catheter may be introduced, and the stone may 
perhaps be felt to strike against it as the urine flows away. But if 
the symptoms are well marked, the surgeon must not be contented 
with one unsuccessful examination. On the other hand, the rub- 
bing of the sound on the bladder, or on gravel entangled in mucus, 
must not be too hastily set down as signs of stone. 
The symptoms of stone vary in their severity,-1, according to its 
size and roughness; 2, according to the state of the urine; 3, ac- 
cording to the condition of the bladder, whether healthy or inflamed. STONE IN THE BLADDER. 
485 
They may be very slight for years,-in fact, a little pain in micturi- 
tion and bloody urine after riding may be the only inconveniences. 
But after a certain period the bladder suffers just as it does from 
any other cause of irritation,-the urine deposits a slight cloud of 
mucus,-the bladder becomes more and more irritable and finally 
inflamed,-the urine becomes alkaline, and loaded with viscid 
mucus, and of course with the triple phosphate and phosphate of 
lime,-the strength fails, and finally, after years of suffering, the 
patient sinks under the irritation. Sir B. Brodie, however, has 
observed, that if the prostate become enlarged, the sufferings from 
stone are often mitigated; because it is prevented from falling on 
the neck of the bladder. 
The sources of vesical calculi are two :-1. From the urine ; 2, 
from the mucus of the bladder; and calculi are exceedingly liable 
to form from the latter source, if the prostate is diseased, or if foreign 
bodies are introduced into the bladder, so as to serve for nuclei. In 
these cases, the stone is invariably phosphatic. And all calculi, 
whatever their original composition, are sure to become coated with 
the phosphates if they remain till the patient becomes old and the 
bladder diseased. 
The composition of a calculus will be determined by the state of 
the urine. Its size may be appreciated, 1, by its composition-for 
the phosphatic are always the largest; 2, by the time it has existed; 
3, by observing the force required to dislodge it from its situation ; 
4, it may be measured by passing the sound across its surface, or 
by the urethra forceps. Calculi have been known to vary in weight 
from a few grains to forty-four ounces, and in number from one to 
one hundred and forty-two. The largest that was ever extracted 
entire weighed sixteen ounces, but the patient died; Sir A. Cooper 
was the operator. Gooch tells us that Mr. Harmer, of Norwich, in 
the year 1746, extracted one entire which weighed nearly fifteen 
ounces, and the patient lived five years. And Mr. C. Mayo, of 
Winchester, extracted one weighing fourteen ounces and a half, but 
it was broken, and the patient lived several years. 
Treatment.-The indications are, 1, to get rid of the diseased 
state of the urine; 2, to allay pain and irritation ; 3, to remove the 
stone. The first and second are to be accomplished by measures 
which have been already spoken of when treating of gravel and of 
chronic inflammation of the bladder. The third may be executed in 
four ways, viz., by extraction of the stone through the urethra,- 
solution of it by injections,-lithotrity,-and lithotomy-to which 
we may add the new operation of lithectasy. 
1. Extraction by the Urethra.-When a stone is known to have 
recently escaped from the ureter into the bladder, the first point is 
to remove all irritability of the bladder by sedatives, and by restoring 
the proper condition of the urine, so that there may be no spasms to 
obstruct its passage into the urethra. The patient also should drink 
plentifully, so that the bladder may be quite filled. Then, when he 
is going to make water, he should be instructed to lie on his face, 
and to grasp the penis so that the urethra may become distended 486 
LITHOTRITY. 
with urine; and thus very probably, the sudden gush that will come, 
when he relinquishes his grasp of the penis, will bring the stone 
with it. In some cases the urethra may be dilated by passing bou- 
gies. But should this plan not succeed after some days, Weiss's 
urethral forceps should be tried. The patient being placed on his 
back with his pelvis raised, a catheter is to be introduced to draw 
off the urine, and five or six ounces of tepid water are to be injected 
afterwards. Next the forceps, being introduced, is to be made to 
feel for the stone, and the blades are to be cautiously opened over 
it and made to seize it. An index on the handle of the forceps will 
now show the size of the stone. If small, it may be extracted at 
once,-if very large, it must be left where it is,-if of a doubtful size, 
it may perhaps be brought into the membranous portion of the 
urethra, whence it can be extracted by incision. 
Solution by injections.-Sir B. Brodie has satisfactorily shown 
that phospha tic calculi may sometimes be dissolved altogether, and 
sometimes be so disintegrated or reduced in size that they may 
escape through the urethra by means of injections of very dilute 
nitric acid passed through a double gold catheter in the manner 
directed for chronic cystitis. At the same time, these injections 
diminish the secretion of mucus, which is the source of the phos- 
phate of lime. Oxalic calculi appear to resist the action of all sol- 
vents. The solution of lithic calculi is at present the subject of 
numerous experiments; but the results cannot yet be spoken of as 
certain. It is to be hoped that the labours of Hoskins, Petit, and 
Dr. Willis, will be seconded by other practical men who possess the 
opportunity, and that this much to be desired object may speedily 
be accomplished. The waters of Vichy, or a solution of from 3 to 
5 grains of bicarbonate of soda to an ounce of water, passed in a 
slow continued current through the bladder by means of a double 
catheter, and used internally likewise, have certainly been known 
to effect the solution of calculus in the bladder, and hold out the 
strongest encouragement for further trials.* 
SECTION XII.-OF LITHOTRITY.t 
It need scarcely be said, that the object of this operation is to 
reduce stones in the bladder into fragments of so small a size, that 
they may be readily expelled through the urethra. 
• Vide the case of D. B. Jacob, at p. 29 of Dr. Willis's work on Stone. 
f [Notwithstanding the frequency of calculous affections in the valley of the Mis- 
sissippi, this operation has never been successfully performed, so far as I can 
learn, on this side of the mountains. On account of the deserved celebrity of Dr. 
Dudley, as a lithotomist, most of the cases have fallen into his hands, and his con- 
fidence is so much greater in the old operation, that he has never attempted the 
new one. • 
When Lithotrity was first exhibited in the operations of Civiale and Heurteloup, 
I participated in the apprehensions, entertained by most prudent surgeons, on 
account of the complex and dangerous machinery employed-apprehensions which 
were but too well justified by experience. 
But after witnessing the beautiful and bloodless operations of Civiale and Leroy, LITHOTRITY. 
487 
The apparatus by which this object was first accomplished by 
Civiale and Leroy was, as Sir C. Bell rightly called it, villanous 
and dangerous enough. A straight cylindrical canula was intro 
duced into the bladder, containing three or four branches which 
could be protruded from its extremity. These were made to grasp 
the stone and hold it tightly, whilst it was bored, and scooped, and 
excavated by drills and other contrivances contained in the centre 
of the canula, and worked by a bow. When the stone was suffi- 
ciently excavated, its shell was crushed by a most complex piece of 
mechanism called the brise coque,or shell-breaker. "For some 
time," says Mr. Liston, "it was maintained, that almost every case 
of stone could be satisfactorily disposed of by this boring and grind- 
ing process. It was tried extensively," but, "after many miserable 
and painful failures, utterly disappointed the hopes of its advo- 
cates." Nor will these failures be wondered at, when we consider 
the difficulty sometimes of seizing the stone, sometimes of disen- 
tangling the instrument from it*-the extremely slow and inefficient 
means of disintegrating it, and the great number of times the opera- 
tion was consequently obliged to be repeated;-not to mention the 
pain caused by the stretching of the urethra with a large straight 
instrument-the risk of entangling the coats of the bladder, and of 
seriously bruising the parts about the neck-and the most incom- 
prehensible perplexity of the instruments employed-the nomen- 
clature, structure, and use of which required not a little study. 
The next method which was employed, and which was first 
practised by Heurteloup,t consisted in hammering the stone to 
during a visit to Paris in 1838,1 was forced to dismiss my fears, and became per- 
suaded that they were practising an improved method of removing vesical calculus, 
which every surgeon should prepare himself to imitate. The original formidable 
apparatus is now dispensed with-Mr. Civiale himself has hung up his drill-bow 
over his operating table, and now uses only the safe and simple instrument, par- 
tially figured in the text, which the combined ingenuity of an English artist and 
French surgeons, has furnished. This instrument may be introduced into the 
bladder with as much ease as a common catheter, and is no more likely to inflict 
injury upon that organ, if employed with ordinary intelligence and address, than 
the forceps that are used in Lithotomy. 
Lithotrity, when employed only in suitable cases, is certainly less dangerous 
than lithotomy,-it is generally less painful, and far less revolting in its pro- 
ceedings. 
There are, of course, certain conditions for its application, w'hich do not obtain 
in every case of urinary calculus. It must not be offered as a universal substitute 
for lithotomy: but only as an alternative in a certain class of cases, and that, as I 
believe, the smaller class. Lithotomy must yet be the general method-lithotrity 
the exception. It is an exception, however, which those, in whose behalf it can 
be applied, are entitled to at the hands of their surgical adviser. 
If practitioners would generally hold themselves prepared to employ this milder 
method of cure, and let the community bS informed of this fact, patients would not 
postpone operative proceedings for relief, as they too frequently do at present from 
a dread of the knife, until the calculus becomes so large as to enhance extremely 
the danger attending the severer process which must then be employed for its re- 
moval. F.] 
t In fact, in one case, the branches could not be returned into the canula; and 
the instrument was obliged to be dragged out open through the neck of the bladder 
and urethra. 
§ In the year 1830, 488 
LITHOTRITY. 
pieces. The patient was confined to a bed of peculiar construction, 
called the lit rectangulaire; and the percuteur courbea marte.au 
-an instrument composed, like that represented in the next figure, 
of two blades sliding on each other, was made to seize the stone. 
It was then broken by repeated blows with a hammer on the other 
extremity of the instrument, which was fixed securely to a vice. 
But this plan was fraught with many inconveniences. The instru- 
ment was liable to be bent or broken; its blades were apt to become 
so clogged with pulverized fragments, that they were withdrawn 
with difficulty, or perhaps not until the orifice of the urethra had 
been slit up;-and the bladder was exposed to injury from percus- 
sion communicated from the instrument, and from the violent split- 
ting of the calculus. 
The instrument which has now superseded the foregoing, is the 
screw lithotrite of Mr. Weiss; which is composed of two sliding 
blades, between which the stone is seized, and then is crushed by 
gradual pressure with a screw. This instrument was, in fact, 
originally invented in 1824 (although it was laid aside at the re- 
commendation of Sir B. Brodie, who thought it liable to some 
objections, and was superseded for a time by the straight drills of 
Civiale and the percuteur of Heurteloup);-and it was from this 
that Heurteloup took the idea of the percuteur; disimproving it, 
however, by substituting the hammer for the screw Mr. Fergus- 
son prefers a kind of hand-rack and pinion as a more convenient 
mechanical power than the screw. In order to prevent any clogging 
Fig. 130. 
Fig. 131. 
Fig. 132. 
of the blades by the lodgment of fragments, the anterior blade is 
made open to receive the other within it. The operation is per- 
formed as follows. The patient is placed on a couch with his 
pelvis well raised, and his shoulders comfortably supported;-the 
bladder is then emptied, and five or six ounces of tepid water in- 489 
LITHOTRITY. 
jected with a proper catheter and syringe. The instrument, pre- 
viously warmed and oiled, is slowly introduced and placed upon 
the stone-its blades are opened and made to grasp it between them 
-the handle is moved from side to side, to ascertain that no part of 
the bladder is entangled-and then it is depressed so as to lift the 
stone towards the neck of the bladder. The screw or handle is then 
slowly and cautiously turned backwards and forwards till the stone 
is crushed by its repeated impulses. Then the instrument should 
be withdrawn. When the irritation has subsided, the fragments 
must be seized and comminuted with the same instrument, or with 
a smaller one, or with one that has not the aperture in the anterior 
blade. Sometimes they may be removed with sundry scoops. But 
whether this can be done at one sitting or at many, must depend 
on the size of the stone, and the degree of inconvenience suffered 
by the patient. 
No fair numerical estimate can yet be made of the proportion of 
cases in which lithotrity has been successful or otherwise. In its 
present improved form, and practised on patients calculated for it, 
it may be considered easy, safe, and effectual. But practised on 
cases not adapted to it, no operation can be compared to it for the 
misery and fatality of its results. We may gather from Dr. Willis, 
who has been at much pains to collect what M. Souberbielle calls 
the martyrology of lithotrity, that the mortality has been in all 
probability at least one in four. Whereas the statistics of litho- 
tomy give only one unfavourable case in seven or eight. Of twelve 
cases narrated by Mr. Key, three were cured by it-in three it was 
either inapplicable or unavailing, and lithotomy was resorted to- 
and the remaining six perished-one with abscess in the prostate 
soon after the operation-four with protracted sufferings from irri- 
tation of the bladder by the fragments which were retained-and 
one with disease of the bladder brought on or aggravated by the 
operation. Mr. W. Fergusson gave the results of eighteen cases; 
of which six were cured ; seven were not cured, (and four of these 
underwent lithotomy afterwards,) and five died.* The sources of 
danger are, the irritability of the urethra and bladder, the great 
pain and inflammation often produced by the introduction of the 
instruments and aggravated by the substitution of many irregular 
fragments for one smooth stone, and the frequent .repetition of the 
operation. The preparatory treatment consists in the use of mea- 
sures for removing the diseased condition of the urine, and any 
irritability of the bladder. In the after treatment, diluents should 
be employed to increase the secretion of urine, and injections of 
warm water to accelerate the passage of the fragments-and hip- 
baths, opiate suppositories or enemata, and leeches, or cupping on 
the perinaeum, for the relief of pain or inflammation. Sometimes 
the fragments stick in the urethra, and require to be removed by' 
incision in the perinseum, and sometimes it is requisite, after all, to 
extract them from the bladder by a regular lithotomy operation. 
* Ed. Med. and Surg. Journ., Oct. 1838. 490 
LITHOTOMY. 
SECTION XIII. OF LITHOTOMY. 
Choice of operation.-Supposing that a patient with stone in the 
bladder is an adult, that the stone is under the size of a chestnut, 
and that the bladder and urethra are healthy, as is shown by the 
power of retaining the water, and making it in a good stream, the 
operation of lithotrity may be recommended. But if the stone is 
very large or very hard-or if there are more than one, or if the 
urethra is strictured, or the prostate enlarged (which would pre- 
vent the debris of the stone from coming away)-or the coats of 
the bladder diseased-or the stone adherent, or contained in pouches 
or sacculi of the bladder -or if, as Mr. Fergusson justly insists, the 
parts are so irritable that the introduction of the instrument occa- 
sions more pain in the urethra than is ordinarily caused by the 
passing of a catheter; if the bladder rebels against the instrument, 
and contracts spasmodically, causing a painful and irresistible effort 
to micturate;-or if the patient is very old or very young, it will 
be safer to extract the stone by lithotomy. 
Contra indications.-The surgeon must, however, in the first 
place, ascertain that the patient is free from serious organic disease 
-which would render him liable to sink under either operation. 
Languor, depression, loss of strength and flesh and appetite, irregu- 
lar shiverings, pain and tenderness in the loins, purulent or highly 
albuminous or bloody urine, indicating organic disease of the kid- 
neys ;-excessively frequent and painful micturition, with the urine 
constantly bloody and purulent, indicating serious organic disease 
or ulceration of the prostate or bladder -the existence of hectic or 
pulmonary consumption, or of any other extensive disease, require 
the surgeon to decline the operation-or at least to perform it only 
at the urgent and repeated request of the patient, who should be 
informed of its probable result. 
Preparatory treatment.-In the second place, the patient must 
be well prepared by measures calculated to improve the general 
health, and to remove all disorder of the urine and irritability or 
congestion of the bladder. He should not even be sounded whilst 
labouring under any local or general vascular excitement. 
There are four methods in which lithotomy may be performed, 
viz., the lateral*operation in the perinamm-the bilateral-the 
recto-vesical-and the high operation. The lateral is that which 
common consent has decided to be the best, except in a few rare 
instances. There are an infinity of minute variations in the man- 
ner of performing it, and in the instruments employed by different 
surgeons. In the following description the author avails himself 
principally of the directions given by Sir B. Brodie, Air. Liston, and 
Mr. Fergusson. 
Lateral Operation. -It is advisable that the bowels should be 
cleared on the morning of the operation with a simple enema. The 
bladder should be moderately full, and if the patient has recently 
emptied it, a few ounces of water may be injected. It is also de- LATERAL OPERATION. 
491 
sirable that the existence of the stone should be clearly demon- 
strated with the sound or staff', immediately before the operation.- 
Then the proceedings may commence by introducing the staff-a. 
solid steel rod like a sound, with a deep groove either on its convex 
border, or, as some surgeons prefer it, a little on its left side. It 
should be as large as can be conveniently introduced. 
Fig 133. 
The next point is to place the patient in a convenient posture. He 
should be placed on his back, on a table two feet and a half high, with 
his shoulders resting in the lap of an assistant, who sits astride be- 
hind him. Then, in order to expose the perinseum thoroughly, he 
must be made to raise and separate his thighs; and to grasp the 
outside of each foot with the hand of the same side; and the hand 
and foot are to be firmly bound together by a broad garter;- 
meanwhile, if not done before, the perinaeum should be shaved. 
The surgeon may, says Mr. Fergusson, pass his left forefinger well 
oiled into the rectum, to ascertain the size of the prostate, and its 
depth from the surface; he should also explore with his fingers the 
surface of the perinseum, and the position of the rami and tubero- 
sities of the ischia. 
Every thing being now prepared,-an assistant on each side hold- 
ing the thighs firmly asunder-another being at hand to give the 
surgeon his instruments-and a third stationed on the left side hold- 
ing the staff perpendicularly, and well hooked against the symphysis 
pubis-in which position he is to hold it steadily from first to last- 
the surgeon commences by passing in his knife to the depth of an 
inch on the left side of the raphe, about an inch before the anus, 
and cuts downwards and outwards to the bottom of the perinseum, 
midway between the anus and tuberosity of the ischium. " The 
forefinger of the left hand," says Mr. Liston, " is then placed in the 
bottom of the wound about its middle, and directed upwards and 
forwards; any fibres of the transverse muscle, or of the levator of 492 
LITHOTOMY. 
the anus, that offer resistance, are divided by the knife, its edge 
turned downward;-the finger passes readily through the loose 
cellular tissue, but is resisted by the deep fascia, immediately ante- 
rior to which, the groove of the staff can be felt not thickly covered. 
The point of the instrument is slipped along the nail of the finger, 
and guided by it, is entered, the back still directed upwards, into 
the groove, at this point.* The finger all along is placed so as to 
depress and protect as much as possible the coats of the rectum, 
and the same knife, pushed forwards, is made to divide the deep 
fascia, the muscular fibres within its layers," and to perforate the 
urethra about two lines in front of the prostate. Then it must be 
• [Most operators at the present day, in performing Lithotomy, employ the knife 
in some one of its modifications for the prostatic section-indeed, I know but a 
single exception to this practice, among distinguished lithotomists. My neighbour 
and friend Prof. Dudley of Lexington, who has cut more frequently than any living 
surgeon, and with better success than any man who ever lived, and has furnished 
authentic reports of his operations, invariably uses the gorget, and all who have 
witnessed this gentleman's operations, admire the dexterity, precision and despatch 
with which he opens the bladder with this instrument, which, in most other hands, 
seems clumsy and unsafe beyond any that has been invented, for the same pur- 
poses. Dr. Dudley's extraordinary success is principally due to his judicious 
management of his cases previous and subsequent to the operation-an attribute 
which should entitle him to more credit, as a good surgeon, than the most impos- 
ing use of the best-constructed apparatus, in the performance of it. 
Prof. Dudley has now operated for stone in the bladder one hundred and seventy- 
Jive times, and he is confident that a fatal termination, occurring as the effect of the 
operation, has taken place in a single instance only. A few years ago, when the 
number of his cases amounted to one hundred and thirty-Jive, he published a state- 
ment which exhibited such unprecedented success as to excite the astonishment of 
surgeons in all countries, and in some quarters to provoke expressions of incre- 
dulity and even suspicion of misrepresentation, injurious towards Dr. Dudley and 
unworthy of those who promulgated them. Yielding even the four unsuccessful 
cases which M. Civiale has inferred from Dr. D.'s own account of his operations, 
a triumphant success must still be conceded to him in this department of our art, 
which should rebuke the spirit of envy, and will secure from all magnanimous 
cotemporaries an acknowledgment of his title to be regarded as the greatest Litho- 
tomist of his day. 
In my own operations I have used the knife recommended, and I believe, 
invented by Mr. Liston-an elongated scalpel with a cutting edge extending from 
the point to about midway of the blade. With this instrument, having a long and 
stout handle, the surgeon may accomplish all his incisions from the integument 
through, with the utmost convenience and precision, and, if sufficiently sure of his 
anatomy to justify an attempt at such an operation, may avoid all parts which 
should remain intact, with more certainty than in the employment of any one of 
the various instruments and apparatus which ancient or modern invention has 
supplied. 
The directions in the text, respecting the staff, are pertinent and important. It 
should be held perpendicularly, and firmly in one position until the incisions are 
completed, as our author directs. Nothing savours more of discomfort and em- 
barrassment in such proceedings, than to hear the operator calling to his staff 
holder to "bulge the staff into the perinmum." If he cannot find the staff, when he 
has approached the membranous portion of the urethra, it is either because his 
anatomy fails him at the most critical point in his undertaking, or because he is 
bewildered by his devious and unskilful progress through the textures already 
divided. 
In observing the direction to have the staff well hooked against the symphysis 
pubis, the operator should be careful not to drag upwards the portions of urethra 
which are to be divided, so that when suffered to resume their natural relations 
upon the withdrawal of the staff, the continuity of the external and internal inci- 
sions shall be interrupted. F.] LITHOTOMY. 
493 
pushed into the bladder, slitting up the urethra and notching the 
margin of the prostate within its course. The knife being with- 
drawn, the left forefinger is gently insinuated into the bladder, dilat- 
ing the parts as it enters; then the assistant having removed the 
staff, the forceps are cautiously introduced over the finger into the 
bladder; the finger being gradually withdrawn as the instrument 
enters. And, at this moment Mr. Fergusson, with admirable dex- 
terity, opens the blades, and catches the stone as it is brought 
within their jaws by the gush of urine that escapes. If, however, 
the stone is not caught in this ready way, the forceps must be 
closed and brought into contact with it-then the blades are opened 
over it and made to grasp it;-if the stone is seized awkwardly, it 
is relinquished and seized again-then it is extracted by slow, cau- 
tious, undulating movements. The forceps should be held with 
the convexity of one blade upwards and of the other downwards; 
and the endeavour should be to make the parts gradually yield and 
dilate, not to tear them. 
The general maxims to be borne in mind during the perform- 
ance of this operation are, (1) to make a free external incision, 
and to bring it low enough down, so that the urine may subse- 
quently escape freely without 
infiltrating the cellular tissue; 
(2) not to cut too high up, or to 
open the urethra too much in 
front, for fear of wounding the 
bulb or its artery; (3) not to 
wound the rectum, or pudic 
artery, by carrying the incisions 
too much inwards or outwards; 
(4) and above all, not to cut 
completely through the pros- 
tate, beyond its fibrous enve- 
lope, otherwise the urine will 
find a ready passage into the 
loose cellular tissue of the pelvis, 
and the patient will almost surely die. The incision into the pros- 
tate should not be of greater extent than six or seven lines ; its 
direction downwards and outwards like the rest of the wound. 
The varieties of this operation before alluded to are as follow. 
Most surgeons direct the assistant to hold the staff so that it may pro- 
ject in the perinaeum, and incline a little to the left side of it,-and 
when they have opened the urethra, and are about to incise the 
neck of the bladder, they take its handle in their own left hand, 
and bring it down horizontally. Mr. Key prefers a straight staff. 
Again, there are great diversities in the manner of cutting into the 
bladder. Some persons use a bistouri cache, an instrument con- 
Fig. 134* 
* This diagram, copied from a paper by Mr. Bryan, Lancet, Feb. 11th, 1843, is 
useful as exhibiting an internal view of the parts of the neck of the bladder 
concerned in lithotomy; a deferentia; b vesicuhe seminales; c prostate; 
d ureters. 494 
LITHOTOMY. 
taining a blade that protrudes to a certain extent on touching a 
spring. Sir B. Brodie prefers a beaked knife; or, if the stone is 
very large, a double-edged knife with a beak in the centre, so as to 
divide both sides of the prostate. When the bladder is opened he 
directs the wound to be dilated by means of the blunt gorget, 
which distends the neck of the bladder, and splits cleanly through 
the prostate, without any risk of haemorrhage or mischief. Many 
surgeons open the bladder by means of the cutting gorget; the 
beak of which being put into the groove of the staff, held horizon- 
tally in the operator's left hand, it is pushed cautiously on, and 
made to cut its way into the bladder. If this instrument is em- 
ployed, every precaution must be used to keep it in contact with 
the staff, and not to let it slip between the bladder and rectum,-an 
accident that has been the death of not a few. In the case of a 
very large stone, it will be expedient to divide both sides of the 
prostate. This may be done, either by cutting into the bladder 
with a double-edged beaked knife-or after one side is incised in 
the ordinary way, by cutting through a little of the other with a 
probe-pointed bistoury, the edge of which should be directed 
towards the right tuber ischii. Lastly, there is the method which 
was employed by Cheselden, and which is still practised by a very 
experienced and successful lithotomist, Mr. C. Mayo of Winchester. 
In this method, the operator, after making the usual external inci- 
sions, " cuts into the side of the prostate as far back as he can 
reach, and brings out the knife, along the groove of the staff, into 
the membranous part of the urethrathus making the incision 
into the neck of the bladder from behind forwards, instead of from 
before backwards, as in the other varieties.* 
lifter treatment.-When every fragment of the stone has been 
removed, and the bladder has been syringed with warm water, the 
patient should be put to bed. Dr. Nott, an American surgeon, is in 
the habit of passing a large catheter, and injecting a stream of warm 
water through it into the bladder, whilst the patient sits over a 
chamber pot. Every fragment is thus washed through the wound. 
The patient should lie on his back with his shoulders elevated; a 
napkin should be applied to the perinaeum to soak up the urine, 
and the bed be protected by oilcloth. It is a good plan to intro- 
duce a large gum elastic canula through the wound into the blad- 
der for it to flow through. If not, the surgeon should introduce his 
finger, after a few hours, to clear the wound of coagula. Pain must 
be allayed by anodynes-the bowels be kept open without purg- 
ing-the wound be kept perfectly clean, and then, in favourable 
cases, the urine begins to flow by the urethra in about one week, 
and the wound heals completely in four or five. 
Complications.-(1.) Severe haemorrhage may proceed from the 
* There has been very much dispute about this operation of Cheselden's; prin- 
cipally because of a bungling description given of it by Dr. Douglas ; and aggra- 
vated by an attempt of Dr. Yellowly to explain it; but whoever will consult Che- 
eelden's Anatomy, 6th ed. London, 1741, p. 330, will see that it agrees strictly with 
that performed by Mr. C. Mayo, and described by him in Med. Chin Trans,, vol, xi, LITHOTOMY. 
495 
pudic or bulbous arteries if wounded. If the bleeding orifice can- 
not be secured, it must be compressed as long as may be necessary 
with the finger. A general venous or arterial oozing must be 
checked by filling the wound firmly with lint or sponge-the tube 
being then indispensable. (2.) Tenderness of the belly and other 
inflammatory symptoms must be combated by leeches, fomenta- 
tions, and, if necessary, venesection. (3.) Chronic inflammation 
of the bladder, with continued secretion of the phosphates, by the 
measures directed at p. 470. (4.) Sloughing of the cellular tissue 
from urinous infiltration, a frequent result of a hasty operation, and 
of too freely incising the neck of the bladder, is indicated by heat 
of the skin and sleepiness, followed by a rapid jerking, intermittent 
pulse-hiccup,-the belly tympanitic, the countenance anxious, 
and the other signs of irritative or typhoid fever. To be treated 
by wine, bark, and ammonia, by thoroughly opening the wound 
with the finger, and, if necessary, laying the wound into the rec- 
tum, so that the urine and fetid discharge may escape. 
The Bilateral Operation is performed by making a curved 
incision, with the convexity upwards, from one side of the peri- 
neum to the other-carrying it between the anus and bulb of the 
urethra-opening the membranous portion of the urethra-and 
then pushing a double bistouri cacht into the bladder, by which 
both sides of the prostate may be divided. 
The Rectovesical Operation consists in cutting into the blad- 
der from the rectum, in the middle line behind the prostate. 
The High Operation is performed by making an incision 
through the linea alba, and opening the bladder, (which is pro- 
jected upwards on the point of a catheter,) at its fore and upper 
part, where it is not covered by peritonaeum. This operation may 
be occasionally resorted to when the stone is of great size, and the 
prostate much enlarged, or the space between the tuberosities of 
the ischia contracted. 
Lithectasy* or Cystectasy.-The object of this operation is 
to remove the stone by a slow and gentle dilatation of the parts at 
the neck of the bladder, without any incision or laceration of the 
prostate. The idea of the operation is not a new one; it was per- 
formed successfully by Sir A. Cooper, at Dr. Arnott's suggestion, 
in the year 1819; but its recent revival is due to the exertions of 
Dr. Willis. The following is the way in which it was performed 
by Mr. Fergusson:-The patient having been placed in the usual 
lithotomy position, an incision was made in the raphe about an 
inch and an half long, terminating half an inch in front of the anus; 
from which point, two incisions, each about three-fourths of an inch 
in length, were carried downwardsand outwards. The superficial 
cellular tissue, having been similarly divided, the point of the 
knife was thrust into the groove of the staff a little in front of the 
triangular ligament. This ligament having been slightly divided 
on both sides, in the direction downwards and outwards, the metal 
* AiSs;, calculus, and sxras-if, extensio. 496 
DISEASES OF THE PENIS. 
point of an Arnott's dilator was carefully guided along the groove 
of the staff into the bladder. The dilator, which is composed of a 
cylindrical bag of oiled silk, was then injected with a little warm 
mucilage of gum arabic, till the patient complained of some pain 
from the distension. The object now is, to increase the dilatation 
at short intervals, till at the end of from thirty to forty hours a for- 
ceps can be introduced, and the stone extracted without difficulty. 
Further experience is required to decide on the safety and efficiency 
of this operation.* 
Stone in women is much less frequent than it is in men, and 
when a renal calculus reaches the bladder, it is much more easily 
voided. If, however, there is a calculus too large to escape, the 
urethra should be dilated with one of Weiss's dilators;-and if the 
stone is large, the process may be expedited by making a slight 
incision with a bistoury, or bistonri cach^ through the urethra 
towards the pubes. Some degree of incontinence of urine is apt to 
follow these operations. 
CHAPTER XXI. 
OF THE DISEASES OF THE MALE GENITALS. 
SECTION I. OF THE DISEASES OF THE PENIS. 
1. Phymosis signifies a preternatural constriction of the orifice of 
the urethra, so that the glans cannot be uncovered without diffi- 
culty, if at all. It may be a congenital affection, or may be caused 
by the contracted cicatrices of ulcers. Besides the obstruction 
which it occasions to the functions of the organ, it prevents the 
washing away of the secretions from the corona glandis, and thus 
renders the patient liable to frequent balanitis and gleets, and in 
advanced age to cancer of the penis; and it is a source of great 
trouble if he happens to be affected with the venereal disease. 
Treatment.-A director should be introduced about half an inch 
between the glans and prepuce, and a curved, narrow-pointed bis- 
toury be passed along its groove, by which the prepuce should be 
slit up. At the same time, if the edge of the prepuce is thickened, 
it should be seized between the blades of a forceps, and be shaved 
off. Then four or five sutures should be passed through the mar- 
gin of the incision, so as to draw together the edge of the skin and 
• Tide Dr. Willis, op. cit.; case by Mr. Fergusson, recorded in Prov. Med. Journ., 
5ih August, 1843; one by Mr. Elliott, in Braithwaite's Retrospect, vol. vii.; and a 
paper by Dr. Arnott, Lancet, August 5th, 1843. DISEASES OF THE TESTIS. 
497 
that of the mucous lining of the prepuce, that they may unite by 
adhesion. If this is not done, the skin and mucous membrane will 
be separated by the swelling that follows the operation, and the 
wound, instead of being a mere line, will be half an inch wide. 
II. Paraphymosis is said to exist when 
a tight prepuce is pulled back over the 
glans, constricting it, and causing it to 
swell. 
Treatment.-The surgeon first com- 
presses the glans with the fingers of one 
hand, so as to squeeze the blood out of it, 
-then pushes it back with that hand, 
whilst he draws the prepuce forwards 
with the other. If this fails, the constrict- 
ing part of the prepuce must be divided 
with a curved pointed bistoury. 
III. Cancer of the penis may begin 
either on the glans or on the prepuce,-and invariably occurs to 
elderly persons who have had phymosis. It forms a foul, ragged, 
excavated ulcer, gradually destroying the whole organ, and con- 
taminating the glands in the groin. 
Treatment.-The part must be amputated before the glands are 
affected. The surgeon stretches it out with one hand, and cuts it 
off with one sweep of a bistoury; bleeding vessels are then to be 
tied, and cold to be applied, and after three or four days a piece of 
bougie is to be introduced into the orifice of the urethra, and to be 
retained there during the cicatrization. 
IV. Epispadias is a congenital malformation, consisting of an im- 
perfect closure of the urethra on its upper surface. Hypospadias is 
a similar deficiency of the under surface. They sometimes may be 
relieved by paring the edges of the skin on each side of the fissure, 
and uniting it by suture,-provided that the urethra is pervious to 
the end of the penis. An American surgeon has proposed to unite 
the edges of the fissure by cauterizing them with nitrate of silver, 
and scraping off the black eschar; by which means the surfaces are 
made raw without haemorrhage or loss of substance. 
V. Tumours.-The natives of warm climates are liable to a 
sarcomatous growth of the cellular tissue of the penis and scrotum, 
forming an immense tumour in which those parts are completely 
buried. Poor Hoo Loo, the Chinese, had a tumour of this sort. 
Extirpation is the only cure, and if the tumour is very large, no 
attempt can be made to save the penis and testicles. 
SECTION II. - OF THE DISEASES OE THE TESTIS AND SCROTUM. 
I. Acute Inflammation of the testis {acute testitis, orchitis, 
hernia humoralis) may be caused by local violence, but more 
frequently occurs in conjunction with gonorrhoea, through an 
extension of inflammation from the urethra. It is very liable to 
Fig. 135. 498 
DISEASES OF THE TESTIS. 
be induced if the patient indulges in violent exercise and fermented 
liquors, or neglects to use a suspensory bandage while employing 
injections. 
Symptoms.-The discharge from the urethra diminishes, and 
the patient soon complains of aching pain in the testis and cord, 
extending up to the loins, and soon followed by great swelling, 
excruciating tenderness, fever, and vomiting. The epididymis is 
the part chiefly affected. The swelling depends upon an effusion 
of lymph and serum into the tunica vaginalis. 
Treatment.-Bleeding, if the habit is very plethoric,-the appli- 
cation of numerous leeches, or the abstraction of blood from some 
of the veins of the scrotum ; purgatives, especially F. 59, followed 
by the exhibition of tartar emetic in doses of a quarter of a grain 
(F. 103), so as to keep down the pulse, and of mercury with opium, 
so as barely to affect the gums, if the disease does not readily yield 
to the tartar emetic alone;-cold lotions or warm fomentations, 
according to the patient's feelings,-a suspensory bandage to ele- 
vate the part. After the acute stage has subsided, strong astringent 
lotions, F. 16, may be employed, and subsequently friction with 
mercurial ointment, in order to remove the hardness and swelling 
which (as the patient should always be informed) remain after the 
acute attack. As soon as the very acute stage has subsided, 
compression will be found a useful means of reducing the swelling, 
and supporting the dilated vessels. The affected testicle is grasped 
and separated from its fellow, and then is encircled with strips of 
adhesive plaster, which are to be applied regularly and as tightly 
as the patient can bear; the first strap being applied round the 
spermatic cord immediately above the testicle, and the others 
downwards in succession, slightly overlapping each other.* 
II. Chronic Inflammation (sarcocele') is known by more or 
less hardness, swelling, tenderness, and occasional pain. Very 
often it commences in the epididymis. It may be a sequel of acute 
inflammation,-or may be caused by disease in the urethra, or dis- 
order of the health. It sometimes depends on a syphilitic taint,- 
which will be probable, if the patient has the aspect of secondary 
syphilis, if the pain is principally severe at night, and if there are 
secondary venereal affections of other parts. It very often, in its 
latter stages, is accompanied with some degree of effusion into the 
tunica vaginalis {hydro-sarcocele}. It may be distinguished from 
malignant disease, by the greater uniformity and smoothness of the 
swelling, its slower progress, and the absence of glandular enlarge- 
ment in the groin ; but the diagnosis is often obscure in the earlier 
stages. On examination, the testicle is found to contain more or 
less yellow, solid lymph, which is interspersed in its substance, and, 
* This practice, which was first recommended by Fricke of Hamburg, was adopted 
by Ricord, and introduced into this country by Mr. Acton and Mr. Langston 
Parker; it seems to be generally approved of, and is recommended by Mr. T. 
Blizard Curling in his Practical Treatise on the Diseases of the Testis, &c., Lond. 
1843; a work of the highest character, and greatest utility. DISEASES OF THE TESTIS. 
499 
according to Sir B. Brodie and Air. Curling, is deposited into the 
tubuli seminiferi, and may be found extending into the vas deferens. 
Treatment.-The patient must be confined to his bed or sofa,- 
mercury be administered till it begins to touch the gums,-the 
bowels be kept open, the diet nutritious but not stimulating, and the 
part be suspended. If an ordinary course of mercury seems inex- 
pedient, the iodide of potassium, or corrosive sublimate, with sar- 
saparilla, F. 29, 30, 56, 57, 93, will probably be of service. The 
part may be frequently bathed with F. 11, 15, 16; or F. 25 may be 
applied with moderate pressure as directed at p. 261. 
III. Abscess of the testis may be a result of chronic or scrofulous 
inflammation-very rarely of the acute. A puncture should be 
made as soon as fluctuation is clearly felt, and the skin is adherent. 
When an aperture is formed, spontaneously or by art, part of the 
tubular texture of the gland is apt to protrude in the form of a pink, 
fungous, irregular mass, to which the name fungus or hernia testis 
has been given. This should be returned to its place by pressure 
with strips of plaster; and stimulating applications should be used 
in order to excite granulation. Sir B. Brodie recommends the red 
precipitate, and Mr. Curling a strong solution of lunar caustic. It 
is not right to shave off the protruding substance, as it would be 
almost equivalent to castration. 
IV. Scrofulous Inflammation commences with a deposit of 
tubercle in some part of the testis or epididymis, either into or be- 
tween the tubuli. A nodular swelling appears externally, attended 
with very little pain or tenderness, which after a time inflames and 
bursts, and gives exit to the fungous protrusion just mentioned. 
Treatment-The health must be invigorated by tonics, altera- 
tives, and change of air, and the local actions be excited by stimu- 
lating lotions. When all the tubercular matter has been evacuated, 
the abscess heals of itself; but, before this occurs, the whole organ 
is often disorganized and rendered useless, and sometimes it is 
necessary to remove it, on account of the irritation and drain on the 
system. 
V. Atrophy of the testicle may be a result of excessive venereal 
indulgence, or of inflammation; the part becoming filled with lymph, 
which first annihilates the tubular structure, and then is itself 
absorbed. The gland dwindles to the size of a pea. There is no 
cure. 
VI. Neuralgia of the testis and cord produces fits of excruciat- 
ing pain, which leaves the parts tender and slightly swollen. The 
treatment must be that of neuralgia generally. All the secreting and 
excreting organs must be set in order. Violent purgatives in general 
do mischief; a few leeches,-the application of intense cold, (F. 12,) 
-counter-irritants, and opiate or belladonna plaster,-sometimes 
afford relief. The internal remedies most likely to do good are sar- 
saparilla, quinine, arsenic, and other tonics. Extreme sensitiveness 
of the testis, so that it cannot bear the slightest touch, is another 
form of this disorder sometimes met with in nervous hypochondria- 
cal subjects; especially in persons who labour under a diseased 500 
DISEASES OF THE TESTIS. 
condition of the urethra, or excessive spermatic discharges. Tonics 
and cold applications may be tried, and the cause of the affection 
should be ascertained, and if possible removed. In these cases, the 
patients often desire to be castrated. Before doing so, the surgeon 
ought to convince himself that the pain originates in a diseased state 
of the testis itself, as it sometimes does.. If it depends on disorder 
of the viscera or general health, it might return in the cord, after the 
removal of the testis. 
VII. The Hydatid or Cystic Disease is a rare affection, and 
occurs almost exclusively to adults. The testicle swells exceedingly, 
and its interior is filled with a number of cysts containing a watery 
fluid. They are supposed to be developed from dilated tubuli 
seminiferi; and their interstices are filled with a solid fibrinous 
substance. This affection is incurable, but not malignant. When 
the part becomes of unsightly magnitude it must be removed. 
VIII. Malignant Disease of the testis is almost invariably 
medullary sarcoma, very rarely scirrhus. At first the gland swells, 
and become very hard and heavy; it is scarcely, if at all, painful 
or tender, and merely causes slight aching in the loins by its weight. 
After a time it enlarges rapidly and feels soft,-the cord swells,- 
there are occasional darting pains,-a fungus protrudes, the lumbar 
glands become affected, and cachexia and death soon follow in the 
ordinary course (pp. 115-119). This disease is to be distinguished 
from hydrocele by its opacity and weight,-and from chronic in- 
flammation or the hydatid disease by the darting pains, swelling of 
the cord, and cancerous cachexia. It may further be distinguished 
from chronic inflammation by the fact, that neither mercury nor any 
other remedy produces any permanent benefit. 
Treatment.-Castration should be performed before the cord is 
affected. 
IX. Castration is performed thus :-the scrotum being shaved, 
the surgeon grasps it behind to stretch the skin, and then makes an 
incision from the external abdominal ring to the very bottom of the 
scrotum. If the skin is adherent, or diseased, or if the tumour is 
very large, two elliptical incisions may be made, so as to remove a 
portion of skin between them. If there is any doubt as to the nature 
of the disease, he may next open the tunica vaginalis to examine 
the testis. Then he separates the cord from its attachments, and an 
assistant holds it between his finger and thumb, to prevent it from 
retracting when divided. The operator now passes his bistoury 
behind the cord, and divides it-and seizing the lower portion draws 
it forwards and dissects out the testicle. The arteries of the cord, 
and any others requiring it, are then to be tied; and the wound 
must not be closed till all the bleeding has ceased, as this operation is 
often followed by secondary haemorrhage.* 
* [It is often more convenient to terminate the operation by the section of the 
cord, having previously separated the testis from the integuments. The retraction 
of the cord leading to irrepressible haemorrhage, so much feared by some surgeons, 
may always be prevented by dissecting its cremaster envelope from the duct and 
vessels well up towards the abdominal ring, and dividing the essential elements of 
the cord by themselves. F.] HYDROCELE. 
501 
X. Hematocele signifies an extravasation of blood into the 
tunica vaginalis in consequence of injury. It is sometimes com- 
bined with ecchymosis of the scrotum. If the quantity extrava- 
sated is small, bleeding and cold lotions may cause it to be absorbed. 
If large, a puncture should be made, and a poultice be applied, for 
the blood to ooze into gradually. Blood may also be extravasated 
into the spermatic cord from local injury or strains. 
XI. Hydrocele signifies a collection of serum in the tunica 
vaginalis. 
Symptoms.-It forms a pear-shaped swelling, smooth on its 
surface, fluctuating if pressed, free from pain and tenderness, and 
causing merely a little uneasiness by its weight. The epididymis 
can be felt on the posterior surface of the tumour near the bottom. 
On placing a lighted candle on one side of the scrotum, the light 
can be discerned through it. 
Causes.-Hydrocele may be a sequel of inflammation of the 
testis, but more frequently arises without any local cause. It is 
often supposed to follow strains of the loins or belly. 
