V-. r &VV «P/ #> C,' \ 3 SURGEON GENERAL'S OFFICE LIBRARY. utiles Section . iX ^x\ €5^ [%&? %( £ THE INSTITUTES AND PRACTICE SURGERY: BEING THE OUTLINES A s Memoirs, by Hall, vol. 1. p. 51. Pernio. S3 Section IV. Pernio, or Chilblain. This inflammatory affection is the result of cold, or of the sudden transition from cold to heat, and is commonly met with in extreme parts of the body, such as the toes, heels, fingers, ears, nose and lips. At first the skin is pale and shrivelled; this state, however, is quickly succeeded by redness, tumefac- tion, more or less pain, pruritus and oedema. In bad cases the skin assumes a purple cast, the itching or tingling becomes intolerable, a serous fluid col- lects beneath the cuticle, and is soon discharged, leaving an ill-conditioned sore, which often pene- trates to the bone, and is exceedingly difficult to heal. The mild form of this complaint, or that unat- tended, by ulceration, is by no means uncommon, es- pecially in moist and temperate climates, where it often disappears spontaneously during summer, and 54 Pernio. regularly returns in winter, attacking for the most part patients who have previously suffered. Treatment of Pernio. Very common applications in the simple or mild form of chilblain, are ice water or snow; and there can be little doubt of their general utility, when used with moderation. To certain patients they are not adapted,—especially those inclined to phthysis or subject to the gout; nor are they suitable for deli- cate females. Spirituous embrocations often prove serviceable. Soap liniment, volatile liniment, spirits of turpentine, and tincture of cantharides are the best remedies of this class. I have frequently known the mild chilblain cured in a few days, simply by co- vering the part with carded cotton. An alum curd is sometimes a very effectual remedy. For the ulcerated chilblain, some of the stimula- ting ointments, as the unguentum hydrargiri nitrati, or basilicon mixed with red precipitate, are often ad- vantageously employed. Solutions of lunar caustic, Pernio. 55 or of the preparations of lead, or lime water mixed with linseed oil, are likewise useful. At first, these remedies are scarcely felt by the patient; but in a little time the sore becomes exquisitely sensible, and should then be covered with poultices and mild dressings until completely healed. See Pearson's Principles, p. 153—Thomson on Inflamma- tion, p. 646—Rees' Cyclopedia, vol. 8. part 1—The Art of preserving the Feet, 8fc, by an experienced Chiropodist, p. 149. London, 1818. 56 Frost-Bile. Section V. Frost-Bite. Intense cold applied to the body, or to a part, may produce effects very different from those last mentioned. The vital functions may be entirely ex- tinguished, or only suspended, or else some particu- lar texture may be destroyed, through the medium of mortification. Although many instances are on re- cord, of persons having died from exposure to severe cold, and of others recovering after the suspension of animation for a considerable time, yet such con- sequences are rare, compared with the partial inju- ries which result from frost-bite or mortification. Few cold seasons, indeed, pass away, especially on our sea-coast, without numerous instances of frost- bite taking place. The part to which the cold is applied first becomes benumbed, stiff and insensible. These symptoms are succeeded by heat, swelling, and more or less pain; the skin assumes a livid hue, and suppuration soon takes place between the sound Frost-Bite. 51 and injured parts. If the surgeon be called in time, which is seldom the case, the warmth of the part, by proper treatment, may perhaps be restored, and mortification prevented. When the cold is long continued, and so intense as to affect the internal organs, the symptoms are drowsiness, shivering, ri- gidity of the limbs, diminution of the circulation, and finally profound sleep, which often terminates in death. Treatment of Frost-Bite. Premature exposure of frost-bitten parts to heat, has frequently been attended with the worst conse- quences. Instead, therefore, of laying a patient in a warm room or before a fire, cold applications, such as snow, or ice water, should first be employed, taking care that very little force be exerted upon the frozen part, lest it be broken or otherwise injured by the friction. After the natural temperature has been restored, stimulating embrocations will per- haps be found useful. But sometimes the inflam- mation is so active as to require cold solutions of Vol. I. H 58 Frost-Bite. the acetate of lead, and other similar applications. In most instances, however, there is a strong ten- dency to gangrene, and the most powerful stimu- lants will of course be required to arrest its pro- gress. When mortification has once taken place, the remedies adapted to that particular state must instantly be employed. When the system is affected by cold to such an extent as to render the patient insensible, various means may be used to produce reaction. The chief indications are to excite the muscles of respiration, and to restore the circulation. The former may often be accomplished by sternutatories and volatiles, and the latter by frictions with flannels, covered with stimulating materials, and applied to the whole sur- face, particularly to the epigastric region. This treatment should be continued, unremittingly, for a considerable time; for instances have occurred of recoveries, after the lapse of several days, and un- der the most unfavourable circumstances. Some writers recommend the immersion of the whole body in ice water; but the practice cannot prove other- wise than injurious, and should never be pursued. After the patient has been somewhat revived, bv Frost-Bite. 59 the means pointed out, it will be proper to admi- nister stimulants internally, such as brandy and water or a little warm wine. See /{'elite's Case of Torpor from Cold, in Edinburgh Me- dical and Surgical Journal, vol. 1. p. 302—TJwmson on In- flammation, p. 613—Larrey's Memoirs, by Hall, vol. 2. p 156. 60 Burns. Section VI Burns. Burns are very common accidents, and produce. not unfrequently, immense injury, and even death. From the time of Hildanus to the present day, they have, commonly, been divided into three species. The particular arrangement of Pearson—the super- ficial, ulcerated and carbuncuhus burn—appears to me the most satisfactory. In the first, the cuticle is injured, but does not separate from the cutis, until a new one is nearly formed. The pain and swelling are inconsiderable, and there is no vesication. In the second, the cutis is extensively injured, a serous effusion takes place, the cuticle separates and leaves behind a painful and suppurating sore. Constitu- tional symptoms, such as rigors, a quick small pulse, followed by a hot skin, furred tongue, and difficult respiration, are likewise common attendants. The third species, or the carbunculous or sloughin* burn, is that in which the cutis and adjoining parts Burns. 61 are disorganized, and converted into a hard es- char. The local and constitutional symptoms are ex- tremely severe, and the shiverings, for several hours after the accident, almost incessant. The pulse is very feeble and quick, and the asthmatic symptoms are so urgent that the patient can scarcely breathe. If he recover from the shock communicated to the system, the slough separates in a few days and leaves a very painful ulcer, which is soon cover- ed with fungous granulations, and will always be found very difficult to heal. The symptoms, how- ever, in all the three species of burns must necessa- rily vary very much, according to the degree of heat applied, the extent of the surface injured, the pecu- liar constitution of the patient, and a variety of other circumstances. Treatment of Burns. Two very opposite modes of treating burns have been in use from time immemorial—by refrigerants and calefacients; and it is not easy to determine which are the most beneficial. There can be little 62 Burns. doubt, however, of the utility of both, provided they are judiciously employed. In superficial burns, rags dipped in cold water. and constantly applied to the part, afford great re- lief. Still better effects result from pounded ice, mixed with hog's lard, or inclosed in bladders. Cold scraped potatoes or turnips are very commonly ap- plied to a burnt part, and are found very soothing and agreeable. But the best application I have ever tried is raw cotton, thinly spread out or carded, and laid directly over the burn. The value of this remedy was ascertained, accidentally, a few years ago, by a lady living in Harford county, Maryland, whose child was scalded by boiling water, nearly over its whole body. The mother was carding cot- ton in an adjoining room at the time of the accident. and having no medical assistance within reach, un- dressed the child as quickly as possible, and covered the whole burnt surface with masses of the cotton. The effect was wonderful; for the child soon became perfectly quiet, fell asleep, and upon removing the cotton, a few hours afterwards, no inflammation whatever could be perceived. Dr. Dallam,^ to See Dallam, on the Use of Cotton in Burns, in Potter >< Medical Lyceum, p. 22. Burns. 63 whom we are indebted for an account of this case, has furnished others of a similar character, in which the cotton proved equally efficacious; and my own experience enables me to confirm his statement of its usefulness. It is only, however, in the super- ficial burn that this remedy can be relied on.—Vine- gar has been highly extolled, of late years, as an ap- plication for burns, by Mr. Cleghorn, a celebrated brewer at Edinburgh, whose workmen often suffered severely from such accidents. I have tried it in many cases of burns, but have never known it of service except in the first species. If used during the vesicated or ulcerated stage, the pain is in- tolerable. The ulcerated burn requires a treatment very dif- ferent from that of the superficial burn. Openings should first be made with a needle through the cuticle, to discharge the serum collected beneath; taking care, at the same time, not to tear the cuti- cle, or expose the raw surface of the cutis to the air, which always has the effect of creating considerable irritation. When ulceration takes place, the patient generally suffers severe pain, and emollient poultices will then be found to afford more relief than any 64 Burns. other applications. These should be continued, so long as they seem to agree with the sore. Powdered chalk, or lapis calaminaris, sprinkled over the whole surface of the burn, and occasionally renewed, are productive of the best effects. The linamentum ex aqua calcis, spread upon fine old linen, and kept constantly in contact with the ulcerated surface, I have often employed with great advantage. The calefacient, or stimulating plan of treatment; is chiefly adapted to the carbunculous or sloughing species of burn. Remedies of this class are not only applied to the injured surface, but are often administered internally, on account of the shiverings, weak pulse, and other symptoms denoting severe constitutional derangement. Great care should be taken, however, lest such medicines be continued too long, or given in too great quantities; for it often happens, after the first effects of the burn subside, that violent reaction takes place, and can only be subdued by rigid attention to the antiphlogistic sys- tem. But in almost every stage of a burn, where the constitutional disturbance and pain are consider- able, opium may be freely and beneficially resorted to. The stimulating articles, usually employed ex- Burns. 65 ternahy, are spirits of wine, or spirits of turpentine, either alone or mixed with oils or ointments, and ap- plied to the injured parts by a feather, brush, or by linen rags. In some cases they excite violent pain, especially when laid on the sound skin.—Baron Lar- rey has condemned all the common modes of treat- ing burns, and depends, chiefly, upon dressings com- posed of saffron ointment, spread on old linen, from which he states that he has derived the most salu- tary effects. From carelessness on the part of the surgeon, it often happens, that fingers, toes and other parts grow together, and produce unnatural contractions or ex- tensions. Such accidents may always be prevented, by interposing lint, or plasters, between the burnt parts, and by using splints and bandages. The mode of relieving these deformities is to cut across the adhesions at particular spots, and restore the parts to their former position; taking care to prevent reunion during the progress of the cure. The operation does not always succeed; although it has answered the purpose in all the cases in which I have tried it. On account of its occasional failure. Vol. I. I 66 Burns. Mr. Henry Earle has lately proposed to remove the cicatrices altogether, and bring the edges of the sound skin towards each other, in a transverse direc- tion, and there retain them by adhesive strips. See Thomson on Inflammation, p. 585—Pearson's Princi- ples of Surgery, p. 171—Earle on the Means of lessening the Effects of Fire on the Human Body—Kentish on Burns—Lar- rey's Memoirs, vol. 1. p. 43—H. Earle, in Medico-Chirurgical Transactions, vol. 5. p. 96—Dickenson on Burns and Scalds. Wounds. 67 CHAPTER III. WOUNDS. Wounds may be divided into incised, punctured, penetrating, contused, lacerated, poisoned and gun- shot. These admit of subdivision—as wounds of the head, face, neck, chest, belly and extremities. All such injuries will prove more or less dangerous, according to their extent, the manner in which they are inflicted, the age and constitution of the pa- tient, the situation and texture of the wounded part, the treatment that may be adopted, and a variety of other circumstances to be considered hereafter. In general it may be stated, that wounds involving large blood-vessels, nerves and joints, are more hazardous than others—that a very trivial wound in a bad con- stitution will sometimes give rise to most violent symptoms, and even death; and that, on the other hand, very extensive wounds often terminate in the most favourable manner. 68 Incised Wounds. Section I. Incised Wounds. Incised wounds are the most simple, and, inde- pendently of hemorrhage, the least dangerous of all. Profuse bleeding, however, is very apt to take place, even from vessels of moderate size,—provided the cutting instrument is exceedingly sharp. A wound produced by a dull instrument, on the contrary, sel- dom pours out much blood. As soon as any part is divided, there is a recession of its edges,—owing either to the size of the instrument by which it is produced, or to the elasticity and contractility inhe- rently possessed by most living textures. Treatment of Incised Wounds. The chief indications, in the treatment of an in- cised wound, are to suppress the bleeding, and af- terwards to retain the edges in contact, by such Incised Wounds. 69 means as are best calculated to favour their reunion. The removal of foreign bodies is also, in many in- stances, an object of considerable importance. Hemorrhage may be stopped either by liga- ture or by compression. The first is always the most effectual, and should be resorted to whenever the situation of the wound will admit of it. The tenaculum, needle, and forceps, are the instruments commonly employed for casting a ligature around the divided vessel. When the wound is open, not very deep, and the vessels large, the tenaculum will be found the most convenient. The point of the te- naculum should be moderately curved, and not very sharp, otherwise the surgeon will find it difficult to catch the mouth of the artery, and when caught the instrument is liable to cut itself out. After the bleed- ing vessel is drawn out, it may be tied by an assist- ant, or if no one be at hand, the surgeon will often succeed by holding the handle of the tenaculum be- tween his teeth, and using his own hands for draw- ing the ligature. Upon such occasions, a tena- culum with a leaden handle, sufficiently heavy to drag out the vessel when suspended from it, will prove very useful. The artery forceps, which should 70 Incised Wounds. always be serrated at the extremities and have a moveable slide to close the blades, will answer near- ly the same purpose as a tenaculum. The needle is now seldom used for securing bleeding vessels, because it is necessary to include with it more or less of the surrounding soft parts, and in so doing important nerves may be tied, or vessels of considerable size opened, from both of which much mischief will result. For taking up deep-seated ar- teries, beyond the reach of a tenaculum or common needle, Dr. Physick has employed, ever since the year 1800, a forceps, so constructed as to hold in its extremities a needle armed with a ligature. The handles of the forceps are fastened together, tempo- rarily, by a string or catch, and when the needle is fairly deposited beneath the vessel, it is disengaged from the forceps and drawn out, leaving the liga- ture behind, which can be tied without difficulty.* —For a view of these different instruments, see Plate I. * Dr. Physick's forceps is a modification of the Acutena- culum or Port-Aguille, an instrument used by the older sur- geons for sewing wounds. Richerand recommends a needle mounted upon a handle for taking up deep-seated arteries. See Nosographie Chirurgicale, torn. iv. p. 37. edit. 4th. Incised Wounds. 71 Ligatures are commonly made of thread, silk, or leather. All may occasionally be used with advan- tage, provided they are of a proper shape and size. Round ligatures are superior to the flat or irregularly twisted, inasmuch as they divide the internal and middle coats of the vessel with uniformity. The use of the leather or animal ligature was first suggested by Dr. Physick,* in the year 1806; but no account of it was published until 1816. The best material for the animal ligature is French kid leather, cut into strips from a quarter to half an inch in breadth, (the grain or polished sur- face being previously peeled off,) well soaked in water and then stretched and rounded. Buck skin or parchment, treated in the same manner, make very good ligatures. Catgut, although recommended by some surgeons for the same purpose, I have never found suitable. The advantage possessed by the animal, over ordinary ligatures, is its speedy decom- position and separation from the artery, whereby the patient is saved much unnecessary irritation and pain. For several years past I have practised the f See Eclectic Repertory, vol. vi. p. 389. 72 Incised Wounds. plan first recommended by Veitch—of cutting oft* one end of every ligature and leaving the other hanging from the wound, in order to diminish irri- tation, and have had every reason to be pleased with the result. I have also tried, upon several occa- sions the method (mentioned it is said as early as the year 1786 by Mr. Haire* of England), of cutting off both ends of the ligature close to the knot, and then healing the wound over them—but generally without any manifest advantage. The fact that a ligature divides the internal and middle coats of an artery, leaving the external coat entire, was first pointed out by Dessault. Compression may be accomplished either by the tourniquet, or by rollers and pledgets. The tourni- quet (see Plate I.) is chiefly adapted to wounds of the extremities. When the regular instrument is not at hand, a very convenient one may instantly be made, by tying together the ends of a common hand- kerchief, throwing the circle around a limb, and twisting with a stick until the necessary degree of pressure is effected. The roller and compress may * See Hennen's Principles of Military Surgery, p. 181. 2d edition. Incised Wounds. 73 often be used with advantage, when the bleeding vessel is superficial and supported by a bone, as in the wrist and temple. Agaiic and sponge, for- merly much used for arresting hemorrhage, are now seldom employed. Under particular circumstances, however, the sponge will prove very serviceable, especially in hemorrhage from deep cavities. Styp- tics, of which the older surgeons were very fond, are scarcely ever thought of, and the actual cautery, an- ciently resorted to upon the most trivial occasions, is nearly banished from practice. Pieces of glass, and other foreign bodies, are oc- casionally lodged in incised wounds. They should always be carefully picked away; for if left behind, great irritation will be excited. Sometimes bits of glass are working out for months or years after the wound has healed, and frequently are never found. The wound should always be kept open, and co- vered with an emollient poultice, when there is rea- son to suspect the lodgment of such articles. Blood, interposed between the edges of an incised wound, may act as an extraneous substance, and on this ac- count ought to be removed before they are brought together. Vol. I. K 74 Incised Wounds. Adhesive plasters are preferable to all other means for retaining in contact the lips of a wound. The parts to which they are applied, should be perfectly free from moisture, and closely shaved if covered by hair. It is difficult, in many instances, to obtain plaster sufficiently adhesive to prevent the edges of the wound from gaping. The material chiefly re- sorted to at present, is a mixture of lead plaster and resin, in the proportion of a pound of the for- mer to two ounces of the latter. This composition should be melted and thinly spread on new linen, which must then be cut into strips of length and breadth adapted to the extent and situation of the wound. Spaces should be left between the differ- ent strips, for the escape of matter; otherwise ab- scesses are liable to form. Adhesive straps may be assisted very much in some cases by bandages, par- ticularly by the uniting bandage, which is merely a double-headed roller, with a slit in its centre, suffi- ciently large to admit one head of the roller to pass through, so as to form a loop well calculated to grasp a limb and afford great support. Previously to the application of plasters and bandages, it is of great consequence to place the wounded part in a propei position. Incised Wounds. 75 Sutures are, at the present day, only used when the wound is so extensive, or so situated, as not to admit of the application of adhesive straps. There are only two sutures in common use—the twisted and interrupted. The twisted is made by passing a silver pin about two inches long armed with a move- able steel point, or a common sewing needle fixed in a temporary handle, through both edges of the wound, and then casting a ligature obliquely from one end of the pin or needle to the other in the form of the figure 8. This suture is well adapted to wounds of the face, lips, &c. To make the interrupted su- ture, two crooked needles, one at each end of a liga- ture, are necessary. The needles are entered on the inner sides of the wound and brought outwards, carrying with them the ligature, which is tied di- rectly across the wound. In extensive wounds, a number of these stitches will be required, and should be placed at moderate distances from each other. Neither the interrupted nor twisted suture should ever be made in an inflamed part, if possible to avoid it. The object of adhesive straps, bandages and su- tures is to procure adhesion, or union by the first in- 76 Incised Wounds. tention, as it has been denominated. This very im- portant process was well understood by some of the older surgeons, particularly by Taliacotius of Bo- logne, who succeeded, by means of it, in restoring mutilated parts, and to a surprising extent. Mr. Hunter restricted the term union by the first inten- tion, to that state in which the divided parts are held together, temporarily, by the interposition of blood. By most surgeons, no distinction is drawn between it and the adhesive inflammation. The French sur- geons are, for the most part, extremely averse to the practice of closing wounds, after injuries or opera- tions, for the purpose of procuring a speedy adhe- sion. They believe that secondary hemorrhage and abscesses not unfrequently result, and give rise to very troublesome consequences. Such apprehen- sions, however, are extremely unfounded in the ge- nerality of cases, although it is certain that much mischief has occasionally arisen, especially after am- putation, owing to the edges of the wound having completely healed, while the deeper parts suppu- rated. On this account, Dr. Physick has for many years been in the habit, in all amputations, of placing a bit of lint between the divided skin, to prevent im- mediate reunion. Besides these instances, cases Incised Wounds. 77 undoubtedly occur in which it would be improper always to bring about direct adhesion—as in certain morbid or cancerous parts. On the other hand, by pursuing an opposite practice and procuring a speedy reunion, immense advantages are gained in the greater number of cases. Not only indeed has the adhesive process been applied to the restoration of parts partially separated, but several very success- ful attempts have been made to restore fingers, toes, and other portions of the body, that have been en- tirely severed. These attempts have been founded upon the well known experiments of Duhamel, Hun- ter and others, of transplanting teeth and of fixing the spur of a cock into the comb of another, so as to establish between them a complete inosculation and identity. An account of some very interesting cases of fingers restored, after being lopped off and remaining separated for some time, will be found in the tenth volume of the Edinburgh Medical and Sur- gical Journal. These cases are drawn up by Mr. Balfour, a respectable surgeon, and are well attested by other practitioners. The result should, at any rate, have the effect of inducing surgeons always to attempt reunion under similar circumstances, whe- ther the process succeed or not, instead of cutting 78 Incised Wounds. away, as too frequently happens, parts which are hanging by a small portion, under the impression thaf restoration would be impossible. See Hunter on Inflammation, article Union by the first Inten- tion, p. 189—J. Bell's Discourses on the Nature and Cure of Wounds; also Principles of Surgery—Thomson on Inflamma- tion, article Adhesion, p. 206— Carpue's Account of two suc- cessful Operations, for restoring a lost Nose, from the Integu- ments of the Forehead—Balfour's Observations on Adhesion, <§"c.—Jones on Hemorrhage, article Ligature, p. 125 and 166 —Lawrence on a New Method of tying Arteries, &c, in Me- dico-Chirurgical Transactions, vol. 6. p. 156—Veitch's Obser- vations on Secondary Hemorrhage, and on the Ligature of Ar- teries after Amputation and other Operations, in the Edinburgh Medical and Surgical Journal, vol. 2. p. 176. Punctured Wounds. 79 Section II. Punctured Wounds. Punctured wounds are created by sharp and narrow instruments—such as needles, pins, thorns, splinters of wood, nails, &c. When slight, they are seldom attended with inconvenience or danger. Much, however, will depend upon the situation of the part wounded, and the constitution of the pa- tient. An apparent trifling puncture among ten- dons, nerves and fasciae, has sometimes caused te- tanus. Again,—large collections of matter have formed under the fasciae, producing great distress, and finally permanent contraction or extension of the limbs, by uniting the muscles or their connecting cellular membrane together. Many years ago I at- tended a young gentleman from the Eastern shore of Maryland, whose forearm was covered with si- nuses, from which matter could be pressed in every direction. The fingers were crooked and useless. The disease arose from a very trivial wound made bv a needle fixed in the end of an arrow. 80 Punctured Wounds. The lymphatics often swell from punctured wounds. A wound of the foot will frequently cause a swelling of the groin, in every respect resembling the venereal bubo. Punctures of the fingers also, accidents very common in the dissecting room, give rise to similar swellings of the armpit. Several Ana- tomists and students have from this cause lost their lives. A red line may, generally, be traced over the tract of the lymphatic, from the wound to the en- larged glands. Needles are sometimes buried under the integu- ments, or deep in the substance of the muscles. They are seldom productive of ill consequences, and in the course of time work out by approaching the surface. I once attended, however, an old gentle- man, who died from a needle, which penetrated the great toe immediately under the nail. A case is re- lated by Mr. Carmichael, in which amputation near the shoulder joint was necessary, in consequence of several needles being imbedded in the pronator quadratus muscle, in the periosteum of the radius and ulna and between these bones.* * Dublin Medical Transactions, vol. ii. p. 377. Punctured Wounds. 81 Treatment of Punctured Wounds. In a common punctured wound it is seldom ne- cessary to do more than apply a soft poultice to the part for a few days, when the wound will heal with- out difficulty. But when the part swells, and evi- dent indications of the formation of matter exist, an incision should be made to prevent its extension, and the orifice kept open by a tent or bougie. If nervous symptoms arise, denoting the approach of tetanus, the wound should be freely dilated, and sti- mulating substances immediately introduced. Opium also must be exhibited in large and repeated doses. Hemorrhage is seldom the consequence of a punc- tured wound, even if a large artery be pricked—the opening being too small for any quantity of blood to flow. When needles, or similar substances are bu- ried under the integuments, it is almost impossible to find them. But they should be searched for, im- mediately after they are introduced, and before they change their position. In some cases they may be readily drawn out by a forceps, and in others may rbe forced through the skin, by folding up the inte- VOL. I. I' 82 Punctured Wounds. guments or muscles around, and making pressure opposite each extremity of the needle. See Wardrop's Case of Nervous Symptoms from a Punc- tured Wound, in vol. 7, of Medico-Chirurgical Transactions. p. 246; also a similar case, in vol. 4, by Dr. Denmark. Penetrating Wounds. 83 Section III. Penetrating Wounds. These wounds are more extensive than punc- tures, and are generally produced by the small sword, bayonet, or dirk. They may prove danger- ous, by entering large cavities, and injuring impor- tant blood-vessels, nerves, or viscera; or they may give rise to extensive collections of matter, among the cellular membrane and muscles or under aponeu- rotic expansions. All penetrating wounds partake more or less of the nature of contused and lacerated wounds—the parts through which they pass being forcibly rent asunder, instead of being separated by a sharp-edged instrument. To this circumstance Richerand attributes the nervous agitation and other ill effects which occasionally result from such wounds. • 84 Penetrating Wounds. Treatment of Penetrating Wounds. The first object, in the treatment of penetrating wounds, is to suppress hemorrhage. This will often be found very difficult, owing to the depth of the wounded vessel, and the narrowness of the passage leading to it. Sometimes, also, the source from which the blood flows cannot be ascertained. Again, —the vessel may be situated between bones, under fasciae, or among tendons, and cannot be reached without an extensive and painful dissection. Under such circumstances, we should cut down upon the main artery of a limb, or upon the chief vessel in the neighbourhood of the wound, from which the bleeding derives its source, and secure it by ligature. In some situations pressure may be found very ser- viceable—as upon the radial artery, in case of wound of the palmar arch, or upon the tibial arteries in wounds of the foot. The plan recommended by Dr. Dorsey should be preferred to any other.* When the wounded vessels are so deeply seated, as in the chest or abdomen, that^they cannot be reached, our Elements of Surgery, vol. i. p. 57. Penetrating Wounds. 85 only resource is to diminish the activity of the cir- culation by general blood-letting, thereby diverting the stream of blood from the wounded part, and pre- venting its further effusion. After inflammation has taken place, severe consti- tutional and local symptoms may arise. These are owing, not to the partial division of nerves and ten- dons, as the older surgeons supposed, but to the in- flamed muscle being confined by a strong and dense fascia, or to inflammation of the fascia itself. These effects are most common after penetrating wounds of the thigh, hip, leg, forearm, bend of the arm, fingers, temple and head, where the fasciae are numerous, firm and unyielding. The true practice, in all such cases, is to dilate the wound, expose the fascia, di- vide it freely in a transverse direction; and the ur- gent symptoms will cease almost immediately. The wound may then be covered with a warm poultice, and in a few hours the thin ichorous discharge which is usually poured out while the nervous symp- toms last, will be converted into a thick, yellow, healthy pus. In simple penetrating wounds, unac- companied by profuse hemorrhage, high inflam- mation, or constitutional disturbance, there can be 86 Penetrating Wounds. no necessity for dilatation. The antiphlogistic re- gimen, and mild superficial dressings, will answer every purpose. Indeed, in many instances, such wounds heal by the first intention. See Charles Bell's Operative Surgery, founded on the Basis of Anatomy, vol. 1. p. 7. Contused Wounds. «7 Section IV. Contused Wounds. In every contusion, more or less injury is sus- tained by the deeper seated parts, even although the skin remain entire. In general the smaller vessels are ruptured, and blood is poured into the cellular texture or among the muscles, producing an ecchy- mosis and discolouration. If considerable vessels be torn, a large circumscribed tumour may form, or else the surrounding parts may be extensively in- jected with blood, giving rise to gangrene from pressure, or to suppuration from irritation. The nerves, also, in contused wounds suffer materially from concussion—the effect being similar to that, although in a less degree, which takes place in in- juries of the head. Hence such wounds are at first attended with little pain, but their sensibility after- wards increases in proportion to the extent of the inflammation. A blunt instrument will operate, ac- cording to the velocity with which it is parried, or to 88 Contused Wounds. the resistance afforded by the texture upon which it is applied. For a blow to produce its full effect, the action and reaction should be equal. Where the parts yield, the shock is diminished and the injury is less considerable. Oftentimes it happens that a limb is crushed by machinery, the bones are mashed into small pieces, the joints destroyed, and the ves- sels bruised or torn, and yet the skin, from its yield- ing nature, is not divided. An injury of this de- scription is dangerous in the extreme, and gangrene the almost certain consequence. When the skin is cut along with the internal parts, it is generally owing to the surface of the contusing weapon being not very broad. Treatment of Contused Wounds. A simple bruise or contusion should be treated upon common antiphlogistic principles. Leeclies applied to the part will be found extremely service- able in subduing the swelling and pain. Cloths dip- ped in a cold solution of the acetate of lead, and con- stantly applied, will also prove very useful. Perfect rest and relaxation of the muscles are essential. Contused Wounds. 89 After the inflammation has subsided, repeated fric- tion with stimulating embrocations, such as the soap and volatile liniments, by promoting the absorption of the effused coagulated blood, will soon effect a cure. When the extravasation of blood has been too considerable to be taken up by the absorbents, an opening should be made in order to evacuate it. In slight cases, however, such an operation should always be avoided. A roller applied with moderate firmness will often assist materially in dissipating the swelling, and in preventing oedema, which is al- ways apt to ensue. Although there is seldom much prospect of uniting a contused wound by the first intention, it should al- ways be attempted, inasmuch as even partial agglu- tination will serve to keep the edges together, and prevent deformity and other ill consequences. But great care must be taken not to approximate the sides of the wound too closely, by rollers, adhesive straps or sutures, lest so much pressure and irrita- tion be produced as to bring on gangrene. Stitches indeed should, in most contused wounds, be pro- hibited. When along with the contusion there has been loss of substance, and the edges of the wound Vol. I. M 90 Contused Wounds. cannot be brought together, a poultice moderately warm, and occasionally repeated for a few days, will keep the part easy and promote granulation. After- wards simple dressings may be employed. As there is always more or less concussion in every extensive contused wound, blood-letting and other general de- pleting remedies should be avoided until reaction is completely established. Should symptomatic fever follow, with high local inflammation, the patient must be bled freely, take purgatives, and be kept on a low diet. Lacerated Wounds. s»i Section V. Lacerated Wounds. Any obtuse or irregular body, driven with force, may produce a lacerated wound. Machinery in full motion, a cannon ball, splinters of wood, are apt to create very extensive and ragged lacerations. Some- times a patient falls from a height, and lights amidst sharp and disjointed stones, by which the soft parts are torn and shockingly mangled, and dirt kneaded into them in such a way as to render it almost im- possible to wash them clean. In other instances, the scalp is suddenly whirled off by the wheel of a cart or carriage passing over the head. Again— whole limbs are torn from the body by being en- tangled in machinery. Many such cases are re- corded by different surgical writers, especially by Chesselden, Carmichael, La Motte and Morand. Lately an interesting case has been detailed by Dr. Kennedy of India, where a dreadful lacerated wound took place from the bite of a shark. The abdominal 92 Lacerated Wounds. muscles were cut asunder and turned back, so as to expose the colon and several convolutions of small intestines; three of the lowest ribs were laid bare, the gluteal muscles torn up, the tendons about the trochanter divided, and the vastus externus and rec- tus muscles completely separated. A more exten- sive and shocking wound could hardly be produced, and yet the patient in a few weeks recovered per- fectly. Every lacerated wound is peculiar in this—it bleeds sparingly. However large or numerous the vessels torn—however extensive or complicated the injury, it will be found universally that the he- morrhage is comparatively inconsiderable. Some years ago I was called to visit a patient at Dorsey's iron works in Maryland, whose right arm above the elbow had been torn off in a mill. Seven or eisht hours elapsed before I reached him, and although the arm had been dreadfully mutilated, the muscles torn to tatters, and the brachial artery was gaping with open mouth on the surface of the stump, yet not more than a few spoonsful of blood was lost. So extensive indeed had been the shock, and so far did its influence extend, that, in amputating the arm Lacerated Wounds. 93 several inches above the torn extremity, hardly any blood was poured out, even when the main artery was cut through in a part apparently sound, and which afterwards healed with great facility. In another instance, a boy in falling from the top of a tree had the brachial artery, at the bend of the arm, torn completely across by a projecting branch. Scarcely a drop of blood was lost, and in searching for the vessel, some hours after, it could hardly be made to bleed, although repeatedly cut with a view of ascertaining the extent of the injury. The indisposition manifested by a lacerated part to bleed, is owing to the injury sustained by the nerves, not only in the immediate vicinity of the wound, but to a greater extent around than the eye can discover. Hence the arteries are paralyzed and do not contract to propel the blood, which coagu- lates in their cavities or among the torn muscu- lar fibres. Hence, also, all lacerated wounds are at- tended with little pain, are liable to gangrene and to secondary hemorrhage, which is then more dan- gerous than bleeding produced by sharp cutting in- struments. 94 Lacerated Wounds. Treatment of Lacerated Wounds. In every lacerated wound the attention of the surgeon should be first directed towards the removal of extraneous bodies, and the suppression of hemorr- hage if any exist. The edges of the wound are next loosely drawn together, and retained by adhe- sive straps. Although we can scarcely calculate upon adhesion to any extent, after such injuries, yet great benefit results from keeping the parts as nearly as possible in their natural situation, inasmuch as fewer granulations will afterwards be required to supply any loss of substance, than if the parts were permitted to recede from each other. Adhesion. however, does in some cases take place to a much greater extent than we could imagine possible, and that too after very severe and extensive lacerations. We should make it a rule, therefore, never to re- move any loose hanging portion, under the idea that it must necessarily slough or separate, since this can only be determined by the event of the case. At any rate, no harm will result from permitting the wounded parts to remain, even if they be in a gan- grenous state, as they must soon separate sponta- Lacerated Wounds. 