• .'i'-iirSHl^^'u^'iii?"•*i'"'"-"--«»-*^-^-.. v^:'-.' •.,■■.'.■"". * '.—?s NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Serrice THE PRINCIPLES AND PRACTICE OP SURGERY. ILLUSTRATED BY THREE HUNDRED AND SIXTEEN ENGRAVINGS ON WOOD. i BY WILLIAM PIRRIE, F.R.S.E., REGIUS PROFESSOR OF SURGERY IN THE MARISCHAL COLLEGE AND UNIVERSITY OF ABERDEEN J SURGEON TO THE ROYAL INFIRMARY, ETC., ETC. EDITED, WITH ADDITIONS, BY JOHN NEILL, M.D., SURGEON TO THE PENNA. HOSPITAL, DEMONSTRATOR OF ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA, ETO. PHILADELPHIA: BLANCHARD AND LEA. 1852. Wo yio^P \3 5fc. Entered, according to Act of Congress, in the year 1852, BY BLANCHARD AND LEA, In the Clerk's Office of the District Court for the Eastern District of Pennsylvania. C. SHERMAN, PRINTER. 19 St. James Street. St p TO THE STUDENTS OE SURGERY OF THE MARISCHAL COLLEGE AND UNIVERSITY OP ABERDEEN, IN GRATEFUL REMEMBRANCE OF THE PLEASURE HE HAS UNIFORMLY EXPERIENCED IN HIS CONNEXION WITH THEM, AND IN TESTIMONY OF THE LIVELY INTEREST HE FEELS IN THEIR PROFESSIONAL PROGRESS, THIS WORK IS DEDICATED BY THE AUTHOR. PREFACE TO THE ENGLISH EDITION. This work is not put before the public with the design of placing it in competition with any of the valuable treatises on the same subject already existing, but in compliance with a wish repeatedly expressed, on the part of the Students of Surgery at this University, to be furnished with a Compendium of my Lectures. For their.use the work has been prepared; and while I would venture to hope that others may find it not unserviceable, yet, if those, for whose especial use it is intended, derive benefit, my chief object will be obtained. It has been my endeavour to combine simplicity of arrangement, and conciseness and clearness of description, with the elucidation of sound principles and practice. How far that endeavour has been successful, I must leave my readers to determine. The wood-engravings are taken from drawings, the greater proportion of which are original delineations of preparations in my own Museum; others are of patients who were under my care while the work was in progress ; and the rest are from authorities which are duly acknow- ledged. To Dr. Westmacott of London, I am indebted for his drawing, from sketches furnished by Mr. Cleland of this place, the greater part of the original illustrations, as well as for directing the artist in the process of engraving. The remainder of these will fully sustain the reputation of XXI1 PREFACE. Mr. Bagg. To Dr. Bennett I owe acknowledgments for the use of many wood-cuts, illustrative of the inflammatory process, and of the microscopic character of Tumours. My warmest thanks are due to my Publisher, for permission to use the blocks belonging to Mr. Liston's " Practical Surgery," with beautiful and instructive engravings from which many pages of this work are adorned. 238 Union Street, West Aberdeen, February 7th, 1852. EDITOR'S PREFACE. The duty which has been assigned the Editor, of bringing another Surgical work before the profession has been cheerfully undertaken, from his conviction of the high character and utility of the present volume. It is true, that comprehensive cyclopaedias and manuals, and instructive trea- tises on special surgical subjects, as well as beautiful illustrations of sur- gical anatomy and operative surgery, have been issued from the press in great profusion; but the want of a suitable text-book on surgery has been constantly felt by those who are called upon to recommend to students a guide to their surgical studies, and who desire to place in the hands of their pupils the elements of sound principles, combined with safe practice. This desideratum has been admirably supplied by Professor Pirrie, who has introduced recent views of pathology, and whose experience, both as a teacher and practitioner, has enabled him to give force and weight to his practical deductions ; and we therefore venture to say, that no work has been offered to the medical public, which has so many claims to re- commend it to the student of medicine. Difficult as it is to limit the amount of matter that should be included in a work of this kind, at the same time, it is equally important that it does not encroach upon the province of a dictionary, or of a work upon Minor Surgery. If every topic had been introduced, it would have exceeded its XXIV EDITOR'S PREFACE. appropriate limits, and not fulfilled the precise object of its publication. The Editor has, therefore, added but few new articles, some of which are upon subjects that may render it more acceptable to the American Stu- dent, while the liberality of the publishers has enabled him to in- crease the number of the illustrations. 317 Spruce Street, July, 1852. CONTENTS CHAPTER I. Inflammation and its Results, . PAGE 33 CHAPTER II. Erythema and Erysipelas, 62 Wounds, CHAPTER III. 73 Burns, CHAPTER IV. 105 Fractures, CHAPTER V. 126 Injuries of the Head, CHAPTER VI. 202 Dislocations, CHAPTER VII. 228 CHAPTER VIII. Affections of the Osseous System, 285 XXV1 CONTENTS CHAPTER IX. TAGE Diseases of Joints, ........ 324 CHAPTER X. Curvatures of the Spine, ....... 359 CHAPTER XI. Talipes, CHAPTER XIII. Hernia, CHAPTER XVII. Affections of Genito-Urinary Organs, CHAPTER XVIII. Amputations and Resections, CHAPTER XIX. Deligation of Arteries, . 382 CHAPTER XII. Affections of the Arteries and Veins, ...... 400 450 CHAPTER XIV. Wounds of Abdomen, ..... 507 CHAPTER XV. Calculous Disorders, ..... r-14 CHAPTER XVI. Affections of the Testicle, . Cf>1 ' • • • • . 501 578 608 634 CONTENTS. XXV11 CHAPTER XX. PAGE Affections of Rectum, ........ 649 CHAPTER XXI. Affections of the Eye and its Appendages, ..... 6o7 CHAPTER XXII. Affections of Nose, ........ 710 CHAPTER XXIII. Affections of Mouth, Throat, and Windpipe, ..... 720 CHAPTER XXIV. Tumours, .......••• 753 CHAPTER XXV. Affections of Breast, ... .... 773 LIST OF ILLUSTRATIONS. 1. Example of Intervascular Deposit, 2. Web in the Foot of a Frog, inflamed, 3. Example of Exudation, 4. Changes in Blood Globules, 5. Nuclei developing themselves into Fibres, 6. Cells developing themselves into Fibres, 7. Pus Corpuscles, 8. Ulcer Cicatrizing in the Middle, 9. Healthy Ulcer, 10. Weak Ulcer, 11. Indolent Ulcer, 12. Inflamed Ulcer, . 13. Phagedenic Ulcer, 14. Gangrenous Ulcer, 15. Interrupted Suture, 16. Hare-lip Suture, 17. Fracture of the Radius at the Wrist, 18. Fracture of the Radius and Ulna, 19, 20. Bond's Splint, 21. Fracture of the Olecranon, 22. Fracture of the Neck of the Humerus, 23. Fracture of the Body of the Scapula, 24. Dressing for Fracture of Neck of Scapula, 25. Fox's Apparatus for Fractured Clavicle, 26. Intra-capsular Fracture of the Neck of the Thigh Bone, 27. Deformity of the Neck of the Thigh Bone, 28. Fracture of the Neck of the Femur without Inversion or Eversion, 29. Extra-capsular Fracture of the Femur, 30. Fracture through the Trochanter Major, 31. Intra-capsular Fracture of the Femur, 32. Liston's Modification of Desault's Splints, 33. Physick's Modification of Desault's Splints, 34. Gibson's Modification of Hagedorn's Splints, 35. Fracture of both Condyles of Femur, 36, 37. Fracture of the Patella, . . 38. Displacement of the Patella, 39. Fracture of both Bones of the Leg, . 40. Liston's Cradle, . 41. Liston's Cradle Applied, 42. Fracture Box, 43. Dupuytren's Splint for the Fibula, 44, 45. Fracture of the Ribs, 46. Fracture at the Base of the Skull, 47. Simple Fissure of the Skull, 48. Simple Fracture with Depression, 49-54. Instruments for Trephining, 55. Punctured Fracture of the Cranium, LIST OF ILLUSTRATIONS. XXIX no. 56. Fracture of the Lower Jaw, 57. Bandage for the Lower Jaw, 58. Barton's Bandage for the Lower Jaw, 59, 60. Dislocations of the Lower Jaw, . 61. Dislocation downwards of the Shoulder Joint, . 62. Dislocation downwards and forwards of the Humerus, 63, 64. Reduction of the Humerus, 65, 66. Dislocation forwards of the Humerus, 67. Dislocation of the Humerus backwards, 68. Dislocation of the Humerus upwards, 69, 70. Dislocation of the Elbow, 71,72. Dislocation forwards of the Radius, 73. Clove Hitch, ..... 74. Dislocation of the Femur upwards and backwards, 75. Reduction of the Femur, 76. Gilbert's Mode of Reduction, 77. Dislocation into the Sciatic Notch, 78. Reduction of Dislocation into the Sciatic Notch, 79. Dislocation of Femur into the Foramen Ovale, 80. Reduction of Dislocation of the Femur into the Foramen Ovale 81. Dislocation of Femur upon the Pubes, 82. Reduction of Dislocation of Femur upon the Pubes, 83, 84. Dislocation of the Tibia inwards, 85. Dislocation of the Tibia outwards, 86. Suppuration in Bone, 87-89. Abscess in Bone, . 90, 91. Caries of the Cranium and Face, 92. Necrosis of Femur, 93. Reproduction of Tibia, 94. Cloacae of Femur, 95, 96. Rickets affecting the Femur, 97. Rickets affecting the Tibia, . 98, 99. Rickets affecting the Humerus, 100. Exostosis of Femur, . 101. Osteosarcoma of Femur, 102. Fimbriated Synovial Membrane, 103-105. Diseased Articular Cartilage, 106. Anchylosis of Hip Joint, 107. Perfect Anchylosis of Hip Joint, 108. Section of Anchylosis of Hip Joint, 109. Morbus Coxarius, showing Deformity, 110. Morbus Coxarius, showing changes in Acetabulum, 111, 112. Morbus Coxarius, showing changes in the Head of the Femur 113. Mutter's Splint for Anchylosis, 114,115. Curvatures of the Spine, 116. Deformity in the Spine, 117. Excurvation of Spine, 118, 119. Lateral Curvature of Spine, 120. Effects of Lateral Curvature, 121. Posterior view of the same, . 122. Talipes Equinus, 123. Stromeyer's Apparatus applied, 124. Little's Boot applied, 125. Opposite View of the same, . 126. Talipes Varus, 226 227 227 238 244 247 . 247, 248 251, 252 254 256 257 261 265 267 268 269 270 271 272 273 274 275 280 282 294 294, 295 . 301, 303 309 310 314 317 317 318 322 323 336 338, 339 341 341 341 351 352 352 356 362 366 371 375, 376 377 377 382 386 387 387 388 XXX LIST OF ILLUSTRATIONS. 127. Talipes Varus, before Operation, . • 128. Appearance of the same a fortnight after Operation, . 129. Appearance six weeks after, 130. Talipes Varus before Operation, 131. The same after Operation, • 132. Talipes Valgus, ..•••• 133. Talipes Calcaneus, . 134. Steatomatous Degeneration of Arteries, 135. Calcareous Deposition, . . • 136. Aneurism of the Aorta, • 137. Aneurism of the Innominata, 138. Aneurism of the Aorta, inducing Caries of the Vertebrae, 139. Aneurism of the Aorta, producing Absorption of the Ribs, 140. Back view of the same, . . • • • 141. Aneurism of the Brachial Artery, 142. Aneurism filled with Coagulum, 143. Hunter's Operation for Aneurism, . 144. Brasdor's Operation for Aneurism, 145. Wardrop's Operation for Aneurism, . 146. False Aneurism, . 147. 148. Aneurism of Varix, .... 149. Varicose Aneurism, .... 150, 151. Dissection for Inguinal Hernia, 152. Dissection, showing Deeper Parts, 153. Dissection, for Inguinal Hernia on both sides, 154. Hernial Sac, ..... 155. Hernial Sac, accompanied by Varicocele, . 156,157. Bistoury for Hernia, 158. Direct Inguinal Hernia on both sides, 159. Sac of a Direct Inguinal Hernia, 160. Seat of Stricture in Hernia, 161. A Scrotal Hernia, .... 162. Congenital Scrotal Hernia, .... 163. The Femoral Arch and Gimbernat's Ligament, . 164. The Femoral Vessels of the left side, 165. The Groin of the right side Dissected, . 166. Certain Parts concerned in Inguinal Hernia, 167. Strangulated Intestine and Stricture, 168. Posterior View of the same, 169. Relations of the Diverticulum to the Intestine, . 170-172. Trocar and Canula, .... 173. Microscopic view of Lithic Acid, 174. Microscopic view of Phosphates, 175. Microscopic view of Oxalates, 176, 177. Renal Calculi, ..... 178. Section of Stone, showing Nucleus, 179. Uric Calculus, ..... 180. Section of Calculus, showing Lamina, . 181. Mulberry Calculus, ..... 182. Section of Calculus, .... 183. Hemp-seed Calculus, .... 184. Phosphatic Calculus, .... 185. Ammoniaco-Magnesian Calculus, 186. Fusible Calculus, .... 187. Section of same, ..... PAGE 391 391 392 392 392 394 395 407 408 416 417 417 418 418 419 421 429 429 429 433 434 435 479, 480 481 485 486 486 487 488 489 490 491 491 493 495 495 498 505 505 506 512 514 517 519 521 526 531 531 532 532 532 532 532 533 533 LIST OF ILLUSTRATIONS. XXXI FIG. 188. 189. 190. 191- 196. 197. 198. 199. 200. 201. 202- 208. 209. 210. 211. 212. 213. 214. 215. 216. 217. 218. 219. 220. 221. 222- 225. 226. 227. 228. 229, 231, 233. 234. 235. 236. 237. 238, 240. 241. 242. 243. 244. 245. 246. 247. 248. 249. 250. 251. 252. 253. 254. 255. 256. Cystic Calculus, . Section of same, ..... Encysted Calculus, . -195. Instruments for Lithotomy, Position of Patient during Lithotomy, Anatomy of-Parts in Lithotomy, Lateral View of the same, Lateral operation of Lithotomy, Probe-pointed Lithotomy Knife, Section of Prostate Gland in Lithotomy, 207. Instruments constituting the Apparatus Major, Double-edged Gorget, Single-edged Gorget, Pbysick's Gorget, Dupuytren's Double Lithotome, Weiss's Lithotriptor, Jacobson's Lithotriptor, Operation of Lithotripsy, Trocar for Hydrocele, Operation for Hydrocele, Phymosis, Paraphymosis, Enlargement of Prostate Gland, Artery Forceps, . Reef Knot, ■224. Amputation of Finger, Amputation of Metacarpal Bone, Appearance afterwards, Amputation of Thumb, Amputation of Forearm, 230. Amputation of Arm, 232. Amputation at Shoulder Joint, Amputation of Great Toe, Hey's Amputation of the Foot, . Chopart's Amputation of the Foot, Syme's Amputation at the Ankle, Amputation of the Leg, 239. Amputation of the Thigh, Amputation of the Hip-joint, Tumour of the Lower Jaw, Resection of the Lower Jaw, Portion removed, Deligation of Carotid Artery, Deligation of Subclavian, Deligation of Axillary, Deligation of the Humeral, Deligation of the Radial and Ulnar, Deligation of the Radial, Deligation of the Common Iliac, Deligation of the Femoral, Deligation of the Anterior Tibial, Deligation of the Posterior Tibial, Operation for Fistula in Ano, Simple Conjunctivitis, Pustular Conjunctivitis, xxxii LIST OF ILLUSTRATIONS. no. 257. Conical Cornea, 258. Rheumatic Ophthalmia, • 259. Choroiditis, . 260. Acute Iritis, • • * 261. Spring Speculum, • 262. Small Tooth Forceps, • 263. Probe-pointed Scissors, • 264. Small Iris Knife, . 265. Hook for seizing the Rectus Muscle, 266. Operation for Fistula Lachrymalis, 267. Case of Lipoma of the Nose, . 268. The same, after operation, . 269. Polypus of the Nose, •..••• 270. Speculum for the Nose, . 271. Forceps for Polypus, ..•••• 272. Operation for Polypus, ..•■•• 273. Operation for Plugging the Posterior Nares, 274. Rhinoplastic Flap, • • • 275. Microscopic view of Cancer of the Cheek, 276. Cancer of the Lip, ..••••• 277. Hare-lip, ..-••■• 278. Hare-lip Suture, . 279. Double Hare-lip, ..•■•• 280. Operation of the same, ..-■•• 281. Removal of the Tonsil, ...•■• 282, 283. Operation of Tracheotomy, . 284. Section of a Fibrous Tumour of the Uterus, 285. Structure of a Fatty Tumour, . • 286. Enchondroma, .....-• 287. Ossification of Enchondromatous Tumours, 288. Osseous Tumours of Innominatum, .... 289. Back view of the same, .... 290-292. Corpuscles from Tubercle, . 293. Section of a Cancer of the Breast, ..... 294. The same treated with Acetic Acid, ... 295. Cancer-Cells, ....... 296. The same, treated with Acetic Acid, .... 297. Dense Fibrous Tissue infiltrated with Cancer-Cells, 298. Cancer-Cells, ....... 299. The same, after addition of Acetic Acid, .... 300. Older Cancer-Cells, ...... 301. Older Cancer-Cells, after addition of Acetic Acid, . 302. Advanced Cancer-Cells, with Secondary Cells, 303-305. Cancer-Cells, ....... 306. Young Cancer-Cells, ...... 307. Young Cancer-Cells, after addition of Acetic Acid, .... 308-311. Structure of Colloid Cancer, before and after the addition of Acetic Acid, 312. Melanic Cancer of Cheek, ....... 313-315. Microscopic Sections of the Nipple Tumour, 316. Serocystic Tumour of the Breast, ..... PAGE 072 673 675 677 697 698 698 699 699 708 710 711 712 713 713 715 716 717 720 722 723 724 724 724 733 736, 737 755 756 758 759 761 761 763 766 766 766 766 767 767 767 768 768 768 768 768 768 769 770 776 770 THE PRINCIPLES AND PRACTICE OF SURGERY. CHAPTER I. INFLAMMATION. Definition.—Inflammatiom may be defined,—" a peculiar perversion of nutrition or of secretion," attended with various abnormal conditions of the blood and its vessels, the most essential of which is exudation in the affected part. To give greater clearness to the description of the phenomena of in- flammation, we shall, in the first instance, allude to those produced by one of its most common forms. Symptoms.—The symptoms of inflammation are divided into the local, comprehending the unusual appearances presented by the inflamed part, and the constitutional, affecting the general system. Local Symptoms.—The principal local symptoms are the six follow- ing : redness, swelling, heat, pain, abnormal exudation, and impairment of function. I. REDNESS. Cause.—This symptom arises from an increased quantity of blood in the inflamed part, not only in the larger vessels, but also in the capil- laries. The smallest of the capillaries, in their natural condition, are invisible to the unassisted eye, and allow only one blood globule to pass through at a time; but in inflammation they become so enlarged as to allow several to pass abreast. In some inflammations the redness is partly caused by extravasation of blood, but in most instances it depends on enlargement of the capillaries, and the consequent increase in the quantity of blood contained by them. Varieties as to tint, extent, and form.—The tint of the redness varies in different inflammations ; in common acute and sthenic inflammation it is bright and vivid, and the colour of arterial blood; in chronic and asthenic inflammation it is more of a dark or purple hue ; in erythema it is a bright rosy red, and perfectly continuous; in erysipelas it is of a darker red; in erysipelas attended with great bilious derangement, it is of a yellowish red; in syphilitic inflammations it has something of a copper tinge ; in scrofulous inflammation it presents a peculiar soft 34 I N F L A M M A T10 N. appearance; and when the inflammation is about to result in gangrene, it is of a dark purple or blackish hue. The extent and form of the redness vary according to the character and intensity of the inflammation, and the nature of the tissue princi- pally involved. In phlegmon, for example, it is circumscribed, in ery- sipelas diffused ; in phlegmon it is gradually and insensibly lost in the surrounding parts ; whereas, in the erratic form of erythema, it presents a distinctly defined margin, or may be said to be abruptly circumscribed. With regard to form, it may be linear, as in inflammation of veins and lymphatics ; or punctiform, as in inflammation of the villi of a mucous membrane, which is not itself involved; or ramiform, as when the smaller arteries and veins only are seen distended; or capilliform, as when the distension of some of the capillaries is also seen; or uniform, as in erysipelas, when there is one continuous blush of efflorescence. The presence or absence of redness is not, by itself, a proof of the pre- sence or absence of inflammation.—Redness alone does not constitute inflammation ; for it often exists without inflammation, as in the crimson spot of the hectic cheek, or in the blush of shame, or when produced by friction, or by the application of heat, or by the cupping glasses. On the other hand, the absence of redness is no proof that inflammation does not exist; for some inflammations, as those of the cornea and of the arachnoid membrane, are attended with opacity instead of redness. It is only in conjunction with other local indications that redness is re- garded as a symptom of inflammation. The diagnostic peculiarity of inflammatory redness is its continuance so long as the inflammatory action, which causes it, still remains. II. SWELLING. Fig. 1. Cause.—The swelling may, in the early stage of the inflammation, be occasioned in some slight degree by the increased quantity of bfood ; but it is chiefly caused by the effusion into the in- tervascular spaces of some matters called products of inflammation. The nature of these matters will afterwards be consi- dered. The extent of the swelling depends partly on the kind and violence of the in- flammation, the more violent the action, the greater generally being the inflam- matory effusion, and partly on the nature of the part affected, being greater in loose and relaxed textures of a supple and dila- table character, such as cellular tissue, than in those of a hard unyield- ing nature, such as bones. In loose textures, generally, the swelling is most remarkable. ° Fig. 1. Granules and granular masses filling up the intervascular spaces and coat- ing the vessel at a. The transparent nuclei of cells may be seen here and there amZ the granules. Examples of intervascular deposit. Plenty of this will account satSfi torily for swelling.— Bennett. ut 8<«isiac- INFLAMMATION. 35 The consequences of swelling vary much according to the impor- tance, the delicate nature, the situations and relations of the part affected. In textures superficially situated, which do not perform a function of great importance, which are loose and dilatable, and so placed that the swelling cannot prevent the performance of any function essential to the animal economy, the occurrence of swelling is followed by relief, and is, therefore, favourably regarded by the surgeon; whereas, in some internal organs, in the sub-mucous cellular tissue of the glottis, and in many textures of a delicate nature, a very slight degree of effusion is sufficient to lead to a fatal result, and in some firm and unyielding struc- tures it not unfrequently causes the total destruction of the part in- flamed. The intelligent practitioner, therefore, in forming a correct judgment of the consequences likely to result from the effusion of pro- ducts of inflammation, will be guided by a consideration of the site, relations, nature, and importance of the affected part. Of swelling, as a symptom of inflammation, it may be remarked, that, like redness, it is generally greatest at the centre of the inflammation,— that it is, in most cases, gradually lost in the surrounding parts,—and that alone (as may be proved by many examples), it is no certain evi- dence of inflammation. III. PAIN. Pain varies in hind.—There are great varieties in the kinds of pain, depending on the part principally affected. It may be of a burning, tingling, or pruriginous character, as in certain inflammations of the skin,—or throbbing, as when the cellular tissue is affected,—or ex- tremely acute, sharp, and lancinating, and greatly increased by stretch- ing the inflamed part, as in inflammation of serous membranes;—some- times it is dull, heavy, obtuse, of an exceedingly oppressive character, and attended with a feeling of nausea, as in inflammations of some glandular organs;—and sometimes it is of a severe, bursting character, as in inflammations of ligaments, fasciae, periosteum, or bone. Pain varies in degree.—Pain, in different kinds of inflammation, varies much in degree, being, in some kinds, exceedingly intense, so as to constitute by far the most urgent symptom, while in others it is com- paratively slight. In some inflammations, under certain circumstances, there is no pain. Usually the intensity of the pain is in the direct ratio of the firmness and unyielding nature of the part affected. For exam- ple, ligament, bone, and fasciae, structures which, when sound, are endowed with little sensibility, are extremely painful when they become the subjects of inflammation. There is generally more pain in external inflammations, and in inflammations of the investing membranes, than in those which affect the substance of the viscera, or mucous mem- branes. In inflammation of some parts of mucous membranes, there is only a sense of heat and uneasiness not amounting to actual pain. The pain is generally greater in common, than in specific inflammations, with the ex- ception of gout. Of inflammation unattended with pain, the following examples may be enumerated:—insidious and indolent forms of scrofu- lous inflammations, in which extensive disorganization is often produced without the patient having ever been conscious of actual pain ;—inflam- 36 INFLAMMATION. mation in a part the subject of paralysis, or succeeding the division of the sensitive nerve of the eye, or in cases where the sensibility of the patient has been benumbed by the habitual use of intoxicating liquors;— very dangerous inflammations of the lungs in low kinds of typhoid fever, and those inflammations which affect the mucous membrane of the uri- nary passages, in complete anasthesia of the lower parts of the body. The absence of pain, therefore, is no certain evidence that inflammation does not exist; and it is equally true that its presence is no sure proof of the existence of inflammation;—of this we have examples in cases of neuralgia. There is usually no difficulty in distinguishing between in- flammatory and neuralgic pains; the former are invariably aggravated by pressure, whereas the latter are not only not increased, but often re- lieved by it. Neuralgic pain is generally intense from the commence- ment, and sometimes subsides suddenly; inflammatory pain steadily increases while the inflammation advances, having been at first, perhaps, nothing more than a slight increase of the natural sensibility. The sudden subsidence of pain in violent inflammations is more to be dreaded than desired, as.it gives good reason to suspect that the part has lost its vitality, from the inflammation having gone on to gangrene. The site of the pain is generally the site of the inflammatory action, but is in some instances at a distance from it; for example, in inflam- mation of the bladder or kidney, the pain is felt at the point of the urethra; in inflammation of the hip joint, it is felt principally at the knee ; in inflammation of the diaphragm, or upper part of the liver, the pain is at the right shoulder; in some inflammations of the brain, it is felt more along the spine; and in inflammation of the spinal cord, it is sometimes felt along the thorax, and in parts of the limbs, more than at the seat of the disease. In all such cases the pain is termed sympathetic, and is met with principally in those instances in which the inflamed and painful parts are closely connected together by function ; or where the latter contain the terminal expansions of nerves whose trunk or branches pass through or near the former. To avoid errors in diagnosis, these peculiarities as to the site of the pain should be carefully kept in view. Cause of Pain.—The pain has been by some ascribed to compression of the nerves of the inflamed part by distended vessels and effusion ; by others to an exaltation of nervous function, or to a painful stretching of the nerves arising from the distension of their small nutritious vessels; and by others to an impression produced on the nervi vasorum by the slight dilatation and elongation of the arteries during each impulse of the blood. From the facts that the pain is great where the nerves are most liable to be compressed, and that it is always increased by pres- sure (unless the pressure be steady, uniform, and such as to support the whole of the inflamed part), and from other considerations, it seems highly probable that pressure is the chief cause of the pain. IV. HEAT. Preternatural heat is usually characteristic of inflammation, and it was no doubt the general presence of this symptom, and an erroneous idea of the changes which take place in inflammation, that led to the adoption of the term derived from inflammo, to burn. This symptom INFLAMMATION. 37 like redness, varies much in degree, according to the violence of the inflammatory action, and the situation of the affected textures : in acute phlegmon, erysipelas, and certain inflammations of the skin and mucous membranes, it is considerable, and much complained of; while in some inflammations it is so slight as to be scarcely felt at all, or appreciated by the patient. John Hunter made many experiments and observations to ascertain the actual increase of temperature caused by inflammation. He excited inflammation in the vagina and rectum of an ass, and in the cavity of the thorax of a dog; and in none of these instances did he ever observe the temperature to rise more than one degree above the natural heat of the part. He had occasion to operate on a man in St. George's Hos- pital for the cure of hydrocele, and on drawing off the fluid he found that the thermometer, on being introduced into the cavity of the tunica vaginalis, stood at 92°; the next day, when inflammation had taken place, it stood at 98f, being an actual rise of 6f degrees. He observed that on applying a blister to the chest, the difference of heat in the in- flamed and surrounding parts did not exceed one degree or two ; whereas on applying a blister to the extremities, which are naturally colder, the difference between the healthy and inflamed parts was found to be from five to six degrees. These experiments and observations warranted the following con- clusions :—That the increase of heat is not so great as the patient might by his feelings be led to imagine, nor as a bystander might sup- pose before making the experiment; that the greatest rise of tempera- ture is found where the inflamed part is considerably removed from the centre of the circulation, and where the natural temperature is several degrees below that of the blood at the heart; that the actual rise of temperature in deep-seated parts is not more than one degree, but that in parts remote from the centre of circulation it may be several degrees ; and that in every instance the heat is below the temperature of the blood at the heart. It is in the parts remote from the centre of circu- lation that the heat is most complained of. The thermometer, however, only measures the degree of actual heat, whereas what the patient experiences is the sensation of it; and when we consider that not only is the sensibility of the inflamed part in- creased, but that the functions of the nerves also are increased and perverted, we need not be surprised that it is sometimes a very distressing symptom. An excellent writer on surgery has very happily remarked, " The heat of inflammation is partly actual, as ascertained by the ther- mometer, partly the result of perverted nervous function, estimated only by the patient." John Hunter attributed the augmented heat to the increased influx of arterial blood. In all cases, animal heat is believed to be derived from the mutual action between the oxygen and the carbon and hydro- gen of the tissues; and we may therefore conclude with Liebig, that together with an increased influx of blood, there is an increased amount of this kind of combustion, or an unnaturally rapid oxidation of the inflamed tissues. 