Diagnosis.-Solid enlargements of the testis may be distin- 
guished from hydrocele by their weight, solidity and greater pain- 
fulness, and by the absence of fluctuation or transparency. The 
diagnosis from hernia will be found at p. 439. 
Varieties.-It sometimes happens that the tunica vaginalis pre- 
serves its communication with the abdomen, and then becomes 
filled with serum, forming a cylindrical tumour extending up to the 
abdominal ring, to which the name congenital hydrocele is applied. 
On raising and compressing it, the fluid is slowly squeezed into the 
abdomen, and slowly trickles down again afterwards. This case 
is liable to be complicated with a congenital or encysted hernia, to 
prevent which, and to close the communication with the cavity of 
the peritonaeum, a truss should be worn. Sometimes the trans- 
parency and fluctuation of hydrocele are absent in consequence of 
a thickening of the tunica vaginalis, which may be known, accord- 
ing to Brodie, by noticing that the thickened membrane forms a 
projection along the epididymis,-whereas in solid enlargements of 
the testicle the projection of the epididymis is lost. Sometimes the 
tunica vaginalis is partially adherent to the testicle. Sometimes 
loose cartilages are found in the sac,-they are easily removed by 
a slight incision. 
Treatment.-The remedies for hydrocele are threefold. (1.) 
Strong discutient lotions (F. 16) which sometimes assist the cure in 
children, but cannot be depended on for adults. (2.) Evacuation 
of the serum, or the palliative cure. This may be accomplished 
by a puncture with a common lancet, or trocar; but the method 
most commonly adopted at present, consists in making a number 
of punctures with a large needle, so that the fluid may escape from 
the tunica vaginalis into the cellular tissue of the scrotum. This 
palliative treatment is always sufficient for children, and some- 
times for adults. 
(3.) Radical cure.-This, which is generally necessary for 502 
DISEASES OF THE TESTIS. 
adults, is performed by injecting certain stimulating fluids, or by 
introducing setons, or other foreign substances into the tunica vagi- 
nalis, in order to excite a degree of inflammation sufficient to 
destroy its secreting faculty. It must not be forgotten, however, 
that this radical cure is totally inadmissible, if the testis is diseased, 
or if the hydrocele is complicated with an irreducible hernia, or if 
the tunica vaginalis preserves its communication with the abdo- 
men. Mere thickening from previous disease is, however, no 
objection. 
Operation.-The surgeon grasps the tumour behind, and intro- 
duces a trocar and canula into the sac-pointing the instrument 
upwards, so that it may not wound the testicle. He next with- 
draws the trocar, at the same time pushing the canula well into the 
sac, so that none of the fluid that is to be injected may pass into the 
cellular tissue of the scrotum. When all the serum has escaped, 
he injects from two to four ounces of some stimulating fluid through 
the canula, by means of an elastic bottle fitted with a stop-cock. 
Equal parts of port-wine and water or zinc lotion (F. 15) are com- 
monly used. Mr. Curling prefers common lime-water. Tincture 
of iodine has been used with great success in India, but the expe- 
rience of European surgeons does not show that it possesses any 
peculiar advantages. Two drachms of the tincture are mixed with 
six of water; and two or three drachms of this combination are 
injected into the sac, and allowed to remain there ; biit, in using 
the other injections, when the fluid has remained from three to five 
minutes, according to the degree of pain which it causes, it is 
suffered to flow out, and the canula is withdrawn. Some degree 
of inflammation follows, and more effusion into the sac-but the 
latter generally disappears in a fortnight or three weeks. If the 
cure is not quite perfect, the operation may be repeated after a few 
weeks. 
XII. Varieties of Hydrocele.- (1.) Encysted Hydrocele. 
Sometimes a serous cyst is developed on or near the testis. Most 
frequently it is situated between the tunica vaginalis and epididymis; 
very rarely between the tunica vaginalis and testis, and more rarely 
still within the substance of the external layer of that tunic. These 
cysts contain a clear water, and not serum. They may be punc- 
tured with a grooved or cataract needle to let the fluid escape, if 
they have become of inconvenient bulk; and if it is necessary to 
adopt some radical method of cure, the best plan seems to be to 
pass a common silk ligature through the sac with a curved needle, 
and retain it till it has caused some inflammation. (2.) Hydrocele 
of the spermatic cord may consist either of an encysted tumour, 
such as lias just been described, or else of a collection of serum in 
the cellular tissue of the cord. In either case, the needle must be 
employed if the swelling becomes troublesome from its bulk. 
XIII. Varicocele (Cirsocele or Spermatocele') signifies a vari- 
cose state of the veins of the spermatic cord. It is caused by the 
ordinary causes of varix ; that is to say, by obstruction to the return 
of blood, through corpulence, constipation, tight belts round the VARICOCELE. 
503 
abdomen, and the like. It is much more common on the left side 
than on the right; obviously because the left spermatic vein is 
more liable to be pressed upon by fsecal accumulations in the sig- 
moid flexure of the colon, and because its course is longer and less 
direct than that of the right vein. 
Treatment.-In ordinary cases sufficient relief may be obtained 
by keeping the bowels thoroughly open;-by frequently washing 
the scrotum with cold water or astringent lotions, so as to constringe 
the skin;-and by supporting it with a suspensory sling made of 
open silk net, and fastened up with two tapes, which are to be 
fastened round the abdomen and tied in front; but it should have 
no tapes passing behind between the legs. But there are some 
cases in which this disease produces very serious inconvenience - 
pain in the scrotum and loins-sense of dragging at the stomach- 
loss of appetite-flatulence-and despondency of mind-and for 
these cases, something more must be done. Mr. Wormaid recom- 
mends the loose skin of the scrotum to be pinched up and confined 
with a steel ring. Blisters and counter-irritants, so as to inflame 
and condense the scrotum;-division of the veins by the knife or 
caustic, and passing setons of thread through them, have had their 
advocates;-and even the barbarous operation of passing a ligature 
through the scrotum, and tying up the skin of half the scrotum, 
with all the vessels except the artery and vas deferens, so that they 
may be divided by ulceration, has been practised in some cases 
with success; in others with fatal results; but certainly always 
with a risk of causing atrophy of the testis. Sir A. Cooper pro- 
posed the operation of cutting away a good piece of the loose re- 
laxed skin. " The manner of performing it is as follows:-The 
patient being placed in the recumbent posture, the relaxed scrotum 
is drawn between the fingers; the testis is to be raised to the ring 
by an assistant; and then the portion of scrotum is to be removed 
by the knife." Any artery requiring it must be tied; and cold 
must be applied to check bleeding; and then the lower flap of the 
scrotum must be brought upwards and forwards, and be attached 
by sutures to the fore and upper part;-and a suspensory bag 
should be applied to press the testis upwards, and glue the scrotum 
to its surface. It is of no use to remove too little of the skin.* 
* [Dr. Pancoast describes in the Medical Examiner (March 4, 1843,) the fol- 
lowing modification of Ricord's operation, which he states he has employed with 
success. "Previous to the operation, the patient is to be directed to walk aboutfor 
an hour or two with the scrotum unsupported, so as to cause an accumulation of 
blood in the enlarged veins. He is to be seated on the side of his bed, with the 
legs separated. The thumb and forefinger of the left hand are then to be pressed 
. in, so as to lift up the enlarged veins, and thus separate them from the vas deferens. 
This duct is readily distinguished by its hard and wiry feel, and is to be pressed 
off with the nail of the left forefinger towards the os pubis. A long, round, lancet- 
pointed needle, curved near the point like that of the sail-makers, and threaded with 
a piece of fine but strong hempen twine passed double through the eye, is then 
carried between the bundle of veins and the vas deferens ; entering it on the side 
of the thumb, and bringing out the point against the pulpy portion of the finger. 
" The loop of the double ligature is to be detached from the needle; the ligature being 
left in the track of the wound. The needle, without being threaded, is again to be 504 
DISEASES OF THE TESTIS. 
The method which appears most promising at present consists 
in the application of moderate pressure to the dilated veins at the 
external abdominal ring, by means of Evans's patent lever truss; 
so as to release them from the pressure of the superincumbent 
column of blood, and afford them a moderate degree of support.* 
XIV. Acute (Edema of the Scrotum.-The loose cellular 
tissue of this part is exceedingly liable to serous infiltration, from 
inflammation or dropsy. But there is one form of acute oedema, 
which has been particularly described by Mr. Liston,t and which 
is liable to supervene on excoriations of the parts in unhealthy 
entered through the same orifice of the skin as before, but carried this time between 
the skin of the scrotum and the veins of the cord, and its point brought out through 
the other puncture made in the skin on the side next the pubis. To facilitate this 
step, the skin should be lightly raised up from above the veins with the thumb and 
finger." If there is any enlargement of the subcutaneous veins of the front part of 
the scrotum, the point of the needle is to be so carried as to scrape the under sur- 
face of the skin, and passed in front of these veins. The needle is now to be left 
in the wound. The place of entry of the needle is to be lower than its place of 
exit; "so that the point of the instrument, which should be pushed well through, may 
lie undisturbed without pressing over the root of the penis. The course of the 
instrument across the cord will be, therefore, rather diagonal than transverse. 
The loop of the ligature (which lies next the pubis) is now to be thrown over the 
point of the needle. Traction is next to be made upon the other side, upon the 
loose ends of the ligature, so as to draw the loop along the needle, through the 
orifice in the skin. One tail of the ligature is now to be drawn out for four inches, 
so as to shift the portion of the thread, forming the loop over the needle, for fear 
that this might have been cut by the point or edge of the needle, so as to break 
■when subsequently knotted. The loose ends of the ligature are then to be tied 
with a single knot over the shank of the needle; this is to be drawn as tightly as 
possible, so as to completely strangulate the veins of the cord, which will be thus 
inclosed by the double ligature on its back part, and the needle in front. To make 
the strangulation more effectual, the two ends of the loop thus formed over the 
needle may be slid towards each other, by pressure through the skin, and the knot 
again tightened. This step is followed by severe pain, which gradually diminishes, 
and at the end of half an hour ceases almost entirely." To be able to tighten the 
ligature at the end of two or three days, when it will be found loosened by having 
partially cut through the compressed mass of veins, an oblong piece of sole leather 
pierced in the centre and notched at the ends, is slid over the heel of the needle, 
and a firm double bow knot made of the ligature above it. " The point of the needle 
is to be sheathed in a small cork, and a compress placed below it to prevent its 
worrying the skin. A piece of thick tape is to be passed through the eye of the 
needle and knotted, in order to prevent the needle when it becomes loosened by 
suppuration, from being pressed through the hole in the leather by the movements 
of the thigh, so as to detach the loop. The scrotum is to be slightly supported by 
a couple of silk handkerchiefs, folded and placed below it. No dressing is required. 
If neuralgic pains arise, they are to be soothed by hot fomentations, and the admi- 
nistration of anodynes." The ligature over the leather is to be untied every third 
day for three successive periods, tightening it again as much as possible at each 
time. On the eleventh the needle is removed; the loop, which is then left detached, 
and will be found but small from the successive tightenings, is at the same time 
withdrawn. Above the place of the ligature, the condition of the cord will be found 
perfectly natural; below it will be found a hardened mass of the size of a walnut,* 
formed by the effusion of lymph, between, and in all probability in the cavities of 
the veins, causing their complete obliteration. After the withdrawal of the needle, 
a light poultice maj- be laid for a few days over the part, to promote suppuration 
from the points of puncture, and to facilitate the resolution of the tumour left.] 
* Vide Sir A. Cooper, Guy's Hosp. Rep. vol. iii.; Reynaud. Journ. des Connais- 
sances Med., Feb. 1839; James in Prov. Med. Trans., for 1840, and Curling, op. cit. 
The diagnosis of Varicocele has been spoken of at p. 440. 
■j Med. Chir. Trans., vol. xxii. IMPOTENCE. 
505 
persons. The scrotum becomes enormously swollen and tense, 
and soon sloughs unless a free incision is made in the mesial line. 
The case very much resembles extravasation of urine, but may be 
distinguished by the absence of swelling in the perinaeum, and of 
obstruction in micturition. 
XV. Chimney-sweeper's Cancer is a foul ragged ulcer of the 
scrotum, with the skin hardened and tuberculated round. It rarely, 
if ever, occurs till after the age of thirty. It commences as a small 
wart, and is caused by the irritation of soot. The whole of the 
ulcer, and of the diseased skin around it, must be extirpated-but it 
is rarely if ever necessary to remove either of the testicles. 
SECTION III. OF IMPOTENCE. 
Impotence in the male may depend on a variety of conditions. 
(1.) It may be caused by absence, or mutilation, or malformation, 
or original weakness and want of development of the genital organs. 
(2.) After a severe and tedious illness, the genitals may remain 
incapable of performing their functions, long after the restoration of 
the health and strength in other respects. Steel and other tonics, 
with cantharides, musk, extract of nux vomica, resin of Indian 
hemp, galvanism cautiously applied to the spine, spices, eggs, and 
oysters, are the remedies. Phosphorus in doses of gr. dissolved 
in oil, is said to be a potent aphrodisiac in these cases. (3.) Blows 
on the head or spine are apt to be followed by impotence ; which 
sometimes is relieved but more frequently is permanent. A cautious 
course of mercury, followed by the stimulating aphrodisiacs just 
mentioned, are the remedies most likely to be of use. A similar 
result sometimes follows a fit of apoplexy. (4.) Certain diseases 
are always attended with a diminution, and sometimes with a 
complete loss, of sexual power; especially diabetes, disease of the 
kidneys, some forms of dyspepsia: and the latter stage of most 
chronic organic diseases. (5.) It often happens that a young man, 
the first time he yields to carnal temptation-or that a newly 
married man on the night of his nuptials, finds himself incapable of 
accomplishing his wishes-through awkwardness, or timidity, or 
over-anxiety on his own part, or, perhaps, from something disagree- 
able in his bed-fellow. He straightway fancies himself impotent- 
and if he applies to one of the advertising scoundrels, will no doubt 
be told that he is so. The surgeon should cheer the patient's 
spirits, and should inform him that his case is by no means un- 
common-that most other men feel the same incapability at times; 
and he should give him a little nitric aether and cinnamon water, 
and make him promise to sleep with the lady three nights without 
touching her, which will seldom fail to prove an effectual cure. 
(6.) Lastly, impotence may be produced by premature and ex- 
cessive venery, or by the practice of self-pollution. Such cases 
frequently come under the observation of the London surgeon, 
who has no difficulty in distinguishing them from the last variety. 506 
DISEASES OF THE FEMALE GENITALS. 
The sexual organs have been rendered in these cases so weak and 
irritable, that the least excitement, from a lascivious idea, or the 
mere friction of the clothes brings on an imperfect erection followed 
immediately by the discharge of a thin fluid. The erection is so 
imperfect, and followed so soon by the discharge, that the patient is 
quite incompetent for sexual connection; and the frequent and 
abundant losses of seminal fluid, (whence the term, spermatorrhoea 
is given to this malady,) together with the patient's consciousness 
of his own imperfection, bring on a most miserable state of bodily 
weakness and mental despondency. General tonics, and cold 
shower bathing will do something to relieve this state; but the 
most essential thing is, the observance of perfect chastity of idea, 
so that all excitement may be avoided. The prostatic portion of 
the urethra in these cases, is almost always preternaturally irritable 
and sensitive; and this condition of the parts at the orifice of the 
seminal ducts tends greatly to keep up the excessive secretion, and 
to promote the action by which it is expelled. It is a very im- 
portant indication, therefore, to attack this irritable surface, destroy 
its sensitiveness, and so interrupt the chain of morbid phenomena. 
This may be effected by the use of nitrate of silver according to the 
plan proposed by M. Lallemand. The porte caustique is passed 
down the urethra, and as soon as it arrives at the painful part, the 
caustic is protruded for an inch, and passed backwards and forwards 
rapidly once or twice,-then the instrument is withdrawn. This is 
followed by more or less pain, and thin bloody discharge-some- 
times by severe inflammation: but the spermatorrhoea is almost 
invariably benefited at once. Injections of thin mucilage, contain- 
ing one grain of opium and three of acetate of lead to the ounce, 
have been recommended by Mr. Douglas, of Glasgow, as less 
painful, and equally efficacious. Enemata of cold water, and small 
doses of cubebs with henbane, are useful adjuncts to the treatment.* 
CHAPTER XXII. 
OF THE SURGICAL DISEASES OF THE FEMALE GENITALS. 
I. Blennorrhcea.-Young female children are sometimes subject 
to mucous or purulent discharges from the parts at the entrance of 
the vagina; which may also perhaps be excoriated. Purgatives 
and tonics-perfect cleanliness, and F. 15, 36, or any mild astring- 
ent lotion, are the remedies. 
• Vide B. Phillips, Med. Gaz., 23d Dec., 1842 ; Curling, op. cit. Douglas, Med. 
Gaz., 29th Sept., 1843. DISEASES OF THE FEMALE GENITALS. 
507 
II. Noma signifies a phagedsenic affection of the labia pudendi 
of young female children, precisely resembling cancrum oris, p. 
389, in its causes, and nature, and symptoms. After two or three 
days of low fever, the little patient is observed to suffer considerably 
whilst making water, and on examination, the labia present a livid 
erysipelatous redness and vesications, that are rapidly followed by 
phagedsenic ulcers. This disease is very frequently fatal. The treat- 
ment is the same as directed for cancrum oris. The surgeon must 
be very careful not to mistake this or the preceding affection for the 
venereal disease;-an error common enough among parents.* 
III. Vesico-Vaginal Fistula signifies a communication be- 
tween the bladder and the vagina. It generally results from slough- 
ing of the parts after a tedious labour. As soon as it is discovered, 
the patient should be made to lie on her face-a catheter should be 
constantly worn in the urethra, and an oiled sponge in the vagina, 
and the bowels should be kept moderately loose. By these means 
the natural contraction of the parts will be aided. After some 
weeks, it will be expedient to pare the edges of the fissure, and 
unite them by suture, by means of Mr. Beaumont's instrument;- 
or if this fails, to touch them frequently with nitrate of silver, or to 
apply the actual cautery at intervals for a few months. To perform 
these operations, the vagina must be dilated with a speculum. If 
these means fail, or if the patient will not submit to them, Dr. 
Reid's plan of plugging the vagina with an India rubber bottle, 
appears to be the best means of preventing the constant dribbling 
of urine. 
IV. Recto-Vaginal Fistula must be treated by constantly 
wearing a sponge in the vagina, so as to prevent the passage of 
faeces through it, and by mild laxatives (F. 42). If after a time the 
aperture does not close, it must be treated as in the last case. Com- 
plete laceration of the perinseum into the anus is attended with 
distressing incontinence of faeces, and is prevented from healing by 
the action of the sphincter. Hence it is necessary to divide the 
sphincter on each side of the laceration, and to prevent these new 
wounds from uniting, by placing a few threads of lint in them, 
until the laceration has united. ♦ 
V. A Vascular Excrescence, varying in size from that of a 
large pin's head to that of a horse-bean, is liable to grow from the 
female urethra. It causes great distress through its exquisite sensi- 
bility. It should be cut off, and the potassa fusa be applied to the 
surface to prevent its reproduction. But, immediately after the 
caustic, a Sponge dipped in diluted vinegar should be applied, in 
order to prevent injury to the surrounding sound parts ;-and if it 
is necessary to introduce the caustic within the urethra, it must be 
by means of a tube which has an aperture in it corresponding to 
the diseased surface. 
VI. Uterine Polypus is a pear-shaped tumour covered by 
mucous membrane, and attached by a narrow neck to some part of 
* Kinder Wood, on a fatal affection of the pudenda of female children. Med. 
Chir. Trans., vol. vii. p 4. 508 
DISEASES OF THE BREAST. 
the uterus. The symptoms that it produces are those of uterine 
irritation-bearing down pains-menorrhagia-and, after a time, 
fetid discharges. On examination, an insensible tumour is found 
partially or entirely protruding through the os uteri. If it projects 
much into the vagina, the surgeon must carefully feel for the os 
uteri, and ascertain that the neck of the polypus is either attached 
to some part of it, or that it passes clear into the womb. Inver- 
sion, or prolapsus of the womb, must not be mistaken for it. 
Treatment.-A ligature should be twisted tightly round its neck, 
but not too near the womb, by means of the double canula invented 
for that purpose by the late Dr. Gooch. 
VII. Imperforate Hymen.-Sometimes this membrane com- 
pletely obstructs the vagina, and causes the menstrual fluid to 
accumulate and distend the uterus. The impediment is easily got 
rid of by a crucial incision. Then all the black treacly fluid that, 
has accumulated should be immediately syringed out with warm 
water, otherwise it might putrefy, and cause typhoid fever and 
death. 
VIII. The labia may be the seat of acute inflammation, and of 
encysted tumours, and sarcomatous or fatty enlargements. The 
treatment of these cases requires no distinct comments. The clitoris 
and nymphae, if they grow to an inconvenient size, should be cur- 
tailed by an incision-and if they are affected with scirrhus, should 
be entirely extirpated at an early period. 
CHAPTER XXIII. 
OF THE DISEASES OF THE BREAST. 
I. Acute Inflammation of the breast is known by great swell- 
ing, tenderness and pain, and fever. These symptoms are soon 
succeeded by shivering, and formation of matter. The abscess is 
very slow to point. This affection may occur at any period during 
lactation. It may be caused by cold-by too stimulating a diet- 
or by neglect in suckling. 
Treatment.-The bowels should be freely kept open by saline 
purgatives-plenty of leeches should be applied as soon as possible, 
and tepid fomentations or poultices after them; the milk should be 
drawn off, if it can be done without very much pain, and Dover's 
powder should be given to allay restlessness. As soon as fluctua- 
tion is well established, a puncture should be made. The aperture 
after a time discharges a milky fluid. If it is long in healing, 
astringent lotions should be injected into it. HYDATID DISEASE. 
509 
II. Chronic Inflammation generally attacks one or two lobules 
only, causing them to swell into firm tumours, which, on examina- 
tion with the finger, are felt to be composed of numerous little 
granules. The whole gland may, however, be affected. There is 
very little tenderness or pain, except at the time of menstruation. 
This affection is distinguished from malignant disease, by the cir- 
cumstance that the patient is generally young, without the leaden 
look of cancer, and that the tumour is more diffused, and not so 
hard. 
Treatment.-The appetite and digestion-the state of the liver 
and bowels, and, above all, of the uterine system, must be regulated 
by Plummer's pills, aloes, steel, and other alteratives, aperients, and 
tonics. Occasional leechings-cold lotions-issues in the back- 
mercurial plasters containing a little belladonna-and, in indolent 
cases, friction with weak mercurial ointment-are the requisite 
local remedies. Marriage is in some cases almost a specific. 
III. Irritable Breast is a neuralgic affection resembling the 
irritable testis.-Extreme pain and tenderness, aggravated at the 
menstrual period, with occasional heat and slight swelling, are the 
symptoms. This, like the other affections of its class, (p. 315,) is 
extremely unmanageable, and may remain for years. 
Treatment.-Steel, aloes, and other tonics-emmenagogues- 
especially the ferri ammonio-chloridum in doses of gr. ii. ter die- 
with change of air, marriage, and other means for the improvement 
of the health,-are the chief remedies. Leeches, cold and warm 
applications-mercurial, belladonna, and other plasters-issues, 
blisters, and other local measures, sometimes do good, but as often 
the reverse. 
IV. Lacteal Tumour.-Sometimes a lacteal duct becomes obli- 
terated, and the milk accumulates in it, forming an oblong fluctuat- 
ing tumour near th| nipple. If this is punctured, milk will continue 
to be discharged during lactation, and, after the child is weaned, it 
will dry up and heal. 
V. Sore Nipples.-Excoriations and chaps about the nipples 
not only cause great pain and inconvenience in suckling, but are a 
frequent cause of acute inflammation, by deterring the mother from 
allowing the child to suckle so freely as it ought. A solution of gr. 
v. of tannin in an ounce of water; a weak solution of nitrate of 
silver; borax and honey--or powdered borax sprinkling on the 
part-lotions of alum, or sulphate of zinc, and arrowroot and cream, 
are the best applications. The nipple should be defended from the 
clothes, and from the child's mouth, by a wooden or caoutchouc 
shield. Women who are subject to this affection, should frequently 
wash the parts with salt and water, or solution of alum during 
pregnancy. 
VI. The Hydatid Disease consists in the development of a 
number of cysts in the gland, filled with clear water. Sometimes 
the cysts are developed by the gland-being lined with a vascular 
membrane, and containing a yellow serum. Sometimes they con- 
sist of hydatids-parasitic animalculae, composed of thin bladders 510 
DISEASES OF THE BREAST. 
filled with a clear water, which are developed in the gland by their 
own vital powers, and are capable of engendering other smaller 
hydatids within themselves. The diagnosis of this affectioh is 
obscure. At first it occasions a hard tumour resembling that of 
chronic inflammation, and unattended with pain, except at the 
menstrual period. Subsequently fluctuation is felt at different parts 
-and when any cyst has acquired a considerable magnitude, it 
ulcerates, discharges its fluid, suppurates, and contracts. 
Treatment.-If there are but one or two cysts, they may be 
punctured, and then they will suppurate and contract. But if the 
whole gland is involved, it should be removed. The inconvenience 
arising from its bulk, and the irritation caused by the ulceration of 
the cysts, will thus be got rid of. At the same time, the chance 
that tliis, like other new structures, may assume a malignant action, 
is an additional reason for the operation. 
VII. The Serocystic Disease is a peculiar affection of the 
breast, described by Sir B. Brodie in a clinical lecture at St. George's 
Hospital, in January 1840. It chiefly affects the upper classes, and 
is rarely met with in hospitals. It consists in the development of 
numerous cysts, formed probably by a dilatation of the lactiferous 
tubes, and containing serum, which often exudes from, or may be 
squeezed out of, the nipple. It generally occurs to women under the 
age of thirty, who are unmarried, or barren. In its first stage, it 
appears as one or more globular tumours-the size perhaps of a 
marble-which seems to be movable, because the whole breast 
moves with them, but are not so in reality. This disease does not 
affect the axillary glands, and may remain stationary for years. 
But in time a second stage arrives. Fibrinous matter is effused 
between the cysts, gluing them together; and tumours are de- 
veloped on their inner walls. As the disease advances, the skin 
ulcerates, the serum escapes, and in a few days^a fungus protrudes, 
which ultimately causes death through bleeding and sloughing. 
Treatment.-In the early stages Sir B. Brodie recommends 
counter-irritation by means of blisters, or tincture of iodine, or by 
flannel cloths soaked in a combination of sp. camphorae, sp. tenuioris 
aa f^iiiss; liq. plumbi fji; intermitting these applications when the 
skin becomes sore. Punctures are not on the whole advisable. In 
the later stages the breast must be amputated, and if the whole of 
it is removed, the disease will not return. 
VIII. Scirrhus generally commences as a hard, circumscribed, 
movable swelling in some part of the breast. In its early stages, 
it is not often tender or painful. After a few weeks or months, how- 
ever, it becomes affected with paroxysms of violent lancinating pain, 
which are most apt to occur about the period of menstruation. Not 
unfrequently a little bloody fluid is discharged from the nipple, 
'fhe cellular tissue and fat about the gland often become atrophied, 
so that the diseased breast is smaller than the sound one, and the 
nipple is generally drawn in, and the skin around it puckered like 
a cicatrix. The progress and termination of this disease have been 
already described (p. 116). The tumour after a time adheres to EXTIRPATION OF THE BREAST. 
511 
the skin, and to the muscle beneath, so as to become fixed and im- 
movable. Then it ulcerates and forms a cancer. The glands in 
the axilla, and sometimes those in the neck, enlarge, and compress 
the axillary veins, and the arm swells and becomes oedematous 
from the obstruction to its circulation. The ribs and pleura become 
scirrhous; water is effused into the chest-the breathing becomes 
difficult-the patient suffers from rheumatic pains in the bones, and 
at last dies. 
Diagnosis.-In well-marked cases, this disease cannot be mis- 
taken. The stony-hard, movable swelling in its early stage, or 
the shrunken gland and retracted nipple subsequently,-the age 
about forty,-the leaden, sallow complexion,-the weakness and 
cachexia,-the lancinating pain,-and the circumstance (which 
very often happens) that the patient's mother or sisters have suf- 
fered from cancer, all distinguish it. But there are several circum- 
stances which may render the diagnosis doubtful. (1.) In the first 
place the scirrhous deposit may be attended with more or less com- 
mon inflammatory pain, tenderness, and swelling, so that it loses its 
characteristic hardness, and becomes blended in its outline with the 
surrounding tissues, and exactly resembles the swelling arising from 
chronic inflammation. (2.) It may occur in a young female be- 
tween twenty and thirty. (3.) The effect of remedies may be 
deceitful. For although no medicine is capable of causing absorp- 
tion of a scirrhous deposit, yet it may diminish the inflammatory 
swelling around, and so cause a temporary decrease of the tumour. 
Treatment.-The local and general treatment of scirrhus of the 
breast must be conducted on the principles laid down in the section 
of Scirrhus generally. Extirpation is the only remedy, and, pro- 
vided the diagnosis is clear, the sooner it is done the better. The 
circumstances which contra-indicate an operation are also detailed 
in the same section. 
IX Medullary Sarcoma of the breast is generally combined 
with more or less scirrhus, and rarely exists alone. It forms a large 
rapidly increasing tumour; lobulated on its surface; and the pro- 
jecting parts yield an elastic sensation. This affection may be dis- 
tinguished from scirrhus by its more rapid growth and greater soft- 
ness. It is often difficult in its early stage to distinguish it from 
innocent chronic tumours, more especially as the latter may after a 
time degenerate into malignant action. Melanosis and gelatiniform 
sarcoma (p. 121) are sometimes found in the breast. 
X. Extirpation of the Breast is thus performed : The patient 
being placed in a convenient position, sitting or reclining, an assist- 
ant takes the arm of the affected side and holds it out, so as to put 
the pectoralis on the stretch. The surgeon then makes a semi-ellip- 
tical incision below the nipple along the lower border of the pectora- 
lis major, and another on the upper and inner side of the nipple, so 
as to include that part between them. He next dissects out the 
lower and outer part of the gland, quite down to the pectoralis, 
(taking care not to get behind that muscle,) and then, cutting from 
below upwards, he separates the remainder. If an adjacent gland 512 
CLUB FOOT. 
is enlarged, the incisions should be managed so as to include it also. 
When the mass is removed, its surface should be wiped and ex- 
amined, and the wound should also be well examined, to ascertain 
that no part of the gland, and that no hardened or discoloured por- 
tions of cellular tissue or of muscular fibre, are left behind. Arteries 
are then to be tied, and the patient to be put to bed,-and when all 
oozing has ceased, a few strips of adhesive plaster may be applied. 
XI. Boys and girls about the age of puberty are subject to slight 
swelling and tenderness of the breast, which, however, may be soon 
got rid of by plasters of emp. ammoniac! cum hydrargyro. 
XII. Men occasionally suffer from malignant disease of the 
breast, which manifests itself in the same manner, and requires the 
same treatment as it does in the female. 
CHAPTER XXIV. 
OF THE DISEASES OF THE HANDS AND FEET, CLUB-FOOT, AND 
OTHER DEFORMITIES OF THE LIMBS. 
I. Club Foot (Talipes) signifies a peculiar deformity of the 
foot, produced by rigidity and contraction of the muscles of the leg. 
(1.) In the most simple variety, which is called talipes equinus, [fig. 
Fig. 136. 
Fig. 137. 
136], the heel merely is raised, so that the patient walks on the ball 
of the foot. (2.) In the talipes varus, which is far more common, CLUB FOOT. 
513 
the distortion is much more complex. In the first place the heel is 
raised ;-secondly, the inner edge of the foot is drawn upwards;- 
and thirdly, the whole foot is twisted inwards; so that the patient 
walks on the outer edge, and in confirmed cases, on the dorsum of 
the foot, and outer ankle. Figure 137 shows the talipes varus. (3.) 
In the talipes valgus the outer edge of the foot is raised up, and 
the patient walks on the inner ankle. 
Causes.-This affection consists essentially in that state of short- 
ening and rigidity of the muscles of the calf, which we have de- 
scribed as rigid atrophy (vide p. 214). The exciting causes are 
various circumstances that interfere with the supply of nervous 
influence, or with the proper nutrition of the muscles. Thus it 
may be a consequence of fevers;-of injuries of the spine;-of 
division of the sciatic nerve;-of long confinement and inactivity; 
-of repeated attacks of rheumatic or other kinds of inflammation 
of the muscles of the calf;-or it may be a sympathetic consequence 
of irritation of the bowels, or of some other part of the system- 
and lastly, it may be congenital, or produced during uterine life. 
Asa proof of the imperfect nutrition and innervation of the dis- 
torted limb, it is always cold and feeble; the bones are small, and 
the muscles wasted. 
Treatment.-If this distortion is congenital, or commences in 
early childhood, it may sometimes be rectified by constantly wear- 
ing a proper apparatus. Slight cases in particular, occurring to 
children after fevers, may generally be remedied, if taken at their 
very commencement, by daily extension with the hands, and fric- 
tion of emollient embrocations on the muscles, together with tonics, 
galvanism, change of air, and sea-bathing. But in confirmed cases, 
it is better at once to resort to Stromeyer's operation of dividing the 
tendo-achillis. The rationale of this operation may readily be 
comprehended. The tendon being divided, heals by a callus, which 
renders it longer, and which, while recent, may be stretched to 
any desired length. Thus the mechanical shortening of the muscle 
is neutralized. At the same time, the antagonist muscles, which 
are always wasted and inert, are relieved from a constant state of 
tension, and are enabled to resume their natural functions, so that 
the limb rapidly increases in strength and bulk. The operation is 
easily performed thus: The tendon is put on the stretch; and a 
narrow sharp-pointed knife is thrust through the skin on one side 
of it; then its edge is turned against the tendon, and made to divide 
it as it is being withdrawn. If the tendons of the tibialis posticus, 
or flexor pollicis; or in fact if any others offer an obstacle to bring- 
ing down the heel, they may be divided as well. It is often expe- 
dient to divide a portion of the plantar fascia, or of the muscles of 
the sole of the foot. As soon after the operation as it can be done 
without causing too much pain, some apparatus should be applied 
to extend the callus and bring the foot into its proper shape. Stro- 
meyer's footboard is recommended by Dr. Little, but Scarpa's 
shoe, as improved by Weiss, seems to be neater and more efficient. 514 
BUNION. 
It is admirably adapted for counteracting the threefold distortion of 
talipes varus. 
11. Weak Ankles.-In this affection the foot is flattened, its 
arch is sunk, and the astragalus forms a projection below the in- 
ternal malleolus, rendering the internal border of the foot convex 
instead of concave. In bad cases the inner ankle almost touches 
the ground, and the patient walks with great pain and lameness. 
This affection depends on a weakness amAelaxation of the bones 
and ligaments. It is sure to be brought on, if weakly children are 
put upon their legs too soon. It is more common amongst girls 
than boys-partly from their greater delicacy-partly because they 
are taught at an early age by ignorant governesses and dancing 
masters, that it is necessary for them to turn their feet out as much 
as possible, as the very first step towards elegance in dancing or 
walking. Thirty years ago it was a common practice to make 
school girls sit for an hour every day in a kind of stocks, with their 
feet turned outwards, so as to be almost in a straight line with each 
other. Children, however, if left to nature, stand with their toes 
slightly turned inwards-the position in fact which is the firmest, 
and most calculated to prevent this distortion whilst the bones are 
yet soft and yielding. 
Treatment.-The patient should wear shoes or boots with high 
heels, and with the inner edge of the sole much thicker than the 
outer. He should also be directed to turn the foot out very little, if 
at all. Benefit may also be derived from a well-applied bandage, 
such as is represented at p. 87. It should always be applied so as 
to be carried round the ankle from the inner side of the foot. In 
severe cases the patient should wear a tightly fitting boot, with a 
piece of steel or whalebone fastened to the sole, and passing per- 
pendicularly upwards to the middle of the inner side of the leg. 
III. Contraction of the Toes.-It often happens that one of 
the toes is permanently elevated, and rides over its neighbours, 
from the habitual use of narrow boots; and the upper surface of 
this toe being peculiarly exposed to friction, is generally covered 
with corns so painful, that many persons have been compelled to 
have the part amputated. Division of the extensor tendon may. 
however, enable the toe to be brought down into its place, and 
prevent the necessity of its removal. 
IV. Bunion-A bunion signifies a distortion of the metatarsal 
joint of the great toe ; which is thrown outwards, so that the head 
of the metatarsal bone projects and forms a swelling on the inner 
side of the foot. The skin covering it is generally very thin ; some- 
times thicker from inflammation, or from the development of a 
bursa underneath. This affection is produced, partly by the use of 
tight boots, which cramp the toes together, and force the great toe 
outwards, in order to make the foot fashionably pointed;-and it is 
partly a consequence, as Mr. Key has shown, of a weak, flattened 
state of the foot, which throws the extremity of that metatarsal 
bone forward, and the toe outwards. The ligaments of the joint 
are thus stretched and thickened, the joint is rendered unnaturally ULCERS ABOUT THE NAILS. 
515 
prominent, and subjected to pressure and friction, a bursa forms 
over it, and there is a constant state of tenderness and pain, subject 
to fits of inflammation. 
Treatment.-The patient must wear proper shoes, so arranged 
as not to press on the tender part. Mr. Key recommends the great 
toe to be kept in its proper place by means of a partition in the 
stocking like the finger of a glove, and a partition of strong cow's 
leather fixed in the sole of the shoe. A mercurial plaster on soft 
leather often gives great comfort. If the bursa inflame, it must be 
treated by rest, leeches, and poultices, in order to avoid suppuration 
and the necessity of a puncture, which is sure to lead to an invete- 
rate fistula; for which Mr. Key says, that a weak solution of 
creosote is the best application.* 
V. Contraction of the Fingers generally depends on shorten- 
ing and rigidity of the palmar aponeuroses and tendinous sheaths- 
-or on a ligamentous degeneration of the cellular tissue on the 
palmar aspect of the fingers. 
Treatment.-Friction with oily liniments, and extension upon 
splints, may be of some service. But the following operation will 
be of more : a longitudinal incision may be made through the skin 
on the palmar surface of the first phalanx, then the edges of the 
wound being held asunder, a curved bistoury may be passed under 
the contracted tissues so as to divide them. If any of the muscles 
in the forearm are rigid, their tendons may be divided by a narrow 
knife, as in the operation for club-foot. 
VI. Webbed Fingers.-This is a deformity consisting of an 
union of the fingers to each other. It may be congenital, or may 
be caused by burns. It is a most intractable affection. Mere 
division of the connecting skin is not often of any avail, for the 
fingers almost inevitably grow together again when the wound 
heals. In order to counteract their union, a flap of skin may either 
be brought from the dorsum of the hand and be engrafted between 
the fingers,-or, as Mr. Liston proposes, a perforation may first of 
all be made in the connecting skin near the roots of the fingers, and 
be prevented from closing, by keeping a piece of cord in it till the 
edges have healed, and then the remainder of the connection may 
be divided. 
VII. Ulcers about the Nails.-1. A very common and 
troublesome affection is that which is popularly termed " the growth 
of the nail into the fleshy and which most usually occurs by the 
side of the great toe. It does not, however, arise from any altera- 
tion in the nail, as its name would imply, but the contiguous soft 
parts are first swelled and inflamed by constant pressure against its 
edge from the use of tight shoes. If this state be permitted to 
increase, suppuration occurs, and an ulcer is formed with fungous 
and exquisitely sensible granulations, in which the edge of the nail 
is imbedded, and which often produces so much pain as totally to 
prevent walking. 
* Vide Key on Bunion, Guy's Hosp. Rep., vol. i.; and Fergusson's Practical 
Surgery, p. 252. 516 
WHITLOW. 
Treatment.-The objects are, to remove the irritation caused by 
the nail, and reduce the swelling of the soft parts. In most cases, 
if the nail, having been well softened by soaking in warm water, is 
shaved as thin as possible with a knife or file, or bit of glass, the pain 
and irritation may easily be allayed by rest for a day or two, with 
leeches and poultices; and then any ulcer that has formed will soon 
heal. But if the case is more obstinate, the edge of the nail must 
be removed. This may either be done in the frightfully painful 
way laid down by Sir A. Cooper and Dupuytren; that is, by passing 
the sharp blade of a pair of scissors under the nail, cutting it through, 
and then tearing away the offending portion with forceps;-or it 
may be effected after a milder fashion, by cutting through the nail 
with a penknife, just down to the thick layer of cuticle intervening 
between it and the quick, (as it is called,) and then turning it back. 
If the complaint return after this, the whole nail had better be re- 
moved by the application of a blister; or by dissecting it out, 
together with the gland that secretes it. Persons disposed to this 
affection should always wear loose shoes, and keep their nails 
scraped rather thin, so that they may be flexible. 
2. Onychia Maligna is a peculiar unhealthy ulcer occurring at 
the root of the nail, either of the fingers or toes, but more frequently 
of the latter. It commences with a deep red swelling, and an oozing 
of a thin ichor from under the fold of skin at the root of the nail; 
and lastly, an ulcer is formed, with a smooth tawny or brown sur- 
face, a very fetid sanious discharge, and swelled jagged edges of a 
peculiar livid dusky hue. It is in general extremely painful, espe- 
cially at night. 
Treatment.-Mr. Wardrop recommends mercury to be em- 
ployed, so as to affect the gums in about a fortnight; and says that 
then the swelling will generally subside, and the ulcer become clean. 
The mercurial effect should be continued gently till the sore is 
healed, and for a short time afterwards. The best local applica- 
tions arc, solution of arsenic, (liq. arsen. 5ij ad aq. sij), as recom- 
mended by Mr. Abernethy, which will generally be found to 
succeed; solution of corrosive sublimate, (P. L.,) of nitrate of silver, 
black and yellow wash, and other compounds of the same descrip- 
tion. Fumigation by means of a candle made with a drachm of 
vermilion to an ounce of wax, is also useful.* 
VIII. Whitlow, or Paronychia, signifies an abscess of the 
fingers. There are three kinds; the cutaneous, the subcutaneous, 
and the tendinous. The cutaneous whitlow consists of inflamma- 
tion of the surface of the skin of the last phalanx, with burning pain 
and effusion of a serous or bloody fluid elevating the cuticle into a 
bladder. The subcutaneous is attended with greater pain and 
throbbing, and suppuration under the skin at the root of the nail, 
which may come off. 
Treatment.-Scdbch should be made for foreign particles sticking 
in the skin; a leech may be applied, and the part be fomented in 
* Vide Lawrence, Lectures in Med. Gaz.; James Wardrop, F. R. S. E., on Dis- 
eases of the Toes and Fingers, Med. Chir. Trans., vol. v. SPURIOUS ANCHYLOSIS. 
517 
hot water; but if these measures do not speedily cause resolution, 
a pretty free incision should be made into the inflamed part. If the 
tip of the finger is long painful and tender without suppurating, it 
should be well pencilled with lunar caustic. Aperients, tonics, and 
alteratives are always of service. 
The tendinous whitlow, or thecal abscess, affects the deeper 
seated tissues, and was described at p. 217. We may observe here, 
however, that the finger should be freely laid open with a scalpel. 
If matter have extended into the palm, the incision should be con- 
tinued along the metacarpal bone till it freely gushes out. It is 
better not to cut into the spaces between the metacarpal bones, (un- 
less matter points there very decidedly indeed,) for fear of wounding 
the digital artery. If it be necessary to slit up the palmar fascia, a 
cut should be made over the head of a metacarpal bone, in order 
that a director may be passed under it. 