95 neously. If much swelling and pain arise after the lips of the wound are approximated, the straps should be removed and the whole surface of the wound co- vered with a warm poultice, which should be re- peated frequently and continued until suppuration is fully established, when the edges may again be drawn together, and generally with decided benefit. After the sloughs have separated and the surface of the wound becomes clean and granulating, simple dressings may be employed. Very severe constitutional symptoms—as fever, restlessness and delirium, sometimes follow lace- rated wounds. These must be subdued by blood- letting, saline purgatives and low diet. But care should be taken not to carry depletion too far or to detract suddenly a large portion of blood, otherwise gangrene, to which at any rate there is generally a predisposition, may be hurried on. Tetanus, more- over, which is very apt to ensue from lacerated wounds, will more readily be induced, if the system has been much prostrated by evacuants. When there is no prospect of healing a lacerated wound, but on the contrary when gangrene is inevitable, then amputation, if the part admit of it, must be re- 96 Lacerated Wounds. sorted to. The surgeon should possess, however, much judgment, to enable him to determine the pre- cise period when the operation should be performed. In particular, he should carefully avoid amputation, so long as the extremities are cold, the pulse weak and fluttering, the wound dry, and the powers of life nearly exhausted. From inattention to these cir- cumstances, I have known four patients lose their lives, who under judicious treatment, might proba- bly have been saved. But there is another extreme into which the sur- geon may fall, if not strictly on his guard—the re- moval of the limb after the circulation has been re- stored, after fever has commenced and the wound become painful and began to discharge a bloody se- rum. A medium, then, should be chosen, and the moment selected for operation when the powers of life have returned, when the lips have regained their colour, the features their natural appearance, and the extremities a proper warmth. When patients die from a premature operation, it is owing to the shock communicated to the nervous system, before the vital energy has rallied sufficiently Lacerated Wounds. 97 to encounter so severe a stimulus. When they die, after the full restoration of the circulating system and the establishment of febrile action, then life is assaulted through the medium of inflammation and high action, and the operation is almost sure to be followed by gangrene. Each state then, it will be seen, is precarious, and it is only by observing a happy medium that we can expect to succeed. Te- tanus in some instances follows very speedily a la- cerated wound. In hopes of arresting its progress, some surgeons have advised immediate amputation. I have known the remedy tried in one instance only, but the patient died before the operation was com- pleted. Immense doses of opium I believe to be the only alternative under such circumstances. See in Pott's Works, vol. l.p.9. a note by Sir James Earle —Chesselden's Anatomy, case of James Wood—Carmichael, in Medical Commentaries, vol. 5—Morand, in Academie de Chi- rurgie, torn. 4. p. 141—La Motte, Traite des Accouchemens— Kennedy, in Medico-Chirurgical Transactions, vol. 9. p. 240. Vol. I. \ 98 Poisoned Wounds. Section VI. Poisoned Wounds. Poisoned wounds occur frequently, and are dan- gerous or otherwise, according to their extent, and the character of the agent by which they are pro- duced. Whether these agents be derived from the animal, vegetable, or mineral kingdoms, they are in many instances equally deleterious. In this coun- try such injuries generally arise from insects; ser- pents, rabid animals, or from the introduction of morbific matter into the system. Among the insect class, wounds from the com- mon bee, humble-bee, wasp,* hornet, yellow-jacket, are very frequent, and sometimes productive of high inflammation and pain. Instances indeed are re- corded of death, both in human subjects and inferior * Mrs. f»iy, aged 69, wife of Colonel Day, of Deerfield, Portage county, died in September last in fifteen minutes after receiving the sting of a yellow wasp whilst engaged in drying apples. Poisoned Wounds. 99 animals, from the attacks of swarms of these animals. Occasionally death has followed from swallowing a wasp or bee, in consequence of the gullet being wounded by the sting of the animal while passing to the stomach. In this way a young woman in Jersey lately lost her life^-a bee having been enclosed in a piece of honey-comb which she swallowed. The mischief resulting from the stings of bees, wasps, &c. does not proceed from the mechanical injury, but from the acrid liquor infused into the wound by these animals; each of which has a subtle poison contained in a receptacle, situated within the abdomen among the air-vessels, and is furnished with muscles and other apparatus for injecting the wound made by the barbed dart or sting. In the hornet and yellow-jacket this liquor is highly acrimonious, and quickly excites very violent inflammation. Besides insects of the bee kind, there are several others which occasionally inflict severe and danger- ous wounds—the common mosquito, some varieties of fly, certain spiders, the scorpion,- &c. In peculiar constitutions the mosquito bite will degenerate into a very troublesome sore, and death has even fol- 100 Poisoned Wounds. lowed. Dr. Dorsey* states, that he once knew gan- grene and death to take place from the bite of this insect, in the case of a lady who previously enjoyed very good health. I am informed by a distinguished naturalist of this city, that numerous instances have occurred at Egg Harbour and other similar situa- tions, of cattle being destroyed by the wounds re- ceived from these animals. The bite of the green- headed fly, common about Cape May and other parts of the Atlantic coast, is extremely severe; but I have never heard of serious injury from it. The spider has long been considered a venomous reptile. There is reason to believe, however, that most of the species are harmless, whilst it is certain that in a few instances very severe symptoms and even death have followed from the bites of particu- lar animals of the class. Dr. Measef mentions an instance of a person who lost his life, from an appa- rently insignificant wound of one of these insects. The bite of the tarantula, a species of spider com- mon about Naples and many other parts of Eu- rope, was formerly supposed to be extremely ve- * Elements of Surgery, vol. i. p. 68. t Domestic Encyclopedia. Poisoned Wounds. 101 nomous and often fatal. Modern observations, how- ever, prove that few ill consequences result from wounds inflicted by these animals. It is very sur- prising that such men as Geoffroy,* Baglivi,f and Mead,J should not only give credit to the fanciful and ridiculous reports of the supposed operation of the poison of the tarantula, but should even endea- vour to account for its specific mode of action and for the imaginary effects of music in promoting its cure.—During the expedition up the Missouri un- der the command of Major Long, Mr. Say and the other naturalists often met with a spider of mon- strous size and very hideous appearance; but no op- portunities were offered of ascertaining whether it was venomous. M. Morau de Ionnes has furnished a memoir on an enormous spider common at Mar- tinique and its vicinity, which attacks small birds and reptiles, and infuses into the wounds made by its strong jaws a subtle poison which quickly proves fatal.§ *■ Royal Academy of Sciences, 1702. t Baglivi Opera. J Mead on Poisons. § For an account of the medical properties and bite of the spider, see Lister, De Araneis Tractatus; also Berner, De Aranete punctura et ejus medela. 102 Poisoned Wounds. The scorpion is a very venomous insect, and often in warm climates inflicts a fatal wound. The largest of the species (scorpio afer) inhabits India, Persia and Africa, and is much dreaded on account of the activity of its poison, which is contained'in a reser- voir situated near the tail of the animal, and ejected from two small holes on each side of the tip of the sting. The American scorpion is not so large as some other species, but is capable of producing by its sting most violent inflammation and sometimes death. From a number of experiments performed on dogs and other animals by Maupertius,* it ap- peared that the sting of the scorpion caused the whole body of the wounded animal to swell, and was productive of violent retching convulsions and death. In other instances no inconvenience what- ever followed from the stings of these insects. " I have frequently seen," says Mr. Allan, " the sting of the scorpion followed by violent inflammation and swelling, similar to those of bees and wasps, only in a more aggravated degree. In the years 1803 and 1804,1 had many opportunities of witnessing wounds inflicted by the sting of the scorpion on board of La Mem. de l'Academie des Sciences, 1731. Poisoned Wounds. 103 Dianne frigate. She was one of those French ships which escaped from the battle of the Nile, but was afterwards captured by the British when coming out of Toulon. In August, 1803, she was commissioned at Plymouth, and taken into the service of the Bri- tish navy. Having been long in the Mediterranean while in the French service, the scorpion had got on board. From the coldness of our climate the in- sect had lost its vigour, and lay concealed behind the lining, in the seams, betwixt the timbers, and in other parts of the ship; but no sooner had the ship gone to sea, and proceeded to the southward, than it was found that she was literally swarming; the heat renewed their activity, they crawled forth from their lurking holes and stung many of the men. The wound was always followed by violent and extensive inflammation, considerable swelling, and great pain: but I never observed any violent constitutional symp- toms succeed to the local."* Of the numerous American serpents two species only are known to be venomous—the raUlesnake and copper-head. Eight species of the former have * Allan's System of Pathological and Operative Surgery, vol. i. p. 370. 104 Poisoned Wounds. long been familiar to naturalists, and two others have been discovered lately by Humboldt* and Bonpland. All are poisonous, but in particular the crotalus du- rissus, horridus, and miliarius. The copper-head, (boa crotaloides,) sometimes called the bastard rat- tlesnake, is also exceedingly malignant. All these reptiles are furnished with long teeth, or poisonous fangs, the roots of which are surrounded by a bag or reservoir containing an active and virulent poison. This poison is discharged into the wound through a small fissure of the tooth situated near its extremity, and in many instances very quickly proves fatal both to man and to the inferior animals. As regards the effects of the poison, much will depend upon the size of the animal bitten—death being produced more readily in the smaller than in the larger ani- mals. According to the experiments of Vosmaer, sparrows, finches and other small birds died in about four minutes, while a mouse died in a minute and a half. The deleterious operation of the poison will also depend materially upon its quantity, and upon the season of the year at which the wound is in- * These are the Crotalus Cumanensis and the Crotalus Lceflingii. See Recueil d"Observations de Zoologie et Ana- tomie Comparee, 4to. Poisoned Wounds. 105 llicted. To ascertain the effect of the bite of the rattlesnake, several experiments were made by Cap- tain Hall of Carolina, upon dogs, cats, chickens and frogs. Three dogs were bitten in succession by a snake four feet long. The first died in less than a quarter of a minute, the second in two hours, and the third in three hours. Four days after, two other dogs were bitten; one of which died in half a mi- nute, the other in four minutes. Several experi- ments nearly similar, were made by the late Profes- sor Barton on chickens. Of three chickens bitten, on three days successively, one died in a few hours, another lived much longer, and the third recovered after having been exceedingly swelled. On the fourth day, several other chickens were bitten, but recovered without a bad symptom. The rattlesnake is more lively, and its venom more active, during very warm weather than at any other period: upon the approach of the cold season, it becomes languid, and then strikes re- luctantly, and frequently without any ill conse- quence. The effects produced by the poison either on the human body or on the lower animals, vary according to the parts wounded, the depth to V«L. i. o 106 Poisoned Wounds. which the fang penetrates, and the quantity and strength of the venom in the reservoir. In many in- stances death follows in a few seconds or minutes* and in others not until many days or weeks. The interesting case detailed by Mr. Home, which I wit- nessed whilst a student in London, furnishes striking proof of the speedy operation of the poison of- the rattlesnake, and at the same time affords incontesta- ble evidence that it may remain a long time in the system before death is produced. The patient was teasing a large rattlesnake with the end of a foot rule, but could not induce the animal to strike; the rule accidentally dropping from his hand, he opened the door of the cage to take it out; the snake im- mediately darted at the hand, and inflicted four wounds—two on the back part of the first phalanx of the thumb, and two on the side of the second joint of the forefinger. The hand soon after began to swell, and in the course of ten or eleven hours the whole arm, axilla and shoulder were very much tu- mefied and cold. There was an unusual coldness also throughout the skin of the whole body. At this period the mind of the patient was perfectly col- lected; but immediately after the accident he talked incoherently, owing probably to strong drink, which Poisoned Wounds. 107 it was ascertained he had taken before he was bit- ten. From the axilla the swelling extended down the side, and blood was extravasated under the skin as far as the loins, giving the back a mottled appear- ance. The skin over the whole body became warm, faintings occurred repeatedly, vesications appeared in different parts of the body, a large abscess formed on the outside of the elbow and discharged half a pint of reddish matter; mortification took place in the axilla, in the forefinger and some other parts2 and finally destroyed the patient, after he had la- boured for eighteen days under the most distressing symptoms. Upon dissection the body presented a natural appearance (with the exception of the arm that had been bitten), and the wounds made by the fangs of the reptile had healed. Instances have occured, both among the Indians and among the white people, who inhabit the moun- tainous and thinly settled parts of our country, of almost instantaneous death from the bite of the rat- tlesnake. On the other hand, it is very certain that many persons wounded by this animal have sus- tained very trivial if any injury. In such cases, it is probable that the teeth enter obliquely and do not 108 Poisoned Wounds. penetrate the true skin, or that the reservoirs at the roots of the fangs have been empty, or the virus it- self, owing to particular circumstances, so modified or changed in its properties or in such small quan- tity as not to produce fatal effects. Again,—where death has followed almost immediately or shortly after the wound, the poisonous fangs have probably penetrated directly a considerable artery or vein, and conveyed the noxious matter at once into the circu- lation. According to Catesby, the Indians very soon ascertain when this has happened, and apply no re- medy under an impression that the wound is neces- sarily fatal. Upon these principles it will be easy to account for the supposed good effects of the nu- merous and diversified remedies, at different times proposed for the cure of the bite of the rattlesnake; inasmuch as there is reason to believe that nature, unassisted, is often sufficient to accomplish a cure, or that a sufficient quantity of virus has not been inserted to produce death. The poison of the rattlesnake is of a yellow co- lour tinged with green: during extreme heat, and particularly in the procreating season, it becomes of a much darker hue. The copper-head is equally Poisoned Wounds. 109 poisonous with the rattlesnake, but few experi- ments have been made to ascertain its peculiar cha- racters. In Europe the viper is more dreaded than any other poisonous reptile: it would appear, however, to be less deadly than the rattlesnake, and according to Fontana (who.has studied its history more than any other naturalist, and who has instituted a great number of experiments in order to become acquaint- ed with the operation of its virus) produces injury or death in proportion to the size of the animal bitten and to the depth of the wound—small animals dying almost immediately, and wounds penetrating beyond the skin being equally fatal. The natives of India often suffer from the bites of the numerous species of Coluber, particularly from the cobra de capello (Coluber naja), which is ex- tremely venomous. In many parts of the Eastern continent, the three Arabias and Africa, the cerastes or horned viper is extremely numerous, and often by its bite proves fatal. According to Bruce, how- ever, the black people in the kingdom of Sennaar are perfectly armed against its bite. " The Arabs," 110 Poisoned Wounds. says he, "have this secret naturally, but from their birth they acquire an exemption from the mortal consequences attending the bite of these animals, by chewing a certain root and washing themselves with an infusion of certain plants in water. One day when I was sitting with the brother of Shekh Ade- lan, prime minister of Sennaar, a slave of his brought in a cerastes, which he had just taken out of a hole and was using with every sort of familiarity; I told him my suspicion that the teeth had been drawn, but he assured me they were not, as did his master Kitton, who took it from him, wound it round his arm, and at my desire ordered the servant to carry it home with me. I took a chicken by the neck and made it flutter before him; his seeming indifference left him, and he bit with signs of anger; the chicken died almost immediately;—I say indifference, for I constantly observed that however lively the viper was before, yet upon being seized by any of these barbarians, he seemed as if taken with sickness and feebleness, frequently shut his eyes and never turned his mouth towards the arm of the person who held him. I will not hesitate to aver that I have seen at Cairo (and this may be seen daily without trouble or expense,) a man who came from above the Cate- Poisoned Wounds. Ill combs, where the pits of the mummy birds are kept, who has taken a cerastes with his naked hand from a number of others lying at the bottom of the tub, has put it upon his bare head, covered it with the common red cap he wears, then taken it out, put it in his breast, and tied it about his neck like a neck- lace: after which it has been applied to a hen and bit it, which has died in a few minutes; and to com- plete the experiment, the man has taken it by the neck, and beginning at the tail, has ate it as one would do a carrot or stock of celery, without any seeming repugnance."* Wounds from the bites of rabid animals are not always followed by rabies canina or hydrophobia; indeed it has been well ascertained, that out of nu- merous persons bitten by dogs undoubtedly mad, very few have sustained material injury. This is owing, probably, to the human system being less susceptible of impression from the virus than that of the lower animals, and to the circumstance of the greater part of the body being covered by clothes, by which the infectious matter is wiped from the ' Bruce's Travels, octavo edition, vol. vii. p. 302. 112 Poisoned Wounds. teeth, and thereby prevented from entering the wound in sufficient quantity to produce its full ef- fects—to the teeth of the rabid animal not pene- trating deep, or not striking a vascular part—to the saliva or venom being in smaller quantity in the ani- mal's mouth at one time than another—and to an erythismus in the lymphatics of the wounded part sufficient to prevent the absorbent action. Dr. Hun- ter relates an instance of twenty persons bitten by the same mad dog, and out of that number only one took the disease. According to an estimate made by Dr. Hamilton, founded upon numerous facts, about one in every sixteen of the human species bitten by mad dogs, take the infection and suffer from the consequent disease. Great doubts still exist respecting the peculiar na- ture or mode of action of the virus, giving rise to rabies canina. Mr. Cline instituted a number of experiments to ascertain whether the saliva of a hy- drophobic man, in the last stage of the disease, could, by inoculation or other means, infect the in- ferior animals, so as to propagate the complaint; but none of the animals into whom fresh saliva was in- serted were in the slightest degree affected, even at Poisoned Wounds. 113 the end of three months. It would appear also, from some experiments by Mr. Astley Cooper, that the saliva of a mad dog, inserted by a lancet in the in- side of the thigh of a dog, a pig, a rabbit and fowl, produced no deleterious effect whatever; notwith- standing some of the animals were kept from nine weeks to twelve months. Between the infection and the appearance of the constitutional disease, the interval is often very va- rious and uncertain. In general, the attack does not commence until after the lapse of thirty or forty days; in some instances no signs of the disease have appeared for twelve or eighteen months, and in one case recorded by Dr. Bardsley, the patient remained perfectly well for twelve years and then died from the disease. These facts would seem to prove that the system is affected through the medium of ab- sorption, and not from any influence exerted by the virus upon the extremities of the nerves of the part. —an opinion formerly entertained. The wound made by the teeth of a rabid animal heals with as much facility as any other wound, and often is en- tirely obliterated, long before the constitutional symptoms have appeared. It has been observed, Vol. I. P 114 Poisoned Wounds. however, that when any constitutional disturbance takes place, before the closure of the wound, then instead of continuing to granulate and discharge a healthy pus, the sore puts on a sloughy character and the matter becomes thin and ill conditioned. The symptoms of rabies canina vary very much according to the constitution of the patient: in ge- neral, some uneasiness, soreness or itching is first felt at the wounded part; the spirits of the patient are depressed, and he oftentimes suffers from inde- scribable anxiety. Occasionally a chill or rigor is the first symptom manifested. At night the patient's sleep is disturbed by frightful dreams and by spas- modic startings; the pulse is quick and fluttering: the appetite fails; but the thirst is increased. At this period it is generally observed, that when the patient attempts to drink he is immediately seized with a sudden and spasmodic catch in the breathing, which is increased upon repetition, and finally is at- tended with indescribable horror and universal agi- tation. The very idea or thought of liquids is after- wards sufficient to excite the same painful and dis- tressing symptoms, and should the patient have reso- lution enough to attempt to swallow, or to struggle Poisoned Wounds. 115 against the spasmodic and agonizing contractions of the muscles of the throat, the whole system becomes so convulsed, that he finds it impossible to accom- plish his purpose. This fear of water, or hydropho- bia, is not, however, an universal concomitant of the disease; in many instances it is altogether absent; it is, moreover, an attendant upon other diseases, not in the slightest degree allied to canine madness. But in the worst forms of the complaint it is for the most part present, and of all the individual symptoms by far the most horrible and appalling. A symptom, less constant than those mentioned, but sometimes very distressing, is a collection of thick, viscid, ropy phlegm, which adheres to the fauces and throat so closely, that the patient finds it extremely difficult and often impossible to throw it out; although the most vehement efforts are em- ployed for the purpose. In a patient attended by Dr. Marcet,* *the quantity of this tenacious lymph was so considerable, and ejected with such extreme torture, that he exclaimed, " Oh! do something for me; I would suffer myself to be cut to pieces! I can- not raise the phlegm; it sticks to me like birdlime." 1 Medico-Chirurgical Transactions, vol. i. 116 Poisoned Wounds. In the latter stages of hydrophobia the pulse be- comes exceedingly agitated and hurried, and the breathing very quick and laborious; the countenance is expressive of great anxiety and fear, the eyeballs glare and seem ready to start from their sockets, and the muscles of the face and neck are horribly con- torted. Sometimes the patient becomes altogether furious and unmanageable, and attempts to tear and bite himself and every one near him; but in general he is perfectly inoffensive, and answers questions with great precision and in the most rational manner. He seldom lives beyond the fourth or sixth day, and is either carried off suddenly by a violent convulsion, or expires quietly—his bodily vigour being com- pletely exhausted by inordinate exertions and con- tinued suffering. The introduction of morbific matter into the sys- tem is sometimes apparently productive of the worst consequences. Persons much engaged in the dis- section or examination of putrid bodies, or in mace- rating or making preparations, have occasionally suf- fered from wounds of the scalpel or dissecting hook, or from punctures made by spicula of bone, cVc. In such cases violent inflammation has followed, ex- Poisoned Wounds. 117 tending up the arm as high as the axilla or neck, rendering the whole limb exceedingly tense and painful, and finally producing extensive abscesses, sometimes gangrene and sometimes death. Exam- ples of this kind have been recorded by different writers. Mr. Fyfe, the celebrated anatomist at Edinburgh, informed me that he nearly lost the use of one arm for several years, owing to a wound of the finger by a dissecting knife. Dr. Chambon of Paris, in attempting to separate a sphenoid bone, which had long remained in maceration, from the other bones of the head, received so severe a wound in one of the fingers as to keep him on the brink of the grave for upwards of three years* Corvisart,f also, in examining a dead body pricked a finger, in consequence of which the whole arm swelled enor- mously, and was only relieved by very extensive in- cisions performed by Dessault. Percy relates the case of a student who died, in three days, from dis- secting a body which had been kept for several weeks. Mortification took place in the wounded finger, and extended rapidly throughout the arm. Professor Le Clerc is said to have lost his life from * Dictionnaire des Sciences Medicalcs, torn. ix. p. t>49. t Ibid. 118 Poisoned Wounds. touching, with a sore finger, the pulse of a patient in a profuse perspiration, who laboured under a malignant fever. Dr. Rush mentions an instance of a young man who died from a wound he received in skinning an ox. Other cases nearly similar have been recorded. But none of these examples fur- nish direct evidence of the absorption of morbific virus; since many others might be adduced to show that the same symptoms have followed from apparent- ly trifling injuries, and under circumstances where no virus could possibly have been absorbed. Dr. Physick informs me, that he once attended a patient who died from gangrene of the whole arm, simply from a slight scratch of the shell in the act of open- ing an oyster; and I have known a puncture from a needle in one of the fingers produce most violent inflammation and suppuration nearly throughout the arm. In all probability, then, a simple puncture, in certain constitutions, is capable of producing effects which might easily be attributed to the operation of some specific virus. This conclusion is rendered more probable from what we know to happen in te- tanus, which is sometimes produced by the most in- significant scratch, and at other times cannot be ex- cited by the most extensive laceration. Poisoned Wounds. 119 Treatment of Poisoned Wounds. It seldom happens that the stings of bees and wasps are so severe as to require active remedies for their cure. In general local applications afford speedy relief. A solution of common salt, applied to the part, will produce almost instantaneous ease. This remedy was first introduced, it is said, by Dios- corides, and has since been found serviceable even in wounds of the oesophagus. An English gentle- man saved the life of his friend, who had swallowed, unperceived, a wasp in a glass of beer, by causing him to drink plentifully of salt and water* The aqua ammonite, applied to a part stung by bees, I have often known to act like a charm. Cold water, rose water, a solution of the acetate of lead or of opium, constantly applied, will in many instances soon cause the pain and inflammation to subside. Bleed- ing and purging, with strict antiphlogistic regimen, will probably become necessary when the patient has suffered from a swarm of bees. The same re- medies will be found equally useful for the bites of spiders, flies, mosquitoes and other insects. * Dictionnaire des Sciences Medicates, torn. i. p. 40. 120 Poisoned Wounds. In Morocco, where the scorpion is very common, most families keep a bottle of olive oil, in which the bodies of several of these reptiles have been infused, and when bitten apply it to the wound, and with re- puted success. A ligature, moreover, is generally placed above the wounded part, to interrupt the pro- gress of the poison, and the wound is afterwards scarified and cauterized. "In Tunis, when any person is stung by a scorpion," says Mr. Jackson,* " or bit by any other venomous reptile, they imme- diately scarify the part with a knife and rub in olive oil as quick as possible, which arrests the progress of the venom. If oil is not applied in a few minutes death is inevitable, particularly from the sting of a scorpion. Those in the kingdom of Tunis are the most venomous in the world." According to the same author, the coolies or porters, who work in the oil stores, have their bodies constantly saturated with oil, and on this account not only never suffer in the slightest degree from the bites of scorpions and other reptiles which creep over them at night as they sleep on the ground, in great numbers; but there is not a single instance known of one of these * Jackson's Reflections on the Commerce of the Mediter- ranean. London, 1804. Poisoned Wounds. 121 people ever having taken the plague, although the disease frequently rages at Tunis in the most fright- ful manner. The use of olive oil has been highly extolled by many writers as a remedy for the bites of poisonous serpents. Dr. Miller* of South Carolina relates the case of a man who was bitten in the sole of the foot by a very large rattlesnake. Although very little time elapsed before he reached the patient, his head and face were prodigiously swelled, and the latter black. "His tongue was enlarged and out of his mouth; his eyes as if starting from their sockets; his senses gone, and every appearance of immediate suf- focation." Two table spoonsful of olive oil were immediately got down, but with great difficulty. The effect was almost instantaneous; in thirty mi- nutes it operated freely by the mouth and bowels, and in two hours the patient could articulate, and soon after recovered. The quantity of oil taken in- ternally and applied to the wound did not exceed eight spoonsful. In the course of twelve years Dr. Miller has met with several similar cases, in which ! New York Medical Repository, vol. ii. p. 242. Vol. I. Q 122 Poisoned Wounds. the oil has proved equally successful. Mr. Oliver* has detailed a number of experiments in proof of the efficacy of warm oil, when applied to the wound made by the bite of the viper; but Linnseusf found it quite inefficient. The volatile alkali was, for a long time, in very ge- neral use as an antidote against the poison of different serpents; but the experiments of Fontana are cal- culated to show, that so far from being useful, the symptoms produced by the bite of the viper were increased either by the internal exhibition of the me- dicine or by its external application. On the other hand, the late Dr. Ramsay I of South Carolina, one of the most distinguished physicians our country can boast of, has subsequently declared " that the vola- tile alkali, properly administered, will in a short time cure the bite of any snake, or the sting of a spider, or any other venomous insect, is a medical fact as well established as that the Peruvian bark will cure an intermittent fever." Dr. Ramsay's declaration is founded upon the result of several cases, wherein * Philosophical Transactions, vol. xxxix. p. 310. t Amcenitates Academicse, vol. xi. p. 407. t London Medical and Physical Journal, vol. xi. p. 3$z, Poisoned Wounds. 123 patients have suffered from the bites of rattlesnakes, and have been cured, apparently, by the volatile al- kali. We are strongly inclined to the opinion, how- ever, that the injuries received were not, indepen- dently of the action of the remedies employed, suffi- cient to cause the patient's death, or in other words that spontaneous cures, which we know to be very common, took place. The same remarks may per- haps apply to the cases detailed by Dr. Anderson* of Madrass, respecting the cure of the bite of the cobra de capello, and by Dr. Brichellf of Savannah, of the rattlesnake and mochison, by means of alka- lies. In the latter case the patient probably would not have died, as it is well known to naturalists that the mochison is not a venomous serpent. As an internal medicine, arsenic has been lately found more decidedly beneficial than any other. Mr. IrelandJ has recorded five cases, in all of which the most violent symptoms produced by the bite of the coluber carinatus, a poisonous serpent very com- mon at the island of St. Lucia, were speedily arrest- * Medical Repository, vol. ix. p. 109. I Ibid. vol. viii. p. 441. t Medico-Chirurgical Transactions, vol. ii. p. 394. 124 Poisoned Wounds. ed, and cures finally effected, by the use of this me- dicine. The supposed efficacy of the Tanjore pill, a medicine very commonly employed in India against the bites of serpents, the chief ingredient of which is arsenic, first led Mr. Ireland to employ Fowler's mineral solution. He gave it to the extent of two drachms every half hour, and repeated for four hours, with the best effects. Severe vomiting and purging followed the exhibition of the medicine, and the patients were soon after relieved. When a person has been bitten in the extremities by a serpent supposed to be poisonous, a ligature should immediately be thrown around the limb above the wound, and drawn exceedingly tight in order to interrupt the progress of the venom through the ab- sorbents: after this a portion of flesh, for some dis- tance beyond the wound, should be quickly removed by the knife; then the kali purum, the lunar caus- tic, or the actual cautery, must be applied until an eschar is produced. The wound should afterwards be dressed with some simple ointment. With regard to internal medicines no objection can arise to the exhibition of oil, volatile alkali, or Fowler's mineral solution; for, if useless, they cannot at any rate Poisoned Wounds. \25 prove injurious, and upon this principle should be tried. As hydrophobia may still be considered an incu- rable disease, the great object of the surgeon must always be to secure the patient against its attack. Fortunately this can be accomplished, in many in- stances, by removing the bitten portion of flesh as speedily as possible after the accident, and in some cases even after weeks have elapsed and the wound has healed. Whenever, therefore, we are called to a patient, who has been bitten by a dog or any other animal supposed to be mad, such incisions should instantly be made as will include a portion of flesh greater than the depth to which the teeth of the ani- mal have extended. This operation should be per- formed, were it only by way of precaution, or in cases where no absolute certainty has existed of the animal being mad. If the surgeon is timid, and cuts sparingly, there will be much reason to apprehend that the operation will not prove successful. In ge- neral, owing to several teeth penetrating at the same time and at different parts, it v% ill be necessary to remove several distinct portions of flesh. Should the teeth perforate between the bones of the hand 126 Poisoned Wounds. or foot, as often happens, so as to leave insufficient room to remove all the injured soft parts, our only resource will be to amputate without delay. By way of security, after the incisions have been prac- tised and the bleeding suppressed, it will be advisa- ble to apply to the wounds the lunar caustic, the kali purum, or what is still better, equal parts of white arsenic and sulphur, a remedy introduced by Mr. Cline, and extolled by Sir Everard Home as extremely valuable in cancer, and which experience has proved to be the most powerful caustic employ- ed in surgery. By adopting these measures, we shall often have the satisfaction to find the fears of our patient allayed, or the disease consequent to the bite of rabid animals entirely prevented. The same operations should be resorted to, after months have elapsed without any thing having been done for the patient, provided the cicatrix becomes sore or pain- ful and indicates the approach of the disease. When any doubt exists of the animal being mad, instead of having it killed as soon as possible, as is generally done, it should be confined until the symptoms be- come so clear as to remove or confirm all suspicion on the subject. Poisoned Wounds. 121 When our operations fail and rabies canina is es- tablished, then various remedies may be tried. Of these opium, mercury, cantharides, volatile alkali, belladonna, musk, arsenic, camphor, lunar caustic, the cold bath and blood-letting, have been considered the most powerful. Blood-letting, carried ad deli- quum animi, has lately been extolled in the highest terms by Mr. Schoolbred of Calcutta, and some facts have been adduced by Mr. Tymon, assistant surgeon of the 22d English light dragoons, which go to prove that taking away, at once, an immense quantity of blood, so that scarcely a pulsation can be felt in either arm, has been attended with the most favour- able result.* According to Professor Brugnatelli,f several cases of hydrophobia have been lately cured in the hospitals of Lombardy, by the external and internal use of hydrochloric acid. Dr. Physick,! some years ago, proposed, uncjer the idea that many- patients labouring under hydrophobia, died from suf- focation cause^by spasm of the muscles of the glot- tis, to open the trachea in order to sustain the breathing, until the effects of different remedies * See Cooper's Surgical Dictionary, edit. 4th, p. 611. t Eclectic Repertory, vol. viii. p. 256. | Medical Repository, vol. v. p. 1, 12S Poisoned Wounds. could be fully tried. I do not know of any instance in which the experiment has actually been perform- ed; but am strongly inclined to believe, from the termination of numerous interesting cases, recorded by different writers, in which the chief symptom was a difficulty of breathing and swallowing, to such a degree as apparently to destroy the patient, that de- cided benefit would result from the practice. Un- der this impression, should a case present, I would perform the operation of tracheotomy, or else intro- duce a gum elastic catheter into the glottis and tra- chea. It is well known that such an instrument may be carried into the larynx, and there suffered to remain for any length of time, without exciting any unpleasant symptom, except a violent and con- vulsive cough at the moment of its passage through the glottis. % An inflammation extending up the arm or leg, in consequence of a punctured wound, *r from the ab- sorption of morbific matter, must be treated upon common principles—such as have already been de- tailed. Should extensive abscesses form in the in- terstices of the muscles, or about the armpit, as fre- quently happens, they should be opened and fistula Gun-shot Wounds. 