38 INFLAMMATION. V. ABNORMAL EXUDATION. In every instance of undoubted inflammatory action, an exudation of blood-plasma occurs, and according to the ideas now entertained, this symptom is essential to inflammation. On this subject, I cannot deny myself the pleasure of giving the following quotation from Dr. Bennett's admirable " Treatise on Inflammation."—" Pain, heat, redness, and swelling, have been made to play too important a part in our views con- cerning inflammation. They are only present when the lesion affects the external surface, and are by no means applicable when it attacks many internal organs. I have seen cases of encephalitis, where no pain or heat was manifested before death, and where no redness or swelling was to be afterwards discovered, although an undoubted inflammatory softening existed. Inflammation also may attack the lungs, liver, kidneys, &c, and yet one or more of these supposed car- dinal symptoms be absent. Again, slight incisions as those with a razor, are generally supposed to heal by means of inflammation, and so they do; but where is the pain, heat, redness, or swelling ! In short, the symptoms of phlegmon, which so frequently come under the notice of surgeons, have been by them too generally applied to all inflamma- tions. An analysis of these symptoms also will show that, whilst some depend upon the previous congestion, others are attributable to the exudation that follows it. Thus the heat and redness are caused by the former, whilst the pain and swelling usually result from the latter. The presence of these symptoms, therefore, cannot be considered as essential to inflammation; whereas the state can never exist, however slight, or however severe, without exudation of blood-plasma. Other pathologists have felt the difficulties which attend the considering exu- dation as a result rather than as the essential phenomenon of inflamma- tion. Thus Dr. Alison observes, ' In order to give the requisite preci- sion to the general notion of inflammation, as a local change of the condition of any part of the body, it seems only necessary to include in it, besides the pain, swelling, heat, and redness, the tendency always observed, even when the changes in question are of short duration, to the effusion from the blood-vessels of some new products, speedily assuming in most instances the form, either of coagulable lymph, or of purulent matter.' If instead of tendency to we read existence of, effusion, the principle laid down is certainly correct." VI. IMPAIRMENT OF FUNCTION. Impairment or perversion of function is an almost invariable symptom varying much in character according to the organ affected, and the degree and progress of the inflammation. In many cases the function is first increased, then perverted, and afterwards, entirely arrested. Of many examples of this symptom, I shall mention only the following. The brain when inflamed, no longer continues to perform its office, L an organ of intellect, having its function at first perhaps exalted as in delirium and afterwards entirely suspended on the supervention of coma; the stomach is incapable, in inflammation, of performing? its office, as a digestive organ; the kidney ceases to be useful as a uro INFLAMMATION. 39 poietic viscus; the bladder becomes impatient of the least distension by urine, and the eye becomes intolerant of the slightest impression of light. The perceptions of taste and smell are lost in inflammations of the mouth and nostrils, so that the parts are incapable of performing their special functions, while at the same time, their common sensibility is often considerably increased, and inflammations of the ear, or of the muscles and vessels, the affected parts fail in the performance of their proper functions. In internal inflammations, derangement of function is frequently an important guide towards forming an accurate diag- nosis. Constitutional symptoms.—The constitutional symptoms may be con- veniently arranged into two general divisions :—first, the symptoms of sympathetic inflammatory fever; and second, the inflammatory appear- ances of the blood. I. SYMPATHETIC INFLAMMATORY FEVER. Various names have been employed at different periods to designate this disturbance in the general system :—it has been called Sympathetic Inflammatory Fever, Constitutional Fever, Sympathetic Synocha, Gene- ral Vascular Reaction, Constitutional Disturbance, Sympathetic Fever, Symptomatic Fever, &c. The patient generally has a sense of coldness, rigors, lassitude, and feebleness, followed by heat and dryness of skin, and generally by increased strength, frequency, fulness, and hardness of pulse. This is not, however, invariably the condition of the pulse; for example, in inflammation of the stomach and intestines it is small and exceedingly feeble, there being an early and decided depression of the action of the heart occasioned, as is supposed, by the combination of nausea with pain; and in inflammation of the brain attended by coma, the pulse is comparatively soft and slow. The respiration becomes hurried, and there is often an uneasy sensation of oppression in the chest; the face is flushed, and the head generally hot; the patient is restless, does not sleep well, complains of much general discomfort, and of dull pains in the loins and limbs; he cannot command his attention, and both the will and the power to exert himself are diminished ; he loses his appetite and is usually thirsty; the tongue becomes white, loaded, and dry; the mouth is parched ; the various secretions are deranged and diminished; the bowels constipated, the urine scanty and high-coloured, the func- tions of digestion and nutrition interrupted; emaciation soon becomes great, and debility excessive; there is incapacity for any mental exer- tion, and, ultimately, the mind is apt to become confused. Sympathetic inflammatory fever is especially marked by the absence of certain symptoms which distinguish the different forms of what is called idiopathic fever, and more particularly by the absence of petechias, of any special eruption on the skin, or the peculiarly overpowering depressio febrilis, muttering delirium, subsultus tendinum, and stupor; in short, by the absence of those peculiar signs of derangement of the nervous system to which we give the name of typhoid symptoms. 40 INFLAMMATION. II. INFLAMMATORY APPEARANCES OF THE BLOOD. When blood taken from a person labouring under inflammation is received into a spherical, or into a deep vessel, and allowed to remain at rest, the two parts into which it separates itself, namely, the clot, cruor, or crassamentum, and the serum, present the following peculiarities :— The clot is firmer and denser than that of healthy blood ; the upper surface, which is of less diameter than the lower, is covered over with a whitish layer formed of fibrin, constituting what is called the buffy coat, and this surface is sometimes hollowed out into a cuplike form, in which case the blood is said to be both buffed and cupped. Under these cir- cumstances, the coagulum is usually oval, but truncated at both extremi- ties, broader below than above, and often adherent to the bottom of the recipient vessel. The coagulable lymph of surgeons, which is observed on cut surfaces, is identical in appearance and chemical characters with the buffy coat, and they, no doubt are the same substance. The appa- rent ratio of the clot to the serum is variable, depending materially on the figure of the containing vessel. When the coagulating blood is con- tained in a spherical vessel, the particles of fibrin, being little removed from a common centre, are more powerfully attracted towards each other, yield a denser clot, and squeeze out more serum than when the coagula- tion takes place in a shallow, wide basin, when the particles are spread over a large surface. The clot, in the one case, is compact and small; in the other, being spongy and retaining much of the serum, it appears to be of a larger size, although the actual quantity of solid matter is the same in both. When the blood is sizy, i. e., but slightly changed, the clot is, for the most part, cylindrical, and floats in the serum. The coagulation of blood taken from a person labouring under in- flammation takes place more slowly than that of healthy blood; and to this circumstance the formation of the buffy coat has been sometimes ascribed. It may, indeed, be assisted by the slowness of coagulation; but it has been proved by many observations to depend principally upon some vital change in the blood itself, in consequence of which there is an unusual disposition to a separation of the fibrin from the red par- ticles, or, as it has been expressed, " to a sort of repulsion between them." This is exemplified, as was first particularly pointed out by Schrceder van der Kolk, in blood abstracted by venesection during in- flammation, and placed so as to form a mere film, so thin as not to permit a stratum of the buffy coat to be over a stratum of red particles; when the fibrin and the red particles separate from each other laterally by horizontal movements. This separation is distinct and immediate, and gives rise to a spotted or mottled appearance, which, like the cupped and buffed appearance, is regarded as characteristic of inflam- » mation. By means of the microscope the separation may be beautifully seen in a single drop of inflammatory blood—the red particles become aggregated together in the form of rolls, which present an areolar ar- rangement, and leave interspaces for the fibrin, "lymph-globules," and serum. Such are the chief appearances of inflammatory blood. With reference to the buffy coat it is to be remarked that its extent varies according INFLAMMATION. 41 to the violence and duration of the inflammation, and according to the character of the texture involved, being much greater in inflammation of fibrous and serous textures than in that of the parenchyma of internal organs; and that it is present in certain states unconnected with in- flammation, as in the state of pregnancy, in the blood of chlorotic females, and in that of persons affected with general plethora. LOCAL CHANGES. By the aid of a microscope the following phenomena may be readily seen in the transparent parts of animals, as in the web of a frog's foot, after the application of a stimulus capable of exciting inflammation, such as alcohol, or acetic acid. Fig. 2. I. The capillary vessels are narrowed and the flow of blood through them accelerated. This stage is of very short duration, more especially Fig. 2. An exact copy of a portion of the web in the foot of a young frog, after a drop of strong alcohol had been placed upon it. The view exhibits a deep-seated artery and vein, somewhat out of focus; the intermediate or capillary plexus running over them, and pigment-cells of various sizes scattered over the whole. On the left of the figure, the circulation is still active and natural. About the middle it is more slow, the column of blood is oscillating, and the corpuscles crowded together. On the right, congestion, followed by exudation, has taken place, constituting inflammatory action in the part. a. A deep-seated vein, partially out of focus. The current of blood is of a deeper colour, and not so rapid as that in the artery. It is running in the opposite direction. The lymph-space on each side, filled with slightly yellowish blood plasma, is very appa- rent, containing a number of colourless corpuscles, clinging to or slowly moving along the sides of the vessel. b. A deep-seated artery, out of focus, the rapid current of blood allowing nothing to be perceived but a reddish-yellow broad streak, with lighter spaces at the sides. Opposite c, laceration of a capillary vessel has produced an extravasation of blood, which resembles a brownish-red spot. At d, congestion has occurred, and the blood-corpuscles are apparently merged into one semitransparent, reddish mass, entirely filling the vessels. The spaces of the web, between the capillaries, are rendered thicker and less transparent, partly by the action of the alcohol, partly by the exudation. This latter entirely fills up the spaces, or only coats the vessel.—Bennett. 42 INFLAMMATION. when the stimulus is very powerful; in which case it may pass so quickly into the next as to escape observation. II. The vessels become greatly distended, and the flow of blood is slower than usual. Such beyond all doubt are the first and second abnormal changes produced by the application of the stimulus. III. The blood flows irregularly: it oscillates, that is, it goes back- wards and forwards, and often is absolutely stagnant for a time. In the neighbourhood of the parts thus affected the vessels are distended and the circulation through them is more rapid than is natural; and over all the affected surface new vessels become visible, the explanation of which is believed to be that the red particles are received in abundance into vessels which previously contained them in such small quantities as not to be perceptible. IV. The vessels • become greatly distended, and the circulation of blood ceases entirely. V. Blood becomes effused into the surrounding textures by rupture of the vessels, and liquor sanguinis is exuded without rupture. VI. Besides these changes in the size of Fig- 3. the vessels and the movement of the blood, others are observed in the relation of the corpuscles of the blood to each other, and to the walls of the vessels. In the transparent parts of animals in the natural state, the red corpuscles of the blood circulate in the centre of the blood-vessels: and on each side there is a space containing the liquor sanguinis, and the lymph-cor- puscles. Two currents are thus circulating, one in the centre, consisting of the red cor- puscles, the circulation of which is very rapid ; and the other at the sides, consisting of the liquor sanguinis with the lymph-cor- puscles, the circulation of which is compara- tively very slow. In inflammation the fol- lowing abnormal changes may be seen. The lymph-corpuscles proceed very slowly in the lymph-spaces, and some of them become adherent at certain parts to the sides of the vessels. The central column of red particles, as the vessels distend, becomes enlarged; the corpuscles encroach on the lymph-spaces, and gradually come into contact at some parts with the walls of the vessels; they become adherent to each other, so that their individual forms are no longer perceptible, and ultimately the vessels giving way some blood becomes extravasated, and the liquor sanguinis exudes through the walls of the vessels. The exudation of liquor sanguinis constitutes the essential phenomenon of inflammation, or in other words, its characteristic or pathognomonic feature; while the other phenomena constitute the state Fig. 3. Two vessels coated with granules, nuclei, and compound granular cornuscles Example of Exudation.— Bennett. * B corpuscles. RESULTS OF INFLAMMATION. 43 of active congestion, which is one step short of inflammation. It is of importance not to confound congestion leading to inflammation with the Fig. 4. inflammation itself. Effusion of serum, capillary hemorrhage, or ex- travasation of blood may take place in consequence of other morbid conditions; but in the present state of our knowledge it is believed that inflammation never exists without the exudation of liquor sanguinis, and that this exudation alone is a proof of inflammation; it is, therefore, regarded as the essential phenomenon of that state. TERMINATIONS, RESULTS, OR EVENTS OF INFLAMMATION. Certain conditions resulting from inflammation were formerly called "terminations of inflammation." But to the use of this expression objections have very properly been made, on the ground that several of the conditions referred to are co-existent states with the inflam- mation, or successive stages in the progress of the same inflamma- tory disease, and the inflammation does not cease or terminate when these conditions occur. The words results or events, are not liable to the same objections, and are now used to denote these conditions. The results of inflammation which we have to consider are, Resolution, Effu- Fig. 4. a. Colourless globules adherent, b. Blood-disks, still circulating, c. Dense, stagnant, homogeneous mass. d. Corpuscles in oscillatory movement, becoming de- tached from the impacted mass.— Williams. 44 EXUDATION OF COAGULABLE LYMPH. sion of Serum, Exudation of coagulable Lymph, Suppuration, Ulcera- tion, G-angrene, and Sphacelus. I. RESOLUTION. Resolution is said to occur when the symptoms gradually subside, and the liquor sanguinis becomes absorbed, so that no trace of it remains, and the part returns in all respects to its former condition and integrity. There is in short a subsidence or resolution of the inflammation, and this result, therefore, may be properly considered a termination of in- flammation. The subsidence may be gradual, when the process is called resolution; or it may be sudden without symptoms of inflammation appearing in any other part, when it is called delitescence ; or it may be sudden and abrupt, and the inflammation may suddenly appear in an- other part, and then metastasis is said to take place. II. EFFUSION OF SERUM. The liquid is deposited by exudation through the vascular coats yet entire, and consists principally of the serum of the blood slightly modi- fied, being of higher specific gravity, and containing more albumen than in health, with more or less of fibrinous matter. This result is some- times seen surrounding an inflamed part, in the centre of which there are other results of inflammation, and then the effusion into the areolar tissue surrounding the part in a higher grade of inflammation constitutes oedema, which is indicated by pitting on pressure. Diffusion of serum presents itself in inflammation of serous membranes, as for example, in pleuritis, when the quantity poured out is in some instances very great; and in such cases, if the effusion has taken place rapidly, it will be found on careful examination that the supernatant portion is usually clear, and the deeper portion turbid and more dense, owing to the fibrinous portions being of greater specific gravity, and sinking to the bottom. In this instance the blood-plasma which exudes separates into the serum and fibrin. The appearance, however, of the effusion varies according to the acuteness of the inflammatory process. The consequences of serous effusion vary much according to the part affected; in some situa- tions it is comparatively harmless, while in others a trifling amount of effusion is sufficient to destroy life. Serous effusion is often the result of congestion not inflammatory, and often of venous obstruction unconnected with inflammation. In every instance of undoubted inflammatory action, exudation of blood-plasma takes place, and the fluid, when poured into a cavity, is more or less turbid, and contains fibrin; whereas, when unconnected with inflamma- tory phenomena, the fluid is clear, and holds no fibrin in solution. III. EXUDATION OF COAGULABLE LYMPH. Of many examples which could be mentioned of this result of inflam- mation, two of the most frequent and striking are to be seen on the free surfaces of inflamed serous membranes, and on the edges of cut wounds. This has been called the adhesive stage of inflammation, and in wounds it leads to the union called by surgeons union by the first intention. In inflammation of serous membranes, the appearances presented by the SUPPURATION. 45 coagulable lymph vary according as the inflammation has been more or less acute, and in instances where it has been decidedly acute, accord- ing as it has been found more or less rapidly fatal. The coagulable lymph, at the earliest period, and while it presents the gelatinous semitranslucent appearance, seems to consist of filaments made up of minute molecules arranged in lines. When the lymph be- comes opaque, it appears to consist of the same filaments, larger in size, and consequently more distinct but less molecular, together with a quan- tity of corpuscles, which, on account of their constituting the charac- teristic structure of plastic lymph, have been denominated plastic cor- puscles. When the lymph has become consistent, and the fluid part has been absorbed, cells, undergoing development into fibres, are obser- vable. The filaments in recent lymph are believed to be results of depo- sition, and are therefore called primary; but those in old lymph are Fig. 5. Fig. 6. considered to be the result of cellular development, as originally de- scribed by Schwann, and are hence called secondary. In the case of cut wounds, exudation of plastic lymph takes place, and cells are de- veloped which pass into fibrous formations; and the result is called union by the first intention. Different opinions have been advanced as to the mode in which new vessels are formed. Some think that the new vessels arise independently of the old, and are in a measure self- formed in the plasma, nucleated cells arranging themselves in lines and communicating by decadence of their opposing walls, and that the vessels thus formed afterwards connect themselves with the old vessels. Others are of opinion that blood-corpuscles escape from the original vessels adjacent, and hollow out for themselves channels in the plasma, and that these are, by and by, succeeded by others in a continuous stream. IV. SUPPURATION. This term is used to denote the transformation of the exuded matter into pus, a result most commonly found in cellular tissue, constituting an abscess, on the surface of granulating sores, and on the mucous mem- branes. Normal pus, such as that formed in phlegmonous abscess, or that yielded by healthy granulating sores, is an opaque, creamy, straw- coloured, or slightly greenish fluid, having a peculiar mawkish odour, Fig. 5. Nuclei developing themselves into fibres.—Bennett. Fig. 6. Cells developing themselves into fibres.—Bennett. 46 SUPPURATION. Fig. 7. which it loses on cooling. On examination of its minute structure, it is found to consist essentially of two distinct parts; numerous minute organized particles, called pus-corpuscles, and a clear yellowish liquid, named the liquor puris, in which the corpuscles are suspended. The form of the pus-corpuscles, in genuine pus, is perfectly spherical, with a finely granulated surface ; they vary in size from l-100th to l-75th of a millimetre in diameter; in pro- portion as the pus deviates from the normal type, varieties are observed both in the form and size of the globules. When the cor- puscles are examined in heaps, they exhibit a yellow tint; but Avhen separately, they appear colourless. They are organized forms, and consist of a nucleus, cell-wall, and con- tents. The nucleus is for the most part composed of several granules, generally two or three, but sometimes four or five, and is hence called a composite multiple nucleus. It is not placed in the centre of the cell, and is usually attached to its inner surface. On the addition of water, the pus-corpuscles become increased in size and more transparent, and they usually lose their finely granulated sur- face. Weak acetic acid partially, and strong acetic acid completely dissolves the cell-wall, and by that means the nucleus can be brought clearly into view. The pus-corpuscles may be formed either from fluid cytoblastema, as in the fluid secretion of fresh wounds, in suppuration on the surface of the body after burns or blisters, and in suppurations on mucous mem- branes, as in catarrhs and gonorrhoea; or from a solid cytoblastema of fibrin after coagulation:—in other words, pus may be formed from fluid blood-plasma before coagulation, and also from exuded matter rendered solid. On the formation from fluid cytoblastema, Vogel remarks :—" The process of the formation of pus from a fluid cytoblastema can be best observed in fresh wounds cleansed from blood. In examining the fluid secretion from a wound, we first observe minute granules, less than the 1000th of a line in diameter, which are chemically identical with the molecules insoluble in the alkalies and in borax. There then appear, partly around these molecules and partly independent of them, some- what larger corpuscles, soluble in the alkalies but not in acetic acid, identical with the nuclei of the pus-corpuscles. These nuclei appear some- times isolated, sometimes in groups of twos or threes, thus forming corpo- rate nuclei; around these the cell-wall is subsequently developed, first appearing as a pale transparent membrane, and subsequently becoming thickened and granular; and thus the pus-corpuscle is formed. The pro- duction of pus-corpuscles in this manner is tolerably rapid ; in the course of three or four hours after the first appearance of the nuclei perfect cor- puscles may frequently be seen: in other cases the process is slower." The formation of pus-corpuscles from a solid cytoblastema of coagulated fibrin Fig. 7. a. Natural appearance of pus-corpuscles, b. Appearance alter application of acetic acid. ABSCESS. 47 is a process of frequent occurrence, as, for example, in abscesses in which the coagulated fibrin is changed into fluid pus, in cases in which pus is formed from the solid exudations from serous membranes, and in numerous other instances where a solid blastema is rendered fluid by the formation of pus. After the formation of the pus-corpuscles, the fibrin of the cytoblastema is exhausted, and the serum of the pus resembles greatly the serum of the blood. Pus-corpuscles are incapable of passing into permanent structures, or of undergoing a higher development, or of conversion into a more perfect organism. When purulent matter is confined in the parenchyma of a part, in a cavity which is not natural, it constitutes an abscess ; when infiltrated through the structures of an organ, the condition is termed purulent infiltration ; when the purulent matter is formed on a mucous membrane, from which it is voided externally, the patient is said to have a purulent discharge ; and when the matter forms an accumulation in some regular and natural cavity, the case is said to be one of purulent effusion, or of suppuration in that cavity. Abscesses may be either acute or chronic. ACUTE ABSCESS. Symptoms.—When inflammation is about to lead to the formation of abscess, the symptoms which at first are the usual local and constitutional symptoms of inflammation, undergo a degree of aggravation. In many instances, however, the suppuration does not proceed so far as to pro- duce sympathetic inflammatory fever. The pain becomes of a distressing pulsatory character, and often after the formation of matter it changes into an uneasy feeling of weight, or of heaviness and pressure ; redness and tension, after being very great, are diminished, and the swelling, on being examined, presents different characters at different stages of the inflammation ; being at first tense and hard in the middle, and oedema- tous around, and afterwards soft in the centre, hard at the circumfe- rence, and oedematous at a still greater distance from the centre of inflammation. When the swelling becomes raised up and prominent at one part, it constitutes the condition technically called the pointing of the abscess. In general, some time before the abscess points, fluctua- tion is discoverable, and this, taken in conjunction with the other symp- toms, is one of the surest signs of the presence of matter, as it can only exist when there is fluid. At an early stage, however, when the super- imposed structures are still thick and tense, and the quantity of matter but scanty, the perception of fluid is obscure, but it becomes more and more distinct, as the textures intervening between the abscess and the surface of the body become thinner. To discover whether fluctuation be present, the fingers may be pressed alternately on the swelling, or (which is preferable) the fingers of one hand may be applied to one side of the swelling, while, with the finger of the other, the opposite side is tapped, and the undulations of the pus will be distinctly perceived. Some surgeons greatly excel others in detecting the presence of matter. This skill is of great importance, and every surgeon should endeavour to acquire it in the greatest possible degree. The tactus eruditus, as it is called, may be acquired by any one who 48 ABSCESS. has experience, and acuteness of the sense of touch, together with the valuable talent of using them aright. When suppuration is deeply seated, so that fluctuation and pointing are not discernible, there are other symptoms (provided the inflammation be to a considerable extent), which afford pretty certain evidence of the formation of matter :—these are shiverings, technically called rigors, before the suppuration occurs, and after it has taken place, a change from the acute pain in the part to a feeling of weight, or numbness, or pressure, or some sensations totally different from those experienced during the acute inflammation. Antecedently to suppuration there is frequently interruption of the proper performance of the function of some organ, and if the abscess be deeply seated and large, the pulse ere long becomes feeble and increases in frequency; the patient becomes emaciated, and the constitutional symptoms are rapidly changed from those of inflammation to those of hectic fever. The condition of the parts.