IX. Spurious Anchylosis.-In cases of spurious anchylosis, 
(p. 268)-that is to say, stiffness of joints depending on rigidity of 
the surrounding tissues,-or on permanent contraction of the flexor 
muscles owing to their having been long kept in a fixed position, 
-divisions of the tendons of the contracted muscles will do much 
towards restoring the mobility of the joint. The tendons of the 
ham-string muscles have been divided by Mr. Philips with great 
success in a case of stiffened knee from rheumatism. The pectoralis 
major, latissimus dorsi, teres major and teres minor muscles have 
been divided by Dieffenbach in order to effect the reduction of an 
old dislocation of the shoulder; and the pectinaeus and sartorius by 
an American surgeon, in a case of contracted hip. All these opera- 
tions are of course to be performed by what is called subcutaneous 
section; that is, in the same manner in which the tendo-achillis is 
divided. The muscle or tendon must be put on the stretch, and a 
puncture be made on one side of it. Then a curved blunt-pointed 
bistoury may be passed under it, and be made to divide it. In 
many cases it is necessary to divide the fasciae under the knee or in 
the sole of the foot, as well as the tendons. A few days after either 
of these operations some apparatus must be applied by which 
gradual extension may be made. PART V. 
OF THE OPERATIONS OF SURGERY. 
CHAPTER I. 
OF OPERATIONS IN GENERAL, AND OF THE EXTIRPATION OF 
TUMOURS. 
I. The Apparatus necessary for operations in general comprises 
one or more bistouries, scalpels, or other specific cutting instruments; 
-a dissecting forceps, a tenaculum, and small forceps (which should 
have a spring or catch) to take up arteries;-plenty of well-waxed 
ligatures, curved needles threaded, fine sponge, water both warm 
and cold, and wine and hartshorn in case of faintness. There should 
also be a sufficient number of assistants to restrain the patient's 
struggles, to administer cordials, to hand the different instruments to 
the surgeon, or to assist him in other respects,-besides a good light, 
and a bed or table with pillows or cushions to make the patient's 
position as easy as possible. 
II. Incisions.-In making incisions, there are several points that 
demand attention. First of all the manner of handling the knife,- 
which, as systematic writers say, may be held either like a com- 
mon dinner knife,-or like a pen,-or like a fiddle-stick. The first 
two positions are those which are employed commonly; the third 
is resorted to in cutting into the different layers over a hernial sac, 
and in sundry other delicate operations. Secondly, before com- 
mencing an incision, the skin must be gently stretched and steadied 
with the points of the fingers, otherwise it will be dragged along by 
the knife, and the incision will be ragged, and shorter than was in- 
tended. Thirdly, in cutting through the skin, the knife should be 
passed in at right angles to the surface, and should be at once carried 
down to the subcutaneous tissue -then the blade should be inclined 
downwards, and be made to cut through the skin to the requisite 
extent,-and lastly, as the incision is finished, the instrument must 
be again brought to a right angle with the surface. By these means 
the whole thickness of the skin will be divided, both at the begin- 
ning and end of the incision; for nothing can be more painful than 
a partial division of it. Moreover, the operator should always cut 
the skin as speedily as possible, for it is a most painful part of every 
operation. lie should also take care to make the incision quite as EXTIRPATION OF TUMOURS. 
519 
long as will be required-and rather too long than too short. To 
pause in the middle of an operation, and cut a little more of the 
skin, is most awkward on the surgeon's part, and most cruel to the 
sufferer. The author has not sufficient space to detail all the tedious 
varieties of incisions that are enumerated in systematic treatises. It 
is of little use to say that they may be made by cutting from with- 
out inwards,-or by first plunging in the instrument, and then cut- 
ting outwards (as in bleeding),-or that they may be simple or 
compound-straight, curved, or angular. It may be noticed, how- 
ever, that when two incisions are to be made to meet near their 
extremities, (as, for example, the two semi-elliptical incisions in 
amputation of the breast,) the second should fall into the first nearly 
but not quite at its extremity, so that there may be no little isthmus 
of skin left undivided between them. Again, in making a V incision, 
the second cut should not be begun where the first terminated, but at 
its other end; that is to say, it should be made towards the first, and 
not from it. In making a T incision likewise, the transverse cut 
should be made first, and the other be directed towards it. Lastly, 
the angle of a V incision should, if possible, be always dependent. 
III. The Preparation of a patient for an operation is a most 
important element in its success. The object is to have every organ 
and every function in as healthy a state as possible, and vascular 
action a little, but not too much, below par. For the full-blooded 
and inflammatory, bleeding will be requisite, and in all cases re- 
course should be had to abstinence, aperients, and gentle alteratives, 
with or without small doses of sedatives, till the pulse has become 
quiet, the tongue clean, the bowels regular, the liver, kidneys, and 
skin in good order, and the mind cheerful. Moreover, it is best not 
to perform an operation in very cold weather, if it can be avoided, 
especially upon the eye. It has also been recommended, and the 
recommendation seems rational, that the patient should be made to 
keep his bed for two or three days before an operation, in order that 
he may become accustomed to the confinement.* 
IV. Extirpation of Tumours.-A different proceeding is to be 
adopted in the case of malignant and of simple growths. In the 
former it may be necessary to remove a portion of the skin by two 
semi-elliptical incisions, if it appears to be contaminated by the dis- 
eased growth. But in extirpating wens of fatty or sarcomatous 
tumours, however large, it is a general rule not to remove any of 
the skin, unless it is much inflamed or ulcerated, or so entirely ad- 
herent to the tumour that its separation would be very tedious and 
difficult. Again, in the former case it is necessary to cut quite wide 
of the diseased mass, and remove plenty of the surrounding tissues, 
-in the latter case the incisions should be carried through the cellu- 
lar cyst of the tumour. In all cases it is a better plan (unless the 
tumour is exceedingly large) to carry the dissection at once boldly 
* Dr. Norman Chevers, and Mr. T. Wilkinson King, have shown that in most 
cases of death after operations, one of the great depurating organs of the blood- 
either the liver or kidneys-is diseased. 520 
VENESECTION. 
to the deepest part where the largest vessels enter the tumour, than 
to tie the different branches as they are divided,-by which means 
some vessels may perhaps be tied more than once. Again, it is 
requisite in every case that the extirpation be complete, because if 
the smallest portion is left, it may become the nucleus of a fresh 
growth. If, therefore, it is found that there is any portion of a tu- 
mour which cannot be cut out without fear of dangerous haemor- 
rhage, a double ligature should be passed through its base, and be 
tied tightly on each side of it. 
V. Air in Veins.-The entrance of air into a vein is a most 
dangerous accident, that has sometimes occurred during the extir- 
pation of tumours from the neck or axilla. A large vein being cut 
across, whose coats adhere to some firm textures around, so that 
they cannot collapse, a sort of bubbling, sucking noise is suddenly 
heard, the patient instantly faints, and generally dies soon after- 
wards. On examination the heart is found distended with air. If 
any such sound should be perceived during an operation, the sur- 
geon should instantly put his fingers on the spot that it proceeds 
from, and the patient, if faint, should be kept in the recumbent 
position with the head low, and should be well supplied with 
stimulants.* 
CHAPTER II. 
OF THE MINOR OPERATIONS. 
I. Venesection at the bend of the arm should always, if possi- 
ble, be performed in the median-cephalic vein. A ligature being 
placed a little above the elbow, (but not tight enough to stop the 
pulse at the wrist,) the operator takes the forearm in his hand, 
places his thumb on the vein a little below the intended puncture, 
-and then (using the right hand for the right arm and vice versd] 
pushes the lancet obliquely into the vein, and makes it cut its way 
directly outwards. When sufficient blood has been taken, the 
ligature is removed, the thumb placed on or just below the aperture 
to check the bleeding, and the wound is closed with a bit of lint 
and plaster, and secured by a small compress and figure of 8 
bandage. 
* For the best account of these curious cases, refer to Sir C. Bell's Practical 
Essays, Lond. 1841. ARTERIOTOMY, 
521 
Fig. 138.* 
Fig. 139 + 
The jugular vein is sometimes opened in cases of apoplexy in 
adults, and in children if the veins at the elbow are hidden by fat. 
The thumb is placed on the vein a little above the clavicle, and an 
incision made in the ordinary way with the lancet, cutting obliquely 
upwards and outwards. The thumb is removed when enough 
blood is obtained, and the wound secured with lint and plaster. 
The veins in the leg, scrotum, or neighbourhood of the eye or ear, 
can readily be opened in the same manner instead of the ordinary 
venaesection, or leeching, or cupping. 
Abscess in the cellular tissue, inflammation of the fascia, phlebitis, 
neuralgia, varicose aneurism, and aneurismal varix, are occasional 
ill consequences of venaesection. 
II. Arteriotomy.-The temporal artery should be opened above 
the outer angle of the eyebrow-not just above the zygoma. -The 
* [The veins of the forearm and bend of the elbow. 1. The radial vein. 2. The 
cephalic vein. 3. Anterior ulnar vein. 4. The posterior ulnar vein. 5. The trunk 
formed by their union. 6. The basilic vein, piercing the deep fascia at 7. 8. The 
median vein. 9. A communicating branch between the deep veins of the forearm 
and the upper part of the median vein. 10. The median cephalic vein. 11. The 
median basilic. 12. A slight convexity of the deep fascia, formed by the brachial 
artery. This fascia is divided and turned aside in fig. 139 to show the brachial 
artery. 13. The process of fascia, derived from the tendon of the biceps, and 
separating the median basilic vein from the brachial artery. 14. The external 
cutaneous nerve, piercing the deep fascia, and dividing into two branches, which 
pass behind the median cephalic vein. 15. The internal cutaneous nerve, dividing 
into branches, which pass in front of the median basilic vein. 16. The intercosto- 
humeral cutaneous nerve. 17. The spiral cutaneous nerve, a branch of the mus- 
culo-spiraL] 
f This cut shows the veins of the bend of the elbow, together with the relation 
of the brachial artery to the median basilic vein. 522 
CUPPING. 
surgeon feels for the largest branch, steadies it with two fingers, one 
placed above, and the other below the intended puncture-then 
pushes in the lancet in the same manner as in vena?section. The 
incision should be directed across the vessel, and should cut it about 
half through. When sufficient blood has flowed, the best plan is 
to introduce the lancet, and cut the vessel completely across, so that 
its ends may retract. A firm graduated compress should then be 
applied, and be confined with a bandage passing round the head; 
and some degree of pressure should be kept up on the wound for a 
week or ten days. Any subsequent bleeding or spurious aneurism 
must be treated by completely dividing the artery, if it has not been 
done already, and by pressure,-but if the wound is much inflamed 
or ulcerated, so as not to admit of pressure, a transverse incision 
should be made on each side of it, and the artery be tied in both 
places. 
III. Cupping.-The patient being placed in a comfortable posi- 
tion, with towels arranged so that his clothes may not be soiled by 
the l?lood, and being moreover protected from cold, so that the flow 
of blood to the surface may not be checked, and the operator 
having his scarificator, glasses, torch, spirits of wine, lighted candle, 
hot water, and sponge, conveniently arranged on a table close by, 
-the first thing is to sponge the skin well with hot water, so as to 
make it somewhat vascular. The operator next dries it with a 
warm towel, and adapts his glasses to the part. Their number 
must depend on the quantity of blood to be taken-from three to 
five ounces is a fair calculation for each glass. In the next place, 
he dips the torch in the spirit, sets it on fire, introduces it for half a 
second into one of the glasses, and immediately claps the latter on 
the skin-and the same with the other glasses in succession. As 
soon as the skin has become red and swollen, he charges the 
scarificator, and takes it between his right forefinger and thumb, 
at the same time holding the lighted torch between the little and 
ring fingers of the same hand. He then detaches one glass by 
insinuating the nail of his left forefinger under its edge-instantly 
discharges the scarificator on the swollen skin, and as expeditiously 
as possible introduces the torch into the glass, and applies it again. 
The same process is repeated with the other glasses. When they 
become tolerably full, or the blood begins to coagulate in them, 
they must be detached in succession and reapplied, if blood enough 
has not been taken-and When the operation is finished, the wounds 
should be closed with lint and plaster. There are several points 
connected with this operation that require notice. In the first 
place, the glasses must not be exhausted too much; if they are, 
the pressure of their rims will occasion severe pain-the blood will 
not flow-and the operation will very probably be followed by a 
considerable ecchymosis. Secondly, the position of the glasses 
must be slightly varied each time they are applied, so that their 
edges may not again press on the same circle of skin. Thirdly, 
the expediency of not burning the patient needs scarcely be hinted 
at. Fourthly, in taking off the glasses, the upper part of each 
should be detached first, so that the blood may not escape. Lastly, ACTUAL CAUTERY. 
523 
the length of the scarificators must be adjusted to the thickness of 
the skin; for if the incisions are too deep, the fat will protrude 
through them, and prevent the flow of blood. The direction of the 
incisions should correspond to the course of the muscular .fibres 
beneath; but this is of no great consequence. For cupping on the 
temples smaller glasses and scarificators are employed. A branch 
of the temporal artery is generally wounded, and the flow of blood 
may be expedited by slightly lifting the lower part of the rim of 
the glass. Pressure should be kept up on the wounds for some 
days afterwards, in order to prevent secondary haemorrhage or 
false aneurism. 
IV. Acupuncture is easily performed by running in five or six 
needles with a rotatory motion. It is certainly very efficacious in 
some cases of neuralgia, but it is by no means easy to explain its 
operation. Acupuncture is also resorted to in anasarca, when the 
skin is much distended;-and we have spoken of its utility in gan- 
glion, hydrothorax, and ascites, for the purpose of permitting the 
serum to exude into the cellular tissue. 
V. Issues may be made by caustic or by incision, or by the actual 
cautery. The first may be made either by rubbing a portion of 
skin of the requisite extent with the potassa fusa, or by making a 
paste with equal parts of the potass and soft soap, and laying it on 
the skin till the latter is converted into a black slough. The parts 
immediately around the tissue should be protected with several 
layers of sticking plaster. After the application of the caustic, the 
part should be poulticed till the slough separates, and then the 
sore may be prevented from healing, either by binding several peas 
firmly on its surface, or by touching it occasionally with the caustic. 
The second species of issue is made by pinching up the skin, and 
slitting it up with a lancet, and then introducing some peas to pre- 
vent it from healing. It may be remarked, that issues should never 
be made over projecting points of bones, nor over the bellies of 
muscles; for they might degenerate into most obstinate sores. 
Thus, for diseased vertebrae, the issues should be made between the 
spinous and transverse processes;-for diseased hip, behind the 
great trochanter, and not over it,-for diseased knee, just below 
the inner tuberosity of the tibia. 
VI. The Actual Cautery is certainly a very efficient, and it is 
very far from being the most painful, manner of effecting counter- 
irritation. On the contrary, its effects are more speedy, and attended 
with far less suffering. It is easily effected by means of an iron rod, 
with a knob of the size and shape of an olive at one end of it, and 
a wooden handle at the other. The knob being heated red hot, is 
rubbed on the skin so as to make two or three blackened lines about 
half an inch wide, and an inch asunder. Then the cold water 
dressing or a poultice may be applied till the shallow eschars sepa- 
rate ;-and it appears to be better to keep the sores open by touch- 
ing them occasionally with the cautery, than by the ordinary irri- 
tating dressings. 
VII. Setons are introduced by pinching up a fold of the skin, 524 
electricity and galvanism. 
and pushing a needle through it armed with a skein of silk or 
cotton, or a long Hat piece of Indian-rubber. As soon as one or 
two inches of the thread are brought through, the needle is cut off. 
A fresh portion of the thread is to be pulled through the wound 
every day, so as to keep up a constant irritation and discharge. If 
the discharge is insufficient, the thread may be covered with some 
irritating ointment before it is drawn under the skin. 
VIII. The Moxa is a peculiar method of counter-irritation long 
practised in the East, and occasionally employed in Europe, for the 
relief of chronic nervous and rheumatic pains, or for chronic dis- 
eases of the joints. One or more small cones, formed of the fine 
fibres of the artemisia chinensis, or of some other porous vegetable 
substance-such as German tinder, or linen impregnated with nitre, 
are placed on the skin over the affected part, and then are set on 
fire, and allowed to burn away so as to form a superficial eschar. 
The surrounding skin must be protected by a piece of wet rag, 
with a hole in it for the moxa. 
It is convenient sometimes to use the moxa as a rubefacient or 
vesicant, and not as a cauterant. A roll of German tinder ignited 
may be held with dressing forceps at a little distance from the skin, 
the surgeon at the same time blowing upon it with a blow-pipe, 
till the skin becomes red. 
IX. Vaccination.-The success of this operation will depend 
partly on the state of health of the patient-for it will most proba- 
bly be defeated if there is any cutaneous disease or disorder of the 
system generally-and partly on the quality of the matter which is 
inoculated. The matter should be taken on the eighth day, before 
an inflamed areola is spread around the vesicle, and it should be 
lymph, clear and transparent, not purulent. The operator should 
make three punctures on one arm with a fine lancet, carrying the 
point of the instrument obliquely under the cuticle for about one- 
eighth of an inch, and, if possible, without drawing blood. Then, 
if he has a patient to take the matter from, he ruptures a portion of 
the vesicle, dips the lances in the lymph, and inserts it into each 
puncture. If he has the matter on points, he should breathe on 
them so as to liquefy it, and then insert one into each puncture, 
and allow it to remain three or four minutes. 
X. Electricity and Galvanism.-Although these powerful 
agents have been by turns overrated and decried, and have lost 
much of their therapeutical reputation, through having been re- 
sorted to as the last desperate remedy in cases where it was irra- 
tional to expect benefit from them, still no one who knows how to 
use them can doubt their efficacy. In certain cases of defective 
circulation and nervous influence;-when the thigh is weakened 
and benumbed after sciatica;-in cases of atrophy of the extremi- 
ties after fever;-when the extensors are paralyzed from long dis- 
use, as after disease of joints; -in deficient menstruation;-in 
dyspnoea from weakness of the stomach;-in loss of voice from 
relaxation of the mucous membrane of the fauces;-in hysterical 
neuralgia, and in other causes of nervous pain unattended with AMPUTATION OF THE THIGH. 
525 
increased vascularity, they may be resorted to with every prospect 
of benefit. But the cases to which they are most applicable, are 
those of asphyxia, from poisoning, or hanging, when the affusion 
of cold water, and other stimulants, fail to excite the action of 
respiration. The best method in these cases is, to place one wire 
at the nape of the neck, and the other at the pit of the stomach;- 
or, if the sensibility is so feeble that this fails to take effect, a needle 
may be inserted deeply between the eighth and ninth ribs on either 
side, so as to reach the diaphragm, and the current be passed 
between them. The most convenient apparatus seems to be a 
single battery on Smee's or Daniell's principle, with a coil wound 
around a piece of soft iron, which is thereby converted into a tem- 
porary magnet, and a contrivance for interrupting the circuit, and 
giving a stream of gentle shocks. 
XI. Galvano-puncture.-In obstinate neuralgia it is a good 
plan to insert two needles deeply, at two points in the course of the 
nerve, and to pass a galvanic current through them. 
XII. Bandaging.-The art of bandaging is not to be learned 
from books. Nor is it worth while to dwell upon the almost innu- 
merable kinds of bandage that are described in the older systems 
of surgery. The suspensory or T bandage-the three-tailed, the 
four-tailed, and many-tailed-the single and double-headed, the 
retentive, expulsive, and uniting bandages,-many of them have 
fallen into oblivion, and the use and application of the others are 
readily acquired in a few months' attendance on hcrspital practice. 
The general rules to be observed in bandaging a limb are, to begin 
at the extremity, and apply the bandage most tightly there, and 
more loosely by degrees as it ascends-to make each successive 
fold overlap about one-third of the preceding-to keep the bandaeg 
close to the limb, and unrol very little of it at a time-and to double 
it on itself on parts (such as the calf of the leg) where it would not 
lie smoothly otherwise. 
CHAPTER HL 
OF THE AMPUTATIONS. 
I. Amputation of the Thigh.-This amputation being proba- 
bly the most important, and one that is very frequently practised, it 
will be convenient to describe it first; and to embody in the descrip- 
tion of it, such general precepts as are applicable to the other am- 
putations. 526 
AMPUTATION OF THE THIGH, 
In the first place, the 
surgeon should have his 
tourniquets, amputat- 
ing knives, saws, for- 
ceps and tenacula, 
ligatures, bone-nippers, 
sponges, and curved 
needles threaded, close 
at hand on a tray, ar- 
ranged in due order; 
and he should see with 
his own eyes that every 
requisite is at hand be- 
fore he begins. 
The next point is, to 
place the patient in 
a convenient posture. 
For amputation of the 
thigh, the patient may 
be placed on a bed, or 
on a table covered with 
a folded blanket;-the 
diseased leg should pro- 
ject sufficiently over the 
edge, and should be supported at the knee by an assistant, who 
sits on a low stool in front;-and the sound limb should be secured 
to one of the legs of the table with a handkerchief. 
Then measures must be adopted for compressing the main artery, 
and preventing too great loss of blood. This may be done, either 
by pressure with the hand, or with the tourniquet. Pressure with 
the hand on the main arterial trunk, if effected by a steady assistant 
who can be trusted, is sufficient in most cases; and if the limb is 
amputated so high up that the tourniquet cannot be applied, there 
is of course no choice;-the femoral artery must be compressed 
against the ramus of the pubes. 
The common tourniquet consists of three parts,-a pad to com- 
press the artery, which should be firm, narrow, and flattish;-a 
strong band which is buckled round the limb;-and a bridge-like 
contrivance, over which the band passes, with a screw, by turning 
which the bridge is raised and the band tightened. The band 
should always be placed so as to compress the artery against the 
bone. The advantage of this instrument is, that it compresses the 
smaller arteries as well as the principal trunk;-its disadvantage is, 
that it arrests the venous circulation, and causes a greater loss of 
venous blood;-wherefore, it should never be constricted tightly 
until the incisions are just commencing. 
This, like other amputations, may be performed in two ways- 
either by the circular incision-that is, by cutting round the limb 
from without towards the bone; or by the flap operation-that is, 
by transfixing the limb, and then cutting outwards. The flap 
Fig. 140. AMPUTATION OF THE THIGH. 
527 
operation is the favourite with the rising generation of surgeons; it 
certainly can be performed with much more facility; it enables the 
surgeon to select a flap where he pleases, so that when the flesh 
on one side of the limb is destroyed by disease or injury, the end of 
the stump may be covered with a flap taken almost entirely from 
the sound side, and a greater length of limb may be preserved. It 
affords, too, a greater certainty of preserving a sufficiency of flesh to 
cover the bone; and it enables the muscles to be more easily re- 
tracted, and the bone exposed for the application of the saw. It 
entirely avoids the difficulty, also, which sometimes occurs in the 
circular operation of retracting the skin, when it has become adhe- 
rent to the part beneath. But as Sir C. Bell observes, the grand 
rule in all cases is, to save integument enough to cover the muscle, 
and muscle enough to cover the bone, and not to scrape off the 
periosteum. And if these things are done, it requires ingenuity to 
make a bad stump. 
(1.) Circular Method.-The surgeon stands on the outer side 
for the left leg, and on the inner for the right; so that he may use 
his left hand to grasp and steady the part which he is to amputate. 
The artery must be compressed by one of the methods before 
described, and an assistant must grasp the limb with both hands, 
so as to draw up the skin as high as possible. Then the surgeon 
commences by putting his arm under the thigh, and makes an inci- 
sion at one sweep completely round the limb, through the skin and 
fat down to the fascia. The assistant is now to draw the skin 
further up, the refraction being aided by a few touches with the 
knife; and then the knife, being put close to the edge of the re- 
tracted skin, is to be made to divide every thing down to the bone by 
another clean circular sweep. The next thing is, to separate the 
muscles from the bone for another inch or two with the point of 
the knife, especially those connected with the Unea aspera; and 
then the periosteum having been divided by one more sweep-the 
retractor,-a piece of linen with a longitudinal slit in it, is put over 
the face of the stump,-and the muscles are to be drawn up with 
it. Now the bone must be sawn through. The heel of the saw 
should first be put on the bone, and it should be drawn up so as to 
make a groove, before working it downwards; it should be used 
very lightly, and the last few strokes should be excessively short 
and gentle, that the bone may not be splintered. If it is, the irregu- 
lar part must be removed with nippers. The femoral artery should 
now be tied, its orifice being seized and slightly drawn out by for- 
ceps ; and afterwards any large branches that appear in the mus- 
cular interstices. Then all compression should be suddenly ceased, 
so that any arteries that are liable to bleed may do so, and be tied 
at once. Haemorrhage from large veins is to be restrained by 
elevating the stump, and making compression for a short time with 
the finger. If, however, nothing else will do, they must be tied. 
Any obstinate oozing from small vessels should be restrained by 
sponging with cold water, or perhaps by a touch with arg. nitras. 
Then a light bandage may be passed round the limb above the 528 
ANPUTATION OF THE THIGH. 
stump, and the edges of the wound should be approximated witli 
a few strips of plaster, with or without sutures. The edges are to 
be brought together in a straight line, which may be made either 
perpendicular or horizontal, the latter, however, being probably the 
better plan. Tiie ligature should be left hanging out in the inter- 
stices of the adhesive straps. The patient should then be removed 
to bed, and the stump be supported on a pillow covered with oil- 
cloth. No other application will be needed save a cloth dipped in 
cold water. Pain may be allayed by an opiate. The stump may 
remain as it is for some days, the discharge being merely wiped 
occasionally from its surface. But, after from four to six days, 
sooner or later, according to the quantity of the discharge and the 
feelings of the patient, the dressings should be changed, the straps 
being taken off and replaced one by one, with care not to disturb 
the ligatures, and the hands of an assistant being employed to sup- 
port the edges, and prevent theiF falling asunder. At the subse- 
quent dressings, the points to be attended to are, to renew the light 
bandage occasionally, which was passed round the stump soon 
after the operation, in order to support the muscles, and prevent 
their retraction-to bring together the edges of the wound with 
adhesive straps-to remove the ligatures when loose-(that on the 
femoral artery should not be disturbed for a fortnight)-and to 
accelerate cicatrization by the nitrate of silver, or other stimulants, 
if the granulations appear languid. 
There are a few varieties in the manner of performing this cir- 
cular operation that require a brief notice. Some surgeons, after 
having cut through the skin, dissect it from the fascia, and turn it 
back-a proceeding necessary enough if this operation is performed 
(which it never should be) when the cellular tissue is condensed 
and adherent. Again, if the patient is very emaciated, the circular 
incision may be carried down to the bone at once without cere- 
mony, because in such patients the muscles always retract greatly. 
Sir C. Bell recommends the skin not to be divided quite circularly, 
but the knife to be inclined a little, first to one side, then to the 
other, so as to make two oval flaps. The same may be done also 
in dividing the muscles. He further recommends that the limb 
should be raised perpendicularly whilst the bone is being sawn, so 
that the saw may be worked horizontally, by which means, he 
says, the bone may be divided more evenly, and much shorter, so 
ttyat its end will be no more seen when the stump is depressed. 
(2.) Flap Operation.-The flaps may be made, either from the 
inner and outer, or from the anterior and posterior aspects of the 
limb. The latter way is the most convenient if the amputation is 
low down; but the former, if it is in the middle or upper third; 
because the end of the bone is liable to be tilted forwards by the 
iliacus and psoas muscles, and to project between the lips of the 
wound. In performing this operation, the surgeon, standing as 
before,* grasps the flesh on the anterior surface of the limb with 
* Mr. Fergusson thinks it more convenient that the surgeon should stand on the 
outer side in amputating the right thigh, as it is awkward to stoop over the sound 
limb; which, moreover, is in the way of the surgeon's hand. 529 
AMPUTATION of the hip-joint. 
Fig. 14L 
his left hand, and lifts it from the bone ; then passes his knife hori- 
zontally through it-carries the point over the bone,-pushes it 
through the other side of the limb, as low as possible ;-then makes 
it cut its way out upwards and forwards, so as to make the anterior 
flap. In amputating the right leg, the knife should be passed in 
behind the saphena vein. It is again entered on the inner side a 
little below the top of the first incision, passed behind the bone, 
brought out at the wound on the outside, and directed so as to 
make a posterior flap in the direction of the dotted line. This 
should be a very little longer than the anterior, because the flexor 
muscles retract more than the extensors which are adherent to the 
bone. Both flaps are now drawn back; the knife is swept round 
the bone to divide any remaining muscular fibres, and the bone is 
sawn through. In the same manner flaps may be made from the 
inner and outer sides of the limb, the surgeon first grasping the 
flesh, and transfixing it, and cutting a flap on one side of the bone, 
then passing the knife close to the bone on the other side, (without 
again piercing the skin,) and making another flap. 
II. Amputation at the Hip-joint is performed by Mr. Liston 
after precisely the same manner in w*hich he amputates the thigh. 
The femoral artery being compressed, the knife is entered about 
midway between the anterior superior spinous process of the ilium 
and the trochanter and is carried across the front of the articulation, 
so as to form the anterior flap. Then the anterior part of the cap- 
sular ligament being cut into, and the ligarnentwni teres and pos- 
terior part of the capsular ligament being divided, the blade of the 
knife is put behind the neck and trochanters of the femur, and the 
posterior flap is formed. The vessels on the posterior flap are tied 
first. But this method can hardly be preferable to that of making 
two lateral flaps ;-first, passing the knife completely through the 
limb on the inner side of the joint, and carrying it forwards and 
inwards, so as to form a flap of the adductor muscles; then cutting 
into the joint, and severing the ligamentum teres, and the muscles 
attached to the digital fossa with a short strong curved knife ; and 530 
AMPUTATION OF THE LEG. 
lastly, putting in the knife over the trochanter, and cutting down- 
wards and outwards, so as to make the external flap. In this 
manner Mr. Mayo performed this operation in less than half a 
minute. He previously tied the femoral artery below Poupart's 
ligament; but most authorities prefer compressing it during the 
operation, and tying its cut orifice afterwards. 
III. Amputation of the Leg.-The rule generally given is, 
that this operation should be performed as near the knee as possible, 
unless the patient can afford an artificial foot; because a labouring 
man would find it very inconvenient to have a long stump trailing 
after him; as it would if he rested on the bent knee with the ordi- 
nary wooden leg. But a wooden leg may be procured, which is 
light and inexpensive, and which enables the patient to rest on the 
stump and to have the use of the knee; and therefore it is better 
not to sacrifice more of the limb than can be avoided. 
(1.) Circular Method.-The artery being under command, as in 
amputations of the thigh, and the leg being placed horizontally, one 
assistant supporting it at the ankle, and another holding it at the 
knee and drawing up the skin,-the surgeon (standing on the inner 
side for the right leg, and vice versd) makes a circular incision 
through the skin, four inches below the tuberosity of the tibia. The 
integuments are next to be dissected up for two inches, and turned 
back, and the muscles are to be divided down to the bone by a 
second circular incision. Then a long slender double-edged knife, 
called a catline, is passed between the bones to divide the inter- 
osseous ligament and muscles, and both bones are sawn through to- 
gether, the flesh being protected by a retractor, which should have 
three tails. The spine of the tibia, if it projects much, may be re- 
moved with a fine saw or bone nippers, and care should be taken 
not to leave the fibula longer than the tibia, or it will give much 
trouble. The anterior and posterior tibial and peronaeal arteries, 
and any others requiring it, being tied, the stump is to be treated as 
directed after amputation of the thigh. The integuments should be 
put together, so as to make a perpendicular line of junction. 
(2.) But it is agreed'on all sides that the flap operation-is by far 
the best for this situation, and the easiest way of performing it is as 
follows:-The surgeon passes his knife horizontally behind both 
bones at the level of an inch below the head of the fibula, and cuts 
downwards and forwards, so as to make a flap of the posterior 
muscles about four or five inches long. A semilunar incision, with 
the convexity downwards, is then made across the front of the limb, 
the skin is slightly turned back, the parts between the bones are 
divided, and the bones are sawn as before. But the manner in 
which Mr. Fergusson performs this amputation renders it by far the 
most elegant and expeditious operation which the author ever wit- 
nessed. He first places the heel of the knife on the side of the limb 
farthest from him, and draws it across the front of the limb, cutting 
a semilunar flap of skin; when its point has arrived at the oppo- 
site side it is at once made to transfix the limb ;-[see fig. 142]- 
and then the flap is cut, as above directed. When transfixing the AMPUTATION OF THE ARM. 
531 
Fig. 142. 
right limb, the surgeon must take great care not to get his knife 
between the two bones. When the operation is performed high up, 
the popliteal artery will be divided instead of the two tibials. The 
tibia, however, should never be sawn higher than its tuberosity, or 
the joint will be laid open. The amputation may be performed near 
the ankle in the same manner. If low down, the tendo-achillis 
will require to be shortened after the flap is made. The flap is to 
be brought forwards, and confined by a stitch or two; the line of 
junction being of course horizontal. 
IV. Amputation of the Arm.-In amputation of the upper 
extremity, the flow of blood may be sufficiently commanded by 
compressing the artery above the clavicle, or in the arm. If it is 
thought proper, however, the tourniquet may be applied so as to 
compress the artery against the humerus. 
Fig. 143. 
(1.) Circular.-The arm being held out, and an assistant draw- 
ing up the skin, one circular incision is made through the skin, 
which being forcibly retracted, another is made down to the bone. 532 
AMPUTATION AT THE ELBOW. 
These incisions should be made with two slight divergences, so as to 
cut the skin and muscles rather longer in front and behind than at 
the sides. The subsequent steps are precisely similar to those in 
amputating the thigh. 
(2.) Flaps.-The knife is entered at one side, carried down to 
the bone, turned over it, brought out at a point opposite, (the 
vessels being left behind for the second flap,) and then made to cut 
a neat rounded anterior flap two or three inches long. It is next 
carried behind the bone, to make a posterior one of equal length; 
and is lastly swept round the bone, to divide any remaining fibres. 
The division of the bone, ligature of the arteries, and treatment of 
the stump as before. 
V. Amputation at the Shoulder may be performed in several 
manners. (1.) The patient being seated in a chair, and well sup- 
ported,-or which is better, being placed on a firm table, with the 
shoulder elevated, and projecting beyond its edge,-and the sub- 
clavian artery being compressed, the surgeon enters a long straight 
knife at the anterior margin of the deltoid muscle, an inch below 
the acromion. From this point he thrusts it through the muscle, 
across the outside of the joint, and brings out the knife at the 
posterior margin of the axilla. If the left side is operated on, the 
knife must be entered at the posterior margin of the axilla, and be 
brought out at the anterior margin of the deltoid muscle. Then, by 
cutting downwards and outwards, the external flap is made. The 
origins of the biceps and triceps, and insertions of the infra and 
supra spinatus, are next cut through, and the joint is laid open. 
Finally, the blade of the knife, being placed on the inner side of 
the head of the bone, must be made to cut the inner flap. 
(2.) The covering for the exposed part of the scapula, in the pre- 
ceding operation, was obtained from the deltoid. But it may also 
be obtained from the muscles in front or behind, supposing the 
deltoid to be implicated in the disease or injury which demands the 
operation. One elliptical incision may be carried from beneath the 
middle of the acromion to the posterior border of the axilla, and 
another to the anterior border. These flaps being dissected up, the 
head of the bone may be turned out of the socket, and the remain- 
ing soft parts be divided ; or the bone may be sawn through just 
beneath its neck. An assistant should be directed to grasp the flap 
which contains the axillary artery as soon as it is divided; because 
the pressure above the clavicle is generally not sufficient to stop 
the circulation. 
VI. Amputation at the Elbow is performed by passing the 
knife through the muscles in front of the joint, and cutting upwards 
and forwards, so as to make a flap of them. Then the operator 
(who stands on the inner side for the right arm, and vice versa) 
makes a transverse incision behind the joint. He next cuts through 
the external lateral ligament, and enters the joint between the head 
of the radius and external condyle, then divides the internal lateral 
ligament, and lastly saws through the olecranon, the apex of which, 
with the triceps attached to it, is of course left in the stump. AMPUTATION OF THE WRIST. 
533 
VII. Amputation of the Forearm should always be per- 
formed as near the wrist as possible. 
(1.) Circular-The limb being supported with the thumb upper- 
most, and an assistant drawing up the skin, a circular incision is 
made through it down to the fascia. When the skin has again 
been retracted as much as 
possible, the muscles are 
divided by a second circu- 
lar incision; the interos- 
seous parts and the remain- 
ing fibres are next cut 
through with a catline; the 
flesh is drawn up with a 
three-tailed retractor, one 
tail of which is put between 
the bones, and the bones 
are then to be sawn through 
together, the saw being 
worked perpendicularly. 
The radial, ulnar, and two 
interosseous arteries re- 
quire ligature. 
(2.) Flaps.-The limb 
being placed in a state of 
pronation, the surgeon 
makes a flap frqm the ex- 
tensor side, just as is represented in the cut (fig. 144); and then 
he transfixes the flexor side, and makes the other flap;-taking 
care not to pass the knife between the bones, whilst performing 
either transfixion. The interosseous parts are next divided, the 
flesh drawn upwards, and the bones sawn through. If the tendons 
project, they must be shortened. 
VIII. Amputation of the Wrist.-(1.) Circular.-The skin 
being pulled back, a circular incision is made a little below the 
level of the line that separates the forearm from the palm of the 
Fig. 144. 
Fig. 145. 534 
AMPUTATION OF THE HAND. 
hand. The external lateral ligament is then cut through, and the 
knife carried across the joint, to divide the remaining attachments. 
(2.) Flaps.-A semilunar incision is made across the back of 
the wrist, its extremities being at the styloid processes, and its 
centre reaching down as far as the second row of carpal bones. 
This flap being dissected up, the joint is opened behind, the lateral 
ligaments are cut through, and the knife, being placed between the 
carpus and bones of the forearm, is made to cut out a flap from the 
anterior surface of the palm, as represented in the figure. 
This operation is scarcely to be preferred to amputation of the 
forearm low down; as the flaps with their numerous tendons may 
not unite readily, and there may be a difficulty in preserving flesh 
enough to cover the ends of the bones. 
IX. Amputation of the Hand. -(1.)-Amputation of the 
gers or thumb at their last joint maybe performed thus: The 
surgeon holds the phalanx firmly between his finger and thumb, 
and bends it, so as to give prominence to the head of the middle 
phalanx. He then makes a straight incision across the head of 
the middle phalanx, so as to cut into the joint, and takes care to 
Fig. 146. 
carry it deeply enough at the sides to divide the lateral ligaments. 
The joint being then thoroughly opened, the bistoury is carried 
through it, and made to cut a flap from the palmar surface of the 
last phalanx, sufficient to cover the head of the bone; and it is 
better to leave too much than too little. 
If, however, the jojnt cannot be bent, this operation may be per- 
formed thus: The surgeon holding the phalanx firmly, with its 
palmar surface upwards, first passes his knife horizontally across 
the front of the joint, the flat surface towards it, and cuts out the AMPUTATION OF THE FINGERS. 
535 
anterior flap; then divides the lateral ligaments and the remaining 
attachments with one sweep of the knife. 
(2.) Amputation at the second joint of the fingers or thumb may- 
be performed in the same manner. 
(3.) It is always expedient to save as much as possible of the fore- 
finger and thumb; consequently, in cases admitting of it, a flap 
may be made from the soft parts in front; those behind may be 
divided by a semilunar incision, and then the bone may be sawn 
through, or be cut with bone nippers. 
(4.) Amputation of a finger at the metacarpal joint may be 
effected by making a semilunar incision on one side of the promi- 
nence of the knuckle, from a quarter of 
an inch beyond the joint, to the mid- 
dle of the digital commissure on the 
other side of it. ' The finger being then 
drawn to the other side, the extensor 
tendon is cut through, and the point of 
the bistoury is passed into the joint, and 
made to divide its ligaments. This will 
allow the head of the bone to be turned 
out, so that the bistoury being placed be- 
hind it may cut through the remaining 
attachments, as represented in the fig. 
and make another flap. This operation 
may also be performed by making an 
incision on one side of the joint, (as in 
the method just described,) and then 
bringing it across the palmar surface, 
and round the other side, to terminate 
where it began. The tendons and liga- 
ments are now to be divided, and the 
head of the bone turned out. The digital arteries must be tied, and 
after bleeding has ceased, the wound may be closed by confining 
the adjoining fingers together. It must be recollected, that the 
situation of this point is full half an inch above the lines that divide 
the fingers from the palm. 
(5.) Amputation of the metacarpal bone of the thumb is per- 
formed thus: The thumb being separated from the fingers, an in- 
cision must be carried from the centre of the commissure between 
it and the forefinger, down to the articulation with the trapezium. 
The incision should be inclined rather towards the metacarpal bone 
of the thumb. The thumb being then forcibly abducted, the blade 
of the bistoury is to be carried through the joint (which, it must be 
recollected, lies obliquely in a line extending to the root of the little 
finger); the head of the bone is to be forcibly dislocated towards 
the palm; the knife is then made to cut its way out, so as to form 
a flap of the skin and muscles which constitute the ball of the thumb. 
When the metacarpal bone of the thumb alone is diseased, it 
should, as Mr. Fergusson advises, be extirpated alone, and its pha- 
langes should be preserved. The bone should be exposed by means 
Fig. 147. 536 
AMPUTATION OF THE FOOT. 
of an incision along its radial margin; then its articulation with the 
phalanges should be divided ; and lastly, it may be turned out and 
separated from the trapezium ;-taking care not to wound the radial 
artery where it passes between the first and second metacarpal 
bones. 
(G.) Amputation of the metacarpal bone of the little finger, at 
the joint between it and the unciform, is performed thus : The flesh 
and the integuments being grasped, and drawn away from the ulnar 
side of the bone, a bistoury is passed perpendicularly through them 
close to the joint, and made to cut its way downwards to a little 
beyond the articulation with the first phalanx. The skin of the hand 
being next strongly drawn towards the thumb side, the bistoury is 
placed on the other side of the bone, (without again piercing the 
skin,) and carried along so as to divide every thing down to the 
digital commissure. Then the ligaments of the joint are to be divided, 
first on the inner, and next on the dorsal aspect. It is, however, a 
much better plan, if it can be effected, to cut through the bone by 
means of the saw or bone nippers, than to remove it at the articu- 
lation. 
(7.) Amputation of the head of a metacarpal bone is effected by 
making an incision on each side 
of it, (as in amputation of the 
fingers at the joint, but extending 
rather higher up,) and then cut- 
ting through the bone with the 
cutting-forceps. Mr. Fergusson 
recommends the head of the 
metacarpal bone to be removed 
in almost every instance where 
the entire finger is abstracted, 
because the deformity is much 
less. But the part need not be 
removed high enough up to 
divide the transverse ligament. 
Care must be taken during the 
cure, to keep the fingers parallel, 
and prevent their crossing at their tips. 
If a part or the whole of the shaft of one of these bones is to be 
removed also, an incision should be made along its dorsum, to the 
point where the two former ones meet; and then the flesh being 
dissected away on either side, the bone may be cut through or 
disarticulated according to circumstances. 
X. Amputations of the Foot.-(1.) Amputation of the toes at 
any of their joints is performed in precisely the same manner as 
amputation of the fingers. In removing a single toe from its 
metatarsal bone, the surgeon should take care first of all to ascer- 
tain the exact situation of the joint, which lies rather deeply. 
Moreover, he should not remove the head of the metatarsal bone, 
as he may of the metacarpal, because it is important to preserve 
the entire breadth of the foot. 
Fig. 148. 537 
AMPUTATION OF THE FOOT. 
(2.) Amputation of all the toes at their metatarsal joints-an 
operation which may be requisite in cases of frost-bite-is performed 
by first making a transverse incision along the dorsal aspect of the 
metatarsal bones-dividing the tendons and lateral ligaments of 
each joint in succession ; and then, the phalanges being dislocated 
upwards, the knife is placed beneath their metatarsal extremities, 
and made to cut out a flap from the skin on the plantar surface, 
sufficient to cover the heads of the metatarsal bones. The arteries 
are to be tied, and the foot laid on its outer side, so that the dis- 
charge may escape more readily. 