129 and sinuses prevented by bandaging, &c. The treat- ment of constitutional symptoms, if any exist, must be regulated by their peculiar character. On wounds from Insects, consult Dictionnaire des Sciences Medicates, torn. 1. p. 40. article Abeille; also torn. 25. p. 315— Richerand's Nosographie Chirurgicale, torn. I. p. 104. On the bites of Serpents, Fontana on Poisons—Barton on the Rattlesnake, in American Philosophical Transactions, vol. 3— Home, in Philosophical Transactions, part \st. 1810. On Hydrophobia, see Hunter, in Transactions of a Societij for the Improvement of Medical and Chirurgical Knowledge, vol. I—Hamilton on Hydrophobia, vol. 1—Cline, in Medical Records and Researches—Bardsley, in Memoirs of the Lite- rary and Philosophical Society of Manchester, vol. 4—Rush's Inquiries—Ferriar's Medical Histories and Reflexions—Fo- thergill, in Medical Observations and Inquiries, vol. 5— Vaughan's Cases and Observations on Hydrophobia—Latta's System of Surgery, vol. 3—Mease on the Bite of a Mad Dog —Physick, in New York MedicaJtRepository, vol. 5. Vol. I. R 130 Gun-shot Wounds. Section VII. Gun-shot Wounds. Under the head of gun-shot wounds are compre- hended all injuries from fire arms, from explosion of shells, rockets, &c. Wounds of this description are oftentimes extremely formidable—destroying the patient immediately or remotely, producing exten- sive mutilation, or giving rise to abscesses, sinuses and diseased bones, which last for months or years, or perhaps during the patient's life. The kind and extent of injury must depend, however, upon the form and size of the instrument inflicting the wound, upon the velocity witjfchich it is carried, and a va- riety of other circumstances. A ball moving with great rapidity and striking the body, enters readily and pursues its course generally in a straight line, either passing through the part or lodging at a greater or less depth. On the contrary, a ball which moves slowly enters with difficulty, and, instead of following a direct line, is diverted by the slightest Gun-shot Wounds. 131 obstacle—always taking an angular course. Owing to this circumstance, it often happens, that a bullet strikes some part of the body, and passes through, apparently; but upon examination it will be found, that it has taken a circuitous route—having followed the course of a rib, or traversed the head between the bone and scalp, or passed entirely around the abdomen or neck. In other instances the ball strikes an extremity, runs beneath the skin, or among the muscles, and is lodged many inches, or even two or three feet beyond the point at which it entered. The opening, made by a ball where it passes out, is always larger and more ragged than that by which it entered—because it passes from the body, which is a dense medium, into the air, which is a rare one. On the other hand, the contusion is greater at the place the ball enters, than j^t that from which it emerges—owing to the verity of the ball being more considerable when it first strikes, than it is af- terwards; hence the first opening is small, round, comparatively insensible and discoloured, not unfre- quently casts off a slough, and seldom heals except through the medium of granulation; whilst the last, approaching to the nature of an incised wound, is 132 Gun-shot Wounds. inflamed and painful, and often heals by the first intention. Two openings, however, are not inva- riably found, for in many instances the ball does not pass through, but lodges in the substance of a mus- cle, or in a bone, or immediately under the skin. In other instances it carries before it the clothing, which, according to its texture, is either torn or re- mains entire. In the latter case, upon withdrawing the cloth, the ball is generally discharged with it. Other extraneous matters besides cloth, may be car- ried before a bullet, and deeply lodged—such as splinters of wood, buttons, pieces of coin, keys, &c. These always excite more or less irritation. The bullet itself will create as little injury as any other foreign body, provided it remain smooth and round; but if it is flattened or angular, or incrusted with spicula of bone, or in any other manner rendered rough or pointed, gr^t pain and profuse suppura- tion will generally fohw. Balls are frequently buried and never found. Sometimes they remain stationary, being either en- closed in a cyst or surrounded by a bone, and the patient feels no inconvenience from them. At other times they change their position, and travel to a con- Gun-shot Wounds. 133 siderable distance, exciting, during their passage, pain and suppuration, and occasionally violent spasms. Not unfrequently they approach the skin and are discharged spontaneously. Balls are some- times divided by striking the edge of a sharp bone, in which case each portion usually makes a passage for itself. I have met with several examples of the kind. The veteran M'Culloch, who signalized him- self at the battle of North Point, had his thigh broken by a bullet, which was divided by the bone as com- pletely as if effected by a knife or chisel. A ball moving with great velocity and encounter- ing a bone, passes through it in an instant, making a round and comparatively smooth opening. If the ball move slowly, however, or be nearly spent, it will be apt to produce extensive fracture or fissure. In some cases of this kind the cylindrical bones have been splintered more than two-thirds of their length. Gun-shot wounds, like all other contused wounds, seldom bleed profusely—the vessels, being torn with violence, retract and bury themselves among the cel- lular membrane Even very large arteries may be torn across, without shedding more than a few drops 134 Gun-shot Wounds. of blood;* but a vessel partially torn will throw out more blood than one which has been completely se- parated. Although the vessels bleed sparingly when first wounded, in a few days secondary hemorrhage is very apt to ensue, from the detachment of the slough with which almost every tract made by a ball is lined; and from this cause many patients have sud- denly lost their lives. A regular slough or dead tube completely formed, is not so invariable a conse- quence as many surgeons imagine. I have met with several cases where no vestige whatever could be discovered of a slough from the commencement to the termination of a wound. When a slough does form, it is liable to be detached at some period be- tween the fifth and twelfth day, and during this pe- riod the patient should be closely watched. It hap- pens frequently that an artery is merely brushed by a ball, and yet its coats are so much injured that in a few days an eschar separates from it, and gives rise to profuse hemorrhage. In other cases large ar- teries are pushed entirely to one side by the passage of balls, without sustaining the slightest injury. This * It must be understood, however, that when arteries of the largest class, such as the carotid or femoral, are cut by a bul- let, the patient dies almost instantly. Gun-shot Wounds. 135 happened, there is reason to believe, to Captain Worth,* a gallant young officer, at the battle of Bridgewater, who received a shocking wound in the thigh by a grape shot, several ounces in weight, which penetrated a little below the groin over the course of the femoral artery, and tore up the mus- cles in a frightful manner, without injuring the vessel. The nerves suffer immensely in some gun-shot wounds, especially those of the extremities* Even after the wound has healed, painful and very dis- tressing sensations are often felt, particularly during an easterly wind, and when the atmosphere is charged with electricity. Many surgeons believe that very serious accidents and even death may result from the wind of a ball; but there is no foundation for such an opinion. The truth is, that a musket and even a cannon ball will now and then strike a part so obliquely, as not to enter or produce the slightest external wound, and yet the bones are crushed and the muscles dreadfully bruised. Now Major Worth, a distinguished officer at West Point. 136 Gun-shot Wounds. If it were possible for the wind of a ball to produce the mischief attributed to it, this ought always to fol- low whenever the ball passes veiy near the body. So far from this being the case, numerous examples are afforded of portions of clothes, hats, &c. being shot away, without the person wearing them sus- taining any injury. There is, however, a real and oftentimes very serious injury, which some have supposed imaginary, resulting from a gun-shot wound, —a perturbation and extraordinary constitutional agitation, which the bravest men cannot resist. This is not an invariable symptom; for some patients are desperately wounded and do not exhibit any alarm whatever; while others are immediately seized with trembling, vomiting, and indescribable anxiety, even from the slightest scratch. Where such constitu- tional disorder, however, continues any length of time, it is to be considered generally very fair evi- dence of the severity and danger of the wound. Treatment of Gun-sliot Wounds. It is very important, in all gun-shot wounds to suppress hemorrhage and extract the foreign body Gun-shot Wounds. 137 as soon as possible. If an artery be torn across, and continues to pour out blood copiously, we shall have good reason to conclude that its size is considerable (for the smaller vessels seldom shed more than a few drops), and the sooner we attempt to secure it the better. In many instances the part must be laid open freely, until we reach the mouth of the vessel, and secure it by ligature. Frequently, however, the vessel, from its depth or situation, cannot be tied; in such a case, a compress thrust to the bottom of the wound and supported by a roller, may perhaps succeed. But the surgeon must not, in every case, think of dilatation, even although the hemorrhage be profuse; otherwise he will incur great risk of wound- ing important organs, or of opening arteries larger than those divided by the ball. As soon as the flow of blood has diminished or ceased, the wound should be carefully examined, either by the finger or by some other instrument. If the finger be too large, or not sufficiently long to reach the bottom of the wound, recourse must be had to the long gun-shot probe, or to a wax bougie, or flexible gum catheter, or to the urethra sound of Bell; all of which are very superior to the small Vol. I. ^ 138 Gun-shot Wounds. probe contained in the common pocket case. Pre- vious to the introduction of an instrument, the wounded part should be placed, as nearly as possi- ble, in the situation it was in at the time the wound was received. Without this precaution, the surgeon will often experience great difficulty in reaching the spot where the foreign body is lodged, and will give the patient unnecessary pain, There are very few cases in which an examination cannot be made im- mediately after the receipt of the wound; for if the patient be overcome by the shock or nervous agita- tion, which is so commonly felt, this may speedily be removed in most instances by a little wine or spirits, or by a glass of cool water. Severe pain should never be an obstacle to examination, which should always be conducted with gentleness and care. If the wound be not examined immediately after its receipt, the lips soon close, and the whole tract becomes so much swelled and so painful, that it is almost impossible afterwards to ascertain the course the ball has taken, or the spot at which it is lodged. On the contrary, when the probe is car- ried along the passage recently made, it glides with facility, and at the bottom frequently encounters the ball or some other foreign matter, which must either Gun-shot Wounds. 139 be drawn out immediately by the forceps, or through a counter opening made directly over it. Provided the exact position of the ball be accurately marked at the time of examination, there will be no neces- sity, in all cases, for removing it at once; it may be left, sometimes, until the wound is healed. Mr. Hunter disapproves of making a counter opening at all, except the skin covering the ball should be dead- ened by the contusion and likely to slough. The experience of modern surgeons, however, proves that a counter opening may, generally, be resorted to with safety and advantage, unless the ball should lodge more than one or two inches from the surface. Forceps of various shapes have been contrived for the removal of balls. In general, they are too clum- sy, and so large as to fill up nearly the whole pas- sage—leaving very little room for the expansion of the blades. The forceps of Chevalier and those of Percy have this fault, in common with the rest, but are superior to any of the regular instruments of the kind. A very narrow forceps, longer and more slen- der than those contained in the common pocket case, with small and very sharp teeth, I have used for several years past, and found them very supe- 140 Gun-shot Wounds. rior to any others I have tried, particularly in those cases where the ball has not been lodged beyond three or four inches in depth; and where it has been deeper seated, advantage has seldom been gain- ed from attempts to remove it by other means. A ball may sometimes be extracted very readily by the scoop, or by a single blade of Percy's forceps. The scoop of Thomassin* is said to be the best instru- ment of the kind ever invented. It has been proposed, for the removal of a bullet lodged in a bone to employ the trephine, or else an instrument formed at its end like a gimlet. The former can seldom be necessary, and the latter could not be used in most cases without giving the patient great pain. For a view of the different instruments spoken of, see Plates II. and III. After the ball has been extract^ or searched for in vain, our attention must be turned to the dressings best adapted to the wound. Some sur- ^ geons, particularly Kern, Assalini, Percy and Guth- rie, extol highly the use of cold water, or even * For a full description of this instrument and its mode of application, see Boyer's Surgery, vol. i. p. 187. PI.?. B,tls <„,„ 9/1 ,-t J'H'bf. 0 I'hsi-tilier's J^crr.-, Zcmcf Iriui -tihft Ptobr Gun -shut forceps Percy's bullet Fojreps. Pi. J. ffl.id^s stpartil'h- .it t/i* Jputt. l\\ 12 frwJiss /onq uyeri. 5 hydrargyri nitrati, corrosive sublimate, camphor, &c. Dr. Underwood extols highly the black basilicon, and represents it as infinitely more efficacious in all cases than the yellow. With some ulcers, however, milder applications answer a better purpose,—such as rhubarb in powder, either alone or combined with crude opium, tincture of myrrh, &c. But as a ge- neral rule in the treatment of all ulcers, the surgeon must not neglect to clmnge his dressings repeatedly; for it has been ascertained beyond all doubt, that sores flag, and are put back for weeks, by the im- proper continuance of a medicine which at first, and for a short time, produced excellent effects. Constitutional remedies often exert great influence over indolent ulcers. In the wards of the Philadel- phia Aims-House I have succeeded, in numerous instances, by the exhibition of the blue pill and other preparations of mercury, after most other medicines had been for months ineffectually tried. Where sinuses exist, well directed pressure by bandages will do a great deal; when these fail, the tract must be laid open by the knife. Fungous granulations are easily repressed by red precipitate. 246 Indolent Ulcer. blue vitriol, or adhesive straps. So long as any por- tion of carious bone remains, the ulcer will keep open in spite of every dressing; in these cases, the gastric juice, nitrous, and other acids, often prove serviceable, by acting upon and removing the earthy parts of the bone. The surgeon should not be too officious in cutting away bones apparently carious, otherwise he will soon find all the symptoms aggra- vated, and the bone in a little time rendered really carious. Nature is generally more efficient in such cases than art. The ulcer accompanied by varicose veins, will generally heal under adhesive straps, the roller, or laced stocking; but in many instances, these veins become so large as to require an operation, with- out which every effort on the part of the surgeon to close the sore will prove fruitless. This opera- tion will be described at a future period under the head of Diseases of the Veins. See Underwood's Surgical Tracts, containing a Treatise upon Ulcers of the Leg, edit. 3d. 1799—Whately's Practical Observations on the Cure of Wounds and Ulcers on the Legs, without Rest, 1799—Home's Practical Observations on the Indolent Ulcer. 247 Treatment of Ulcers on the Legs, considered as a branch of .Military Surgery, tifc. edit. 2d. 1801—B. Bell on the Theory and Treatment of Ulcers, in vol. 2d. of System of Surgery, edit. 7. p. 214—Thomson on Inflammation, p. 423—Roux's Narrative of a Journey to London iw 1814; or, a Parallel of the English and French Surgery, edit. 2d. 1816, p. 127. 248 Specific Diseases. CHAPTER VI. SPECIFIC DISEASES. Under this head I propose to arrange certain diseases which it appears to me cannot be treated of with propriety in any other place, inasmuch as they are closely connected with inflammation and its ter- minations, and with other subjects discussed in the foregoing pages. Some of these diseases may ap- pear perhaps to belong to the practice of medicine. In a limited point of view this is really true; but it is equally obvious, that a* large share of their pa- thology and treatment must come within the sur- gical department. Besides scrofula, cancer, fun- gus nematodes and syphilis, there are specific affec- tions not so obtrusive to the senses, but sometimes equally formidable and not less difficult to cure. Scrofula. 249 Section I. Scrofula. Without attempting to explain or reconcile in this place the discordant, multifarious, and too often wild and hypothetical views regarding the nature of scrofula, it mayjbe sufficient to state that we know very little of its origin, of the circumstances respec- tively calculated to modify the forms and variations under which it appears in the different textures of the body, or of the method of cure. We are per- fectly familiar, however, with its effects both consti- tutional and local, and with the symptoms by which it is characterized. In most instances, certain premonitory signs no- ticed by all writers, are very perceptible long before the disease itself becomes evident. The complexion is extremely delicate, of a lively red colour mixed with a beautiful white, the red of the lips approaches to a carnation tint, but the lips themselves, the up- per especially, are thick and protuberant. The pu- Voi.. I. 2 I 250 Scrofula. pils of the eyes are dilated, and the conjunctiva re- markably clear and free from vessels. The eyelids droop unnaturally, and give to the countenance a melancholy but interesting expression. The head is large and protuberant at the occiput, the neck short, the lower jaw thick and fleshy, the hair and eyes of a light grey or blue colour, the belly swollen and prominent. These signs, taken collectively, un- doubtedly manifest the scrofulous constitution; but some of them are at least equivocal* such as the co- lour of the eyes and hair, which is, perhaps, as of- ten dark as light, and in some instances extremely black. Children are more subject to scrofula than grown persons, and the disease may show itself at any pe- riod between infancy and puberty. It may appear also in almost any texture of the body, and is cer- tainly not, as some authors have imagined, peculiar to the lymphatic absorbent system. But the lym- phatic glands undoubtedly are more susceptible of the disease than other parts, especially the glands of the neck and mesentery. Next to these the lungs and spongy parts of the bones are most apt to suffer. Scrofula. 251 In whatever situation a scrofulous tumour may be met with, it uniformly exhibits the following appear- ances and symptoms. At first there is simple en- largement without pain or unnatural heat; in a short time, however, the patient complains, if the tumour be pressed upon, and the warmth of the part is sen- sibly augmented by several degrees. In this state, or without any material change, the disease may con- tinue for months or years, and afterwards disappear spontaneously. Commonly it follows a different course—gradually taking on inflammation, and at last terminating in abscess and ulceration. Long be- fore the abscess breaks the skin assumes a dark pur- ple or leaden colour, and retains it in many instances for a considerable time after the sore has cicatrized. The matter discharged from the abscess is thin, gleety, and mixed with flocculi or small portions of a substance resembling cheese. The discharge sometimes continues for many weeks; in other in- stances, the openings from which it is poured out rapidly enlarge, and the whole tumour or its rem- nant is converted into an ulcer peculiar in appear- ance and difficult to cure. When a scrofulous ab- scess follows an enlargement of a lymphatic gland, it might be supposed that the matter was formed 252 Scrofula. within the substance of the gland; this, however, is not invariablv the case—the gland sometimes re- maining entire and the matter having only formed around it. This particular state is ascertained by the probe, by the circumstance of the tumour un- dergoing no diminution, and occasionally by the se- paration and evacuation of the unaltered gland itself. Scrofulous abscesses of large size seldom proceed from a single gland, but from a cluster of glands united by inflammation. When such enlarged masses are seated in the neck, they sometimes by pressure impede respiration and deglutition. The scrofulous ulcer usually puts on the follow- ing appearances. The edges are thin, smooth, ob- tuse, of a pale red or purple hue, and overhang the ulcer, the bottom of which is deep and the granula- tions loose, indistinct, of a faint rose colour and glossy aspect. From the sore is discharged a thin, curdled, colourless, offensive matter. This ulcer is never painful unless inflamed by rude treatment, improper applications, or carious bones; in that case, the whole surface is changed, becomes of a fiery red colour, accompanied by fungous granulations, elevated and Scrofula. 25$ retorted edges, and a profuse discharge of watery matter. Although the nature of scrofula is involved in ureat obscurity, there are certain occasional causes which appear to exert considerable influence in bringing the disease into action. These are parti- cular degrees of cold, especially when conjoined with moisture, irregularities of diet, meagre and unwhole- some provisions, an impure or tainted atmosphere generated in crowded manufactories, hospitals and schools, deficient clothing, external injuries, fevers, mercurial frictions, want of exercise, filth, fatigue, mental anxiety, &c. Of all these causes a cold, damp and variable climate is the most powerful in inducing the disease; and next to this, perhaps, derangement of the digestive organs, from improper and particular modes of living. It is well known that Mr. Aber- nethy, within the last few years, has endeavoured to show by a variety of illustrations, that a great many local diseases derive their origjn from disorder of the digestive functions. The same train of reasoning has been applied by Carmichael and Lloyd to the explanation of scrofula, and, as it appears to me, with very considerable success. With regard to the 254t Scrofula. hereditary, or adventitious, origin of scrofula, much diversity of opinion still prevails: it seems to me, however, that the advocates of each side of the ques- tion have chiefly erred in admitting the influence of one to the entire exclusion of the other. I have no hesitation in stating that I believe in the hereditary transmission of scrofula, and am at the same time fully persuaded that it may take place in a perfectly healthy constitution when exposed to the influence of the different occasional causes above enumerated. Treatment of Scrofula. There can be no stronger proof of the difficulty of curing scrofula, than the circumstance of the im- mense number of articles offered at different periods, as constitutional, specific, and local remedies—such as bark, mercury, antimony, cicuta, hyosciamus, bel- ladonna, opium, dulcamara, aconitum, cold and warm bathing, mineral waters, &c; all of which and many more have been highly extolled by some writers and as pointedly condemned by others. I believe, how- ever, that it is now generally acknowledged that * Scrofula. 255 these means, when they do prove serviceable, only act by invigorating the system or by keeping the stomach and bowels loose and free from acidity. If so, a sufficient hint is furnished the practitioner to select those articles best calculated to produce such effects, without incommoding the patient by imparting too much tone, or prostrating him unnecessarily by profuse evacuations. With this view, small doses of mild purgatives, such as magnesia, rhubarb, sul- phur, castor oil, and the blue pill, should be pre- scribed occasionally. Without a strict regard to diet, however, these purgatives will answer very little purpose. It must not be understood that the patient is to live scantily, and on very meagre nutri- ment; on the contrary, his system should be sup- ported by a light and moderately nourishing diet, consisting chiefly of plain animal food and such other articles as the stomach can easily digest. Con- joiued with this treatment, tonics, particularly bark. used alone or combined with the preparations of iron, a change of climate, or removal from a cold and damp to a dry and warm situation, flannel next to the skin, covering the extremities as well as the body, and other warm clothing, together with mode- 256 Scrofida. rate exercise, will do more for the patient, perhaps, than all the reputed specifics ever imagined. Scrofulous tumours or abscesses are seldom bene- fited by local applications; when very large and in- dolent, blisters, stimulating liniments, frictions and is- sues have been used with advantage. The older sur- geons often extirpated indurated scrofulous glands, and according to their own accounts with success. Such an operation, however, can very rarely if ever prove necessary. For the scrofulous ulcer many different applica- tions have been recommended. The best, I con- ceive, are dry lint, mild ointments, slightly astringent washes and moderate pressure. If the sore should become indolent, the black basilicon, nitrate of sil- ver, and other remedies formerly recommended for the common indolent ulcer, may be required. See White on Struma—Burns' Dissertations on Inflamma- tion, vol. 2. p. 145. edit. 1812—Hamilton's (of Lynn Regis Hospital) Observations on Scrofulous Affections—Russel on Scrofula, 1808—Thomson on Inflammation—Carmichael's Essay on the Nature of Scrofula, with Evidence of its Origin Scrofula. 251 from Disorder of the Digestive Organs, 1810—-Lloyd's Trea- tise on the Nature and Treatment of Scrofula; describing its Connexion with Diseases of the Spine, Joints, Eyes, Glands, Sfc. 1821—Alihert's Nosologic Naturelle, ou les Maladies du Corps ftumain distributes par Families, torn. 1. p. 441—Hen- ning^s Critical Inquiry into the Pathology of Scrofula, 1815— Goodlad's Practical Essay on the Diseases of the Vessels and GImids of the Absorbent System, 1814. Vol. I I K 258 Cancer. Section II Cancer. Notwithstanding the numerous treatises on cancer within the last twenty years, and the great encouragement held out by societies for investigating its nature and treatment, we are now almost as much in the dark concerning the disease, as at any former period. All that can be done under these circum- stances, is to point out in a general way, the symp- toms and appearances which the best writers have agreed to constitute the disease, and to notice such remedies only as are acknowledged to possess some efficacy. By the term schirms which is usually considered the forerunner of cancer, is understood a preternatural density or induration of the soft parts, not easily re- solved and very prone to ulceration. Besides these characters, genuine schirrus is designated by certain external marks, and by a peculiar internal structure. The whole tumour is unequal on the surface, uncom- Cancer. 259 monly heavy, and the skin covering it puckered and of a faint bluish or leaden hue. The pain also is vehement and of a peculiar kind—at first prurient, but afterwards lancinating and compared by many patients to the gnawing of an animal. In a greater or less time, the tumour is apt to form adhesions with the integuments above, and the muscles below. In this condition the disease may remain for months or years without material alteration, but eventually the skin cracks in one or more places, and from the fissures is discharged a thin, acrimonious and fetid matter, which excoriates the adjoining parts, and hurries on the ulcerative and sloughing process. Not unfrequently a large cavity is produced, as it were suddenly, from the whole surface of which there is an immoderate discharge of bloody, ill con- ditioned matter, in smell approaching to ammonia. This cavily is rapidly filled up by a hard, irregular, fungous mass, which protrudes beyond the edges of the sore, and often bleeds profusely of its own ac- cord, or from the slightest irritation. Around the ulcer thus formed, the skin continues of a purple co- lour, and its edges remain extremely hard. The surface of the sore is of a dark red colour, and has a peculiar glossy lustre. The margins are elevated 260 Cancer. and irregularly serrated. Many patients are worn out by irritation and hectic soon after the tumour takes on the ulcerative action, others live for years— the ulcer proving apparently so far beneficial as to arrest temporarily the extension of the disease. When examined by dissection the schirrous tu- mour exhibits the following appearances. In the early stage a small, very compact, and central nu- cleus is found, resembling cartilage in consistence, from which radiated and narrow bands proceed in irregular lines towards the circumference of the tu- mour. These bands are intersected transversely by others of a fainter appearance, and conjointly form a plexus or net-work which encloses a softer and more pulpy substance. As the tumour ad- vances, however, towards ulceration, these varia- tions of structure become less distinct and are finally blended together, or else the pulpy matter is con- verted into a dark fluid of a greenish cast or of a jet black colour, and enclosed in cysts formed of the radiated bands. Sometimes these cysts are fill- ed with a perfectly pellucid fluid, are of different sizes, extremely numerous, and resemble exactly the common hydatid. According to Burns, these Cancer. 261 cavities are never wanting, and are to be considered the most certain evidence of the existence of schir- rus. When the schirrous tumour is recently re- moved from the body, and the transparent cysts open- ed with a needle, the fluid immediately spirts out to a considerable distance, owing apparently to a con- tractile power in the cyst itself. Such effects have been witnessed by different surgeons, and remark- able instances of the kind are recorded by Le Dran, Carmichael and others. It is not yet ascertained in what particular texture of the body cancer originates, or whether it be con- fined indeed to any texture. According to Pearson, the disease seldom if ever commences in an absorb- ent gland. It is still also a disputed point, whether cancer be a local or constitutional disease. There is so much evidence, however, now extant in favour of the former position as to leave very little doubt, it appears to me, on the subject, and indeed to ren- der it very questionable whether cancer ever be- comes, strictly speaking, a constitutional affection. As regards the immediate cause of cancer, innu- merable hypotheses have been framed. That which 262 Cancer. approaches nearest to truth, it seems to me, as- cribes the disease to animalcular origin, or, as con- tended by Adams and Carmichael, to the presence of hydatids—thus giving to cancer an independent vitality. This theory will not appear so absurd as some have imagined, when it is recollected that many cutaneous diseases, especially itch, arise be- yond all doubt from insects which may be distinctly seen by the eye or microscope,—that worms are found in the liver, urinary bladder, arteries, veins, among the humours of the eye, and in many other situations where their presence is little suspected.— The exciting causes of cancer are often sufficiently manifest. In many instances the disease may be traced to a blow or some other external injury, by which the organization is altered and a predisposi- tion given to morbid action, or in other words, such a condition of the part brought about as to afford a nidus particularly suited to the lodgement and growth of independent beings.* Treatment of Cancer. It is now generally acknowledged that internal medicines are incapable of removing cancerous com- * See Carmichael on Cancer, p. 273. Qancer. 263 plaints, however beneficial certain articles may prove in arresting their progress and in relieving pain. The same observation will apply, with few excep- tions, to all local applications. Without recounting, therefore, the numerous specifics proposed at differ- ent periods, it may be observed, that by rigid absti- nence, or a close confinement to a very low vege- table diet, amounting to little more than bread and water, and that in quantity barely sufficient to sus- tain life, schirrous and cancerous tumours have been reduced to so small a compass as scarcely to be per- ceptible; but the moment the patients have relapsed into their former modes of living, all the symptoms have returned, and often in an aggravated form. There are Sew patients, at any rate, courageous enough to encounter such a system, or to sustain it long enough to produce even temporary relief.— With regard to local remedies, experience demon- strates that such only can be relied on as will eradi- cate every particle of the schirrous or cancerous mass, and that the knife or very active caustics are alone sufficient to accomplish this purpose, but often fail from unskilfulness or the advanced stage of the disease. These sentiments, I believe, will accord with'those of the most experienced members of the 264 Cancer4 profession; but it is proper at the same time to state, that within a few years past Mr. Carmichael of Dub- lin, a highly respectable and intelligent surgeon, and one who appears to have enjoyed most ample op- portunities of treating cancerous diseases, variously situated and in different stages, unreservedly de- clares that he has effected complete cures by fen^u- ginous and arsenical preparations. Hitherto this practice has not been pursued to any extent in the United States; but it emanates from authority so deservedly high as to entitle it justly to a full trial. See Pearson's Practical Observations on Cancerous Com- plaints, Svo. 1793—Home's Observations on Cancer, connected with Histories of the Disease, 8vo. 1805—Johnson's Practi- cal Essay on Cancer, being the Substance of Observations to which the annual prize for 1808 was adjudged by the Royal College of Surgeons of London, 8vo. 1811—Carmichael's Essay on the Effects of Carbonate and other Preparations of Iron upon Cancer, with an Inquiry into the Nature of that and other Diseases to which it bears a Relation, Svo. 1809, 2d. edit.—Lambe's Reports on the Effects of a Peculiar Regimen on Schirrous Tumours and Cancerous Ulcers, Svo. 1815— Burns' Dissertations on Inflammation, vol. 2d. p. 177—Adams on Morbid Poisons. Cancer of the Eye. 265 Section III. Cancer of tfie Eye. Trde carcinoma of the eyeball is seldom met with, though a disease bearing considerable resem- blance to it and allied to fungus haematodes is not unfrequent. The former occurs chiefly in old, the latter in young subjects. Formerly the two affec- tions were confounded, and then cancer of the eye was considered almost peculiar to children under twelve years of age. Subsequent observations tend to establish the reverse. Cancer usually commences in the anterior parts of the eye, and speedily destroys vision by involving the cornea, iris, and crystalline lens in one confused mass. The whole globe of the eye is gradually en- larged, and becomes very painful from the distention of its coats and the inflammation which ensues. Soon afterwards the cornea gives way, and a soft, irregular, tuberculated, very vascular fungus sprouts Vol. I. 2 L 266 Cancer of the Eye. forth, and is so luxuriant as to attain in a short time the size of a large egg or apple—projecting beyond the lids and covering a considerable portion of the cheek. The colour of the fungus varies in different cases, according to the state of inflammation—being in some of a bright red or scarlet hue, in others of a chocolate brown or deep purple cast. So very vascular and tender is this morbid growth that the slightest touch is sufficient to induce pro- fuse haemorrhage, and so often does this occur spon- taneously or by ulceration that the patient is soon reduced exceedingly low. According to Scarpa, this soft pulpy fungus becomes hard and warty before it assumes a very malignant character. The same writer expresses his belief that the disease, with the exception of the lachrymal gland, never ori- ginates in any other texture than the conjunctiva. I have met with one instance, however, in which the caruncula lachrymalis was primarily affected and subsequently the globe of the eye—the disease having extended regularly from one to the other. In another case, that of a gentleman of North Carolina who lately came to Philadelphia to consult me on his disease, a tumour formed deep in the inner side Cancer of the Eye. 267 of the left orbit, and after several years growth push- ed the eye forward, and so far beyond its natural limits as to create considerable deformity. A small fluctuating tumour about the size of a marble occu- pied the upper part of the inner canthus of the eye, and the parts all around this seemed of a stony hard- ness. I determined, by way of ascertaining the na- ture of the complaint, to cut through the orbicular muscle and penetrate towards the bottom of the or- bit—taking the soft tumour as my guide. After ac- curate examination, this was found of a deep blue colour, resembling in appearance exactly the com- mon fox grape, and contained a thin fluid like ink, but changeable when exposed to a varied light. This sac and its contents being removed, a solid tumour, which served as the base of the sac, was felt at the bottom of the orbit, surrounding apparently the optic nerve, and was extremely sensible to the touch. It was evident, both to Dr. Physick who assisted in the operation and to myself, that no benefit would result from a further dissection, unless the globe of the eye were also removed. This was not advised, as vision, notwithstanding the protruded state of the eye, was still perfect. The wound was therefore closed and healed by the first intention. The pa- 268 Cancer of the Eye. tient returned home, with a determination to sub- mit at a future period to the removal of the whole contents of the orbit, should the eye be disorga- nized by fungus and other characteristics of cancer. About twelve years ago he fell, whilst walking in a field, upon a sharp pointed tobacco stalk, which entered at the precise spot afterwards occupied by the encysted tumour; and to this circumstance he attributes his disease. Both eyes are seldom affected simultaneously with carcinoma, nor does it often happen that the destruc- tion of one is followed by disease in the other. Upon dissection the cancerous eye commonly ex- hibits the following appearances. All the coats are very much thickened and indurated, and their interstices occupied by a whitish fibrous mass, in- termixed with pulpy matter. The humours are ab- sorbed, or so changed as not to be recognised, and their places filled up by fungus or small cysts con- taining a transparent fluid. Sometimes the whole cavity of the eye is distended by the same substance that is interposed between the coats. The fungus, when examined minutely, appears to be made up of 'V /'/I. Dr/7/rii/h'M A'.i/ii'Y />v 7/.'Oil'son. i:>i,n /7vm .. Vit/rr/ r fiv f'.t 'i'rt/>f/i <• thy,;,,,,-,//,. ('.Tr'sh'trf Cancer of the Lip. 278 found in the form of a chocolate coloured, warty ex- crescence; this never attains a large size, but is con- stantly casting off scabs, the place of which is spee- dily supplied by others. These tumours are all ca- pable of contaminating by extension the adjoining parts of the face and neck, especially the lymphatic glands, and when this occurs there is very little hope of the patient's recovery. In Plate V. there is an excellent representation of cancer of the lip, accompanied by fungus and an enlargement of the lymphatic glands of the left cheek and angle of the jaw. The patient resided in Delaware county in this state, and came to Phi- ladelphia about two years since to obtain relief; the disease however, though not of long standing, was from its advanced state beyond the reach of sur- gery. Contrary to my advice, he placed himself under the care of a quack, who attempted to re- move the different tumours by caustic, which so far from proving beneficial, aggravated all the symp- toms and speedily produced his death. Venereal ulceration of the lip and lupus have been mistaken for cancer, and treated according- v.l. I. 2 M 274 Cancer of the Lip. \y. The surgeon, therefore, should be strictly on his guard, and never without full investigation pro- nounce decisively as to the nature of the complaint, or propose an operation unless well assured of the existence of cancer. Treatment of Cancer of the Lip. Although Stark and Langenbeck have praised highly the use of arsenic in cancerous ulcers of the lip, little dependance can be placed upon it or any other remedy except the knife; and this, too, often fails from want of timely application. When deter- mined upon, the operation may be done in the fol- lowing way. An assistant holds between the lip and gums of the patient a piece of wood, about six inches long, an inch in breadth, and the eighth of an inch in thickness. Upon this the lip is spread out and two incisions made, one on each side of the tu- mour, quite through a sound part of the lip, in shape of the letter V, and the diseased mass removed. If Cancer of the Lip. 215 the tumour has been large and of long standing, con- siderable hemorrhage will follow the operation, and it may be necessary to tie several vessels. Frequently, however, the bleeding is effectually suppressed upon drawing together and placing in exact apposition the divided edges of the lip, and there retaining them by the twisted suture or by adhesive straps. In a few days the pins should be removed, when the wound will be found as firmly united as it commonly is after the operation for hare lip. See C. Bell's Operative Surgery, vol. 2. p. 33.