—The condition of the parts in acute abscess may be stated to be :—suppuration, where fluctuation is per- ceptible ; deposition of fibrin around the pus, offering a barrier to infil- tration of pus into the surrounding textures, and constituting the hardness at the circumference; and, serous effusion into the parts ex- ternal to the barrier of fibrin, giving rise to oedema, evidenced by pitting on pressure. Treatment.—To remove general and local causes of excitement and irritation, and to promote the approach of the matter toward the surface, are important indications in the treatment of abscess. The best means of fulfilling these indications, are the strict observance of antiphlogistic regimen, perfect rest of the affected part, strict maintenance of a proper attitude, the removal of all sources of irritation, as well as of tension, or pressure, and the diligent use of warm emollient poultices, hot fomenta- tions being applied each time the poultice is removed. Purulent matter having once been formed, it may be stated as a general rule in the treatment of acute abscess, that the grand indication then to be fulfilled is the early and free discharge of the matter. In some circumstances very early attention to this rule is of the utmost importance; as in abscesses under dense aponeuroses, and under thick fasciae (as, for ex- ample, under the temporal aponeurosis, or under the tendon of the occi- pito-frontalis muscle, or under the fascia of the thigh, of the leg, of the arm, or of the fore-arm, or under the palmar or plantar fasciae), within tendinous sheaths, as in paronychia tendinosa, or underneath the peri- osteum, as in paronychia periostei, or under the pericranium, in the proximity of bones, in the natural cavities, or in the texture of bones; also in abscesses arising from the extravasation of irritating fluids, as collections of matter caused by the extravasation of urine into the cel- lular tissue of the perineum and scrotum ; abscesses in parts abounding with cellular tissue, when there is great risk of the spreading of the in- flammation, or in situations where there is danger of making their way into some of the natural cavities, as into the chest, or abdomen, or the joints ; or such as are likely to occasion injury by pressing upon or im- peding the functions of important parts, as the trachea, the pharynx, the urethra; or abscesses, in highly vascular and sensitive parts, where ABSCESS. 49 the pain of an abscess is often most excruciating. With scarcely more than one exception, early and free opening of an abscess is the proper course ; but in the above-mentioned conditions, it is peculiarly necessary to adopt this proceeding at the earliest possible period after we are cer- tain of the actual existence of matter : for not only are time and suffer- ing saved and tissue preserved by its adoption, but by its neglect the danger of most destructive local results is increased, and in some cir- cumstances, even the loss of life itself may result. Almost the only condition in which it is proper to delay opening, is in cases of glandular enlargement, in which, when other means have failed to produce absorp- tion, and suppuration has occurred, the opening should be deferred, that the pressure of the matter may more effectually secure the disintegra- tion and breaking up of the glandular structure, and thereby favour its removal. Of the various methods of opening abscesses I shall refer to only two ; namely, by means of a bistoury, and by means of caustic. The former is preferable, except in two conditions, presently to be mentioned. It consists in making a free, direct opening in a depending situation, and as already stated, at an early period. In the event of the matter making its way in a different direction, a second opening should be made, which, from often being opposite to the first, is called a counter- opening. By making an early, large, direct opening in a depending situation, and keeping it open while matter continues to be secreted, the formation of sinuses, loss of substances, and disintegration are generally prevented, and the desired result is attained more speedily, and with less suffering than it would be by any other proceeding. The two conditions in which opening by means of caustic is preferable, are the following :— 1. In small abscesses, partaking of a chronic character, where the integuments are attenuated in consequence of the opening having been delayed, or where they are in a diseased state. In such cases Ae inte- guments are too much weakened to take on the necessary action for uniting with the subjacent parts ; and as no healing process takes place until they are destroyed by ulceration, it is better to destroy them at once, and make a free opening by means of caustic. For this purpose the potassa fusa is preferred, and is applied so as to destroy the whole of the diseased and thinned integument. 2. In cases of glandular enlargement in the state of abscess, in which condition the caustic should be used very freely, and be pressed into the gland in different situations, so as to lead to the action by which the diseased structure may be separated and removed. CHRONIC ABSCESSES. Collections of matter sometimes form slowly and insidiously, and tho symptoms of inflammation which precede them, are but slightly, if at all, perceptible; in such cases, the abscesses are said to be chronic. These collections often attain a great size; there being little fibrin effused around the matter, the sac is thin, and the resistance to exten- sion feeble; they are frequently irregular in form, and the superimposed skin remains unaltered in colour. 4 50 ULCERATION. The treatment of chronic abscess is a matter of great anxiety to the intelligent surgeon, in consequence of the danger, lest the opening of the sac should be followed by violent irritative fever, which has a ten- dency to merge very speedily into hectic fever. Where such collections are small, the patient's health tolerably good, and his constitution not very susceptible of inflammatory action, the treatment proper for acute abscesses, namely, free, direct incision, may be ventured upon; but as the danger of this proceeding is considerable, the surgeon is only justi- fied in resorting to it in the conditions mentioned above. In all other cases, the treatment should consist in drawing off the matter by small valvular tapping—in closing up the wound so as to prevent the admis- sion of air, by the presence of which, the opposite sides of the sac would be separated from each other, the putrefaction of the remaining matter promoted, and much constitutional disturbance induced,—in preserving the sides of the sac in contact, by gentle support,—and in renewing the valvular opening, before any great reaccumulation has taken place, so that the sac may not be allowed to regain anything like its former size, each opening being made with the observance of the same precau- tions as in the first instance. Sometimes, although very rarely, after the first operation the cavity contracts, and the desired result is ob- tained; but more frequently several repetitions of the operation are required, before the disease is cured; and in some instances, after the sac has become very much contracted by the adoption of the above pro- cedure, it becomes safe to resort to the treatment for acute abscess, namely, free, direct incision, for perfecting the cure. The best appa- ratus for this mode of treatment consists of a long trocar, a canula furnished with a stop-cock, and a fine exhausting syringe which fits the canula. ^ About an inch and a half or two inches from the spot where the sac is to be opened, a small aperture should be made in the skin; through this the trocar is to be inserted, carried under the skin, and sent thtough the sac where it is to be opened; the trocar should be withdrawn, the stop-cock being shut before it is completely removed; the syringe should be applied to the canula, and the matter drawn off, care being taken to shut the stop-cock after each stroke of the syringe. Gentle pressure should be applied to the sac, and while the canula is being withdrawn, pressure should be applied over its track, to prevent the admission of air; the opening should be closed up very carefully by means of plaster, and be preserved close, until adhesions have taken place. Rest, and every judicious precaution should be strictly enjoined, for some time after each operation, to diminish the danger of inflamma- tion of the sac. This treatment is, in my opinion, the safest that has yet been proposed for this form of abscess, and by means of it, a favour- able result is occasionally obtained; but in many instances, these ab- scesses are connected with incurable diseases of the bones or ioints; and, as patients live much longer in such cases, when the abscesses are not opened, there can be no doubt whatever, that, under these circum- stances, it is the duty of the surgeon to let them alone. V. ULCERATION. This is a frequent result of inflammation. Great differences are ob- served m the different tissues, with respect to their tendency to ulcera- ULCERATION. 51 tion, when they become affected with inflammation, and these differences have important pathological bearing. It is most common in the skin, mucous membranes, cellular tissue, and the other tegumentary mem- branes ; it is frequently met with in bones, and the inner coats of arteries, but is very rare in fibrous tissues of all kinds, in serous mem- branes, in the outer coats of arteries, and in nervous tissue. The pro- cess of ulceration, according to the views now entertained, is very clearly explained in the following quotation from Dr. Bennett's admi- rable " Treatise on Inflammation."—" The process of ulceration is some- what similar to that of mortification, only it is more chronic, and the exudation, instead of undergoing decomposition, only exhibits an indis- position to pass into organization. In this case, the exudation is poured out slowly, it coagulates, and presses upon the surrounding parts, more or less obstructing the flow of blood to them, and acts as a foreign body. By means of the continued pressure, the circulation is obstructed, and death of the portion affected results. Sometimes this is imprisoned in fresh exudation, as ulceration extends, and the whole at length becomes disintegrated. All this time, the exudation exhibits little of that tendency so conspicuous in healthy persons, to undergo changes in itself, and when examined microscopically, is found to con- sist principally of very minute granules, varying in size from the T2i>(j<5 to the 5^0 °f a millimeter in diameter. These are occasionally mixed with irregularly-formed cells, usually more or less angular, containing one or more granules. The cells are more numerous, in proportion to the stage of the ulceration, and the healthy powers of the constitution. These different granules and imperfect cells, with the structures they involve, at length become broken down, and separate from each other, constituting a semi-fluid mass, which has a tendency to point where it can most readily be discharged, that is, towards the surface of the skin or mucous membranes. Here, on account of the less degree of re- sistance offered, the continued pressure and disintegration of tissue first cause an aperture to be formed. Another portion of solid exudation is now broken down with the tissues involved in it, and in this way the opening is enlarged. If the morbid process continue,, a fresh exudation is slowly poured out below the already coagulated blood-plasma, which supplies the loss thrown off in the form of discharge, and thus chronic ulceration may be increased indefinitely. The whole of this process may be well observed in scrofulous and syphilitic ulcers, or in the cal- lous sores of the leg in weavers, and others of a cachectic constitution. Indeed, the general powers of the constitution are almost always in such cases enfeebled, and hence the indisposition of the exudation to be trans- formed into organized cells. Ulcers produced by direct pressure are occasioned in a similar manner ; only in most cases the pressure is not derived in the first instance from solid exudation poured out. Thus in stumps, not sufficiently covered by soft parts, in places long pressed upon by lying, or by the growth of tumours, the vitality of the part is slowly destroyed. At the same time an exudation is poured out from the neighbouring vessels, which becomes broken up, and assists in dis- integrating the textures, whose vitality is destroyed. The finely mole- cular particles are thus absorbed, whilst the grosser portions are thrown off in the form of discharge." 52 ULCERATION. Granulation— The process by which the cavity is filled up, and con- tinuity of tissue restored, is called granulation : it consists in exudation, from the surface of the cavity, of blood-plasma, constituting the fluid cytoblastema. Part of this blood-plasma degenerates into pus-corpus- cles, but part becomes transformed into nucleated cells. Minute gra- nules, forming the nucleoli (as they are called) are developed, and to the assemblage of these the term nucleus is given. On the nucleus, a cell- wall becomes developed, which, at first, closely embracing the nucleus, is afterwards raised up from it, and the nucleus thus separated from the cell-wall occupies an eccentric position within it. In these organized products vessels are formed, and the whole, when thus developed, con- stitutes a layer of granulations, spreading over the surface of the cavity, and giving it the appearance of being covered with innumerable small bodies of a conical form, and of a florid red colour. From the granula- tions blood-plasma is exuded, part of which degenerates into purulent matter for the defence of the granulations, and part is transformed into nucleated cells, by which a new layer of granulations is formed. The cells of the first-formed layer undergo further changes, and are ultimately developed into the texture of the part, from the vessels of which the exudation of blood-plasma took place, and each subse- quent exudation furnishes a cytoblastema for the formation of puru- lent matter and nucleated cells. By the successive formation of these cells, by their becoming ultimately developed into permanent tissue, and by the centripetal contraction of the original textures, the cavity is filled up, and the next part of the process is cicatrization, or the formation of cicatrix. This usually begins when the granulations arrive on a level with the surrounding skin, when the blood-plasma, hitherto converted partly into pus-corpuscles, and partly into nucleated cells, passes into cells which, by the process of development, are con- verted into fibres, and constitute the cicatrix. The new skin usually takes its rise from the margins of the old skin ; but in some few instances, portions of new skin are seen forming on the surface of the granula- tions, like little islands, quite remote from the margins. Some have endeavoured to account for this fact, but the supposition that the old skin has not been completely destroyed, as we not unfrequently find in burns, and that the isolated portions of new skin spring from the parts not entirely destroyed by the burn or ulceration; but I am convinced Fig. 8. by various cases which have come under my own observation, that this explanation is not satisfactory. I shall only refer to one case, that of a young lady, whom I had the opportunity of seeing, together with one of my colleagues in the University. The lady was the subject of pha- ULCERS. 53 gedaenic ulcer, of considerable size and of great depth, in the leg; and as other means had had no effect in arresting the destructive action, the whole surface was destroyed to a considerable depth by pure nitric acid. After the removal of the slough, healthy action took place, and a large isolated portion of the skin formed in the middle, and gradually increased until it joined that formed from the circumference of the ulcer. I have for several years been in the habit of showing to my class in the Uni- versity, a drawing of this case, as it is an incontrovertible instance of an exception to the ordinary rule of the formation of skin from the circum- ference only, and an evidence that the explanation mentioned above is not satisfactory. ULCERS. An ulcer may be defined—a solution of continuity caused, by ulcera- tion. Future chapters will give a description of specific ulcers, that is, ulcers caused by a specific poison, as syphilitic ulcers, and those con- nected with particular diatheses, such as the scrofulous, the scorbutic, or the cancerous. Other ulcers, not coming under either of these divi- sions, we shall, for the sake of clearness, arrange into seven varieties, namely :—1st, healthy ulcer; 2d, weak ulcer; 3d, indolent ulcer; 4th, inflamed ulcer; 5th, phagedaenic ulcer; 6th, gangrenous or sloughing ulcer; and 7th, sloughing phagedaena. In describing the appearances of ulcers, we shall refer to the state of the edges, the granulations, and the discharge. I. HEALTHY ULCER. The healthy ulcer, the simple, and the simple purulent, are different names given to the same ulcer. Characters of a healthy ulcer.—The edges are smooth, neither inverted nor everted, and adhere to the granulations, and when the latter rise to a level with the common integu- ment, a semi-transparent white film of cica- trix fringes round the edges, and gradually spreads over the granulations. The granula- tions are small, florid, firm, numerous, and pointed at the top, vascular, apt to bleed on being touched, sensitive, and attended with a slight feeling of tenderness instead of uneasi- ness or pain. When the granulations come to be on a level with the integument, they begin to be covered over by cicatrix. The discharge is thick and purulent, and easily separated from the surface of the sore. Treatment.—The treatment consists in pre- serving the part at rest, maintaining such an attitude as will promote venous return, and prevent unpleasant sensations and conse- quences from tension, and in defending the part from the action of the air. Of the various means adopted for fulfilling this last- Fig. 9. 54 ULCERS. mentioned indication, the most elegant is tepid water-dressing, applied by means of a small bit of lint with a piece of oiled silk over it to prevent the lint from being dried. The frequency of the dressing should depend on the quantity of the discharge; it being unneces- sary to change it more frequently than is requisite to preserve the parts perfectly clean and comfortable. Another application still em- ployed by some is simple ointment; but, for my own part, I almost invariably, like many others, give the preference to the tepid water- dressing, with a small piece of oiled silk, and a few turns of a bandage to afford gentle support when necessary. II. WEAK ULCER. Characters.—In the weak ulcer, called by many writers the fungous ulcer, the granulations, instead of being like those described in the cha- racters of the healthy ulcer, are much larger, paler, flabby, less nume- rous, not pointed on the top, but, on the contrary, sometimes even bul- bous, less vascular, less apt to bleed on being touched, less sensitive, unattended with pain, and when they have filled up the cavity of the ulcer, they rise up above the level of the surrounding integument, so that the margins are sometimes at this stage overlaid by them, and concealed from view. The edges are smooth, and the discharge is pale, and thinner than in healthy ulcer. Fig. 10. Treatment.—A necessary part of the proper treatment consists in removing, if possible, the cause; and, in addition to this, suitable means are to be adopted for removing the effects. The cause of the ulcer assuming the characters above described may be general, operating on the system at large, such as, a deficiency in the quantity or nutritive quality of food, an unwholesome atmosphere, a weak or disordered con- dition of the digestive apparatus, the debilitating effects of mental anxiety, or feebleness of constitution, however induced; or the cause may be local, such as improper treatment, as, for example, the use of relaxing applications, venous congestion caused by some obstacle to the ULCERS. 55 return of the blood, or a weakened condition of the parts occasioned by the nature of the injury of which the ulcer is the result, or the delay of cicatrization, for perfectly healthy granulations become weak when healing is by any cause delayed. With regard to local treatment, rest should be enjoined, and an attitude favourable to venous return; together with the careful application of gentle pressure by uniform bandaging, which acts as a gentle stimulant to the granulations, and corrects the tendency to passive congestion. The use of a medicated water-dressing of a stimulant nature, instead of plain tepid water-dress- ing, should also be adopted. Solutions of the sulphate of zinc, or the sulphate of copper, varying in strength from one to two grains, or even more, to an ounce of water, generally answer most satisfactorily in the treatment of this ulcer. I usually prefer the solution of the sulphate of zinc, either the simple solution, or medicated with two drachms of the compound spirit of lavender and a drachm of the spirit of rosemary to eight ounces of water. The lotion should be kept applied by means of a little lint, with a piece of oiled silk placed over it to prevent drying, and at the same time bandaging should be employed, not merely as in healthy ulcer for retentive purposes, but to secure gentle and uniform pressure. Other modes of treatment which have been adopted are, pressure together with the application of dry lint to the granulations as a dress- ing, shaving off the fungous granulations with a knife, and destruction of them by escharotics. The treatment already described will very rarely be found to fail in producing the desired effect; but when it does fail, recourse may for a short time be had with advantage to pressure, with a dressing of dry lint. III. INDOLENT ULCER. Characters.—The form of this ulcer is seldom irregular, but usually nearly oval or circular. The edges are thick, prominent, comparatively insensible, glossy, smooth, firm, incompressible, and without any appear- ance of cicatrix; the surrounding parts are also firm, hard, incompres- sible, and usually discoloured by passive congestion; the surface of the ulcer is nearly devoid of granulations, is smooth and glossy, and varies in colour, being in some examples whitish, in some gray, and in others brownish. The discharge is scanty, thin, and watery. This ulcer may be said to be almost exclusively confined to the labouring poor, occurring in their lower extremities, and after the middle period of life. Treatment.—An important indication, as may readily be imagined, in the treatment of this ulcer, is to improve and maintain the general health and strength; and with this view, generous diet, residence in an airy situation, and the due regulation of the digestive organs should be prescribed, together with the use of tonics in many instances, and even of stimulants, when indicated by the particular circumstances of the case. Of many different modes of treatment I shall refer only to two, namely, that suggested by Mr. Baynton, and that by Professor Syme. Of these the former has hitherto been generally regarded with favour, and has received the general adoption of the profession. When it is carefully conducted, its results are very satisfactory. The following is 56 ULCERS. Mr. Baynton's description of his method of treatment:—" The parts should be first cleared of the hair, sometimes found in considerable quantities upon the legs, by means of a razor, that none of the dis- Fig. 11. charges, by being retained, may become acrid and inflame the skin, and that the dressings may be removed with ease at each time of their renewal, which in some cases, when the discharges are profuse and the ulcers very irritable, may perhaps be necessary twice in twenty-four hours, but which I have in every instance been only under the necessity of performing once in that time. The plaster is to be cut into slips about two inches in breadth, and of a length that will, after being passed round the limb, leave an end of about four or five inches. The middle of the piece, so prepared, is to be applied to the sound part of the limb, opposite to the inferior part of the ulcer, so that the lower edge of the plaster may be placed about an inch below the lower part of the sore, and the ends drawn over the ulcer with as much gradual extension as the patient can well bear; other slips are to be secured in the same way, each above and in contact with another, until the whole surface of the sore and the limb is completely covered at least one inch below and two above the diseased part. The whole of the leg should then be equally defended with pieces of soft calico, three or four times doubled, and a bandage of the same, about three inches in breadth and four or five yards in length, or rather, as much as will be sufficient to support the limb from the toes to the knee, should be applied as smoothly as can possibly be performed by the surgeon, and with as much firmness as can be borne by the patient. It is to be first passed round the leg at the ankle-joint, then as many times round the foot as will cover and support every part of it except the toes, and afterwards up the limb till it reaches the knee; observing that each turn of the bandage should leave its lower edge so placed as to be about an inch above the lower edge of the fold below it." The success of this method of treatment, when applied in suitable circumstances, is generally acknowledged. Callous ulcers are often presented for treatment in an inflamed state; soothing applications should in such circumstances be prescribed, until that condition be removed, and the treatment above described may then with propriety be resorted to. One great advantage of this method of treatment is, that perfect rest and constant elevation of the limb are not so essential auxiliaries as in other methods; and this is in some circumstances, a matter of great importance. The good effects of this mode of treatment are properly ascribed to pressure, which, by pro- moting absorption of the swelling, favours the contraction requisite for ULCERS. 57 cicatrization. The merit of first pointing out the beneficial effects of pressure in the treatment of this ulcer is due to Mr. Whateley, who applied pressure by bandages alone; that of prescribing adhesive plaster, together with the use of a bandage, belongs to Mr. Baynton. Professor Syme's treatment consists in the application of a blister sufficiently large to cover the ulcer, and a portion of the surrounding parts. In favour of this mode it is urged, that it is more speedy and more economical than Baynton's ; but as the risk of erysipelas is con- siderable, and as the first effect is to enlarge the ulcer (which is far from desirable, although it may improve its character), it has always appeared to me, that as a general practice, the method of Baynton is to be preferred: at the same time, however, I am perfectly aware that satisfactory results are often obtained by the adoption of that of Syme. IV. INFLAMED ULCER. Characters.—The edges and surrounding parts are red, swollen, hot, tense, tender, and painful; the surface of the sore is destitute of granu- lations, and presents a raw and pulpy, or a foul and livid appearance; the discharge is profuse, offensive, and often streaked with blood, mingled with ulcerative debris. The pain is great, and there is always more or less constitutional disturbance. Fig. 12. Treatment.