(3.) Amputation of the metatarsal bone of the great toe is 
performed precisely like the operation for the removal of the meta- 
carpal bone of the little finger. It is better, if circumstances permit, 
to cut through the bone, than to disarticulate it from the internal 
cuneiform bone, and it may be observed that, in dividing the 
metatarsal bones of the great or little toes, or the metacarpal bones 
of the fore or little finger, the forceps should be held obliquely, so 
as not to leave any prominent angle. 
(4.) Amputation of all the metatarsal bones is performed in the 
following manner: The exact situation of the articulation of the 
great toe to the inner cuneiform bone (to which the tendon of the 
tibialis anticus may serve as a guide) being ascertained, a semi- 
lunar incision, with the convexity forwards, is made down to the 
bone, across the instep, from a point just in front of it, to the outside 
of the tuberosity of the fifth metatarsal bone. The flap of skin thus 
formed being turned back, the bistoury is to be passed round 
behind the projection of the fifth metatarsal bone, so as to divide 
the external ligaments which connect it with the cuboid. The 
dorsal ligaments are next to be cut through, and then the remain- 
ing ones, the bone being depressed. The fourth and third metatarsal 
bones are to be disarticulated in a similar manner, dividing their 
ligaments with the point of the knife, and taking care not to let the 
instrument become locked between the bones. The first metatarsal 
is next to be attacked, and lastly the second, the extremity of which, 
being locked in between the three cuneiform, will be more diffi- 
cult to dislodge. Perhaps it may be convenient to saw it across. 
When all the five bones are detached, the surgeon completes the 
division of their plantar ligaments, and slightly separates the textures 
which adhere to their under surface with the point of the knife, 
and then, the foot being placed horizontally, he puts the blade 
under the five bones, and carries it forwards along their inferior 
surface, so as to form a flap from the sole of the foot sufficient to 
cover the denuded tarsal bones. The flap should be about two 
inches wide on the inner side and on the outer. 
(5.) Amputation may be performed through the tar sits, so as to 
remove the navicular and cuboid bones, with all the parts in front 
of them. This is commonly called Chop art's operation. In the 
first place, the articulation of the cuboid with the os calcis, (which 
lies about midway between the external malleolus and the tubero- 
sity of the fifth metatarsal bone,) and that of the navicular with the 538 
STUMPS. 
astragalus-(which will be found just behind the prominence of the 
navicular bone in front of the inner ankle)-must be sought for, 
and a semilunar incision be made from one to the other, as in the 
Fig. 149. 
last described operation. The flap of skin being turned back, the 
internal and dorsal ligaments that connect the navicular to the 
astragalus, are to be divided with the point of the bistoury- 
recollecting the convex shape of the head of the latter bone. The 
ligaments connecting the os calcis and cuboid are next divided- 
and lastly, a flap is to be procured from the sole of the foot, as in 
the last operation.* 
XI. Amputation op the Ankle-joint.-This operation is pro- 
posed by Mr. Syme to be substituted for amputation above the 
ankle in cases where disease or injury of the tarsal bones impli- 
cates the astragalus and os calcis, and for which, therefore, Cho- 
part's operation is inadmissible. He makes one curved incision 
across the instep; and carries a second across the sole of the foot. 
The flaps are dissected from-the subjacent parts, which is easily 
effected except just at the heel; thq astragalus and os calcis, with 
the rest of the foot, are removed, and the projections of the malleo- 
lar processes cut off with forceps. If the ankle-joint itself is dis- 
eased, a thin slice of the lower extremities of the tibia and fibula 
may be removed with a saw. It appears useful to make a punc- 
ture through the integuments of the heel, to let the discharge escape 
freely.t 
Stumps, Affections of.-(1.) Secondary hemorrhage may occur 
under the same circumstances as after other wounds, and requires 
no observations distinct from those made at pages 122 and 285. 
(2.) Erysipelas and phlebitis have also been fully treated of 
elsewhere; one of them may be suspected to be coming on if the 
patient, a few days after amputation, is seized with a violent 
shivering. 
* For every further information concerning amputations, the author must refer 
his readers to Mr. Liston's frequently quoted Practical Surgery, to Mr. Fergusson's 
Practical Surgery, and to Malgaigne's Manuel de Medecine Operatoire. 
f Lond. and Ed. Journ. Med. Science, Feb. and April, 1843. STUMPS. 
539 
(3.) It sometimes happens that the flesh shrinks away from the 
end of the bone, which becomes white and dry, and finally exfo- 
liates. The nitric acid lotion is the best application. 
(4.) Protrusion of the bone is a very awkward circumstance. 
It not only greatly retards the healing of the stump, but the cicatrix 
when formed is thin, red, constantly liable to ulcerate, and unable 
to bear the least pressure or friction. The cause of the conical 
stump, as it is technically called, is generally a want of skin and 
muscle sufficient to cover the end of the bone. Sometimes, how- 
ever, it arises from spasmodic retraction of the muscles-especially 
if they have not been properly supported by bandages during the 
cure. The remedy is simple; the bone must be shortened. This 
may be done in slight cases by making a longitudinal incision over 
the bone on the side opposite the vessels, and sawing oft' a suffi- 
cient portion of it-removing at the same time any diseased por- 
tion of the cicatrix. But if the projection is considerable, a second 
amputation is necessary. 
(5.) Neuralgia of the stump is another very untoward event. It 
sometimes arises, because the truncated extremities of the nerves 
(which after amputation always swell and become bulbous) adhere 
to the cicatrix, so as to be subject to constant compression and ten- 
sion. Sometimes, however, it is entirely independent of any mor- 
bid state of the extremities of the nerves, but arises from some irri- 
tation in their course, or from some disease in the spinal cord at 
their origin. Sometimes, again, no local cause whatever is detecti- 
ble; and the pain is evidently connected with an hysterical state of 
the system. In any state the symptoms are extreme irritability 
and tenderness-paroxysms of violent neuralgic pain-and spasms 
and twitchings of the muscles-which not unfrequently retract, and 
cause the bone to protrude, and the stump to become conical. 
Treatment.-(1.) Gentle friction with strong mercurial oint- 
ment-to which a little powdered camphor or extract of belladonna 
may be advantageously added-or Scott's ointment, F. 25, spread 
on lint, and worn as a plaster, or the emplastrum saponis or 
plumbi, combined with a little belladonna or opium-together with 
change of air, and the administration of remedies calculated to 
restore the strength, maintain the secretions, and allay irritability, 
such as sarsaparilla with henbane ;-steel in various forms;-and 
aloetic pills with galbanum - sometimes suffice to remove the ex- 
treme sensitiveness of these as well as of other irregular cicatrices. 
(2.) If the pain and tenderness are referred to one or two nerves 
only, their bulbous extremities should be cut down upon and 
removed. (3.) If, however, the whole surface of the stump is 
implicated, or if the bone protrudes, a second amputation should be 
resorted to. But in the case of young hysterical women, the pro- 
priety of a second operation is extremely doubtful. The cases on 
record in which this practice was adopted, present no satisfactory 
results ; the pain was removed for a time, but returned when the 
wound healed. It can therefore be justifiable only when performed 540 
EXCISION OF JOINTS. 
at the patient's urgent request, after every local and general remedy 
likely to be of service has been tried perseveringly, but in vain. 
Excision of Joints.-In certain cases of chronic disease or gun- 
shot injuries of joints, an attempt may be made to save the limb, 
by cutting out the joint, instead of performing amputation. This 
operation has now been performed on most of the joints; and the 
results cannot be stated better than in the words of Mr. Blackburn, 
who says, " that excision is advisable in the shoulder and elbow;- 
that it is admissible, though of doubtful utility, in the ankle;-and 
that it is inadmissible, except under very peculiar circumstances, in 
the wrist, hip, and knee."* 
Excision of the Elbow-joint is effected in the following man- 
ner. The patient sits in a chair; the limb is held out and well 
supported. The joint is laid open by cutting through the coverings 
of its dorsal aspect. If the disease is not very extensive, it will be 
sufficient to make a crucial incision-a perpendicular cut three or 
four inches long, and a transverse one at the level of the interval 
between the external condyle and the head of the radius. If the 
disease is more extensive, an II incision should be made, so that 
two flaps can be turned up. The ulnar nerve should be carefully 
preserved, and held aside; the insertion of the triceps should be 
divided, and then, says Air. Liston, "the ends of the bones, but 
slightly retained by their ligaments, are turned out of the wound by 
flexing the forearm; the soft parts are detached, as much as is 
necessary, by cutting upon and close to the bones; the extent of 
ulceration and necrosis is then well ascertained, and by the applica- 
tion of the saw the unsound parts may be removed." A copper 
spatula may be used to protect the nerve and soft parts whilst the 
bones are sawed. The cutting bone forceps may be substituted for 
the saw with young patients ; and Mr. Fergusson recommends the 
gouge to be used for the purpose of scooping away small spots of 
the carious bone, which cannot be removed by either forceps or 
saw. Any arteries that require it having been tied, the wound is 
closed by two or three sutures and slips of plaster, and placed half- 
bent on a pillow. The ends of the bones will unite by ligament, 
and in many cases a very useful degree of motion will be acquired. 
The shoulder-joint may be exposed by making a perpendicular 
incision through the deltoid, three or four inches downwards from 
the acromion; and another from the extremity of the first incision 
upwards and backwards to the posterior border of the deltoid. The 
triangular flap, thus formed, is reflected upwards and backwards; 
the joint may be laid open; the head of the humerus be exposed 
and turned out, and sawn off; and the glenoid cavity of the scapula, 
if diseased, may be removed by the bone nippers or gouge. But 
as this operation is most frequently required in cases of gun-shot 
wound, the surgeon may vary his incisions, according to the ex- 
tent and situation of the wound; and may make them of a V or T 
shape, or may make a simple curved flap, by cutting from near 
f Guy's Hosp. Rep., vol. i. 541 
LIGATURE OF ARTERIES. 
the coracoid process to an inch behind and below the root of the 
acromion. 
These operations must of course be well considered before they 
are set about. They must neither be performed unnecessarily, in 
cases that might get well with proper local and constitutional treat- 
ment;-nor, on the other hand, should they be resorted to when 
the constitution has become exhausted, and the limb disorganized 
by long suppuration;-nor yet in cases of injury so complicated, 
that the patient would be liable to sink from the ensuing irritation 
and discharge. 
CHAPTER IV. 
OF THE LIGATURE OF ARTERIES. 
' It may be as well to remind the reader, that when an artery is 
wounded, the wounded part should always, if possible, be exposed, 
and a ligature be placed both above and below it. If the wound 
in the superjacent parts pass directly to the vessel, it may be en- 
larged in the proper direction and to the requisite extent. If, how- 
ever, the wound, pass indirectly, (from the back of the thigh, for 
instance, to the femoral artery,) the part of the vessel supposed to be 
wounded should be cut down upon in the ordinary way. In both 
cases the introduction of a probe will be a useful guide to the seat 
of injury. If the wounded part of the artery cannot be tied, a liga- 
ture must be placed on the main trunk above, at the nearest practi- 
cable point;-and perhaps it may be expedient to place another 
'below to prevent-regurgitation. 
I. The Common Carotid Artery is generally tied below the 
spot where it is crossed by the omo-hyoideus muscle. The patient 
being placed on his back, with the shoulders raised, and with the 
head thrown back and slightly turned towards the opposite side, an 
incision three inches in length is made along the inner margin of 
the sterno-mastoid muscle. This incision should be carried through 
skin, platysma, and superficial fascia, and should terminate about 
an inch above the sternum. The head should now be brought a 
little forwards, so as to relax the sterno-mastoid muscle, and the 
cellular tissue beneath is to be raised with forceps and divided; but 
any veins that are found are to be turned aside with the handle of 
the scalpel, and are not to be wounded if it can be avoided. Next 
come the thin strong deep fascia and the omo-hyoideus muscle, to 
the margins of which it adheres. It should be pinched up slightly 
with the forceps, just below that muscle, and be divided by cau- 
tious touches with the knife, which should be held with its flat sur- 542 
LIGATURE OF ARTERIES. 
Fig. 150. 
face towards the artery; and this division of the fascia should be 
made immediately over the artery, the situation of which is to be 
carefully ascertained with the finger. Then about half an inch of the 
sheath is to be opened in the same manner-avoiding the descen- 
dens noni nerve, which ramifies upon it. It should be opened 
rather to the inner side of the artery, so^hat the jugular vein may 
not be interfered with. Then an aneurism needle, armed with a 
single ligature, is to be carried round the vessel. It is to be passed 
from the outer side, and to be kept close to the vessel, within its 
sheath. When its point appears on the inner side, the surgeon 
seizes the ligature with forceps, and withdraws the needle -ascer- 
tains that the nervus vagus is not included in the ligature-and then 
ties it tightly in the double knot. One end of ihe ligature may, 
then be cut off close to the knot, and the other be left hanging out 
of the wound, which is to be closed with plaster when bleeding 
has ceased. The patient must be kept at perfect rest in bed till the 
ligature separates. 
This artery may also be tied above the omo-hyoideus, by making 
an incision through the skin and platysma three inches in length, 
and terminating at the level of the cricoid cartilage. The fascia 
should next be divided on a director, in the same manner as the 
layers over a hernial sac (p. 441). The surgeon then separates the 
cellular tissue and veins from the sheath, and opens the sheath and 
passes the ligature in the manner described above. 
II. The External Carotid may if wounded require a ligature ; 
or if many of its branches are wounded, and cannot be tied; but 
such an operation is very rarely, if ever, practised. An incision of 
the same length and direction as in the two preceding operations 
should be made through the skin, platysma, and sheath, so as to tie 543 
THE SUBCLAVIAN ARTERY. 
the vessel near its origin, that is, at the level of the os-hyoides, and 
below the part where it is crossed by the digastric muscle and ninth 
nerve. 
III. The Lingual Artery may be tied by making a transverse 
incision along the os-hyoides from a little below the symphysis of 
the jaw to near the border of the sterno-mastoid muscle. The skin, 
platysma, and fascia being divided, the artery must be looked for 
where it lies upon the greater cornu of the os-hyoides, below the 
digastric muscle and ninth nerve. This artery has been tied in 
cases of tumours and wounds of the tongue; but considering the 
depth at which it lies from the surface, the irregularity of its origin, 
and the important parts in its vicinity, it is much better, as a general 
rule, to tie the external or common carotid. 
IV. The Facial Artery may easily be tied by cutting through 
the skin and cellular tissue that cover it where it turns over the jaw, 
at the anterior border of the masseter; but such an operation can 
hardly ever be requisite. 
V. The Arteria Innominata has been tied in cases of aneurism 
of the right subclavian, extending inwards as far as the scalenus. 
The patient being placed on his back, with the shoulders raised and 
the head thrown back, one incision, two inches in length, is to be 
made along the inner margin of the sterno-mastoid muscle, termi- 
nating at the clavicle-and another across the origin of that muscle, 
meeting the former at a right angle. The flap of integument thus 
formed is to be turned up, and the sternal and part of the clavicular 
origin of the sterno-mastoid are to be divided on a director, which is 
to be passed behind the muscle, and kept as close to it as possible. 
The cellular tissue and fat which now appear, being turned aside, 
the sterno-hyoideus and sterno-thyroideus muscles must be separate- 
ly divided on a director. A strong fascia, which next appears, must 
be cautiously scratched through, and the carotid be traced with the 
finger down to its origin. Then the vena innominata being de- 
pressed, a ligature may be carried from without inwards, round the 
artery, close to its bifurcation, taking care to avoid the vagus, 
recurrent, and cardiac nerves. 
VI. The Right Subclavian Artery in the first part of its 
course, that is to say, between its origin from the innominata and 
the scalenus muscle, may be tied by an operation almost precisely 
similar to the latter; but it is the most difficult operation in surgery, 
and the most unsuccessful. This artery and the innominata have 
each been tied four or five times in cases of aneurism of the sub- 
clavian, reaching inwards as far as the scalenus, but with no very 
happy results.* 
VII. The Subclavian Artery of either side may be readily 
tied external to the scalenus muscle. The patient should be laid on 
a table, with the shoulder of the affected side drawn down as far as 
possible, and the head slightly turned to the other side. An incision 
* The right subclavian was tied in the first part of its course by Mr. Partridge, 
in the King's College Hospital, in February, 1841. The patient died four days 
afterwards, apparently from irritation of the pneumogastric nerve. 544 
LIGATURE OF ARTERIES. 
must then be made above and parallel with the clavicle three or 
four inches in length. It should cut through the skin and platysma, 
and should extend from the margin of the sterno-mastoid to that 
of the trapezius. This preliminary incision may be conveniently 
made by drawing down the skin, and cutting through it while it 
is steadied on the clavicle. The superficial fascia must next be 
divided to the same extent, taking care not to wound the external 
jugular vein. If the sterno-mastoid muscle has rather a wide 
attachment to the clavicle, some of its fibres may be divided, to give 
more room. The succeeding steps of the operation consist in cut- 
ting cautiously through the cellular tissue and fascia down to the 
outer edge of the scalenus muscle. Many surgeons tear through 
them with a director or blunt silver knife. The point of the finger 
must next be passed along the scalenus down to the rib-and 
in the angle between that muscle and the rib, the artery will be 
found. The needle must be passed round it from below upwards. 
If there is much difficulty with the common needle, that of Dr. 
Mott or Mr. Weiss, with a contrivance for separating the point, and 
bringing it and the ligature round on the other side of the vessel, 
may be used instead. 
VIII. The Axillary Artery below the clavicle may be tied 
by making a semilunar incision, with its convexity upwards, from 
near the sternal end of the clavicle to the anterior margin of the 
deltoid muscle. The skin, superficial fascia, and clavicular fibres 
of the pectoralis major muscle, are to be divided in succession - 
avoiding the cephalic vein and thoracica-acromialis artery, where 
they pass between the pectoralis and deltoid. The flap being 
turned down, a strong fascia which intervenes between the pecto- 
ralis minor and subclavian muscles is next to be divided on a 
director;-the cellular tissue and veins covering the vessels are to 
be turned aside;-then the axillary vein being pressed downwards, 
a ligature is carried round the artery from below upwards. This 
operation is exceedingly difficult, and only to be performed in case 
of wounds. 
It is much more easy to tie this artery in the axilla. The arm 
being widely separated from the trunk, and the forearm supinated, 
an incision three inches in length is made over the head of the 
humerus, between the margins of the pectoralis major and latis- 
simus dorsi muscles, but rather near the latter. The cellular tissue 
having been dissected through so as to expose the vessel, and the 
vein and nerves drawn aside, the aneurism needle should be passed 
from the inner side. 
IX. The Brachial Artery is superficial in the whole of its 
course, and may be tied by making an incision two inches in length 
on the inner border of the coraco-brachialis muscle in the upper 
part, and of the biceps in the lower part of the limb. The incisions 
must be directed towards the centre of the limb-and the cellular 
tissue must be divided with caution, so as not to injure the internal 
cutaneous nerve, which lies superficial to the artery in the upper 
part of its course. At the lower part of the limb, the basilic vein 545 
RADIAL ARTERY. 
must be avoided. It must be recollected that the median nerve 
lies over the artery in the middle of its course-and that the vessel 
has two venae comites, both of which must be carefully excluded 
from the ligature. Before tying the ligature, it should be ascer- 
tained whether or not there is high division of the artery, and 
whether the trunk that is exposed commands the circulation at the 
wounded or aneurismal part. 
In the case of a small puncture of this artery at the bend of the 
elbow, from carelessness in bleeding, the surgeon may either close 
the wound, and attempt the cure by compression-placing a gra- 
duated compress on the wound-bandaging the whole limb-and 
keeping the patient in bed and on low diet, so as to maintain a 
tranquil state of the circulation-or may at once enlarge the wound 
upwards and downwards to the extent of three inches-divide the 
fascia to the same extent, and tie the vessel above and below the 
wound-recollecting that the median nerve lies to its inner side. 
There are authorities for both practices. Supposing an aneurism 
to follow such an accident, it is better to cut into the tumour and 
tie the vessel above and below it, than to trust to one ligature at 
the lower part of the arm. 
X. The Radial Artery in the upper 
third of the forearm may be tied by 
making an incision three inches in length, 
in a line from the bend of the elbow to 
the thumb, through the skin and super- 
ficial fascia, avoiding the veins. The 
supinator longus and pronator teres be- 
ing drawn asunder, and the deep fascia 
being divided to the same extent, the 
artery will be exposed, with its accom- 
panying veins, which are to be carefully 
separated before the ligature is passed. 
The aneurism needle should be intro- 
duced from without, in order to avoid the 
radial nerve, which lies at a distance on 
the radial side. 
This vessel can be readily tied in its 
middle third by making a similar incision 
through the same parts on the ulnar 
border of the supinator longus-and in 
the lower third, by making an incision 
on the radial side of the flexor carpi 
radialis. It may also be tied at the back 
of the carpus, just before it dips into the 
palm between the first and second me- 
tacarpal bones, by making an incision 
between the tendons of the extensor 
secundi and primi internodii pollicis. 
But it is easier to tie it at the lower part 
of the forearm. 
Fig. 151. 546 
LIGATURE OF ARTERIES. 
XI. Ulnar Artery.-When this vessel is wounded in its 
upper third, where it is covered deeply by muscles, it is an unde- 
cided point whether the wound should be dilated-cutting through 
or across the muscles to reach the bleeding point,- or whether the 
lower end of the brachial should be tied. In the middle and inferior 
thirds of the forearm, this vessel may be readily exposed by cutting 
through the integuments and superficial fascia along the outer margin 
of the flexor carpi ulnaris for the extent of three inches. That 
muscle is then to be drawn inwards, the deep fascia to be divided, 
the veins to be separated from the artery, and the needle to be 
passed from within, so as to avoid the ulnar nerve which lies on 
the ulnar side. 
In wounds of the palm of the hand, with great haemorrhage, the 
wound should be dilated, and the bleeding vessels be tied, unless 
they lie too deeply. If that is the case, methodical pressure should 
be resorted to-the wound being cleared of coagula, and filled with 
lint, (which may or may not be dipped in oil of turpentine,) and 
firm pressure being made upon it, before and behind, in the manner 
described at p. 297. But if haemorrhage has recurred again and 
again, and the parts are inflamed or infiltrated with blood, the bra- 
chial artery should be tied just above, the elbow. If an operation 
is required at all, it is better at once to do this, since the anastomoses 
are so numerous that, after tying both radial and ulnar above the 
wrist, the haemorrhage may still continue through the interosseal 
arteries. 
XII. The Aorta, the Common Iliac, and the Internal Iliac 
arteries, may be tied by a similar operation. An incision from four 
to six inches in length must be made on the anterior surface of the 
abdomen. It may either be made parallel to the outer border of the 
rectus, or to the epigastric artery-and it should terminate an inch 
above Poupart's ligament. The three layers of abdominal muscles 
are to be cautiously divided to the same extent-and the fascia 
transversalis likewise-it being first scratched through, so that the 
finger may be introduced between it and the peritonaeum-to divide 
it upon. The peritonaeum must now be detected by the fingers from 
the iliac fossa, as far as the brim of the pelvis, where the external 
iliac artery will be found beating-and by following this vessel up- 
wards, the operator will come upon the internal or common iliac, 
or the aorta. The edges of the wound being now held asunder by 
copper spatula}, the artery to be tied must be separated from its vein 
with the nail of the forefinger or the flat end of a probe, and the 
aneurism-needle be passed round between it and the vein. It will 
be recollected that the common iliac veins lie behind and to the 
right of their respective arteries-that the left internal iliac vein is 
behind its artery-and that the right is a little external as well as 
posterior. The internal iliac may require to be tied for disease or 
injury of the glutceal or other branches outside the pelvis. 
XIII. The External Iliac artery may be tied, according to 
Sir A. Cooper's method, by making a semilunar incision (with the 
convexity looking downwards and outwards) from near the anterior FEMORAL ARTERY. 
547 
superior spinous process of the ilium to the superior angle of the 
external abdominal ring. This incision will be nearly parallel with 
Poupart's ligament, and about an inch above it. The skin, super- 
ficial fascia, and tendon of the external oblique having been divided, 
the lower margin of the internal oblique and transversalis muscles 
must be raised on the finger and be detached from Poupart's liga- 
ment,-the fascia transversalis must be carefully scratched through, 
-and then, if the finger is passed back under the spermatic cord, it 
will come in contact with the artery. The dense cellular tissue 
connecting the artery with the vein (which lies on its internal and 
posterior aspect) must be scratched through, and the needle be 
passed between them. 
XIV. The Femoral artery may be 
tied in any part of its course from Pou- 
part's ligament downwards,-but the best 
spot for the ligature, when performed for 
popliteal aneurism, is just above the part 
where the vessel is overlapped by the sar- 
torious-some little distance below the 
origin of the profunda. The patient being 
placed on his back, with the knee slightly 
bent, and the limb turned outwards, an 
incision must be made through the skin in 
the course of the vessel-which, it will be 
recollected, corresponds to a line drawn 
from the middle of Poupart's ligament to 
the inner edge of the patella. The incision 
may commence two inches below the 
groin, but its length must depend on the 
thickness of the parts to be divided. It is 
better to make it too long than too short. 
The cellular tissue must next be dissected 
down to the fascia lata-avoiding the sa- 
phenic vein. If any glands are in the way 
they should be turned aside. The fascia 
lata is now to be divided for about two 
inches, and the sartorius to be gently 
drawn outwards. The artery may now 
be felt, and when the sheath and the cellu- 
lar tissue over it have been raised with the 
forceps and divided by cautious touches 
with the knife, (held with its flat surface towards the artery,)-the 
point of the aneurism needle is to be gently insinuated between the 
artery and the vein (which lies behind it). The needle should be 
passed from the inner side. Before finally tightening the ligature, 
the artery should be compressed, to see whether the pulsation in the 
aneurism ceases, in case of any irregularity in the course and distri- 
bution of the vessel. 
The Femoral artery may also be tied in the middle third of the 
thigh, where it is covered by the sartorius, by cutting on the inner 
Fig. 152. 548 
ligature of arteries. 
edge of that muscle and turning it aside, and then slitting up the 
strong fibrous sheath which envelopes the artery at that part; but 
this is a much more difficult operation, and it has no commensurate 
advantages.* 
XV. The Glutjeal artery may be tied by placing the patient on 
his face, with the toes turned inwards, and making an incision 
from an inch below the posterior spinous process of the ilium, and 
an inch from the sacrum, towards the great trochanter. This 
incision should be about four inches long. The fibres of the 
glutaius maximus having been cut through or separated to the like 
extent, and a strong fascia beneath having been cut through, the 
vessel will be found emerging from the upper part of the sciatic 
notch. The Sciatic artery may be found by making an incision 
through the same parts and for the same extent, but an inch and a 
half lower down. Both these operations are extremely difficult, 
from the great depth to which the dissection must be carried, the 
unyielding nature of the surrounding parts, and the haemorrhage 
from the numerous blood-vessels that must necessarily be wounded. 
They should be attempted, however, in case of wounds -but for 
aneurisms of these arteries, it is necessary to tie the internal or 
common iliac. 
XVI. The Popliteal artery may be tied by cutting through 
the skin and fascia lata for the extent of three inches on the outer 
border of the tendon of the semi-membranosus muscle-the patient 
being placed on his face, with his knee straight. On pressing that 
tendon inwards, the artery may be felt. Its vein, which lies super- 
ficial and rather external to it, must be cautiously separated and 
drawn outwards, and the needle be passed between them. This 
operation is very seldom performed. 
XVII. Posterior Tibial Artery.-The operation usually re- 
commended for tying this artery in the upper part of the leg is 
performed thus: The limb being placed on its outer side, with the 
knee bent and the foot extended, an incision four inches in length 
must be made through the skin and fascia over the inner margin of 
the tibia, avoiding the saphena vein. The edge of the gastrocne- 
mius thus exposed is to be turned back. A director must then be 
insinuated beneath the inner head of the solasus, and this muscle 
must be divided from its attachment to the tibia. The strong and 
tense fascia beneath it must next be divided in the same manner. 
Then the muscles being relaxed as much as possible by bending 
the knee and extending the foot, the artery may be felt about an 
inch from the edge of the tibia. The veins are to be separated from 
it, and an aneurism needle passed round it from without, inwards, 
so as to avoid the nerve. 
This operation, however, is considered by Mr. Guthrie to be so 
•"When the skin and fascia have been divided," says Mr. Fergusson, "and 
some muscular fibres exposed, it may be doubtful to which muscle they belong- 
whether to the sartorius or the vastus. If to the latter, they will seem to run to- 
wards the inner side of the thigh; if to the former, they will pass nearly in its long 
axis."-Practical Surgery, p. 312. PERONEAL ARTERY. 
549 
Fig. 153. 
" painful, difficult, bloody, tedious, and dangerous," that he proposes 
to reach the artery by making a perpendicular incision six or seven 
inches in length, at the back of the leg, through the skin, gastrocne- 
mius, plantaris, and solseus-then the fascia will be exposed with 
the artery beneath it, and the nerve to the outer side. Perhaps 
this operation cannot be spoken of in much more complimentary 
terms than the preceding one. 
The posterior tibial artery may be easily exposed, in the lower 
third of the leg, by cutting parallel to the tendo-achillis, and on its 
inner side, for the extent of two or three inches, through the skin 
and two layers of fascia. The cellular tissue and sheath of the 
vessel must next be cautiously divided, and the venee comites 
having been separated from it, the needle must be passed round 
the vessel from the outer side. 
This artery may also be tied behind the inner ankle. A semi- 
lunar incision, two or three inches long, is made in the hollow 
between the heel and the ankle, but rather nearer to the latter. 
The integuments, the superficial fascia, and a very strong tendinous 
aponeurosis, continuous with the deep fascia of the leg, must be 
successively divided to the same extent. The sheath of the vessels 
which will be thus exposed must be opened-the venae comites 
separated, and the needle passed from the heel towards the ankle 
in order to avoid the nerve, which lies a little nearer to the heel. 
XVIII. The Peronjeal artery may be exposed in the upper 
part of the leg by an incision similar to that which Mr. Guthrie pro- 
poses for the ligature of the posterior tibial, only rather more ex- 
ternal. For the first few inches of its course, this vessel lies under- 
neath the deep fascia-afterwards it lies concealed under the inner 
edge of the flexor longus pollicis, which must be turned aside to 
expose it. But this is an operation which is enumerated rather 
from form than because it is of real utility. 550 
LIGATURE OF ARTERIES, 
XIX. The Anterior I ibial artery 
in the first third of its course, where it 
is covered by the extensor muscles, is 
very difficult to reach. If, however, it 
is expedient to place a ligature on it, an 
incision four or five inches in length 
must be made down to the fascia, in the 
direction of a line drawn from the head 
of the fibula to the base of the great toe. 
The intermuscular septum, between the 
tibialis anticus and extensor digitorum 
muscles must then be cut into, and the 
muscles be separated down to the in- 
terosseous ligament, where the artery 
will be found. The foot should be 
moved backwards and forwards at the 
ankle, in order to ascertain with exact- 
ness the junction of the muscles. 
Below the middle of the leg, at any 
point to the termination of its course, 
this artery may be found on the fibular 
side of the extensor proprius pollicis 
tendon, which must be the guide for the 
incision. But it lies much more deeply 
in the living subject, than would be sur- 
mised from a mere dissection of the 
dead. The coverings must be divided 
with the usual precautions, and neither 
the peronaeal nerve nor the venae comi- 
tes should be wounded with the knife, 
or be included in the ligature. 
In wounds of the arteries in the sole of the foot, (except, perhaps, 
of the external plantar, opposite the base of the little toe,) it is 
scarcely judicious to enlarge the wound with the view of securing 
the bleeding point. But methodical pressure should be applied 
after the manner recommended at page 297; and if that fails, the 
posterior tibial artery should be tied behind the inner ankle-and 
the anterior tibial on the dorsum of the foot likewise, if necessary.* 
Fig 154. 
• For further information on these operations, vide Manec on the Arteries; and 
the works of Harrison, Liston, and Fergusson. APPENDIX OF FORMULA. 
F. 1. Tonic Draught. 
R. Acidi sulphurici diluti 1f[v.-xv.; syrupi aurantii f3j.; infusi cascarillae, (vel 
decocti cinchonae,) fgx. Misce, fiat haustus, ter vel quater die sumendus. 
2. Quinine Draught, with Ammonia. 
R. Quinae disulphatis gr. ii.-v.; tincturae opii 1T[ii.-v.; spirittis aetheris com- 
positi, spirittis ammoniae aromatici, aa fgss.; decocti cinchonae fgx. Misce, fiat 
haustus, ter vel quater die sumendus. In cases of great Debility, with Restlessness or 
low Delirium. 
3. Quinine Draughts, with Acid. 
R. Quinae disulphatis gr. ii.-v.; acidi sulphurici diluti TT[v.-xv.; tincturae 
aurantii, syrupi ejusdem, aa f3j.; aquae fgj. Misce, fiat haustus, ter die sumendus. 
R. Quinae disulphatis gr. ii.-v.; acidi hydrochlorici Tljx.-xv.; camphorae gr. ii.; 
spirittis aetheris nitrici fgj.; tincturae cardamomi compositae fgj.; aquae menthae 
viridis fgx. Misce, fiat haustus, sexta quaque hora sumendus. 
4. Black Draughts. 
R. Sennae foliorum gvj.; zinziberis concisi gss.; extracti glycyrrhizae gii.; aquae 
ferventis fgix. Post horas tres cola, et adde spirittis ammoniae aromatici fgii.; 
tincturae sennae, tincturae cardamomi compositae aa fgss. Dosis fgiss.* 
5. Saline Draughts. 
R. Potassae nitratis 9ii.; sodae sesquicarbonatis 9ss.; vini antimonii fgii.; syrupi 
croci, spirittis aetheris nitrici, aa fgi.; aquae fgv. Misce. Dosis fgiss, quarts qua- 
que hori. 
6. Calomel Pill. 
R. Calomelanos gr. i.-iii.; antimonii potassio-tartratis gr. |-5; extracti hyos- 
cyami (vel conii) gr. iii. (vel pulveris opii gr. |.) Misce, fiat pilula tertia-sexta 
quaque hora sumenda. 
7. Alterative Pill. 
R. Pilulae hydrargyri gr. iii.; extracti hyoscyami (vel pulveris Doveri) gr. iii.; 
pulveris ipecacuanhae gr. j. Misce, fiant pilulae duae omni nocti sumendae. 
8. Cordial Aperient Draught. 
R. Pulveris rhei, potassae sulphatis aa 9j.; decocti aloes compositi, aquae menthae 
viridis aa fgvj.; spirittis ammoniae compositi fgss. Misce, fiat haustus. 
9. Mild Aperient Draughts. 
R. Sodae potassio-tartratis giv.; tincturae sennae fgiii.; spirittis myristicae fgss.: 
aquae fgiss. Misce, fiat haustus. 
* The above is the common formula. But the draught is greatly improved, both in flavour and 
efficacy, by the addition of a few caraway seeds, one ounce of buckthorn juice, one of tincture of 
jalap, and six of moist sugar. 552 
APPENDIX OF FORMULA. 
R. Soda potassio-tartratis ^ii.; magnesias calcinatae 9j.; syrupi aitrantii fjj.; 
aquas f3iss. Misce. 
10. Alterative Powder. 
R. Hydrargyri cum creta gr. iii;-vi.; pulveris Doveri gr. i.-v. Misce, fiat 
pulvis omni nocte sumendus. 
11. Lead Lotion. 
R. Liquoris plumbi diacetatis f$j.; acidi acetici diluti, spiritus rectificati aaf§ss.; 
aquae f^ix. Misce, fiat lotio. 
12. Frigorific Mixture. 
R. Sodii chloridi, potassas nitratis, ammonias hydrochloratis, partes aequales; 
aquae quantum satis sit ad solvendas. 
13. Spirit Lotion. 
R. Spiritus vini rectificati f^j; aquae f^xv. Misce fiat lotio. 
14. Stimulating Liniment. 
R. Liquoris ammoniae f^ii.; linimenti saponis (vel linimenti camphorae compositi) 
f^j. Misce, fiat linimentum. 
15. Zinc Lotion. 
R. Zinci sulphatis gj.; aquae octarium. Misce, fiat lotio. 
16. Discutient Lotion. 
R. Ammoniae hydrochloratis 3ss.; acidi acetici diluti, spiritus rectificati aa f jss.; 
misturae camphorae fgxv. Misce, fiat lotio. 
17. Nitric Acid Lotion. 
R. Rosae petalorum 9j.; aquae ferventis fgviij.; acidi nitrici diluti fgiiss. Misce, 
et cola post horam, ut fiat lotio. 
18. Castor Oil and Turpentine Draught. 
R. Olei terebinthinae, olei ricini aa fgvj.; tincturae sennas fgij.; mucilaginis 
acacia f^ii.; aquae menthae quantum satis sit ut fiat haustus. 
19. Demulcent Mixture far Gonorrhoea. 
R. Sodas sesquicarbonatis gss.; (tel liquoris potassa fgij.;) tinctura hyoscyami, 
spiritus atheris nitrici aa jliquoris opii sedativi B[xx.-xxx.; mistura amygdala 
fgviiss. Misce, sumantur cochlearia tria ampla quarts. quSque hora. 
20. Copaiba Mixture. 
R. Copaiba fgii.-iv.; mucilaginis acacia fgiv.; spiritus atheris nitrici, spiritus 
lavandula aa fgii.; olei cinnamomi guttas vi.; aqua fgv. Misce. Dosis fgi., ter 
die. 
21. Acetate of Zinc Injection. 
R. Zinci sulphatis gr. v.; liquoris plumbi diacetatis fgss.; aqua rosa fgiv. 
Misce, fiat injectio. 
22. Acetate of Copper Injection. 
R. Cupri sulphatis gr. v.; liquoris plumbi diacetatis fgss.;aqua rosa fgiv. Misce, 
fiat injectio. 
23. Ammoniuret of Copper Injection. 
R. Liquoris cupri ammonio-sulphatis 1T[xx.; tinctura opii fgss.; aqua rosa f3iv. 
Misce, fiat lotio. 553 
APPENDIX OF FORMULA:. 
24. Pearson's Liniment. 
R. Olei olivae f3iss.; olei terebinthinae f^ss.; acidi sulphurici fortissimi fgiss. 
Misce gradatim. 
25. Scott's Ointment. 
R. Unguenti hydrargyri fortioris, cerati saponis aa §j.; camphorae pulverizatae gj. 
Misce. ( Vide p. 252.)* 
26. Bottley's Liquor Cinchona; f 
R. Liquoris Cinchonas flavae H[xx.; aquae pimentae f^j. Misce, fiat haustus 
quater die sumendus. 
27. Antacid Mixtures for Children. 
R. Magnesiae ustae 9j.; spiritus ammoniae aromatici fgss.; syrupi aurantii fgiii.; 
aquae calcis, aquae destillatae aa f^iij. Misce, sumantur cochlearia duo magna 
ter die. 
R. Cretae preparatae gss.; liquoris calcis fgiii.; aquae anethi fgiii. Misce, suman- 
tur cochlearia duo magna ter die. 
28. Steel and Aloes Mixture. 
R. Ferri sulphatis 9j.; sodae subcarbonatis gr. xxv.; ammoniae sesquicarbonatis 
9j.; vini aloes f§ss.;spiritiis myristicae fgiii.; aquae destillatae fgvij. Misce. Dosis 
f^ss. ter die. 
29. Sarsaparilla and Nitric Acid. 
R. Decocti sarsae compositi f^iv.; acidi nitrici diluti TT[xx.-lx.; tincturae hyos- 
cyami fgss. Misce, fiat haustus ter die sumendus. 
30. Corrosive Sublimate Pills. 
R. Hydrargyri sublimati corrosivi, ammoniae hydrochloratis aa gr. i.-ii.; aquae 
destillatae guttam; micae panis quantum satis est, ut fiant pilulae xii., quarum 
sumatur una ter die. 
31. Bark and Guaiacum. 
R. Tincturae guaiaci ammoniatae, tincturae humuli aa f3ss.; decocti cinchonae 
lancifoliae fgii. Misce, fiat haustus, ter die sumendus. 
32. Eye Snuff. 
R. Pulveris asari partes tres; pulveris florum lavandulae partes duas. Misce. 
Vel, R. Pulveris euphorbii partem unam, pulveris amyli partes septem. Misce. 
33. Mercurial Eye Snuff. 
R. Hydrargyri sub-sulphatis flavi gss.; pulveris glycyrrhizae gii. Misce intime. 
34. Schmucker's Pills. 
R. Sagapeni, galbani, saponis aa gj.; rhei giss.; antimonii potassio-tartratis gr. 
xv.; succi glycyrrhizae gj. Misce. Dosis gr. xv. bis die. 
35. Richter's Pills. 
R. Ammoniaci, asafoetidae, saponis, valerianae, arnicae aa 3ii.; antimonii potassio- 
tartratis gr. xviii.; syrupi quantum satis est, ut fiat massa. Dosis gr. xx.-xxx. ter die. 
36. Collyria. 
R. Zinci sulphatis gr. i.-iv.; vel aluminis gr. i.-iv.; vel cupri sulphatis gr. |-ii.; 
vel argenti nitratis gr. i.-iv.; vel zinci acetatis gr. i.-vi.; vel liq. plumbi diacetatis 
lt[x.; aquae destillatae f^j. Misce. 
* This ointment may easily be combined with pulv. opii, or ext. belladonnas, 
t One fluid drachm of this solution is equal to an ounce of the finest bark. 554 
APPENDIX OF FORMULA!. 
37. Corrosive Sublimate Collyrium. 
R. Hydrargyri sublimati corrosivi gr. j.; aquae destillatae fgviij. Misce. (Mac- 
kenzie.) 
38. Tartar Emetic Ointment. 
R. Antimonii potassio-tartratis jj.; adipis §j. Misce. 
39. Detergent Gargle. 
R. Liquoris calcis chlorinatae f^iv.; mellis ^j.; aquae destillatae f^iii. Misce. A 
tablespoonful to be mixed with a glass of warm brandy and water, and to be used as a 
gargle. 
40. Cooling Gargle. 
R. Meilis, confectionis rosae caninae aa jii.; aceti destillati f^ss.; acidi hydro- 
chloric! lT|xxx.; aquae rosae f 3j.; aquae purae f§vj. Misce. 
41. Astringent Gargle. 
R. Aluminis $j.; acidi sulphuric! diluli Tllxx.; tincturae myrrhae f^ii.; decocti 
cinchonas, f^vi. Misce. 
42. Aperient Electuaries. 
R. Pulveris potassae supertartratis, ^ss.; sulphuris praecipitati, jii.-iv.; confec- 
tionis sennae, 3j.; syrupi zinziberis, quantum satis sit. 
R. Magnesiae ustae, potassae supertartratis, florum sulphuris, pulveris rhei, aa 
Jj.; pulveris zinziberis, ^ss.; theriacae, quantum satis sit. 
R. Mannae, confectionis sennae, aa ^j.; sulphuris ^iij., syrupi quantum satis sit; 
dosis, gi.-jiv., omni nocte hora somni. 
43. Ointment for Piles. 
R. Pulveris gallae gj.; liquoris plumbi diacetatis 1t[xv.; adipis Misce. 
44. Mustard Poultice. 
R. Lini seminum, sinapis, singulorum contritorum libram dimidiam; aceti ferve- 
facti, quantum satis sit; ut fiat cataplasmatis crassitudo. Misce. (Pharm. Lond.) 
45. Linseed Meal Poultice. 
The highest authority on poultices was Mr. Abernethy, who seemed to revel in 
the idea of them. " Scald your basin," he says, " by pouring a little hot water into 
it, then put a small quantity of finely-ground linseed meal into the basin, pour a 
little hot water on it, and stir it round briskly until you have well incorporated 
them; add a little more meal and a little more water, then stir it again. Do not 
let any lumps remain in the basin, but stir the poultice well, and do not be sparing 
of your trouble. If properly made, it is so well worked together that you might 
throw it up to the ceiling, and it would come down again without falling into pieces; 
it is in fact like a pancake. What you do next, is to take as much of it out of the 
basin as you may require, lay it on a piece of soft linen, let it be about a quarter of 
an inch thick, and so wide that it may cover the whole of the inflamed part." 