—Diction- naite des Sciences Medicates, torn. 28. p. 74—Alibert's De- scription des Maladies de la Peau, observee a VHospital Saint Louis, fol.—Delpech's Precis Elementaire des Maladies Re- putees Chirurgicales, torn. 3. p. 549. 276 Cancer of the Tongue. Section V. Cancer of the Tongue. Tumours of the tongue, having all the appear- ances of schirrus, frequently arise from disorder of the digestive organs, or from irritation produced by carious and ragged teeth. Sometimes also the whole tongue becomes enormously enlarged, fills up the mouth and hangs below the chin. Many cases of this kind are recorded by writers, and in particu- lar two very remarkable ones by Percy.* The tongue is likewise studded over, in some instances, with small excrescences, having broad tops and nar- row pedicles, resembling a mushroom. At other times deep fissures or irregular cracks occupy the whole surface of the tongue. But these are all dif- ferent from genuine schirrus or cancerous ulceration, known by the hard, rough, broad bottomed, wart- like tumour usually situated about the middle of the * See Dictionnaire des Sciences Medicales,tom.xxvii.p. 246. Cancer of the Tongue. 277 tongue towards the tip, or by the ragged ill condi- tioned sore, covered with fungus and bleeding upon the slightest irritation; both of which are character- ized by deep-seated lancinating pain, extending to the throat and base of the skull, and terminate eventually, if not interrupted in their progress, by- total annihilation of the organ. Children are occa- sionally subject to this disease, but it occurs most frequently in persons beyond the middle age. Treatment of Cancer of the Tongue. There are two operations in use for the removal of the schirrous or cancerous tongue—excision and ligature. The former was much employed by the older surgeons, but owing to its frequent failure, and the difficulty of arresting the hemorrhage, is now seldom resorted to. The ligature, when appli- ed in the manner first pointed out and performed by Mr. Home, is a very effectual remedy, easy of execution and by no means painful. The surgeon takes a common crooked needle. and having drawn it to the middle of a strong 21S Cancer of the Tongue. ligature, passes it through the substance of the tongue immediately behind the tumour. The mid- dle of the ligature being cut and the needle re- moved, there are left hanging two ligatures, one of which is to be drawn forcibly on one side of the tumour, and the other on the opposite side, so as to include a segment of the tongue. A sharp pain follows the tightening of the ligatures, but this soon subsides and the patient afterwards feels little inconvenience except from salivation which usually ensues in a few hours after the operation. In four or five days the tumour sloughs away and leaves an extensive granulating surface, which fills up with great rapidity. Arsenic has been extolled by Lane and others in the removal of cancer of the tongue, but I have never employed it. See Home on Cancer,p. Ill and 207—C. Bell's Operative Surgery, vol. 2. p. 29—Lane's Case of Ill-conditioned Ulcer of the Tongue successfully treated by Arsenic, in Medico-Chi- rurgical Transactions, vol. 8. p. 201—Louis, sur les Maladies de la Langue, in Memoires de I'Academie de Chirurgie, oc- tavo edit. torn. 14. p. 364. Cancer of the Breast. 279 Section VI. Cancer of the Breast. The female mamma is oftener the seat of carci- nomatous disease than any other part of the body; though the male breast is rarely affected. Women who have suckled a great many children, and un- married females, when they arrive at that period of life at which the catamenia cease, are in a peculiar manner liable to suffer. In a few instances I have met with tumours, having all the marks of genuine schirrus, in girls under the age of sixteen. Generally a small tumour is first perceived in the substance of the breast, not far from the nipple, so loosely connected with the surrounding parts as to move freely under the finger and devoid of pain unless rudely handled, or stretched by the pecto- ral muscle during the different movements of the arm. For many years the tumour may remain stationary, but in other instances it grows rapid- ^80 Cancer of the Breast. \y, and sometimes acquires great bulk. In the worst cases, however, the lump, after having at- tained a moderate size, becomes shrivelled or con- tracted, the nipple curls inward, and is soon buried below the surface, the skin assumes a leaden colour and adheres to the tumour so closely as not to be lifted from it, the whole breast is altered in shape, is irregular and knotted on the surface, and of a stony hardness, attended with deep stinging or lancinating pain extending to the armpit or into the chest. The lymphatic glands now suffer, and the whole chain along the armpit, under the clavicle, and up the neck is successively enlarged and indurated. Some- times the glands of the axilla are not affected, while those near the sternum or in the intercostal spaces are thoroughly contaminated. When the disease has advanced thus far, the skin usually gives way, and is followed by. the discharge of a thin, sanious matter. Soon afterwards a fungus shoots forth and occupies the centre of the ulceration, while the edges appear irregular and distorted. Oftentimes, however, the patient is destroyed before the ulcerative stage is es- tablished—the disease having extended to the lungs and produced dyspnoea, cough, hectic fever, emacia- tion and death. Cancer of the Breast. 281 Treatment of Cancer of the Breast. In the early stages of schirrous breast, or when the tumour is solitary, free from pain, not attached by adhesion to the surrounding parts, and the axil- lary glands uncontaminated, there is every prospect of success from an operation skilfully performed. The entire removal of the breast, however, in such a case will seldom be necessary, though the remark of Mr. Hunter should never for a moment be for- gotten—that the disease often extends much further than the eye can discover. In dissecting out, there- fore, an apparently insulated lump from the breast, the surgeon should make it a rule to go beyond the immediate limits of the tumour into the sound parts, taking care at the same time to injure them as lit- tle as possible by his fingers, knives or hooks. In most cases a single incision through the skin two or three inches in length, will afford ample space for the removal of the diseased part. When the disease has extended so far as to in- volve the whole breast and adjacent lymphatic glands, a very different kind of operation will be re- Voi.. I. 2 N 282 Cancer of the Breast. quired. The patient should be laid on a strong narrow table, previously covered by blankets, and her head, shoulders, and back raised and well sup- ported by pillows. The arm of the affected side is carried off at right angles from the body to put the pectoral muscle on the stretch, and is kept by an assistant in that position until the operation is finished. The surgeon stands on the opposite side, and commencing his incision in the armpit, below the edge of the pectoral muscle, extends it along on the lower or outer side of the nipple, two inches beyond the base of the breast. A second incision is commenced at the spot from which the first started and carried downwards, between the nipple and sternum, until the two meet below the breast. An oval space is thus formed, between two curvi- linear cuts, which includes the nipple, areola, and perhaps two or three inches, in breadth, of skin. The integuments are next elevated from the outer edges of the breast, until the greater .part of it be fairly ex- posed; then the breast must be separated from the pectoral muscle beneath, by a regular but careful dissection from below upwards as far as the axilla. Should the lymphatic glands be found free from dis- ease the breast may be removed at once; if how- Cancer of the Breast. 283 ever, the glands are enlarged, or otherwise so con- laminated as to require extirpation, then the breast serves as a handle and by its weight drags them down, and the whole diseased mass is removed in a string. During the progress of the dissection the arteries should be taken up the moment they are cut, otherwise they speedily retract among the cellu- lar membrane and do not afterwards bleed, until the dressings are applied and the patient put to bed. Owing to negligence in this respect, secondary he- morrhage is more frequent after amputation of the breast than any other operation in surgery. Before the edges of the wound are brought together, the whole surface, from which the tumour has been taken, should be accurately examined, and any dis- eased portions that may have been left carefully re- moved by the knife or scissors. When the two cur- vilinear incisions are made in the manner directed, there is no redundant skin, and the edges meet with the utmost nicety; the surgeon has only, therefore, to retain them in contact by a few adhesive straps, supported by lint and a common roller. In several instances in which I have performed the operation, the wound has healed nearly by the first intention. 284 Cancer of the Breast. Under favourable circumstances the operation very frequently succeeds in the most perfect man- ner, and the patietit never has the slightest return of the complaint; it must not be concealed, how- ever, that it often recurs very unexpectedly, and ad- vances with wonderful rapidity, and in a way plainly to show—that the knife has not only not eradicated the disease but hastened its progress. A surgeon, therefore, who values his reputation and the good of his patient, will be very careful not to promise too much, and never to operate unless there is some prospect of success—leaving the hopeless cases to be palliated by diet and medicines, and the unfortu- nate patients to live as long as their inveterate mala- dy will permit. I say nothing of the use of the ac- tual and potential cauteries, of artificial gangrene, as proposed by Rigal, Garneri, and other French surgeons, of pressure, as recommended by Young; because I believe them all to be worse than useless, or only beneficial under circumstances in which the knife would prove less painful and more expeditious. In conclusion I may state, that there are many- indurated lumps of the breast, proceeding from de- rangement of the digestive functions, from irregulari- Cancer of the Breast. 285 ties of the catamenial discharge, and from accumu- lated milk—easily removed by internal medicines, appropriate diet and local applications. See Home on Cancer—Adams on Cancerous Breasts—Aber- nethy's Surgical Works, vol. 2. p. 68, 1819—Johnson on Can- cer, p. 25 and 116—C. Bell's Surgical Observations, vol. 1. p. 1—Allan's Surgery, p. 235 and 313—C. Bell's Operative Sur- gery, vol. l.p. 177. 286 Cancer of the Uterus. Section VII Cancer of the Uterus. Prolapsus, polypus, and venereal ulcerations of the uterus, often bear so striking a resemblance to cancer as hardly to be distinguished from it. A minute inquiry, however, into the history of the dis- ease and careful manual examination, will enable the surgeon in most instances to decide correctly. The usual symptoms.of cancer of the womb are, pain in coitu, a discharge of acrimonious, offensive, sanious matter, shooting pains at the lower part of the abdomen and throughout the pelvis; but as these are equivocal and common to other uterine and va- ginal complaints, other diagnostics must be sought for. When in a schirrous state the neck of the uterus will be found enlarged, unusually heavy, in- durated in some parts, softened in others, and placed lower in the vagina than natural. Its orifice also is enlarged and irregular. After ulceration has taken Cancel' of the Uterus. 287 place, the patient complains when the part is touch- ed, the finger is soiled with blood and matter, and the whole diseased surface feels rough and unequal. The vagina too is more or less affected, loses its natu- ral rugose structure, becomes so contracted or filled up by indurated folds that the finger cannot be intro- duced without great pain, and finally takes on ulce- ration, which extends to the external parts of gene- ration and in some instances even to the thighs and abdomen. When the disease begins within the cavity of the uterus itself, its progress is somewhat differ- ent. The neck for a long time remains unaltered, while the body of the womb enlarges in every di- rection and soon attains a considerable magnitude. From its cavity is copiously distilled a very fetid, acrid matter, mixed with lumps of putrid sloughs, and quantities of blood. In this wretched condition a few patients have been known to exist upwards of ten or twelve years; but generally the strongest con- stitutions sink under the repeated hemorrhages and suffering within a much shorter period. Cancer of the uterus is seldom met with in pa- 288 Cancer of the Uterus. tients under forty or fifty years of age, and next to cancer of the breast occurs oftener perhaps than any other similar affection. Indeed, the two dis- eases not unfrequenfly exist in the same individual simultaneously. Treatment of Cancer of the Uterus. • Unfortunately the remedies for this disease, when it affects the whole body of the uterus, are palliative only—such as low diet, frequent purging, opium, rest in a horizontal position, astringent injections, repeated and accurate ablution. But that schirrus. when confined to the neck of the uterus, may be suc- cessfully removed, is proved beyond all doubt—by the result of numerous interesting cases, in which the operation of excision has been performed. Pro- fessor Osiander, of Gottingen, was the first to con- ceive and execute so bold a project; and his exam- ple has been followed by Dupuytren and other Eu- ropean surgeons. The first operation of the kind was performed by Osiander in 1801, on a widow whose vagina was filled by a very vascular, fetid Cancer of the Uterus. 289 fungus from the orifice of the womb, as large as a child's head. By means of Smellie's forceps the fungus was brought down low in the vagina, but being accidentally broken off, a tremendous he- morrhage ensued: undismayed, however, by this event, the operator determined to proceed, and im- mediately pushed a number of crooked needles armed with strong ligatures through the bottom of the vagina and body of the uterus until they emerged at the inner orifice. These ligatures served to draw down the uterus and retain it in the vagina near the external orifice. The surgeon then introduced a strong bistoury above the schirrous portion and di- vided the womb completely in a horizontal direction. The hemorrhage for an instant was violent, but speedily suppressed by a sponge saturated with styp- tics, and the patient recovered in three or four weeks. Osiander afterwards performed eight si- milar operations upon different patients, all of whom recovered without the slightest difficulty. Dupuytren also has performed the operation eight times; but instead of employing the ligatures and bistoury re- commended by Osiander, he drew down the ute- rus with forceps, and divided it above the schirrous part by curved knives and scissors. One of the Vol. I. 2 0 290 Cancer of the Uterus. patients upon whom Dupuytren operated had a re- turn of the disease, and submitted to a second ope- ration with no better success, until Recamier, a sur- geon of the Hotel Dieu, contrived a speculum through which caustic was repeatedly introduced, and by it a complete cure was at last effected. See Observations on the Cure of Cancer of the Womb by Excision, by F. B. Osiander, in Edinburgh Medical and Sur- gical Journal, vol. 12. p. 286—Dictionnaire des Sciences Me- dicates, torn. 3. p. 588 and 600; also torn. 23. article Hyster'o- tomie, p. 293; also torn. 31. p. 240. Cancer of the Rectum. 291 Section VIII. Cancer of the Rectum. This, like most other cancerous affections, sel- dom occurs except in persons advanced in life, and is more common among women than men. It commences in the mucous membrane of the gut, which is thickened and indurated, and its sur- face sometimes covered with rounded or irregular tubercles. The peritoneal and muscular coats are also enlarged and their interstices filled by numerous membranous partitions. At last all traces of the natural structure are lost, and the different coats are converted into a homogeneous substance resembling gristle, which occupies so large a portion of the ca- vity of the rectum as almost to obliterate the pas- sage. Thus situated the patient makes violent and often ineffectual efforts to expel the faeces, which when they are discharged, are squeezed into a very narrow compass and resemble worms in form. These efforts give rise to pain and inflammation about the rectum and neck of the bladder, and fre- 292 Cancer of the Rectum. quently produce suppression of urine and other dis- tressing symptoms. Moreover the incessant irrita- tion kept up within the cavity of the gut hastens the ulcerative process; large quantities of ropy mucus are then discharged, mixed with ichorous, offensive matter, a fungus sprouts from the ulcerated surface and frequently covers the whole verge of the anus. The disease having reached this height must neces- sarily soon terminate in death, which takes place either from over-distention of the bowels above the strictured part, or from general irritation and debility. When examined by dissection, all the parts ad- joining the rectum are found more or less diseased, and the bladder, gut, and vagina often communi- cating freely with each other by ulcerated open- ings.—There are strictures and other diseases of the rectum bearing some similitude to cancer, that will be noticed under a different head. Treatment of Cancer of the Rectum. To prevent an entire closure of the rectum and to render the patient's situation as comfortable as possi- Cancer of the Rectum. 295 ble, is as much as we can accomplish; for, whatever may be said to the contrary, genuine schirrus or can- cer of the rectum is absolutely incurable. By common wax bougies (or by pieces of sponge cut into a proper shape, dipped in melted wax and afterwards rolled with a spatula and polished), oiled, and introduced into the rectum beyond the contracted portion, and suffered to remain for two or three hours at a time, or longer if they do not excite too much irritation, and worn for several weeks or months, the passage may be so much enlarged as to permit a free dis- charge of faeces, and thereby relieve the patient from the unpleasant necessity of perpetual strain- ing to procure a stool. The size of the dilating in- struments should be gradually increased in propor- tion as the passage widens. Conjoined with this local treatment, moderate diet and occasional pur- gatives will be found extremely serviceable in keep- ing the bowels regular and in obviating inflamma- tion. After ulceration is established the bougies or tents must be discontinued, as they will only serve to aggravate all the symptoms. To relieve the pa- tient from pain and procure sleep, an opium pill softened and deposited in the rectum by the end of a bougie will be found the most effectual remedy 294 Cancer of the Rectum. Copeland recommends in obstinate cases that have long resisted the bougie, a division of the indurated contraction by the bistoury. See Dessault's Works, by Smith, vol. 1. p. 366—Home on Cancer, p. 129—Monro's Morbid Anatomy of the Human Gul- let, Stomach and Intestines, p. 347—Baillie's Morbid Anato- my, p. 173—Copeland's Observations on the Principal Dis- eases of the Rectum—Sherwin on the Schirro-contracted Rec- tum, in Memoirs of the London Medical Society, vol. 2— White on the Contracted Intestinum Rectum—Howship on the Rectum. Cancer of the Penis. 295 Section IX. Cancer of the Penis. Both the prepuce and glans penis are liable to cancer; fortunately, however, the disease is not very common. Persons troubled with a natural phymo- sis are most subject to it—owing perhaps to a mor- bid sensibility of the glans, produced by its confined situation. A tubercle or wart first appears among the glands of the prepuce or on the glans penis itself. Its base is broad and deep seated, and seems to be a continuation of the substance of the part upon which it is situated, rather than a diseased super- structure. This will distinguish it from the vene- real wart, with which it has sometimes been con- founded—the latter having a narrow neck or pedicle while the top is expanded. Whether it occupy the prepuce or glans, the cancerous tumour slowly ad- vances, and at last ulcerates and throws out a cauli- flower-like fungus. Then there is a plentiful dis- charge of fetid matter, mixed with blood, and severe -96 Cancer of the Penis. pains are felt darting along the penis into the abdo- men. In time the spongy and cavernous .bodies of the penis are contaminated, the inguinal glands swell as well as those about the rectum, and the patient's constitution is completely ruined. Sometimes the penis sloughs off as high as the pubis, at other times is gradually destroyed by ulceration. Cancer of the penis is commonly met with amongst old and disso- lute subjects who have frequently suffered from ve- nereal attacks; but it may also occur in healthy persons from contusion and other external injury, as proved by Mr. Home in his interesting account of the case of J. Wallace. Treatment of Cancer of the Penis. When the tumour is small, not of long standing, and confined to the prepuce, it may sometimes be dissected out with success. In most instances, how- ever, amputation of the penis is the only resource and even this does not always answer; in general it may be stated, that an operation is fruitless after contamination of the glands about the groin and Cancer of the Penis. 297 root of the penis. Before amputation is decided upon the surgeon must be well assured of its necessity, for it has happened that the glans penis has been found after its removal perfectly free from disease, or only covered by venereal warts. In doubtful cases the prepuce should be slit up previous to am- putation. There are two or three modes of amputating the penis—each very simple. It may be done by a sin- gle stroke of the knife; or by two separate cuts, the first through the skin, which is drawn towards the pubis, the second through the body of the penis. The object of this particular mode is to save the skin, as in common amputation of the limbs, to co- ver the stump; but experience proves that there is always enough, and frequently too much skin, which by interfering with the stream of urine, or forming a pocket for the lodgement of matter, is attended with serious inconvenience. Both these operations are objectionable upon another ground—the diffi- culty and sometimes impossibility of arresting the hemorrhage, especially when amputation is perform- ed near the pubis, from the shrinking of the cor- pora cavernosa into the perineum—an accident from Vol. I. 2 P 298 Cancer of the Penis. which more than one patient has lost his life. On this account I prefer the operation lately proposed by Schreger, and which may be done in the follow- ing manner. The surgeon takes hold of the penis, and draw- ing the integuments as much forward as possible, secures them by a tape. An incision is then made through that part of the skin which imme- diately covers the dorsal arteries. These are cut and tied. The next incisions penetrate the cor- pora cavernosa until the two arterice profunda are opened. These being secured in like manner, it only remains to divide the corpus spongiosum ure- thrae. This must be done gradually, or in such manner as to divide and tie the two arterial caverno- sas before the penis is entirely separated. The ad- vantages gained by this mode of operating must be very apparent, since the surgeon by preventing the retraction of the penis until the six principal arte- ries are secured, has the hemorrhage completely under his control. The sides of the urethra, in some instances, unite permanently after amputation of the penis. Cases Cancer of the Penis. 299 of the kind are recorded by Le Dran, Hey, Des- sault and Bertrandi. To prevent such an accident, which would necessarily produce suppression of urine and other ill effects, many writers recommend the introduction of a metalic canula or gum elastic catheter. There is reason to believe, however, that the occasional use of a probe or small bougie would answer every purpose, without subjecting the pa- tient to the pain and inconvenience of wearing an instrument constantly. The surgeon should make it a rule in amputating the penis, never to remove more than is absolutely necessary to destroy the disease; for it is.now well ascertained, that the glans penis may be lost with- out annihilation of the procreative powers. See Hey's Practical Observations in Surgery, p. 461. edit. C,d.—S. Cooper's First Lines of the Practice of Surgery, vol. 2. p. 204. edit. 4th—C. Bell's Operative Surgery, vol. 1. p. 130—Home on Cancer, p. 1—Pearson on Cancerous Com- plaints—Roux's Narrative of a Journey to London in 1814. p. 261—Wadd's Cases of Diseases of the Prepuce and Scro- tum, p. 17. plate 7. 300 Cancer of the Testicle. Section X. Cancer of the Testicle. Under the name of sarcocele, several diseases of the testicle have been comprehended, very different in their nature. These will be considered at a fu- ture period under separate heads. The present re- marks will apply exclusively to that condition of the testicle which bears a striking similitude to the schirrous and cancerous structure met with in other parts of the body. The external characters are a stony hardness of the body of the testicle and epididymis, ac- companied by enlargement, great inequality and uncommon weight—the tumour feeling, when han- dled, like a lump of lead. In the progress of the disease, the cord and inguinal glands become contaminated and enlarged, and if the patient sur- vives sufficiently long the scrotum sometimes in- flames and ulcerates, and throws out the bleeding Cancer of the Testicle. 301 fungus peculiar to cancer. The symptoms are deep- seated, lancinating and incessant pain, extending up the cord, along the loins, and down the thighs. The true malignant schirrus of the testicle seldom attains a very large size. I have met with two or three in- stances, however, where the tumour became as large as a cocoa-nut and was surrounded by water, con- stituting the disease usually called hydro-sarcocele. From forty to sixty years of age is the period at which the schirrous testicle generally occurs. When dissected, the morbid structure is found to correspond exactly with that of the cancerous breast. The cancer scroti, chimney-sweeper's cancer or soot-wart, a disease endemial in England, and in its advanced stage resembling in many respects com- mon cancer of the testicle, has never been seen that I know of in America. This may perhaps be owing to the general use of wood instead of coal, or to the circumstance of negroes alone being em- ployed in the sweeping of chimneys. 302 Cancer of the Testicle. Treatment of Cancer of the Testicle. Although the schirrous or cancerous testicle may remain for a long time dormant, in the end it is sure to display its true character, and to prove fatal un- less arrested by an operation. Before the surgeon ventures, however, to decide upon so important a measure, he must be well assured not only of its ne- cessity, but of its probable success. There are two points then deserving attention—not to confound the schirrous testicle with other tumours bearing a re- semblance to it, such as fungus nematodes, vene- real sarcocele, scrofulous enlargement of the testi- cle; and again—never to operate after the cord has become extensively diseased and the glands of the groin or those within the abdomen contaminated. The extirpation of the testicle is one of the most simple but severe operations in surgery. It is per- formed in the following manner. The patient is placed on the edge of a table and the thighs kept asunder, while the surgeon, seated before him grasps the testicle in one hand and with the other makes an incision through the skin, commencing Cancer of the Testicle. 303 above the abdominal ring and extending to the base of the scrotum. Some of the branches of the ex- ternal pudic now spring and must be secured by ligature. A second incision lays bare the cord and freely exposes the tunica vaginalis. With the han- dle of the knife, and by slight dissection, the* cord is gently separated from the loose cellular membrane around, to an extent sufficient to admit the finger beneath it, and carefully examined lest a small her- nia or piece of omentum should be concealed with- in the condensed cellular membrane attached to its sheath. The next step is to divide the cord, not by a single stroke, but by successive touches with the knife, picking out the arteries as they spring with the point of the tenaculum or forceps, and tying each separately with a very fine ligature. The whole being secured and all danger of hemorrhage at an end, the cord is cut across, and is immediately drawn up to the ring by the action of the cremaster muscle. It only remains to detach the testicle from the scrotum and loose cellular membrane which sur- rounds it. This is easily accomplished and without much pain, as the sensibility of the testicle is very much blunted after the separation of the cord. The operation is finished by drawing together the edges 304 Cancel' of the Testicle. of the scrotum with three or four stitches, covering the part with lint and supporting the whole by a bag truss or handkerchief. The arteries of the cord are sometimes so much enlarged as to bleed profusely if not well secured, and several patients have lost their lives, either from negligence of the surgeon or from the cord slipping within the ring before the vessels were tied. On this account, a general practice formerly prevailed of including the whole cord in a single ligature. But the great pain and violent symptoms, arising from compression of the vas deferens and numerous nerves of the cord, which sometimes followed, rendered the operation extremely objectionable, and induced Mr. Home to attempt an improvement on it, by excluding the vas deferens and encircling the remainder of the cord by passing a needle, armed with two ligatures, through its centre, and tying one on each side of -it —thereby making the compression more effectual, and obviating all risk of the ligatures slipping. Even with this modification, however, the plan is still re- prehensible, since it exposes the patient to unneces- sary suffering without adequate advantage; for it is now acknowledged, that it is seldom necessary to Cancer of the Testicle. 305 secure more than two arteries—the spermatic and that of the vas deferens. These, it is true, are sometimes greatly enlarged, but nevertheless per- fectly under command of the surgeon, when he fol- lows the course I have pointed out. At any rate, it is very easy to include the whole cord in a ligature, after having failed to secure the individual vessels. The arteries of the scrotum are often of large size, and when cut shrink among the cellular membrane, and do not bleed until the dressings are applied and the general circulation is completely restored. The surgeon should be aware of this, and endeavour to tie them before the operation is finished. When the schirrous testicle attains an unusual magnitude there will be redundancy of skin, unless two cur- vilinear incisions are made (instead of a single cut), in the manner formerly directed for cancerous breast. Weiuhold has proposed, in cases of diseased testis, to cut across the cord merely, and leave the tumour in the scrotum to be diminished or removed by ab- sorption; and the practice has received the sanction of Maunoir of Geneva. The idea is extremely in- Vol. I. 2 Q 306 Cancer of the Testicle. genious, but experience must determine the pro- priety of the measure. Consult Home on Cancer, p. 116 and 231—C. Bell's Ope- rative Surgery, vol. 1. p. 222—Cooper's First Lines, vol. 2. p. 129 and 135—Dessault's Works, vol. 1. p. 390—Ramsden's Practical Observations on Sclerocele—Nouvelle Methode de traiter le Sarcocele, sans avoir recours a VExtirpation du Testicule, par C. Th. Maunoir, Svo. 1820. Fungus Haimatodes. 307 Section XI. Fungus Hmmatodes. Mr. John Burns, of Glasgow, was the first to give any regular account of this very formidable and de- structive disease. His observations were soon fol- lowed by those of Hey and Abernethy, both of whom described the affection under a different appellation. The term fungus haematodes, invented by Hey, has been considered less objectionable than any other, and therefore retained by most writers. This disease may occur in almost any part of the body; but the extremities are particularly liable to it. Though not very common in America, it occurs often enough to deserve the attention of the surgeon. When it occupies any of the external parts it is characterized by the following appearances. In the incipient stage a small tumour is perceived, almost devoid of sensa- tion, smooth on the surface, moveable under the in- 308 Fungus Hazmatodes. teguments and elastic to the touch. This may re- main stationary for years, without giving the patient the slightest uneasiness, until a blow or strain, or some accidental injury causes it to inflame, and then it increases with wonderful rapidity, while the skiu loses its natural colour, and becomes mottled or red in some parts and purple in others. In a few weeks the tumour attains a considerable bulk, and in proportion to its growth is rendered protuberant or lobulated; at the same time the veins on its sur- face are greatly enlarged and very conspicuous, and at no very distant period ulceration takes place in one or more spots, from which a fungus sprouts with the utmost luxuriancy. This fungus is of a dark red colour, extremely vascular and commonly con- tracted about the neck, while the top is expanded and irregular. The disease having advanced thus far soon contaminates the contiguous lymphatic glands, which are converted into a substance ex- actly resembling that of the original tumour. In the mean time the patient's health gradually declines, the countenance assumes a yellow cadaverous hue, the whole constitution is undermined by hectic, and death speedily follows. Fungus Hojmatodes. 309 The morbid mass, when examined by dissection, exhibits appearances altogether distinct from those met with in any other disease. A very thin and undefined capsule invests the whole tumour, and, within this, lobes separated from each other by membranous partitions of soft pulpy matter, resem- bling brain in consistence and colour, compose the greater portion of the distempered fabric. In the midst of this medullary-like matter are often found cells filled with clotted blood; at other times small cysts are met with containing a thin, sanious and fetid serum. So extensively involved are all the textures in the neighbourhood of the tumour, that the mus- cles are often annihilated, or their structure so sub- verted as scarcely to be recognised, and the arte- ries, veins, nerves and cellular membrane all blend- ed together in one confused mass. When the lym- phatic glands and those in the course of the circula- tion are examined, they are found equally diseased, often throughout the body. The same may fre- quently be said of the liver, lungs, kidneys, and brain, all of which exhibit proofs of universal con- tamination. Fungus haematodes has been confounded with 310 Fungus Haematodes. aneurisms, cancerous tumours and other diseases; and I have known such mistakes attended with very serious consequences. From cancer, to which it bears a greater resemblance than any other affec- tion, it differs in the following respects. The tu- mour of fungus haematodes is large, soft and elastic, and to the touch imparts so deceptive a sensation of fluctuation, that a lancet has often been pushed into it—under an idea that it contained purulent mat- ter. The schirrous or cancerous tumour, on the contrary, is hard, solid and incompressible, and in the advanced stages frequently shrivelled or con- tracted. Fungus haematodes, when dissected, is found to consist chiefly of a soft, pulpy, tenacious medullary-like matter. Cancer, when examined in the same way, exhibits a hard, fibrous substance, re- sembling cartilage, which occupies the centre of the tumour as a nucleus, and from this centre white narrow bands proceed irregularly towards the cir- cumference. Fungus haematodes is almost invaria- bly met with amongst children and young persons- cancer may be said to be almost peculiar to the old. Fungus haematodes occurs in organs which cancer never attacks—such as the brain, liver, kidneys, and spleen. Other distinctions might be pointed Fungus Haematodes. 311 out, but these are sufficient to designate the com- plaint The eye, according to late European writers on that organ, is particularly subject to fungus haema- todes. In this country I have never seen more than three or four cases of the disease; these differed materially from cancer of the eye. The retina and optic nerve are the textures in which fungus haema- todes usually commences, and the first symptom is an obscurity of vision, occasioned by a small shining tumour which occupies the bottom of the posterior chamber and may be distinctly seen by looking into the pupil. This tumour slowly increases, advances into the vitreous humour and finally reaches the iris, behind which it appears so much like cataract as to be with difficulty distinguished from that disease. Soon after the whole eyeball loses its spherical form, becomes irregular or protuberant, the cornea ulcerates, and a large, soft, dark red or purple fun- gus is sent forth. When the diseased mass is re- moved by an operation and examined, it is found to consist of medullary-like matter throughout, and so exactly resembling in other respects the structure of fungus haematodes as to render further description 312 Fungus Hcematodes. unnecessary. The circumstance of fungus haema- todes commencing generally at the bottom of the eye, its attacking almost invariably children and young subjects, and the peculiar structure of the morbid mass, are sufficient proofs that the disease is distinct from cancer, which usually occurs in old people, originates in the anterior parts of the eye, and when dissected presents appearances very dif- ferent from those just pointed out. The testicle, when affected by fungus haematodes, sometimes resembles hydrocele so closely, that the most intelligent and experienced surgeon is unable to decide between the two diseases. This decep- tion, however, cannot endure a very long time; for after the fungus haematodes tumour attains a mo- derate bulk, the constitution shows evident marks of contamination, and the lymphatic glands of the thigh and groin are sensibly enlarged. It is hardly possible to confound the schirrous testicle with fun- gus haematodes of the same organ. The one is very firm in its texture and extremely heavy—the other soft, fluctuating, pulpy, and generally free from pain. When dissected, the structure of fungus haematodes of the testicle is better marked perhaps, and af- r. it. /Jr-f/l/in //■/>/// .\',/////;' /iy U'f,'iA.\;>t A'.'//■*.- As regards the treatment of fungus haematodes very little satisfaction can be afforded; for in the whole range of surgical disease there is no affec- tion so truly alarming or so intractable in its nature. In vain are internal medicines and local applications prescribed; they do not even palliate the complaint. Even extirpation of the tumour, and that too in its Fungus Haematodes. 315 very incipiency, answers so little purpose, that there is hardly a case on record where the operation has succeeded. One of the most extraordinary and in- teresting cases perhaps ever related, in which the fairest trial was given, without effect, to repeated and most extensive operations, is detailed by Mr. Allan* The patient suffered during thirteen years from a very large tumour which occupied the left hip. When it attained the size of a child's head it was dissected out by Mr. Newbigging, of Edin- burgh, apparently with success; for the wound heal- ed and the patient felt perfectly well. At the end of nine months, however, it grew again, and in se- venteen months from the first operation, a second was performed by Mr. Russel, upon a tumour as large as the two fists. The wound soon healed, but in nine months following the tumour recurred, and soon equalled in size a very large mamma. A third operation was now undertaken by Mr. Allan, and so extensive was the dissection, that the wound was as large as the crown of a hat. In a few weeks it healed perfectly; but the tumour appeared again in seven months. The late Mr. John Bell * See Allan's Surgery, vol. i. p. 264. 316 Fungus Haematodes. was then consulted, and performed a fourth opera- tion upon it—the tumour at the time being as large as the head of a child eight years old. Several months after, the diseased mass was reproduced and from the surface a fungus sprouted, in shape and size resembling a large cauliflower. This, Mr. Allan removed by ligature, and the patient for the time was relieved. His constitution, however, was com- pletely ruined, and although he lived for several months afterwards, he died at last, quite exhausted by the long continued discharge from the fungus —nearly eight years having elapsed from the time of the first operation. This case plainly shows how little we are to expect from extirpation; and it only remains to say, that nothing less than amputation of a limb, when the disease happens to be so situated as to admit of it, will afford any chance whatever of saving the patient's life, and that even this re- source is fr piently unavailing—owing to the stump taking on the same morbid action, or to thorough contamination of the internal organs. See Pott's Works, vol. 3. p. 223—Burns's Dissertations on Inflammation, article Spongoid Inflammation, vol. 2. p. 132— Hey's Practical Observations in Surgery, p. 239. edit. 3d.