—The object aimed at in the first instance being the con- version of the inflamed, into a simple, healthy ulcer, undue irritability and excessive action must be first subdued ; and for this purpose general, as well as local, treatment must be instituted. The diet should be care- fully regulated, and the secretions of the digestive organs, and of the skin, be brought into a proper state by purging, antimonials, calomel, and opium, or such other remedies as seem to be indicated by the parti- cular circumstances of the case. With regard to local treatment, per- fect immunity from motion, the observance of an attitude calculated to promote venous return and relaxation, are absolutely indispensable; of local applications, the most useful are warm poultices and fomentations, or opiate poultices, and opiate fomentations; in short, heat with mois- ture, or heat and moisture combined with opiate applications, are the most soothing remedies. Simple poultices, or poultices medicated with decoction of opium, are very useful and grateful in such cases. Local depletion by leeches, or scarification of the edges of the ulcer, is some- times resorted to, but it is very seldom indeed that such a proceeding is necessary. 58 ULCERS. V. VI. VII. PHAGEDENIC ULCER.—GANGRENOUS ULCER.—SLOUGHING PHAGEDENIC ULCER. The characters and treatment of the phagedaenic and the gangrenous ulcers, and of sloughing phagedaena will be minutely described in the chapter on the state of constitution in which they are most frequently Fig. 13. observed ; but their characters may be briefly stated in this chapter. The three varieties—namely, phagedaena or phagedaenic sore, sloughing or gangrenous sore, and sloughing phagedaena, called by some writers Fig. 14. the phagedaena gangrenosa, are so similar to each other in the circum- stances in which they are found, in their symptoms and in their treat- ment, that it will be more convenient to describe them together than to assign a separate section to each. The term phagedaena, derived from cpxyu, to eat, is well applied to this kind of ulcer, as there is the appear- ance of regular eating away, or destruction by phagedaenic ulceration, without any attempt at granulation. Phagedaena, or a phagedaenic ulcer, may be distinguished by the fol- lowing peculiarities. The edges are extremely irregular, and of a dark purplish appearance, a red colour extending a considerable way into the surrounding parts ; they are exceedingly painful, and at parts inverted; the surface of the sore is uneven, and extends underneath the edges; it is of a livid or dark red colour, and, together with the edges, has a very irritable appearance. It is covered by a thin, ichorous, bloody discharge. The sore enlarges with alarming rapidity ; and the destructive process may continue to be carried on, by ulceration alone, or by ulceration together with sloughing, so as to constitute the variety called by some writers the sloughing phagedaena, and by others the phagedaena gan- grenosa. In the'other variety, namely, the sloughing sore, the destruc- tion is by sloughing alone; the sore enlarges by the formation of one slough after another, and the surface of the sore on the separation of the slough, has a raw, red, irrritable appearance. These three varieties MORTIFICATION — GANGRENE — SPHACELUS. 59 exhibit the same appearance of edges, and occur in similar circum- stances ; they differ chiefly in the appearance of the surface of the sore; there being in the phagedaenic sore an irregular appearance of the surface, occasioned by the ulcerative process; in the sloughing pha- gedaena the same appearance at some parts, and a wet ash-coloured slough at others ; and in the sloughing variety a wet slough covering the sore. The characters of these ulcers are so peculiar that there can be no difficulty in distinguishing them from each other, or from any of the other varieties of ulcers. A high degree of constitutional disturb- ance attends each of these varieties. The constitutional symptoms and treatment will be given in a future chapter. GANGRENE AND SPHACELUS. The three terms—Mortification, Gangrene, and Sphacelus, have been indiscriminately used by some authors to express an important result of inflammation, namely, the death of thejsart. In the use of them here, we shall follow the guidance of those who regard mortification as a generic term comprehending the whole series of phenomena, from the first diminution of the vital powers to their entire destruction; gan- grene, as denoting the stage in which there is diminution but not per- fect destruction of the powers of life; and sphacelus, as denoting the complete death of the part. Local and Constitutional Symptoms of Cfangrene and Sphacelus from Inflammation.—In gangrene the redness is changed into a dark or livid hue; the heat, sensibility, and pain are diminished; the swelling, though not diminished, but sometimes even increased in extent, is less tense, and generally pits on pressure ; and on different parts of the surface we usually find portions of the cuticle elevated into small blis- ters, called phlyctenae, containing unhealthy serum of a yellowish or greenish colour. These symptoms do not indicate an entire extinction of the vital powers, and, consequently, the part sometimes recovers, or only a very small portion of it becomes dead. Generally, however, the symptoms of gangrene merge into those of sphacelus, in which the part presents a black, a dark, or an ash-gray colour, according as it is more or less exposed to the atmosphere; it becomes cold, and not only ceases to be painful, but entirely loses its sensibility; instead of having the appearance of excessive distension, as in the inflammation preceding the occurrence of gangrene, it becomes soft, flaccid, and shrunk in its dimensions : it crepitates on pressure, and emits a peculiar cadaverous, characteristic odour. Such are the local appearances of the sphacelated part. This part is called the slough, and the process by which it is formed, sloughing. When the mortification has a disposition to spread, the dark colour extends, and is insensibly lost in the surrounding parts ; whereas, when the mortification ceases to spread, a red line, called the line of demarcation, separates the sphacelated from the living parts. This line is, in the living part, in immediate contact with the dead, and its appearance is always regarded as most important, as indicating not only that sphacelation or sloughing has ceased, but also that a process has been commenced by nature for the removal of the sphacelated part 60 GANGRENE — SPHACELUS. from the system. In this process, exudation and partial organization of fibrin precedes suppuration and ulceration, and thus hemorrhage from vessels, and infiltration into loose tissues, are both prevented. As the process advances, the cuticle is separated from the line of adhesive in- flammation, and the part exhibits the appearance of a circular vesicle; this gives way, and an inflamed and ulcerated surface is then brought into view, called the line of separation. The continuity of the parts being thus fairly interrupted, the furrow deepens and extends, till the sphacelated portion is entirely detached, leaving, generally, a healthy granulated surface. In this very remarkable process, there are various results of inflammation, namely—adhesion, which effects two purposes, preventing both hemorrhage and purulent infiltration,—ulceration and suppuration; the ulceration being for the purpose of effecting the sepa- ration. The process is the same, whether it extends only to a certain depth below the surface, or whether the whole thickness of the part perishes. In the latter case, remarkable as this process is, the surgeon does not leave to nature the work of amputation, partly on account of the length of time that would *be required, and partly because of the irregularity and form of the stump that would be left, as the ulceration, in these circumstances, does not proceed perpendicularly to the surface, but in a slanting direction, leaving the bones uncovered. To obtain, therefore, a more useful stump, the surgeon resorts to amputation. The question of amputation, and the time and site that ought to be selected when it is advisable, will be considered in a subsequent chapter. Local changes in inflammatory Mortification.—Dr. Bennett, to whom the profession is much indebted for his valuable " Treatise on Inflam- mation," gives the following description of the condition of the parts in inflammatory mortification. " Occasionally a very large amount of blood- plasma is thrown out, constituting a violent inflammation; a greater or less number of capillaries are also ruptured, and blood-corpuscles are more or less mixed up with the liquor sanguineus exuded. The exuda- tion thus formed compresses the part, so as to obstruct the blood-vessels, and prevent the continuation of any circulation in it. Under these cir- cumstances, instead of forming a blastema for the production of new organisms, it undergoes chemical changes, which induce in it decompo- sition, and the part is said to be mortified, or to be affected with moist gangrene. This change commences first in the blood extravasated, which becomes of a purple colour, more or less deep ; corpuscles break down and become disintegrated ; their hematosine dissolves, and colours the serum, and should the exudation have coagulated, it forms brown, rust-coloured, purple or blackish masses. An acrid matter is now formed, which, acting on the neighbouring tissues, produces fetid gases, that are abundantly given off from the affected part. Sulphuretted hydrogen is evolved, which causes^ the blackish sloughs usually observed in such cases, and discolours silver probes, and the preparations of lead. After a time, the elementary tissues surrounding or involved in the exudation, become more or less affected. The transverse striae, in the fasiculi of voluntary muscles, become first pale, and are then obliterated. Cellular tissues, fat, and other soft substances, lose their connexion, and fall into an undefined granular mass. The tendons and fibrous tissues retain GANGRENE — SPHACELUS. 61 their characteristic structure for a long time after the other soft parts have been reduced to a softened pulp. The bones resist the action longer, but at length become rough, soft, and commencing externally, are more or less broken down, and reduced to the same pulpy consistence, and granular structure, as the surrounding parts. As the tissues thus be- come broken down and fluid, they are discharged from the system in the form of an ichorous matter, which, examined microscopically, presents numerous granules, imperfect or broken-down cells, blood-corpuscles, and fragments of filamentous tissue or other structures involved." Constitutional symptoms of inflammatory Mortification.—During the inflammation which precedes the mortification, and when a disposition to form a line of demarcation is observed, the constitutional symptoms are those of inflammatory fever ; but when the mortified part is of great importance in the animaf economy, or when the mortification is exten- sive, the constitutional symptoms very speedily merge into those of the worst typhoid type. Some of the principal symptoms are the following:— the pulse is rapid, thready, and feeble, in some instances irregular, and in others intermitting ; but the most striking peculiarities of the pulse are great diminution of strength, and great increase of frequency, and before death it becomes exceedingly indistinct and flickering; the pa- tient lies on his back ; the countenance is cold and has an expression of great anxiety; the features are pinched, and the face has a peculiar livid hue ; the tongue is at an early period furred and dry in the middle, and ultimately the whole of the mouth exhibits the same condition; hic- cup comes on, and occasionally vomiting of a substance of a coffee-colour; the patient is often observed picking at the bedclothes; the skin is at first dry, but as the case advances it becomes cold and clammy; on pressing the hand to it, it feels raw, and is so relaxed, that on the hand being raised up, it gives the impression of sticking to the hand so as to follow it slightly and be raised up from the subjacent parts; the perspi- ration, like the other secretions, has a peculiar cadaverous odour ; the evacuations are passed involuntarily ; the patient sometimes retains his mental faculties to the last, but more frequently he is affected with low muttering delirium. Such are the symptoms that precede the closing scene in many examples of death from inflammatory mortification. G2 CHAPTER II. ERYTHEMA AND ERYSIPELAS. I. ERYTHEMA. In this chapter it is proposed to give a brr?f but comprehensive ac- count of the doctrines of Erythema and Erysipelas. To render the description more clear, we shall refer to the different varieties of those affections, stating their symptoms and causes, together with the cir- cumstances under which they are usually met with, and their treat- ment. Erythema (from ievSwx, redness) is a term to which all writers have not been careful to affix the same signification. Hippocrates used it to denote any kind of morbid redness of the skin; at a subsequent period Celsus, and still later, Galen substituted the term erysipelas for ery- thema, and this has, no doubt, occasioned part of the confusion which has arisen in the use of the term; some others, employing it as synony- mous with idiopathic erysipelas, others to designate the slightest grade of erysipelas; while some, as J. P. Frank and J. Frank, have applied it to several affections of a chronic kind, perfectly distinct from those to which it has been given by recent British and French pathologists. Erythema, in the sense in which the term is generally employed in this country, may be defined to be a superficial redness of the skin, dis- appearing momentarily on pressure ; usually of an acute character, and not infectious; attended with a burning pain, tenderness, and dryness of the part, and generally unaccompanied with vesication, or with swell- ing beyond a slight and barely perceptible degree. On the subsidence of the inflammation the part is covered with scales, in consequence of desquamation of the cuticle. The idiopathic, or primary, or local, form generally proceeds from some topical irritation, as friction, attrition of contiguous surfaces, pressure, irritation caused by morbid secretions, by vicissitudes of tem- perature, by chemical or mechanical irritants, or by stings of insects. Even this form of erythema, although caused by topical irritation, is favoured by, and almost always more or less associated with disorder of the digestive, excreting, or eliminating organs. The increased action very rarely rises beyond the grade of active congestion; and the slight form of the local affection, its non-extension to the cellular tissue under the skin, and the very limited amount of constitutional disturbance, suf- ficiently distinguish erythema from erysipelas. In this form the proper local treatment consists in the removal of the cause of irritation, rest, an attitude favourable to venous return, ERYSIPELAS. 63 and fomentations; and should these prove insufficient, in pencilling over the part with a strong solution of the nitrate of silver. Rest, restriction of diet, and a few gentle alterative aperients, constitute the general treatment; and for preventing the return of the disease, the most important precautions are, to avoid exciting causes of the affection, and to use proper means for regulating the functions of the stomach, the liver, and the skin. The sympathetic erythema of Rayer may be said to comprehend the different varieties enumerated by Willan and Bateman; these, are the six following:—erythema fugax, which appears upon the breast, arms, and face, in cases of bilious diarrhoea, in certain affections of the ali- mentary organs, and in various febrile disorders: erythema Iceve, which is most frequently met with as an accompaniment to anasarca or oede- matous swellings, but occasionally attends the catamenia in weak and irritable females, and is sometimes symptomatic of disorder of the digestive system: erythema marginatum, which, deriving its name from being bounded on one side by a hard, elevated border, occurs chiefly in old persons in the progress of some internal disorders, and is always regarded as an unfavourable symptom: erythema papulatum, sometimes attended with general disturbance of a slight nature, but frequently with anorexia and. much prostration of strength: erythema tuberculatum, a very rare variety attended with great languor, irritability, and rest- lessness, and succeeded by hectic (Bateman never met with this variety, and Willan only saw three examples): and erythema nodosum, which shows itself in vivid patches on the foreparts of the legs, mostly in young females of a relaxed constitution; is preceded by slight febrile symptoms, and is sometimes connected with the approach of the cata- menia. Rayer mentions another variety which other observers have over- looked—general erythema. A case came under my notice some time ago, which I believe was an example of this variety: the pulse was rapid and feeble, the redness was pretty general over the body, there was great prostration of strength, the tongue was dry, and the bowels very loose; it continued nearly a week, and was followed by desqua- mation. The different varieties of symptomatic erythema must all be treated by internal or constitutional remedies, and according to indications furnished by the internal disorders which they are found to accompany. II. ERYSIPELAS. Names and Definition.—Erysipelas, derived from lew, I draw, and 7re*xr, adjoining, so named from its tendency to spread to the adjoining parts of the skin, may be defined to be an inflammation of the skin and subjacent cellular tissue, characterized by a deep-red tint, by swelling of the parts affected, and by a remarkable tendency to spread by con- tinuity. It is also called the Rose, from the colour of the integument, and St. Anthony's Fire, a name given to it in former ages on account of the burning heat which accompanies it, and from the belief that St. Anthony had special power to heal this kind of disease. Divisions.—The varieties of erysipelas have been very differently 64 ERYSIPELAS. divided by different writers. Some have proposed a division according to the region in which the disease appears:—1st, Erysipelas of the face and head ; 2d, Erysipelas of the trunk ; and 3d, Erysipelas of the extre- mities. Burserius suggested a division according to the supposed causes:—1st, Primary, or Idiopathic, when it arises from an internal disease not preceded by any other; 2d, Symptomatic, or Secondary, when it supervenes on another disease; and 3d, Accidental^ when ex- cited by some obvious external cause. Biett and Cazenave divide them into True and Phlegmonoid; Alibert and Rayer into Simple, Phlegmo- nous, and CEdematous. The division employed by Willan and Bateman was into Phlegmonous, Edematous, Gangrenous, and Erratic; and that by Desault into Phlegmonous, Bilious, and Local. We shall refer to the following varieties :—1st, Simple ; 2d, Phlegmonous ; 3d, (Edema- tous ; 4th, Bilious; 5th, Erratic ; and 6th, Periodic. SIMPLE ERYSIPELAS. Symptoms.—Simple, called by some authors true or legitimate erysipelas, is characterized by the following symptoms:—Redness of the skin, more or less vivid, occasionally partaking somewhat of a livid and in many instances of a yellow tint; disappearing under the pressure of the finger, but returning on its removal; and defined by a distinct elevated margin, which irregularly circumscribes it; slight tumefaction, never acuminated or convex ; and pain of a tensive, peculiar, or stinging character, accompanied by itching, and a sense of burning diffused over the whole inflamed surface. For three or four days these symptoms continue to increase in intensity, and then begin to decrease, remaining, however, in some degree for three or four days longer. When the inflammation is acute, small miliary vesicles, like those of eczema, are developed on the inflamed skin, and when it is very intense bullae or phlyctenae often appear on the erysipelatous part. These bullae may be isolated or confluent; they burst soon after their ap- pearance, most frequently about the fifth or sixth day of the disease, and the humour they emit dries on the skin, forming flavescent crusts, which afterwards become brown or blackish, and ultimately are detached along with the epidermis, which falls off in scales. The local symptoms usually make their appearance after certain precursory signs, such as languor, lassitude, depression, shiverings, general uneasiness, nausea, and very frequently other manifest symp- toms of disturbance of the functions of the alimentary canal. The con- stitutional symptoms take the precedence for some time; then the local symptoms appear, and afterwards they increase and decrease together. It has, however, been correctly remarked by careful observers, that the local disorder is by no means invariably in the direct ratio of the se- verity of the febrile symptoms. Results.—The most frequent and most favourable result of this form of erysipelas is resolution; slight discoloration and thickening of the skin, together with desquamation of the epidermis, remaining for a very short time, and then disappearing. In the very mildest form there is scarcely any desquamation, but in more acute cases it is considerable, and slight thickening of the skin and discoloration remain for a short ERYSIPELAS. 65 time; and if the action be still more intense, serous effusion may take place, both on the external surface of the cutis, constituting bullae or phlyctenae, and in the subcutaneous cellular tissue, which becomes infil- trated. By the absorption of the fluid in the cellular tissue, ajid the bursting and desiccation of the vesicles on the surface, all traces of the disease disappear. At a certain stage, in some cases, the part is found to be covered over with dry cuticle, and, in others, where bullae have formed, with crusts. Sometimes, though very rarely in this form, and only when the action is very acute, the inflammation proceeds to the extent of suppuration, forming abscesses; the matter in such cases being surrounded by a fibrous cyst, does not constitute diffuse suppura- tion, which condition is met with in a more serious variety of erysipelas. Although abscess is comparatively unusual, as an immediate result of this simple form of the disease, it is by no means uncommon for persons of a feeble and irritable constitution to have inflammation ex- cited in a part recently the subject of erysipelas, or in its immediate neighbourhood, and for that inflammation to go on to the formation of abscess, requiring very early and free evacuation, in order to prevent destruction of tissue. Sometimes the inflammation suddenly disappears, and presents itself in some other part of the external surface, constituting erratic or am- bulant erysipelas ; and sometimes, although more rarely, its sudden disappearance is followed by asthenic inflammation of some internal part, constituting metastatic erysipelas. Causes.—The causes of erysipelas are various, and sometimes very obscure. The chief predisposing causes are intemperate living, espe- cially addiction to spirituous liquors, unwholesome or insufficient nour- ishment, the bilious and irritable temperaments, the gouty diathesis, previous disease, general cachexia, low spirits, anxiety, the feeble, ple- thoric, and leucophlegmatic habits, disordered condition of the biliary and digestive organs, certain seasons of the year, more especially, spring and autumn, irritability or tenderness of the skin, feeble capil- lary circulation, previous attack of the disease, and in females certain periods of life, as that of menstruation, and that of the cessation of the catamenia. Of the many exciting causes some act locally, as wounds, contusions, trifling injuries, surgical operations, abrasions of the cuticle, irritation caused by morbid secretions, or by leech-bites, or by cold, or by friction of clothes, or by acrid or irritating substances of any kind, or by inflammation of the skin, from whatever cause proceeding. Of the exciting causes which originate in the system itself, and of those which act on the system generally, some are errors in diet, violent mental emotions, suppression of accustomed secretions or discharges,, living in an unwholesome atmosphere, more especially in cold, damp, stagnant situations, atmospheric vicissitudes, impure air from the crowding together of patients in hospitals, contagion, and particular conditions of the air, in consequence of which it occasionally assumes an epidemic character, and is in such circumstances usually very severe and frequently fatal. Erysipelas no doubt comes on in many instances without any obvious cause, but that it often spreads by means of contagion has been proved 66 ERYSIPELAS. by incontestable evidence. There seems also to be good ground for believing that erysipelas originating in some common cause, and erysi- pelas induced by local causes may spread by means of contagion. Most of the.French authorities deny that erysipelas is transmissible by con- tagion ; but that it is so, facts recorded by Dr. Wells, Dr. Stevenson, Mr. Arnot, Dr. Gibson, and Mr. Lawrence, in various interesting papers published by them on this subject, furnish most conclusive evidence, and set this question at rest. Many other cautious observers have arrived at the same conclusions on this subject as the authorities I have mentioned. PHLEGMONOUS ERYSIPELAS. This disease, although met with at all periods of life, and in all parts of the body, is much more commonly found in young and plethoric than in elderly persons, and more frequently in the extremities than in the other regions of the body. This is a very dangerous form of the dis- ease, especially when it occurs epidemically, or from infection. Both the local and constitutional symptoms are severe; the inflammation not only has its seat in the skin and subcutaneous cellular tissue, but fre- quently extends also to the deeper portions of cellular tissue between the muscles. To make the description of this disease more clear, we shall adopt the arrangement of those authors who divide it into three grades, differing from each other in the degree of their intensity. In the first grade, after rigors, anxiety, and other symptoms of con- stitutional disturbance, soon followed by stinging pain, tingling, redness, and a feeling of heat of the inflamed part, tumefaction of rather a hard character takes place, occasioned by the integument being raised up by swelling of the subjacent cellular tissue. After pressure with the finger, the redness returns more slowly than in the simple and superfi- cial form of erysipelas. If about the fifth day, the skin is observed to be less red and tense, and to be covered with furfuraceous scales, and the subsidence of the swelling shows that the subcutaneous cellular tis- sue is beginning to regain its usual state, the phlegmonous erysipelas will end in resolution. But if, on the contrary, the pain at this stage becomes pulsatory, suppuration is the inevitable result, the matter form- ing into an abscess of healthy character, the opening of which is usually followed by the speedy healing of the part. In the second grade, both the constitutional and local symptoms are much more severe; the disease occupies a large extent; at a variable period, but generally not before the fifth nor after the ninth day, puru- lent collections form beneath the skin or between the muscles, and, on their being opened, gangrenous masses of the cellular tissue are dis- charged along with the matter. Often, instead of abscesses, there is extensive sero-purulent infiltration into the cellular tissue. There are many sources of danger in this variety, some of which are great irrita- bility of the stomach and bowels, exhaustion from diarrhoea or from extensive suppuration and disorganization of the cellular tissue, severe nervous symptoms, contamination of the blood from absorption of the morbid secretion of the affected part, or combinations of these condi- tions. ERYSIPELAS. 67 In the third grade, the constitutional and local symptoms are still more intense from the commencement; the skin is tense, shining, and of a dark dusky red, and only retains, for an instant, the impression made by the finger ; the swelling is diffused, very great, and intolerant of pressure. About the fifth or sixth day, the skin loses its sensibility, assumes a violet tint, and becomes flaccid and covered over with phlyc- tenae containing a reddish serosity, and, soon afterwards, sloughs are formed along with ichorous suppuration, destruction, and suppurating boils in the surrounding cellular tissue. This is what some authors call gangrenous erysipelas. In the most favourable cases, after the sloughs are detached, the subjacent parts take on a healthy action, and, after a con- siderable time, the part granulates and cicatrizes : but most frequently, from absorption of matter or inflammation of veins, or some affection of the brain, stomach, or bowels, the patient sinks, the precursor of death being the symptoms of the worst form of adynamic fever. 