46. Yeast Poultice. 
R. Farinae Ibi; cerevisise ferment! f^i. Misce, et calorem lenem adhibe donee 
intumescant. (Pharm. Lond.) 
47. Bread Poultice. 
"I shall now speak," says Mr. Abernethy, "of the bread and water poultice. 
The way in which I direct it to be made is the following:-Pat half a pint of hot 
water in a pint basin, add to this as much of the crumb Of bread as the water will 
cover; then place a plate over the basin, and let it remain about ten minutes; stir APPENDIX OF formula:. 
555 
the bread about in the water, or, if necessary, chop it a little with the edge of the 
knife, and drain off the water by holding the knife on the top of the basin, but do 
not press the bread, as is usually done ; then take it out lightly, and spread it about 
one-third of an inch thick on some soft linen, and lay it upon the part." 
A very admirable soft poultice for parts that are excoriated, or that threaten to 
slough from pressure, during long illnesses, may be made by mixing together equal 
parts of bread crumbs and of mutton suet grated very fine, with a little boiling water, 
and stirring them in a saucepan over the fire till they are well incorporated. 
48. Opiate Enema. 
R. Decocti amyli f^iv.; tincturae opii f^ss-jj. Misce. (Pharm. Lond.) 
Opiate Suppository. 
R. Pulveris opii gr. i.-iv.; saponis gr. x.; contunde simul. 
49. Turpentine Enema. 
R. Olei terebinthinae f^j.; vitelli ovi, {vel mucilaginis acaciae,) quantum satis 
sit; tere simul et adde, decocti hordei, vel decocti avenae f^xix. 
50. Tobacco Enema. 
R. Tabaci foliorum gss.; aquae octarium dimidium; macera per horae quartam 
partem, et cola. 
51. Castor OU Enema. 
R. Olei ricini fgiii.; potassae carbonatis gr. xv.; saponis gj.; aquae ferventis 
octarium ; tere simul donee bene misceantur. 
52. Alterative Powder. 
R. Hydrargyri cum creta gr. ii.; pulveris rhei gr. v. Misce, fiat pulvis, omni 
nocte sumendus. 
53. Zinc Mixture. 
R. Zinci sulphatis gr. vj.; acidi sulphurici diluti Tt[xxx.; syrupi aurantii f^ss.; 
infusi aurantii f 3vss. Misce, sumantur cochlearia duo ter die. 
54. Antacid Mixture. 
R. Sodae sesquicarbonatis gss.; spiritus ammoniae aromatici f^iii.; syrupi zinzi- 
beris f 3ss.; tincturae cardamomi compositae f.^ss.; aquae cinnamomi f^v. Misce, 
sumantur cochlearia duo ter die {after meals'). 
55. Rhubarb and Magnesia. 
R. Pulveris rhei gr. x.; magnesias ustae gr. v.; pulveris zinziberis gr. ii. Misce, 
fiq.t pulvis, omni mane sumendus. 
56. Alkaline Infusion of Sarsaparilla. 
R. Sarsaparillae Jamaicensis radicis, consisae et contusae^ii.; radicis glycyrrhizae 
consisae gii.; liquoris potassae Tt[xl.-lx.; aquae destillatae ferventis f,^x.; tincturae. 
cardamomi compositae fjiii. Macera per horas viginti quatuor, et cola. Sumatur 
totum quotidie. 
57. Sarsaparilla and Limi Water. 
R. Sarsaparillae §ii.; glycyrrhizae gii.; liquoris calcis f3x. Macera per horas 
viginti quatuor, et cola. Sumatur totum indies.* 
58. Corrosive Sublimate and Bark for Children. 
R. Hydrargyri sublimati corrosivi gr. j.; tincturae cinchonae {vel tincturae rhei) 
3ii.; solve. Dosis f^j.; ter die ex aqua.f 
* 56, 57. It is far better to give sarsaparilla in a concentrated form, than to flood the stomach with 
a pint of it. Besides, private patients will not drink a whole pint; it makes them cold, windy, and 
comfortless. 
t 58. This, as well as arsenic, iodine, and other irritating medicines, should betaken aftermeals. 556 
APPENDIX OF FORMULAE. 
59. Epsom Salls and Tartar Emetic. 
R. Magnesia? sulphatis 3j.; antimonii tartarizati gr. j.; sp. aetheris nitrici jii.; 
aquae menthae f 3x. Misce; sumantur cochlearia magna tria, quarta quaque hora. 
60. Lead Pills. 
R. Plumbi acetatis gr. iii.; pulveris opii gr. jss.; micae panis 9ss. Misce; fiant 
pilulae sex; quarum sumatur una, quarta quaque hora, cum haustu sequente. 
• 61. Vinegar Draught. 
R. Aceti destillati fjiii.; syrupi papaveris f$j.; aquae f^j. Misce. 
62. Ammoniated Iron. 
R. Ferri ammonio-chloridi gr. xii.-xx.; sodae sesquicarbonatis gr. xii.; ammoniae 
sesquicarbonatis 9j.; syrupi f3ss.; aquae destillatae f3vss. Misce. Dosis f 3j. 
ter die. 
63. Chalybeate Mixture. 
R. Tincturae ferri sesquichloridi fxii.; spiritus aetheris nitrici f^ij.; sacchari 3j.; 
aquae f3v. Misce. Sumantur cochlearia duo magna ter die. 
R. Vini ferri fjvi.; tincturae ferri sesquichloridi TT[xx.; aquae destillatae f3vj. 
Misce. Sumantur cochlearia duo ter die. 
64. Opiate Lotion. 
R. Pulveris opii jss.; aquae destillatae ferventis f 3viii.; macera per horas duas, 
et cola. 
65. Opiate Poultice. 
R. Micae panis, etlotionis opiatx suprapraescriptae, singulorum, quantum satis sit. 
66. Conium Lotion. 
R. Extracti conii jj.; aquae destillatae f3iii.; tere simul, et macera per horas 
duas; dein cola. 
67. Conium Poultice. 
R. Cataplasmatis panis (F. 47) quantum satis sit; extracti conii 9j. Misce. 
68. Arsenical Lotion. 
R. Liquoris arsenicalis fji.-ii.; aquae destillatae f3j. Misce. 
69. Steel and Acid Mixture. 
R. Ferri sulphatis gr. xii.; acidi sulphurici diluti f3j^ tincturae cardamomi com- 
positae f3ss.; infusi rosa? compositi f^vss. Misce; sumantur cochlearia duo 
magna ter die. 
70. Black Wash. 
R. Calomelanos jj.; mucilaginis acaciae f3ss.; liquoris calcis f3vss. Misce. 
71. Yellow Wash. 
R. Hydrargyri sublimati corrosivi gf. vi.-xii.; liquoris calcis f 3vj. Misce. 
72. Peruvian Balsam Ointment. 
R. Balsam Peruvian! jj.; unguenti cetacei 3j. Misce. 
73. Ointments for the Eyelids.* 
R. Unguenti hydrargyri nitratis Jss.; olei amygdala? f^ss. Solve leni calore. 
♦ Singleton's Golden Ointment is said to be composed of equal parts of orpiment and lard. 557 
R. Unguenti hydrargyri nitratis Jss.; hydrargyri nitrico-oxydi in pulverem sub- 
tilissimum redacti gr. v.; adipis gj. Misce bene. 
R. Calomelanos 9ss.; plumbi acetatis gr. iij.; morphi® acetatis gr. iij., adipis gii. 
Misce. In obstinate psorophthalmia. 
74. Iodine Mixture.* 
R. lodinii gr. 3; potassii iodidi gr. j.; aquae destillatae f 3vj. 
Vel R. Tincturae iodinii compositi (p. l.) Tl^xx.; aquae destillatae f 3vj. 
Vel R. Liquoris potassii iodidi compositi (p. i.) f^ss.; aquae destillatae f 3vss. 
Misce. Sumatur totum indies divisis dosibus. 
75. Iodine Ointment. 
R. lodinii gr. vj.; potassii iodidi 9ii.; adipis §j. Misce. 
76. Iodine Lotion. 
R. Liquoris potassii iodidi compositi f 3j.; aquae destillatae f3x. Misce. For 
scrofulous ulcers, fistulx, ophthalmia, <%c. 
77. Rubefacient Solution of Iodine. 
R. lodinii giv^ potassii iodidi 3j.; aquae destillatae f3vj. Misce. To touch very 
indolent sores ; the edges of the eyelids, ozeena, $0. 
78. Caustic Solution of Iodine. 
R. lodinii, potassii iodidi aa 3j.; aquae destillatae f3ij. Misce. To destroy weak 
granulations, ragged edges of sores, $c. 
79. Iodine Bath. 
Should contain, for children, half a grain of iodine to each quart of warm water; 
-and for adults, one drachm to twenty-five gallons. The body may be immersed 
ten minutes.f 
80. Tonic Aperient and Antacid Powder. 
R. Sodae carbonatis exsiccatae gr. v.; pulveris calumbae gr. x.; pulveris rhei gr. ii. 
Misce; fiat pulvis quotidie, ante prandium sumendus. 
81. Strong Camphor Mixture. 
R. Camphorae gr. xxv.; amygdalas dulces decorticatas sex; sacchari purificati 
giii.; optime contere, dein adde gradatim, aquae menthae viridis f3viiss. ut fiat 
mistura, cujus sumantur cochlearia tria magna, quarta quaque hora. (Hooper.) 
82. Steel, Soda, and Rhubarb. 
R. Ferri sesquioxydi 9j.; sodae sesquicarbonatis gr. iii.; pulveris rhei gr. iii. 
Misce. Fiat pulvis, ter die sumendus. 
83. Demulcent Mixtures for Gonorrhoea. 
R. Liquoris potassae f^ii.; liquoris opii sedativi f^ss.; mistur® amygdal® f 3vj. 
Misce. Sumantur cochlearia duo quarta quaque hora. 
R. Liquoris potass®, tinclur® hyoscyami, aa fgij.; aqu® f3iv. Misce. Suma- 
tur pars quarta ter die. 
APPENDIX OF FORMULA!. 
* These three formulee are of the same strength. The dose of iodine may be gradually increased 
to gr 4 olhs, or gr. i. daily. 
f Vide Essays on the Edicts of Iodine in scrofulous diseases, by Lugol; translated by O'Shaugh- 
nessy; London, 1831. 558 
APPENDIX OF FORMULA. 
84. Copaiba and Oil of Cubebs. 
R. Copaib® fgiii.; olei cubeb® TT[xx.; Jiquoris potass® fgii.;sp. myristic® fgiii.; 
mistur® camphor® fSvii. Misce. Sumantur cochlearia tria magna ter die. 
85. Cubebs and Soda. 
R. Pulveris cubeb® 9ii.; sod® sesquicarbonatis, potass® bitartratis aa 9ss. 
Misce; fiat pulvis, ter die sumendus. 
86. Copaiba and Kino. 
R. Copaib® f 3ss.; pulveris kino gj.; mucilaginis acaci® fgiii.; splritus lavan- 
dul® compositi fgiii^ aqu® f 3v. Misce. Sumantur cochlearia duo magna ter die. 
87. Copaiba and Catechu. 
R. Copaib® f3ss.; tinctur® catechu fgvj.; oleijuniperi guttas duas; mucila- 
ginis fgiii.; aqu® f3v. Misce. 
88. Cantharides and Zinc. 
R. Zinci sulphatis gr. xxiv.; pulveris cantharides gr. vj.; pulveris rhei gj.; 
terebinthin® venetiensis quantum satis sit, ut fiant pilul® viginti quatuor, quarum 
sumantur duo ter die. 
89. Cantharides and Steel. 
R. Tinctur® ferri sesquichloridi, tinctur® cantharidis, aa f gii.; tinctur® capsici 
fgi.; syrupi croci fgiii.; aqu® piment® f3vj. Misce. Sumantur cochlearia duo 
ter die. 
90. Turpentine and Copaiba. 
R. Olei terebinthin® fgii.; copaib® fgvj. Misce; sumantur gutt® quadraginta 
ter die, ex cyatho aqu®. 
91. Buchu and Uva Ursi. 
R. Foliorum buchu, et uv® ursi, aa gii.; aqu® ferventis f3vj. Macera per 
horas duas; dein cola, et adde liquoris potass® f^j.; tinctur® cinnamoni, tinctur® 
hyoscyami aa fgiii. Misce; sumantur cochlearia duo ter die.* 
92. Tannin Garble. 
R. Tannin 9j.; Brandy f3ss.; mistur® camphor® f 3vss. Misce. For saliva- 
tion, spongy gums, relaxed throat, ^c. 
93. Iodide of Potassium. 
R. Potassii iodidi, extracti conii aa 3ss. Misce; fiant pilul® xij.; quarum 
sumatur una ter die. , 
94. Warm Emetic. 
R. Pulveris ipecacuanh®, ammonia; sesquicarbonatis, aa 9ss.; spiritus lavan- 
dul® compositi 1t[x.; aqu® fgj. Misce; fiat haustus. Bibat ®ger postek infusi 
anthemidis tepidi octarium. 
95. Colchicum and Magnesia. 
R. Vini colchici f3ii.; solutionis magnesi®f fgiss.; syrupi croci fgii.; mistur® 
camphor® f 3ivss. Misce; sumantur cochlearia duo quarta quaque hora. 
96. Steel and Bitters. 
R. Infusi quassi® f 3ss.; tinctur® ferri ammoniati fgss.; amtnoni® sesquicarbo- 
* The alkali to be omitted, if the urine tends to be alkaline 
t Made by Murray, or Dinneford. This is the best application of this much advertised nostrum. APPENDIX OF FORMULA. 
559 
natis gr. vj; syrupi aurantii f 3j.; aquae destillatae f3vii. Misce; fiat haustus, bis 
vel ter quotidie sumendus. For hysterical women. {Brodie.') 
97. Opiate Collyrium. 
R. Zinci sulphatis gr. xii.; {vel liquoris plumbi diacetatis fjss.;) tincturae opii 
aquae destillatae f3vj. .Misce. 
98. Anti-Phosphatic Mixture. 
R. Acidi nitrici diluti; acidi muriatici diluti aa f^iiss.; syrupi aurantii f3i.; 
aquae florum aurantii f^j.; aquae destillatae f^xiiiss. Misce; sumatur cyathus 
vinarius, ter vel quater die. {Brodie.') 
99. Anti-Lithic Pill. 
R. Extract! colchici acetici, pilulae hydrargyri aa gr. j.; extract! colocynthidis 
compositi gr. ii. Misce; fiat pilula omni nocte sumenda. 
100. Corrosive Sublimate Gargle. 
R. Hydrargyri sublimati corrosivi gr. ii.; acidi hydrochloric! 1T[xx; mellis 3j.» 
aquae destillatae f3vii. Misce. 
101. Sulphuric Acid and .Ether. 
R. Acidi sulphurici diluti Tt[xl.; spiritris aetheris sulphurici compositi f3ii.; 
sacchari albi 3ss.; aquae menthae viridis f3vj. Misce. Sumatur pars quarta, 
quater die. {An admirable restorative after illness.) 
102. Chalk Ointment. 
R. Cretae, subtilissime pulverizatae 3j.; oleiolivae 3ii.; adipis 3ss. Misce. {For 
bums, excoriations with acrid discharge, ^c.) 
103. Tartar Emetic Mixture. 
R. Antimonii potassio-tartratis gr. j-ii.; syrupi papaveris f 3ss.; aquae destillatae 
f3viiss. Misce; sumantur cochlearia duo magna ter die. 
104. Tartar Emetic with Mercury. 
R. Antimonii potassio-tartratis gr. j.; hydrargyri cum creta gr. viii.; extracti conii 
gr. viii. Misce, et divide in pilulas octo; quarum sumatur una bis vel ter die. 
105. Steel and Aloes Pills. 
R. Ferri sulphatis, aloes aa 3ii.; pulveris rhei 3j. Misce et divide in pilulas lx. 
Dosis, una vel duae hora somni. {An admirable aperient for weak constipated persons.) 
106. Iodide of Potassium with Bitter Extract. 
R. Potassii iodidi gr. xii.; extracti gentianae 9ij. Misce et divide in pilulas duo- 
decim. 
107. Iodide of Potassium with Alkali. 
R. Potassi iodidi gr. xii; potassae bicarbonatis 3j.; {vel liquoris potassae f3ij.;) 
syrupi f3ss.; aquae f3vss. Misce. Dosis, f3j. bis die. 
108. Iodide of Potassium with Steel. 
R. Potassii iodidi gr. xii.; ferri sulphatis gr. vj.; syrupi f3ss.; aquae destillatae 
fvss. Misce. Dosis, f3j. bis die. 
109. Arsenical Mixture. 
R. Liquoris arsenicalis ntxx-xxx.; syrupi croci f 3iij.; tincturae cardamomi 
f3iij.; aquae destillatae f3vss. Misce. Dosis, f 3j. ter die. 560 
APPENDIX OF FORMULAE. 
110. Bark for Children. 
R. Decocti cinchona? lancifoliae fSiijss.; syrupi zinziberis f 3ss.; acidi sulphurici 
diluti lT[xv. Misce; sumatur pars quarta ter die. 
111. Citrate of Iron for Children. 
R. Ferri citratis gr. xii.; syrupi fSiij.; aquae destillatae f3iij. Misce. Dosis. 
f 3ss. ter die. 
112. Solution of Iodide of Iron. 
R. Ferri ramentorum 3ij.; iodinii gvj.; aquae destillatae f 3xvj. Put the iodine 
and iron into a bottle, then add the water, and having shaken them well together, keep 
the bottle in a warm place for three days. Lastly, pour off the clear solution, and keep 
a coil of iron wire suspended in it. Dose, TT[xv-f3i. thrice daily in a little aromatic 
water with syrup. 
113. Copaiba and Magnesia Pills. 
R. Copaiba? f3ss.; magnesias carbonatis quantum satis est ut fiat massa; in 
pilulas dividenda. 
114. Sulphate of Iron for Children. 
R. Ferri sulphatis gr. vj.; acidi sulphurici diluti lt|xii. Syrupi zinziberis f3iij.» 
aquae florum aurantii fgiij., aquae destillatae f3iiss. Misce; dosis, f3ss. ter die. 
115. ^Ethereal Tincture of Tannin. 
R. Tannin 9j.; mastiches 9ss.; spiritus aetheris sulphurici f3ss. Solve. 
116. Anti-Lithic Powder. 
R. Magnesia? gr. vj.; potassa? bicarbonatis gr. xii.; potassae tartratis gr. xv. 
Misce, fiat pulvis omni vespere sumendus, e cyatho parvo aquae. (Brodie.') INDEX. 
Abdomen, affections of, 419. 
Abscess, acute, 67. 
„ alveolar, 399. 
„ antrum, 382. 
„ of abdominal parietes, 422. 
„ in bone, 224. 
„ in the brain, 325. 
„ in the chest, 416. 
„ chronic, 71. 
„ consecutive, 66, 175, 309. 
„ diffused, 80, 161. 
„ in joints, 262. 
„ in kidney, 475. 
„ lumbar, 331. 
„ metastatic, 66. 
„ from phlebitis, 309. 
„ of prostate, 467. 
„ psoas, 331. 
„ psoas, diagnosis of from her- 
nia, 443. 
„ near rectum, 452. 
„ scrofulous, 111. 
„ in testis, 499. 
„ urinary, 464. 
Acids, injuries from, 151. 
Acupuncture, 523. 
Adhesion, 58. 
Air in veins, 520. 
Albugo, 346. 
Alkalis, injuries from, 152. 
Alterative medicines, 56. 
Amaurosis, 364. 
Amputations described, 525. 
Amputation for fracture, 234. 
-J „ for gangrene, 102. 
„ for gunshot wounds, 138. 
„ for diseased joints, 267. 
„ primary or secondary, 139. 
Anchylosis, 268. 
„ spurious, division of mus- 
cles for, 517. 
Ancyloblepharon, 337. 
Aneurism, 300. 
„ by anastomosis, 305. 
„ diffused, 300, 304. 
„ false, 300, 305. 
„ varicose, 305. 
Ankles, weak, 514. 
„ dislocations of, 291. 
Antimony, chloride of, 152. 
I Antrum, diseases of, 382. 
Anus, artificial, 425. 
„ „ as a remedy for imper- 
forate anus, 447. 
„ diseases of, 446. 
j Aquo-capsulitis, 350. 
| Arsenic, injuries from, 152. 
„ for snake-bites, 157. 
„ as a caustic, 152, 214. 
„ for onychia, 516. 
■ Arteries, wounds of, 293. 
„ inflammation of, 299. 
„ laceration of, by fracture, 235. 
„ ligature of, for aneurism, 303. 
„ operations for tying, 541. 
■ Arteriotomy, 521. 
| Artery, intercostal wounds of, 417. 
„ palmar wounds of, 297. 
i Ascites, 419. 
. Atresia ani 447. 
„ iridis, 352. 
Balanitis, 183, 194. 
I Bandages, 87, 525. 
„ four tailed, 236. 
„ many tailed, 256. 
„ starched, 232. 
„ • stellate, 237. 
Bathing, rules for, 108. 
Bees, sting of, 153, 
Belladonna, 352. 
Biceps tendon, rupture of, 280. 
Bladder, diseases of, 469. 
„ puncture of, by rectum, 459. 
„ „ by perinaeum, 463. 
„ „ above pubes, 469. 
„ wounds of, 424. 
Blennorrhcea, 182, 506. 
Blood buffed and cupped, 24. 
Blood, organizable? 60. 
Blood-letting for inflammation, 43. 
„ operation of, 520. 
Boils, 208. 
Bone, atrophy of, 222. 
., diseases of, 221. 
„ venereal diseases of, 204. 
„ inflammation of, 223. 
„ tumours of, 211, 221, 226. 
„ malignant tumours of, 228. 
Bowels, wounds of, 423. 562 
INDEX. 
Bowels, inflammation of, 424. 
" rupture of, by blows, 422. 
Brain, compression of, 319. 
„ concussion of, 317. 
„ inflammation of, 324. 
„ softening of, 65, 325. 
„ wounds of, 323. 
Breast, diseases of, 508. 
„ extirpation of, 511. 
Bronchocele, 410. 
Brow ague, 314. 
Bubo, 200. 
Bubonocele, 436. 
Bunions, 514. 
Burns, 141. 
Bursae, affections of, 218. 
Calculus, salivary, 398. 
„ vide stone. 
Callus, formation of, 229. 
Cancer, 114. 
„ gelatiniform, 120. 
„ chimney-sweepers', 505. 
„ of breast, 510. 
„ of lip, 388. 
„ of eye, 372. 
„ of nose, 382. 
„ of penis, 497. 
„ of scrotum, 505. 
„ of skin,212. 
„ of tongue, 391. 
Cancrum oris, 389. 
Cannon balls, spent, 132. 
Carbuncle, 207. 
Carcinoma, simplex, 115. 
„ alveolare, 120. 
„ medullare, 119. 
„ reticulare, 115. 
Caries, articular, 266. 
„ of bone, 226. 
„ of teeth, 393. 
„ of temporal bone, 375. 
„ of vertebrae, 329. 
Cartilage, ulceration of, 264. 
„ senile atrophy, 264. 
Cartilages loose in joints, 262. 
„ „ in bursae, 262. 
„ ,, in tunica vaginalis, 501. 
Castration, 500. 
Cataract, 354. 
„ capsular, 355, 361. 
„ „ operation for, 358. 
„ in infants, 361. 
„ diagnosis from amaurosis, 365. 
Catarrhus vesicas, 470. 
Caustics, 213. 
Cautery, actual, 523. 
Cellular tissue, suppuration in, 65. 
„ diffuse inflammation of, 
74, 80. 
„ diseases and tumours of, 
203. 
„ ulcer of, 96. 
Cellular tissue around joints, inflamma- 
tion of, 263. 
Chalkstone, 217. 
Chancre, 191. 
,, diagnosis of, 194. 
Charbon, 95. 
Chemosis, 342. 
Chest, wounds and affections of, 415. 
Chilblains, 150. 
Chordee, 189, 183. 
Choroid, diseases of, 362. 
Cicatrization, 68. 
Cicatrices from burns, 147. 
„ nerves implicated in, 312. 
„ irritable, 539. 
„ tumours of, 212. 
Circumcision, 497. 
Circocele, 502. 
Clavicle fracture of, 237. 
„ dislocation of, 274. 
Climate for the scrofulous, 108. 
Club-foot, 512. 
Cold, effects of, 148. 
„ applications for inflammation, 53. 
Collapse, 17. 
Colloid disease, 120. 
Condylomata, 203, 451. 
Congestion, 46. 
Conjunctiva, diseases of, 340. 
„ granular, 345. 
Contusion, 126. 
Convulsions, 19. 
Copaiba, 188. 
Coretomia, corectomia, 353. 
Coredialysis, 353. 
Cornea, diseases of, 346. 
„ conical, 348. 
Corns, 211. 
Couching, 359. 
Crisis, 23. 
Crystalline lens, diseases of, 354. 
• „ „ inflammation of cap- 
sule of, 354. 
Cubebs, 188. 
Curvature of the spine, 328. 
Cupping, 522. 
Cystitis, cystirrhoea, 469. 
Cytoblast, 58. 
Deafness, 377. 
Delirium traumaticum, 20. 
Derbyshire neck, 410. 
Diarrhoea, 28. 
Diplopia, 365. 
Dislocations, 272. 
Dissections, effects of, on health, 159. 
„ wounds, 160. 
Districhiasis, 336. 
Dropsy, acute, 57. 
„ of abdomen, 419. 
„ of antrum, 383. 
„ of chest, 415. 
„ of pericardium, 416. 
„ ovarian, 420. INDEX. 
563 
Dropsy, of vitreous humour, 363. 
„ gangrene from, 102. 
Drowning, 408. 
Dura mater, wounds of, 323. 
Ear, affections of, 374. 
Ecchymosis, 127. 
Ectropion, 336. 
Ecthyma, 203. 
Eczema, mercuriale, 197. 
Elbow-joint, dislocation of, 280. 
„ „ excision of, 540. 
Electricity, 524. 
Emphysema, from broken rib, 246. 
Empyema, 416. 
Encanthis, 373. 
Enchondroma, 227. 
Entropion, 339. 
Epiphora, 338. 
Epispadias, 497. 
Epistaxis, 380. 
Epulis, 399. 
Erethismus mercurialis, 198. 
Eruptions, venereal, 202. 
Erysipelas, 74. 
Excoriation, nature of, 81. 
„ of penis, 192. 
Exfoliation of bone, 225. 
Exostosis, 221. 
„ cartilaginous, 227. 
„ of teeth, 395. 
Eye, affections of, 334, 340. 
„ malignant diseases of, 372. 
„ extirpation of, 373. 
Eyelids, diseases of, 335. 
„ operations for closing, 373. 
Face, affections of, 379. 
„ cancerous ulcer of, 212. 
Farcy, 174. 
Fasciae, diseases of, 217. 
Femur, fracture of, 247. 
Fever, 21. 
„ hectic, 27. 
„ inflammatory, 22. 
„ intermittent, 22. 
„ irritative, 27. 
„ typhoid, 29. 
Fibrine, 58. 
Fibula, dislocations of, 291. 
Fingers, webbed, 515. 
„ contracted, 515. 
Fistula, 89. 
„ in ano, 452. 
„ faecal, 425. 
„ lachrymal, 338. 
„ in perinaeo, 465. 
„ recto-vaginal, 507. 
„ salivary, 379. 
„ vesico-vaginal, 507. 
Foot, dislocation of, 292. 
Forearm, fracture of, 243. 
Fracture, 229. 
„ compound, 234. 
Fracture, non-union of, 233. 
„ of skull, 321. 
„ of spine, 331. 
Frost Bite, 148. 
Fumigation, mercurial, 206. 
Fungus medullaris, haematodes, 119,373, 
383. 
„ pulpy, of synovial membrane, 
262. 
Gall-bladder, wounds of, 423. 
Galvanism, 524. 
Galvano-puncture, 525. 
Ganglion, 218. 
Gangrene, 97, 99. 
„ from aneurism, 302. 
„ from cold, 150. 
„ from wound of artery, 135. 
„ from gunshot wound, 135. 
„ hospital, 91. 
„ from oedema, 102. 
„ from pressure, 103. 
„ senile, 103. 
„ white, of skin, 104. 
Gelatiniform cancer, 120. 
Genitals, male, affections of, 496. 
I „ female, 506. 
• Glanders, 174. 
Glands, vide Lymphatics. 
| Glaucoma, 361. 
! Gleet, 189. 
Glottis, ^calds of, 407. 
„ foreign bodies in, 405. 
Goitre, 410. 
„ aerienne, 413. 
Gonotrhoea, 182, 
Gonorrhoeal rheumatism, 183, 190, 259. 
Granulation, 67. 
Gravel, red, 477. 
„ white, 480. 
Gums, affections of, 398. 
„ lancing, 392. 
Gunshot wounds, 130. 
Gunpowder, burns from, 142. 
Hsematocele, 501. 
Haematuria, 475. 
Haemorrhage, active, 61. 
„ passive, 62. 
„ from wounds of artery, 293. 
„ from wound of vein, 308. 
„ from bladder, 475. 
„ from kidneys, 475. 
„ from prostate, 475. 
„ from urethra, 466. 
„ from nose, 380. 
„ from rectum, 451. 
„ after extracting teeth, 397. 
„ secondary, from wound of 
artery, 298. 
„ „ from gunshot 
wound, 130, 135. 
„ „ from wound of 
chest, 415. 564 
INDEX. 
Haemorrhagic diathesis, 299. 
Haemorrhoids, 448, 460. 
Haemothorax, 415. 
Hand, fracture of, 245. 
„ dislocation of, 283. 
Hanging, 407. 
Hare-lip, 387. 
Head, injuries of, 317. 
Heart, wounds of, 419. 
Hectic, 27. 
Hemicrania, 314. 
Hemiopia, 365. 
Hemorrhoids, 460. L 
Hernia, 426. 
„ bronchialis, 413. 
„ cerebri, 323. 
„ congenital, 438. 
„ corneae, 348. 
„ diaphragmatic, 446. 
„ encysted, 438. 
„ femoral, 442. 
„ inguinal, 436. 
„ irreducible. 430. 
„ ischiatic, 446. 
„ obturator, 446. 
„ omental, 428. 
„ pudendal, 445. 
„ perinaeal, 445. 
„ reducible, 428. 
„ strangulated, 431. 
' „ umbilical, 444. 
„ vaginal, 445. 
„ ventral, 445. 
Herpes exedens, 213. 
„ preputialis, 195. 
Hiccup, 19. 
Hip-joint disease, 269. 
„ dislocation of, 284. 
Hordeolum, 335. 
Hospital gangrene, 91, 92. 
Housemaid's knee, 219. 
Humerus, fracture of, 240. 
Hydatid disease of breast, 509. 
„ testicle, 500. 
Hydatids in bone, 227. 
Hydrargyria, 197. 
Hydrarthus, 261. 
Hydrocele, 501. 
„ diagnosis from hernia, 439. 
Hydrophobia, 166. 
„ spontaneous, 166,171. 
Hydrophthalmia, 363. 
Hydrops, articuli, 260. 
„ pericardii, 416. 
Hydrorachitis, 333. 
Hydrothorax, 415. 
Hymen, imperforate, 508. 
Hypopyon, 350. 
Hypospadias, 497. 
Hysteria, diagnosis of from hydrophobia, 
171. 
Hysterical neuralgia, 315. 
Imperforate anus, 447. 
Impotence, 505. 
Incisions, 518. 
Inflammation, 41. 
„ acute, 48. 
„ adhesive, 58. 
„ chronic, 54. 
„ diffused, 80. 
„ erysipelatous, 74. * 
„ oedematous, 57. 
„ theory of, 46. 
Inoculation for diagnosis of chancre, 194. 
Insects, poison of, 153. 
Injections for gonorrhoea, 187. 
„ of bladder, 471. 
Iodide of potassium, 56, 198, 205. 
Iodine for scrofula, 110. 
„ for bronchocele, 410. 
„ vide Appendix. 
Iris, prolapse of, 348. 
„ diseases of, 335, 350. 
Irritants, mineral and vegetable, 151. 
Issues, 523. 
Jaw, lower, dislocation of, 274. 
„ „ tumours of, 399. 
„ upper, tumours of, 384. 
Jaws, closure of, 400. 
Joints, abscess of, 262. 
„ diseases of, 259. 
„ excision Iff, 540. 
„ false, 233. 
„ wounds of, 272. 
Keloides, 211. 
Keratonyxis, 360. 
Kidneys, diseases of, 473. 
„ wounds of, 423. 
Knee, dislocations of, 289. 
Labia pudendi, affections of, 508. 
Lacerations and contusions, 126. 
Lachrymal apparatus, affections of, 338. 
Lagophthalmos, 336. 
Laryngotomy, 406. 
Larynx, foreign bodies in. 405. 
„ venereal disease of, 204. 
Lateritious sediment, 23, 477. 
Lead, remedy for aneurism, 304. 
„ colly ria of, 348. 
Leech bites, 53. 
Leg, fracture of, 256. 
Lepoides, 212. 
Lepra syphilitica, 202. 
Leucoma, 347. 
Leucorrhosa, 187. 
Ligaments, affections of, 215, 264. 
Lip, diseases of, 387, 388. 
Ligature, effects of, 295. 
Lipoma of nose, 380. 
Lithectasy, 495. 
Lithic acid, 477, 483. 
Lithotomy, 490. 
Lithotrity, 486. 
Liver, wounds of, 423. INDEX, 
565 
Lower jaw, fracture of, 236. 
Lung, wound of, 417. 
Lupus, 213. 
Luscitas, 370. 
Lymph, 58. 
Lymphatic glands, disease of, 111. 
Lymphatics, affections of, 160, 200, 219. 
Malignant disease, 113. 
„ pustule, 95. 
Marasmus, 112. 
Maxilla, superior, tumours of, 383. 
Medullary sarcoma, 119, 228. 
Melanosis, 121. 
Mercury in primary syphilis, 196. 
„ in secondary syphilis, 205. 
„ ill effects of, 197. 
„ bichloride of, 152. 
Metallic tinkling, 415. 
Modelling process, 68, 125. 
Moles, 212. 
Mollifies ossium, 222. 
Mortification, 97, vide gangrene. 
Moxa, 524. 
Mucus, relation of to pus, 64. 
Muscse volitantes, 363, 365. 
Muscles, affections of, 214. 
„ atrophy of, 214. 
„ sutures of, 215. 
Musket balls, course of, 131. 
Mydriasis, 352. 
Myocephalon, 348. 
Myopia, 368. 
Myosis, 352. 
Naevus, 305. 
Nails, ulcers near, 515. 
Nebula, 346. 
Neck, affections of, 401. 
„ scrofulous abscess in, 73, 111. 
„ tumours of, 413. 
Necrosis, 224. 
„ of teeth, 395. 
Nephritis, 473. 
Nerves, affections of, 312. 
Neuralgia, 313. 
„ hysterical, 315. 
„ of stumps, 539. 
„ of testis and cord, 499. 
Nipples, sore, 509. 
Nodes, 204, 223. 
Noli me tangere, 213. 
Noma, 507. 
Nose, affections of, 380. 
„ venereal disease of, 203. 
Nostrils, imperforate, 382. 
(Edema, 57. 
„ acute, of scrotum, 504. 
(Esophagotomy, 405. 
(Esophagus, affections of, 402. 
Onychia maligna, 516. 
Onyx, 347. 
Operations, 518. 
Ophthalmia, 310. 
„ catarrhal, 340. 
„ catarrho-rheumatic, 349. 
„ gonorrhoeal, 343. 
„ purulent, 341, 342. 
„ rheumatic, 349. 
„ scrofulous, 344. 
„ tarsi, 335. 
Orchitis, 497. 
Osteo-aneurism, 227. 
Osteo-sarcoma, 228. 
Otalgia, 376. 
Otitis, 374. 
Otorrhcea, 375. 
Ovarian dropsy, 420. 
Oxalic acid diathesis, 479. 
„ stone, 482. 
Oztena, 382. 
Palate, fissure of, 388. 
Palm of the hand, wounds of, 297. 
Paracentesis abdominis, 419. 
„ capitis, 326. 
„ pericardii, 416. 
„ thoracis, 416. 
Paraphymosis, 497. 
Parotid, tumours of, 413. 
Paronychia, 516. 
Parulis, 399. 
Patella, fracture of, 255. 
„ dislocation of, 290. 
Pediculi palpebrarum, 337. 
Pelvis, fracture of, 246. 
Penis, affections of, 177,496. 
Pericardium, dropsy of, 416. 
Perinaeum, abscess in, 464. 
„ laceration of, 507. 
Periosteum, inflammation of, 223. 
Phagedsena, 91. 
„ sloughing, 91. 
„ venereal, 193. 
Phlebitis, 308. 
Phlegmon, 67. * 
Phosphatic gravel, 480. 
Phymosis, 199, 496. 
„ with chancre, 194, 199. 
Piles, 460. tz 
Plymouth dockyard disease, 80. 
Pneumothorax, 415. 
Poisons of healthy animals, 153. 
„ of diseased animals, 166. 
„ mineral and vegetable, 151. 
„ putrid or septic, 158. 
Polypus of epiglottis, 402. 
„ nasal, 381. 
„ uterine, 507. 
Presbyopia, 369. 
Prolapsus ani, 454. 
Prostate, affections of, 467. 
Prostration, 17. 
„ with excitement, 20. 
Pruritus ani, 457. 
i Psoriasis, pra?putii, 195. 
„ syphilitic, 202. 566 
INDEX. 
Pterygium, 345. 
Ptosis, 337. 
Pulse, theory of, 23. 
Pupil, artificial, 353. 
Pus, formation of, 62. 
„ in the blood, 63. 
„ varieties of, 63. 
Pustule, formation of, 81. 
„ malignant, 95. 
Pyelitis, 474. 
Ramollissement, 65. 
Ranula, 390. 
Rattlesnake, 155. 
Reaction after bleeding, 50. 
Rectum, affections of, 446. 
Respiration, artificial, 408. 
Retention, vide urine. 
Retina, diseases of, 364. 
Rhagades, 454. 
Rheumatism, gonorrhoeal, 183,259. 
„ of joints, 259. 
Rhino-plastic operation, 385. 
Ribs, fracture of, 245. 
" dislocations of, 283. 
Rickets, 222. 
Rupia, syphilitic, 202. 
Salivation, 197. 
Sarcoma, fleshy, 208. 
„ glandular, 221. 
„ mammary, 121. 
„ medullary, 119. 
Sarsaparilla, 110, 199. 
Scabbing, 68, 111. 
Scalds, 141. 
„ of the glottis, 407. 
Scalp, wounds of, 317. 
Scapula, fracture of, 238. 
Schneiderian membrane, inflammation 
of, 382. 
Scirrhus, 115, 228. 
„ of breast, 510. 
„ of eye, 372. 
„ of oesophagus, 404. 
„ of rectum, 456. 
„ tide cancer. 
Sclerotic, diseases of, 349. 
Scott's ointment, 261. 
Scrofula, 105. 
Scrofulous diseases of bone, 222. 
„ „ of eye, 346. 
„ „ of joints, 269. 
„ „ of kidneys, 474. 
„ „ of lymphatics, 111. 
„ „ of skin, 111. 
„ „ of testicle, 499. 
Scrofulous ulcers, 112. 
Scurvy of the gums, 398. 
Scull, fracture of, 321. 
Sea scurvy, effects of, 59, 234. 
Senile gangrene, 103. 
Sero-cystic disease, 510. 
Serum, effusion of, 57. 
Serpents, poison of, 154. 
Seton, 523. 
Short sight, 368. 
Shoulder joint, dislocation of, 275. 
„ „ excision of, 540. 
Silver, nitrate of, for ulcers, 86. 
„ „ injuries from, 152. 
„ „ discolours the conjunc- 
tiva, 349. 
Skin, diseases of, 210. 
„ scrofulous disease of, 111. 
„ ulcers of, 96, 212. 
„ tumours of, 210. 
Skull, fracture of, 321. 
Snake bites, 154. 
Softening of brain, 325. 
„ of spinal cord, 332. 
Spermatocele, 502. 
Spermatorrhoea, 506. 
Sphacelus, 97. 
Sphincter ani, division of, 448. 
„ „ spasm of, 448. 
Spiders, bite of, 154. 
Spina bifida, 333. 
Spina ventosa, 221. 
Spine, affections of, 327. 
Spine, malignant disease of, 334. 
Spleen, wounds of, 423. 
Splints, 231, 252, 257. 
Sprains, 216. 
Squinting, 369. 
Stammering, 391. 
Staphyloma corneae, 348. 
„ iridis, 348. 
„ scleroticae, 363. 
Staphyloraphe, 388. 
| Steam bath, 54. 
1 Sternum, fracture of, 246. 
| Stillicidium lachrymarum, 338. 
I Stomach, wounds of, 423. 
Stomach-pump, 408. 
Stone, 482. 
„ in the kidney, 483. 
„ in bladder, 484. 
„ ip prostate, 469,. 
„ in ureter, 483. 
„ in urethra, 466. 
„ in woman, 496. 
Strains, 216. 
| Stricture of oesophagus, 403. 
„ of rectum, 455. 
„ of urethra, spasmodic, 457. 
„ of urethra, permanent, 460. 
| Stumps, affections of, 538. 
Styptics, 297. 
| Suppuration, 62. 
Sutures, 122. 
| Symblepharon, 337. 
Synechia, 352. 
। Synchysis, 363. 
I Synovial membrane, diseases of, 259. 
Syphilis, primary, 191, 195. 
„ secondary, 202. 
I • „ of children, 206. INDEX. 
567 
Tabes mesenterica, 112. 
Talipes, 512. 
Tarantula, bite of, 154. 
Tartar on the teeth, 398. 
Taxis, 432. 
Teeth, affections of, 392. 
„ extraction of, 395. 
Tendons, affections of, 215. 
Testis, diseases of, 497. 
Tetanus, 31. 
„ chronic, 39. 
„ hysterical, 40. 
Throat, venereal sores in, 203. 
„ wounds of, 409. 
Thyroid gland, affections of, 410. 
Tic douloureux, 313. 
Toes, distortion of, 514. 
Tolerance of bleeding, 49. 
Tongue, affections of, 390. 
„ tie, 390. 
Tonsils, affections of, 401. 
Toothache, 393. 
Torsion, 297. 
Tourniquet, 526. 
Tracheotomy, 406. 
Trephining, 326. 
Trichiasis, 336. 
Trismus infantum, 40. 
Trusses, 428. 
Tubercle, pathology of, 106. 
Tumours, of bone, 221, 226. 
„ of bursae, 218. 
„ of cellular tissue, 208. 
„ cancerous, 212. 
„ chalk stone, 217. 
„ cicatrices, 212. 
„ • encysted, 209. 
„ in eyelids, 337. 
„ extirpation of, 209, 519. 
„ fatty, 209. 
„ fleshy, 208. 
„ glandular, 220. 
„ horny, 211. 
„ of iris, 353. 
„ of synovial membrane in 
joints, 259. 
„ lacteal, 509. 
„ of lips, 388. 
„ malignant, 212. 
„ of male genitals, 497. 
„ of female genitals, 508. 
„ of maxilla superior, 384. 
„ of maxilla inferior, 399. 
„ in the neck, 412, 483. 
„ of nerves, 313. 
„ on oesophagus, 404. 
„ parotid, 413. 
„ painful subcutaneous, 210, 
313. 
„ of the skin, 210. 
„ cheloid, 211. 
„ of tendons, 217. 
„ in urethra, 466. 
Tumours, vascular, of female urethra, 
507. 
Turpentine for burns, 145. 
„ as a purge, 164. 
„ in iritis, 352. 
Ulceration, pathology of, 81. 
Ulcers, 84. 
„ from burns, 146. 
„ cancerous, 115. 
„ cutaneous, 96. 
„ cancerous of skin, 212. 
„ weak, 86. 