— Fungus Haematodes. 317 Abernethy's Surgical Works, vol. 2. p. 56, article Medullary Sarcoma—Wardrop's Observations on Fungus Hmmatodes or Soft Cancer, in several of the most important Organs of the Human Body—Langstaff's Cases of Fungus Haematodes, in vol. 8. part. 1. of Medico-Chirurgical Transactions, p. 272— Langstaff's Cases of Fungus Haematodes, Cancer, and Tuber- culated Sarcoma, in vol. 9. part 2. of Medico-Chirurgical Transactions—Roux's Journey to London, p. 189—Bayer's Treatise on Surgical Diseases, by Stevens, vol. 1. p. 318, arti- cle Bloody Fungus—Scarpa on the Eye, by Briggs, edit. 2d —Stevens's Cases of Fungus Hcematodes of the Eye, in the New York Medical Register, p. 117—C. Bell's Surgical Observations, article Soft Cancer, p. 365—Delpech's Precis Elementaire des Maladies Chirurgicales, torn. 3.p. 480__Bail- lie's Morbid Anatomy—Travers' Synopsis of Diseases of the Eye. 318 Gonorrhoea. Section XII Gonorrhoea. Gonorrhoea, or at least a purulent discharge from the urethra, may be considered a disease of very ancient date; for we find it expressly enjoined in the Levitical law,* that " when any man hath a running issue out of his flesh" or a yioppves, as the Septuagint terms it, he must be secluded, or restrain- ed from sexual intercourse, in order to prevent con- tamination. It is still a matter of doubt, how ever, whether the disease now termed virulent gonorrhoea, was implied in the passage referred to, or merely that discharge from the urethra which often takes place without the application of any morbid poison, arises from irritation, severe exercise, fluor albus, immoderate use of the genital organs, and known to surgeons under the name of simple gonorrhoea. * See Patrick's Commentary on the third book of Moses chap. xv. p. 245—also Clark's Commentary on the Bible, xvth chapter of Leviticus. Gonorrhoea. 319 But these are matters of very little importance at the present day, except as regards the question— whether gonorrhoea and syphilis be of the same or of a different nature. The symptoms of the virulent gonorrhoea are a slight titillation or uneasiness of the glans penis, a pouting or tumidity of the lips of the urethra, more or less redness or inflammation about the prepuce and glans, together with a general fulness of the whole penis. These are soon followed by a discharge from the urethra, of a thin, whitish fluid, at first resembling common mucus, but speedily changing into a thick, tenacious, purulent matter, of yellow colour and peculiar smell. Considerable pain is now felt along the urethra and perineum, the urine is discharged in a thin, wire-like or forked stream, accompanied with a burning heat or severe scalding. By this time the inflammation attains a considerable height, the glans penis becomes swollen, tense, of a bright red colour, and its surface has a peculiar shining aspect, as if glazed or highly polished. The pain and ardor urines are increased in proportion as the inflammation rises, and the colour of the dis- charge, from the same cause, changes from a deep 320 Gonorrhoea. yellow to a greenish tint. Oftentimes the glans pe- nis is excoriated, and there is a copious discbarge not only from the urethra but from the whole in- ternal surface of the prepuce. These are the ordi- nary symptoms of the complaint; they are liable, however, to be more or less modified by peculiari- ties of constitution and by other causes; hence we find some patients to suffer immensely, whilst others experience very little inconvenience during the whole course of the disease. A very painful affection frequently accompanies gonorrhoea, and is known by the name of clwrdee. This consists in an involuntary erection of the penis, which generally occurs at night, while the patient is warm in bed, and is so severe as to prevent sleep. It arises during the height of the inflammation, and is always one of the most troublesome symptoms that the patient has to contend with. The penis is drawn downwards or bent into a semicircular shape; and if the inflammation runs high, and the erections conti- nue to recur repeatedly, coagulable lymph is effused into the cells of the corpus spongiosum, the sides of which are agglutinated in such a way as to prevent the future distention of the cells, to an extent equal Gonorrhoea. 321 to that of the corpora cavernosa, and the penis ever afterwards, during erection, remains crooked and deformed. There are other symptoms also which occasionally take place during the violence of the inflammation. These are a frequent and irresistible inclination to pass urine, owing to the inflammation having ex- tended along the whole course of the urethra as far as the bladder. So severe is the pain in some in- stances from this cause, that the patient is afraid or unable to evacuate a single drop of urine, and a total suppression ensues, which adds greatly to his dis- tress. From the bladder the irritation extends to the rectum and adjoining parts; a tenesmus takes place and becomes exceedingly severe and trouble- some; there is an acute, lancinating pain shooting from the neck of the bladder above the pubis the small glands along the tract of the urethra, whose ducts open into that passage, are enlarged, and sometimes suppurate and discharge externally through the skin. The glands of the groin likewise are frequently affected in a similar manner, and the vas deferens, testicles, ureters, and kidneys often sympathise with the inflamed urethra and bladder. Vol. I. 2 S 322 Gonorrhoea. But of the sympathetic affection of these differ- ent organs, that of the testicle, known by the name of hernia humoralis, is the most common. It usu- ally occurs about the decline of gonorrhoea, and fre- quently after the inflammation and discharge have entirely ceased. At other times, it takes place sud- denly during the height of the inflammation, and then the discharge as suddenly ceases, and the pain leaves the urethra and fixes upon one or both tes- ticles, which " seem/' as Mr. Hunter has expressed it, " in many cases rather to be acting for the ure- thra than for themselves, an idea applicable to all sympathies." Generally, however, only one testicle is affected at a time, though the transition of the dis- ease from one to the other is often extremely rapid. In either case, there is first a soft, diffused swelling of the testicle, which soon becomes hard and very painful. The hardness is *most remarkable at the epididymis, and the pain from that part extending up the cord and along the loins, frequently so acute as to induce rigors, fever, sickness of stomach and great derangement of the digestive organs. These symptoms may continue for a considerable time, and give rise to permanent enlargement of the testicle, or they may disappear in a few hours or days, as sud- Gonorrhoea. 323 denly as they were induced, without the gland hav- ing sustained any injury. In general the swelling diminishes in proportion as the discharge from the urethra is increased, and when it is fully established entirely disappears. Women are not so liable to gonorrhoea as men, nor do they suffer as much from it—owing to the in- sensibility of the vagina compared with that of the urethra. It is not easy, indeed, in every instance to determine the existence of the disease in a fe- male, so slight is the pain and so equivocal the dis- charge; though I have met with several cases, in which the inflammation ran so high and produced such intolerable anguish, that the patients were unable to leave their beds. Gonorrhoea has often been confounded with fluor albus; but close atten- tion to the symptoms peculiar to each complaint will be sufficient, in general, to distinguish them. Most violent inflammation, and even total extinc- tion of sight, has followed the accidental application of gonorrhoeal matter to the eye. I have met with several cases of this description, two or three of which originated from the patient's washing the eye 324 Gonorrhoea. with their own urine (while they laboured under gonorrhoea) in order to relieve a common inflamma- tion of that organ—a practice exceedingly frequent among the vulgar. The disease will be further no- ticed under the head of ophthalmia. Gonorrhoea may terminate spontaneously or " wear itself out," or else degenerate into a disease commonly known by the name of gleet, which is characterized by the discharge from the urethra of a white, limpid mucus, destitute of virus, and pro- ceeds from a relaxation or debility of the lining mem- brane of the passage—a consequence very apt to follow inflammation of all mucous membranes. Such at least is the account usually given of the disease by writers, though I very much question the accuracy of their statements, and am inclined to be- lieve that the discharge denominated gleet, in most instances, is in truth a chronic gonorrhoea, and as such capable of communicating infection. There is also a mucous discharge from the urethra attend- ing other diseases of that passage, particularly stric- ture, which I am persuaded is often considered a gleet, and treated accordingly; but this is certainly Gonorrhoea. $25 not infectious, and differs widely from the discharge which follows a gonorrhoea. Treatment of Gonorrhoea. The remedies for gonorrhoea are constitutional and local. The former are chiefly indicated in the commencement or during the height of the inflam- mation, while the latter may be employed at any stage of the disorder. In severe cases and in ple- thoric habits, blood-letting, purgatives and low diet will generally all prove necessary. Considerable experience, however, in the treatment of this disease has taught me, that steady purging is more to be re- lied on in lessening the inflammation and in remov- ing pain, than even copious depletion by the lancet. Repeated and small doses of jalap or rhubarb, com- bined with the supertartrate of potash, I have found extremely useful; indeed in many cases I have pre- scribed the cremor tartar alone in such quantities as to produce botli purgative and diuretic effects, and continued it steadily for two or three weeks with the greatest advantage, after most other reme- 326 Gonorrhoea. dies had failed. Besides purgatives, stimulating diu- retics often prove highly serviceable, both in the in- flammatory and chronic stages of gonorrhoea. The balsam copaivoz is more decidedly beneficial than any other remedy of the class. It had long been used in the advanced stages of gonorrhoea, but Dr. Chapman was the first to prescribe it during the height of the inflammation or from the very com- mencement of the attack. So far back as the year 1806,1 well remember to have heard him express his decided conviction of the superior efficacy of the remedy when thus administered. Dr. Arm- strong, in his late work on scarlet fever, speaks of the practice as novel, and seems to attribute its in- troduction to a Dr. Dawson, who, it is stated, had prescribed the medicine with great success for more than twelve years, in the very commencement of vi- rulent gonorrhoea. Dr. Chapman's claim to pri- ority, however, is most unquestionable. For many years past I have employed the remedy very exten- sively, both in the recent and advanced stages of the complaint sometimes with most decided effect, but in other instances without the slightest alleviation of the symptoms. This may have proceeded from the bad quality of the medicine, which, it is well known, Gonorrhoea. 327 is often ruined by adulteration. The cubebs, ano- ther stimulating diuretic, formerly much employed in the treatment of gonorrhoea, has recently been highly extolled as possessing very superior powers. From numerous trials, however, I am inclined to be- lieve that its virtues have been greatly overrated. Demulcents, by blunting the acrimony of the ure- thral discharge and by exciting the action of the kid- neys, are always used with advantage in gonorrhoea, and should never be- neglected. The local remedies for gonorrhoea may be applied either to the penis itself or to the urethra. For se- veral years past I have been in the habit of pre- scribing a warm bread and milk poultice in the very commencement of the disease, and always with the utmost advantage/ To derive full benefit from the application, the prepuce should be retractedand the glans penis completely buried in the poultice, which should be as warm as the patient can bear it and renewed as often as it becomes cold and stiff. By persevering in the use of the poultice for a few days all the symptoms are mitigated, and the way paved for mild and warm injections—such as rose water, thin solutions of gum arabic, flax seed or 328 Gonorrhoea. opium, weak decoctions of oak bark, &c. These check the discharge gradually, and often effect a cure. As the ardor urinae and discharge diminish, more astringent injections may become necessary. Those commonly employed are solutions of the ace- tate of lead, of white, green and blue vitriol, alum, borax, &c. They are all inferior, however, to a so- lution of the nitrate of silver, a medicine that has been strenuously commended lately in the cure of every stage of gonorrhoea, but which I have used extensively for the last thirteen years and with the greatest success. By commencing with three grains of the caustic to an ounce of water, and gradually increasing the strength of the solution until the pa- tient feels it sensibly, a cure may be produced in a very short time. Some surgeons commence with twenty grains to the ounce; but great irritation, sup- pression of the discharge, and swelling of the testi- cle have followed the practice. In some instances I have derived considerable advantage from the caustic, when mixed with oil and introduced into the urethra on a small bougie. The nitiic acid, pro- perly diluted, was a favourite remedy with Vigaroux, an eminent French surgeon. Dr. Physick has also employed it very successfully in several obstinate Gonorrhoea. 329 cases of gonorrhoea.. The vinous tincture of opium I have often used with great advantage in the early stages of gonorrhoea. At first it should be consider- ably diluted, but afterwards may be used pure.* * Any of the following formulse of injections may be em- ployed in the early or inflammatory stages of gonorrhoea. R Liq. plumb, acetat. . . gutt. vi Aquae distillatse, . . . 5iv M. ft Liq. plumb, acet. . . gutt. vi Opii. purif......^i Aquae distillatse, . . . 5vi M. R Zinci acetatis.....grs. x Aquse distillatse, . . . 5vi M. R Zinci sulphatis, . . . grs. iv Aquae distillatse, , . . 5v M. R Acidi muriatici, . . . gutt x Aquse distillatse, . . . 5v M. ft Acidi nitrici, . . . gutt. xij Aquse distillatse, . . . 5vi M. ft Vini opii,......?i Aquse distillatse, . . . 5iij M. 8 Balsami copaibse, ... 31 Mucilaginis acacise, . . . 5ss Aquse rosse,.....Ivi M. Vol. I 2 T 330 Gonorrhoea. As chordee is one of the most troublesome attend- ants on gonorrhoea, it should be checked as soon as possible. Camphor, combined with opium and given in large doses, will be found singularly effica- cious in arresting its progress. Hernia humoralis being generally dependant upon suppression of the urethral discharge, induced by irregularities, debauch, the use of strong injections, &c, the first object of the surgeon should be to re- establish the running. This may often be accom- plished by warm poultices, large enough to cover the whole penis and testicles, or by the introduction of a bougie into the urethra. With this treatment, general and local blood-letting should be combined together with purgatives, while the patient is con- fined to the horizontal posture, and the testicles sup- ported by a bag truss or handkerchief. For the relief of the irritable bladder and rectum, I know of no remedies so effectual as the warm bath, opiate glysters, and warm poultices or fomentations to the perinaeum. Gleet, when it really proceeds from gonorrhoea, Gonorrhoea. 331 and is not connected with stricture of the urethra, will generally be benefited or cured by stimulating injections,* blisters to the perinaeum, the internal use of cantharides, the muriated tincture of iron, tincture of cubebs, and by the introduction of plain or medicated bougies. * The best injections for gleet are those composed of the sulphate or acetate of copper, of the supersulphate of alum, of the oxymuriate of mercury, of the ammoniaret of copper, &c. Any of the following formulae will frequently answer, and if one fail another should be tried. R Cupri sulphatis,.....grs. ij Aquae distillatse, ...... iviij M. R .dEruginis prseparatse, . . . grs. x Olei amygdalse,......5iv M. R Aluminis supersulphatis, . . grs. iv Aquse distillatse,......5iv M. R Liquoris cupri ammoniati, . gutt. xx Aquse rosse,........^iv M. ft Liquoris hydrarg. oxymuriatis, gutt. iij Aquse distillatse,......^n M 332 Gonorrhoea. The remedies for gonorrhoea in women do not differ from those required for men, except in being used stronger or in larger doses. Consult Hunter's Treatise on the Venereal Disease, by Adams, p. 58. London, 1810—B. Bell's Treatise on Gonor- rhoea Virulenta and Lues Venerea—Swediaur's Practical Ob- servations on Venereal Complaints, by Hewson—Adams on Morbid Poisons, edit. 2d—Sawrey's Inquiry into some of the Effects of the Venereal Poison, 1802—Carmichael's Essays on the Venereal Diseases which have been confounded with Sy- philis—Carmichael's Observations on the Symptoms and Spe- cific Distinctions of Venereal Diseases—Jeffrey's Practical Observations on Cubebs. London, 1821—Johnston and Bart- lett's Report of Cases of Gonorrhoea, in Edinburgh Medical and Surgical Journal, vol. 14—Roberton's Remarks on the Internal Use of Tincture of Cantharides in Gleet, tifc, in Edinburgh Medical and Surgical Journal, vol. 2. p. 134. Syphilis. 333 Section XII. Syphilis. It may perhaps with truth be said, that previous to the time of the illustrious Huuter no very accu- rate views were entertained respecting the nature of syphilis or lues venerea. This great pathologist, aware of the confusion and obscurity in which the disease had been involved from loose and fallacious descriptions of its symptoms, and of the ill conse- quences which often resulted from confounding af- fections in reality very opposite to each other, en- deavoured to establish the true character of the ve- nereal ulcer, as contradistinguished from other ul- cerations to which the genitals had been subject from time immemorial. The fidelity of his details and accuracy of his distinctions have been amply ac- knowledged by most subsequent writers; within a few years, however, new facts have accumulated, or at least forms of disease apparently new have been brought forward, which, if admitted to be 334 Syphilis. strictly venereal, are calculated to subvert all former distinctions, and in defiance of precepts founded upon data supposed to be firmly established, are likely to involve in utter confusion and perplexity all knowledge of the disease or of the method of cure. But fortunately, many of Mr. Hunter's facts, and the inferences which he drew from them, are confirmed and supported, unintentionally, by the ad- vocates of the new-fangled doctrines and the promul- gators of new diseases. Most of these diseases, it is well known, have been described with great precision and accuracy by Celsus, in his chapter " de obsccena- rum partium vitiis," upwards of twelve centuries ago, and long before syphilis was known to exist That the venereal disease appears now under the exact forms described by Mr. Hunter, I shall ever be firmly persuaded, so long as I observe the symptoms and appearances daily met with in patients, to corres- pond with his descriptions. What changes the dis- ease may have undergone in Europe, I cannot say; but in this country, so far as numerous opportuni- ties of treating it can be depended on, I have no hesitation to declare, that the old fashioned chan- cre, so minutely and accurately pourtrayed by Hunter, is exceedingly common, and may be seen Syphilis. 335 at any time in full luxuriancy. These remarks are not made to invalidate the statements of the respectable European and American writers, who contend for the existence of a plurality of vene- real poisons, but merely to express a belief, that diseases resembling syphilis, and often confounded with it, are by no means unfrequent; and that ge- nuine syphilis, as it was understood by Mr. Hun- ter, is still known, however modified occasion- ally by peculiarities of constitution, climate, &c. Under this impression, I shall proceed to treat of the primary symptoms of syphilis, commencing with chancre. Chancre, or the true syphilitic sore, usually begins with a slight redness or inflammation on some part of the genital organs, attended with pruritus or itch- ing. This itching is soon converted into pain, and a pimple is in a short time formed, filled with pus. which upon bursting leaves an excavated ulcer of a circular shape, with hard and abrupt edges and a surface coated with a grey, tenacious matter. The base of the ulcer is thickened and indurated, and the parts surrounding it for some distance convert- ed into a tumour so distinct and circumscribed, that 336 Syphilis. it may be elevated by the fingers, and feels like a hard and moveable body beneath the skin. This description will particularly apply to chancre when seated on the glans penis; some variation is observa- ble, however, when the prepuce or fraenum are af- fected. In such cases the inflammation is generally higher, the pain more considerable, and, instead of a regular pimple filled with matter, the chancre often follows directly a slight excoriation or abra- sion of surface. When seated on the common skin of the penis or scrotum, the matter discharged from the sore soon dries and forms a scab, which quickly drops off and is succeeded by another of larger size. Wherever situated, chancre commonly preserves certain general features that serve to distinguish it from common sores, the edges of which are usu- ally smooth and shelving—while those of chancre are jagged and vertical. But, perhaps, the most characteristic sign of genuine primary syphilitic ul- ceration is the indurated base; and so long as this continues, even although the sore may have healed, little doubt will remain of the presence of disease. Chancres may occupy any part of the surface of the body, but they occur more readily on mucous Syphilis. 337 membrane than on the common skin. When situ- ated on the penis, they are usually met with along the fraenum, behind the corona glandis, in the mouth of the urethra, or on the internal surface of the prepuce. Among females, the parts commonly attacked are the labia, the nymphae, and the en- trance of the vagina; though not unfrequently very large and virulent chancres appear on the perinae- um, the outside of the labia, near the anus, or on the hip. Sometimes the lips, eyelids, or edges of the nostrils, are covered with chancres from the in- advertent application of syphilitic matter by the fin- gers. The fingers themselves, if their extremities be pricked or sore, may suffer from handling chan- cres, or from delivering infected women. The period at which a chancre appears after the application of the venereal virus, is very uncertain. Sometimes the disease follows in twelve or fifteen hours; at other times several days elapse; and in a few instances no ulceration takes place for two or three months. There is reason to believe that a chancre, so small as scarcely to be perceptible, sometimes exists; and, again, that absorption of the virus now and then follows from the most insignifi- Vol. I. 2U 338 Syphilis. cant scratch, or from an abrasion of the surface of the penis so slight as to escape the patient's notice. So long as a chancre is confined to the penis, or any other texture it may happen to occupy, the disease may be considered strictly local; in a greater or less time, however, if not arrested in its progress, the virus extends to the system through the medium of the absorbents, and gives rise to secondary symp- toms. The first evidence of its approach towards the system, is generally an enlargement of the lym- phatic glands in the vicinity of the sore, known by the name of bubo. Bubo always takes place in those lymphatic glands in the immediate neighbourhood of the chancre, while the deeper seated or remote glands remain unconta- minated, or at least do not enlarge or suppurate. As chancre generally occupies some part of the penis. the glands of the groin are the ones commonly af- fected. Sometimes several glands are enlarged and form a cluster; but, according to Mr. Hunter, one gland only is usually affected. A bubo does not invariably follow a chancre, and yet the system is not less liable in such cases to contamination. This circumstance, amongst others, has induced some sur- Syphilis. 339 geons to believe that bubo does not arise, as is com- monly imagined, from the absorption of venereal virus, but from an inflammation in the extremities of the lymphatics excited by the chancre* Such an idea appears not improbable, and yet it must be recollected that the matter of bubo is infectious, which could hardly happen from simple irritation excited by inflammation. Why the glands, how- ever, contiguous to the sore should suffer while the distant ones escape, is not easily explained; for, upon the supposition of the virus being absorbed, it should follow that, by passing through the whole, all should be equally liable to disease. Bubo seldom arises from a chronic chancre, but usually makes its appearance soon after the chan- cre is established. It is more apt to follow a chan- cre on the prepuce or fraenum, than one situated on the glans penis, and is late or early in its appear- ance according to the degree of inflammation exist- ing in the sore. Oftentimes a bubo remains sta- tionary for weeks, neither tending towards resolu- tion nor suppuration; in general, however, it is of a See Allan's Surgery, vol. i. p. 200. 340 Syphilis. bright scarlet colour, exceedingly painful, and quick- ly runs into suppuration. Occasionally it takes on the erysipelatous inflammation. The ulceration which follows a bubo does not differ from that of common chancre, and the matter from it is equally infectious. The bottom of the ulcer is hard and solid to the touch, and the surface either of a dark red or brownish colour, or of a yellowish cast. Very extensive ulcerations now and then follow a bubo. I have seen each groin and the greater part of the pubis laid bare, or entirely divested of integu- ment. In some constitutions buboes degenerate into insensible and very troublesome fistulae, that resist every application. Sometimes the skin covering a bubo entirely closes, but not uniting with the parts beneath leaves a hollow, from which in a short time a thin serum is discharged through small holes or pores formed in the skin. In such cases, the in- teguments generally assume a leaden or bluish co- lour and have an unhealthy aspect. Buboes frequently arise from other causes than the absorption of venereal virus-from wounds or injuries of the foot, from colds, fevers, the Syphilis. o4>\ mechanical irritation of mercurial ointment ap- plied to the leg or thigh of the affected side, from gonorrhoea, &c. Such swellings cannot be distin- guished always from the true syphilitic bubo, and much mischief has resulted from severe and unne- cessary salivations—under an imaginary idea of ve- nereal taint. The surgeon should, therefore, care- fully inquire into the history of every such com- plaint before he ventures to give a decided opinion respecting its nature. Bubo should be looked upon as one of the pri- mary symptoms of syphilis; for so long as the vene- real virus is detained in the glands or their vessels, it may be considered as only on its way to the sys- tem. When the lymphatics themselves are inflamed from a chancre, there is usually perceived a hard cord, which runs from the sore along the back of the penis towards the pubis or groin. The secondary or constitutional symptoms of sy- philis present themselves under several forms, which usually appear in regular order or succession. The parts first attacked are the throat, nose, mouth, tongue and skin; and next to these the periosteum, 342 Syphilis. fasciae, tendons, bones, ligaments, eyes, ears, &c. Frequently the skin is the texture first affected; but the throat, as far as my observation extends, com- monly affords the earliest evidence of absorption of the venereal virus. The disease appears in the form of ulceration, and usually occupies the tonsils. So slight is the pain in most instances, that the dis- covery of the sore is often accidental. When ex- amined, the ulcer will be found coated with an ash coloured or brownish matter, that gives it a foul or unhealthy appearance, while the surrounding parts are slightly inflamed and tinged with a copper cast. In the advanced stages of the disease the ulcer is excavated, or, as Mr. Hunter has expressed it, " dug out." These marks will be sufficient to distinguish it from other ulcerations to which the throat is lia- ble; though in some instances the resemblance to common sore throat is so striking as to deceive the most experienced practitioner. In general, how- ever, there is less inflammation and pain in the ve- nereal sore throat than in the common forms of the disease. As the ulceration advances, one or both tonsils, the uvula, velum palati, membranous part of the Syphilis. 343 eustachian tube, and even the epiglottis, may be en- tirely destroyed—giving rise to permanent deaf- ness and incessant cough, and endangering the pa- tient's life from suffocation, by permitting food and drink to enter the larynx. In many instances a com- munication is established between the nose and mouth—from the ulceration having destroyed the soft parts and bones of the palate. At other times, the disease travels along the schneiderian membrane, undermines the septum and cartilaginous part of the nose, destroys the periosteum covering the thin and delicate bones, which are soon rendered completely carious, and crumble away, leaving the nose sunk and ruined, the features dreadfully deformed, and the patient in the most loathsome condition, with foul and fetid matter flowing perpetually from the nostrils or into the throat, and a breath so extremely offensive as to render the sufferer hateful to himself and disgusting to his friends. Venereal eruptions, or cutaneous blotches, do not always possess uniform characters; though the symp- toms in general are sufficiently decided to enable us to form a correct diagnosis. In many instances the whole skin becomes discoloured or mottled, or co- 344 Syphilis. vered by an efflorescence, which is often preceded by general indisposition—such as fever, restlessness, headache. At other times circular patches appear, in distinct spots on different parts of the body, each of which proceeds from an indurated lump of a pale red colour. The patch slowly enlarges, and in a lit- tle time its centre is rendered flat and becomes in- crusted with whitish scales. These gradually des- quamate and are succeeded by others of a similar appearance, until at last the skin cracks and dis- charges matter, which soon hardens on the surface and forms a scab of a dark brown or copper colour. This seldom extends beyond half an inch in diame- ter, and after a time drops off and leaves an ulce- rated surface, which gradually spreads, deepens, and becomes covered with a thick, fetid, greenish matter. The parts commonly occupied by venereal erup- tions are the back of the neck, the forehead, breast and groin. Frequently the palms of the hand and soles of the feet are affected. The extremities of the fingers and toes are also liable to suffer; in which case, the surface beneath the nail becomes red and tender, and the nail soon drops off Syphilis. 34:"* The periosteum and bones dire next in the order of contamination. All the bones do not appear to be equally susceptible of impression from absorp- tion of the virus. Those thinly covered by inte- guments, or situated near the surface of the body, particularly the cranium, clavicle, sternum, tibia, radius and ulna, are most liable to suffer. The first evidence of the disease having reached the pe- riosteum and bones, is an enlargement or tumour, called a node, which increases slowly, never attains a very large size, and is seldom painful until it has existed a considerable time. At last, however, the integuments covering the tumour become red and inflamed, deep-seated and acute pain is felt in the part, and extends from it to a considerable distance, often throughout the limbs, especially at night when the patient lies warm in bed. In a greater or less time the swelling loses its hard and solid con- sistence, becomes soft and fluctuating, ulceration takes place on the most prominent part and soon opens a communication with the interior, from which is discharged an ill-conditioned, glairy mat- ter. The bone may now be felt rough and bare, or completely carious. When the node is seated on the skull, both tables are often perforated with nu- V ol. I. 2 X 346 Syphilis. merous holes, and resemble in some respects a piece of worm-eaten wood. Patients who have suffered from repeated attacks of syphilis, and have taken large quantities of mercury, often have the bones greatly enlarged and thickened throughout their whole extent When examined also, such bones are found much heavier than usual. When a node proceeds from inflammation of the periosteum alone, the swelling may frequently be removed entirely; but it seldom wholly disappears when once the sub- stance of the bone itself has been involved. All the secondary symptoms of syphilis are pre- ceded or accompanied by more or less constitution- al derangement; but this is oftener observed during the latter stages of the complaint, than at any other period. The fever is either periodical or constant, and generally assumes the hectic form. Sometimes it is so severe and unrelenting, as greatly to reduce the patient's strength, producing resUessness, ema- ciation, diarrhoea. At other times it seems to be the immediate cause of his death. Secondary symptoms of every description are dis- tinguished from the primary, in not communicating Syphilis. 347 a specific or infectious disease, similar to that arising from chancre or bubo. This has been proved in the most satisfactory manner, by the experiments of Mr. Hunter. Besides the venereal sore throat, blotches, and affections of the bones, there are other symptoms that have been generally considered belonging to the secondary order. These are venereal warts, condylomatous tumours, alopecia or falling off of the hair, syphilitic ophthalmia or iritis, and other affec- tions, some of which are not strictly venereal. Venereal warts are very apt to follow chancres, and usually occupy the same situations. They arise by a narrow neck or pedicle, and are expanded on the surface—resembling a mushroom. They are some- times exceedingly painful, and bleed profusely upon the slightest touch. Frequently the whole glans penis or vulva are completely covered by these ex- crescences. Condylomatous tumours usually occupy the verge of the anus. They are firm and fleshy, broad at the 348 Syphilis. base, jrregular on the surface, and frequently ulce- rate and become very troublesome. Alopecia does not invariably follow the secondary symptoms of syphilis, even when the system is tho- roughly contaminated. In many cases, however, large quantities of scurfs or scales form about the roots of the hair, which are soon loosened and drop out, leaving the scalp perfectly bare. The eye- brows, also, not unfrequently fall off and are seldom regenerated. Iritis will be noticed when we treat of ophthal- mia. There are many diseases which bear a considera- ble resemblance to the primary and secondary forms of syphilis. These have been described by different writers under the name of pseudo-syphilis, aud other similar appellations. At a future period an account will be given of each under separate heads. The question concerning the identity of syphilis and gonorrhoea might next be entered upon. Im- mense difficulties, however, necessarily attend an in Syphilis. 349 quiry of this sort,—especially as the most opposite conclusions have been drawn from experiments per- formed by surgeons of equal intelligence and respec- tability. Thus, Mr. Hunter, from experiments made upon himself, as now generally understood, and upon other patients with the matter of gonorrhoea and of chancre, was induced to declare that the dis- eases were essentially the same, but often produced opposite effects—owing to the difference in the na- ture of the textures to which they were applied. Again—Vigaroux, in support of the same opinion, details the cases of six Frenchmen who had connex- ion with the same woman in rapid succession; the first of whom had a chancre, the second and third a gonorrhoea, the fourth and fifth a chancre, and the sixth a bubo. On the other hand, Mr. Benjamin Bell has furnished an account of several experi- ments, some of which were performed by medical students upon themselves, with the matter of gonor- rhoea and that of chancre,—the former of which was applied to the glans penis, both by simple con- tact and by inoculation, without producing more than a slight inflammation and discharge from the surface; while the matter of chancre, introduced into the urethra, instead of creating gonorrhoea. 350 Syphilis. produced chancre within the passage. Similar results have been obtained by other surgeons of the first respectability, all of which tend to estab- lish the reverse of Mr. Hunter's position, and to prove that the two diseases are totally distinct from each other. How are such conflicting discrepan* cies to be reconciled, and with what prospect of success can we enter upon an investigation, which seems to have puzzled and defied some of the ablest men that have ever attempted to unravel its myste- ries? The arguments on each side of the question, at any rate, are too numerous to be introduced into an elementary work of this description; but I have no hesitation to affirm my belief in the existence of two distinct and separate poisons, each of which is capable of producing effects peculiar to itself. Treatment of Syphilis. It is well known, perhaps, that within a few- years, an attempt has been made, chiefly by the Bri- tish army surgeons, to remove the different forms of syphilis without the use of mercury; and in proof Syphilis. 351 of the efficiency of the plan, the results of experi- ments, made upon a most extensive scale, have been brought forward, and are so well attested as to leave no room to question the accuracy of the details or the correctness of the inferences drawn from them. From an official document, pub- lished by Sir James M'Grigor and Dr. Franklin, it appears that nineteen hundred and forty cases of pri- mary venereal ulcerations on the penis were cured without mercury, between December, 1816, and December, 1818; and that during the same period, two thousand eight hundred and twenty-seven chan- cres, the greater number of which were charac- terized by a hardened base, were cured with mer- cury. Out of this number the average period oc- cupied in the treatment of chancres, unattended by bubo, by the non-mercurial plan was twenty-one days,—those with bubo, forty-five days. On the other hand, it is stated, that the chancres unaccom- panied by bubo, and treated with mercury, required upon an average thirty-three days for their removal, and fifty days when conjoined with bubo. From these data the inference is plain, that primary syphi- litic sores may be cured in a shorter time without the use of mercury than with it; and this conclusion 352 Syphilis. has actually been drawn by the advocates for the non-mercurial plan of treatment, whilst at the same time they acknowledge the utility of mercury under particular circumstances, and admit that certain cases prove obstinate or incurable unless this medi- cine be employed. With regard to the greater or less frequency of secondary symptoms, after the re- moval of primary sores treated by mercury, or with- out it, the amount of evidence afforded up to the present time is, that such symptoms are most con> mon when mercury has not been employed; but on the other hand, that those troublesome and severe affections of the bones—nodes, caries, &c, formerly so common, hardly ever follow the non-mercurial course, and that all the other secondary symptoms are milder and more easily subdued when mercury has not been used. It must not be concealed, however, that there are still many respectable and intelligent surgeons, both in Britain and in other countries, who not only condemn the anti-mercurial practice, but doubt the accuracy of many of the statements furnished by the army surgeons; and contend that there is every reason to believe that the patients, supposed Syphilis. 