03DEMAT0US ERYSIPELAS. In this form the skin is smooth, shining, and of a pale red colour, which, in some instances, inclines somewhat to a yellowish brown ; the heat and pain are less than in the other forms; the swelling is conside- rable, and gradually extends; it leaves the impression of the finger as in anasarca, and from this circumstance this variety has received its distinctive appellation. Vesication is less common than in the other varieties, and, when it is present, the vesicles are small and numerous. The inflammation is of a subacute character, and gives rise to serous effusion ; in some situations it is apt to result in gangrene, as when it occurs in dropsical limbs from excessive distension, or when punctures have been made to allow the fluid to drain off. To diminish the risk of the occurrence of gangrene, in such circumstances, some have judiciously allowed the fluid to escape by numerous punctures with a needle, rather than by incisions. This form of erysipelas is in degree intermediate between the simple and phlegmonous, and most commonly presents itself in persons of a debilitated constitution, and very frequently in those who have a ten- dency to, or are affected with, dropsy. The infiltrated limbs of dropsi- cal patients, the scrotum in men, and the genitals in women, are the most usual seats of oedematous erysipelas ; and, of all the results of this variety, gangrene is the one most to be dreaded, and is indicated by severe pain, and a red, glossy state of the skin passing into a leaden or * lurid hue. BILIOUS ERYSIPELAS. Antecedent disorder of the digestive and assimilative organs is more or less evident in all the forms of erysipelas ; but in this form symptoms of bilious derangement, both before and during the attack, constitute the most prominent features. In such cases, the local symptoms are far from urgent; the redness partakes much of a yellowish hue, and all the local signs indicate but a slight grade of inflammatory action. The constitutional symptoms also exhibit a very moderate degree of the in- flammatory type ; the principal being nausea, bilious vomiting, loathing 68 ERYSIPELAS. of food, thirst, loaded tongue, a yellowish tinge of the body, and other manifest signs of disordered secretions in the prima via. ERRATIC ERYSIPELAS. The peculiarities of this form are—that it invariably presents itself in persons of a feeble or debilitated constitution, that the constitutional symptoms precede and attend the attack, and that they are much more of the asthenic than of the sthenic character, the symptoms of debility usually becoming very apparent; that the local symptoms are even less severe than is usual in ordinary cases of simple erysipelas ; that, in most instances, exfoliation is the only effect remaining, and that the inflammation spreads from one part to another by continuous unbroken extension, the circumference of the inflamed part being always distinct, so that it is very evident where the inflamed and unaffected parts of the skin join each other. PERIODIC ERYSIPELAS. The peculiarity of this form is not merely that it returns, but that it is sometimes strictly periodical, returning more frequently (so far as my observation has enabled me to form an opinion) to the parts which were previously attacked; in some instances it has been found to be periodi- cal in return, and universal in extent—that is, extending over the whole body; an example of which occurred in the experience of Mr. Maul, of Southampton, in the case of a lady who had several attacks at intervals of two years. In some instances the attack is monthly, at the time the catamenia should appear. This form of erysipelas is, I believe, most frequently met with in females of a weak and chlorotic habit. I have a patient who, for some years, had a return of it every six weeks, but got over the tendency by residence in the country, and the use of suitable remedies for the improvement of her general health and strength. I know an instance of a man who had for years an attack every two months. In both the last-mentioned cases, the head was the part attacked. One man, whose case I remember, had an attack regularly twice a year, and another every spring. The local symptoms, so far as I have had opportunity of observing, are not very severe, and rarely give rise to more than oedema of the cellular tissue, and exfoliation of the cuticle. The constitutional symptoms are both antecedent and attendant. TREATMENT OF ERYSIPELAS. From what has been stated regarding the various forms of erysipelas, the different states of the system in which they take place, and the varieties, both as to the degree of the inflammatory action, and as to the degree and type of accompanying fever, it must be very clear that it will be necessary to modify the treatment according to the particular circumstances of each form and case. Some cases require little treat- ment beyond rest, suitable regimen, and a proper attitude of the inflamed part; in some, purging and the antiphlogistic regimen are needful; in some, local remedies of a decided character must be joined to general antiphlogistic treatment; while others are attended with so much of a ERYSIPELAS. 69 typhoid type as to require the use of remedies of a very different nature. It has been well observed:—" In some instances large deple- tions are required; in others, moderate or local depletion only is advi- sable ; and, in many, depletion is most injurious, the most energetic tonics being often indispensably necessary." Whilst the disease thus requires, from the very commencement, most varied and often opposite modes of treatment, it frequently, also, demands an almost equal diver- sity at different stages of its progress. In simple erysipelas, the general treatment in slight cases consists in the observance of the antiphlogistic regimen, and the exhibition of mild purgatives, together with rest, cool air, and the maintenance of a proper attitude ; but in more severe cases, emetics, purgatives, and antimonials are to be employed, and, in some instances, early general depletion. With reference, however, to depletion, great regard must be paid to the powers and habits of the patient, the stage of the disease, and the pre- vailing character of the epidemic. Of the many cases which have come under my own observation, in comparatively few have I thought general bleeding necessary, or at all likely to be serviceable; and, except in some very severe cases of erysipelas in the head and face in young and vigorous persons, I very rarely indeed resort to it. Even in such cases, and in others where, from the exceedingly acute character of the symp- toms, depletion may be deemed prudent, it should be employed with much circumspection; for however strong and hard the pulse may be, or however great the heat and the urgency of acute inflammatory symp- toms, there is soon, in most cases, a tendency to asthenic vascular action and deficiency of vital powers. It is, therefore, judicious in most in- stances, to rely on other means for allaying excited action, and to resort to bleeding only when it seems absolutely indispensable. In most cases, rest, an emetic, mercurial and other purgatives, followed by antimonials, and aided of course by suitable regimen, fulfil the desired indications, which are to correct the secretions in the alimentary canal, to promote the secretions generally, and thereby to diminish in- flammatory action and febrile excitement. As the indications of treat- ment often alter very quickly, cases should be watched with the greatest care, and the treatment changed, if symptoms of debility present them- selves. If any doubt exist whether it be desirable to administer decided stimulants, beef-tea may be given, and four or five grains of carbonate of ammonia every two or three hours ; and if the symptoms should not improve, then wine may be administered, and the bowels regulated by mild aperients, but not by drastic purgatives. The following extract from Mr. Liston, as to the means recommended for subduing inflammatory action in erysipelas without resorting to bleeding, will be perused with interest:— " The exhibition of the extract of aconite in this and other inflamma- tory affections, is often followed by great abatement of vascular excite- ment, so that the necessity for abstraction of blood is done away with. The medicine may be given in doses of half a grain in substance, or dis- solved in pure water, and repeated every third Or fourth hour. The sensible effect is relaxation of the surface, and frequently profuse per- spiration ; the arterial pulsations are diminished in frequency and force. 70 ERYSIPELAS. The extract of belladonna, in doses of fB of a grain, may then be sub- stituted with great advantage, and often with the most extraordinary effect upon the disease."—Liston's "Elements of Surgery," Second Edition, p. 61. Erysipelas.—For report of cases of erysipelas thus treated,'see "Reports of North London Hospital," contained in the "Lancet" of 6th and 13th of February, and 16th of April, 1836. Local treatment.—In mild cases no local treatment is required, beyond rest, and an attitude favourable to venous return. In others local applications are useful. Of all the applications in use, my ex- perience leads to the conclusion, that the most generally grateful to the feelings of the patient, and the most useful are warm opiate fomenta- tions, or opiate and lead lotion, applied as warm as the patient can bear them, and as long as he finds them pleasant to his feelings. Sometimes, though very rarely, warm applications are painful; and then I do not hesitate, if the erysipelas be in the extremities, to use the above appli- cations cold, and if they give relief, to continue their use as long as they prove a comfort to the patient. In more urgent cases, when the action is very acute, I have, together with the use of warm applications, adopted, with the happiest results, the mode of proceeding which was proposed by Dobson, and has been much and deservedly praised by many, namely, local depletion by numerous small punctures, rapidly made with a fine lancet. The punc- tures should extend only into the true skin, and should be made rapidly. Of the advantages of this proceeding, in acute cases, I can speak in the strongest terms, patients having often expressed themselves grateful for the relief it has afforded. Other local remedies, used in many cases with much advantage, are, brushing over the part with a strong solution of the nitrate of silver (as recommended by Higginbotham, and practised by many), or lightly touching the inflamed surface with the lunar caustic in substance. The former mode is that which I have usually preferred, and my experience leads me to speak very favourably of it, especially in erysipelas of the extremities. After brushing over the part with a strong solution of the nitrate of silver, dusting the surface with flour or magnesia, keeping it fomented with warm opiate, or lead and opiate lotions, or applying them cold, when warm applications are not grateful, are all proceedings from which, in my own experience, I have seen the happiest results. I am satisfied from my own observation, that Higgin- botham, Jobert, and others, were fully justified in speaking so strongly as they have of the advantages of using the nitrate of silver as a local application in the treatment of erysipelas. Of the advantage of keeping the part covered with mercurial ointment, as proposed by Little and Dean of America, or of the application of a lotion, or ointment of the sulphate of iron, in the proportion of a drachm of the sulphate of iron to a pint of water or an ounce of lard, as recommended by Velpeau, principally in cases where there are no vesications, and where the in- flammation is superficial, I can say nothing from my own observation. To the use of blisters, first recommended by Dupuytren, I have rarely resorted, and to bandaging never, except as a means of support when all inflammatory action has ceased; but some continental surgeons have adopted a proceeding, which, so far as I know, has never been followed ERYSIPELAS. 71 in this country, and which must surely be attended with great risk, namely, bandaging from the very commencement of the attack, even when the action is acute. In phlegmonous Erysipelas, the constitutional and local treatment, in the first instance, differs in no respect from that proper for severe cases of simple erysipelas; but it must be strictly kept in view, that whatever may be the activity of the symptoms in the early stage, the general powers are weak, that the disease not unfrequently occurs in those whose powers are naturally feeble, or in persons advanced in life, and that the disease, although accompanied with excitement in the early stage, is afterwards marked by impaired energy, so that if the powers of the patient be greatly exhausted, he will be in the greatest possible danger of sinking under the process of suppuration and sloughing. The most important part of local treatment is the employment of incisions, which, though suggested centuries ago, was first practised in this country by Mr. Copland Hutchison, and has been strongly recommended by him, by Mr. Lawrence, and by many others, and is well worthy of general adoption. Mr. Hutchison recommends that the incisions be made about an inch and a half in length, from two to four inches apart, varying in number according to the extent of surface occupied by the disease. Mr. Lawrence recommends, in preference to numerous incisions, one or two long incisions in a direction parallel to the axis of the limb. Much difference of opinion has prevailed, as to which of these recommenda- tions should be followed ; but, on this point, the judicious course surely is for the surgeon, while he is careful to confine incisions to parts where the erysipelas has the phlegmonous character, and, avoids all unneces- sary division of parts, to proportion both the number and the depth of the incisions to the extent of the inflammation; and a very important rule is to divide fasciae, provided the inflammation extend beneath them. The treatment by incisions is adopted at different stages of the disease for the attainment of different objects. At the beginning of the disease it is employed with great advantage, and is often very quickly followed by relief of the painful tension, and a corresponding diminution of the inflammatory action, thus preventing the occurrence of suppuration and sloughing. In short, suffering and tissue are both spared by the ener- getic adoption of this proceeding at an early stage. The local depletion is useful, the liquor sanguinis is allowed to escape before its disor- ganization has taken place, and disastrous results are averted. At a more advanced period of the disease, incisions limit the extent of sup- puration by opening a way for the evacuation of matter, and still later, they afford the readiest outlet to matter and sloughs. At this advanced period, however, the incisions must be made sufficiently deep to reach the whole of the infiltrated and gangrenous structures; otherwise they cannot fulfil the important indications for which they are employed. Fomentations, in the first instance, and afterwards poultices, should be applied over the part. The patient should be watched, until all bleed- ing has ceased, as it may be necessary to resort to some proceeding, such as elevation of the limb, or slight pressure for some time, to prevent the hemorrhage from becoming excessive and injurious. The general strength requires to be kept up by generous diet, wine 72 ERYSIPELAS. and other suitable means, during the severe trial to which it is subjected under the process of suppuration and granulation. In oedematous Erysipelas the constitutional treatment, in the first in- stance, consists in promoting a healthy condition of the secretions, by the employment of mild aperients with suitable regimen, and subsequently in improving the general health and strength, by the use of a light, nu- tritious diet, and by all the means suitable and available in the circum- stances. In most instances, as the case progresses, quinine will be in- dicated. The local treatment consists of rest, elevation of the affected part, warm fomentations, small punctures to allow the escape of serous effusion, and, at a not very advanced stage of the disease, support by means of bandages. In bilious Erysipelas, if the head be not severely affected, and the disease unattended with much pain or tenderness at the epigastrium, an emetic given at the commencement of the attack is usually of service ; after the operation of which a smart dose of calomel, followed by smart purgatives and diaphoretics is of great benefit. The subsequent consti- tutional treatment must be regulated according to the character of the disease, the states of general and local vascular action, and the condition of the vital powers. If there be much tenderness of the epigastric or hypochondriac regions, together with nausea or vomiting, local depletion in the vicinity, and afterwards blisters or sinapisms, are of essential ser- vice. Little local treatment is required beyond rest, and an attitude favourable to venous return ; the local, as well as the constitutional symptoms, being chiefly combated by internal remedies. 73 CHAPTER III. WOUNDS. The term wound, in the language of surgery, signifies a recent solu- tion of continuity in the living structures induced by some mechanical cause. Classification of Wounds.—Of the various divisions which have been made, an important one is the following, viz.;—wounds of the head, neck, thorax, abdomen, and extremities. The peculiarities of symptoms, dangers, results and treatment depending on situation, will be mentioned in other parts of this work, where the affections of the particular regions are described; but, in the present chapter, we shall adopt the classifica- tion into incised, lacerated, contused, punctured, gunshot, and poisoned. Various modes of healing.—The various modes in which wounds heal, may be enumerated as the processes of adhesion, granulation, and incrustation. 1. Adhesion—union by adhesion—union by adhesive inflammation, and union by the first intention, are the synonymes by which this mode of healing is referred to. For <; description of this process, the reader is referred to the section on the results of inflammation, where, under the head of exudation of coagulable lymph, the opinions entertained regarding this mode of healing are mentioned. The conditions favour- able for this mode of healing are—clean surfaces, unimpaired vitality, entire cessation of bleeding, perfect coaptation, exclusion of air, light dressing, and only a very slight grade of the inflammatory process. The treatment for adhesion will be afterwards considered. 2. Granulation is the mode of healing usually to be promoted when adhesion fails. The little conical eminences which form on the surfaces of suppurating wounds are named granulations, from their granular appearance, and serve for filling up the cavities and bringing together the edges of wounds, and uniting them by what is called the second intention. As the processes of granulation and cicatrization have been already fully described, and as the treatment will come to be afterwards con- sidered, it seems necessary in this place only to mention that this is the suitable, and indeed the only practicable mode of healing, when the wound is of such depth and extent that it is impossible to place or retain the surfaces in coaptation ; when apposition is prevented by the presence of coagulated blood, or other foreign matter, which cannot be removed; and also when, in consequence of prolonged exposure to the atmosphere, or of any other cause, such as contusion, the inflammatory process has been made to reach the suppurative grade. 74 WOUNDS. 3. The incrusting or " modelling" process, better known by the fami- liar, though less euphonious name of "scabbing," is best adapted for wounds presenting a superficial denuded surface, perhaps of considerable extent, but of little depth. It comes into operation when, there not being enough of inflammation to induce suppuration and granulation, or when, the vascular action of these processes having greatly subsided, a crust is formed on the surface of the wound by the drying, in the former case of coagulated blood or fibrin, and in the latter of fibrin and pus commingled. The crust may also be formed artificially, its use being to exclude atmospheric air, protection from the stimulus of which is essen- tial to this process. Beneath this covering, new matter is added on the surface of the wound, raising its level, if depressed, and skinning it over when nearly on a plane with the surrounding integument; but the exact steps of the process are not fully ascertained. There is no suppuration, but merely a little serous discharge, oozing from beneath the edges of the crust. The cicatrix, when at last exposed, on detachment of that temporary covering, is more uniform, more similar to the original parts, and less liable to contraction, than a cicatrix obtained in any other way. If the inflammatory action increase during the process, suppuration ensues, and pus accumulates under the crust, raising it up and causing painful tension, and thus suspending, for the time at least, farther advance of the modelling process. Wounds heal very readily by this mode in the inferior animals, there being in them much less inflamma- tory tendency than in man. This mode of healing is most suitable for superficial wounds exposing a single surface, to which none other can be applied, provided there is no contusion of tissue, and little likelihood of inflammation. In deep wounds of uncomplicated character, the sides of which can be approximated, adhesion is more applicable and certain ; while in a deep wound, attended with loss of substance, so that coapta- tion is prevented, or in one of any form accompanied with much contu- sion, which must be followed by considerable inflammation, granulation offers the most available cure. The crust, if not naturally formed, may be supplied artificially by covering the surface with lint, which soon becomes soaked with the oozing blood, and on drying, hardens into a strong, well-adapted cover- ing ; or the crust may be furnished by gently pencilling the surface with nitrate of silver, which coagulates the secretion. A piece of gold- beater's skin should be applied over, and for a short distance around, the thin pellicle thus formed by the lunar caustic, to prevent its prema- ture cracking and detachment. Or, the crust may be formed, as Pro- fessor Miller recommends, by using a " thick semifluid solution of gum tragacanth," which is laid uniformly over the surface, where it soon dries, forming an unirritating, transparent, and effectual covering from the atmosphere, which covering can easily be repaired at any part when necessary, and which, should undue vascular action set in, is softened and set loose by the discharge to which the excess of inflammation gives rise. In the absence of the tragacanth solution, ordinary mucilage of gum acacia would form a similar, though probably a more brittle,0 and therefore inferior, pellicle. The part should be kept at rest, and,' still further to assist in restraining local action, the antiphlogistic regimen WOUNDS. 75 should be enjoined. When the modelling process1 fails, the treatment for granulation is to be instituted. The permanent tissues of repair.—With regard to the repair of in- juries, it is known that in healing, the lesion of some textures is effaced by a reproduction of similar tissue, while the injury of other parts is repaired by the formation of a tissue less highly organized. Osseous and cellular tissue may be reproduced, and minute nervous and vascular filaments are formed in the connecting substance. The development of blood-vessels for granulations, or for superficial deposits of lymph, adhe- sions, or the like, has been referred to in the chapter on Inflammation, and the views entertained by many regarding their formation, have been mentioned ; but in addition to the opinions already brought for- ward, it is proper to state, that, according to Mr. Paget, their develop- ment is always effected by the projection of culs de sac, commencing as mere dilatations, from a capillary arch passing close to the adventitious structure. These coecal diverticula, crowded with corpuscles, are pro- longed in a definite manner, towards and into the new tissue, so that they meet and adhere; the double partition formed by apposition of their closed extremities gives way, and a new capillary arch, transmit- ting blood, is formed. Fibrous tissue is the medium of repair in wounds of cartilage, in the cut extremities of which, however, bone is sometimes deposited. Muscular fibre, when divided, is never reproduced, cellular and fibrous tissues forming the new bond of connexion, which gradually contracting, in most instances, draw the retracted ends of the muscle at last into pretty close apposition. Nerves, when divided, if their cut extremities be in contact, rapidly unite, but with some confusion of function, apparently from the precise continuity of individual fibres not being accurately restored. Even when a considerable interval has occurred between the ends, union has been effected, in the first place by material similar to that effused after wounds of other soft tissues; but, in time, nerve-fibres become developed within this substance, probably by prolongation from the cut extremities, between which they form a communication, partially restoring the functions of the nerve. Not less, it is believed, than two years will suffice for the accomplishment of this process. There is " no example in which the nerve or ganglia cor- puscles have been reproduced." The repair of wounds differs somewhat according to their amount of exposure. In an open wound healing by granulation, all the parts become more or less matted together, but a subcutaneous incised wound, as practised on tendon, and properly treated, is much better regulated in its cure, and motion becomes free as before. The end of the tendon connected with the muscle retracts, and thus lies surrounded by healthy uninjured structures, quite removed from the site of the external wound. Liquor sanguinis is effused, and collects in greatest quantity, in that part of the sheath where there is most space, namely, that part vacated by the retracted tendon. The serum is absorbed, and the fibrin coagulates. In a few hours, those parts of the wound which are in coaptation, in- cluding the opening in the skin, subjacent cellular tissue, and sheath of 1 So named, it is said, because the new matter is added to the surface of the wounded part, so as to restore its original formation or model. 76 WOUNDS. tendon, have quite healed, but within the sheath, in the space between the ends of the tendon, fibrin exists in large quantity, chiefly derived from the muscular extremity of the tendon, which is the better nourished. By the usual process this becomes organized, and supplied with vessels. "About the tenth day," says Mr. Paget, " it is paler again, seemingly less vascular, and distinctly filamentous." These minute threads run on for some little distance, between those of both extremities of the original tendon, interlacing, and gaining a very firm connexion. In two or three weeks, the cure may be considered complete, continuity being quite restored, though still, for some little time, the new structure and its connexions are scarcely so strong as they ultimately become. They equal, in this respect, at least, any other part of the tendon, and, indeed, become quite undistinguishable from it. The cicatrix, after a wound, progressively improves in texture; new cuticle, or a structure identical with it is formed; but in the fibro-cellular tissue beneath, which occupies the place of the dermis, papillae, when formed at all, are few in number, and imperfectly developed. After the lapse of several months, occasionally of more than a year, elastic tissue, similar to that of the original integument, but in very sparing quantity, is sometimes discovered. INCISED WOUNDS. Incised wounds are such as are inflicted with a sharp cutting instru- ment. The form of wound presents regular and smooth-cut surfaces, and is consequently best adapted for healing by adhesion. The prin- cipal danger is from primary hemorrhage, which is greater in this kind of wound than in any other. The treatment of wounds.—The treatment of wounds varies accord- ing to their nature, and the mode of healing desired. In this depart- ment of practical surgery, a great and salutary revolution has been effected within the last seventy or eighty years. This change had, for many years before the period above mentioned, been occasionally advo- cated by individuals, whose efforts, though at the time isolated, and apparently little appreciated, no doubt tended to the introduction of a more enlightened system. Thus Paracelsus, who flourished from 1493 to 1541, and who was after Hippocrates, the first who advocated simplicity in the treatment of wounds, plainly asserted, that, in the healing of inju- ries, nature is supreme, and that the office of the surgeon is merely to protect the vis medicatrix Naturae from hindrance or interruption. In 1542, the application of water-dressing to wounds was recommended in a paper by Blondus, published at Venice. But, probably, the first occasion, on which public attention was at all aroused, was by the cures, then deemed wonderful, accomplished at the siege of Metz, in the year 1553, by an empiric named Doublet, who employed linen dipped in pure water. In his practice its value was supposed to depend on cer- tain charms and incantations pronounced over it. Shortly afterwards, Pare', the father of French surgery, adopted the water-dressing without the mummeries of incantation. Writers followed at intervals. The French military surgeons, Barons Percy and Larrey, in their cam- paigns, also proved its value. The late Dr. Macartney, in Ireland, WOUNDS. 