„ of cellular membrane, 96. 
„ of cornea, 347. 
„ of eyelids, 336. 
„ fistulous, 89. 
„ healthy, 84. 
„ indolent, 86. 
„ inflamed, 85. 
„ irritable, 85. 
„ on lips, 388. 
„ malignant, 95. 
„ menstrual, 96. 
„ morbid, 96. 
„ about the nails, 515. 
„ about the nose, 213. 
„ of oesophagus, 404. 
„ phagedeenic, 91. 
„ of rectum, 456. 
„ semi-malignant, 212. 
„ sloughing, 90. 
„ scrofulous, 112. 
„ on tongue, 391. 
„ varicose, 90. 
„ venereal, primary, 191. 
Urethra, male, affections of, 182,466. 
„ contraction of orifice of, 466. 
„ rupture of, 464. 
„ discharges from, 182. 
„ chancre in, 193. 
„ . female, affections of, 506. 
Urinary abscesses, 464. 
„ fistula, 465. 
Urine, albuminous, 474. 
„ extravasation of, 464. 
„ incontinence of, 472. 
., retention of, from stricture, 457. 
„ „ from diseased prostate, 
469. 
„ „ from palsy of bladder, 
472. 
„ „ hysterical, 472. 
„ sediments in, 476. 
„ serous, 474. 
„ suppression of, 476. 
Uvula, enlargement of, 402. 
Vaccination, 524. 
Valgus, 513. 
Varicocele, 502. 
„ diagnosis of, from hernia, 
440. 568 
INDEX. 
Varicose ulcers, 90. 
(Varix, 310. 
„ aneurismal, 304. 
Varus, 512. 
Veins, aflections of, 308. 
Vegetable irritants, 151. 
Venaesection, 520. 
Venereal disease, 177. 
Vertebras, diseases of, 327. 
Viper, 155. 
Vitreous humour, diseases of, 361. 
Vomiting, 19. 
Warts, 210. 
„ in the ear, 376. 
Wasps, sting of, 154. 
Wens, 209. 
White gangrene, 104. 
Whitlow, 516. 
Wind-contusions, 133. 
Wounds, contused and lacerated, 129. 
„ gunshot, 130. 
Wounds, incised, 122. 
„ poisoned, 153. 
„ punctured, 125. 
„ of abdomen, 422. 
„ of arteries, 293. 
„ of chest, 417. 
„ of joints, 272. 
„ of lung, 417. 
„ of heart, 419. 
„ of scalp, 317. 
„ of throat, 409. 
„ of brain, 323. 
„ of veins, 308. 
„ nerves, 312. 
„ eyelids, 334. 
„ tongue, 390, 
Wourali, 39, 174. 
Wry-neck, 413. 
Xerophthalmia, 338. 
Zinc, chloride of, 214. 
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particularly to American practice. LEA & BLANCHARD'S PUBLICATIONS. 
5 
Cyclopedia of Practical Medicine, continued. 
Abdomen, Exploration of the, Dr. 
Forbes. 
Abortion, Dr. Lee. 
Abscess, Internal, Dr. Tweedie. 
Abstinence, Dr. Marshal] Hall. 
Achor, Dr. Todd. 
Acne, Dr. Todd. 
Acrodynia, Dr. Dunglison. 
Acupuncture, Dr. Elliotson. 
Age, Dr. Roget. 
Air, Change of. Sir James Clarke. 
Alopecia, Dr. Todd. 
Alteratives, Dr. Conolly. 
Amaurosis, Dr. Jacob. 
Amenorrhrea. Dr. Locock. 
Anaemia, Dr. Marshall Hall. 
Anasarca, Dr. Darwall. 
Angina Pectoris. Dr. Forbes. 
Anodynes, Dr. Whiting. 
Anthelmintics. Dr. A. T. Thomson. 
Anthracion. Dr. Dunglison. 
Antiphlogistic Regimen, Dr. Barlow. 
Antispasmodics, Dr. A. T. Thomson. 
Aorta, Aneurism of, Dr. Hope. 
Apoplexy, Cerebral, Dr. Clutterbuck. 
" Pulmonary, Dr. Town- 
send. 
Arteritis, Dr. Hope. 
Ascites, Dr. Darwall. 
Artisans, Diseases of, Dr. Darwall. 
Asphyxia, Dr. Roget. 
" of the New Bom, Dr. Dun- 
glison. 
Asthma, Dr. Forbes. 
Astringents, Dr. A. T. Thomson. 
Atrophy, Dr. Townsend. 
Auscultation, Dr. Forbes. 
Barbiers, Dr. Scott. 1 
Bathing, Dr. Forbes. । 
Beriberi, Dr. Scott 
CONTENTS OF VOLUME I. 
Blood, Determination of. Dr. Barlow. 
" Morbid States of, Dr. Marshall 
Hall. । 
Blood-letting, Dr. Marshall Hall. 
Brain, Inflammation of the, 
Meningitis, Dr. Quain. 
Cerebritis, Dr. Adair Craw- 
ford. 
Bronchial Glands, Diseases of the, 
Dr. Dunglison. 
Bronchitis, Acute and Chronic, Dr. 
Williams. 
" Summer, Dr. Dunglison. 
Bronchocele, Dr. And. Crawford. 
Bullae, Dr, Todd. 
Cachexia, Dr. Dunglison. 
Calculi, Dr. T. Thomson. 
Calculous Diseases, Dr. Cumin. 
Catalepsy, Dr. Joy. 
Catarrh. Dr. Williams. 
Cathartics, Dr. A. T. Thomson. 
Chest, Exploration of the, Dr. Forbes. 
Chicken Pox, Dr. Gregory. 
Chlorosis, Dr. Marshall Hall. 
Cholera, Common and Epidemic, Dr. 
Brown. 
" Infantum, Dr. Dunglison. 
Chorea, Dr. And. Crawford. 
Cirrhosis of the Lung, Dr. Dunglison. 
Climate, Dr. Clark. 
Cold, Dr. Whiting. 
•Colic, Drs. Whiting and Tweedie. 
Colica Pictonum, Dr. Whiting. 
Colon, Torpor of the, Dr. Dunglison 
Coma, Dr. Adair Crawford. 
Combustion, Spontaneous, Dr. Ap- 
john. 
Congestion of Blood. Dr. Barlow. 
Constipation, Drs. Hastings and 
Streeten. 
. Contagion. Dr. Brown. 
I Convalescence, Dr. Tweedie. 
Convulsions, Dr. Adair Crawford. 
" Infantile, Dr. Locock. 
" Puerperal, Dr. Locock. 
Coryza, Dr. Williams. 
Counter Irritation. Dr. Williams. 
Croup, Dr. Cheyne. 
Cyanosis. Dr Crampton. 
Cystitis, Dr. Cumin. 
Dead. Persons found, Dr. Beatty. 
Delirium, Dr. Pritchard. 
" Tremens. Drs. Carter and 
Dunglison . 
Dengue, Dr. Dunglison. 
Dentition, Disorders of, Dr. Joy. 
Derivation. Dr. Stokes. 
Diabetes, Dr. Bardsley. 
Diagnosis, Dr. Marshall Hall. 
Diaphoretics. Dr. A. T. Thomson. 
Diarrhata, Drs. Crampton and Forbes. 
" Adipous, Dr. Dunglison. 
Dietetics, Dr. Paris. 
Disease, Dr. Conolly. 
. Disinfectants. Dr. Dunglison.. 
Disinfection. Dr. Brown. 
Diuretics. Dr. A. T. Thomsons 
Dropsy, Dr. Darwajl. 
. Dysentery, Dr. Brown. 
Dysmenorrhcea, Dr. Locock. 
Dysphagia. Dr. Stokes. 
Dyspncea, Dr. Williams. 
Dysuria, Dr. Cumin. 
Ecthyma, Dr. Todd. 
Eczema, Dr. Joy. 
Education, Physical, Dr. Barlow. 
Electricity, Dr. Apjohn. 
Elephantiasis, Dr. Joy. 
Emetics, Dr. A. T. Thomson. 
Emmenagogues, Dr. A. T. Thomson 
CONTENTS OF VOLUME IL 
Emphysema, Dr. R. Townsend. 
" of the Lungs, Dr. R. 
Townsend. 
Empyema, Dr. R. Townsend. 
Endemic diseases. Dr. Hancock. 
Enteritis, Drs. Stokes and Dunglison.1 
Ephelis, Dr. Todd. 
Epidemics. Dr. Hancock. 
Epilepsy, Dr. Cheyne. 
Epistaxis. Dr. Kerr. ' 
Erethismus Mercurialis, Dr. Burder. 
Erysipelas, Dr. Tweedie. 
Erythema, Dr. Joy. 
Eutrophic, Dr. Dunglison. 
Exanthemata, Dr. Tweedie. 
Expectorants, Dr. A. T. Thomson. 
Expectoration. Dr. Williams. 
Favus, Dr. A. T. Thomson. 
Feigned diseases, Drs. Scott, Forbes 
and Marshall. 
Fever, general doctrine of, Dr. Twee- 
die. 
" Continued, and its modifica- 
tions, Dr. Tweedie. 
" Typhus, Dr. Tweedie. 
" Epidemic Gastric, Dr. Cheyne. 
" Intermittent. Dr. Brown. 
" Remittent, Dr Brown. 
" Malignant Remittent, Dr. Dun- 
glison. 
Fever, Infantile, Dr. Joy. 
" Hectic. Dr Brown. 
" Puerperal, Dr. Lee. 
" Yellow, Dr. Gilkrest. 
Fungus Hamatodes, Dr. Kerr. 
Galvanism, Drs. Apjohn and Dungli- 
son. 
Gastritis, Dr. Stokes. 
Gastrodynia. Dr Barlow, 
Gastro-Enteritis, Dr. Stokes. 
Glanders. Dr. Dunglison. 
Glossitis, Dr. Kerr. 
Glottis. Spasm of the, Dr. Joy. 
Gout, Dr. Barlow. 
HaBmatemesis. Dr. Goldie. 
Hsemoptysis, Dr. Law. 
Headache, Dr. Burder. 
Heart, Diseases of the, Dr. Hope. 
" Dilatation of the, Dr. Hope. 
" Displacement of the, Dr. 
Townsend. 
" Fatly and greasy degenera- 
tion of the, Dr. Hope. 
" Hypertrophy of the. Dr. Hope. 
" Malformations of the, Dr. Wil- 
liams. 
" Polypus of the, Dr. Dunglison. 
" Rupture of the, Dr. Townsend. 
" Diseases of the Valves of the, 
Dr. Hope. 
Haemorrhage, Dr. Watson. 
Haemorrhoids, Dr. Bane. 
Hereditary Transmission of Disease, 
Dr. Brown. 
Herpes, Dr. A. T. Thomson. 
Hiccup, Dr. Ash. 
Hooping Cough. Dr. Johnson. 
Hydatids. Dr. Kerr. 
Hydrocephalus, Dr. Joy. 
Hydroperieardium, Dr. Darwalk 
Hydrophobia. Dr. Bardsley. 
Hydrothorax. Dr. Darwall. 
Hyperaesthesin. Dr. Dunglison. 
Hypertrophy, Dr. Townsend. 
Hypochondriasis. Dr. Pritchard. 
Hysteria, Dr. Conolly. 
Ichthyosis, Dr. Thomson. / 
Identity, Dr. Montgomery. 
Impetigo, Dr. A. T. Thomson. 
Impotence, Dr. Beatty. 
Incubus, Dr. Williams. 
Indigestion, Dr. Todd. 
Induration, Dr. Carswell. 
Infanticide, Dr. Arrowsmith. 
Infection, Dr. Brown. 
InSammat ion, Drs. Adair Crawford 
and Tweedie. 
CONTENTS OF VOLUME III. 
Influenza, Dr. Hancock. 
Insanity, Dr. Pritchard. 
Intussusception. Dr. Dunglison. 
Irritation, Dr. Williams. 
Jaundice. Dr. Burden 
of the Infant. Dr. Dunglison. 
Kidneys, diseases of, Dr. Carter. 
Lactation, Dr. Locock. 
Laryngitis, Dr. Cheyne. 
" Chronic, Dr. Dunglison. 
Latent diseases, Dr. Christison. 
Lepra, Dr. Houghton. 
Leucorrhrea, Dr. Locock. 
Lichen. Dr. Houghton. 
Liver, D:seases of the, Dr. Stokes. 
Liver, Diseases of the, Dr. Venables. 
" Inflammation of the, Dr. 
Stokes. 
Malaria and Miasma. Dr. Brown. 
Medicine, History of, Dr. Bostock. 
" American, before the Re- 
volution, Dr. J. B. Beck. 
Medicine, State of in the 19th Cen* 
tury, Dr. Alison. 
" Practical, Principles of, 
Dr Conolly. 
Melaena. Dr. Goldie. 
Melanosis, Dr. Carswell. 
Menorrhagia, Dr. Locock. 
Menstruation, Pathology of, Dr. Lo- 
cock. 
Miliaria, Dr. Tweedie. 
Milk Sickness, Dr. Dunglison. LEA & BLANCHARD'S PUBLICATIONS. 
6 
Cyclopaedia of Practical Medicine, continued. 
Mind. Soundness and Unsoundness 
of, Drs. Pritchard andDunglison. 
Molluscutn, Dr. Dunglison. 
Mortification. Dr. Carswell. 
Narcoties, Dr. A. T. Thomson. 
Nauseants, Dr. Dunglison. 
Nephralgia and Nephritis, Dr. Carter. 
Neuralgia. Dr. Elliotson. 
Noli-Me-Tangere or Lupus, Dr. 
Houghton. 
Nyctalopia, Dr Grant. 
Obesity, Dr. Williams. 
(Edema, Dr. Darwall. 
Ophthalmia, Drs. Jacobs and Dungli- 
son. 
Otalgia and Otitis, Dr. Burne. 
Ovaria, Diseases of the, Dr. Lee. 
Palpitation, Drs. Hope and Dunglison. 
CONTENTS OF VOLUME III -Continued. 
Pancreas, diseases of the, Dr. Carter. 
Paralysis, Dr. Todd. 
Parotitis, Dr. Kerr. 
Parturients, Dr. Dunglison. 
Pellagra, Dr. Kerr. 
Pemphigus, Dr. Corrigan. 
Perforation of the Hollow Viscera, 
Dr. Carswell. 
Pericarditis, Dr. Hope. 
Peritonitis. Drs. McAdam and Stokes. 
Phlegmasia Dolens, Dr. Lee. 
Pityriasis. Dr. Cumin. 
Plague, Dr. Brown. 
Plethora, Dr. Barlow. 
Pleurisy, Dr. Law. 
Plica Polonica, Dr. Corrigan. 
Pneumonia, Dr. Williams. 
Pneumothorax, Dr. Houghton. 
Porrigo, Dr. A. T. Thomson. 
Pregnancy and Delivery, signs of, 
Dr. Montgomery. 
Prognosis, Dr. Ash. 
Prurigo, Dr. A. T. Thomson. 
Pseudo-Morbid Appearances, Dr. 
Todd. 
Psoriasis, Dr. Cumin. 
Ptyalism. Dr. Dunglison. 
Puerperal Diseases, Dr. Marshall 
Hall. 
Pulse, Dr. Bostock. 
Purpura, Dr. Goldie. 
Pus, Dr. Tweedie. 
Pyrosis. Dr. Kerr. 
Rape, Dr. Beatty. 
CONTENTS OF VOLUME IV. 
Refrigerants, Dr. A. T. Thomson. f 
Rheumatism, Drs. Barlow and Dun- 
glison. f 
Rickets. Dr. Cumin. : 
Roseola, Dr. Tweedie. ! 
Rubeola, Dr. Montgomery. 
Rupi a, Dr. Corrigan. I 
Scabies, Dr. Houghton. 
Scarlatina. Dr. Tweedie. ! 
Scirrhus, Dr. Carswell. 
Scorbutus. Dr. Kerr. 
Scrofula, Dr. Cumin. ! 
Sedatives, Drs. A. T. Thomson and! 
Dunglison. : 
Sex, Doubtful, Dr. Beatty. 
Small Pox, Dr. Gregory. 
Softening of Organs. Dr. Carswell. ' 
Somnambulism and Animal Magne-' 
tism, Dr. Pritchard. 
Spermatorrhcea, Dr. Dunglison. 
Spinal Marrow, Diseases of the, Dr. 
Todd. 
Spleen, Diseases of the, Drs. Bigsby,' 
and Dunglison. 
Statistics, Medical, Drs. Hawkins ' 
and Dunglison. 
Stethoscope, Dr. Williams. 
Stimulants. Dr. A. T. Thomson. 
Stomach, Organic Diseases of, Dr.' 
Houghton and Dunglison. 
Stomatitis, Dr. Dunglison. 
Strophulus. Dr. Dunglison. 
Succession of Inheritance, Legitima- 
. cy, Dr. Montgomery, 
Suppuration, Dr. Todd. 
Survivorship, Dr. Beatty. 
Sycosis, Dr. Cumin. 
Symptomatology. Dr. Marshall Hall. 
Syncope, Dr. Ash. 
Tabes Meseuterica, Dr. Joy. 
Temperament. Dr. Pritchard. 
Tetanies, Dr. Dunglison. 
Tetanus, Dr. Symonds. 
Throat, Diseases of the, Dr. Tweedie. 
• Tissue Adventitious. 
Tonics, Dr. A.T. Thomson. 
Toothache, Dr. Dunglison. 
Toxicology, Drs. Apjohn and Dungli- 
son. 
Transformations, Dr. Duesbury. 
Transfusion. Dr. Kay. 
.Tubercle, Dr. Carswell. 
Tubercular Phthisis,Sir James Clark. 
Tympanitis, Dr. Kerr. 
Urine, Incontinence of. Dr. Cumin. 
•Urine, Suppression of, Dr. Carter. 
Urine, Morbid States of, Dr. Bostock. 
Urine, Bloody, Dr. Goldie. 
Urticaria, Dr. Houghton. 
Uterus, Pathology of. Dr. Lee. 
Vaccination, Dr. Gregory. 
Varicella, Dr. Gregory. 
Veins, Diseases of; Dr. Lee. 
Ventilation, Dr. Brown. 
Wakefulness, Dr. Cheyne. 
Waters Mineral, Dr. T.Thompson. 
.Worms, Dr. Joy. 
Yaws, Dr. Kerr .J 
Index, Ac. 
The Publishers wish it to be particularly understood that this work not 
only embraces all the subjects properly belonging to 
PRACTICAL MEDICINE, 
but includes all the diseases and treatment of 
WOMEN AND CHILDREN, 
as well as all of particular importance on 
MATERIA MEDICA. THERAPEUTICS, 
AND 
MEDICAL JURISPRUDENCE, 
Thus presenting important claims on the profession from the greater 
extent of subjects embraced in this than in other works on the mere 
Practice of Medicine; while, notwithstanding its BEAUTIFUL 
EXEC UT ION, its REMARKABLE CHEAPNESS places it 
within the reach of all. LEA & BLANCHARD'S PUBLICATIONS. 
7 
Cyclopaedia of Practical Medicine, continued. 
The Publishers present a few of the notices which the work has received 
from the press in this country and in England. 
"We rejoice that this work is to be placed within 
the reach of the profession in this country, it being 
unquestionably one of very great Value to the practi- 
tioner. This estimate of it has not been formed from 
a hasty examination, but after an intimate acquaint- 
ance derived from frequent consultation of it during 
the past nine or ten years. The editors are practition- 
ers of established reputation, and the list of contribu- 
tors embraces many of the most eminent professors 
and teachers of London, Edinburgh, Dublin and Glas- 
gow. It is, indeed, the great merit of this work that 
the principal articles have been furnished by practi- 
tioners who have not only devoted especial attention 
to the diseases about which they have written, but 
have also enjoyed opportunities for an extensive prac- 
tical acquaintance with them, and whose reputation 
carries the assurance of their competency justly to 
appreciate the opinions of others, while it stamps their 
own doctrines with high and just authority."-Ameri- 
can Medical Journal. 
"Do young physicians generally know what a trea- 
sure is offered to them in Dr. Dunglison's revised edi- 
tion? Without wishing to be thought importunate, we 
cannot very well refrain from urging upon them the 
claims of this highly meritorious undertaking."-Bos- 
ton Medical and Surgical Journal. 
u It has been to us, both as learner and teacher, a 
work for ready and frequent reference, one in which 
modern English medicine is exhibited in the most 
advantageous light, and with adaptations to various 
tastes and expectations."-Medical Examiner. 
"Such a work as this has long been wanting in this 
country. British medicine ought to have set itself 
forth in this way much sooner. We have often won- 
dered that the medical profession and the enterprising 
publishers of Great Britain did not, long ere this, 
enter upon such an undertaking as a Cyclopedia of 
Practical Medicine."-London Medical Gazette. 
" It is what it claims to be, a Cyclopedia, in which 
Practical Medicine is posted up to the present day, 
and as such constitutes a storehouse of medical know- 
ledge upon which the student and practitioner may 
draw with equal advantage."- The Western Journal 
of Medicine and Surgery. 
"The Cyclopedia of Practical Medicine, a work 
which does honour to our country, and to which one 
is proud to see the names of so many provincial phy- 
sicians attached."-Dr. Hastings' Address to Pro- 
vincial Medical and Surgical Association. 
" Of the medical publications of the past year, one 
may be more particularly noticed, as partaking, from 
its extent and the number of contributors, somewhat 
of the nature of a national undertaking, namely, the 
•Cyclopedia of Practical Medicine.' It accomplishes 
what has been noticed as most desirable, by present- 
ing, on several important topics of medical inquiry, 
full, comprehensive, and well digested expositions, 
showing the present state of our knowledge on each. 
In this country, a work of this kind was much wanted: 
and that now supplied cannot but be deemed an im- 
portant acquisition. The difficulties of the undertak- 
ing were not slight, and it required great energies to 
surmount them. These energies, however, were pos- 
sessed by the able and distinguished editors, who, 
with diligence and labour such as few can know or 
■appreciate,have succeeded in concentrating in a work 
of moderate size, a body of practical knowledge of 
great extent and usefulness."-Dr. Barlow's Address 
to the Med. and Sur. Association. 
" For reference, it is above all price to every practi- 
tioner."- The Western Lancet. 
•'This Cyclopedia is pronounced on all hands to be 
one of the most valuable medical publications of the 
day. It is meant to be a library of Practical Medicine. 
As a work of reference it is invaluable. Among the 
contributors to its pages, it numbers many of the most 
experienced and learned physicians of the age, and as 
a whole it forms a compendium of medical science 
and practice from which practitioners and students 
may draw the richest instruction "- Western Journ. 
of Med. and Surgery. 
"The contributors are very numerous, including 
the most distinguished physicians in the kingdom. 
The design of the work embraces practical articles of 
judicious length in Medicine, Therapeutics, Hygiene, 
&c., so that, within a small compass, and of easy re- 
ference, the student possesses a complete library, 
composed of the highest authorities. To the country 
practitioner, especially, a publication of this kind is 
of inestimable value."- V. S. Gazette. 
"When it is considered that this great work em- 
braces three hundred original essays, from sources of 
the highest authority, we cannot but hope that our 
medical friends will offer all the requisite encourage- 
ment to the publishers."-Boston Medical and Sur- 
gical Journal. 
"Incur last number we noticed the publication of 
this splendid work by Lea & Blanchard. We have 
since received three additional parts, an examination 
of which has confirmed us in our first impression, that 
as a work of reference for the practitioner-as a Cyclo- 
paedia of Practical Medicine-it is admirably adapted 
to the wants of the American profession. In fact, it 
might advantageously find a place in the library of 
any gentleman, who has leisure and taste for looking 
somewhat into the nature, causes, and cure of dis- 
eases."- Western Journal of Med. and Surgery. 
" The favourable opinion which we expressed on 
former occasions from the specimens then before us, 
is in no degree lessened by a further acquaintance 
with its scope and execution."- Medical Examiner. 
" The Cyclopedia must be regarded as the most 
complete work of Practical Medicine extant; or, at 
least in our language. The amount of information on 
every topic which it embraces, is posted up to the 
present time ; and so far as we are able to judge, it is 
generally more free from natural exclusiveness and 
prejudices, than is usually the case with British pub- 
lications. The getting up of the American edition is 
very creditable to the Publishers. It will compare very 
favourably with the English edition. In some re- 
spects, it is much to be preferred. During the original 
publication, many of the articles not being in readi- 
ness to be printed in proper alphabetical order, it be- 
came necessary to include them together in a single 
volume, as a supplement to the work. This difficulty 
is obviated in the American edition. On the whole, 
we advise those who desire a compendious collection 
of the latest and most important information in the 
various departments of Practical Medicine, including 
Midwifery, Materia Medica, Medical Jurisprudence, 
&c^ to possess themselves of this work."-The Buf- 
falo Medical Journal. 
*** In reply to the numerous inquiries made to them respecting Tweedie's Library of Practical 
Medicine, the Publishers beg leave to state that its place is supplied, in a great measure, by the 
Cyclopaedia of Practical Medicine, a work much more extended in its plan and execution. The 
works are entirely distinct and by different authors. The " Library"consists -of essays on diseases, 
systematically arranged. The " Cyclopaedia" embraces these subjects treated in a more extended 
manner, together with numerous interesting essays on all important points of Medical Jurispru- 
dence, Materia Medica, Therapeutics, Diseases of Women and Children, History of Medicine, &c., 
•&c, by the first physicians of England, the whole arranged alphabetically for easier reference. 8 
LEA & BLANCHARD'S PUBLICATIONS. 
WATSON'S PRACTICE. 
NEW AND IMPROVED EDITION. 
Now Ready, 
LECTURES 
ON THE 
PRINCIPLES AND PRACTICE OF PHYSIG. 
DELIVERED AT KING'S COLLEGE, LONDON. 
Bv THOMAS WATSON, M. D., &c. &c. 
SECOND AMERICAN, FROM THE SECOND LONDON EDITION. 
REVISED, WITH ADDITIONS, 
By D. FRANCIS CONDIE, M. D., 
Author of a work on the " Diseases of Children," &c. 
In one Octavo Volume. 
Of nearly eleven hundred large pages, strongly bound with raised bands. 
The rapid sale of the first edition of this work is an evidence of its 
merits, and of its general favour with the American practitioner. To 
commend it still more strongly to the profession, the publishers have gone 
to a great expense in preparing this edition with larger type, finer paper, 
and stronger binding, with raised bands. It is edited with reference par- 
ticularly to American practice, by Dr. Condie; and with these numerous 
improvements, the price is still kept so low as to be within the reach of 
all, and to render it among tne cheapest works offered to the.profession. 
It has been received with the utmost favour by the medical press, both 
of this country and of England, a few of the notices of which, together 
with a letter from Professor Chapman, are submitted. 
"We know of no work better calculated for being 
placed in the hands of the student, and for a text book, 
and as such we are sure it will be very extensively 
adopted. Ou every important point the author seems 
to have posted up his knowledge to the day."-Ameri- 
can Medical Journal. 
"In the Lectures of Dr. Watson, now republished 
here in a large and closely-printed volume, we have 
a body of doctrine nnd practice of medicine well cal- 
culated, by its intrinsic soundness and correctness of 
style, to instruct the student and younger practitioner, 
and improve members of the profession of every age." 
-Bulletin of Medical Science. 
"We regard these Lectures as the best exposition 
of their subjects of nnv we remember to have read. 
The. author is assuredly master of his art. His has 
been a life of observation and study, and in this work 
he has given us the matured results of these mental 
efforts.''-New Orleans Medical Journal. 
" We find that, from the great length we hare gone 
in our analysis of this work, we must close our notice 
of it here lor the present-not, however, without ex- 
pressing our unqualified approbation of the manner in 
which the author has performed his task. Hut it is as 
a book of elementary instruction that we admire Dr. 
Watson's work.'--Medico-Chirurgical Review. 
''One of the most practically useful books that ever 
was presented to the student-indeed a more admira- 
ble summary of general and special pathology, and of 
the application ot therapeutics to diseases, we are free 
to say has not appeared for very many years. The 
lecturer proceeds through the whole classification of 
human ills, a capitc ad ealevm. showing at every step 
an extensive knowledge of his subject, with the ability 
of communicating his precise ideas in a style remark- 
able for its clearness and simplicity.'' - N . Jownal 
of Medicine and Surgery. LEA & BLANCHARD'S PUBLICATIONS. 
9 
WATSONS PRACTICE-Continued. 
Philadelphia, September 21th, 1844. 
Watson's Practice of Physic, in my opinion, is among the most com- 
prehensive works on the subject extant, replete with curious and important 
matter, and written with great perspicuity and felicity of manner. As 
calculated to do much good, I cordially recommend it to that portion of 
the profession in this country who may be influenced by my judgment. 
N. CHAPMAN, M.D. 
Professor of the Practice and Theory of Medicine 
in the University of Pennsylvania. 
"We know not, indeed, of any work of the same 
size that contains a greater amount of interesting and 
useful matter The author is evidently well acquainted 
with everything appertaining to the principles and 
practice ot medicine, and has incorporated the stores 
of his well stocked mind, in the work before us, so 
ably and agreeably, that it is impossible for the inte- 
rest of the reader to flag for a moment. That they are 
well adapted for such a purpose all must admit; but 
their sphere of usefulness may extend much beyond 
this. We are satisfied, indeed, that no physician, well 
read and observant as he may be,can rise from their 
perusal without having aaded largely to his stock of 
valuable information."-Medical Examiner. 
"The medical literature of this country has been 
enriched by a work of standard excellence, which we 
can proudly hold up to our brethren of other countries 
as a representative of the natural state of British me- 
dicine, as professed and practised by our most en- 
lightened physicians. And, for our own parts, we are 
not only willing that our characters as scientific phy- 
sicians and skilful practitioners may be deduced trom 
the doctrines contained in this book, but we hesitate 
not to declare our belief that for sound, trustworthy 
principles, and substantial good practice, it cannot be 
paralleled by any similar production in any other 
country. * * * * We would advise no one lo set 
himself down in practice unprovided with a copy."- 
British and Foreign Medical Review. 
"We cannot refrain from calling the attention of 
our younger brethren, as soon as possible, to Dr. Wat- 
son's Lectures, if they' want a safe and comprehensive 
guide to the study of practical medicine. 
" In fact, to any of our more advanced brethren who 
wish to possess a commodious book of reference on 
any of the topics usually treated of in a course of lec- 
tures on the practice of ph"ysic, or who wish to have 
a simple enunciation of any facts or doctrines which, 
from their novelty or their difficulty, the busy practi- 
tioner may not have made himself master of amidst 
the all-absorbing toils of his professional career, we 
can recommend these lectures most cordially. Here 
we meet with none of those brilliant theories which 
are so seductive to young men, because they are made 
to explain every phenomenon, and save all the trouble 
of observation aad reflection; here are no exclusive 
doctrines; none of those 
'Bubbles that glitter as they rise and break 
On vain Philosophy's all babbling spring.' 
But we have the sterling production of a liberal, well- 
stored and truly' honest m nd, possessed of all that is 
currently known and established of professional know- 
ledge, and capable of pronouncing a trustworthy and 
impartial judgment on those numerous points in which 
Truth is yet obscured with false facts or false hypo- 
theses."- Provincial Medical Journal. 
"The style is correct and pleasing, and the matter 
worthy the attention of all practitioners, young and 
old."- Western Lancet. 
" We are free to state that a careful examination of 
this volume has satisfied us that it merits all the com- 
mendation bestowed on it in this country and at 
home. It is a work adapted to the wants of young 
practitioners, combining, as it does, sound principles 
and substantial practice. It is not too much to say 
that it is a representative of the actual state of medi- 
cine as taught and practised by the most eminent phy- 
sicians of the present day, and as such we would 
advise every one about embarking in the practice of 
physic to provide himself with a copy of it."-Western 
Journal of Medicine and Surgery. 
"It is the production of a physician of undoubted 
talent and great learning, and whose industry in per- 
forming the most laborious duties of this profession 
has been well known for a long series of years. * * 
Let us not forget to add that the style and general 
character of the work are peculiarly practical; and 
the cases which Dr. Watson has from time to time 
introduced to illustrate his views, are highly appro- 
priate and interesting, and add much to the value of 
the work; and this certainly must be admitted to be 
one of the great advantages of casting this work in 
the shape of lectures, in which these cases assuredly 
appear more filly, and in which they are introduced 
more easily and naturally than they could have been 
had the form of the work been different. Lastly, we 
are well pleased to observe that a strong vein of 
common sense, as well as good taste, runs through 
the whole treatise, and sustains both the interest and 
the confidence of the reader throughout."-Edinburgh 
Medical and Surgical Journal. 
" In calling the attention of the profession to the ele- 
gant volume recently published by Lea & Blanchard 
-the lectures delivered at King's College, London, by 
Dr. Watson-we do not suppose anyone at all con- 
versant with the medical literature of the day to be 
unacquainted with its general character. Dr. W. de- 
livered these now celebrated lectures during the me- 
dical session of 1S3&-7. They have been revised by 
the author, and those who now study these erudite 
productions will have them divested of any objection- 
able matter that might have formerly crept in through 
inadvertence. There are ninety lectures, fully written, 
embracing the W'hole domain of human maladies, with- 
their treatment, besides an appendix particularly re- 
markable for its richness in important practical infor- 
mation. We could not give even a tolerable synopsis 
of the subjects discussed in this great undertaking 
Without materially entrenching on the limits assigned 
to other matter. * * * Open this huge, well-finished 
volume wherever we may, the eye immediately rests 
on something that carries value on its front. We are 
impressed at once with the strength and depth of the 
lecturer's views; he gains on our admiration in pro- 
portion to the extent of our acquaintance with his 
profound researches. Whoever owns this book will 
have an acknowledged treasure, if the combined wis- 
dom of the highest authorities is appreciated."-Boston 
Medical and Surgical Journal. 
HORNER'S ANATOMY. 
SPECIAL ANATOMY AND HISTOLOGY. 
BY WILLIAM E. HORNER, M.D., 
Professor of Anatomy in the University of Pennsylvania, Member of the Imperial Medico-Chirurgical Academy 
of St. Petersburg, of the Am. Philosophical Society, &c.. &c. 
Sixth Edition, in two Volumes, Svo. 
"Another edition of this standard work of Professor Horner has made its appearance to which 
many additions have been made, and upon which much labour has been bestowed by the author.- 
The additions are chiefly in the department of Histology, or Elementary Anatomy, and so import- 
ant are they that the Professor has added the term to the title of his work. Every part of this 
edition seems to have undergone the most careful revision, and its readers may rest assured of hav- 
ing the science of Anatomy fully brought up to the present d^y."-Am. Med. Journal. A ItEAGWIFICElVT AZ^D CHEAP WORK. 
SMITH & HORNER'S ANATOMICAL ATLAS. 
Just Published, Price Five Dollars in Parts. 
AN 
ANATOMICAL ATLAS 
ILLUSTRATIVE OF THE STRUCTURE OF THE HUMAN BODY. 
BY HENRY H. SMITH, M. D., 
Fellow of the College of Physicians, ^c. 
UNDER THE SUPERVISION OF 
WILLIAM E. HORNER, M. D., 
Professor of Jinatomy in the University of Pennsylvania. 
In One large Volume, Imperial Octavo. 
This work is but just completed, having been delayed over the time intended by the great difficulty in giving 
to the illustrations the desired finish and perfection. It consists of five parts, whose contents are as follows: 
Part I. The Bones and Ligaments; with one hundred and thirty engravings. 
Tart II. The Muscular and Dermoid Systems, with ninety-one engravings. 
Part III. The Organs of Digestion and Generation, with one hundred and ninety-one engravings. 
Part IV. The Organs of Respiration and Circulation, with ninety-eight engravings. 
Part V. The Nervous System and the Senses, with one hundred and twenty-six engravings. 
Forming altogether a complete System of Anatomical Plates, of nearly 
SIX HUNDRED AND FIFTY FIGURES, 
executed in the best style of an, and making one large imperial octavo volume. Those who do not want it in 
parts can have the work bound in extra clotli or sheep at an extra cost. 
This work possesses novelty both in the design and the execution. It is the first attempt to apply engraving 
on wood, on a large scale, to the illustration of human anatomy, and the beauty of the parts issued induces the 
publishers to flatter themselves with the hope of the perfect success of their undertaking. The plan of the 
work is at once novel and convenient. Each page is perfect in itself, the references being immediately under 
the figures, so that the eye takes in the whole at a glance, and obviates the necessity of continual reference 
backwards and forwards. The cuts are selected from the best and most accurate sources; and, where neces- 
sary, original drawings have been made from the admirable Anatomical Collection of the University of Penn- 
sylvania. It embraces all the late beautiful discoveries arising from the use of the microscope in the investi- 
gation of the minute structure of the tissues. 
In the getting up of this very complete work, the publishers have spared neither pains nor expense, and they 
now present it to the profession, with the full confidence that it will be deemed all that is wanted in a scientific 
and artistical point ot view, while, at the same time, its very low price places it within the reach of all. 
It is particularly adapted to supply the place qf skeletons or subjects, as the profession will see by examining the list 
of plates now annexed. 
" These figures are well selected, and present a complete and accurate representation of that wonderful fabric, 
the human body. The plan of this Atlas, which renders it so peculiarly convenient for the student, and its 
superb artistical execution, have been already pointed out. We must congratulate the student upon the 
completion of this atlas, as it is the most convenient work of the kind that has yet appeared; and, we must 
add, the very beautiful manner in which it is 'got up' is so creditable to the country as to be flattering to our 
national pride."-American Medical Journal. 
"This is an exquisite volume, and a beautiful specimen of art. We have numerous Anatomical Atlases, 
but we will venture to say that none equal it in cheapness, and none surpass it in faithfulness and spirit We 
strongly recommend to our friends, both urban and suburban, the purchase of this excellenrwork, for which 
both editor and publisher deserve the thanks of the profession."-Medical Examiner. 
"We would strongly recommend it, not only to the student, but also to the working practitioner, who, 
although grown rusty in the toils of his harness, still Jias the desire, and often the necessity, of refreshing his 
knowledge in this fundamental part of the science of medicine."-New York Journal of Medicine and Surg. 
" The plan of this Atlas is admirable, and its execution superior to any thing of the kind before published in 
this country. It is a real labour-saving affair, and we regard its publication as the greatest boon that could be 
conferred on the student of anatomy. It will be equally valuable to the practitioner, by affording him an easy 
means of recalling the details learned in the dissecting room, and which are soon forgotten."-American Medi- 
cal Journal. 
" It is a beautiful as well as particularly useful design, which should be extensively patronized by physicians, 
surgeons and medical students."-Boston Med. and Surg. Journal. 
"It has been the aim of the author of the Atlas to comprise in it the valuable points of all previous works, to 
embrace the latest microscopical observations on the anatomy- of the tissues, and by placing it at a moderate 
price to enable all to acquire it who may need its assistance in the dissecting or operating room, or other field 
of practice."-Western Journal of Med. and Surgery. ' 
" These numbers complete the series of this beautiful work, which fully merits the praise bestowed upon the 
earlier numbers. We regard all the engravings as possessing an accuracy only equalled by their beauty, 
and cordially recommend the work to all engaged in the study of anatomy."-New York Journal of Medicine 
and Surgery'. 
" A more elegant work than the one before us could not easily be placed by a physician upon the table of 
his student."-Western Journal of Medicine and Surgery. 
"We were much pleased with Part I. but the Second Part gratifies us still more, both as regards the attract- 
ive nature of the subject, (The Dermoid and Muscular Systems.) and the beautiful artistical execution of the 
.llustrations. We have here delineated the most accurate microscopic views of some of the tissues, as, for 
instance, the cellular and adipose tissues, the epidermis, rete mucosum and cutis vera, the sebaceous and 
perspiratory organs of the skin, the perspiratory glands and hairs of the skin, and the hair and nails. Then 
follows the general anatomy of the muscles, and. lastly, their separate delineations. We would recommend 
this Anatomical Atlas to our readers in the very strongest terms."-New York Journal of Medicine and Sur- 
gery- LIAT OF 
THE ILLUSTRATIONS 
EMBRACING 
SIX HUNDRED AND THIRTY-SIX FIGURES 
IN SMITH AND HORNER'S ATLAS. 
A Highly-finished View of the Bones of the Head, .... facing the title-page 
View of Cuvier's Anatomical Theatre, ... vignette 
PART I.-BONES AND LIGAMENTS. 
Fig. 
1 Front view of adult skeleton. 
2 Back view of adult skeleton. 
3 Foetal skeleton. 
4 Cellular structure of femur. 
5 Cellular and compound structure of tibia. 
. 6 Fibres of compact matter of bone. 
7 Concentric lamella: of bone. 
8 Compact matter under the microscope. 
9 Haversian canals and lacunae of bone. 
10 Vessels of compact matter. 
11 Minute structure of bones. 
12 Ossification in cartilage. 
13 Ossification in the scapula. 
14 Puncta ossification'is in femur. 
15 Side view of the spinal column. 
16 Epiphyses and diaphysis of bone. 
17 External periosteum. 
18 Punctum ossificationis in the head. 
19 A cervical vertebra. 
20 The atlas. 21 The dentata. 
22 Side view of the cervical vertebrae. 
23 Side view of the dorsal vertebrae. 
24 A dorsal vertebra. 
25 Side vie w of the lumbar vertebrae. 
26 Side view of one of the lumbar vertebrae. 
27 Perpendicular view of the lumbar vertebrae. 
28 Anterior view of sacrum. 
29 Posterior view of sacrum. 
30 The bones of the coccyx. 
31 Outside view of the innominatum. 
32 Inside view of the innominatum. 
33 Anterior view of the male pelvis. 
34 Anterior view of the female pelvis. 
35 Front of the thorax. 36 The first rib. 
37 General characters of a rib. 
38 Front view of the sternum. 
39 Head of a Peruvian Indian. 
40 Head of a Choctaw Indian. 
41 Front view of the os frontis. 
42 Under surface of the os frontis. 
43 Internal surface of the os frontis. 
44 External surface of the parietal bone.s 
45 Internal surface of the parietal bone. 
46 External surface of the os occipitis. 
47 Internal surface of the os occipitis. 
48 External surface of the temporal bone. 
49 Internal surface of the temporal bone. 
50 Internal surface of the sphenoid bone. 
51 Anterior surface of the sphenoid bone. 
52 Posterior surface of the ethmoid bone. 
53 Front view of the bones of the face. 
54 Outside of the upper maxilla. 
55 Inside of the upper maxilla. 
56 Posterior surface of the palate bone. 
57 The nasal bones. 
58 The os unguis. 59 Inferior spongy bone. 
60 Right malar bone. 61 The vomer. 
62 Inferior maxillary bone. 
63 Sutures of the vault of the cranium. 
Fig. 
64 Sutures of the posterior of the cranium. 
65 Diploe of the cranium. 
66 Inside of the base of the cranium. 
67 Outside of the base of the cranium. 
68 The facial angle. 69 The fontanels. 
70 The os hyoides. 
71 Posterior of the scapula. 
72 Axillary margin of the scapula. 
73 The clavicle. 74 The humerus. 
75 The ulna. 76 The radius. 
77 The bones of the carpus. 
78 The bones of the hand. 
79 Articulation of the carpal bones. 
80 Anterior view of the femur. 
81 Posterior vie w of the femur. 
82 The tibia. 83 The fibula. 
84 Anterior view of the patella. 
85 Posterior view of the patella. 
86 Theoscalcis. 87 The astragalus. 
88 The naviculare. 89 The cuboid bone. 
90 The three cuneiform bones. 
91 Top of the foot. 
92 The sole of the foot. 93 Cells in cartilage. 
94 Articular cartilage under the microscope. 
95 Costal cartilage under the microscope. 
96 Magnified section of cartilage. 
97 Magnified view of fibro-cartilage. 
98 White fibrous tissue. 
99 Yellow fibrous tissue. 
100 Ligaments of the jaw. 
101 Internal view of the same. 
102 Vertical section of the same. 
103 Anterior vertebral ligaments. 
104 Posterior vertebral ligaments. 
105 Yellow ligaments. 
106 Costo-vertebral ligaments. 
107 Occipito-altoidien ligaments. 
108 Posterior view of the same. 
109 Upper part of the same. 
110 Moderator ligaments. 
Ill Anterior pelvic ligaments. 