353 to have been cured without mercury, have taken the medicine surreptitiously, employed secretly caustic applications to their sores, or that cures have follow- ed from the mercurial dressings, acknowledged by the army surgeons themselves to have been used in numerous instances. But these inferences and sus- picions, it appears to me, are unjustifiable, inasmuch as the cases brought forward in support of the prac- tice are too numerous, and the authority of the sur- geons too respectable, to admit of any doubt on the subject Whilst it must be acknowledged, then, that the venereal disease, contrary to the tenets of Mr. Hunter, does not become progressively worse and worse unless arrested by the use of mercury, and that complete cures have been effected in nume- rous instances by different remedies, yet it re- mains to be ascertained how far these remedies can with certainty be depended on, the particu- lar cases to which they are adapted, and the circumstances under which mercury may be dis- pensed with or administered with advantage. It is true, this has already been attempted, but not upon so sure a foundation as to induce us to lay aside a Vol. I. 2 Y 354 Syphilis. remedy which we know to possess undoubted sana- tive powers, and which we have reason to believe will be followed by no ill consequences if judiciously employed. As chancre, in its commencement, must be con- sidered strictly a local disease, local remedies will often prove sufficient to arrest its progress or effect a cure. It is proper, therefore, in every instance, provided the inflammation does not run very high, to touch the sore repeatedly with some active es- charotic—such as the lunar caustic, or the caustic potash. These lessen the irritability and convert the chancre into a simple ulcer, which speedily heals without contaminating the system. If, how- ever, the chancre has existed for some time pre- vious to the application of the caustic, in all proba- bility no benefit will result, owing to the virus hav- ing extended beyond the sore, which indeed, under such circumstances, may be rendered worse, or at least larger, by the caustic. It will then become necessary to employ internal remedies, and there are none so effectual as mer- curial preparations. Of these calomel and the blue Syphilis. 355 pill will be found most useful. The former may be given alone in the dose of a grain, morning and evening, or in combination with opium, which pre- vents the medicine from passing off by stool; the lat- ter may be exhibited two or three times a day, in the proportion of five grains at each dose. In gene- ral, the blue pill should be preferred to calomel, in- asmuch as it is milder and more gradual in its opera- tion. With particular constitutions, however, it dis- agrees—owing, perhaps, in some instances to an im- proper mode of preparing the medicine. Conjoined with the internal use of mercury, its application to the skin in the form of inunction will often prove absolutely necessary. Two or three drams of the ointment should be rubbed on the in- ner surface of the thighs, every morning and even- ing, by an assistant, until the greater part of it dis- appears. If pimples or ulcerations arise from the friction, which is often the case, the rubbing should be discontinued or transferred to the legs and arms. Sometimes an inflammation is excited in the course of the absorbents by mercurial friction, from which a bubo arises. Under these circumstances, it must immediately be laid aside. 356 Syphilis. In no instance can it be necessary to push the mercury, as it is termed, either for the cure of a chancre or any other stage of syphilis. Nothing more will at any time be required than to touch the mouth lightly or produce a gentle ptyalism. From inattention to this, many patients have suffered im- mensely, and others have lost their lives. As local applications to the chancre, several arti- cles will prove highly serviceable. The black wash, prepared by adding two drams of cilomel to an ounce of lime water, I have used with the utmost advantage. The mixture should be well shaken pre- vious to its application, and the cavity of the chancre covered by the thick powder that afterwards settles at the bottom of the vial. Dry lint sometimes forms an excellent application to a chancre. When the sore requires stimulating, I have known no articles so useful as the compound ointment of the acetate of lead, the yellow wash, citrine ointment, and the diluted tincture of the muriate of iron. Some chancres spread and become extremely in- dolent, or else are converted into indurated excres- cences, which occasionally attain a large size and feel Syphilis. 357 like an ordinary schirrus. At other times the ulcer burrows or creeps from one part of the penis to another, opens the cells of the corpus spongiosum, and gives rise to profuse hemorrhage, and eventu- ally, if not arrested, destroys the penis. In all these cases, I have derived great benefit from the internal use of the phosphate of mercury, cautiously admin- istered in doses of half a grain twice a day, and lo- cally from adhesive plasters, which, by drawing to- gether the edges of the sore, often promote their reunion. To obviate erections, which frequently cause the chancre to spread by breaking up the adhesions as fast as they are formed, the internal use of camphor will be found indispensable. Sometimes chancres, instead of becoming indo- lent, take on acute inflammation, which may run so high as to terminate in mortification and loss of the penis. In bad constitutions, this state is frequently brought about by the operation of mercury. When this happens, the medicine should instantly be laid aside, and the patient placed on a low diet, whilst blood-letting and purgatives are freely employed. 358 Syphilis. together with warm poultices to the penis and opiate and other injections between the glans and prepuce. If the chancre is accompanied by phymosis, or paraphymosis, as often happens, we should never think of slitting up the prepuce, during the height of the inflammation, as sloughing would be very apt to follow, or at any rate the cut edges be converted into chancres. Simple and unimportant as an ope- ration of this kind may appear, I have known morti- fication and death to follow from it in one instance, which occurred not long since in the practice of a respectable surgeon of this city. The true practice, in all such cases, is to combat the inflammatory symptoms by appropriate remedies. In spite of all our efforts, it frequently happens, that the disease is not removed, but pursues its course towards the system and appears next in the shape of bubo. To prevent this from terminating by suppuration, blood-letting, purgatives and other parts of the antiphlogistic system should be immediately resorted to. These, unaided, will often prove suf- ficient to discuss the swelling or to procure resolu- Syphilis. 359 tion; but in many instances this purpose cannot be effected until the system is placed under the influ- ence of mercury; and the sooner, therefore, this event can be brought about the better. It may be proper, however, to state, that mercury, when em- ployed in certain irritable constitutions, instead of resolving a bubo, will sometimes cause it to suppu- rate and to degenerate into a troublesome sore; and again—that the same effect may occasionally arise from the inflammation produced by the mechanical operation of friction, in the act of introducing the mercury into the thigh of the affected side. When- ever there is reason to suspect that inordinate irri- tation proceeds from either of these causes, the mer- cury must be discontinued and the patient confined to the horizontal position, in order to keep the parts as still as possible, whilst at the same time cold sa- turnine solutions are applied constantly to the groin; or what frequently answers a better purpose, the tu- mour may be covered by a blister, which has always been a favourite remedy with Dr. Physick in the early stage of bubo. Some surgeons, under similar circumstances, recommend leeches to the swelling. I have known, however, great irritation and trouble- some ulcerations to follow from the bites of these 360 Syphilis. animals when applied to the inflamed gland, and therefore seldom prescribe them in such cases. Should these remedies fail, and suppuration be- come inevitable, then the mercury should be re- sumed, and warm poultices applied to the groin un- til the matter is discharged. Sometimes it happens that suppuration is established, and yet the matter, owing to the impression made upon the disease by mercury, is afterwards absorbed and the skin re- mains entire. If there is reason to think such an event probable, the poultice should be laid aside, and a simple dressing substituted. On the other hand, when the matter is copiously secreted, and at the same time backward in its approach to the surface, the abscess should be opened by the lancet or caus- tic. The former I prefer in every instance, as it gives less pain than the caustic and discharges the matter at once. Dr. Parrish informs me, that he has sometimes treated suppurating buboes very suc- cessfully, by making a number of small openings through the skin, discharging the matter gradually, and afterwards pressing the sides of the cavity to- gether by a soft sponge or compress. Syphilis. 361 When the ulceration which frequently follows a bubo proves obstinate and spreads, the applications recommended for chancre, particularly the black wash, should be tried. If the edges of the sore be- come hard and insensible, they may be pared away with the knife or destroyed by repeated touches with caustic. Indeed, the whole surface of an ulcerated bubo is often rendered so indolent as to require a very liberal use of caustic, savin powder, and other articles equally stimulating. The treatment of secondary symptoms must de- pend upon the extent of the disease. In general, mercury will be necessary throughout every stage; though the quantity administered will be trivial, compared with that employed for the removal of primary symptoms. There are certain preparations of the medicine also, which seem particularly adapt- ed to the advanced stages of syphilis. The muriate of mercury or corrosive sublimate, has acquired in this particular a very high reputation, and as I think deservedly; many practitioners, indeed, very much depend upon it throughout every form of the complaint. Mr. Pearson, however, whose oppor- Vol. I. 2 z 362 Syphilis. tunities of testing the anti-venereal powers of various medicines have been very extensive, holds it in low7 estimation, when applied to the treatment of primary symptoms; whilst he admits that it is "peculiarly efficacious in relieving venereal pains, in healing ulcers of the throat, and in promoting the desqua- mation of eruptions." There are various modes of exhibiting the article, which, if given in large doses and in an improper vehicle, will frequently give rise to excessive thirst, burning in the throat, nausea, vomiting and other violent symptoms. For several years past I have used the medicine very extensively in all the consecutive affections, and frequently with immense advantage, in doses of thirty or forty drops of a solution, composed of a grain of the salt to an ounce and an half of water, and given two or three times a day. As a gargle, also, in venereal sore throat, there is no application more effectual. Should the corrosive sublimate, internally admin- istered, prove insufficient to touch the mouth or re- move the disease, the blue pill and calomel may be resorted to; and if these also fail, there is another mode, and the most expeditious we are acquainted with, of introducing the medicine into the system —by fumigation. Syphilis. 363 This practice was known at a very early period, and indeed employed extensively in every form of syphilis, in preference to the internal use of mer- cury. It appears at one time to have been aban- doned, but afterwards revived by Lalouette, a cele- brated physician at Paris, who states, that during the space of thirty-five years, he had cured by means of it upwards of four hundred patients, after all the ordinary remedies had failed. Upon the re- commendation of Mr. Abernethy, I commenced many years ago this plan of treatment, and found it greatly to exceed my expectations,—producing in a very short time a decided impression, after the sys- tem had resisted for weeks or months the operations of calomel and the blue pill. It is well known, in- deed, that there are many patients upon whom these and most other preparations of mercury fail to in- duce a salivant effect—which is afterwards brought about very speedily by fumigation. This circum- stance has been adduced as an objection to the gene- ral employment of the remedy, inasmuch as it is diffi- cult to introduce into the system a sufficient quan- tity to insure permanent benefit—owing to the ra- pidity with which the mercury operates when thus administered. 364 Syphilis. There are two or three modes of conducting the fumigating process; one of which, and per- haps the most simple, is to seat the patient, who is previously stript to the skin, in a common arm chair, and surround the whole body, with the ex- ception of the head and neck, with thick blankets. Beneath the chair is then placed a common iron pot or chafing-dish, full of live coals, and over this a thin sheet of iron, the surface of which, when heated, must be strewed with some mercurial preparation capable of volatilization. The fumes ascending, penetrate the skin in every direction and enter perhaps the lungs. A copious perspiration is usually the result of the operation; and to prevent the patient from taking cold, he should be carefully wrapt in the blankets and conveyed to bed. Another method, more complicated and perhaps not more effectual, is to enclose the patient in a box, resembling a sedan chair, having an opening at the top to let out the head, and another at the bottom holding a small furnace. The preparations usually employed in either process are factitious cinnabar, the black sulphuret of mercury, or else a grey powder, formed by mixing together four ounces of calomel, Syphilis. 365 two drams of aqua ammoniae and six ounces of dis- tilled water. This powder is separated by filter, and dried, and is preferred by Mr. Abernethy to any other in use. The great advantage possessed by fumigation over the common modes of introducing mercury is, as before mentioned, its speedy operation, which ren- ders it particularly valuable in all those ulcerations of the throat and nose, which are rapidly spreading, and threaten destruction to the delicate parts amongst which they are seated. From extensive experience, I can recommend the plan, in all such cases, with the utmost confidence. Nor have I found it less effectual in dispelling venereal discolourations of the skin and blotches. Besides mercurial preparations, there are others equally efficacious in breaking up the remnants of sy- philis. These are the mineral acids, used singly or conjointly, certain vegetable extracts, particularly sarsaparilla, guiacum, mezereon, administered in the form of decoction or mixed with syrups, and generally containing more or less of corrosive sub- limate—such as the syrup of Cuisiniere, the de- 366 Syphilis. purative ptysan of Vigaroux, the rob anti-syphili- tique of Laffecteur, the panacea of Swaim; all of which, in particular cases, often prove extremely serviceable, in relieving pain, healing ulcerations, or in restoring constitutions enfeebled or injured by the abuse of mercury. Of the acids, the nitro-mu- riatic, as used by Dr. Scott in the treatment of he- patitis, and by Mr. Charles Bell for secondary sy- philitic symptoms, will be found the most convenient and serviceable. In many cases the muriate of gold effects a cure, after the failure of all other remedies. Nodes are often extremely difficult to remove. In general they are benefited by mercury slowly introduced, and by external applications, such as the linimentum hydrargyri ammoniatum.* As an internal remedy, arsenic has been found highly ser- * The following formula of this medicine will answer for a variety of surgical purposes. R. Ung. hydrargyri fort. Adip. suillse. prsep. sing. |i. Camphorse. 31J. Ammonise liq. giv. First rub the camphor with a few drops of alcohol, and then with the ointment and lard, and lastly add by degrees the liquor ammonise, and mix the whole together in a glass mortar. Syphilis. 367 viceable in obstinate nodes. Dr. Dewees informs me, that he has successfully prescribed the medi- cine in such cases for the last twenty years, and Dr. Colhoun of this city, who has published a short account of the remedy as adapted to these affections, speaks in high terms of its utility. Venereal warts may be removed by the knife or scissors, and sometimes by the application of acetic acid, the compound powders of rhubarb or savin, the muriated tincture of iron, butter of antimony, finely levigated arsenic, &c. Consult Hunter on the Venereal Disease, by Adams—Ben- jamin Bell on Lues Venerea—Adams on Morbid Poisons__ Sawrey's Inquiry into some of the Effects of the Venereal Poison, 1802—Swediaur on Syphilis, Sfc, translated by Hew- son—Abernethy's Surgical Works, vol. 1—Blair's Essay on the Venereal Disease, and the Effects of Nitrous Acid and other analogous Remedies, lately proposed as Substitutes for Mercury, 1808—Pearson on the Effects of various Articles of the Materia Medica in the Cure of Lues Venerea, edit. 2d. 1807—Carmichael's Essays on the Venereal Diseases which have been confounded with Syphilis, 1814—Carmichael's Ob- servations on the Symptoms and Specific Distinctions of Ve- 368 Syphilis. nereal Diseases, 1818—Rose's Observations on the Treat- ment of Syphilis, with an Account of several Cases in which a Cure was effected without Mercury, in Medico-Chirurgical Transactions, vol. 8—Hennen's Observations on Syphilis, in his Principles of Military Surgery, p. 488—Evans's Remarks on Ulcerations of the Genital Organs, 1819—Bacot on Sy- philis, 1821—Charles Bell's Report on the Use of the Nitro- Muriatic Acid Bath in certain obscure Cases of Syphilis, in his Surgical Observations, vol. 1. p. 338. Fractures. 369 CHAPTER VII FRACTURES. The bones are all subject to fracture; though some yield more readily than others. In general, the long or cylindrical bones more frequently suffer than the short or flat ones, inasmuch as they serve a greater number of purposes, and are commonly under the influence and direction of large and pow- erful muscles. A bone may be broken either by a direct blow, or by force applied to both of its extremities at the same moment. In the former case, the fracture oc- curs at the spot upon which the injury is imme- diately received; in the latter, the bone commonly yields about its centre, or at some intermediate por- tion. The muscles are always more or less con- cerned in the production of fractures, and in many instances without any other co-operating power break the largest and strongest bones. At other Vol. I. 3 A 370 Fractures. times, the bones themselves, from old age and dis- eases,* are rendered brittle and are easily fractured, either from external violence or muscular action. Fractures are most frequent during very cold weather. On this account many have supposed that cold affects the texture of bones, and predis- poses them to give way. But the true explanation is, that persons in walking while the ground is hard and slippery, make unusual efforts to sustain them- selves, by which the muscles are rendered tense and thrown into full action, and if they happen to fall, the two powers combined—the resistance of the frozen earth and inordinate muscular exertion—very * A patient of mine, a Mr. Green, residing near Trenton in Jersey, has a son, now nineteen years of age, who from in- fancy up to the present period has been subject to fracture? from the slightest causes, owing to an extraordinary brittle- ness of the bones. The bones of the arm, fore-arm, thio-h and leg, have all been broken repeatedly, even from so trivial an accident as catching the foot in a fold of carpet whilst walking across the room. The clavicles have suffered more than any other bone—having been fractured eight times. What is remarkable, the boy has always enjoyed excellent health, and the bones have united without difficulty or much deformity. Fractures. 371 readily produce fractures, and sometimes more im- portant injuries. Fractures have been divided into different spe- cies—according to the extent of the injury, and the particular direction in which the fibres of the bone happen to yield. Thus, we have a simple, com- pound, and complicated fracture; and again, a trans- verse, oblique, comminutive, and longitudinal frac- ture. By the term simple fracture, is understood a mere separation of bony fibres, unattended by se- vere contusion or external wound. From this, a compound fracture differs, in being conjoined with an external wound, or with a protruded bone. A complicated fracture implies that the bone is broken at more than one place, or is combined with luxa- tion, with laceration of one or more large vessels, or rupture of ligaments, tendons, &c, or with a gun-shot wound A fracture is said to be trans- verse, when its direction is perpendicular to the axis of the bone. It is denominated oblique, when it deviates from the perpendicular direction. In comminutive fracture, the bone is broken into seve- ral pieces or Grushed into fragments. A longitudi- nal fracture runs parallel with the axis of the bone. 372 Fractures. The signs of fracture are not-always very deci- sive. In general, however, crepitation, or that par- ticular noise or sensation produced by rubbing to- gether the fragments of a broken bone, is more to be relied on than any other, and is an almost certain indication of fracture. Added to this, there is usually more or less deformity, pain, swelling, inability to use or move the limb. But these symptoms may at- tend luxation and other diseases, and are therefore not unequivocal proofs of fracture. Besides, it is possible for a patient actually to labour under frac- ture of one or more bones, and yet, from inter- locking of the fragments, or from a sound bone serving as a splint and supporting the broken one, no distortion will be perceived. Many instances are related of patients walking about, under these cir- cumstances, for some time after the accident." The prognosis in fracture will depend very much upon the extent of the injury, the constitution and age of the patient, the direction of the fracture, and the particular bone broken. Complicated and com- pound fractures will prove more dangerous than any * See Dorsey's Elements, vol. i. p. 113, and Allan's Sur- gery, vol. ii. p. 60. Fractures. 373 others, especially if they occur in old people and in bad habits of body. An oblique fracture is com- monly more difficult to manage than a transverse one, owing to the fragments of bone overlapping from muscular contraction. It is possible, however, for the ends of a bone, when broken transversely, to pass each other; though this seldom happens un- less the cause of the fracture act with uncommon violence, or some subsequent force be applied. In either case, the parts will sustain more injury, and the danger will be greater, than if the bone were broken obliquely and by a moderate force. The direction of displacement, or derangement of the fragments of a broken bone, must always depend either upon the force by which the accident was produced, upon muscular action or upon the weight of the body, or that of the injured part. Sometimes the derangement is angular, sometimes longitudinal or parallel with the axis of the bone, in other in- stances in the direction of its diameter, and again— in that of its circumference. 374 Fractures. Treatment of Fractures. The general indications in the treatment of frac- tures are, to prevent or subdue inflammation, and to coaptate and retain the fragments in contact by appropriate mechanical means, until they are restored to their pristine condition through the me- dium of callus. The former are best accomplished by the antiphlogistic system and by position—the latter by extension, counter-extension, splints and bandages. By extension is understood a force applied to the lower fragment, sufficient to remove it from the su- perior fragment; by counter-extension, a power cal- culated to resist the operations of extension. These means are not necessary, however, or applicable to all fractures. Frequently coaptation or a proper ad- justment of the fragments by the fingers will answer every purpose. In other instances, position, splints and bandages are only required. The bandages usually employed in fractures are made of coarse muslin or hummum, an ar- Fractures. 375 tide, from its flexibility and roughness, peculiarly adapted to fit accurately and adhere closely to any part of the body. The muslin should always be washed before it is used, and the selvage or rough edge torn off. Bandages should, if possible, be free from seams, which by pressure often excite irrita- tion or produce welts in the skin, that annoy the pa- tient more than the fracture itself. The single- headed roller and the bandage of Scultetus have superseded most others, and are adapted to a great variety of purposes. The roller is chiefly employed in fractures of the upper extremities, the bones of the chest, &c. In general, it accommodates it- self best to the shape of the part when somewhat narrow. The bandage of Scultetus is chiefly useful in frac- tures of the thigh and leg. It consists of numerous strips or pieces of the same breadth, and of equal or unequal length, according to the shape of the part it is intended to surround. Each piece over- laps the other about two-thirds. The great value of this bandage arises from the facility with which it can be removed and reapplied, without disturbing 376 Fractures. or moving the limb. It will be more particularly de- scribed hereafter. To apply a roller or any other bandage with neat- ness and effect, a great deal of practice will be re- quired. A student should be very careful, however, not to fall into the error I have known some young surgeons commit, from aiming at feats of dexterity and despatch—by drawing the roller with immode- rate tightness in order to make it lay smooth and hide rough edges—a practice well enough on the dead subject, but followed by pain, obstruction of the circulation, and other ill consequences, when applied to the living body. Again—the more a sur- geon accustoms himself to roll up his bandages with his own hands, the more dexterity will he acquire in applying them. Splints are made of different materials—of paste- board, binders' boards, wood, and tin. Binders' boards, however, answer a better purpose than the others in most fractures, inasmuch as they adapt themselves when moist to the shape of the injured part, and when dry have sufficient strength and stiff- ness to retain the position given to them. Common Fractures. 377 pasteboard is too thin and flexible to give any sup- port to a fractured bone, and tin, from its hard and unyielding nature, cannot be employed without creating pain or uneasiness. Wooden splints are chiefly adapted to fractures of the long and large cylindrical bones—as those of the thigh and leg. In general, splints should at least equal in length the fractured bone; sometimes they are required longer. The time necessary for reunion and consolidation of fractures, must vary according to the age and constitution of the patient, the situation and extent of the fracture, and some other circumstances. Young and healthy subjects recover in a shorter time than old and infirm, and the process of re- union is sooner completed in a small than a large bone. From two to eight weeks usually elapse be- fore consolidation is established, but a much longer time will be required for perfect restoration of the injured part. Vol. I. 378 Fracture of the Nose. Section I. Fracture of the Nose, fyc. The bones of the nose may be fractured and driven in by a blow, or they may be crushed by the passage of a wheel, or by a gun shot. In either case there is commonly more or less concussion of the brain. Sometimes the impulse is communicated to the septum, and from thence transmitted to the de- licate cribriform plate of the ethmoid bone, which is broken up and forced upon the brain—producing violent symptoms and even death. Such accidents, however, are rare; and the usual symptoms are severe pain, copious flow of blood, and difficulty of breathing. If the case has been* neglected, permanent deformity may ensue—from lateral dis- tortion or depression of the bones. From the same cause, also, incurable epiphora or fistula lachrymalis may result. The cheek and upper jaw bones are seldom frac- Fracture of the Nose. 379 tured, except by a gun-shot wound, or from the application of very great violence. In two instances I have known a considerable portion of the alveolar process broken off along with the teeth, from immo- derate force employed by an ignorant dentist in an attempt to extract a large stump. The antrum max- illare in one of the patients was completely exposed. Le Dran has furnished an interesting case of frac- ture of the upper jaw, in which four of the molar teeth, along with their alveolar processes, were broken up and forced under the roof of the mouth. Treatment of Fracture of the Nose. The nasal bones when fractured should be elevated and replaced as soon as possible, otherwise the pain and tumefaction become so great, that it is not easy to discover the direction of displacement; and be- fore these symptoms can be reduced, the bones may become fixed in their unnatural situation, and create great deformity and fistula lachrymalis. A case of the kind has been related by Boyer. To restore the fragments to their proper places. 380 Fracture of the Nose. the end of a female catheter or a strong probe, or any similar instrument, may be introduced into the nostrils and used as a lever, while the fingers are em- ployed externally in modelling the parts to their natu- ral shape. After the fragments have been elevated, they generally preserve their situation without the assistance of quills, lint, and other contrivances ad- vised to be stuffed into the nostrils, which cannot prove serviceable, but on the contrary must add to the irritation. The remainder of the treatment con- sists in removing the inflammation; after which the bones soon become firm, and a cure follows. Fractures of the upper jaw and bones of the cheek seldom require any other remedies than those calculated to subdue inflammation. When large portions of the alveolar processes, to which the teeth adhere, have been broken, and remain only attached to the soft parts, it has been proposed to replace the fragments and secure them, by fastening the insu- lated teeth with silk or thread to those in the sound part of the bone. This was successfully practised in Le Dran's case, but I much question the neces- sity of the measure. Fracture of the Lower Jaw. 381 Section II. Fracture of the Lower Jaw. The lower jaw, notwithstanding its mobility, is frequently fractured. The fracture may take place at or near the symphysis, between the symphysis and angle, at the angle itself, or in the condyloid or co- ronoid processes. Sometimes it is fractured in two places—on each side of the chin; in which case the chin is insulated, and there are three fragments and two fractures. The coronoid process, being co- vered and protected by very strong and fleshy mus- cles, is seldom broken; nor is the condyloid much exposed to such injuries. A separation of the jaw at the symphysis is usually met with amongst young subjects; though I have seen one instance of it in a man beyond forty years of age. Fracture commonly takes place on one side of the jaw only, and the most frequent seat of it is intermediate to the symphysis and angle. The 382 Fracture of the Lower Jaw. direction of the fracture may be oblique or trans- verse; except in fractures of the alveolar ridge, in which case the direction will be longitudinal. The signs of a fractured lower jaw are generally very distinct and evident. Crepitation can almost al- ways be observed, and upon looking into the mouth the teeth will be found irregular and oftentimes loosened. When the chin has been insulated by a fracture on each side of it, it will be drawn down- ward, considerably below the level of the adjoining fragments, by the action of the muscles of the throat inserted into its point Fracture of the neck of the condyloid process may generally be distinguished by the grating noise and pain produced in the neighbourhood of the ear when the jaw is moved, and by the circumstance of the condyle being dragged forward by the action of the pterygoideus extern us muscle. Treatment of Fracture of the Lower Jaw. The surgeon having carefully examined the injured parts, and replaced such teeth as are shaken or loose, Fracture of Hue Lower Jaw. 383 runs his fingers along the margin of the jaw, models the parts into a proper shape, and closes the mouth firmly, making the lower teeth rest fairly against the upper. Then a cotton or linen compress of moderate thickness, reaching from the angle of the jaw nearly to the chin, is placed beneath and held by an assistant, while the surgeon takes a roller, four or five yards long, an inch and an half wide, and passes it by several successive turns under the jaw up along the sides of the face and over the head; now changing the course of the bandage, he causes it to pass off at a right angle from the perpendicular cast, and to encircle the temple, occiput and fore- head horizontally by several turns: finally, to render the whole more secure, several additional horizontal turns are made around the back of the neck, under the ear, along the base of the jaw, over the point of the ehin. To prevent the roller from slipping or changing its position, a short piece may be secured by a pin to the horizontal turn that encircles the fore- head, and passed backwards along the centre of the head as far as the neck, where it must be tacked to the lower horizontal turn—taking care to fix one or more pins at every point at which the roller has crossed. This simple method of securing a fractured 384 Fracture of the Lower Jaw. jaw I have practised very successfully for several years. The operation is easier performed than de- scribed, but may be well understood by examination of the sketch in Plate VIII. A mode of securing the fractured lower jaw, apparently well calculated to answer the purpose, has been devised by Dr. J. R. Barton of this city.* Whatever plan may be pursued in bandaging the jaw, there can be no necessity for the interposition of pieces of cork between the teeth, or for pulling a tooth to nourish the patient, or for the introduc- tion of a gum elastic catheter through the nostrils for the same purpose, as there is always sufficient * The operation is thus described by Dr. Barton. " With a roller an inch and a half or three quarter's wide, comntence just below the prominence in the os occipitis, continue it ob- liquely over the centre of the parietal bone, across the junc- ture of the coronal and sagittal sutures, over the zygomatic arch, under the chin, and pursuing the same direction on the opposite side until you arrive at the back of the head, then pass it obliquely around and parallel to the base of the lower jaw, over the chin; and continue the same course on the other side, until it ends where you commenced; and repeat." Fracture of the Lower Jaw. 385 space between the teeth to enable the patient to imbibe broth or any other thin fluid placed between his lips. During the cure the jaw should be kept as still as possible, otherwise deformity is apt to ensue. Vol. I. sc 386 Fracture of the Vertebrae. Section III. Fracture of the Vertebras. The bones composing the spinal column are sel- dom fractured. Such accidents, however, when they do occur, are always the result of great vio- lence, and are generally followed, immediately or remotely, by most severe symptoms or by death. In some cases there is violent concussion of the spine without fracture, which gives rise to paralysis of the lower extremities; but this subsides in a little time and the patient recovers. The effects of frac- ture are more permanent, and although at first not always severe, may terminate most unfavourably. Sometimes an effusion of blood is found upon dis- section, either on the outer or inner surface of the spinal sheath; at other times the spinal marrow is compressed or wounded by a projecting fragment of bone. From either cause high excitement and pa- ralysis ensue, and at a later period inflammation and suppuration within the membranes of the spinal marrow. So copious, indeed, in some instances is Fracture of the Vertebras. 387 the matter, that it travels along the sheath, and is lodged at a great distance from the injured part. It is this thickening of the sheath from inflammation and suppuration within its cavity, that is the cause of death in nine out of ten cases. This explanation was first given by Mr Charles Bell, the only writer that appears to have taken a correct view of the pa- thology and treatment of injuries of the spine. Fractures of the vertebrae produce different ef- fects, according to the particular situation of the bone injured. If the fracture take place above the fourth cervical vertebra, death follows almost instantaneous- ly—owing to the injury sustained by the phrenic nerve. When the fracture occurs below the fourth vertebra, there is usually paralysis of the arms and difficult respiration, and death follows in four or five days. Fractures of the dorsal vertebrae are succeed- ed by paralysis of the lower extremities and by great torpor of the intestines. In some cases, the abdomen becomes enormously distended from quan- tities of air contained within !ie bowels. The pa- tient seldom lives beyond the third or fourth week. 388 Fracture of the Vertebrae. When the lumbar vertebrae are fractured, the bladder and rectum lose their powers of retention, and the urine and faeces pass away involuntarily; the lower extremities are completely paralyzed and perfectly insensible to the most powerful stimulus, while the heat and circulation in the limbs are but slightly if at all diminished. Death follows at a later period than after similar injuries of the cervi- cal and dorsal vertebrae; though the patient seldom survives beyond five or six weeks. Fracture of the spinous processes of the vertebrae is seldom followed by any serious consequences, un- less accompanied by violent concussion or some other injury. Treatment of Fracture of the Vertebras. From what has been said it will appear that little benefit may be expected in most cases from any treatment that can be adopted. It was long ago proposed to cut down upon the injured part, and re- move by the trephine the displaced portion of bone Fracture of the Vertebrae. 389 compressing the spinal marrow. Such an operation was actually performed by Mr. Henry Cline, but without success. I concur, however, entirely with Mr. Charles Bell, in thinking " that the palsy is a consequence of the swelling of the membranes, and proceeds from inflammation; and if you cut down upon the bone and saw it out, and expose these membranes, you will not only increase the swelling and thickening of the involving membranes, but you will most probably raise such direct inflammation and mischief as to cut off the patient suddenly."* Should the patient survive the immediate effects of the injury, the urine must be drawn off frequently by the catheter, and'such measures taken as are calculated to obviate inflammation within the sheath of the spinal marrow. Afterwards stimulating fric- tions, issues, &c. may perhaps prove serviceable. . * Surgical Observations, vol. i. p. 160. 390 Fracture of the Ribs. Section IV. Fracture of the Ribs. The ribs may be fractured from a direct blow or from force applied to their extremities. In the for- mer case an internal angular derangement will fol- low—in the latter the angle will be salient exter- nally. Owing to the extremities of the ribs being strongly connected to the sternum and spine, the fractured portions cannot overlap or pass each other; but derangement may occur in almost any other di- rection, though the angular is most common. Boyer has declared that derangement cannot happen in the direction of the diameter of a rib: this, however, is a mistake, as several specimens in my cabinet suffi- ciently prove. Fracture of a rib may be transverse, oblique, com- pound, complicated, and comminuted. The trans- verse are most frequent, although the oblique are by no means uncommon. The others are the most Fracture of the Ribs. 391 dangerous, and are generally combined with rupture of the intercostal arteries, emphysema, and injuries of the lungs. It is not always easy to discover a fracture of the rib. Sometimes there is distinct crepitation, and then the nature of the accident is rendered very plain. The presence of emphysema also affords al- most certain evidence of the existence of fracture. Generally the patient complains of difficult respira- tion, especially when lying in the recumbent pos- ture, and of sharp, pricking pain in the seat of the injury, which is increased upon making a full inspi- ration or upon coughing. Treatment of Fracture of the Ribs. Little benefit commonly results from an attempt to coaptate the fractured ends of a rib. When the force, however, causing the injury has been very vio- lent, and the fragments have been driven internally or towards the pleura and lungs, well directed pres- sure upon each extremity of the rib may cause them 392 Fracture of the Ribs. to resume their former position. On the contrary, pressure applied to the fracture itself will become necessary when there is angular derangement exter- nally. But the chief indication in the treatment is to oblige the patient to breathe by the diaphragm and abdominal muscles, in order to keep the inter- costal muscles at rest while the process of reunion is taking place. This is accomplished by a broad roller, passed circularly about the chest, and made to envelop the greater part of it, placing a single compress, if the derangement be external, over the fractured part and under the roller, and two if the derangement be internal—one at each end of the rib. These co-operate with the bandage in forcing the fragments into their proper places. Conjoined with this treatment, general blood-letting and ele- vation of the patient's shoulders by pillows placed be- hiud his back, will prove extremely useful. Should hemorrhage take place from a wound of the inter- costal artery, or emphysema follow from a wounded lung, the treatment formerly pointed out, under the head of Wounds of the CJusst, must be pursued. Fracture of the Sternum. 