77 ardently inculcated the use of water-dressing, and, to his successful exertions, much of the general adoption of that method of treatment is attributable. Very much is due on the same account in Great Britain to the late Mr. Liston, who, in his writings and practice, very strongly inculcated simplicity in every department of surgical practice: while eminent surgeons, yet alive, might be cited, who have contributed not a little towards obtaining for the simple and cleanly water-dressing, its present universal estimation. Even when adhesion is not desired, or attainable, the same application used warm, has, in the practice of very many, superseded the employment of the poultice. The treatment for adhesion — with reference, chiefly, to incised wounds, comprehends four important indications, namely, to arrest hemorrhage—to remove foreign matter—to effect and maintain coapta- tion—and to guard against excess of vascular action. The first indication is fulfilled, by aspersion of cold water, if mere oozing exists; or, by the ligature, when a distinct artery is seen pour- ing forth its contents. The ligatures, one end of each having been cut off near the noose, are brought out between the lips of the wound, by the shortest route ; and if numerous, are arranged without entanglement into one or more bundles. These should, when otherwise convenient, leave the wound at its most dependent part; so that the slight purulent secretion, which is pretty certain to occur in their track, may find the most direct and easy exit, and, by at once escaping, not interfere me- chanically with the process of adhesion in other parts of the wound. In amputations of the extremities, they are usually brought out at the angles of commissure between the flaps. The method of cutting off both ends of the ligature, and leaving only the knot, is now restricted, by almost all surgical authorities, to those cases in which the wound has no chance of uniting by the first intention. The second indication, which is to remove all foreign matter, includ- ing coagulated blood, should be attended to as soon as active bleeding has been suppressed. Were its fulfilment neglected, adhesion would in consequence be prevented. All oozing having been completely arrested, foreign matter removed, and the surface of the wound having taken on a glazed appearance ;— the third indication,—namely, to effect and maintain coaptation, should next be proceeded with. Such are the conditions which render coapta- tion advisable; and with regard to the means employed for effecting it, they are position, plaster, sutures, when necessary, and, in some parti- cular circumstances, carefully adapted pressure. The position should be such as will best relieve tension of the muscles and integuments, and obviate venous congestion. A greater amount of relaxation is necessary in some wounds than in others. As muscles are the principal agents in causing retraction, and in preventing easy coaptation, the general rule is to put the limb or part into the position that would be given to it by the natural contraction of the wounded muscle. When muscular fibres are cut transversely, there is much greater retraction, and consequently more necessity for the observance of a position that will secure relaxation, than when the wound runs parallel to, or between them, in which case relaxation might be carried 78 WOUNDS. too far, bv making the sides of the wound bulge loosely, and thus pre- venting accurate coaptation. In such cases, the parts should be laid so as sufficiently to relieve tension, without permitting undue laxity. In amputation wounds of the limbs, where little relaxation is necessary, more than is already present, elevation, to such a degree as to prevent congestion, is the chief point of consequence with regard to position. Of retentive appliances, plaster is one of the most generally useful; and of the various kinds of plaster, the best, though unfortunately also the most expensive, is that which was introduced into practice by Mr. Liston, and known by the name of isinglass plaster. It consists of gauze or silk, which, being stretched out, is frequently coated with a film of isinglass, until the adhesive layer be of the requisite thickness; after which the other side is turned up and varnished with boiled oil. Its advantages are these,—the isinglass is perfectly non-irritating to the sound skin or its cut margins; the oiled gauze is transparent, and accordingly does not conceal the state of matters below; it is very easily applied, having only to be moistened with warm water; it soon dries, becoming firmly adherent; and the impervious nature of its varnished tissue prevents any moisture from the outside detaching it. When the wound is discharging, the plaster becomes loosened immediately over the edges, and for a little way beyond; but this is really advantageous, as it favours free escape of secretion from between the lips of the wound; and the loose, central portion stretching a little, allows room for the slight tumefaction which generally exists in some degree, when any discharge is being poured forth. On the other hand, cheapness is the sole recommendation of the common plaster, composed of emplas- trum plumbi, with resin added to make it sufficiently adhesive. From the nature of the latter ingredient, this plaster is irritating to the skin, and so favours inflammation and erysipelas. It does not adhere firmly when the skin is at all moist; the calico on which it is spread being opaque, hides from inspection the parts beneath; and when any ill-conditioned foetid pus comes from the wound, the plaster, if carelessly prepared, becomes blackened by the formation of sulphuret of lead, which smears the parts beneath; in the removal of which layer, as cleanliness de- mands, more washing and sponging are required than can be beneficial to the delicate margins of the wound. By slow boiling, however, for double the usual time, plaster may be made pretty adhesive without the addition of the irritative resin. The strips of plaster, varying in breadth according to the size of the lesion, are applied at intervals about as wide as the strips, while the assistant carefully holds the parts in the most favourable position for coaptation, and gently presses the cut surfaces and edges into apposi- tion. The intervals left between the strips of plaster permit the escape of any secretion of serum or of pus, if afterwards formed; and, it is in these intervals that sutures and the extremities of ligatures are, when employed, to be placed. The slips should be long,*so as not merely to hold the edges m contact, but, by their adhesion to an extensive sur- face, to keep the parts well together. In longitudinal wounds of the extremities, however, they should not be so long as completely to en- circle the limb, as they would then constrict it, prove hurtful and pro- WOUNDS. 79 vocative of inflammation and oedema, by obstructing venous return, and by rudely opposing the slight swelling which takes place in every large wound, even although adhesion be attained. Instead of isinglass plaster, strips of linen dipped in, or spread with collodion, have lately been employed. This substance, made by dis- solving gun-cotton in ether till the solution be of a syrupy consistence, dries very rapidly when spread out, in consequence of the evaporation of the solvent; and in so doing, it contracts and tightens, leaving a transparent and colourless layer which adheres very firmly to the skin, and is unaffected by and impervious to any of the ordinary fluids natu- rally or artificially present about a wound. To procure its thorough adhesion, the skin must be quite dry at the moment of application. In cutaneous wounds, after the strips are dry and adherent, if there be no oozing of serum from the cut, a little collodion may be smeared in the intervals over the margins, by which means the edges will be preserved in contact, and protected from atmospheric irritation. The collodion may be tinted any colour, and it is worthy of remembrance, when large quantities of it are used, that it is highly inflammable, and that the dry sub- stance left by the evaporation of the ether, is quite as combustible as the gun-cotton before its solution, except that its now more compact and solid form renders combustion or explosion less rapid than in its original fleecy state. A substance closely resembling collodion in its properties and capabilities of application is prepared by dissolving certain propor- tions of gutta percha and caoutchouc in chloroform, and is used in pre- cisely the same manner. A third substitute for the isinglass and com- mon adhesive plaster has lately been employed. It consists of a thick, semifluid solution of gum-lac in alcohol, which may be prepared and kept in a wide-mouthed bottle with a closely-fitting cork. It is more economical than collodion, it is employed in the same manner, and is represented as being quite as efficient. It has, along with the gutta percha solution, the disadvantage of not being like collodion altogether colourless; but it is said to possess, over both these preparations, this advantage, that moderate moisture does not prevent its adherence. All of these solutions, when applied to a raw surface, excite momentary smarting. Sutures, the next of the retentive apparatus, should not be employed, when it is possible to maintain steady apposition without them. During the first day or two, and before they have cut their way by ulceration through the skin, they certainly act more powerfully than plasters in maintaining coaptation,—one of the essentials for obtaining adhesion; but they also irritate much more, and, if not speedily removed, excite, at least in their immediate vicinity, sufficient inflammation to lead to ulceration, preparatory to their spontaneous extrusion; and the vascular action thus set up in one part of a wound, may extend so far as mate- rially to interfere with or prevent adhesion. Even under the most favourable circumstances, a slight suppuration seldom fails to follow in the track of each stitch; and though, when the action stops here, the general healing of the wound may not be retarded, still the greater marking of the cicatrix, at each of these points, is an additional reason for avoiding their employment when possible, especially on exposed 80 WOUNDS. Fie. 15. parts. soon, indeed. but, if there Fig. 16. Sutures, then, are to be employed when there is difficulty in keeping the parts satisfactorily in contact by means of plasters? but they should be as " few and far between" as consists with the attainment of their immediate object. They are introduced before the plasters are ap- plied; and on each side, but not over them, the strips of the latter should be placed. For deep wounds and for those of irregularly shaped parts, the interrupted stitch is usually employed (Fig. 15); though, for the former class the quilled suture is sometimes recommended; and for wounds m some situations, as will be explained in a future chapter, the twisted suture (Fig. 16) is the best for maintaining coaptation. The sutures should, in all instances, be removed as soon as it can be done without endangering the separation of the parts. If the structures be lax and easily kept together, they may be cut and removed at a very early period; as as the plasters have become dry and strongly adherent; be tension in the lips of the wound, the whole, or some of the stitches, must be allowed to remain until the parts have become somewhat moulded to their new relations, and partially adherent. Again, if severe inflammation attack the wound, the sutures must be snapped and withdrawn, as their presence would only increase the mischief:—they would soon be set free by ulceration, but before this was accomplished, the undue constriction which they must have exerted on the tumefying wound, would stimulate the local action and aggravate the pain. Instead of the suture, M. Vidal employs a little spring forceps, about an inch and a half in length, to maintain coaptation. Its points are so far blunt, that, though they take hold of the skin, they pierce no more than the cuticle at most. It excites little or no irritation, and, when removed, leaves no mark. Another and smaller forceps, on a similar principle, but only about three-quarters of an inch long, is also employed in Paris. In venereal cases, in which circumcision is there frequently performed, the glans penis is surrounded with, as it were, a corona of these forcipes, the points of which keep the cut margins of the delicate skin and mucous membrane in most intimate contact, and the wound speedily heals with a cicatrix scarcely perceptible. In many, indeed, in most wounds, no other retentive apparatus than suture and plaster need be employed'; but in certain cases, when the wound is very deep, and its sides exceedingly loose,—conditions occa- sionally coexistent in persons of flabby fibre, and which favour the accu- mulation of secretions between the parted sides,—it may then be advi- sable to surround the wounded part with a turn or two of a bandage; under which, but not over the mouth of the wound, a soft compress may sometimes be placed with advantage. The roller, at this early stage, must, however, be applied very lightly; so that it shall merely assist in giving support, and in preserving apposition of every part, deep as well as superficial; and operate more as a precautionary measure to WOUNDS. 81 prevent displacement during any irregular muscular twitching, than as an immediate means of retention. Gentle support—not actual and in- jurious pressure—is wanted; and the better to avoid this evil, it is well to damp the bandage previous to application; for the dry fibre soon im- bibes moisture from the integument or the wound, and, in so doing, grows thicker and shorter, so as ultimately to become much tighter than when applied, or than was intended. The retentive apparatus having been thus applied, the wounded part is to be laid in a suitable position, combining relaxation and elevation. The latter is the point chiefly to be attended to after amputation; and, for this purpose, the stump or other part is laid on a soft pillow, or any convenient rest, over which, for the sake of cleanliness, is spread a piece of oilcloth, or of thin sheet gutta percha, in order to prevent the parts beneath being soaked with any discharge. Along the margins of the wound, when large, a single strip of soft linen is placed, and kept moist with cold water; but in smaller and more sheltered injuries, this may be omitted. When the wounded part lies beneath the bedclothes, their pressure and heating effect must be prevented by a suitable cradle. All that now for some time requires to be done, is merely to keep the parts clean, wiping away any fluid secretion from the neighbourhood of the wound, but never actually touching its raw and tender margins. These matters being attended to, the part is to be kept otherwise, as far as possible, at perfect rest. Supposing all to go on well, the stitches, if such have been employed, are removed at the proper time, as before explained ; but the plasters may possibly, in a large wound, require occasional renewal, owing to the fluid secretion trickling down and loosening their dependent extre- mities, or from their becoming unduly loose as the process of adhesion goes on, and the edges spontaneously approximate more perfectly. When, from any of these causes, it becomes necessary to change the plasters, they should be seized by both their extremities, and raised from each end towards the centre, which overlies the line of wound, and from this lastly they are with gentleness to be lifted. If, on the contrary, the strip were seized at one end, and pulled off along its whole course towards the other, it is obvious that after passing the central part, it would, if at all adherent, be apt to tear away the edge of the wound covered by its last half, from that margin to which its first raised por- tion had been applied. In renewing plasters, no more than one or two of the old strips, however loosely adherent, should be removed at once, before supplying their place with new pieces; but as each slip is taken away, the vacancy is to be filled up before detaching another. This precaution is necessary, because if all the strips were removed at once,. the wound, being unsupported, might fall open, and tender adhesions— the work of several days—be in an instant destroyed. Any necessary moving of the wounded part, whether for correcting malposition, clean- ing the support on which it rests, or applying fresh plasters, must be conducted with great care and gentleness. When ligatures have been employed, some of them will probably be loose by the end of ten days. Accordingly, about the expiration of that period, each ligature, except that on the main artery, which should be 82 W Ol'ND S. left undisturbed for at least a week longer, may be carefully isolated from the others, and gently pulled by the fingers or forceps. It loose, it will come away immediately; but if the slightest resistance be felt, no force must, on any account, be used to withdraw it; a few days lon- ger being allowed to elapse before it be again tried. The utmost gen- tleness is to be observed in this proceeding, lest the ligature should be drawn away before perfect occlusion of the vessel has taken place ; but with this precaution, it is better to try the ligatures, and remove them when loose, as if left to themselves they might remain in the wound long after they were detached, and thus retard its complete healing. Perfect healing, after adhesion has progressed favourably for about a week, is often retarded by an oedematous swelling, the result of undue vascular relaxation. In these circumstances, a bandage is to be ap- plied, so as to give support, and exert a moderate degree of pressure. This, however, must neither be severe nor unequally disposed, because in either case it would excite irritation, and the swelling of oedema would soon give place to that of inflammation. It must always be remembered, that at any stage, however late, excess of vascular action may set in, and prevent the further progress of adhesion, or even destroy the union already effected. It is frequently induced by cumbersome dressings, officious sponging and rubbing of the wound, and by an over-stimulating diet. The fourth indication, which is to repress inflammatory action, is ful- filled, partly by the simple local treatment just detailed, and partly by treatment directed to the system in general. The strict antiphlogistic regimen should be enforced, all stimuli removed, and perfect rest, gene- ral as well as local, enjoined. The food must be small in quantity, unstimulating in character, and given pretty cold. In feeble persons, and in individuals at an advanced period of life, the antiphlogistic regi- men must, however, be instituted with great caution, and its effects closely watched; but, regarding these and many other points, the sur- geon must be guided by the peculiar circumstances of each particular case. Treatment for G-ranulation.—Wounds may require to be treated for granulation, either when inflammation has proceeded too far in a case which it was first attempted to heal by adhesion, or when, from the beginning, it was evident that granulation was the most suitable mode of healing, whether owing to loss of substance preventing coaptation, or to extensive contusion, or to the presence of foreign matter which could not be removed; all of which conditions are incompatible with the attainment of adhesion, on account of the active inflammation to which they give rise. In the former case, that of a wound treated hitherto for adhesion, its edges become swollen, red, and painful. Swelling more deeply seated causes the margins to separate, and purulent matter is soon poured forth. The indication here is to repress inflammation ; in fulfilment of which, all sources of local irritation and general stimulation must be withdrawn. Sutures, if present, should be removed, and only a few strips of plaster left, to prevent any unnecessary gaping of the wound, and in many cases they also must be dispensed with. To the parts thus WOUNDS. 83 relieved from every kind of local irritation, warm water-dressings are applied, or a light, soft, moist, and warm poultice, if that application be still employed. In the second case, where granulation is from the first considered to be the most available mode of cure, the treatment is essentially the same as that mentioned above. The part is elevated, and kept at per- fect rest; no sutures are employed, and only a few strips of plaster are used to connect the more loose portions of the wound. Cold water- dressing is applied till oozing of blood ceases; it is then gradually changed to the tepid, and next to the warm dressing, as the vascular action rises, so as to soothe and relax the tumefying wound. When the inflammation proves so active as to threaten gangrene, it must be repressed by local bleeding, and if absolutely necessary, by general de- pletion, in addition to the antiphlogistic regimen, which, during this stage of acute inflammation, is to be adopted. In both cases the same point is now reached. Warm dressings are continued so long as inflammation remains active; but as it subsides, the heat of the dressing is gradually lowered until it be again merely tepid, or even cool. Under this treatment the surfaces, if matters go on favourably, be- come clean in a few days; granulations spring up, and healing advances. The discharge which, during the height of the inflammation, had been very profuse, and far from laudable, now diminishes in quantity and improves in quality. In these circumstances, the wound, when superfi- cial and broad rather than narrow and deep, requires merely the treat- ment proper for an ordinary ulcer; comprising the water-dressing, medicated, when necessary, with metallic salts, to stimulate indolent granulations, and the employment of carefully-adapted pressure by a bandage, when necessary to repress oedematous swelling. But if the wound be deep, without much loss of substance—in fact, such a case as would have healed by adhesion had not inflammation prevented—then, at this stage, when the surfaces are granulating well, and secreting little pus, they will, if placed in mutual contact, speedily cohere, affording a most satisfactory and rapid cure by secondary adhe- sion. Plasters are employed to retain the parts in apposition, and a bandage, lightly and uniformly applied, is in general necessary to give support. As absolute local rest is necessary for healing, any neigh- bouring joint, which interferes with this essential condition in the wound, must be prevented from exercising its natural functions, by a splint fastened with a few turns of a roller, or with a buckle bandage applied at two or more points, lightly, so that no oedema may ensue on the distal aspect, and arranged so that neither splint nor bandage shall compress the injured parts, or come in the way of the requisite dressings. Cleanliness is throughout attended to; the actual edges of the wound are not touched, but from all around them the discharge is frequently wiped away with a small dossil of clean lint, tow, or rag, or indeed of anything clean, soft, and absorbent. A good sponge answers well when there is only one wound to dress, because it can then be fre- quently washed; but, in hospital practice, it would come into contact with all kinds of sores, and would never be sufficiently well or often 84 WOUNDS. cleansed after each time of its employment. On the other hand, the morsel of tow, being of small value, may be destroyed, and a fresh piece employed on each occasion. # The constitutional treatment—which, during the height of the inflam- mation, comprised at least the antiphlogistic regimen, and sometimes also local or general bleeding, according to circumstances—consists now, while matters are going on favourably, in attention to the secre- tions, and avoiding, equally, undue stimulation or hurtful abstinence. In individuals of debilitated constitution, and even in persons previously of good health, when the wound is large, suppuration may continue pro- fuse, cicatrization proceed very slowly, and the secondary adhesion fail. Under these circumstances the diet must be full and nutritious, with a due allowance of stimuli. In severer cases this generous regimen must be farther assisted by the exhibition of medicinal tonics. Though the part itself must be kept at rest so that it may heal, yet it may be much benefited indirectly by appropriate general exercise, with the view of strengthening the system. LACERATED WOUNDS. Lacerated wounds are produced by a blunt body being driven into and through the textures, or by a moving body becoming attached to a part, and tearing it away. In both cases the edges are ragged and uneven, the parts being torn rather than cut; in both there is considerable straining of the surrounding structures, and in the former an amount of contusion is inflicted by the body entering and passing through the tis- sues. This dragging and bruising of the parts weaken their vitality. From the depression of the nervous system in severe cases of this nature, there may be little pain. So much, indeed, is this the case, that an arm has been torn off by machinery, and yet the person has for some time experienced little or no pain. There is, in general, also but little hemorrhage, partly because the surface of the wound being irre- gular, the blood is very apt to adhere and become coagulated; partly because the vitality of the vessel has been diminished by the straining. But the chief reasons why arteries bleed less when lacerated than when cut, are, that when torn the coats do not retract equally, the inner and middle coats contract and retract within the external tunic ; the external coat next retracts within the sheath to a less degree, and the sheath forms a conical cavity beyond the outer tunic. These conditions are obviously much more favourable for the arrest of hemorrhage than the uniformly retracted coats of a cut artery. Although the pain may often be slight at first, and although there may be little primary hemor- rhage, these wounds are ultimately much more dangerous than those of a simple incised character. They are very apt to be followed by severe inflammation; and, if there be much bruising by sloughing, they are more liable to be followed by severe constitutional disturbance, and by tetanus; and, if gangrene ensue, there is danger of secondary hemor- rhage on the separation of the slough. In the case of a purely lacerated wound, or when contusion, though present, is so only in a very slight degree, adhesion is possible, and ought to be attempted; and if it should fail, from inflammation running WOUNDS. 