112 Posterior pelvic ligaments. 
113 Sterno-clavicular ligaments. 
114 Scapulo-humeral articulation. 
115 External view of elbow joint. 
116 Internal view of elbow joint. 
117 Ligaments of the wrist. 
118 Diagram of the carpal synovial membrane 
119 Ligaments of the hip joint. 
120 Anterior view of the knee joint. 
121 Posterior view of the knee joint. 
122 Section of the right knee joint. 
123 Section of the left knee joint. 
124 Internal side of the ankle joint. 
125 External side of the ankle joint. 
126 Posterior view of the ankle joint. 
127 Ligaments of the sole of the foot. 
128 Vertical section of the foot. 
PART II.-DERMOID AND MUSCULAR SYSTEMS. 
129 Muscles on the front of the body, full length. 
131 Muscles on the back of the body,/'/// length. 
ISO The cellular tissue. 132 Fat vesicles. 
183 Blood-vessels of fat. 
134 Cell membrane of fat vesicles. 
135 Magnified view of the epidermis. Illustrations to Smith and Horner's Jltlas, continued. 
Fig. 
136 Cellular tissue of the skin. 
137 Rete mucosuin, &c., of foot. 
188 Epidermis and rete mucosum. 
139 Cutis vera, magnified. 
140 Cutaneous papillae. 
141 Internal face of cutis vera. 
142 Integuments of foot under the microscope. 
143 Cutaneous glands. 144 Sudoriferous organs. 
145 Sebaceous glands and hairs. 
146 Perspiratory gland magnified. 
147 A hair under the microscope. 
148 A hair from the face under the microscope. 
149 Follicle of a hair. 150 Arteries of a hair. 
151 Skin of the beard magnified. 
152 External surface of the thumb nail. 
153 Internal surface of the thumb nail. 
154 Section of nail of fore finger. 
155 Same highly magnified. 
156 Development of muscular fibre. 
157 Another view of the same. 
158 Arrangement of fibres of muscle. 
159 Discs of muscular fibre. 
160 Muscular fibre broken transversely. 
161 Striped elementary fibres magnified. 
162 Stria of fibres from the heart of an ox. 
163 Transverse section of biceps muscle. 
164 Fibres of the pectoralis major. 
165 Attachment of tendon to muscle. 
166 Nerve terminating in muscle. 
167 Superficial muscles of face and neck. 
168 Deep-seated muscles of face and neck. 
169 Lateral view of the same. 
170 Lateral view of superficial muscles of face. 
171 Lateral view of deep-seated muscles of face. 
172 Tensor tarsi or muscle of Horner. 
173 Pterygoid muscles. 174 Muscles of neck. 
175 Muscles of tongue. 
176 Fascia profunda colli. 
177 Superficial muscles of thorax. 
178 Deep-seated muscles of thorax. 
179 Front view of abdominal muscles. 
Fig. 
180 Side view of abdominal muscles. 
181 External parts concerned in hernia. 
182 Internal parts concerned in hernia. 
183 Deep-seated muscles of trunk. 
184 Inguinal and femoral rings. 
185 Deep-seated muscles of neck. 
186 Superficial muscles of back. 
187 Posterior parietes of chest and abdomen. 
188 Under side of diaphragm. 
189 Second layer of muscles of back. 
190 Muscles of vertebral gutter. 
191 Fourth layer of muscles of back. 
192 Muscles behind cervical vertebrae. 
193 Deltoid muscle. 
194 Anterior view of muscles of shoulder. 
195 Posterior view of muscles of shoulder. 
196 Another view of the same. 
197 Fascia brachialis. 
198 Fascia of the fore-arm. 
199 Muscles on the back of the hand. 
200 Muscles on the front of the arm. 
201 Muscles on the back of the arm. 
202 Pronators of the fore-arm. 
203 Flexor muscles of fore-arm. 
204 Muscles in palm of hand. 
205 Deep flexors of the fingers. 
206 Superficial extensors. 
207 Deep-seated extensors. 
208 Rotator muscles of the thigh. 
209 Muscles on the back of the hip. 
210 Deep muscles on the front of thigh. 
211 Superficial muscles on the front of thigh. 
212 Muscles on the back of the thigh. 
213 Muscles on front of leg. 
214 Muscles on back of leg. 
215 Deep-seated muscles on back of leg. 
216 Muscles on the sole of the foot. 
217 Another view of the same. 
218 Deep muscles on front of arm. 
219 Deep muscles on back of arm. 
PART III.-ORGANS OF DIGESTION AND GENERATION. 
220 Digestive organs in their whole length. 
221 Cavity of the mouth. 
222 Labial and buccal glands. 
223 Teeth in the upper and lower jaws. 
224 Upper jaw, with sockets for teeth. 
225 Lower jaw, with sockets for teeth. 
226 Under side of the teeth in the upper jaw. 
227 Upper side of the teeth in the lower jaw. 
228 to 235. Eight teeth, from the upper jaw. 
236 to 243. Eight teeth from the lower jaw. 
244 to 251. Side view of eight upper jaw teeth. 
252 to 259. Side view of eight lower jaw teeth. 
260 to 265. Sections of eight teeth. 
266 to 267. Enamel and structure of two of the 
teeth. 
268 Bicuspis tooth under the microscope. 
269 Position of enamel fibres. 
270 Hexagonal enamel fibres. 
271 Enamel fibres very highly magnified. 
272 A very highly magnified view of fig. 268. 
273 Internal portion of the dental tubes. 
274 External portion of the dental tubes. 
275 Section of the crown of a tooth. 
276 Tubes at the root of a bicuspis. 
277 Upper surface of the tongue. 
278 Under surface of the tongue. 
279 Periglottis turned off the tongue. 
280 Muscles of the tongue. 
281 Another view of the same. 
282 Section of the tongue. 
283 Styloid muscles, He. 
284 Section of a gustatory papilla. 
285 View of another papilla. 
£86 Root of the mouth and soft palate. 
287 Front view of the pharynx and muscles. 
288 Back view of the pharynx and muscle*. 
289 Under side of the soft palate. 
290 A lobule of the parotid gland. 
291 Saliwtry glands. 
292 Internal surface of the pharynx. 
293 External surface of the pharynx. 
294 Vertical section of the pharynx. 
295 Muscular coat of the oesophagus. 
296 Longitudinal section of the oesophagus. 
297 Parietes of the abdomen. 
298 Reflexions of the peritoneum. 
299 Viscera of the chest and abdomen. 
300 Another view of the same. 
301 The intestines in situ. 
302 Stomach and oesophagus. 
303 Front view of the stomach. 
304 Interior of the stomach. 
305 The stomach and duodenum. 
306 Interior of the duodenum. 
307 Gastric glands. 
308 Mucous coat of the stomach. 
309 An intestinal villus. 310 Its vessels. 
311 Glands of the stomach magnified. 
312 Villus and lacteal. 
313 Muscular coat of the ileum. 
314 Jejunum distended and dried. 
315 Follicles of Lieberkuhn 
316 Glands of Brunner. 517 Intestinal glands. 
818 Valvul® conniveutes. 319 Ileo-colic valve. 
320 Villi and intestinal follicles. 
321 Veins of the ileum. 
322 Villi filled with chyle. 323 Peyer's glands 
324 Villi of the jejunum under the microscope. 
325 The caecum. 326 The mesocolon and colon, 
327 Muscular coat of the colon. Illustrations to Smith and Horner's Jltlas continued. 
Fig. 
328 Muscular fibres of the rectum. 
329 Curvatures of the large intestine. 
330 Mucous follicles of the rectum. 
331 Rectal pouches. 
332 Follicles of the colon, highly magnified. 
333 Folds and follicles of the stomach. 
334 Follicles, &c. of the jejunum. 
335 Villi and follicles of the ileum. 
336 Muciparous glands of the stomach. 
337 Ileum inverted, kc. 
338 Glands of Peyer magnified. 
339 Peritoneum of the liver injected. 
340 Liver in situ. 
341 Under surface of the liver. 342 Hepatic vein. 
343 Parenchyma of the liver. 
344 Hepatic blood-vessels. 345 Biliary ducts. 
346 Angular lobules of the liver. 
347 Rounded hepatic lobules. 
348 Coats of the gall bladder. 
349 Gall bladder injected. 
350 Vena portarum. 
351 External face of the spleen. 
352 Internal face of the spleen. 
353 Splenic vein. 
354 Pancreas &c., injected. 355 Urinary organs. 
356 Right kidney and capsule. 
357 Left kidney and capsule. 
358 Kidney under the microscope. 
359 The ureter. 360 Section of right kidney. 
361 Section of the left kidney. 
362 Pyramids of Malpighi. 
363 Lobes of the kidney. 
364 Renal arteries, &c., injected. 
365 Section of the kidney highly magnified. 
366 Copora Malpighiana. 367 Same magnified. 
368 Tubuli uriniferi. 369 Corpora Wolffiana. 
370 The bladder and urethra, full length. 
371 Muscular coat of the bladder. 
372 Another view of the same. 
Fig. 
373 Sphincter apparatus of the bladder. 
374 Prostate and vesicular seminales. 
375 Side view of the pelvic viscera. 
376 The glans penis injected. 
377 The penis distended and dried. 
378 Section of the same. 
879 Vertical section of the male pelvis, &c. 
380 Septum pectiniforme. ' » 
381 Arteries of the penis. 
382 Vertical section of the urethra. 
383 Vesiculse seminales injected. 
384 Muscles of the male perineum. 
385 Interior of the pelvis, seen from above. 
386 Testis in the fcetus. 
387 Diagram of the descent of the testis. 
388 Tunica vaginalis testis. 
389 Transverse section of the testis. 
390 Relative position of the prostate. 
391 Vas deferens. 
392 Vertical section of the bladder. 
393 The testicle injected with mercury. 
394 Another view. 
395 Minute structure of the testis. 
396 Female generative organs. 
397 Another view of the same. 
398 External organs in the fcetus. 
399 Muscles of the female perineum. 
400 Side view of the female pelvis, See. 
401 Relative position of the female organs. ' 
402 Section of the uterus, See. 
403 Fallopian tubes, ovaries. See. 
404 Front view of the mammary gland. 
405 The same after removal of the skin. 
406 Side view of the br^st. 
407 Origin of lactiferous ducts. 
408 Lactiferous tubes during lactation. 
409 Minute termination of a tube. 
410 Ducts injected ; after Sir Astley Cooper. 
PART IV.-ORGANS OF RESPIRATION AND CIRCULATION. 
411 Front view of the thyroid cartilage. 
412 Side view of the thyroid cartilage. 
413 Posterior of the arytenoid cartilage. 
414 Anterior of the arytenoid cartilage. 
415 Epiglottis cartilage. 416 Cricoid cartilage. 
417 Ligaments of the larynx. 
418 Side view of the same. 
419 The thyroid gland. 
420 Internal surface of the larynx. 
421 Crico-thyroid muscles. 
422 Crico-arytenoid muscles. 
423 Articulations of the larynx. 
424 Vertical section of the larynx. 
425 The vocal ligaments. 426 Thymus gland. 
427 Front view of the lungs. 
428 Back view of the lungs. 
429 The trachea and bronchia. 
430 Lungs, heart, &c. 
431 First appearance of the blood-vessels. 
432 Capillary vessels magnified. 
433 Another view of the same. 
434 Blood globules. 
435 Another view of the same. 
436 The mediastina. 
437 Parenchyma of the lung. 
438 The heart and pericardium. 
439 Anterior view of the heart. 
440 Posterior view of the heart. 
441 Anterior view of its muscular structure. 
442 Posterior view of the same. 
443 Interior of the right ventricle. 
444 Interior of the left ventricle. 
445 Mitral valve, the size of life. 
446 The auriculo-ventricular valves. 
447 Section of the ventricles. 
448 The arteries from the arch of the aorta. 
449 The arteries of the neck, the size of life. 
450 The external carotid artery. 
451 A front view of arteries of head and neck. 
452 The internal maxillary artery. 
453 Vertebral and carotid arteries with the aorta. 
454 Axillary and brachial arteries. 
455 The brachial artery. 
456 Its division at the elbow. 
457 One of the anomalies of the brachial artery. 
458 Radial and ulnar arteries. 
459 Another view of the same. 
460 The arcus sublimis and profundus. 
461 The aorta in its entire length. 
462 Arteries of the stomach and liver. 
463 Superior mesenteric artery. 
464 Inferior mesenteric artery. 
465 Abdominal aorta. 
466 Primitive iliac and femoral arteries. 
467 Perineal arteries of the male. 
468 Position of the arteries in the inguinal canal. 
469 Internal iliac artery. 470 Femoral artery. 
471 Gluteal and ischiatic arteries. 
472 Branches of the ischiatic artery. 
473 Popliteal artery. 
474 Anterior tibial artery. 
475 Posterior tibial artery. 
476 Superficial arteries on the top of the foot. 
477 Deep-seated arteries on the top of the foot. 
478 Posterior tibial artery at the ankle. 
479 The plantar arteries. 
480 Arteries and veins of the face and neck. 
481 Great vessels from the heart. 
482 External jugular vein. 
483 Lateral view of the vertebral sinuses. 
484 Posterior view of the vertebral sinuses. 
485 Anterior view of the vertebral sinuses. 
486 Superficial veins of the arm. 
487 The same at the elbow. Illustrations to Smith and Horner's Atlas continued. 
F'g- 
488 The veins of the hand. 
489 The great veins of the trunk. 
490 Positions of the arteries and veins of the trunk. 
491 The venae cavae. 492 The vena portarum. 
493 Deep veins of the back of the leg. 
494 Positions of the veins to the arteries in the 
arm. 495 Superficial veins of the thigh. 
496 Saphena vein. 
497 Superficial veins of the leg. 
498 Lymphatics of the upper extremity. 
Fig. 
499 The lymphatics and glands of the ax'Ua. 
500 The femoral and aortic lymphatics. 
501 The lymphatics of the small intestines. 
502 The thoracic duct. 
503 The lymphatics of the groin. 
504 Superficial lymphatics of the utigh. 
505 Lymphatics of the jejunum. 
506 Deep lymphatics of the thigh. 
507 Superficial lymphatics of the leg. 
508 Deep lymphatics of the leg. 
509 Dura mater cerebri and spinalis. 
510 Anterior view of brain and spinal marrow. 
511 Anterior view of the spinal marrow, &c. 
512 Lateral view of the spinal marrow, See. J 
513 Posterior view of the spinal marrow, &c. 
514 Decussation of Mitischelli. 
515 Origins of the spinal nerves. 
516 Anterior view of spinal marrow and nerves. 
517 Posterior view of spinal marrow and nerves. 
518 Anterior spinal commissure. 
519 Posterior spinal commissure. 
520 Transverse section of the spinal marrow. 
521 Dura mater and sinuses. 
522 Sinuses laid open. 
523 Sinuses at the base of the cranium. 
524 Pons Varolii, cerebellum, &c. 
525 Superior face of the cerebellum. 
526 Inferior face of the cerebellum. 
527 Another view of the cerebellum. 
528 View of the arbor vitae, &c. 
529 Posterior view of the medulla oblongata. 
530 A vertical section of the cerebellum. 
531 Another section of the cerebellum. 
532 Convolutions of the cerebrum. 
533 The cerebrum entire. 
534 A section of its base. 
535 The corpus callosum entire. 
536 Diverging fibres of the cerebrum, &c. 
537 Vertical section of the head. 
538 Section of the corpus callosum. 
539 Longitudinal section of the brain. 
540 View of a dissection by Gall. 
541 The commissures of the brain. 
542 Lateral ventricles. 
543 Corpora striata-fornix, &c. 
544 Fifth ventricle and lyra. 
545 Anotherjview of the lateral ventricles. 
546 Another view of the ventricles. 
547 Origins of the 4th and 5th pairs of nerves. 
548 The circle of Willis. 
549 A side view of the nose. 
550 The nasal cartilages. 
551 Bones and cartilages of the nose. 
552 Oval cartilages, &c. 
553 Schneiderian membrane. 
554 External parietes of the left nostril. 
555 Arteries of the nose. 
556 Pituitary membrane injected. 
557 Posterior ^••'es. 558 Front view of the eye. 
559 Side view of the eye. 
560 Posterior view of the eyelids, &c. 
561 Glandules palpebrarum. 
562 Lachrymal canals. 
563 Muscles of the eyeball. 
564 Side view of the eyeball. 
565 Longitudinal section of the eyeball. 
566 Horizontal section of the eyeball. 
567 Anterior view of a transverse section. 
568 Posterior view of a transverse section. 
569 Choroid coat injected. 
570 Veins of the choroid coat. 
571 The iris, 572 Then-etna and lens. 
PART V.-THE NERVOUS SYSTEM AND SENSES. 
573 External view of the same. 
574 Vessels in the conjunctiva. 
575 Retina, injected and magnified. 
576 Iris, highly magnified. 
577 Vitreous humour and lens. 
578 Crystalline adult lens. 
579 Lens of the foetus, magnified. 
580 Side view of the lens. 
581 Membrana papillaris. 
582 Another view of the same. 
583 Posterior view of the same. 
584 A view of the left ear. 
585 Its sebaceous follicles. 
586 Cartilages of the ear. 
587 The same with its muscles. 
588 The cranial side of the ear. 
589 Meatus auditorius externus, &c. 
590 Labyrinth and bones of the ear. 
591 Full view of the malleus. 592 The incus. 
593 Another view of the malleus. 
594 A front view of the stapes. 
595 Magnified view of the stapes. 
596 Magnified view of the incus. 
597 Cellular structure of the malleus. 
598 Magnified view of the labyrinth. 
599 Natural size of the labyrinth. 
600 Labyrinth laid open and magnified. 
601 Labyrinth, natural size. 
602 Labyrinth of a foetus. 
603 Another view"of the same. 
604 Nerves of the labyrinth. 
605 A view of the vestibule, &c. 
606 Its soft parts, &c. 
607 An ampulla and nerve. 
608 Plan of the cochlea. 
609 Lamina spiralis, &c. 
610 The auditory nerve. 
611 Nerve on the lamina spiralis. 
612 Arrangement of the cochlea. 
613 Veins of the cochlea, highly magnified. 
614 Opening of the Eustachian tube in the throat 
615 Portio mollis of the seventh pair of nerves 
616 The olfactory nerves. 
617 The optic and seven other pairs of nerves. 
618 Third, fourth and sixth pairs of nerves. 
619 Distribution of the fifth pair. 
620 The facial nerve. 
621 The hypo-glossal nerves. 
622 A plan of the eighth pair of nerves. 
623 The distribution of the eighth pair. 
624 The great sympathetic nerve. 
625 The brachial plexus. 
626 Nerves of the front of the arm. 
627 Nerves of the back of the arm. 
628 .Lumbar and ischiatic nerves. 
629 Posterior branches to the hip, &c. 
630 Anterior crural nerve. 
631 Anterior tibial nerve. 
632 Branches of the popliteal nerve. 
633 Posterior tibial nerve on the leg. 
634 Posterior tibial nerve on the fool. PROFESSOR DUNGLISON'S WORKS. 
The Works of Professor Dunglison on various departments of Medicine are here presented.- 
Nearly all of them are extensively used as text books in the branches of science to which they re- 
late, and the profession and students may rely upon the great care and accuracy of the author in 
■having each new edition of his works posted up to the day of publication. 
LEA & BLANCHARD'S PUBLICATIONS. 
15 
A NEW EDITION OF THE STANDARD MEDICAL DICTIONARY. 
A DICTIONARY OF MEDICAL SCIENCE: 
CONTAINING A CONCISE ACCOUNT OF THE VARIOUS SUBJECTS AND TERMS, WITH 
THE FRENCH AND OTHER SYNONYMES, NOTICES OF CLIMATES AND OF CELE- 
BRATED MINERAL WATERS, FORMULAS FOR VARIOUS OFFICINAL AND EMPIRI- 
CAL PREPARATIONS, &c. 
Fifth Edition, Extensively Modified and Improved over former Editions. 
BY ROBLEY DUNGLISON, M.D. 
Professor of the Institutes of Medicine, &c., in Jefferson Medical College, Philada.; Secretary to 
the American Philosophical Society, &c., &c. 
In one large royal octavo volume of nearly 800 double columned pages, and bound with raised bands. 
The author's object has not been to make the work a mere Lexicon, or Dictionary of terms, but 
to afford, under each, a condensed view of its various medical relations, and thus to render the 
work a complete epitome of the existing condition of medical science. This he has been in a great 
measure enabled to do, as the work is not stereotyped^by adding in each successive edition all 
new and interesting matters or whatever of importance had been formerly omitted. To show 
the advantage of this, it need only be remarked that in the present work will be found at least two 
thousand subjects and terms not embraced in the third edition. 
" To execute such a work requires great erudition, unwearied industry, and extensive research; 
and we know no one who could bring to the task higher qualifications of this description than Pro- 
fessor Dunglison."-American Medical Journal. 
DUNGLISON'S PRACTICE, A NEW EDITION. 
THE PRACTICE OF MEDICINE. 
OR A TREATISE ON SPECIAL PATHOLOGY AND THERAPEUTICS. 
BY ROBLEY DUNGLISON, M.D., 
Second Edition, carefully Revised and with Additions. 
In Two Large Octavo Volumes of over thirteen hundred pages. 
The Publishers annex a condensed statement of the Contents:-Diseases of the Mouth, Tongue, 
Teeth, Gums, Velum Palati and Uvula, Pharynx and ffisophagus, Stomach, Intestines, Peritoneum, 
Morbid Productions in the Peritoneum, and Intestines.-Diseases of the Larynx and Trachea, Bron- 
chia and Lungs, Pleura, Asphyxia.-Morbid conditions of the Blood, Diseases of the Heart and 
Membranes, Arteries, Veins, Intermediate or Capillary Vessels,-Spleen, Thyroid Gland, Thymus 
Gland, and Supra Renal Capsules, Mesenteric Glands,-Salivary Glands, Pancreas, Biliary Appara- 
tus, Kidney, Ureter, Urinary Bladder.-Diseases of the Skin, Exanthematous, Vesicular, Bullar, 
Pustular, Papular, Squamous, Tuberculous, Maculse, Syphilides.-Organic Diseases of the Nervous 
Centres, Neuroses, Diseases of the Nerves.-Diseases of the Eye, Ear, Nose.-Diseases of the 
Male and Female Organs of Reproduction. Fever,-Intermittent, Remittent, Continued, Eruptive, 
Arthritic.-Cachexies, Scrofulous, Scorbutic, Chlorotic, Rhachitic, Hydropic and Cancerous. 
This work has been introduced as a text-book in many of the Medical Colleges, 
and the general favour w.th which it has been received, is a guarantee of its value 
to the practitioner and student. 
" In the volumes before us, Dr. Dunglison has proved that his acquaintance with the present facts 
and doctrines, wheresoever originating, is most extensive and intimate, and the judgment, skill, 
and impartiality with which the materials of the work have been collected, weighed, arranged, and 
exposed, are strikingly manifested in every chapter. Great care is everywhere taken to indicate 
the source of information, and under the head of treatment, formulae of the most appropriate reme- 
dies are everywhere introduced. We congratulate the students and junior practitioners of Ame- 
rica, on possessing in the present volumes, a work of standard merit, to which they may confidently 
refer in their doubts and difficulties."-British and Foreign Medical Review, for July, 1842. 
" Since the foregoing observations were written, we have received a second edition of Dungli- 
son's work, a sufficient indication of the high character it has already attained in America, and 
justly attained."-British and Foreign Medical 'Review, for October, 1844. 
"We hail the appearance of this work, which has just been issued from the prolific press of 
Messrs. Lea & Blanchard of Philadelphia, with no ordinary degree of pleasure. Comprised in two 
large and closely printed volumes, it exhibits a more full, accurate, and comprehensive digest of 
the existing state of medicine than any other treatise with which we are acquainted in the English 
language. It discusses many topics-some of them of great practical importance, which are en- 
tirely omitted in the writings of Eberle, Dewees, Hosack, Graves, Stokes, McIntosh, and Gregory ; 
and it cannot fail, therefore, to be of great value, not only to the student, but to the practitioner, as 
it affords him ready access to information of which be stand? in daily need in the exercise of his 
profession-"-Louisville Journal. 16 
LEA & BLANCHARD'S PUBLICATIONS. 
PROFESSOR DUNGLISON S WORKS-Continued. 
GEKER^L THERAPEUTICS AND MATERIA MtDICA, 
ADAPTED FOR A MEDICAL TEXT-BOOK. 
BY ROBLEY DUNGLISON, M.D., 
In two Volumes, Svo. 
44 The subject of Materia Medica has been handled by our author with more than usual judgment. 
The greater part of treatises on that subject are, in effect expositions of the natural and chemical 
history < f the substances used in medicine, with very brief notices at all of the indications they are 
capable of fulfilling, and the general principles of Therapeutics. Dr. Dunglison, very wisely, in 
our opinion, has reversed all this, and given his principal attention to the articles of the Materia 
Medica as medicines In conclusion, we strongly recommend these volumes to onr readers.- 
No medica] student on either side of the Atlantic should be without them."-Forbes' British and 
Foreign Medical Review. 
44 Our junior brethren in America will find in these volumes of Professor Dunglison a 4 Thesau- 
rus Medicaminum,' more valuable than a large purse of gold."-Medico-Chirurgical Review, for 
January, 1845. 
WITH UPWARDS OF THREE HUNDRED ILLUSTRATIONS, 
BY ROBLEY DUNGLISON, M.D., 
Fifth Edition, Greatly'Modified aA Improved, in 2 Vols. of 1304 Large Octavo Pages. 
44 We' have on two former occasions, brought this excellent work under the notice of our readers, 
and we have now only to say that, instead of falling behind in the rapid march of physiological 
science, each edition brings it nearer to the van. Without increasing the bulk of the treatise, the 
author has contrived to introduce a large quantity of new matter into this edition from the works of 
Valentin, Bischoff, Henle, Wildebrand, Muller, Wagner, Mandi, Gerber, Liebig, Carpenter, Todd 
and Bowman, as well as from various monographs which have appeared in the Cyclopedias, Trans- 
actions of learned societies and journals. The large mass of references which it contains renders 
it a most valuable bibliographical record, and bears the highest testimony to the zeal and industry 
of the author."-British and Foreign Medical Review. 
Ci Many will be surprised to see a fifth edition of this admirable treatise so rapidly succeeding the 
fourth. But such has been the rapid progress of physiology within a short period that to make his 
work a fair reflection of the present state of the science, no less than an account of its extensive 
popularity, Dr. Dunglison has found it necessary to put forth a new edition with materia) modifica- 
tions and additions. To those who may be unacquainted with the work, we may say that, Dr. D. 
does not belong to the mechanical, chemical, or vital school exclusively; but that, with a discri- 
minating hand he culls from each and all, making his treatise a very excellent and complete digest 
of the vast subject."- Western Journal of Medicine and Surgery. 
NEW REMEDIES, 
PHARMACEUTICALLY AND THERAPEUTICALLY CONSIDERED, 
BY ROBLEY DUNGLISON, M.D., 
In One Volume, Octavo, over 600 pages, the Fourth Edition. 
Or, the Influence of Atmosphere and Locality, Change of Air and Climate, 
Seasons, Food, Clothing, Bathing and Mineral Springs, Exercise, 
Sleep, Corporeal and Intellectual Pursuits, Ac , &c., on 
Healthy Man: Constituting x 
ELEMENTS OF HYGIENE. 
BY ROBLEY DUNGLISON, M.D. 
A New Edition with many Modifications and Additions. In One Volume, Svo. 
"We have just received the new edition of this learned work on the 4 Elements of Hygiene.'- 
Dr. Dunglison is one of the most industrious and voluminous authors of the day. How he finds 
time to amass and arrange the immense amount of matter contained in his various works, is almost 
above the comprehension of men possessing but ordinary talents and industry. Such labour de- 
serves immortality."-St. Louis Med- and Surg. Journal. 
A NEW EDITION OF 
THE MEDICAL STUDENT, 
OR AIDS TO THE STUDY OF MEDICINE. 
A REVISED AND MODIFIED EDITION. 
BY ROBLEY DUNGLISON, M.D., 
In One neat 12mo. Volume, LEA & BLANCHARD'S PUBLICATIONS. 
17 
CHAPMAN'S WORKS 0* THE PRACTICE OF MEDICINE. 
CHAPMAN ON FEVERS, ETC. 
LECTURES ON THE MORE IMPORTANT 
ERUPTIVE FEVERS, HAEMORRHAGES AND 
DROPSIES, AND ON GOUT AND RHEUMATISM, 
DELIVERED IN THE UNIVERSITY OF PENNSYLVANIA. 
By N. CHAPMAN, M.D., 
Professor of the Theory and Practice of Medicine, &c. &c. 
In one neat Octavo Volume. 
Thjs volume contains Lectures on the following subjects: 
EXANTHEMATOUS FEVERS. 
Variola, or Small Pox ; Inoculated Small Pox; Varicella, or Chicken Pox ; Variolae Vacciniae, or Vaccinia, 
or Cow-pock; Varioloid Disease; Rubeola, Morhilli. or Measles; Scarlatina vel Febris Rubra-Scarlet Fever. 
HAEMORRHAGES. 
Haemoptysis, Spitting of Blood; Haemorrhagia Narium, or Haemorrhage from the Nose; Haematemesis, or 
Vomiting of Blood; Haematuria. or Voiding of Bloody Urine ; Haemorrhagia Uterina, or Uterine Haemorrhage; 
Hsemorrhois or Haemorrhoids; Cutaneous Haemorrhage; Purpura Haemorrhagica. 
DROPSIES. 
Ascites; Encysted Dropsy; Hydrothorax; Hydrops Pericardii; Hydrocephalus Interims, acute, subacute, 
and chronic: Anasarca; with a Disquisition on the Management of the whole. 
GOUT, RHEUMATISM, Ac. &c. 
"The name of Chapman stands deservedly high in the annals of American medical science. A teacher and a 
lecturer for nearly forty years, in the oldest and, we believe, the first medical school on this side of the Atlantic, 
the intimate friend and companion ofRush, Kuhn, Physick, Wistar. Woodhouse, Dewees, and a host of others 
scarcely less renowned, Professor Chapman reflects upon the profession of this generation something of the 
genius and wisdom of that which has passed ; he stands out the able and eloquent champion of the doctrines 
and principles of other times, when Cullen's "first lines" formed the rule of faith for all the Doctors in Medicine 
throughout Christendom. In him is embodied the experience of three score and ten, strengthened by reading, 
and enlightened by a familiar intercourse with many of the ablest medical men in the New and Old World. 
" In conclusion, we must declare our belief that the name of Chapman will survive when that of many of his 
cotemporaries shall have been forgotten; when other generations shall tread the great tltealre of human 
affairs, and when other discoveries yet undisclosed, shall shed a brighter light upon the path of medical science. 
The various lectures which he has been publishing, containing, as they do, the doctrines that he has so long 
and so eloquently taught to large and admiring classes, we doubt not will be welcomed with delight by his nu. 
merous pupils throughout the Union."-New Orleans Medical Journal. 
CHAPMAN ON THORACIC VISCERA, ETC. 
LECTURES ON THE MORE IMPORTANT BISEASES 
OF THE 
THORACIC AND ABDOMINAL VISCERA. 
DELIVERED IN THE UNIVERSITY OF PENNSYLVANIA. 
By N. CHAPMAN, M. D. 
Professor of the Theory and Practice of Medicine, Ac. 
In one Volume, Octavo. 
WILLIAMS AND CLYMER ON THE RESPIRATORY ORGANS, ETC. 
A TREATISE ON THE 
DISEASES OF THE RESPIRATORY ORGANS, 
INCLUDING 
THE TRACHEA, LARYNX, LUNGS, AND PLEURA. 
By CHARLES J. B. WILLIAMS, M.D., 
Consulting Physician to the Hospital for Consumption and Diseases of the Chest; Author of 
" Principles of Medicine," &c. &c. 
WITH NUMEROUS ADDITIONS AND NOTES. 
By MEREDITH CLYMER, M.D., 
Physician to the Philadelphia Hospital. 
In one neat 8vo. Volume, with Cuts. 
This work recommends itself to the notice of the profession as containing a more particu- 
lar and detailed account of the affections of which it treats than perhaps any other volume 
before the public. 
"The wood cuts illustrating the physical examination of the chest, are admirably executed, and the whole 
mechanical execution of the work, does much credit/to the publishers. This work is undoubtedly destined to 
take precedence of all others yet published on the " Respiratory Organs," and as a text book for teachers and 
students, no better in the present state of the science is to be expected."-New York Journal of Medicint. 18 
LEA & BLANCHARD'S PUBLICATIONS. 
NOW READY, 
A NEW AND IMPROVED EDITION 
OF RAMSBDTHAM'S STANDARD WORK ON PARTURITION. 
THE PRINCIPLES AND PRACTICE OF 
OBSTETRIC MEDICINE AND SURGERY, 
IN REFERENCE TO J 
THE PROCESS OF PARTURITION. 
ILLUSTRATED BY 
One hundred and forty-eight targe Figures on 85 lithographic Plates. 
By FRANCIS H. RAMSBOTHAM, M. D., &c. 
A NEW EDITION, FROM THE ENLARGED AND REVISED LONDON EDITION. 
In one large imperial octavo volume, well bound. 
The present edition of this standard work will be found to contain numerous and important improvements 
over the last. Besides much additional matter, there are several more plates and wood-cuts, and those which 
were before used have been re-drawn. This book has long been known to the profession, by whom it has 
been most flatteringly received. The publishers take great pleasure in submitting the following testimony to 
its value from Professor Hodge, of the Pennsylvania University. 
Philadelphia, August Oth, 1845. 
Gentlemen:-I have looked over the proofs of Ramsbotham on Human Parturition, with its important 
improvements, from the new London edition. 
This Work needs no commendation from me, receiving, as it does, the unanimous recommendation of the 
British periodical press, as the standard work on Midwifery; "chaste in language, classical in composition, 
happy in point of arrangement, and abounding in most interesting illustrations."* 
To the American public, therefore, it is most valuable-from its intrinsic undoubted excellence, and as 
being the best authorized exponent of British Midwifery. Ils circulation will, I trust, be extensive through- 
out our country. 
There is, however, a portion of Obstetric Science to which sufficient attention, it appears to me, has not 
been paid. Through you, I have promised to the public a work on this subject, and although the continued 
occupation of my time and thoughts in the duties of a teacher and practitioner have as yet prevented the ful- 
filment of the promise, the day, I trust, is not distant, when, under the hope of being useful, I shall prepare 
an account of the Mechanism of Labour, illustrated by suitable engravings, which may be regarded as an 
addendum to the standard works of Ramsbotham, and our own Dewees. 
Very respectfully, yours, 
HUGH L. HODGE, M. D., 
Professor of Obstetrics, tyc. ^e., in the University of Pennsylvania. 
Messrs. Lea & Blanchard. 
" This new edition of Dr. Ramsbotham's work forms one of the most complete and thoroughly useful treatises 
on Midwifery with which we are acquainted. Il is not a mere reprint of the first edition; the entire work 
has undergone a careful revision, with additions. We have already given specimens of the work sufficient 
to justify our hearty recommendation of it as one of the best guides that the student or young practitioner can 
follow."-British and Foreign Medical Review, Jan., 1845. 
" The work of Dr. Ramsbotham may be described as a complete system of the principles and practice of 
Midwifery; and the author has been at very great pains, indeed, to present a just and useful view of the pre- 
eent state of obstetrical knowledge. The illustrations are numerous, well selected, and appropriate, and en- 
graved with great accuracy and ability. In short, we regard this work, between accurate descriptions and 
useful illustrations, as by far the most able work on the Principles and Practice of Midwifery that has ap- 
peared for a long time. Dr. Ramsbotham has contrived to infuse a larger proportion of common sense, and 
plain unpretending practical knowledge into this work, than is commonly found in works on this subject; 
* Northern Journal of Medicine for July 1845. LEA & BLANCHARD'S PUBLICATIONS. 
19 
EAMSBOTHAM ON PARTURITION-Continued. 
and as such we have great pleasure in recommending it to the attention of obstetrical practitioners."- Edin- 
burgh. Medical and Surgical Journal. 
"This is one of the most beautiful works which have lately issued from the medical press; and is alike 
creditable to the talents of the author and the enterprise of the publisher. It is a good and thoroughly prac- 
tical treatise; the different subjects are laid down in a clear and perspicuous form, and whatever is of import 
ance, is illustrated by first rate engravings. A remarkable feature of this work, which ought to be mentioned, 
is its extraordinary cheapness. As a work conveying good, sound, practical precepts, and clearly demonstra- 
ting the doctrines of Obstetrical Science, we can confidently recommend it either to the student or practi- 
tioner."-Edinburgh Journal of Medical Science. 
"This work forms a very handsome volume. Dr. Ramsbotham has treated the subject in a manner worthy 
of the reputation he possesses, and has succeeded in forming a book of reference for practitioners, and a solid 
and easy guide for students. Looking at the contents of the volume, and its remarkably low price, we have 
no hesitation in saying that it has no parallel in the history of publishing."-Provincial Medical and Surgi- 
cal Journal. • 
"It is the book of Midwifery for students; clear, but not too minute in its details, and sound fn its practi- 
cal instructions. It is so completely illustrated by plates (admirably chosen and executed,) that the student 
must be stupid indeed who does not understand the details of this branch of the science, so far at least as 
description can make them intelligible."-Dublin Journal of Medical Science. 
"Our chief object now is to state our decided opinion, that this work is by far the best that has appeared in 
this country for those who seek practical information upon Midwifery, conveyed in a clear and concise style. 
The value of the work, too, is strongly enhanced by the numerous and beautiful drawings, which are in the 
first style of excellence."- London Medical Journal. 
"We most earnestlyrecommend this work to the student who wishes to acquire knowledge, and to the 
practitioner who wishes lorefresh his memory, as a most faithful picture of practical Midwifery ; and we can 
with justice say, that altogether it is one of the best books we have read on the subject of Obstetric Medi- 
cine."-Medico-Chirurgical Review. 
"All the organs concerned in the process of parturition, and every step of this process, in all its different 
forms, are illustrated with admirable plates When we call to mind the toil we underwent in 
acquiring a knowledge of this subject, we cannot but envy the student of the present day the aid which this 
work will afford him We recommend the student who desires to master this difficult subject with 
the least possible trouble, to possess himself at once of a copy of this work."-American Journal of the Me- 
dical Sciences. 
"It is intended expressly for students and junior practitioners in Midwifery ; it is, therefore, as it ought to 
be, elementary, and will not consequently, admit of an elaborate and extended review. Our chief object 
now is to state our decided opinion, that this work is by far the best that has appeared in this country, for 
those who seek practical information upon Midwifery, conveyed in a clear and concise style. The value of 
the work, loo, is strongly enhanced by the numerous and beautiful drawings by Bagg, which are in the first 
style of excellence. Every point of practical importance is illustrated, that requires the aid of the engraver 
to fix it upon the mind, and to render it clear to the comprehension of the student."-London Medical 
Gazette. 
" We feel much pleasure in recommending to the notice of the profession one of the cheapest and most ele- 
gant productions of the medical press of the present day. The text is written in a clear, concise, and simple 
style. We offer our most sincere wishes that the undertaking may enjoy all the success which it so well 
merits."-Dublin Medical Press. 
" We strongly recommend the work of Dr. Ramsbotham to all our obstetrical readers, especially to those 
who are entering upon practice. It is not only one of the cheapest, but one of the most beautiful works in 
Midwifery."- British and Foreign Medical Review. 
"Among the many literary undertakings with which the Medical press at present teems, there are few that 
deserve a warmer recommendation al our hands than the work-we might almost say the obstetrical library, 
comprised in a single volume-which is now before us. Few works surpass Dr. Ramsbotham's in beauty and 
elegance of getting up, and in the abundant and excellent engravings with which it is illustrated. We hear- 
tily wish the volume the success which it merits, and we have no doubt that before long it will occupy a 
place in every medical library in the kingdom. The illustrations are admirable; they are the joint production 
of Bagg and Adlard, and comprise within the series the best obstetrical plates of our best obstetrical authors, 
ancient and modern. Many of the engravings are calculated to fix the eye as much by their excellence of 
execution, and their beauty as wdrks of art, as by their fidelity to nature and anatomical accuracy."-The 
Lancet. 
" This is a work of unusual interest and importance to students and physicians. It is from the pen of Dr. 
Ramsbotham, consulting physician in obstetric cases of the London Hospital, and embodies in one volume 
the Principles and Practice of Obstetric Medicine and Surgery. The treatise is admirably written, and illus- 
trated by a great variety of engravings: Indeed every thing in the obstetric art, capable of being explained 
by engravings, is displayed to the eye in these admirably executed prints. A medical correspondent of the 
New York American, says, that the 'universal voice of the British journals accords in commending this 
work to the profession, as one of the best elementary treatises in the language,' and we can only say, in addL 
tion, that the American publishers have, as faras we can judge from the execution of the plates in their edi- 
tion, done full justice to the original work. We sincerely hope that it may meet with entire success, and we 
cannot doubt that, when its merits are fully known, it will be found in every medical library in the country." 
-Saturday Evening Post, LEA & BLANCHARD'S PUBLICATIONS. 
20 
Now Ready, 
CHEMISTRY FOR STUDENTS. 
ELEMENTARY CHEMISTRY, THEORETICAL AND PRACTICAL. 
Bi- GEORGE FOWNES, Ph. D., 
Chemical Lecturer in the Middlesex Hospital Medical School, &c. &c. 
With Numerous Illustrations. Edited, with Additions, 
By ROBERT BRIDGES, M. D., 
Professor of General and Pharmaceutical Chemistry in the Philadelphia College 
of Pharmacy, &c., &c. 
In one large duodecimo volume, sheep or extra cloth. 
This is among the cheapest volumes on Chemistry yet presented to the pro- 
fession. The character of the work is such as should recommend it to all col- 
leges in want of a text-book as an introduction to the larger and more advanced 
systems, such as Graham's and others. The great advantage which it possesses 
over all the other elementary works on the same subject now before the public, 
is the perfect manner in which it is brought up to the day on every point, em- 
bracing all the latest investigations and discoveries of importance, in a concise 
and simple manner, adapted to the time and comprehension of students com- 
mencing the science. It forms a royal 12mo. volume of 460 large pages, on small 
type, embellished with over one hundred and sixty wood engravings, which 
will be found peculiarly instructive as to the practical operations of the labora- 
tory, and the new and improved methods of experimenting. 
It has already been adopted as a Text-book by Professor Silliman of Yale Col- 
lege, and by other Colleges in different parts of the country. 
Extract from a letter from Professor Millington, of 
William and Mary College, Fa. 
"I have perused the book with much pleasure, and 
find it a most admirable work; and, to my mind, such 
a one as is just now much needed in schools and col- 
leges. * * * All the books I have met with on che- 
mistry are either too puerile or too erudite, and I con- 
fess Dr. Fownes' book seems to be the happiest medium 
I have seen, and admirably suited to fill up the hiatus." 
being omitted, and appears to us extremely well 
adapted as a text-book for the pupil attending a course 
of lectures on chemistry. Indeed we have no doubt 
that it will ultimately become the medical student's 
favourite manual.''-Dublin Medical Press. 
"Having examined it with some attention, we feel 
qualified to recommend it to our younger readers as an 
admirable exposition of the present state of chemical 
science, simply and clearly written, and displaying a 
thorough practical knowledge of its details, as well as 
a profound acquaintance with its principles."-British 
and Foreign Medical Review. 