393 Section V. Fracture of the Sternum. Fracture of the sternum is usually the result of considerable violence; hence the mischief that en- sues is not always confined to the bone, but extends to the sensible membranes and organs within the chest: these inflame and suppurate, and not unfre- quently considerable collections of pus take place in the anterior mediastinum—either from the imme- diate injury or from subsequent caries of the bone. I have met with several cases of the kind, and had occasion last year, in the Aims-House Infirmary, twice to trephine the sternum in two different pa- tients, on account of caries and lodgment of matter. Fracture of the sternum may be known by the incessant grating of the fragments upon each other during respiration, which is so remarkable in some instances as to be heard a considerable distance. Besides this sign, which is very decisive, there are Vol. I. 3 D 394 Fracture of the Sternum. others—palpitation of the heart, difficult respiration, severe pain and troublesome cougb. The bone will sometimes be found broken in three or four pieces. The direction*of the fracture is commonly transverse. Treatment of Fracture of the Sternum. The chief indications in the treatment of this in- jury, are to prevent or subdue inflammation, and to appease the incessant cough and difficult respiration that usually attend. The former are best accom- plished by repeated blood-letting,—the latter by opiates and by supporting the patient in bed in a sitting posture. Quiescence of the chest, also, is essential, and readily effected by a roller drawn with sufficient tightness to impede the action of the intercostal muscles. Should matter form beneath the sternum, or col- lect within the mediastinum, an opening should cautiously be made with the crown of a trephine— Fracture of the Sternum. 395 so small as not to exceed half an inch in diameter. The same instrument, aided by Hey's saw, bone nippers, and forceps, will also answer for removing carious portions of bone—bearing in mind, at the same time, not to be too officious in picking away or scraping the bone, which by such means may be rendered diseased or made to exfoliate, when, if left to nature, it might have recovered. 396 Fracture of the Clavicle. Section VI. Fracture of the Clavicle. The clavicle, from its exposed situation and deli- cate form, is peculiarly subject to fracture. It may be broken by a force directly applied to it, or by a counter-stroke. In the latter case, the effect is ge- nerally produced by a fall upon the point of the shoulder, or on the hand which is instinctively put forward to save the body. From either cause frac- ture is most common about the middle or vaulted part of the bone, is usually oblique or transverse, and seldom compound or complicated. The accident is easily distinguished from other injuries by crepitation, by the depression of the hu- meral beneath the level of the sternal fragment, by the shoulder, of which the clavicle is the support or stay, falling forward upon the breast and sinking below the level of the opposite shoulder, by the ina- bility experienced by the patient in carrying the Fracture of the Clavicle. 397 hand to the head without bending the forearm and dropping the head to meet it, and by the particular attitude which most patients assume to relieve them- selves from pain—supporting the injured limb with the opposite hand, and inclining the head and body towards the affected side. Fracture of the clavicle may occur at or near the humeral or sternal extremities of the bone. The former seldom happens, owing to the thickness and strength of the humeral portion, and to its close con- nexion with the scapula, to which it is tied by very firm and unyielding ligaments. Fracture of the ster- nal end is commonly the result of counter-stroke. Treatment of Fracture of the Clavicle. As the shoulder sinks and approaches the ster- num after the clavicle is fractured, it follows that the chief indications in the treatment are, to ele- vate it again to its natural height, and at the same lime to carry it backwards and outwards, and there retain it by an appropriate apparatus. The two first 398 Fracture of the Clavicle. indications had long been acknowledged as ne- cessary, but the third and most important of all —that of keeping the shoulder outwards—was ori- ginally suggested by Desault, who, upon the prin- ciples just pointed out, has devised an apparatus for reducing and maintaining in contact the fragments of bone, infinitely more efficacious than any other ever invented, at the same time extremely simple in construction and composed of materials easily ob- tained in any situation however remote. Thks apparatus consists of three rollers, each three inches wide, and seven or eight yards long—a pad, the shape of a wedge, composed of pieces of old linen, four or five inches broad, three inches thick at the base, and in length equal to the humerus, hav- ing at each corner of the base a strip of muslin an inch wide and a yard and an half long—three com- presses—a small sling for supporting the forearm— and a piece of linen or muslin large enough to cover the bandages and envelop the whole chest. The surgeon directs an assistant, while the patient is in a standing or sitting position, to elevate the arm of the injured side, and keep it extended at a right \ ~~3Sk ri. ix. Ti7\inm.7'romZ>ff hjT. Sulii/ a.- Frignn>i\f by t'.d.C/u'Us. Fracture of the Clavicle. 399 angle with the body. He then takes the pad, and placing its base or large extremity in the armpit, se- cures it slightly to the body by the muslin strips at- tached to its corners. See Plate IX. fig. 1. The end of one of the rollers is now placed on the pad, and fixed by two or three circular turns around the body; the roller next ascends obliquely over the front of the chest to the sound shoulder, passes over this posteriorly under the armpit, appears again in front of the chest, makes a circular turn nearly around the body, ascends from behind to the sound shoulder, passes over it and under the armpit, ap- pears again on the back of the chest, and finishes by circular turns which cover the whole pad and fix it securely to the body. See Plate IX. jig. 2. The next step of the operation is to reduce the fracture or to restore the ends of the bone to their proper places. To accomplish this, the surgeon takes hold of.the arm, carries it downwards, lays it closely along the pad, bends the forearm across the chest, runs his fingers along the clavicle, and adjusts the fragments. The deformity disappears in an instant, and the principle upon which the bone is replaced 400 Fracture of the Clavicle. immediately understood—the arm being converted into a lever of the first kind serves as the handle or power, while the clavicle forms the resistance and the pad the fulcrum or prop. To keep the bone in its position, the surgeon next takes a second roller, whilst an assistant maintains the arm in contact with the pad, and commencing at the armpit of the sound side carries it to the shoulder of the injured side, and from thence by oblique and circular turns around the body and arm, gradually descending (each cast overlapping the other and tightened in propor- tion to its descent,) until it passes under the elbow as far as the middle of the forearm. This fulfils the second and most important indication—to retain the shoulder outwards. See Plate X.fig. 1. The third and last roller must now be applied. Commencing at the armpit of the sound side, the surgeon carries the roller obliquely upwards over the injured shoulder (previously covering the clavicle with the compresses) down on the posterior part of the arm, under the elbow, obliquely upwards across the chest to the armpit from whence it started, over the back to the shoulder of the affected side, across the compresses, down in front of the arm, under the X Fuj.l. /',,/.? Dt.imh /r.mi.Zire /■// T. ft'ty X hi.jnu .i ty <'.G.t'M.i* Fracture of the Clavicle. 49 \ elbow, across the back to the sound armpit,—from which it commences again to run the same course until the roller is exhausted. The bandage, when thus applied, forms a double triangle—one appearing on the back, the other on the breast—and serves to retain the arm and shoulder in their elevated posi- tion. See Plate X. jig. 2. The different turns or casts of the three rollers being firmly fastened to each other by numerous pins, it only remains to apply the sling (made of a piece of common roller passed around the hand and wrist, and pinned above to one of the bandages) and to cover the whole with the large muslin cloth. The last I have never employed, as the rollers have always remained sufficiently firm without. The patient is relieved of pain from the moment the arm is secured by the second roller, and when the operation is finished is generally able to walk about without inconvenience. In a few days, how- ever, the bandages become more or less relaxed or discomposed, and must be replaced. There are some surgeons, however, who object to the ban- 402 Fracture of the Clavicle. dages of Desault, upon the ground chiefly of be- coming loose, and seem extremely averse to a re- newal of them, as if the trouble of replacing a dressing did not fall as much within tiieir province as its original application. Others have expressed idle fears about excoriation, high inflammation, mortification, from the rollers being drawn with immoderate force. It is perhaps possible, (though I have never witnessed it,) if the bandages are put on in a slovenly manner, as they too often are, whether forcibly drawn or relaxed, and suffered to remain until they become foul, that excoriation may follow; and so it may from any other bandage or species of clothing. But it is the business of the surgeon to guard against such things, to lay his bandages smooth and flat, and to remove them as soon as they become loose, wrinkled or twisted. As to high inflammation and mortification ever hav- ing followed from Desault's bandage, the idea is ir- resistibly ridiculous and unworthy of serious refuta- tion, and only proves that those who have advanced the assertion know very little, practically, about such matters. Indeed I have commonly observed, that the surgeons who are most loud in their condemna- tion, and extravagant in their assertions about these Fracture of Hue Clavicle. 403 bandages, have never applied them, never had con- trol of a public infirmary, where such accidents are commonly met with, and have enjoyed very limited opportunities in private practice. The only incon- venience that I have ever known to result from the apparatus, has occurred from pressure on the large and flaccid mammae of old and fat females; but this so rarely happens, that it can hardly be considered as an objection to the general practice. On the con- trary, the simplicity of the apparatus, the facility of obtaining the materials of which it is composed, and its efficiency when properly applied, compared with the difficulty of procuring or fabricating machines made of straps and buckles and quilted bands and bolsters, all of which must be made by regular work- men, and a separate machine adapted to the size of each individual, during which days may elapse while the patient is suffering, must in the eyes of every sensible and experienced person determine at once in favour of Desault's particular plan. 404 Fracture of the Scapula. Section VII. Fracture of the Scapula. The scapula, owing to its great mobility, is sel- dom fractured; though it is often contused, and sometimes so severely as to give rise to collections of matter between it and the chest. The acromion process and lower angle of the scapula are more fre- quently broken than any other parts. The coracoid process, owing to its retired situation, is scarcely ever injured. Fracture of the acromion may be known by the change in the form of the shoulder, which is sunk and flattened—being drawn downwards by the weight of the arm and the action of the deltoid muscle—by the pain, crepitation and mobility of the acromion, which are readily produced by raising and depress- ing the arm. The lower angle of the scapula, when fractured. Fracture of the Scapula. 405 is drawn forwards by the serratus anticus major, and is so completely insulated as to be easily distinguished by its inequality and unnatural position. Longitudinal fractures of the scapula seldom oc- cur, and are attended with little displacement, owing to the manner in which the muscles covering the surface of the bone are arranged. Treatment of Fracture of the Scapula. These accidents are usually accompanied with so much contusion, as to render the removal of the in- flammation that follows an object of greater impor- tance than the treatment of the fracture itself. So profuse in some instances has been the secretion of matter beneath the scapula, as to require the operation of the trephine for its evacuation; at least the scapula has been perforated with this view, al- though the proceeding has always appeared to me unnecessary, from a persuasion that the abscess un- der any circumstances might be reached by pene- trating the soft parts on either edge of the bone. 406 Fracture of the Scapula. Fracture of the acromion merely is easily reduced and secured by elevating the arm to its natural height, fixing a pad in the axilla by a roller around the body. and binding the arm to the pad by a second roller, after Desault's manner of treating the fractured clavicle. When the lower angle has been separated from the body of the scapula, it is hardly possible to over- come the action of the serratus anticus muscle, so far as to restore the fragment to its former position; by a thick compress, however, placed in front of the fragment, and there retained by a roller passed around the chest, the arm being afterwards fixed by an additional roller or sling, the fractured portions may be made to approximate so closely as to leave little or no deformity. Sometimes the patient re- covers sooner when confined to bed during the whole treatment. Fracture of the Arm. 407 Section VIII. Fracture of the Arm. The humerus is very subject to fracture, and may be broken at any portion of its length—at its head, neck, middle, or condyles. By the term neck of the humerus is understood, among surgical writers, that portion intermediate to the tuberosities of the bone and the insertion of the pectoralis major and latissimus dorsi muscles. Except in old subjects the neck of the hume- rus is not often fractured; but among these the accident is by no means uncommon. In young persons the epiphysis is sometimes separated from the shaft of the humerus. In either case the up- per fragment is drawn outwards by the action of the subscapularis and teres minor, while the lower one is pulled inwards by the latissimus dorsi and pectoralis major. At the same time the weight of the arm, by keeping down the lower fragment, pre- 408 Fracture of the Arm. vents it from overlapping the upper. Sometimes, though rarely, the lower fragment is forced out- wards. Fracture of the head of the humerus is occasion- ally met with, and arises for the most part from a violent force directly applied, or from a gun-shot wound. That portion of the bone articulated with the glenoid cavity, there is reason to believe, in all such cases, is either absorbed or changed in figure. Three or four well marked cases of the kind are contained in my cabinet, in all of which the head has lost its spherical form, is very much diminished and rough and flattened next to the scapula. Simi- lar examples are recorded by different writers. • Fractures of the neck or head of the humerus have been confounded with luxation, and much mis- chief has sometimes followed the mistake. The ac- cidents, however, are easily distinguished by any one familiar with the structure of the joints and the parts in its vicinity. When fractured, the head of the bone still remains in the glenoid cavity, and the ro- tundity of the shoulder is thereby preserved. In luxation a hollow may always be felt under the aero- Fracture of the Arm. 409 mion, and a tumour, formed by the displaced head of the bone, distinctly perceived in the axilla. Be- sides these signs, which in general are sufficiently indicative of the nature of each case, more or less crepitation may always be perceived when the bone is fractured, but in luxation can never be observed. The middle of the humerus is oftener fractured than any other part of the bone. A direct force, a counter-stroke, or muscular action may each pro- duce the fracture, which is usually oblique or trans- verse, and easily known by the mobility of the arm at the injured part, by the angular derangement pain, crepitation, &c. The condyles are frequently fractured by violence immediately applied to them. When both are broken, a longitudinal fissure commonly runs along the cen- tre of the bone for some distance, and then termi- nates by a transverse or oblique division of the shaft of the humerus. When one condyle only is sepa- rated, the direction of the fracture is necessarily ob- lique. These injuries are often followed by high inflammation, anchylosis, and deformity of the whole arm, and should therefore be carefully distinguished 410 Fracture of the Arm. from other accidents to which the elbow joint is liable. Instances are mentioned by Sir Astley Cooper* in which the condyles were fractured just above the elbow joint, and presented appearances very similar to those produced by dislocation of the radius and ulna backwards. When both condyles are fractured, the deformity is greater than when one only is separated. In either case the crepita- tion is commonly very distinct upon impelling the fragments in opposite directions, and pressure upon the olecranon and bend of the arm increases the breadth of the elbow, which can only happen by the recession of the condyles from each other. Treatment of Fracture of the Arm. The most effectual plan I have ever tried for re- taining in accurate apposition the fragments of the humerus, when fractured at its head or neck, is that described by Desault. * See a Treatise on Dislocations and on Fracture of the Joints, by Sir Astley Cooper, 4to. 1822, p. 480. Fracture of the Arm. 411 The patient being seated on a chair, an assist- ant takes hold of the hand of the sound side and makes counter-extension; another assistant grasps the forearm of the injured limb, which is previously placed in a semiflexed position, and makes extension, while the fingers of the surgeon are employed in ad- justing the fragments. The surgeon next takes a roller six or eight yards long, and commencing at the palm of the hand carries it up the forearm and arm by circular and reversed turns as high as the shoulder, from thence across the breast, around the shoulder and armpit of the sound side, then across the back to the injured shoulder, where it is held by an assistant until the surgeon places three strong splints, each two inches wide, and the length of the humerus, on the anterior, outer and posterior parts of the arm, and then resuming the roller, which is made to descend towards the elbow, secures them firmly to the limb—taking especial care to cover their extremities with tow or lint, to prevent inordi- nate pressure and excoriation. Having proceeded thus far, the surgeon takes a pad, exactly similar to that used for the fractured clavicle, and placing the small end of it in the axilla 412 Fracture of the Arm. (if the lower fragment should be drawn outwards, and vice versa,) lays it along the arm, and secures it to the body and shoulder by the narrow strips attached to its corners and by pins. Then taking another roller somewhat longer than the one previously ap- plied to the arm, and commencing at the armpit of the sound side he carries it to the injured arm and fastens it to the body and the pad, precisely after the manner of the second roller for fractured clavicle. The pad being fixed serves the purpose of a fourth splint for the arm, while it affords support to the fractured portion, upon which a common splint can have very little purchase. It only remains to sus- pend the forearm, which is fixed upon the breast in a sling, and to secure the different turns of the rollers by pins or stitches. Fractures of the middle of the humerus are readily managed by a single roller, and by four splints of unequal length. The roller must commence at the hand (a rule to be observed in all fractures of the arm and forearm) and extend as high as the shoul- der, where it is held by an assistant while the sur- geon surrounds the arm with the splints, which are secured to the limb by the remainder of the roller Fracture of the Arm. 413 carried towards the elbow and forearm. The hand and forearm are placed across the chest and sus- tained by a sling. The condyles, when fractured, are best secured by a roller and two angular splints, a practice first suggested by Dr. Physick to obviate deformity,* which is extremely apt to follow all fractures about the elbow joint. The fracture being reduced and the forearm bent, a roller is applied in the usual way, and extends as high as the shoulder; the sur- geon then takes the splints (about two inches broad, long enough to extend from the shoulder to the el- bow and from the elbow two or three inches beyond the fingers, in shape exactly resembling a workman's square), and applies one on the outside the other on the inside of the limb, and secures them by the re- maining part of the roller. To prevent anchylosis, * "The deformity alluded to consists in an angular pro- jection of the elbow outwards. It is most evident when the whole arm is. placed at right angles to the body, with the thumb upwards, the patient standing erect. In that case, in- stead of a gentle curve downwards at the elbow, which is na tural, the curve is directly reversed.'* Dorsey's Surgery. edit. 3d. vol. i. p. 168. 414 Fracture of the Arm the dressings should be taken off frequently, and re- newed after repeated but gentle flexion and exten; sion of the joint. After two or three weeks the rectangular splints may be laid aside, and others substituted that are more obtuse in the angle. % Fracture of the Forearm. 415 Section IX. Fracture of the Forearm. The radius and ulna may both be fractured at the same moment, opposite each other, or upon a dif- ferent level. Usually the fracture occurs about the middle of the bones, and is either transverse or ob- lique, while the derangement is angular, or in the direction of the diameter of the bones. The radius is oftener fractured than the ulna, be- cause it is connected with the bones of the carpus, and therefore liable to receive directly any shock communicated to the hand. The fracture occurs near the wrist, at the middle, but rarely at the up- per extremity of the bone. Receiving partial sup- port from the ulna, which serves as a splint, the de- formity is less than in fracture of both bones. By placing a finger upon the upper extremity of the ra- dius, while the lower part is made to turn on its axis by moving the hand, the superior fragment, if frac- 416 Fracture of the Forearm. tured, will remain stationary; but, on the contrary, if entire, will move with the rest of the bone, and afford very conclusive evidence of the nature of the case. Fracture of the ulna commonly occurs towards the lower or smaller extremity of the bone, some- times about the middle, but seldom at the upper ex- tremity. The accident is easily known by the cre- pitation, deformity and mobility of the lower frag- ment, when the separation takes place below the elbow. The olecranon, which constitutes the summit of the ulna, may be fractured by direct violence or by the inordinate action of the triceps muscle. The former is the most frequent cause, and is generally produced by a fall, in which the patient catches upon the elbow in the act of saving the body. As soon as the fracture occurs, the process is drawn upwards by the triceps, and separated a greater or less distance from the shaft of the bone. The space thus produced is increased upon bending the fore- arm, and diminished by extending it—signs so per- fectly decisive of the character of the fracture as Fracture of the Forearm. 417 generally to render other evidence unnecessary. Sometimes, however, the tumefaction around the joint is so considerable as to prevent satisfactory ex- amination, at least for several days. The coronoid process is sometimes fractured. One instance of the kind occurred to Dr. Physick, and two others are mentioned by Sir Astley Cooper. Treatment of Fracture of the Forearm. With the exception of the olecranon, fractures of the bones of the forearm should be treated upon the same principle. Whether one or both bones be broken, the limb is placed in the bent position, and counter-extension made by an assistant, who grasps the arm above the condyles; another assistant keeps up extension by pulling at the hand, and the fingers of the surgeon are employed in compressing the muscles situated between the bones, in order to force the fragments outwards or in a lateral direction, and thereby prevent them from encroaching upon the interosseous space. Having restored by these Vol. I. 3 G 418 Fracture of the Forearm. means the natural form of the limb, the surgeon ap- plies two graduated compresses (about three inches wide, the length of the hand and forearm, and half an inch thick at the base) one on the anterior, the other on the posterior part of the forearm and hand— the base of each being placed downwards. These compresses are secured by a roller, commencing as usual at the hand and extending a short distance above the elbow. Over this are placed two splints, equal in length and breadth to the compresses, one in front, the other on the back of the limb, to which they are fastened by the remaining part of the roller. The compresses serve the double purpose of render- ing the limb throughout of uniform thickness, and of creating pressure upon the muscles between the interosseous space. Two splints are quite sufficient to keep the bones firm; indeed, additional ones, by making lateral pressure, would prove injurious, and counteract the design of the compresses. The splints in every instance should extend to the extremities of the fingers and afford complete support to the hand, otherwise deformity will ensue from the radius cross- ing the ulna and following the movements of the hand. This mode of treatment, without variation. Fracture of the Forearm. 419 will answer extremely well either for the radius or ulna individually, or for fracture of both bones. Fracture of the olecranon requires a very differ- ent management, and is not so easily secured. In- stead of flexing the forearm, which would tend to separate widely the fragments, it is placed in the ex- tended position, and there retained, while a roller, se- veral yards long and between three and four inches wide, is applied by circular and reversed turns as high as the elbow, when it is given to an assistant until the surgeon draws down with his fingers the fragment of olecranon attached to the triceps, and brings it in contact with the lower fragment: the roller being then resumed, is passed obliquely by several succes- sive turns around the joint and above the inser- tion of the triceps, in form of the figure 8; from thence it is continued by circular turns up the arm, and made to compress, the muscles firmly. The bend of the arm is next filled with lint or tow, and over this is placed a firm splint, long enough to ex- tend from the middle of the arm to the same distance on the forearm. This splint is completely covered by the roller, and serves to preserve the extended position and to ensure the contact of the fragments. 420 Fracture of the Forearm. When properly managed, the fractured olecranon unites in a much shorter time and with less defor- mity than is commonly imagined. Under any cir- cumstances, however, it is difficult to preserve, ow- ing to the incessant action of the triceps and the little purchase offered by the olecranon to act upon, the fragments so closely together as to bring about ossific reunion; instead of which a ligamentous sub- stance, abundant in proportion to the space between the fragments, is secreted, and forms the connecting medium. Owing to this, the arm long remains weak, and sometimes never recovers its former strength. When the coronoid process is fractured, there will be a constant tendency to displacement of the ulna backwards, so that the accident resembles luxation of the bones of the forearm posteriorly. By pulling the forearm, however, and at the same time bending it, the deformity is removed, but quickly returns un- less prevented. The best mode of treating the in- jury is to preserve the limb in the flexed position for several weeks. Fracture of the Hand and Fingers. 421 Section X. Fracture of the Hand and Fingers. The bones composing the carpus or wrist are so compact and firmly united to each other, as to resist effectually any common force applied to them; they are sometimes broken, however, by great and direct violence, in which case the soft parts suffer in pro- portion. The metacarpus is sometimes fractured by a force immediately applied, but seldom in any other way. In two or three instances I have known these bones very much shattered by the bursting of a gun, while the patients were grasping the barrel with their left hand. In one case, a very fine youth lost his life from carelessly crossing his hands over the muzzle of his piece, and resting one foot on the lock: by which the cock was pushed back, the gun dis- charged, and the contents driven through both 422 Fracture of the Hand and Fingers. hands, tearing up the metacarpal bones in a shock- ing manner, and producing tetanus in a few days. The fingers are sometimes broken by machinery, mashed by heavy weights, or caught within the fold of a door. In such cases they may be fractured in several places, dreadfully bruised, or nearly divided. When simply broken, without much injury of the soft parts, the accident is comparatively trivial, and easily distinguished by the deformity, crepitation, &c. Treatment of Fracture of the Hand and Fingers. When the carpal and metacarpal bones have sus- tained serious injury, we have more cause to dread the effects of inflammation, than any mischief that may result from the fracture merely. Frequently the necessity of amputation is clearly indicated; at other times an attempt to save the hand or a part of it must be made. The fingers, when simply broken, should be sur- rounded with a narrow roller, and sustained by four Fracture of the Hand and Fingers. 423 splints made of binders' boards, two of which should extend as high as the wrist, and the others the length of the finger merely. Fingers that have been very much lacerated, near- ly separated, or hanging by shreds, should always be replaced, and reunion attempted; for it has hap- pened, as in the cases formerly referred to and de- tailed by Balfour, that adhesion has been accom- plished even after the total separation of one or more phalanges. 424 Fracture of the Pelvis. Section XI. Fracture of the Pelvis. The bones of the pelvis are rarely fractured, owing to their great strength and the unyielding tex- ture of the ligaments by which they are tied to- gether. Such injuries, when they do occur, are al- ways the result of great violence, and on this ac- count usually have an unfavourable termination. Of the individual bones, the innominatum is per- haps most liable to fracture, and commonly from force directly applied, as when a patient is squeezed against a wall or post by the wheel of a cart, or by the passage of the wheel of a wagon heavily laden over the hips while lying on the ground. In such cases both bones are generally crushed inwards. The sacrum may be fractured, or severely con- tused, by falls from a height upon the buttocks, from which more or less concussion results, or injury to Fracture oftfue Pelvis. 425 the sacral nerves. But the most formidable accident is fracture of the innominatum combined with that of the acetabulum, especially when the bones sepa- rate so far as to allow the head of the femur to enter the pelvis; in which case the thigh is shortened, and the disease may be mistaken for luxation. It can be distinguished from it, however, by the crepitation produced by moving the fragments in opposite direc- tions, and by the eversion of the foot The os coccygis is sometimes fractured in old sub- jects, but seldom in young ones, owing, in the latter, to the great mobility of the bone. In all cases where the shocks communicated to the pelvis are violent, whether the bones be fractured or not, symptoms resembling those from injuries of the vertebrae are apt to arise—such as paralysis of the extremities, incontinence or suppression of urine, &c. Treatment of Fracture of the Pelvis. No benefit w ill result in these cases from splints and bandages, and the treatment should be chiefly di- 426 Fracture of the Pelvis. rected towards the removal of inflammation, which is best accomplished by copious depletion, low diet, and perfect rest. In addition, the catheter, if required, must be used two or three times a day, and care taken, by the application of adhesive plasters to the parts that sustain the greatest pressure, to prevent ulceration and sloughing. Fracture of the Patella. 4-21 Section XII. Fracture of the Patella. Muscular action is the most common cause of fracture of the patella; he#nce the accident usually occurs amongst dancing masters, circus riders, and persons much accustomed to the exercise of leap- ing. The bone may be broken, also, by force di- rectly applied to it, especially if the knee be bent at the time the injury is received; in which case the centre of the patella, being.unsupported by the heads of the femur and tibia, is the more apt to give way. From whatever cause the accident proceed, the di- rection may be transverse, oblique, or longitudinal. The transverse fracture, however, is infinitely more common than the rest, and easily known by the upper half of the patella being mounted upon the anterior part of the thigh four or five inches above its natural position, being drawn thither by the combined action of the rectus, cruraeus, and 428 Fracture of the Patella. vasti muscles. Besides this sign, which is very une- quivocal, a manifest hollow can always be felt and seen at the knee, into which the fingers may be pressed as far as the integuments will allow; the pa- tient, moreover, falls to the ground, is unable to rise without assistance, cannot walk, and is generally sen- sible at the moment of the fracture of an audible noise or smart report. When the fracture is longitudinal, none of these symptoms exist, because the fragments still retain their position, or at least can only be made to sepa- rate from each other laterally, or in the direction of the breadth of the knee. Compound and complicated fractures of the pa- tella fortunately are not very frequent: they are al- ways attended with immense risk, and may termi- nate fatally or in incurable lameness. The patella, when once fractured, ever after re- mains comparatively weak, and is very prone to a recurrence of the injury. This arises from the dif- ficulty, perhaps impossibility, of maintaining the frag- ments of a transverse fracture in exact apposition; Fracture of the Patella. 429 bony matter is therefore not secreted in sufficient quantity to fill up the vacuity, and its place is sup- plied by a ligamentous substance, which for a long time after the accident continues soft, and is easily torn. It is true, that bony matter has been found on dissection; but instances of the kind are so ex- tremely rare as not to affect the general position— that the bond of reunion, except in longitudinal frac- tures, is ligamentous. This has, moreover, been con- firmed by the experiments of Sir Astley Cooper and others on inferior animals. A fracture of the patella in one limb is very apt to be followed by a similar injury in the other— owing perhaps to the sound limb sustaining, for a long time after the first accident, more than its pro- portion of the weight of the body, and performing a greater variety of offices. Treatment of Fracture of the Patella. Various means have been employed to overcome the action of the extensor muscles and retain the 430 Fracture of the Patella. fragments together; but the plan devised by Desault I have always found the most simple and effectual. A splint two inches wide, long enough to extend from the tuberosity of the ischium to a short dis- tance above the heel—two rollers, each six yards long and three inches wide—another roller or com- press, somewhat longer than the thigh and leg, are the materials of which the apparatus consists. The thigh being bent on the pelvis, and the leg extended on the thigh, is supported by an assistant at a con- siderable elevation, whilst another assistant stands at the pelvis and keeps it fixed. The surgeon then takes the short roller or compress, and extending it on the anterior part of the whole limb, gives an end to each of the assistants who keep it tense. One of the long rollers is next passed around the instep by two or three circular turns, so as to enclose and se- cure the end of the compress, and is then passed by reversed and circular turns as high as the knee, when it is given in charge to the assistant who stands at the pelvis. The surgeon now makes two longi- tudinal slits with a penknife or scissors in the com- press, corresponding with the situation of the knee pan; through each of these a finger is introduced, Fracture of the Patella. 431 and the patella drawn down and placed in contact with its lower portion; the roller is then resumed and carried around the joint, above and below both fragments, several times in form of the figure 8. These oblique turns being crossed by circular ones, the roller is continued up the thigh and terminates by fixing securely the upper extremity of the com- press. The use of the compress, it will now be seen, is to prevent on the one hand the casts of the roller on the leg from slipping downwards, and on the other those applied to the thigh from ascending by the action of the extensor muscles. The limb being still sustained in its elevated po- sition by the assistant standing at the foot, the sur- geon next takes the splint, and placing one end un- der the ischium lays it beneath the thigh, leg and heel, then filling up the inequalities of the limb with lint or tow, and padding the parts well, with either of these materials, upon which the greatest pressure is made by the splint, the remaining long roller is passed, commencing at the ancle, around the splint and limb, connecting the one firmly to the other throughout their whole extent. It only remains to retain the limb in its elevated situation. This is 432 Fracture of the Patella. easily accomplished by forming an inclined plane, composed of pillows, the highest part of which is placed at the heel. Whenever the bandage becomes relaxed, which it generally does in six or eight days, it must be reap- plied. The inclined plane should be examined daily, and never suffered to sink beyond the level at which it was first placed. In sixty or seventy days the fragments are usually consolidated; but the pa- tient should be very careful not to try, for a long time, the strength of the limb, or to exert more force upon it than the intermediate ligamentous substance may be able to bear. Fracture of the Thigh. 433 Section XIII. Fracture of the Thigh. The osfemoris being very long, somewhat curved, and surrounded by powerful muscles, is frequently fractured. The fracture may take place at the head, neck, shaft and condyles of the bone, either in a transverse or oblique direction. Compound and complicated fractures of the femur may also occur, though such accidents are comparatively rare. Fracture of the neck of the femur may happen within the capsular ligament or exterior to it The former is most common, and met with almost exclu- sively in very old subjects; the latter may occur at any period of life. Women, moreover, are more liable to fractures of the neck of the bone than men, from what cause is not exactly known. It seldom happens that the neck of the os femoris is broken by a direct force. A counter-stroke or a twist of 434 Fracture of the Thigh. the limb are the most frequent causes of it. Thus, a fall upon the trochanter or upon the feet, by which an impulse is communicated to the bone, will often fracture it obliquely or transversely. The latter direction is most common. A very slight twist of the pelvis or thigh in an old subject will sometimes be sufficient to break the neck within the capsule. I have known it happen from the patient's attempt- ing suddenly to turn round, while the foot remained fixed by some slight irregularity on the floor. The signs of this fracture are in general very evi- dent. Instead of retaining its natural length, the limb is drawn upwards, the shaft of the bone lodged on the ilium, the foot turned outwards, and the tro- chanter major inclined backwards. In addition, the limb can be restored without difficulty to its natural length, but reascends as soon as the extension is dis- continued; again—upon rotating the thigh on its axis, whilst a hand is laid upon the trochanter, this projection will be found to turn, as it were, upon a pivot, whereas in the entire state of the bone, it de- scribes the arch of a circle, the radius of .which is formed by the neck of the femur. Other signs have been enumerated; but these, taken collectively, will Fracture of the Thigh. 