85 too high, the wound is still as much disposed for granulation as it would have been, had adhesion not been tried. Besides, a part of the lesion may adhere and remain united, even while granulation occurs in the remaining portions. The treatment of those wounds which are purely lacerated in their character, or at least attended with extremely slight contusion, is, with some modifications, the same as that already related as conducive to adhesion. Sutures should, if possible, be still more avoided than in simple incised wounds, and isinglass plaster chiefly trusted to for main- taining coaptation, so as to diminish, to the utmost, all sources of local irritation. Absolute rest of the part, and usually of the whole body also, is requisite. The water-dressing is applied cold or nearly cool, for the latter is usually more agreeable to the feelings of the patient. If the attainment of adhesion be peculiarly desirable, it may be necessary, in addition to the abstraction of all sources of local or general excitement, and the rigid observance of the antiphlogistic regimen, to take blood from the part, or even from the system, in order to keep the inflamma- tion within proper limits. Under this treatment many such wounds heal partially, if not altogether, by adhesion. Should, however, inflam- mation prove too active, a change should be made to the treatment for granulation. CONTUSED WOUNDS. Contused wounds are caused by very blunt bodies passing in a tear- ing manner through the tissues, inflicting in their passage a large amount of contusion and straining. They are, in general, merely lace- rated wounds, accompanied by much contusion; but this complication renders them more dangerous, more tedious to cure, and productive of greater deformity. When the bruising is very decided and instantaneous, there is usually not much pain. This circumstance, however, is merely a symptom of the contusion being very severe; for if it be but slight, the pain may be pretty acute. The primary hemorrhage is seldom con- siderable ; but bleeding may occur to a dangerous extent on the separa- tion of sloughs. In severe cases, there is considerable collapse, and reaction is proportionately violent. Excessive inflammation attacks the wound, and gangrene not unfrequently occurs, sometimes to a large extent, especially in vitiated constitutions. A large sore follows the loss of substance, suppuration is profuse, and may be so prolonged as to induce hectic fever. Or pyaemia may occur, and typhoid symptoms become developed. The treatment of wounds, in which the contused character prevails, is regulated with a view to granulation. The bleeding having ceased, foreign matters being removed, and the wound cleansed, the part should be placed in a position that combines relaxation with elevation, both these conditions being calculated to relieve the supervening local action. Sutures are useless, and the irritation caused by them would be injurious. Even plasters are unnecessary, except when the wound has a strong tendency to gape widely, or when, at some parts, the contusion having been slight, there may be some hope of partial adhesion, on coaptation being effected. Warmth is applied either by means of cloths dipped in 8(5 w 0 U N D S. warm water, or bv means of a soft, light poultice in which the bruised part is imbedded: Neither application must be allowed to become dry or cold, but is to be renewed as frequently as may be requisite. When the inflammatory action runs high, depletion—local and gene- ral—may be necessary to repress its violence, and limit the consequent amount of sloughing. But this part of the treatment must always be conducted with the greatest caution ; remembering that ere long the system may be taxed to the utmost, in maintaining suppuration from an extensive surface, and which may, by long continuance, induce hectic fever before cicatrization be effected. During the progress of the inflammation, diffuse abscess occasionally occurs, and must be evacuated by free incisions. As the slough sepa- rates, the patient should be watched, lest secondary hemorrhage should occur ; and after the separation, the proper treatment instituted. The warmth of the applications should of course be reduced when the process of granulation commences, as the relaxing effects of the heat would then be injurious. Amputation may be necessary when there is very exten- sive crushing of the soft parts, or comminution of bones ; and also when the gangrene is very extensive, accompanied by proportionate constitu- tional disturbance. The constitutional treatment need scarcely be recapitulated. During collapse, if long persistent, stimuli may be required, yet should be given as sparingly as consists with the attainment of the object for which they are given, and not to such extent as to aggravate the subsequent reac- tion and its consequences. During the height of the inflammation, the antiphlogistic regimen should be adopted; and, when necessary, local or general bloodletting, according to the violence of the action, but in every case with great caution. PUNCTURED WOUNDS. Punctured wounds are produced by the penetration of a narrow and pointed object into the tissues,—usually to a depth disproportionate to the small aperture of entrance. According as the point of the instru- ment is sharp or blunt, and its blade thin and flat, or thick and bulky, will the injury partake chiefly of the physical characters of an incised wound, or of those of the lacerated and contused varieties; that is to say, the wound has some of the characters belonging to each of these three species, and according as one or other predominates, the lesion is more or less serious. Unless some very important organ has been in- jured, the shock is less marked in this than in some other kinds of wound; but whenever the weapon has passed far and deeply into any tissues, the lesion must be considered of a serious character, more par- ticularly as it cannot at first be known what parts have suffered, and what have escaped. There may be at the time little primary hemor- rhage, although a considerable artery has been wounded, because of the form of the wound being unfavourable to the free exit of blood. In such a case, however, the blood is certain to break out speedily, and even although no large vessel be wounded, there is still the danger of secon- dary hemorrhage, if there has been bruising to an extent calculated to lead to inflammation and sloughing. Nerves likewise may be cut, torn, WOUNDS. 87 or punctured, and consequently for this reason, as well as for others, tetanus is more to be dreaded in these wounds than almost in any of the other varieties. Very violent inflammation usually follows punctured wounds of any considerable depth; not only on account of the mode of their infliction, but also because the blood, which oozes from the surface, does not meet with a ready exit, but remains coagulated, forming a layer of foreign matter, or becomes infiltrated into the soft tissues, chiefly the cellular. Inflammation is further favoured by the probable lodgment of extrane- ous bodies ; perhaps of a portion of clothing driven in before a blunt- pointed weapon, or of the sharp point of a more delicate instrument which has been broken off against a bone that resisted its farther pro- gress. Violent inflammation is pretty certain to follow punctured wounds of synovial and serous cavities, of dense fibrous structures, and of the scalp, in which latter situation it usually assumes the erysipelatous form. When of considerable depth, several layers of aponeurosis are generally traversed; and these unyielding structures, by tightly con- fining the parts beneath and preventing their tumefaction as vascular action rises, aggravate the subsequent inflammation, while the matter, not finding sufficiently free vent, is very apt to burrow along the muscu- lar interspaces beneath the fasciae, and give rise to diffuse purulent infiltration of the cellular tissue. The treatment of punctured wounds varies according to the depth of injury, and the amount of accompanying contusion and laceration. When the wound is of small depth, attended with little or no bruising, and is free from foreign matter, adhesion is possible and should be pro- moted. Till oozing ceases from the external orifice, cold aspersion is to be practised. When no more blood issues, any little apposition re- quired by this form of wound is to be effected, and a piece of isinglass plaster placed over the opening, so as to cover it entirely, or with the exception of the most dependent point. The patient is to be kept quiet, and restricted to the antiphlogistic regimen. Under this treatment, most of these slight wounds heal; but if the case be a little more severe, the cold water-dressing, or a cooling saturnine lotion may be applied; still, however, retaining the morsel of plaster, so as to preserve the actual margins of the wound from irritation, and to prevent the liquid application from insinuating itself along its track. A single layer of moistened lint is employed, but without oiled silk above it, as the object is to encourage rapid evaporation, and procure its refrigerant effect. In more serious cases the treatment becomes, in a corresponding degree, complicated. Thus if hemorrhage takes place from a wounded vessel, which cannot be reached on account of its deep situation, and the narrowness of the wound—while pressure fails to arrest it, or, owing to the peculiar situation of the injury, cannot be employed — then the wound must be dilated by careful incision to the required extent, and in the safest direction, so as to permit the artery to be tied above and below the point of lesion. Dilatation may also be requisite, when foreign matter has lodged in the wound, the presence of which will be ascertained by learning the mode of infliction, by inspecting the weapon, 88 WOUNDS. or, if necessary, by the gentle use of the probe. The foreign substance may then be removed by a forceps, or any convenient instrument. It was formerly the custom to dilate every punctured wound by tents and plugs. More recently simple incision was substituted with the hope of transforming the lesion into a mere incised wound, which, as has already been seen, is of a much more simple character. This indis- criminate use of the knife is now justly abandoned, and dilatation prac- tised at this early stage only with a view to permit the ligature of a bleeding vessel, or the removal of foreign bodies; and, at a later period, to effect evacuation of matter, and thus afford relief from tension. The wound being now free from extraneous substances, its edges are brought gently together, and cold water is applied till oozing ceases. Apposi- tion is then effected, and preserved by one or more slips of isinglass plaster; and cool water-dressing applied to prevent undue vascular action. Subsequently, when pain, tension, and inflammation ensue, and prove severe, warm fomentations, medicated, if necessary, with opium, are applied to soothe and relax the parts. Adhesion not having taken place, the subsequent treatment is adapted for granulation. In cases still more severe, abstraction of blood from the parts around the wound, and from the system, may be necessary to limit the action and sympathetic dis- order of the constitution. When deep-seated inflammation occurs, par- ticularly when under dense fasciae, indicated by severe pain, diffuse swelling and hardness, then early and free incisions are demanded to relieve tension and afford free vent to matter. The constitutional treatment, which in punctured wounds frequently requires to be pretty active, is conducted on the same principles which have so often been referred to in pages immediately preceding, and therefore need not here be recapitulated. GUN-SHOT WOUNDS. Gun-shot wounds, the most frequent injuries in modern warfare, are inflicted by shot projected from pistol, musket, rifle, or cannon, by splinters of wood or stone, shattered by an impinging ball, and by frag- ments of iron, or other substance, scattered around on the explosion of shells. They present, according to the nature of the penetrating body, various degrees and combinations of contusion, laceration, and puncture. With regard to these injuries, there are many circumstances which require to be understood. A ball projected through the air, proceeds at first with great force and rapidity, nearly in a rectilineal direction; and if it come, during this part of its course, in contact with any por- tion of the body, it either penetrates and lodges, or passes directly through, or carries the part away, according to the force and size of the shot. _ After a time, the ball describes a curve, called the parabola; its velo- city diminishes, and it acquires a new motion of rotation on its own axis. In this stage, very slight obstacles deflect it from its course, and should it now impinge against the body, the ball, even though large, may not sweep away the opposing part, but merely be turned aside, roll- ing over the surface, and inflicting, in proportion to its remaining mo- WOUNDS. 89 mentum, a dreadful amount of contusion. This is indicated by the cold, soft, and flaccid feeling of the part, and its diminished or destroyed sen- sation. Such is the explanation, as given by Larrey and modern mili- tary surgeons, of those cases of violent bruising of the soft parts, frac- ture of bones, and dangerous or instantaneously fatal concussion of internal organs, by large shot, frequently without laceration of the inte- guments, or the infliction in rapidly fatal cases, of any outward sign of injury. These accidents were formerly attributed to the " wind of the shot," caused by its passing with extreme velocity close to the body; but they are now with more accuracy referred, as above, to the actual contact of "spent balls." The aperture of entrance made by a ball, is much smaller than the aperture of exit; and very generally, owing to the elasticity of the in- tegument, much smaller than the shot which actually entered, while its margins are inverted and uneven. The aperture of exit is larger ; its edges are everted, and more ragged than the former. When discharged, either at a very short or long distance from the body, a ball enters more roughly, and produces a more ragged wound than when it strikes in the middle of its range. At its entrance, and during the first part of its course through the tissues, its transit is chiefly characterized by contu- sion ; while farther on, and towards its exit, its effect is more purely laceration. In the former part, therefore, sloughing is more probable. In the stage of diminished momentum, the shot, if small, may also be deflected, when it impinges very obliquely upon the surface; or, piercing the integument, it may proceed beneath it, sometimes along the trunk, or the hollow aspect of a limb during flexion, sometimes partially or completely round either; or penetrating more deeply, it may enter the thoracic or abdominal cavities, and course around their interior circum- ference, without wounding the contained viscera. It is, in fact, deflected from its straight course, when the obstacles to its direct continuance are greater than to slight deviation. From these circumstances, it happens that the course of balls is very uncertain. A button, or other hard ap- pendage of the dress, and the common articles usually contained in the pockets, have frequently repelled, arrested, or deflected a ball, to the manifest preservation of life. Sometimes, on the other hand, these bodies are forced into the tissues before the bullet. After penetration, their course is not more certain. Bone, and softer structures, may alter their direction; and the elasticity of the common integument often confines them after passing through denser structures. A bullet may lodge, or escape, after the most direct or the most devious route. It may lodge immediately beneath the integument, either at the point of entrance; or after passing through towards the opposite aspect; or after coursing on beneath the skin—its direction in this subcutaneous course being indicated by a discoloured mark, com- monly called a "weal." It may lodge in bone, in any of the soft tissues, in the interior cavities, in fact in any part, however distant from its point of entrance, after the most direct or the most circuitous and lengthened route. It may escape, by an opening directly opposite to the aperture of entrance, after passing directly through the part, or merely running round beneath the integument; or it may proceed 90 WOUNDS. further in the latter course, escaping near the aperture of entrance, by which it may indeed emerge, so that only one opening is made,—a cir- cumstance which might lead to the belief that the shot had lodged. Under one other condition the same may occur. Thus, sometimes, when the ball, possessing slight impetus, strikes a part of the body covered by dress, it may, if this be thin and tough, force a portion of it before itself into the wound, and that without tearing it off, so forming an in- volution, or cul de sac, in the interior of which the ball lies, and from which it drops accidentally, or is brought away by traction on the re- mainder of the cloth. In this case, where the wound lies beneath cloth- ing of unbroken continuity, it cannot of course be supposed that the ball has lodged, although there be but one aperture. A leaden bullet, impinging on a sharp edge of bone, may be divided, and a half pass on each side of the opposing bone, each portion emerging by a separate aperture; or one part may escape and the other be detained. The ball may force a portion of clothing into the wound, and both lodge together; or, itself passing by, may lodge further on, or escape. Perhaps it is no bullet of lead or of iron which enters, but a frag- ment or splinter, dashed up by the striking of a shot in the neighbour- hood, or by the bursting of a shell. Or it may be neither metal, stone, nor wood which enters, but merely wadding, as may occur when the gun is fired at close quarters, and not loaded with any more solid pro- jectiles : for, at short distances, wadding may penetrate many layers of dress, carrying portions along with it, inflicting a ragged wound, and, when deep enough, almost invariably lodging. A single deep and very uneven wound may also be produced by an aggregation of small shot, ere they have proceeded far enough from the gun to have become widely separated. When there is more than mere contusion, the opening of entrance is of course always present, but that of exit is more inconstant. It may be wanting altogether, as when a bullet lodges; or wanting, at least as a separate orifice, when the bullet emerges at the same aperture by which it entered, either after crossing beneath the integument, com- pletely around the limb, or when drawn out along with an untorn tubu- lar invagination of the dress. The opening may be single, by which the whole bullet, or only half of it, when split after entrance, has escaped; or it may be double, when both portions of the bullet, split on a crest of bone, have emerged each by a separate wound of the integument. But two bullets may have entered by the same wound, and only one of them have escaped; and though there may be one or more apertures of exit, yet these apertures may have been apertures of entrance to other balls which also have lodged. The amount of injury varies, of course, according to the parts wounded. Owing to the uncertainty regarding the course of the ball, it is impossible, at first, to say what these parts are; and time alone can show what shall be the ultimate amount of destruction, after inflam- mation and sloughing to a greater or less extent have occurred. Large vessels may be wounded, while yet sometimes they marvellously escape division, as when a bullet passes between a large artery and its vein WOUNDS. 91 lying together in close juxtaposition. In these cases, however, the ves- sels are generally so much bruised, as to slough or ulcerate during the coming inflammation, giving rise to secondary hemorrhage. Important nerves may narrowly escape, or be bruised and divided. Bone may be simply fractured, with or without wound of the integument; yet still not without much contusion, favouring the occurrence of necrosis : or, it may be, extensively comminuted and splintered, or perforated, the aperture thus made being always, in the flat bones at least, considerably larger than the bullet: or, it may be the resisting body in which the ball lodges. Serous or synovial cavities, and mucous canals may be traversed, or merely entered, while the foreign body lodges. Vital or other important organs may be injured, but it by no means fol- lows that death shall be immediate, in even extensive lesion of some of these parts. Gun-shot wounds are very liable to be complicated in their progress by various affections. They are peculiarly apt to be followed by deep- seated inflammation, and purulent infiltration of cellular tissue. Necro- sis is a very common result of exposure or bruising of bone. The pain occasioned by a mere flesh-wound from fire-arms is usually not severe at first. There may be a momentary pang, but it is gene- rally more a sense of numbness and loss of power that are experienced. When, however, bones are fractured, and large nerves lacerated, severe pain is at once produced. Hemorrhage may not be great when no large vessel is divided, but when such is the case, bleeding may be copious. It is really as abundant—though perhaps it may not appear externally for some time, as after most other kinds of wounds, except the smooth incision; and certainly much more so than after a simple laceration. The form of a gun-shot, as of a punctured wound, favours the easy sup- pression for a time of external hemorrhage, even when a large vessel,, deep-seated, has been opened ; but here, after a period, blood will break out unexpectedly, or it may be pouring forth internally to a fatal extent. Secondary hemorrhage, also, is much to be dreaded, particu- larly when extensive sloughing, or sloughing phagedaena, occurs— neither of which is very uncommon during unhealthy seasons, and in crowded military hospitals during time of war. The shock varies much in degree. There seems every reason to believe that the mental part of it, at least, is generally more severe in gun-shot, than in other wounds of equal extent. Owing to the extra- ordinary force and rapidity of the missiles, against which no guard can be raised, an injury thus inflicted is regarded with a greater degree of apprehension than others of a nature which can, to some extent, be foreseen and guarded against, and which, in a slighter degree, are more generally incurred. I refer to cuts, and stabs, those received in action being aggravated examples of what happens, on a much reduced scale indeed, but still very frequently, to all persons who employ sharp instru- ments of any sort. Some men certainly sustain very extensive gun-shot injury of the extremities, without being much depressed; or are so only for a short time. But in others, undoubtedly brave, a comparatively slight wound of this nature is productive of the severest symptoms of shock. In this case, however, words of encouragement, together with 92 WOUNDS. the exhibition, if necessary, of diffusible stimuli, soon rouse the patient from this chiefly mental depression. But when the symptoms of shock continue long and severe, notwithstanding the employment of the resto- ratives just indicated, it may with reason be concluded that there are ample grounds, of a physical character, for its long continuance; and that, owing to the lesion of some important organ, the wound is in reality of a much more serious character than was at first imagined. In the treatment of gunshot wounds, the first indication is, to promote the departure of collapse when this is present to a serious degree, by encouraging language, and, when necessary, the administration of diffu- sible, or even more permanent stimuli. The latter, however, should for obvious prospective reasons be, when possible, avoided. If the pain at this early period be excessive, anodyne fomentations are advisable. When the shock has by these means worn off, the subsequent treatment is to be regulated by a consideration of the nature of the wound—of the part injured, and the extent and kind of lesion—of the present and pre- vious sanatory condition of the patient—and of the means of treatment at command. Thus, when a limb has been rudely carried away, leaving the remain- ing parts very much contused and ragged, conditions which would neces- sarily insure the occurrence of extensive gangrene, great constitutional disturbance, an useless stump, and probably also hectic fever from pro- fuse discharge, and tardy cicatrization;—when there is extensive contu- sion, amounting almost to disorganization of the soft tissues of a limb, either with or without fracture of bone ;—when there is extensive bruising, laceration, or removal of the soft tissues, especially of the chief vessels and nerves ;—when there is much comminution, or bad compound fracture of the shafts of bone, particularly of the femur ;—when the joint-ends of bones are shattered, and large articulations laid open, such as the laiee, ankle, or hip-joint—then, in all these cases, unless there be also some other and decided mortal injury, amputation is generally considered requisite, either actually to save life, or to protect the system from very great risk and suffering, which if at last surmounted, could only result in affording a very bad natural stump, or in the preservation of a useless limb. In military practice, primary amputation, performed during the few hours between the departure of collapse and the supervening of inflam- mation and symptomatic fever, has been found far more successful than a similar operation performed at a later period, after the system has suffered from inflammation, irritation, and it may be, typhoid symptoms, extensive gangrene, and probably hectic fever. During the more violent stages of most of these complications, no operation could well be practised, but would require to be further delayed, until the system lapse into a more quiescent state. In campaigns also, it is, in order to save life, frequently necessary to amputate a limb at once, which, with the more ample conveniences for treatment enjoyed in civil practice, might possi- bly have been saved : but which, owing to the turmoil of the camp, the jolting of the march, the possible deficiency of suitable apparatus, and the crowded condition of military hospitals during war, where the num- bers prevent any extraordinary attention from being paid to a single case would certainly, if not removed, be attended with fatal consequences ' WOUNDS. 93 It must be remembered that in the upper extremity, although bones may be badly fractured, or joints opened, with or without shattering of the articular extremities of the bones, yet a useful limb may be saved. In the former case, when there is merely a simple laceration, adhesion may possibly be attained ; and in the latter, excision of the joint-ends is preferable to amputation of the limb. The last remark applies also to open fracture of the neck of the thigh-bone, accompanied with bruising, when neither the trochanter nor the pelvis has shared in the comminution. These injuries, converted by amputation into clean incised wounds, to be healed by adhesion or granulation, being now kept out of view, other cases of a less immediately dangerous character come to be considered. In addition to promoting departure of collapse, the principal indica- tions are,—to arrest hemorrhage,—to remove foreign matter, whether balls, fragments of metal, clothing, stone, wool, or earth, as well as any portions of bone which have become so detached as to afford no chance of reuniting, but would, if left, become necrosed ;—to limit by local and general means the coming inflammation, and its probable sequence, gan- grene, which would entail loss of parts and serious constitutional dis- turbance ;—to obviate the accidental complications ;—to promote heal- ing, and support the system under suppuration; to remove the limb under certain circumstances by amputation, when extensive or extend- ing gangrene occurs, or suppuration is excessive, and hectic fever other- wise intractable, this being called secondary amputation ; and to perform another and second amputation, when the stump obtained by the pri- mary, or secondary operation has been destroyed, or much injured by further gangrene or sloughing phagedaena, with consequent protrusion, and exfoliation of the bone. The wounds inflicted by fire-arms, which are of an open, lacerated, or contused character, being treated exactly as similar injuries produced in any other manner, the following observations are chiefly directed to those lesions most characteristic of the passage of a comparatively small body into or through the living structures, namely, those wounds which, in addition to contusion and laceration, have a punctured or tubular character. The first indication, namely, to arrest hemorrhage, may be accom- plished by cold, and slight pressure, when there is mere oozing. But whenever an important arterial trunk has been wounded, nothing but ligature of the vessel, above and below the point of lesion, can be trusted to. In order to reach the artery, and permit the application of liga- tures, the wound may require to be dilated by incision, perhaps in a very free manner;—a practice which is also necessary under two other conditions, namely, when foreign matter has lodged and cannot be re- moved without enlargement of its tract, or when matter forms and is not freely discharged. Pressure is usually inefficient to stay the bleed- ing, and could seldom be applied with the requisite nicety, or without resting injuriously on the neighbouring parts, some of which, as well as a portion of the artery itself, are pretty certain to slough. The second indication,—removal of foreign matter of whatever nature,—may some- times be effected by the finger or forceps without enlargement of the wound, sometimes by slight dilatation, and occasionally by a mere cuta- 94 WOUNDS. neous incision, ,, when the ball is felt resting beneath the integument It is very important to remove all extraneous substances, when possible, without great meddling and cutting, because their presence aggravates the coming inflammation, and in this manner retards the cure. But when the foreign matter is deeply lodged among important parts, where dilatation could not be practised without danger, or when it is firmly lodged in or between bones, whence it could not be extracted^ without further crushing or fracture, it must be allowed to remain until suppu- ration has ensued. Then the part being relaxed, and the channel widened, it may in general be withdrawn with facility. From some situations, however, bullets cannot be even then removed without very extensive incision. It is sometimes difficult, if not_ impossible, to ascer- tain with certainty whether or not foreign matter is present. In some circumstances, indeed, as when it is known that there was only one dis- charge of a piece of fire-arms, loaded with a single bullet, then the num- ber and situation of the apertures will afford pretty strong presumptive proof of the ball having lodged or escaped, while the part of the body injured, and its distance from the weapon, may indicate whether or not portions of clothing or wadding may also have entered. But, from former remarks, it is evident that in action, where numberless missiles are flying about in all directions, no such inference can be drawn from simple inspection of the wound. Accordingly, the part is placed in the same attitude in which it received the ball, as by the position, the tract of wound, through successive layers of struc- tures, is made more directly continuous, and its exact direction may be more easily guessed. The finger or probe is now to be employed, gently, but with decision, so as to ascertain the presence of foreign matter. Probing is much better tolerated at this early period than on any subsequent occasion. On the extremities, this operation may be performed with some degree of freedom; but when the ball has pierced the parietes, and entered either of the three great cavities, no exploratory proceeding is justifiable. If it be felt imbedded in the sub- stance of the walls, or immediately within them, it should, of course, be removed; but if not at once discovered, no further manipulation is proper. A contrary proceeding might, indeed, at the expense of much injury, satisfy curiosity, yet without in the slightest degree affording oppor- tunity of adopting any important alteration of treatment. Smooth and rounded balls, when they cannot be removed at first, sometimes remain imbedded for a long series of years, enclosed in a cyst or capsule, seemingly of condensed cellular tissue, or in the dilata- tion or cul-de-sac of a long, winding, and narrow sinus, so as to be pro- ductive of little inconvenience or uneasiness, except during atmospheric changes, much exercise, or general ill-health. In general, they at last come slowly to the surface, when they may be removed, or by creating an unusual amount of discomfort the patient is ultimately induced to submit to a deep operation for their removal. Rough and angular frag- ments of iron, or of detached bone, create greater mechanical irritation, lead to more active inflammation and suppuration, and require more speedy extrusion. The third indication,—to limit inflammation and its consequences,—is effected locally by rest, elevation, and relaxation of the WOUNDS. 