"Numerous and useful as are the works extant on 
the Science of Chemistry, we are nevertheless pre- 
pared to admit that the author of this publication has 
made a valuable addition to them by offering the stu- 
dent and those in general who desire to obtain informa- 
tion, an accurate compendium of the state of chemical 
science; which is. moreover, well illustrated by ap- 
propriate and neatly executed wood engravings. * * 
After what we have stated of this work, our readers 
will not be surprised that it has our hearty commenda- 
tion. and that, in our opinion, it is calculated, and at a 
trifling expense, to spread the doctrines of the intricate' 
science which it so clearly explains."-Medico-Chi- 
rurgieal Review. 
Extract from a letter from Professor IF E. A. Aikin, of 
the University of Maryland. 
" The first cursory examination left me prepossessed 
in its favour, and a subsequent more careful review 
has confirmed these first impressions. I shall certainly 
recommend it to my classes, and feel sure that they 
will profit by using it during the session of lectures. 
"As a judicious compendium, I think Fownes' Che- 
mistry cannot fail to be highly useful to the class of 
readers for whom it was designed." 
"Mr. Fownes' work, although consisting of only a 
single thick 12mo. volume, includes a notice of almost 
every branch of the subject, nothing of any importance LEA & BLANCHARD'S PUBLICATIONS. 
"This is an unpretending, but decidedly valuable 
treatise, on the elements of chemistry, theoretical and 
practical. Dr. Bridges has a perfect ide i of what is 
needed, and the preparation of this excellent guide 
should have the countenance of all public instructors, 
and especially those of medical students."-Boston 
Med. Surg. Journal. 
" This is a very excellent manual for the use of stu- 
dents and junior practitioners, being sufficiently full 
and complete on the elements of the science, without 
omitting any nebessary information, or extending too 
far into detail. It is written in a clear and concise 
style, and illustrated by a sufficient number of well 
executed wood-cuts and diagrams. The Editor has 
executed his task in a creditable manner, and we have 
no doubt the work will prove entirely satisfactory, as 
an introduction to the science of which it treats."-N. 
Y. Journal of Med. 4- Surgery. 
" He has succeeded in comprising the matter of his 
work in 460 duodecimo pages, which, assuredly, is a 
recommendation of the volume as a text-book for stu- 
dents. In this respect it has advantages over any 
treatise which has yet been offered to American stu- 
dents. The difficulty in a text-book of chemistry is to 
treat the subject with sufficient fullness without going 
too much into detail. For students comparatively 
ignorant of chemical science, the larger systems are 
unprofitable companions in their attendance upon lec- 
tures. They need a work of a more elementary cha- 
racter, by which they may be inducted into the first 
principles of the science, and prepared for mastering 
its more abstruse subjects. Such a treatise is the one 
which we have now the pleasure of introducing to our 
readers ; no manual of chemistry with which we have 
met comes so near meeting the wants of the beginner. 
All the prominent truths of the science, up to the pre- 
sent time, will be found given in it with the utmost 
practicable brevity. The style is admirable for its 
conciseness and clearness. Many wood-cuts are 
supplied, by which processes are made intelligible- 
The author expresses regret, that he could not enter 
more largely into organic chemistry, but his details 
will be found to embrace the most important facts in 
that interesting branch of the science. We shall re- 
commend his manual to our class next winter."-The 
Western, Journal of Medicine, and Surgery. 
"We are presented with a work, not only compre- 
hensive as regards general principles, but full of prac- 
tical details of the working processes of the scientific 
laboratory; and in addition, it contains numerous 
wood engravings, showing the most useful forms of 
apparatus, with their adjustments and methods of use. 
"The original work having Seen full and complete, 
as far as the limits of such a volume would permit, 
and on every point brought up to the date of its publi- 
cation (in September last,) the task of the editor has 
been to add any important matter which appeared 
since, and to correct such typographical errors as had 
escaped the author. That this task has been well 
and ably performed, the known zeal and competency 
of Dr. Bridges afford a sufficient guarantee."-The 
Medical Examiner. 
21 
GRAHAM'S CHSDZISTRY. 
THE ELEMENTS OF CHEMISTRY. 
INCLUDING THE APPLICATION OF THE SCIENCE TO THE ARTS. 
With Numerous Illustrations. 
BY THOMAS GRAHAM, F. R. S. L. and E. D. 
Professor of Chemistry in University College, London, &c. &c. 
WITH NOTES AND ADDITIONS, 
BY ROBERT BRIDGES, M.D., &c. &c. 
In One Vol. Octavo. 
The great advancement recently made in all branches of chemical investigation, ren- 
ders necessary an enlarged work which shall clearly elucidate the numerous discoveries, 
especially in the department connected with organic Chemistry and Physiology, in 
which such gigantic strides have been made during the last few years. The present 
treatise is considered by eminent judges to fulfil these indications, and to be pecu- 
liarly adapted to the necessities of the advanced medical student and practitioner. In 
adapting it to the wants of the American profession, the editor has endeavoured to render 
his portion of the work worthy the exalted reputation of the first chemist of England. 
It is already introduced in many of the Colleges, and has universal approbation. 
Though so recently published, it has been translated into German, by Dr. F. Julius 
Otto, the eminent professor at Brunswick, and has already passed to a second edition. 22 
LEA & BLANCHARD'S PUBLICATIONS. 
A NEW MEDICAL DICTIONARY. 
In one Volume, large 12mo., now ready, at a low price. 
A DICTIONARY OF 
THE TERMS USED IN MEDICINE 
AND 
THE COLLATERAL SCIENCES; 
By RICHARD D. HOBLYN, A.M., Oxon. 
FIRST AMERICAN, FROM THE SECOND LONDON EDITION. 
REVISED, WITH NUMEROUS ADDITIONS, 
BY ISAAC HAYS, M.D., 
EDITOR OF THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. 
Believing that a work of this kind would be useful to the profession in 
this country, the publishers have issued an edition in a neat form for the 
office table, at a low price. Its object is to serve as an introduction to the 
larger and more elaborate Dictionaries, and to assist the student commenc- 
ing the study of Medicine, by presenting in a concise form an explanation 
of the terms most used in Medicine and the collateral sciences, by giving 
the etymology and definition in a manner as simple and clear as possible, 
without going into details; and bringing up the work to the present time 
by including the numerous terms lately introduced. This design the author 
has so ably executed as to elicit the highest encomiums of the medical 
press, a few of the testimonies of which are subjoined. 
It has been edited with especial reference to the wants of the American 
practitioner, the native medicinal plants being introduced, with the for- 
mulae for the various officinal preparations; and the whole being made to 
conform to the Pharmacopoeia of the United States. It is now ready in 
one neat royal duodecimo volume of four hundred pages in double co- 
lumns. - 
Extract from a Letter from Professor Watts of the College of Physicians and Surgeons, N. York. 
"It is a valuable book for those more advanced in the profession, but especially for 
students of Medicine, and I shall take pleasure in recommending it to my class during 
the coming session." 
OPINIONS OF THE PRESS. 
" We hardly remember to have seen so much valuable matter condensed into 
such a small compass as this little volume presents. The first edition was pub- 
lished in 1835, and the present may be said to be almost re-written, introducing 
the most recent terms on each subject. The Etymology, Greek, Latin, &c., is 
carefully attended to, and the explanations are clear and precise. We cannot too 
strongly recommend this small and cheap volume to the library of every student and 
every practitioner."-Medico-Chirurgical Review. 
" We gave a very favourable account of this little book on its first appearance, 
and we have only to repeat the praise with increased emphasis. It is, for its size, 
decidedly the best book of the kind, and ought to be in the possession of every 
student. Its plan is sufficiently comprehensive, and it contains an immense mass 
of necessary information in a very small compass."-British and Foreign Medi- 
cal Review. 
" A work much wanted, and very ably executed."-London Medical Journal. 
" This compendious volume is well adapted for the use of students. It contains 
a complete glossary of the terms used in medicine-not only those in common 
use, but also the more recent and less familiar names introduced by modern wri- 
ters. The introduction of tabular views of different subjects is at once compre- 
hensive and satisfactory."-Medical Gazette. 
" Concise and ingenious."-Johnson's Medico-Chirur. Journal. 
"It is a very learned, pains-taking, complete, and useful work-a Dictionary 
absolutely necessary in a medical library."-Spectator. LEA & BLANCHARD'S PUBLICATIONS. 
23 
LATELY PUBLISHED. 
A NEW EDITION OF 
OARFEWTER'S HUHtAiT 
REVISED AND MUCH IMPROVED. 
PRINCIPLES OF HUMAN PHYSIOLOGY, 
WITH THEIR CHIEF APPLICATIONS TO 
PATHOLOGY. HYGIENE & FORENSIC MEDICINE. 
By WILLIAM B. CARPENTER, M.D., F.R.S., &c. 
SECOND AMERICAN, FROM A NEW AND REVISED LONDON EDITION. 
WITH NOTES AND ADDITIONS, 
BY MEREDITH CLYMER, M.D., &c., 
With Two Hundred and Sixteen Wood-cut and other Illustrations. 
In one octavo volume, of about 650 closely and beautifully printed pages. 
The very rapid sale of a large impression of the first edition is an evidence of the merits of this 
valuable work, and that it has been duly appreciated by the profession of this country. The pub- 
lishers hope that the present edition will be found still more worthy of approbation, not only from 
the additions of the author and editor, but also from its superior execution and the abundance of 
its illustrations. No less than eighty-five wood-cuts and another lithographic plate will be found 
to have been added, affording the most material assistance to the student. 
" We have much satisfaction in declaring our opinion that this work is the best systematic treat- 
ise on physiology in our own language, and the best adapted for the student existing in any lan- 
guage."-Medico-Chirurgical Review. 
NOW READY. 
A NEW AND IMPROVED EDITION OF 
OPERATIVE SUHCrEHY. 
A SYSTEM OF PRACTICAL SURGERY. 
By WILLIAM FERGUSSON, F.R.S.E. 
Second American Edition, Revised and Improved. 
WITH TWO HUNDRED AND FIFTY-TWO ILLUSTRATIONS FROM DRAWINGS BY BAGG, ENGRAVED BY 
GILBERT, WITH NOTES AND ADDITIONAL ILLUSTRATIONS, 
BY GEORGE W. NORRIS, M.D., &c. 
In one beautiful octavo volume of six hundred and forty large pages. 
The publishers commend to the attention of the profession this new and improved edition of 
Fergusson's standard work, as combining cheapness and elegance, with a clear, sound and practical 
treatment of every subject in surgical science. Neither pains nor expense have been spared to 
make it worthy of the reputation which it has already acquired, and of which the rapid exhaustion 
of the first edition is sufficient evidence. It is extensively used as a text-book in many medical 
colleges throughout the country. 
The object and nature of this volume are thus described by the author :-" The present work 
has not been produced to compete with any already before the Profession; the arrangement, the 
manner in which the subjects have been treated, and the illustrations, are all different from any of 
the kind in the English language. It is not intended to be placed in comparison with the elemen- 
tary systems of Cooper, Burns, Liston, Symes, Lizars, and that excellent epitome of Mr. Druitt.- 
It may with more propriety be likened to the Operative Surgery of Sir C. Bell, and that of Mr. 
Averill, both excellent in their day, or the more modern production of Mr. Hargrave, and the 
PracticaU Surgery of Mr. Liston. There are subjects treated of in this volume, however, which 
none of these gentlemen have noticed ; and the author is sufficiently sanguine to entertain the idea 
that this work may in some degree assume that relative position in British Surgery, which the 
classical volumes of Velpeau and Malgaigne occupy on the Continent." 
"If we were to say that this volume by Mr. Fergusson, is one excellently adapted to the stu- 
dent, and the yet inexperienced practitioner of surgery, we should restrict unduly its range. It is 
of the kind which every medical man ought to have by him for ready reference, as a guide to the 
prompt treatment of many accidents and injuries, which whilst he hesitates, may be followed by 
incurable defects, and deformities of structure, if not by death itself. In drawing to a close our 
notice of Mr. Fergusson's Practical Surgery, we cannot refrain from again adverting to the nume- 
rous and beautiful illustrations by wood-cuts, which contribute so admirably to elucidate the de- 
scriptions jn the text. Dr. Norris has, as usual, acquitted himself judiciously in his office of 
annotator. His additions are strictly practical and to the point,"-Bulletin of Medical Science, 24 
LEA & BLANCHARD'S PUBLICATIONS. 
3LATELYT PUBLISHED, . 
A NEW EDITION OF 
WILSON'S HUMAN ANATOMY, 
Much Improved. 
GENERAL AND SPECIAL. 
BIT ERASMUS WILSON, M.D., 
Lecturer on Anatomy, London. 
SECOND AMERICAN EDITION, EDITED BY 
PAUL B: GODDARD, A.M., M.D., 
Lecturer on Anatomy and Demonstrator in the University of Pennsylvania, SfC. 
WITH OVER TWO HUNDRED ILLUSTRATIONS, 
Beautifully Printed from the Second London Edition. 
IN ONE VERY NEAT OCTAVO VOLUME. 
From the Preface to the Second American Edition. 
" The very rapid sale of the first edition of this work, is evidence of its appreciation by the pro- 
fession, and is most gratifying to the author and American editor. In preparing the present edition 
no pains have been spared to render it as complete a manual of Anatomy for the medical student as 
possible. A chapter on Histology has therefore been prefixed, and a considerable number of new 
cuts added. Among the latter, are some very fine ones of the nerves which were almost wholly 
omitted from the original work. Great care has also been taken to have this edition correct, and 
the cuts carefully and beautifully worked, and it is confidently believed that it will give satisfaction, 
offering a further inducement to its general use as a Text-book in the various Colleges." 
" Mr. Wilson, before the publication of this work, was very favourably known to the profession 
by his treatise on Practical and Surgical Anatomy; and, as this is the Second American Edition, 
from the second London Edition, since 1840, any special commendation of the high value of the 
present work, on our part, would be supererogatory. Besides the work has been translated at Ber- 
lin, and overtures were repeatedly made to the London publisher for its reproduction in France.- 
The work is, undoubtedly, a complete system ofhuman anatomy, brought up to the present day.- 
The illustrations are certainly very beautiful, the originals having been expressly designed and exe- 
cuted for this work by the celebrated Bagg of London; and, in the American edition they have 
been copied in a masterly and spirited manner. As a text-book in the various colleges we would 
commend it in the highest terms."-New York Journal of Medicine. 
CHURCHILL'S MIDWIFERY. 
ON THE THEORY AND PRACTICE OF MIDWIFERY, 
BY FLEETWOOD CHURCHILL, M.D., M.R.I.A., 
PHYSICIAN TO THE WESTERN LYING-IN-HOSPITAL, ETC., ETC. 
WITH NOTES AND ADDITIONS 
BY ROBERT HUSTON, M.D., 
Professor in the Jefferson Medical College, &c., &c. 
And One Hundred and Sixteen Illustrations, 
Engraved by Gilbert from Drawings by Bagg and others. 
In one volume, octavo. 
This work commends itself to the notice of the profession from the high reputation of the author 
and editor, and the number and beauty of its illustrations. Besides accurate directions for 
THE PRACTICE OF MIDWIFERY, 
a portion of the work is also devoted to 
THE PHYSIOLOGY AND PATHOLOGY 
connected with that essential branch of medical knowledge. 
" It is impossible to conceive a more useful or elegant manual: the letter-press contains all that 
the practical man can desire ; the illustrations are very numerous, well chosen, and of the most ele- 
gant description, and the work has been brought out at a moderate price."-Provincial Med. Jour. 
" We expected a first rate production, and we have not been in the leastdisappointed. Although 
we have many, very many valuable works on tokology, were we reduced to the necessity of pos- 
sessing but one, and permitted to choose, we would unhesitatingly take Churchill."-Western Med. 
and Surg. Journal. ' 
This work is printed, illustrated and bound to match Carpenter's Physiology, 
Fergusson's Surgery and Wilson's Anatomy, and the whole, with Watson's Prac- 
tice. Pereira's Materia Medica and Graham's Chemistry, are extensively used in 
the various colleges. LEA & BLANCHARD'S PUBLICATIONS. 
25 
PEREIRA'S MATERIA MEDICA. 
WITH NEAR THREE HUNDRED ENGRAVINGS ON WOOD. 
A NEW EDITION NOW HEADY. 
THE ELEMENTS OF MATERIA MEBICA AND THERAPEUTICS. 
COMPREHENDING THE NATURAL HISTORY, PREPARATION, PROPERTIES, COMPO- 
SITION, EFFECTS, AND USES OF MEDICINES. 
BY JONATHAN PEREIRA, M.D., F.R.S. and L. S. 
Member of the Society of Pharmacy of Paris; Examiner in Materia Medica and Pharmacy of the 
University of London; Lecturer on Materia Medica at the London Hospital, &c., &c. 
Second American, from the last London Edition, enlarged and improved. With Notes and Additions 
BY JOSEPH CARSON, M.D., 
In two volumes, octavo. 
Part I, contains the General Action and Classification of Medicines and the Mineral Materia Me- 
dica. Part II, the Vegetable and Animal Kingdoms, and including diagrams explanatory of the 
Processes of the Pharmacopreias, a tabular view of the History of the Materia Medica, from the 
earliest times to the present day, and a very copious index. From the last London Edition, which 
has been thoroughly revised, with the Introduction of the Processes of the New Edinburgh Phar- 
macopoeia, and containing additional articles on Mental Remedies, Light, Heat, Cold, Electricity, 
Magnetism, Exercise, Dietetics and Climate, and many additional Wood-cuts, Illustrative of Phar- 
maceutical Operations, Crystallography, Shape and Organization of the Feculas of Commerce, and 
the Natural History of tire Materia Medica. 
The object of the author has been to supply the Medical Student with a Class Book on Materia 
Medica, containing a faithful outline of this Department of Medicine, which should embrace a con- 
cise account of the most important discoveries in Natural History, Chemistry, Physiology, and The- 
rapeutics, in so far as they pertain to Pharmacology, and treat the subjects in the order of their 
natural historical relations. 
The opportunity has been embraced in passing this New Edition through the hands of the Editor, 
Dr. Carson, to make such additions as were required to the day, and to correct such errors as had 
passed the inspection of the Author and Editor of the first edition. It may now be considered as 
worthy the entire confidence of the Physician and Pharmaceutist as a standard work. 
This great Library or Cyclopaedia of Materia Medica has been fully revised, the errors corrected, 
and numerous additions made by DR. JOSEPH CARSON, Professor of Materia Medica and Phar- 
macy in the "College of Pharmacy," and forms Two Volumes, octavo, of near 1600 large and 
closely printed pages. It may be fully relied upon as a permanent and standard work for the coun- 
try-embodying, as it does, full references to the U. S. Pharmacopoeia and an account of the Medi- 
cal Plants indigenous to the United States. 
" An Encyclopaedia of knowledge in that department of medical science-by the common con' 
sent of theBprofession the most elaborate and scientific Treatise on Materia Medica in our lan- 
guage."- Western Journal of Medicine and Surgery. 
" Upon looking over the American edition of the Materia Medica of Dr. Pereira, we have seen no 
reason to alter the very favourable opinion expressed in former numbers of this Journal. (See Am. 
Med. Journal, XXIV, 413, and N. S., I. 192.) We are glad to perceive that it has been repub- 
lished here without curtailment. Independently of the injustice done to an author by putting forth 
an abbreviated edition of his works, without his superintendence or consent, such a course would 
in the present instance have been unjust also to the public, as one of the chief recommendations 
of Dr. Pereira's treatise is its almost encyclopedic copiousness. We turn to its pages with 
the expectation of finding information upon all points of Materia Medica, and would have good 
reason to complain were this expectation disappointed by the scissors of an American Editor. 
Indeed, the main defect of the work, in relation to American practitioners, was the want of 
sufficient notices of the medicines and preparations peculiar to this country. In the edition 
before us this defect has been supplied by the Editor, Dr. Joseph Carson, who was, in a high 
degree qualified for the task, and, so far as we are able to judge from a very partial perusal, has 
executed it with judgment and fidelity. The nomenclature and preparations of our national 
standard have been introduced when wanting in the English edition, and many of our medical 
plants, either briefly noticed or altogether omitted by Dr. Pereira, because unknown in Europe, 
have been sufficiently described. We must repeat the expression of our opinion that the work will 
be found an invaluable storehouse of information for the physician and medical teacher, and con- 
gratulate the profession of this country that it is now placed within their reach."-Am. Med. Journ. 
" To say that these volumes on Materia Medica and Therapeutics, by Dr. Pereira, are comprehen- 
sive, learned and practical, and adapted to the requirements of the practitioner, the advanced stu- 
dent, as well as the apothecary, expresses the opinion, we will venture to assert, of nearly every 
judge of the subject, but fails to convey to those who are not acquainted with the work, a definite 
idea of its really distinctive traits, according to our general usage, we shall, therefore, proceed to 
place these before our readers, so that they may know what it is, and why we praise. Valuable 
and various as are the contents of the volumes of Dr. Pereira, we have no hesitation in assert- 
ing, despite the adverse cant in some quarters on the subject of the American additions to English 
works, that the value of the present edition is enhanced by the appropriate contributions of 
Dr. Carson, who has introduced succinct histories of the most important indigenous medicines of 
the United States Pharmacopoeia."-Select Med. Library. 26 
LEA & BLANCHARD'S PUBLICATIONS. 
THE SURGICAL WORKS OF SiR ASTLEY COOPER. 
LEA & BLANCHARD have now completed the last volume of the illustrated works of Sir Astley Cooper. 
They form an elegant series; the works on Hernia, the Testis, the Thymus Gland and the Breast, being print- 
ed, illustrated and bound to match, in imperial octavo with numerous LI THOGR APH1C PLATES, while the 
Treatise on Dislocations is in a neat medium octavo form, with NUMEROUS WOOD-CUTS similar to the 
last Loudon Edition. 
COOPER ON THE 
ANATOMY AND DISEASES OF THE BREAST, &c„ 
JUST PtTBUSSKD. 
This large and beautiful volume contains THE ANATOMY OF THE BREAST : 
THE COMPARATIVE ANATOMY OF THE MAMMARY GLANDS; 
ILLUSTRATIONS OF THE DISEASES OF THE BREAST; 
And Twenty-five Miscellaneous Surgical Papers, now first published in a collected form. 
By SIR ASTLEY COOPER, Bart., F.R.S.,&c. 
The whole in one large imperial octavo volume, illumrated with two hundred and fifty-two figures on 
thirty six Lithographic Plates ; well and strongly bound. 
SIR ASTLEY COOPER ON HERNIA, 
With One Hundred and Thirty Figures in LillMgraphyt 
THE ANATOMY AND SURGICAL TREATMENT OF 
ABDOMINAL HERNIA. 
By Sir ASTLEY COOPER, Bart. 
Edited by C. Aston. Key, Surgeon to Guy's Hospital, &c. 
This Important work of Sir Astley is printed from the authorized second edition, published in London, in 
targe super royal folio, and edited by his nephew, Professor Key. It contains all the Plates and all the Let- 
terpress- there are no omissions, interpolations, or modifications-it is the complete work in 
One Large Imperial Octavo Volume. 
WITH OVER 130 FIGURES ON 26 PLATES, AND OVER 400 LARGE PAGES OF LETTERPRESS. 
The correctness of the Plate® is guaranteed by a revision and close examination under the eye of a distin* 
guished Surgeon of this city. 
ANOTHER VOLUME OF THE SERIES CONTAINS HIS TREATISE 
ON THE STRUCTURE AND DISEASES OF THE TESTIS. 
Illustrated by 120 Figures. From Ihe Second London Edition. 
By BRANSBY B. COOPER, Esq. 
AND ALSO 
ON THE ANATOMY OF THE THYMUS GLAND. 
Illustrated by 57 Figures. 
The two works together in one beautiful imperial octavo volume, illustrated with twenty-nine plates in 
the best style of lithography, and printed and bound to match. 
COOPER ON FRACTURES ANU DISLOCATIONS, 
WITH NUMEROUS WOOD-CUTS. 
A TREATISE ON DISLOCATIONS AND FRACTURES OF THE JOI NTS. By SIR ASTLEY COOPER, 
Bart., F. R. S., Sergeant Surgeon to the King. Ac. 
A new edition much enlarged ; edited by BRANS BY COOPER. F.R.S , Suigeon to Guy's Hospital, with ad- 
dilional Observations from Professor John C. Warren, of Boston. W ith numerous engravings on wood, 
after designs by Bagg, a memoir and a splendid portrait of Sir Astley. In one octavovolume. 
The peculiar value of this, as of all Sir Astley Cooper's works, consists in its eminently practical character. 
His nephew, Bransby B. Cooper, from his own experience, has added a number of cases. Besides this, Sir 
Astley left behind hirn very considerable additions in MS. for the express purpose of being introduced into this 
edition. The volume is embellished with ONE HUNDRED AND THIRTY-THREE WOOD-CUTS, and 
contains the history of no less than three hundred and sixty-one cases, thus embodying the records of a life of 
practice of the Author and his various editors. There are also additional Observations from notes furnished 
by John C. Warren, M.D., the Professorof Anatomy and Surgery in Harvard University. 
" After the fiat of the profession, it would be absurd in us to eulogize Sir Astley Cooper's work on Fractures 
nnd Dislocations. It is a national one, and will probably subsist as long as English surgery."-Medico-Chirur- 
fical Keerew. LEA & BLANCHARD'S PUBLICATIONS. 
27 
LATELY PUBLISHED. 
MEIGS' TRANSLATION 
COLOMBAT DE L'ISERE GN THE DISEASES OF FEMALES. 
A TREATISE ON THE DISEASES OF FEMALES, 
AND ON 
THE SPECIAL HYGIENE OF THEIR SEX. 
WITH NUMEROUS WOOD-CUTS. 
* BY COLOMBAT DE L'ISERE, M.D., 
Chevalier of the Legion, of Honor; late Surgeon to the Hospital of the Rue de Valois, devoted to the Disease! of 
Females, ^-c.. ^-c. 
TRANSLATED, WITH MANY NOTES AND ADDITIONS, 
By C. D. MEIGS, M.D., 
Professor of Obstetrics and Diseases of Women and Children in the Jefferson Medical College, S;c., S;c. 
In One Large Volume, 8vo. 
" We are satisfied it is destined to take the front rank in this department of medical science; it is 
beyond all comparison, the most learned Treatise on the Diseases of Females that has ever been 
written, there being more than one thousand distinct authorities quoted and collected by the inde- 
fatigable author. It is in fact a complete exposition of the opinions and practical methods of all 
the celebrated practitioners of ancient and modern times. The Editor and Translator has per- 
formed his part in a manner hardly to be surpassed. The translation is faithful to the original, and 
yet elegant. More than one hundred pages of original matter have been incorporated in the text, 
constituting a seventh part of the whole volume."-New York Journal of Medicine. 
ASHWELL ON THE DISEASES OF FEMALES. 
A PRACTICAL TREATISE ON THE 
DISEASES PECULIAR TO WOMEN, 
ILLUSTRATED BY CASES DERIVED FROM HOSPITAL AND PRIVATE PRACTICE. • 
By SAMUEL ASHWELL, M.D., 
Member of the Royal College of Physicians; Obstetric Physician and Lecturer to Guy's Hospital, &e. 
WITH ADDITIONS, 
By PAU,L BECK GODDARD, M.D. 
F The whole complete in one Large Octavo Volume. 
" The most able, and certainly the most standard and practical work on female diseases that we 
have yet seen."-Medico-Chirurgical Review. 
A NEW EDITION OF CHURCHILL ON FEMALES. 
THE DISEASES OF FEMALES, 
INCLUDING THOSE OF ' 
By FLEETWOOD CHURCHILL. M.D., 
Author of "Theory and Practice of Midwifery," &c., &c. 
THIRD AMERICAN, FROM THE SECOND LONDON EDITION. 
With Illustrations. Edited with Notes, 
By ROBERT M. HUSTON, M.D., &c., &c. 
In One Volume, 8vo. 
" In complying with the demand of the profession in this country for a third edition, the Editor 
has much pleasure in the opportunity thus afforded of presenting the work in its more perfect form. 
All the additional references and illustrations contained in the English copy, are retained in this." 
TAILOR'S JURISPRUDENCE. 
MEDICAL JURISPRUDENCE, 
BY ALFRED S. TAYLOR. 
Lecturer on Medical Jurisprudence and Chemistry at Guy's Hospital. 
With numerous Notes and Additions, and References to American Law. 
BY R. E. GRIFFITH, M. D. 
In one volume, octavo, sheep. Also, done up in neat law sheep. 28 
LEA & BLANCHARD'S PUBLICATIONS. 
CONDIB ON CHILDREN. 
A PRACTICAL TREATISE 
ON 
THE DISEASES OF CHILDREN, 
BY D. FRANCIS CONDIE, M. D. 
Fellow of the College of Physicians; Member of the American Philosophical Society. &c. &c. 
In one volume, octavo. 
55* The Publishers would particularly call the attention of the Profession to an examination 
of this work. 
" Dr. Condie, from the very great labour which he has evidently bestowed upon this book, is entitled 
to our respect as an indefatigable and conscientious student; but if we consider the results of his 
labour, we cannot but admit his claim to a place in the very first rank of eminent writers on the 
practice of medicine. Regarding his treatise as a whole, it is more complete and accurate in its 
descriptions, while it is more copious and more judicious in its therapeutical precepts than any of 
its predecessors, and we feel persuaded that the American medical profession will very soon regard 
it, not only as a very good, but as the very best ' Practical Treatise on the Diseases of Children.' " 
-Am. Meil. Journal. 
THOMSON ON THE SICK ROOM. 
THE DOMESTIC MANAOEMENT OF THE SICK ROOM, 
NECESSARY, IN AID OF MEDICAL TREATMENT, FOR THE 
CURE OF DISEASES. 
BY A. T. THOMSON. M. D., &c. &c. 
First American) from the Second London Edition. 
Edited by R. E. GRIFFITH. M. D. 
In one royal 12mo. volume, extra cloth, with cuts. 
" Thore is no interference with the duties of the medical attendant, but sound, sensible, and 
clear advice what to do, and how to act, so as to meet unforeseen emergencies, and co-operate with 
professional skill."-Literary Gazette. 
MILLER'S PRINCIPLES OF SURGERY. 
THE PRINCIPLES OF SURGERY. 
Bv JAMES MILLER, F.R.S.E., F.R.C.S.E., 
Professor of Surgery in the University of Edinburgh, &c. 
In one neat 8vo. volume. 
To match in size with Fergusson's Operative Surgery. 
" No one can peruse this work without the conviction that he has been addressed by an accom- 
plished surgeon, endowed with no mean literary skill or doubtful good sense, and who knows how 
to grace or illumine his subjects with the later lights of our rapidly advancing physiology. The 
book deserves a strong recommendation, and must secure itself a general perusal."-Medical Timm. 
WILLIAMS' PATHOLOGY. 
PRINCIPLES OF MEDICINE, 
COMPRISING 
GENERAL PATHOLOGY AND THERAPEUTICS, and a general view of ETIOLOGY, 
NOSOLOGY, SEMEIOLOGY, DIAGNOSIS AND PROGNOSIS. 
BY CHARLES J B. WILLIAMS, M.D., F. R. S., 
Fellow of the Royal College of Physicians, etc.' 
WITH ADDITIONS AND NOTES 
BY MEREDITH CLYMER, M. D. 
Lecturer on the Institutes of Medicine, &c. &c. 
In one volume, Svo. 
ALISON'S PATHOLOGY. 
OUTLINES OF PATHOMSY AM PRACTICE CP MEDICINE. 
BY WILLIAM PULTENEY AI,ISON, M. 11, 
Professor of the Practice of Medicine in the University of Edinburgh, &c. &c. 
In Three Parts-Part T.-Preliminary Observations-Part II.-Inflammatory and Febrile Diseasea* 
and ^art III.-Chronic or Non-Febrile Diseases. In one volume, octavo. WORKS ON THE VARIOUS DEPARTMENTS OF MEDICINE 
AND SCLNCE 
PUBLISHED BY LEA & BLANCHARD. 
ANATOMICAL ATLAS. One vol. 8vo. 
See Advertisement. 
AMERICAN JOURNAL OF THE MEDI- 
CAL SCIENCES. Sec Advertisement. 
ANDRAL ON THE BLOOD. Pathologi- 
cal Haematology; An Essay on the Blood in 
Disease. Translated by J. F. Meigs and Alfred 
Stille. In one octavo volume, cloth. 
ARNOTT'S PHYSICS. The Elements of 
Physics, in Plain, or Non-Technical Language. 
A New Edition. Edited by Isaac Hays. One 
octavo volume, sheep. With numerous cuts. 
ABERCROMBIE OxN THE BRAIN. Pa- 
thological and Practical Researches on the 
Diseases of the Brain and Spinal Cord. A 
New Edition. In one volume, 8vo. 
ABERCROMBIE ON THE STOMACH. 
Pathological and Practical Researches on Dis- 
eases of the Stomach, Intestinal Canal, &c. 
The Fourth Edition. In one vol. Svo. 
ALISON'S PATHOLOGY. One vol. 8vo. 
See Advertisement. 
ASHWELL ON FEMALES. One vol. 
8vo. See Advertisement. 
BERZELIUS ON KIDNEYS, &c. The 
Kidneys and Urine. Translated by J. C. 
Booth and M. H. Boye. One Svo. vol. cloth. 
BARTLETT OxN FEVERS -OF THE U. S. 
The History, Diagnosis, and Treatment of 
Typhus and Typhoid Fevers; and on Bilious, 
Remittent and Yellow Fever. In one neat 
octavo volume, extra cloth. 
BARTLETT'S PHILOSOPHY OF MEDI- 
CINE. Essay on the Philosophy of Medical 
Science. In Two Parts. One neat octavo 
volume, extra cloth. 
BILLING'S PRINCIPLES OF MEDI- 
CINE. The First Principles of Medicine. 
From the Fourth London Edition. In one 
octavo volame, cloth. 
BRIGHAM ON MENTAL EXCITE- 
MENT. The Influence of Mental Cultiva- 
tion, and Mental Excitement on Health. In 
one 12mo. volume, cloth. 
BRODIE ON URINARY ORGANS. Lec- 
tures on the Diseases of the Urinary Organs. 
In one small octavo voiume, cloth. 
BRODIE ON THE JOINTS. Pathological 
and Surgical Observations on the Diseases of 
the Joints. In one small octavo volume cloth. 
BRODIE'S LECTURES OxN PROMINENT 
POINTS OP SURGERY. One volume, Svo. 
BUCKLAND'S GEOLOGY. Geology and 
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logy. A Bridgewater Treatise. In two vols. 
8vo. With numerous Maps, Plates, and Cuts. 
BREWSTER'S OPTICS. A Treatise on 
Optics, With numerous Wood Cuts. One vol- 
ume, 12mo. half bound. 
CH RHUS' SYSTExM OF SURGERY. 
Edited by South and Norris. Now publishing 
in Parts, to make 2 volumes octavo. 
COLOM BAT DE L'ISERE ON FE- 
MALES. A Treatise on the Diseases of Fe- 
males, and on the Special Hygiene of their Sex. 
Translated by C. D. Meigs. In one large Svo. 
vol. sheep. With Cuts. See Advertisement. 
CHAPMAN ON VISCERA, &c. &c. 1 
vol. 8vo. See Advertisement. 
CHAPMAN ON FEVERS, &c. 1 vo*. 
8vo. See Advertisement. 
CARPENTER S HUMAN PHYSIOLOGY. 
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CARPENTER'S VEGETABLE PHYSIO- 
LOGY. Popular Vegetable Physiology. With 
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volume, extra cloth. 
COOPER'S (Sir Astley,) GREAT WORK 
ON HERNIA. See Advertisement. 
COOPER, (Sir Astley,) ON THE TES- 
TIS, &c. See Advertisement. 
COOPER, (Sir Astley.) ON THE 
BREAST, &c. See Advertisement. 
COOPER ON DISLOCATIONS. One vol. 
Svo. See Advertisement. 
CONDIE ON CHILDREN. 1 vol. 8vo, 
See Advertisement. 
CHURCHILL ON FEMALES. One vol. 
8vo. See Advertisement, 
CHURCHILL'S MIDWIFERY. One vol. 
Svo. See Advertisement. 
CHITTY'S MEDICAL JURISPRU- 
DENCE. A Practical Treatise on Medical 
Jurisprudence. With Explanatory Plates. In 
one octavo volume. 
CLATER AND SKINNER'S FARRIER. 
Every Man his own Farrier. Containing, the 
Causes, Symptoms, and most approved Me- 
thods of Cure of the Diseases ofHorses. From 
the 28th London Edition. Edited by Skinner, 
In one 12mo. volume, cloth, 
CLATER AND YOUATT'S CATTLE 
DOCTOR. Every Man his-own Cattle Doctor. 
Containing the Diseases of Oxen, Sheep, 
Swine, &c. Edited by Yonatt,and revised by 
Skinner. With Wood Cuts. In one vol. J2mo, 
CYCLOPAEDIA OF PRACTICAL MEDI- 
CINE. In four large octavo volumes, con- 
taining, nearly 3200 large double columned 
pages. See Advertisement. 
DEWEES' MIDWIFERY. A Compre- 
hensive System of Midwifery ; chiefly designed 
for the use of Students. With many Engrav- 
ings. Tenth Edition, with the Author's Iasi 
corrections. In one octavo volume, sheep. 
DEWEES ON CHILDREN. A Treatise 
on the Physical and Medical Treatment of 
Children. Sth Edition. In one 8vo. vol. sheep, 
DEWEES ON FEMALES. A Treatise on 
the Diseases of Females. Eighth Edition, 
revised and corrected. In one octavo volume, 
sheep. With Plates. 
DUNGLISON'S PHYSIOLOGY. See Ad- 
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RY. See Advertisement. 
DUNGLISON'S PRACTICE. In two vols, 
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DUNGLISON ON NEW REMEDIES. 
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DUNGLISON'S THERAPEUTICS AND 
MATERIA-MEDICA. Two vols. 8vo. Setf 
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DUNGLISON S Hl GIENE Onevol. 8vo, 
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DUNGLISON'S MEDICAL STUDENT, 
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LEA & BLANCHARD'S PUBLICATIONS. 
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ESQUIROL ON INSANITY. Mental 
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GUTHRIE ON THE BLADDER. The 
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HOPE ON THE HEART. A Treatise on 
the Diseases of the Heart and Great Vessels. 
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KIRBY ON ANIMALS. The History, 
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Isaac Hays. In one large octavo volume, 
sheep. With Cuts. 
LAWRENCE ON RUPTURES. A Trea- 
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MAURY'S DENTAL SURGERY. A 
Treatise on the Dental Art, founded on Actual 
Experience. Illustrated by 241 lithographic 
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MILLER'S PRINCIPLES OF SURGERY. 
One vol. 8vo. See Advertisement. 
MULLER'S PHYSIOLOGY. Elements of 
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PHILIP ON INDIGESTION. A Treatise 
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PROUT ON THE STOMACH. On the 
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Outlines of a bourse of Lectures on Medical 
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WATSON'S PRACTICE OF PHYSIC. 
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volume, sheep. 
" In this work we have another valuable aid 
to the student of Practical Anatomy."-N. Y. 
Journal of Medicine. 
WILSON ON THE SKIN. A Practical 
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the Skin. In one octavo volume, cloth. 
M1LLIAMS PATHOLOGY. In one vol. 
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WILLIAMS ON THE RESPIRATORY 
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YOUATT ON THE HORSE. The Horse; 
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31 
THE 
AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
Edited by ISAAC HAYS, M. D., 
Published Quarterly on the first of January, April, July and October; 
each Number having at least 264 large and closely printed pages. 
When necessary, cases are 
FULLY ILLUSTRATED WITH LITHOGRAPHIC PLATES AND WOOD CUTS. 
ALSO, 
THE MEDICAL NEWS AND LIBRARY, 
OF 32 LARGE PAGES, PUBLISHED MONTHLY, 
IS GIVEN GRATIS 
to Subscribers to The Journal who pay, by the first of February of each year, 
Five Dollars free of expense to the Publishers. 
Under the new law the postage on the Journal is reduced to about 13^ cents, 
per number, while the News and Library is sent through the mail as a News- 
paper. 
The Number of the Journal for January will soon go to press, so that persons 
wishing to subscribe should advise the publishers at once, as the whole quantity 
for 1844 and '43 was taken at an early day. 
The publishers do not deem it necessary to refer to the past course of the Journal, It 
is sufficient that for the last TWENTY-SIX YEARS it has received the approbation of 
the profession at home and abroad; but they would call attention to the extended and 
liberal arrangement existing and to be pursued that shall embody the latest intelligence 
from all quarters. 
Its pages will be devoted first to 
ORIGINAL COMMUNICATIONS 
from all sections of the Union, with 
REVUEWS OF ALL NEW WORKS 
of interest, and 
BIBLIOGRAPHICAL NOTICES; 
while its QUARTERLY SUMMARY will embrace a full and extended 
RETROSPECT AND ABSTRACT 
from the various 
FOREIGN AND DOMESTIC JOURNALS. 
With reference to this department, the arrangementsof the Publishers are so extensive as 
to embrace for the gleanings of the editor the various Journals from 
GREAT BRITAIN, FRANCE, GERMANY, 
AND OTHER SECTIONS OF THE WORLD. 
Including as prominent among the English, 
BRAITHWAITE'S RETROSPECT, 
RANKING'S HALF YEARLY ABSTRACT, 
THE LOWDOXr LAHOET, 
THE L©N0©H MEDOOAL TOMES, 
GULSSWtBa 
FORBES' BRITISH AND FOREIGN QUARTERLY, 32 
LEA & BLANCHARD'S PUBLICATIONS. 
THE MEDICO-CHIRURGICAL REVIEW, 
EDIJVtiVRGH JUEU. Mf!> WM. JOVKlfM, 
AND NUMEROUS OTHERS. 
While from France 
THE GAZETTE MEDICALE DE PARIS-L'EXPERIENCE-REVUE MEDICALE 
-JOURNAL DE MEDECINE- JOURN AL DES CONNAIS8ANCES MEDICO- 
CHIRURGICALE8. 
and various others, with the 
ZEITSCHRIFT FUR DIE GESAMMTE MEDICIN, 
with several others from Germany, 
AND THE DENMARK BIBLIOTHEK FOR L2EGER, 
together with 
ALL THE AMERICAN JOURNALS, 
are put in requisition. 
It will thus be seen that the material for a full Summary of all 
NEW MATTERS AND IMPORTANT DISCOVERIES 
is full and ample, while ihe exertions of the Editor and the time of publication insure 
a fullness and newness to this department. 
All the late and important 
is fully recorded-while 
THE MONTHLY NEWS 
furnishes the lighter and floating information, and embraces important Books for 
Sfdfat 2621232341231 232321»4i232m2£^J>tP» 
Among those works already published in the Monthly Library and News, may be 
mentioned 
WATSON'S LECTURES ON THE PRACTICE OF PHYSIC, 
as also 
BRODIE'S DEOTUKES CiJ STOGEBT, 
concluded this year, (1845.) 
The work selected to commence the year 1846 is a new one, 
ROYLE'S MANUAL OF MATERIA MEDICA AND THERAPEUTICS, 
now at press in England. 
The high character of the Author is a pledge of a valuable work, which will be sub- 
ject to a revision and editing in this country, and have numerous Cuts. 
Each Work in the Library is regularly paged so as to be bound separately. 
THE THRIVES APE 
For the Medical Journal and News, if paid for by the first of February 
of each Year, and remitted free of cost to the Publishers, - - Five Dollars. 
For the Journal only, when ordered without funds, or paid for after the 
first of February of each year, ------- Five Dollars. 
For the Medical News only, to be paid for always in advance, and free of 
cost. One Dollar. 
gCj" In no case can The News be sent without pay in advance. 
ICT* This paper may be delivered to any physician if declined by the person 
to whom it is addressed, or if they have removed-and Postmasters and others 
will particularly oblige the publishers by furnishing a list of the Physicians and 
Lawyers of their county or neighbourhood. In addition to the business it may 
bring to the office, a copy of "The Complete Florist," or such other volume, 
will be sent by mail gratis for any ten or more names furnished free of cost. 
Philadelphia, October, 1845.