435 generally prove sufficient to indicate the nature of the injury. The prognosis, as respects reunion of the frag- ments after fracture of the neck of the femur within the capsular ligament, is as unfavourable as can well be imagined. Scarcely, indeed, is it possible to find on record a well attested example of perfect bony reunion after such an accident. It is true that many alleged specimens of the kind have been brought for- ward, especially of late years, but few if any have been able to stand the test of rigid scrutiny, and upon examination have turned out to be fractures of the neck of the bone on the outer side of the capsu- lar ligament. Although reunion is never accom- plished, however, in some subjects, especially very old and infirm ones, and the fragments remain for ever insulated, it must not be inferred that this inva- riably happens; for even under the greatest disad- vantages, nature always makes an effort towards re- paration, and often succeeds so far as to effect a li- gamentous reunion similar in some respects to that which occurs in fracture of the patella and olecra- non. Still the joint remains weak, imperfect and deformed, and never able afterwards to sustain the 436 Fracture of the Thigh. full weight of the body or to encounter shocks which originally it was accustomed to bear with impunity. This imperfect reproduction may be owing to two or three different causes—to the portion of bone connected with the acetabulum being deprived of its vascularity or nutriment by the rupture of the pe- riosteum and reflected membrane of the cervix fe- moris, upon which it chiefly depends for its supply of blood; the quantity which it receives through the medium of the round ligament, and upon which it must now mainly depend, not being sufficient for its support—to a wide separation of the fragments, from muscular action or want of appropriate means to keep them in apposition—and to a copious secretion or accumulation of a serous fluid within the capsule of the joint, which by its interposition and circum- fusion effectually cuts off all interchange or connex- ion between the separated fragments. As already remarked, fracture of the neck of the femur may take place exteriorly to the capsular ligament; in this case the diagnostic marks do not differ materially from those pointed out as belong- ing to fracture of the same bone within the capsule; the result, however, both as respects the defor- Fracture of the Thigh. 437 mity and utility of the limb, is very different, for in fracture on the outside of the capsule perfect bony reunion, from a full vascular supply, is soon esta- blished, and the limb becomes as strong as ever. Fracture of the trochanter major alone, sometimes occurs. In this case, the shaft of the femur remain- ing entire, no shortening takes place. The accident may be known by the mobility of the trochanter, and by its Being drawn upwards or towards the ilium. The middle of the os femoris, in young subjects, is perhaps more liable to fracture than any other portion of the bone. This arises from its exposed situation, and to its being more under the influence of muscular action. There will be an essential dif- ference in the nature of the accident, especially as regards the result of the treatment according to the direction of the fracture. If there be a transverse fracture, the ends being fairly supported against each other, no deformity will- ensue. If the fracture be oblique, the ends overlap, and the inferior fragment is generally drawn for several inches upon the pos- terior surface of the upper fragment, and hence a shortening of the limb, followed by all those difficul- 438 Fracture of the Thigh. ties which have been complained of from time imme- morial. The higher, however, the fracture is situ- ated upon the shaft of the bone, the greater will be the overlapping, because a greater number of mus- cular fibres will be employed in producing the re- traction. The signs indicative of fracture of the middle of the bone, correspond in most respects with those of fracture of its neck. Like the condyles of the os humeri, those of the femur may both be broken, or only one. In the former case, crepitation, together with shortening of the limb and a facility of increasing the breadth of the knee by pressing upon the patella, will be suffi- cient to distinguish the accident from any other af- fection. Compound fracture of the femur just above the condyles, especially when the fracture is oblique and the superior fragment penetrates the rectus muscle, should always be considered a very grievous accident, and liable to terminate in death or ampu- tation. Fracture of the Thigh. 439 Treatment of Fracture of the Thigh. Had the surgeon no other difficulties to encoun- ter than such as present themselves after simple transverse fracture of the shaft of the thigh bone, he would have little reason to complain of the defec- tiveness of art, or of the power of nature in pro- moting a cure. So different, however, from this is the result of an oblique fracture of the body of the bone or of a transverse fracture of its neck, that it is hardly possible in any case to calculate with cer- tainty upon reunion without more or less shortening and deformity of the limb. The remark will apply most forcibly to fracture of the cervix femoris within the capsule, and the surgeon should be careful in such cases how he ventures to promise a favourable result, especially in very old subjects. Indeed, as respects these cases, I have strong doubts of the pro- priety of attempting more for the relief of the pa- tient, than merely keeping him as quiet and easy as possible, by supporting the hips with pillows and retaining the limb as much in the extended posi- tion as can be born*\ If extension and counter- extension, however, should be deemed admissible. 440 Fracture of the Thigh. then recourse must be had, I conceive, not to the means commonly employed, but to others I shall presently point out Without recounting the various contrivances that have been used at different periods for effecting ex- tension and counter-extension, most of which are detailed at length in the different works written ex- pressly on fractures, I shall merely speak of the means which have commonly been employed in this country within the last twenty or thirty years, and of such recent European and American inventions as may appear deserving of notice. The celebrated Desault, it is well known, em- ployed an apparatus consisting of a strong splint, long enough to reach from the spine of the ilium to four inches beyond the foot; of another splint, ex- tending from the perinaeum to the sole of the foot; of a third, the length of the thigh itself. To these were added extending and counter-extending bands, junks or long narrow bags filled with chaff, the bandage of Scultetus, a splint cloth, &c. The whole being arranged, extension was made from the foot by passing the band around the ancle, and fixing it Fracture of the Thigh. 441 to the lower end of the long splint, counter-exten- sion from the perinaeum, securing the end of the band to the upper extremity of the splint Dr. Physick, having in several instances tried the apparatus of Desault, found it defective, chiefly on account of the obliquity of the action of the counter- extending band, which, owing to the splint not ex- tending above the spine of the ilium, passed across the upper fragment of the femur and forced it out- wards. Again—the extending band, by pulling the foot outwards and pressing it against the lower ex- tremity of the splint, sometimes occasioned trouble- some excoriation. To obviate these inconveniences, Dr. Physick modified the apparatus in the following way. The long external splint, instead of termi- nating at the hip, was made to ascend as high as the armpit, where its extremity was formed like the head of a crutch, and padded to take off pressure from the axilla. Immediately below the crutch- like head of the splint, a hole or mortise was made, sufficiently large to admit the end of a handker- chief or counter-extending band. The lower end of the splint, at the suggestion of Dr. Physick, was altered by Dr. James Hutchinson, then a student at 442 Fracture of the Thigh. the Pennsylvania Hospital. The alteration consist- ed merely in attaching to the splint, a little above its lower end, a small block, which, projecting inwards at a right angle with the splint, and being notched at its extremity, served to receive the extending band, and by diverting it inwards, to prevent exco- riation of the external parts of the foot, and to keep up extension precisely in the direction of the limb. Previous to the application of the apparatus thus modified, a common bedstead, between two and three feet wide, the bottom of which is covered with wooden slats instead of a sacking bottom, is selected; over this is placed a firm and even mattress, a sheet above it, and a pillow for the patient's head. Com- mencing about the middle of the mattress, five or six pieces of broad tape, a yard in length, are laid upon the sheet transversely, and placed eight or ten inches from each other. Next a splint cloth, or piece of muslin, a yard and an half long and a yard wide, is placed above the tapes—its longest diameter running parallel with them. Over the middle of the splint cloth, near its upper edge, is then laid, longitudinally with respect to the mattress, a splint of binders' boards, two inches broad, nine long, and above and Fracture of the Thigh. 443 across the splint the bandage of Scultetus. This is made of a common roller two or three inches wide, divided into strips long enough to surround the thigh and overlap. The first strip is laid near the upper edge of the splint cloth; the second overlaps about an inch and an half, and the others are similarly ar- ranged and in regular succession, until a sufficient number are laid down to equal the length of the thigh. Two bags, filled with chaff or cut straw, ex- tending from the hip to the foot, and four inches wide, are then prepared. Lastly, three silk or ma- drass handkerchiefs, each about a yard long, pre- viously washed and folded diagonally, and the three wooden splints—the long external one, the internal one reaching from the perinaeum to the foot, and the short one the length of the thigh, are all placed within the surgeon's reach. Every arrangement being made, the patient is placed on the bed by careful assistant*, and the in- jured thigh (previously stripped of every species of clothing) laid in the centre of the dressings without disturbing them in the slightest degree. One of the handkerchiefs is then passed around the ancle and instep of the injured limb, somewhat in the form of 444 Fracture of the Thigh. the figure 8, knotted under the sole of the foot, and its ends given to an assistant; another is carried along the perinaeum, between the genitals and thigh, and its ends, which pass above the pelvis before and behind, delivered to a second assistant. By these ex- tension and counter-extension are next made, while the surgeon, after having adjusted the fragments and restored the natural shape of the limb, applies the bandage of Scultetus by commencing at the strip last laid down or that nearest the knee. The ends of this are brought over the front of the thigh and crossed; a second strip secures the first, and in like manner all are made to overlap until the whole thigh is covered, when the last strip is fastened by a pin. The two long splints are next rolled in the splint cloth, and, thus covered, are brought along- side the limb, leaving a space merely sufficient for the interposition of the bags of chaff, which are then applied, and serve to fill up inequalities and to pre- vent the splints from irritating the thigh and leg. Now the extending and counter-extending bands are fixed by the assistants in their respective places- one being carried around the notched extremity of the projecting block situated near the end of the ex- ternal splint and tied to a mortise below it, the other Fracture of the Thigh. 445 drawn nearly in a line with the body and secured to the mortise at the upper end of the splint. The short splint being laid over the front of the thigh, and the third handkerchief passed around the ex- ternal splint and the pelvis, the tapes are all drawn around the limb and splints, and tied, and the ope- ration finished. A mode of securing the fractured thigh, very dif- ferent from that of Desault, I have latterly practised. This consists in extending the patient's limbs upon a mattress, and confining both feet by gaiters or handkerchiefs to a footboard^ which is firmly sup- ported by the ends of two splints passed through mortises near its edges. These splints extend from the armpit, where they are padded like the head of a crutch, along each side of the body, thigh and leg, beyond the foot, and being well stuffed on their inner surfaces to prevent irritation, are confined by six or eight broad tapes or bandages passed around the limbs, pelvis, chest, &c. See Plate XI. The principle upon which extension and counter- extension are effected by this contrivance, will in- stantly be understood. The sound limb being ex- 446 Fracture of the Thigh. tended, serves as a splint to the broken one. Coun- ter-extension then is made upon the acetabulum of the sound side, and extension upon the ancle of the injured limb, which, so long as the two feet are kept upon the same level, cannot be shortened, provided rotation of the pelvis be prevented. This purpose is answered by extending the splints to the armpit on each side, and not with a view, as might be sup- posed, of producing counter-extension from these points. The principle upon which this apparatus acts was first suggested by Brunninghausen, and af- terwards revived by Hagedorn, upon whose particu- lar contrivance for effecting extension and counter- extension, the one I have just described is designed as an improvement. Finding, upon trial, that the patient in the original machine of Hagedorn* (which consists of a single splint merely and footboard, in- dependently of leather straps, &c.) could incline the pelvis towards the affected side, and thereby shorten the limb, by causing the superior fragment to de- scend and overlap the inferior, the additional splint was added, and has been found to answer completely * For a full account of Hagedorn's apparatus, see First Lines of the Practice of Surgery, by S. Cooper, vol. ii. p. 430, edit, by Stevens. Fracture of the Thigh. 447 the end designed* The apparatus, modified in the manner I have described, has been used by different practitioners in the United States, and with perfect success. Dr. Faures of this city succeeded in re- storing to its original length, by means of it, a limb shortened three inches, and after it had re- mained three weeks in the splints of Desault Cures have also been effected, in the most satisfactory man- ner, by Dr. Lott, of Jersey, and by Dr. C. Cocke, of Virginia. As I am informed also by two intelligent students—Messrs. Stone and Willis—their precep- tor, Dr. Brown, an accomplished physician of Fre- dericksburg, Virginia, has effected lately in his own person a very perfect cure of an oblique fracture of the thigh bone by the same means.f * See Chapman's Journal, No. 6, p. 231. t The following communication I have just received from Mr. Thomas, a very diligent and respectable student from North Carolina. " A boy, the property of Mr. D., a^ed about fourteen years, in driving a loaded wagon was thrown from his horse, and one or two of the wheels passing over his thigh, fractured it near the middle. Dr. Tuck, an eminent practitioner near Halifax Court House, Virginia, was immediately called, and applied the apparatus of Desault, by which a cure was effected in 448 Fracture of the Thigh. I have yet another mode, however, of treating the fractured thigh, which may perhaps, in some re- spects, possess advantages over the one just detailed, and chiefly in relaxing the muscles of the thigh and enabling the patient to have a stool without a move- ment of the limb or body, and without employing the bed of Earle—a machine complicated and expen- sive, and liable to become, especially when used in public establishments by numerous patients, insuf- ferably offensive. The contrivance to which I allude is exceedingly simple, and may be made upon the spur of the oc- casion by the most indifferent workman, or by the surgeon himself, in a few minutes, in the following way. First take a piece of plank three or four feet seven weeks. Mr. D. then sent for his boy and conveyed him home, a distance of forty miles. The night after his arrival, the boy, while standing, turned his body suddenly round, and again fractured the thigh. Drs. Thomas and Garland were then called in, and applied Dr. Gibson's apparatus, and in seven weeks a perfect cure was effected, without any de- formity whatever. The boy states that he did not expe- rience half so much inconvenience from this as from De- sault's splint." Milton, North Carolina. Fracture of the Thigh. 449 in length and twenty inches wide, place it perpendi- cularly against the foot of a common bedstead with one end resting on the floor, and fix it securely by three or four stout screws to the cross piece which connects the posts. Secondly, another plank of the same breadth, long enough to extend from the tro- chanter to the heel, at one extremity of which is cut an oblong opening, about eight inches wide and ten long. This extremity is then placed upon the mattress, while the other is raised and con- nected to the perpendicular piece by leather straps or hinges at an angle more or less oblique, so as to form an inclined plane, the most elevated part of which is distant from the upper end of the per- pendicular piece about ten or twelve inches. A blanket or quilt is next folded several times, to the width of the inclined piece, and secured to it by tacks. The patient is then laid on the mattress, previously covered by a sheet, and both lower extre- mities elevated upon the plane, and the feet con- nected to the upright piece by handkerchiefs or by buckskin gaiters, the ends or straps of which pass through holes in the upright and are tied on the back of it. The foot of the injured limb being thus secured on a level with the sound one, keeps up per- \OL. I. ;' h 450 Fracture of the Thigh. manent extension, whilst counter-extension is effected by the weight of the body.* To give additional se- curity, and to prevent the patient from raising either limb from the plane, a piece of roller, two or three inches wide, is passed around each leg immediately below the knee, through holes in the inclined board, and tied underneath. Two pegs, also, eight or ten inches long, are fixed in an upright position on each side of the pelvis, to prevent lateral movement If necessary, a band can easily be passed around the pelvis and inclined board, and will effectually pre- vent every kind of motion. See Plate XII. At this time there is a female patient, 50 years of age, in the Aims-House Infirmary, under treat- ment for oblique fracture of the neck of the os femoris. The accident happened on Christmas; and the day after, in presence of the clinical class! I restored the bone to its natural length (although shortened between four and five inches) in less than half a minute, by placing her extremities over * For a full explanation of this apparatus, and its mode of action, see Additional Remarks on the Treatment of Frac tures of the Thigh, in the tenth number of the Journal of Me- dical and Physical Sciences, p. 372. Jr-rJ Fracture of the Thigh. 451 the inclined frame above described. Although la- bouring under diarrhoea at the time of the accident and since, the patient has not experienced the slight- est difficulty in having a passage, which is readily effected by slipping a pan through the oblong hole in the lower extremity of the inclined board, and without moving the body in the slightest degree. During the first thirty-six hours new madrass hand- kerchiefs were used as extending bands: but the pa- tient complaining of their being too stiff and creating pain, buckskin gaiters were substituted, since which she has not experienced any uneasiness. How long a time may elapse before reunion is accom- plished, (if indeed it ever take place, for the patient is intemperate and advanced in years) time will show; one thing, however, is certain, that the two limbs are of the natural length and the fragments in exact apposition. 452 Fracture of the Leg and Foot. Section XIV. Fracture of the Leg and Foot. The bones of the leg are susceptible of every va- riety of fracture, and may be broken at any place intermediate to the knee and ancle. Oblique and transverse fractures, however, about the middle of the limb, are most common. When both bones are fractured at the same time, there is commonly an angular derangement together with evident crepita- tion, and by these signs the nature of the accident is rendered very plain. But a longitudinal displace- ment sometimes occurs, in which case the bones overlap and produce a shortening of the limb. If only one bone be broken, the other serves as a splint, and prevents in a measure deformity, though it cannot obviate the crepitation, and by this sign the character of the accident is evinced. Although the fibula is exceedingly weak and slen- der, and apparently contributes very little to the Fracture of the Leg and Foot. 453 strength of the leg, yet when broken near its lower end, deformity and permanent lameness are extreme- ly apt to follow, unless the case be well understood and managed with adroitness. The lower part of the fibula in fact forms the external boundary to the ancle joint, and serves mainly to preserve the foot in its natural situation. As soon, therefore, as frac- ture of the bone takes place just above the ancle, the lower extremity of it is forced outwards by the abduction of the foot, while its upper portion, or that which is in contact with the upper fragment or shaft of the fibula, is directed inwards in an angular direc- tion. Hence the astragalus may be thrown from the tibia, the foot drawn to the outside of the leg, and great deformity ensue. Fractures of the middle, or of the upper extremity of the fibula, are compa- ratively unimportant The os calcis, from its great thickness and strength, is seldom fractured, except by great vio- lence conjoined with inordinate action of the exten- sor muscles. A fall from a height, by which the pa- tient lights on the heels, is the most common cause of it Upon examination, the extremity of the bone will be found separated from its body and drawn up- 454 Fracture of the Leg and Foot. wards on the posterior surface of the leg, where it forms a distinct tumour. By this sign the nature of the case will be clearly manifested. The remaining bones of the foot may be commi- nuted by great violence directly applied to them, but are hardly susceptible of any other species of fracture. Like similar injuries of the hand, they are chiefly dangerous from the inflammation that follows. Treatment of Fracture of the Leg and Foot. Simple fractures of one or both bones of the leg * may all be treated upon the same principle—with the exception of fracture of the fibula immediately above the ancle. My own plan of managing these accidents is the following. A mattress should first be prepared as directed for fracture of the thigh. Over the sheet which covers it five or six pieces of tape are laid; above the tapes a splint cloth, a yard ■nlryFSvSy. Fracture of the Leg and Foot. 455 and an half long and eighteen inches wide; next to the splint a small firm pillow, covered by its case, and on the pillow the bandage of Scultetus, com- prising a sufficient number of strips to reach from the ancle to the knee. Four or five assistants then take hold of the patient, and lifting him upon the mattress, place the limb on the pillow in the centre of the dressings. Extension and counter-extension are next, made from the foot and knee, the fragments properly replaced, and the bandage of Scultetus ap- plied. Two wooden splints, somewhat longer than the leg, half an inch thick and three inches wide, are then rolled in the splint cloth and folded closely against the pillow, so as to elevate its sides and cause it to fit the limb with the utmost accuracy; after which the tapes are tied over the edges of the splints, and the whole secured. To support the foot and keep it steadily fixed, the centre of a piece of roller, about a yard long, should be placed on the sole, the ends crossed on the instep, and pinned above on each side to the splint cloth. Lastly, two segments of a common barrel hoop are crossed at the centre and tied, and their ends placed upon the mattress over the foot and dressings, to take off the weight of the bed clothes. See Plate XIII. 456 Fracture of the Leg and Foot. When the bones pass each other and the limb is shortened, which very seldom occurs, it may be- come necessary to keep up extension and counter- extension by some apparatus. That employed by Dr. Hutchinson will be found most convenient. It consists of two firm splints, long enough to extend from the knee several inches beyond the foot. The upper end of each splint has four small holes in it for the passage of tapes, and the lower a .mortise, intended to receive a bar eight inches long. The bandage of Scultetus being applied and the leg laid on a pillow, two tapes are placed on each side of the leg and parallel with it immediately below the knee, and are secured by a roller passed several times around the limb. Through the holes in the splints the ends of these tapes are next passed, and tied on the outside. Around the ancle, in the form of the figure 8, a silk handkerchief is placed, and the ends secured to the bar, which is previously passed through the mortises at the lower ends of the splint. By the tapes and roller counter-extension is produced, and by the handkerchief extension.* * A representation of this apparatus maybe seen in Dorsey's Surgery, vol. i. p. 207. edit 3d. Fracture of the Leg and Foot. 457 Should fracture of the fibula take place near its lower end, accompanied by distortion of the foot outwards, the method proposed by Dupuytren will be found the most effectual. Two bandages, a cushion or pad, and a splint, constitute the means by which reduction is accomplished and maintained. The cushion, made of old linen or any similar ma- terial, must be two feet six inches long, five inches broad and four thick; the splint two feet, and the rollers each five yards in length. The cushion be- ing doubled and formed into the shape of a wedge, is laid along the internal surface of the leg, with its thick end downwards, and should extend from the upper end of the tibia to the ancle. Over the cushion the splint is laid so as to project four or five inches beyond the foot; one of the rollers is then passed around the cushion and splint immediately below the knee, and extended down the leg as far as the ancle. A space of several inches will thus be left between the foot and splint, which must be filled up by drawing the one to the other with the remaining roller, passed over the instep and heel in form of the figure 8. It must be obvious that, in proportion as the lower fragment of the fibula is drawn down- wards and inwards along with the foot, the upper Vol. I. 3 iM 458 Fracture of the Leg and Foot. end must be carried outwards or recede from the tibia and resume its natural situation. To replace the fractured os calcis, the surgeon bends the thigh on the pelvis, the leg of the thigh, and extends the foot on the leg. The superior frag- ment is then drawn downwards, and by an assistant retained in contact with the inferior, while the sur- geon lays one end of a compress or short roller on the instep, carries it over the toes, under the sole of the foot and heel, along the posterior surface of the whole limb, as high as the pelvis, where it is held tense by another assistant. He then takes a com- mon roller, eight or ten yards long, and passing it around the foot by two or three circular turns, se- cures the end of the compress; after which the roller is carried about the os calcis and foot several times in form of the figure 8, from thence passes up the leg and thigh by reversed and circular turns, and terminates at the hip, where it is fixed to the upper end of the compress. It only remains to preserve the limb in the position first given to it and this is easily accomplished by placing three or four pillows under the ham, in the form of a double inclined plane. Compound Fracture. 459 Section XV. Compound Fracture. A wound communicating with the cavity of a broken bone, in which sense the term compound fracture is generally understood, may be produced by external violence, or by the protrusion of the bone itself. In the latter case, the bone is usually broken in a very oblique direction, though it some- times happens that a very obtuse fragment will pene- trate the integuments and produce an extensive wound. The bones are all liable to compound frac- ture, but the long or cylindrical ones, especially those of the leg, are most apt to suffer. Unless combined with other injury, the mere protrusion of the bone does not necessarily increase the danger of the case, for it often happens that the wound heals by the first intention immediately after the fragments are replaced. A complicated fracture is not necessarily accom- 460 Compound Fracture. panied by an external wound or a protruded bone, and in this respect, among others, differs from a compound fracture. An open wound, however, conjoined with a luxation or with a lacerated artery, will generally exasperate all the symptoms, which at any rate are always liable to terminate most unfa- vourably. Treatment of Compound Fracture. The treatment of compound fracture must be re- gulated by the extent of the injury, and by the age, constitution and habits of the patient. If the external wound is slight and the hemorrhage in- considerable, it will be sufficient to replace the bones and apply the dressings for simple fracture —merely covering the wound with a piece of lint or adhesive plaster. On the contrary, when the bones have been extensively shattered and their ends project several inches beyond the wound, whilst the surrounding soft parts are lacerated and mangled, and blood is streaming from the limb, a very different course should be pursued. To re- Compound Fracture. 461 place the bones under these circumstances will sometimes be found very difficult; but the surgeon should always make the attempt before he ven- tures to dilate the wound or saw off the bones. By well directed and gentle efforts at extension and counter-extension, the fragments may often be re- stored to their places; if these fail, then the soft parts which appear to bind the bones and prevent them from yielding may be slightly divided, and other trials by extension made. Should every en- deavour of the kind prove fruitless, there can be no other resource than to cut off the bone, though it must be obvious that such an operation can very sel- dom prove necessary, and must always be attended with disadvantage, inasmuch as the limb will proba- bly remain shortened or months elapse before the bone is regenerated. After the bones are replaced, it generally happens that the hemorrhage stops; should the blood, however, continue to flow co- piously, it may be necessary to dilate the wound and search for the vessel, which must be secured by the ligature or compress. Instead of confining the limb by splints and rollers, it should be placed on a pillow and surrounded lightly with the ban- dage of Scultetus, and every care taken to obviate 462 Compound Fracture. and remove inflammation. After this has subsided and the wound begun to heal, splints and the usual dressings may be applied. When old, debilitated, and intemperate patients suffer from compound frac- tures, mortification may ensue. Such patients gene- rally require a nutritive diet, bark, wine, &c. Complicated fractures not unfrequently terminate in death or render amputation necessary. Under favourable circumstances the treatment does not dif- fer from that of compound fracture. Pseudo-Aiihrosis. 463 Section XVI. Pseudo-Arthrosis, or Artificial Joint. When the extremities of a fractured bone, instead of uniting through the medium of callus, remain loose and unconnected, a kind of false articulation is established and the limb is rendered nearly use- less. This disease may follow a fracture of any bone, though it has been most frequently observed in the humerus. It may arise from premature use of the limb, from the interposition of a tendon, liga- ment, or muscle, from old age, certain peculiarities of constitution, disease in the osseous system, or from want of proper contact between the fragments. Reunion having been prevented by any of these means, the extremities of the bone generally become smooth and round, and are covered with a cellular or ligamentous substance. " Sometimes a hall and socket are formed, and the ends of the bone roll upon each other. Two specimens of the kind are contained in my cabinet 464 Pseudo-Arthrosis. Treatment of Artificial Joint. In old subjects and in peculiar constitutions cal- lus is sometimes secreted very slowly, and months elapse before reunion is perfected. Aware of this, the surgeon should never despair of effecting a cure, but continue the dressings so long as any reasonable hope of success remains. Sometimes, however, it may be proper to deviate from this rule and permit the patient to use the limb, even although the frag- ments should continue moveable—a practice first suggested, I believe, by Mr. Hunter. By adopting this plan, the formation of callus w ill be promoted and artificial joint often prevented. Indeed, in the early stage of this disease similar means have occa- sionally been used with success; at least friction, or rubbing of the fragments upon each other, has been found in a few instances to excite ossific ac- tion to a sufficient degree to effect a cure. In cases of long standing, however, there are two modes of procedure—the removal of the ends of the bone, or the introduction of a seton between them. The former has sometimes succeeded, but is difficult of execution, and liable to be followed by Pseudo-Arthrosis. 465 severe symptoms and even death; the latter is ex- tremely simple, and when well managed rarely fails. To Dr. Physick is exclusively due the merit of having first proposed and executed with success this ingenious operation. Upon my arrival in Edin- burgh in 1806,1 communicated to the elder Monro, and afterwards to several distinguished surgeons of London, the result of two or three cases in which Dr. Physick had introduced the seton with com- plete success. The only one, however, who seemed to feel an interest in the operation was Mr. Charles Bell, to whom, by particular request, I transmitted upon my return home in 1810, an account of all the cases in which Dr. Physick had then operated. These were afterwards published in the second edi- tion of his " Operative Surgery," and in answer to my communication, Mr. Bell remarks," I have been read- ing your cases of the operation of the seton in artifi- cial joint to my class. I continue to think it one of the most ingenious things in modern surgery. I have a patient who I am in hopes will submit to the opera- tion. He is a captain of an Indiaman. His thigh bone was broken by a spent cannon ball about eigh- teen months ago, and has not united." Upon show- 466 Pseudo-Arthrosis. ing Mr. Bell's letter to Dr. Physick, he desired me to say to him, that he had twice tried the seton in the thigh but without effect, and he was fearful it would not succeed in any case of the kind. Whether Mr. Bell afterwards performed the operation re- ferred to, I have not ascertained; but that Dr. Phy- sick's apprehension was unfounded, has since been proved by Mr. Brodie and others who have succeed- ed upon the thigh as well as other bones. That the seton sometimes fails there can be no doubt, but that it generally succeeds is equally certain. A case occurred two or three years ago at the Aims-House, in which a seton was twice passed at different times, between the ends of a disunited hu- merus without effect Dr. Hewson afterwards cut off the extremities of the bone with a saw, union took place and the patient recovered the use of his arm. On the other hand, a case is related by Mr. Samuel Cooper* "of a strong robust man, whose chief peculiarity seemed to be his indifference to pain: the ends of his broken humerus were cut down to, turned out and sawn off by Mr. Long, in * See Dictionary of Surgery. Pseudo-Arthrosis. 467 St Bartholomew's Hospital, and the limb was after- wards put in splints, and taken the greatest care of; but no union followed." In general when the seton fails to procure reunion, there is reason to believe that it has not been conti- nued a sufficient length of time. In 1806,1 was pre- sent at an operation performed by Dr. Physick, upon the humerus of a woman residing at Baltimore; for some trivial reason, the physician under whose care the patient was left, removed the seton in two or three weeks, and no benefit of course resulted. Again—within the last two years, Dr. Physick pass- ed a seton between the ends of a disunited lower jaw, and the patient returned home. In a little time his attending physician became anxious to re- move the cord, under an idea that no union would take place; the patient, however, had promised Dr. Physick before his departure, that no one except himself should take it out. It was therefore con- tinued a few weeks longer, and in the mean time perfect bony reunion was established. To perform this operation, the surgeon should be provided with a skein of silk, and a long narrow 468 Pseudo-Arthrosis. » seton needle, somewhat curved near the point The limb should then be extended by assistants, in order to separate the extremities of the bones as much as possible from each other, while the surgeon passes the needle, armed with the silk, through the integu- ments and muscles, and between the bones, taking care to avoid all the large vessels and nerves. Over each orifice made by the seton is placed a bit of lint and a pledget, and the limb supported by a roller and splints. Four or five months should elapse before the seton is removed; at the end of this time the fragments will generally be found perfectly con- solidated. On Fractures, consult Desault on Fractures, Luxations, and other Affections of the Bones, translated by Caldwell, edit. 2d. 1811—Boyer's Lectures on Diseases of the Bones— Boyer's Treatise on Surgical Diseases, vol. 2d. by Stevens__ Dorsey's Elements of Surgery, vol. 1. p. 118. edit, by Ran- dolph—Surgical Essays, by Cooper and Travers—Bell's Ope- rative Surgery, vol. 2d.—J. Bell's Principles of Surgery, vol. 1. p. 587—Pott on Fractures and Dislocations, vol. 1. —A Treatise on Dislocations and on Fractures of the Joints, by Sir Astley Cooper, 4to. London, lS22—Dupuytren sur la Fracture de I'Extremite Inferieure du Per one Sfc. in An- nuaire Medico Chirurgicale, torn. 1.—Roux's Narrative Pseudo-Arthrosis. 469 of a Journey to London in 1814, 2d. edit. p. 159—Cross' Sketches of the Medical Schools of Paris—Practical Ob- servations in Surgery, by Henry Earle, p. 17, octavo. Lon- don, 1823.—Larrey's Surgical Essays, translated by Revere, p. 247. On Artificial Joint, consult Physick's " Case of Fracture of the Os Humeri, in which the broken Ends of the Bone not uni- ting in the usual Manner, a Cure was effected by Means of a Seton," in New Fork Medical Repository, vol. l.p. 122.— Also Caldwell's Appendix to Desault—Dorsey's Surgery, vol. l.p. 133—Brodie, in Medico-Chirurgical Transactions, vol. 5th. p. 387— Wardrop, in the same work, vol. 5. p. 365— Roux's Journey, p. 172—-Hutchinson's Practical Observations in Surgery, p. 162—Inglis on Unnatural Articulations, in Edinburgh Medical and Surgical Journal, vol. 1. jp. 419— White's Cases in Surgery. ^ ^*mxwssL Is page 451, where a short account is given of a case of frac- tured thigh, under treatment at the Aims-House, it is stated that no uneasiness was experienced after the gaiters were sub- stituted in place of the handkerchiefs. It is proper to mention, however, that since the passage referred to was printed, it has been found necessary to abandon every mode of treatment calculated to effect extension and counter-extension, owing to the extreme intemperance of the patient, the exhausted con- dition of her constitution (amounting almost to mania a potu), and the criminality of the nurses in supplying her at all times with undiluted spirits, in altering and sometimes remov- ing, during my absence from the house, the extending bands, and in fact deviating in every particular from the directions given them. From these different causes, ulceration, similar to that which often arises from Desault's extending band, took place about the ancle, and rendered the removal of every spe- cies of dressing necessary. In proof, however, of the efficacy of the apparatus, and of the little inconvenience to which it subjects the patient, it may be proper to mention, that I have since had under care in the same establishment for the last fort- night, a man of strong and healthy constitution, whose thigh bone was fractured below the trochanter minor, and although exceedingly shortened and deformed, was almost instanta- neously reduced, in presence of the Clinical class, by placing it over the inclined plane; nnce which it has remained in its natural situation, and the patient feels little inconvenience except that arising from confinement to bed. 0tb» ■ / ,-' V\ ; 'S- - v. ■*