95 part; by careful adjustment; and by cold water-dressing, under the use of which, Mr. Guthrie has shown that the sloughing consequent on gun-shot wounds is much less than under the old treatment by heat and poultice. The cold applications are continued for a considerable time, and when the inflammation has become very high, they are gradually changed for the tepid, and finally for the warm dressing, which by its relaxing effects affords more relief to the parts in their state of tension. Abstraction of blood from the neighbourhood by means of leeches or scarifying, is, in many instances, an important part of local treatment during the inflammatory stage. Generally, the same indication is ful- filled by the antiphlogistic regimen, comprising a moderate unstimu- lating diet, saline purgatives, and diaphoretics. Purging is, however, to be avoided in any wound as much as possible. When the injured part is disturbed by the motion attending alvine evacuations, venesection may even be necessary; but, as in all wounds which heal chiefly by granulation, depletive measures must be employed with caution. In a very few instances, where the wound is small and clean, with no lodgment of foreign matter, and a very quiet constitution, it has healed under the above treatment, by adhesion, throughout its whole extent. But it much more generally happens, even when inflammation has been limited to moderate bounds, that a tubular slough is detached from the point of entrance, and a little way beyond it, at which places the con- tusion has been greatest. When excessive vascular action ensues, the whole track of the wound may slough, and gangrene extend in any direction. The remaining indications of treatment are to be fulfilled in accord- ance with the general principles which regulate practice in lacerated, contused, and punctured wounds. The conditions which require primary, secondary, and second amputation, have already been considered. In the latter two cases, they are in no respect peculiar, or different from the circumstances which, in other injuries, are considered on sound principles to require similar treatment. POISONED WOUNDS. Poisoned wounds are those in which the introduction of noxious mat- ter accompanies solution of continuity. The poisonous principle is absorbed by the wound, enters the general circulation, and is rapidly distributed through the body, producing its pernicious effects on the various organs and the vital functions, but manifesting itself in a pecu- liar degree on the nervous system. On it certain poisons act so rapidly as to have given rise to the suspicion of their having some more direct mode of communication with the cerebro-spinal axis; and this is sup- posed to be by the nerves of the part with which they have come in contact. The interval between the introduction of the virus, and the manifestation of its peculiar effects, differs in different poisons—varying also in each according to the quantity introduced, and the proximity of the point of entrance to the brain. Some of the more virulent varieties have exhibited their effects in so short a time as the sixth part of a minute; but, generally, the interval is much longer; and some, such as the virus of hydrophobia, may remain in the system for weeks, or even 96 WOUNDS. months, before their characteristic results become apparent. ^ During this period of incubation, as it has been termed, between the introduc- tion of the poison and the manifestation of its effects^ it is supposed to become increased in quantity by exciting certain morbid changes in the blood, which, when once commenced, go on multiplying the poison. This process is named zymosis, from its supposed analogy to that of fermentation in saccharine liquids on the addition of the yeast-plant. Those poisons, which exhibit their effects very speedily, must, if they operate by a zymotic action, accomplish this process with extreme rapidity. There are, applicable to all poisoned wounds, certain general princi- ples of treatment, the local particulars of which are the most satisfac- tory in their results. The grand indication is, to prevent absorption of the virus, by immediate excision of the wounded part, by destroying it chemically with an escharotic, or by suction of the mouth, or by an exhausted cupping-glass—a ligature having been applied tightly round the part on the cardiac aspect of the lesion, and retained until either of the above operations has been performed, and until blood has flowed pretty freely from the wound. In some injuries, the gentlest of these means is amply sufficient to prevent bad consequences; but, in others, one or all of them may be found to fail. Subsequent local complica- tions must be treated according to ordinary principles. These injuries, if at all severe, are generally followed by a stage of depression, which may be so great that the patient rapidly sinks; and in nervous persons, very slight wounds, of a scarcely poisonous nature, are followed by a shock, chiefly of a mental character, produced by the fright more than by the actual injury. During this stage the usual restoratives, of a mental and physical nature, are to be employed. These comprise gentle reassurance, and stimuli when necessary, of which ammonia and brandy are those usually preferred. If the patient live, reaction ensues, violent perhaps, but very generally asthenic. In the slighter forms, sedatives and mild antiphlogistics are to be employed with caution, in order to moderate the excitement of the system gene- rally, and of the local action which, during this stage, is often very severe. At the same time, gentle purgatives and diaphoretics should be exhibited, with the view of promoting elimination from the system. In many instances, however, there is already such prostration of the vital powers, that even in this stage none of the lowering measures can be employed. In some cases, the action is of a more specific character, and its treatment more uncertain; while in others, the patient, after surviving both the previous periods, and after having been much depressed in vital energy by the poison, is brought into great danger by extensive sloughing and diffuse suppuration—conditions demanding, in addition to suitable local treatment, generous support and the judi- cious employment of all advisable means for maintaining the general DISSECTION WOUNDS. Dissection wounds are frequently received without bad consequences, but sometimes they give rise to serious and fatal results. They are WOUNDS. 97 chiefly dangerous when the health of the dissector is impaired from any cause, or when the virus is received from a body in which the cause of death has been puerperal disease, or acute inflammation of serous mem- branes. In slight cases, where bad results occur, the wound inflames in a few hours, and a pustule forms, which, on bursting, discharges a thin, un- healthy matter, and is converted into an acute ulcer. [The pustule is often umbilicoid, resembling a small-pox pustule. When opened in the early stage, serum escapes, which is nearly transparent, and the yellow appearance of the pustule still remains, showing that its colour does not depend always upon pus, but upon a fibrinous exudation. In a short time the vesicle becomes larger, and is refilled with serum, which, as the inflammation advances, will be found to contain pus. Should it heal by scabbing, the scab will be very thick, and composed in a great measure of cuticle, and will be very slow in dropping off.—Ed.] In more severe cases, erythema, erysipelas, whitlow, or inflammation of the lymphatics of the arm, may occur; or chronic abscess with indura- tion, or acute abscess with purulent infiltration, may form in the axilla ; and this last complication frequently extends down the corresponding side of the thorax. In very severe cases, the axillary symptoms, com- mencing with acute pain and rapid formation of abscess, may occur before much irritation about the wound is perceived. The constitutional symptoms vary in intensity. In slight cases the constitutional affection may be sthenic and trivial, but in more severe instances, the asthenic, irritative, or even typhoid type prevails. In the worst instances, the systemic disorder appears before the occurrence of any very distinct local signs of inflammation. The treatment of the wound varies according to its form and the sub- ject from which the virus has been introduced If the body be that of a person who has died of acute peritoneal or puerperal disease, it is advisable, after washing, to make a perfect excision of the wounded part; to allow oozing to go on for a short period, and if any time has been allowed to elapse between the infliction of the wound and the performance of excision, in addition to the above proceedings, to employ suction; and after oozing has ceased, to touch the part very freely with the nitrate of silver, with the view of effecting destruction of any virus that may be lurking in it. In any ordinary case, it will be considered sufficient to wash the part instantly, to suck it well, and if it be a mere puncture, and do not bleed, to enlarge the opening slightly with a clean pointed knife, so as to encourage the flow of blood, and thus favour the removal of any matter. The nitrate of silver is frequently employed as an escharotic after suction, without excision, and is proba- bly useful by destroying or neutralizing the virus, if present, and by forming a crust of coagulated effusion, which prevents admission of noxious matter. I should never, in any case of poisoned wound, trust to an escharotic alone ; and it ought to be remembered that, if the nitrate of silver be used gently, it acts merely as an astringent, and that it is only when it is used very energetically, that it has an escharotic effect. It is advisable for some time to preserve the part at rest, in an elevated position, and to enclose it for a few hours in a soft soothing poultice. 98 W 0 U N D S. [In the treatment of pustules arising from dissecting wounds, I have found it very serviceable to apply the nitrate of silver freely to the inflamed surface contiguous to the pustule, and to enclose the limb in a large cold poultice of Indian meal. The burning sensation expe- rienced in dissecting wounds is increased by hot adhesive poultices, such as those made of ground flaxseed, but the Indian meal, being less ^glutinous, allows evaporation to take place whilst the skin is still kept moist.—Ed.] The digestive organs should be cleared out, the diet attended to, and all sources of local and constitutional irritation avoided. If constitutional or local symptoms supervene, they should be treated according to the principles already mentioned. MALIGNANT PUSTULE. Butchers and others who have to do with the bodies of the inferior animals, occasionally meet with wounds of a similar character, and requiring the same treatment as those to which the medical student in the anatomical rooms is liable. But there is one variety of wound thus obtained, which is somewhat peculiar in its consequences. The affection is characterized by the formation of a dark vesicle, rapidly followed by very painful inflammation and hardening of the dermis immediately below and around it. The vesicle bursts, the cellular tissue becomes involved, and sloughing phagedaenic ulcer is produced. The constitu- tional disorder may at first be sthenic, but it very soon becomes typhoid, and as the local destruction extends, life is brought into the greatest danger. The constitutional and local treatment for malignant pustule is the same as that resorted to in the worst forms of sloughing phagedaena, attended with great constitutional depression. WOUNDS INFLICTED BY THE BITE OF A DOG. Wounds inflicted by the bite of a dog are always regarded with appre- hension, because, although the animal seem healthy at the time, and may not become evidently rabid for several weeks after, yet a person, bitten during the stage of incubation in the animal, is liable to be attacked with the fatal disease, Hydrophobia. Many more persons, however, are bitten than are so attacked, even when the dog is manifestly affected. When the wound is "inflicted through a portion of clothing, there seems to be less danger, probably owing to the teeth having been wiped clean in their passage through the dress. The virus contained in the saliva of the animal, whether dog, wolf, fox, cat, or badger,—for all these may become rabid,—must, as far as the integument is concerned, be applied to an abraded surface or wound, ere it can produce the disease. But several very striking cases, recorded by the late Mr. Youatt, seem to warrant the conclusion at which he arrived, namely, that mere con- tact with the mucous membranes may, without abrasion or breach of surface, communicate the disorder. The local treatment of a bite from a dog varies according as it is believed that the animal is healthy or not. If there seems every reason to conclude that the animal is perfectly well, not being even in the stage of incubation, and that the bite, consequently, was merely inflicted after provocation, or in self-defence, then the part should be well washed, a WOUNDS. 99 cupping glass applied to withdraw any simply irritating matter, and the wound afterwards treated for granulation, like any other puncture or laceration. But if there be the slightest grounds for suspecting that the animal is rabid, or in the stage of incubation, instant and complete excision of the bitten parts is the only practice which can be trusted; and, till this is accomplished, a ligature should be bound tightly around the limb between the point of lesion and the heart, so as to prevent venous return and absorption. An exhausted cupping glass is then to be applied, Avhich will abstract any virus that may have penetrated more deeply, at the same time that it draws blood. The raw surface is finally to be treated with lunar caustic, which will arrest any persis- tent oozing, and, if possible, make security doubly sure, as regards the destruction of noxious matter. The nitrate of silver is sometimes employed alone, by persons of great experience, in preference to exci- sion. Amputation even is requisite, if the part, such as a finger or hand, is so much lacerated and bruised that complete excision cannot well be effected. Though a period of several days may have elapsed after the bite, still, until the commencement of the local sensations which precede that of hydrophobic symptoms, the operation of excision or amputation should be performed. Subsequently, the tone of the general health is to be maintained, and mental anxiety as much as pos- sible calmed. Dr. Watson, in his admirable work on " The Principles and Practice of Physic," has so clearly stated what ought to be the proceedings of the surgeon regarding these wounds, that I cannot avoid transcribing his observations. " In the matter of cure, surgery, I fear, is as impotent as physic. Not so, however, in the matter of prevention: this is the most important part of the practice. The early and com- plete excision of the bitten part is the only measure in which we can put any confidence: and even here we are met with a source of fallacy. In the majority of cases, no hydrophobia would ensue, though nothing at all were done to the wound. How can we know, then, that the disease is ever prevented by its excision ? No doubt many persons go through the pain of the operation needlessly. But in no given case can we be sure of this. They get at any rate relief from the most harass- ing suspense, with which they would probably have been tortured for months. And if a large number of bitten persons, who have suffered the wound to heal as it would, could be compared with an equal number who had had the bitten part cut out, hydrophobia would be found a fre- quent consequence of the bite in the first class,—a very rare conse- quence of it in the second. " Mr. Youatt, who trusted to caustic, and who had himself been bitten seven times, tells us that he had operated, with the caustic, on more than four hundred persons, all bitten by dogs, respecting the nature of whose disease there could be no question, and that he had not lost a case. One man died of fright, but not one of hydrophobia. Moreover, a surgeon of St. George's Hospital told him that ten times that num- ber had undergone the operation of excision there, after being bitten by dogs (all of which might not, however, have been rabid), and that it was not known that any one had been lost. Mr. Youatt, I say, trusted to caustic, and the caustic he used was the nitrate of silver. But I 100 WOUNDS. advise you to trust to nothing but the knife, if the situation of the bite will allow vou to employ it effectually. If the injury be so deep, or extensive, or so situated, that you cannot remove the whole surface of the wound, cut away what you can ; then wash the wound thoroughly, and for some hours together, by means of a stream of warm water, which may be poured from a tea-kettle, place an exhausted cupping-glass from time to time over the exposed wound; and, finally, apply to every point of it a pencil of lunar caustic. If you cannot bring the solid caustic in contact with every part, you had better make use of some liquid escha- rotic—the nitric acid, for example. In my own case—and what I should choose for myself I should advise for another—if I had received a bite from a decidedly rabid animal upon my arm or leg, and the bite was of such a kind that the whole wound could not be excised, my rea- son would teach me to desire, and I hope I should have fortitude to endure, amputation of the limb, above the place of the injury. I say early excision is the only sure preventive; but let me repeat that it will, in all suspicious cases be advisable (if, for any reason, the operation have been omitted in the first instance) to cut out the wound, or the cicatrix, within the first two months, or at any time before the symptoms of recrudescence have appeared. One would do it, though with less hope, as soon as possible after they had appeared; but I do not expect to hear of excision being successful then in stopping the disease. Dr. Bright has recorded a case in which the arm was ampu- tated upon the supervention of tingling and other symptoms in the hand, in which the patient had been bitten some time before; but the amputation did not save him." THE STINGS OF INSECTS. The stings of insects are rarely dangerous in this country, unless when very numerous, when inflicted on delicate parts, or on persons of an irritable constitution. If the sting be discovered by aid of a lens, it should be withdrawn by the point of a needle or fine forceps. Then, if it be a single puncture, mere suction for a considerable time will afford perfect relief; or the minute wound may be supplied with a drop of liquor potassae, which is supposed to neutralize or destroy the irritating matter. But this remedy must be applied to the exact spot alone, as, when undiluted, it exercises a powerful solvent effect upon the skin. Cold is then kept continuously applied by pure water or a saturnine lotion. When the stings are numerous, or the individual nervous, con- siderable depression may ensue, from the actual effects of the injury in the one case, or from mere fright in the other. Restoratives and stimuli may therefore be necessary; and when reaction occurs, attended by nervous excitement and irritability, sedatives and mild antiphlogistics are indicated. When an insect gains entrance to the nostril, mouth, or fauces, its sting is particularly distressing, and, in the last-named case, even dangerous, owing to the great and rapid tumefaction of the mucous membrane, and consequent interference with respiration, demanding instant relief by local scarification, followed by fomentation, and counter- irritation externally. WOUNDS. 101 EQUINA. Equina—a disease so named because animals of the equine genus, as, the horse, ass, and mule, are subject to it—is sometimes transmitted to man by inoculation, or contact, and sometimes also, it is said, by infec- tion. In the former case, the local consequences, up to a certain stage, are the same as in the more severe forms of dissection wounds. In both, there is fever of an asthenic type. The disease is afterwards character- ized by severe pains in the joints and limbs, followed by hard, circum- scribed swellings beneath the integument of these parts, which then ulcerates or sloughs; by a sanious purulent discharge from the nostrils, but which, however, is not uniformly present; by the formation of numerous characteristic pustules, which generally become gangrenous; by a very low typhoid fever ; and by speedy death, which usually occurs about the end of the first fortnight. The pustular eruption is considered most characteristic of this disease, which is commonly called " Glan- ders," when this symptom is present along with the affection of the nasal passages, and "Farcy," when these peculiarities are absent. Hitherto the disease has been almost uniformly fatal, and the treat- ment adopted is merely palliative. The indications are, to support the system, and to alleviate local symptoms by fomentations, and deodorising lotions. Of the former, a solution of creasote; and of the latter the chlorides dissolved in water are the most efficient. THE BITES OF SERPENTS. The bites of serpents lead to results varying according to the species which inflicts them. The common viper is the most dangerous that is found in this country, but its bite is very seldom fatal. The effects are often distressing, but are scarcely dangerous, except in children, and in delicate persons of great susceptibility. The local irritation is repressed by the continuous application of cold, or subsequently soothed by heat and moisture, if it proceed to actual inflammation. In this case mode- rate antiphlogistics may be required. Any other consequences, similar to those which result from dissection wounds, are treated on similar principles. " Of the numerous American serpents two species only are known to be venomous—the rattlesnake and copperhead. Eight varieties of the former have been familiar to naturalists, and two others have been discovered lately by Humboldt1 and Bonpland. All are poisonous, but in particular the crotalus durissus, horridus, and miliarus. The copper- head (boa crotaloides) sometimes called the bastard rattlesnake, 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 or 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 inferior animals. As regards the effect of the poison, 1 These are the Crotalus Cumanensis and the Crotalus Laflingii. See Recueil d'Obser- vations de Zoologie et Anatomie Compared, 4to. 102 WOUNDS. much will depend upon the size of the animal bitten—death being produced more readily in the smaller than in the larger animals. 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 inflicted. To ascertain the effect of the bite of the rattle- snake, several experiments Avere made by Captain Hall, of Caro- lina, 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 minute, the other in four minutes. Several experiments, nearly similar, were made by the late Professor 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 cold seasons it becomes languid, and then strikes reluctantly, and frequently without any ill consequence. 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 which the fang penetrates, and the quantity and strength of the venom in the reservoir. In many instances death follows in a few seconds or minutes, and in others not until many days or weeks. The interesting case detailed by Sir Everard Home, which I witnessed whilst a student in London, furnishes striking proof of the speedy operation of the poison of the rattlesnake, and at the same time affords incontestable 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 dropped from his hand, he opened the door of the cage to take it out; the snake immediately 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 tumefied, and cold. There was an unusual coldness also through- out the skin of the whole body. At this period, the mind of the patient was perfectly collected; but immediately after the accident he talked incoherently, owing probably to strong drink, which it was ascertained he had taken before he was bitten. 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 appearance. The skin over the whole body became warm, faintings occurred repeatedly, vesications appeared m 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 parts, and finally destroyed the patient, after he had laboured for WOUNDS. 103 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 occurred, both among the Indians and among the white people, who inhabit the mountainous and thinly-settled parts of our country, of almost instantaneous death from the bite of the rattle- snake. On the other hand, it is very certain that many persons wounded by this animal have sustained very trivial injury, if any. In such cases, it is probable that the teeth enter obliquely, and do not penetrate the true skin, or that the reservoirs at the roots of the fangs have been empty, or the virus itself, owing to particular circumstances, so modified or changed in its properties or in such small quantity 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 an absorbent artery or vein, and conveyed the noxious matter at once into the circulation. According to Catesby, the Indians very soon ascertain when this has happened, and under an impression that the wound is necessarily fatal, apply no remedy. Upon these principles it will be easy to account for the supposed good effects of the numerous and diversified remedies at different times proposed for the cure of the rattlesnake; inasmuch as there is reason to believe that nature, unas- sisted, 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 colour tinged with green: during extreme heat, and particularly in the procreating season, it becomes of a much darker hue. The copperhead is equally poisonous with the rattlesnake; but few experiments have been made to ascertain its peculiar character."1 [" But the best plan of all, is that recommended by Sir David Barry. He directs, first, that an exhausted cupping-glass shall be applied over the wound, for a few minutes ; next, the glass is to be taken off, and the wound freely excised; and lastly, the glass is to be applied again, in order to promote the flow of blood, and cause the re-exudation of any of the poison, that may have found its way into the neighbouring blood- vessels. The cupping-glass, used in the manner we have just detailed, possesses all the efficacy and none of the disadvantages of ligatures; for, without interrupting the general circulation of the limb, it produces a complete afflux of all the fluids in the vicinity towards the wounded part, and entirely prevents them from conveying their contaminated contents towards the centre of the circulation. If the glass is applied in this manner, it is far from being advantageous (as is generally sup- posed), to make incisions or scarifications near the wound, whether before or after its excision ; for the object is to concentrate the course of the blood towards the original wound itself, so that it may carry the venom with it, as it escapes; and this object would be counteracted by any extraneous incisions. " The treatment of snake-bites during the first stage, consists first, in 1 Gibson's Surgery, vol. i., pp. 79-81. 104 WOUNDS. the administration of powerful diffusive stimulants, such as hot brandy and water, ammonia, or the eau de luce, to support the nervous system; and secondly, in the use of remedies which may be supposed to eliminate the poison from the blood. Thus, if there is no vomiting, it should be excited by a mustard emetic, to get rid of the vast quantity of bile that is often formed in the blood, and secreted by the liver under these cir- cumstances ; if, however, vomiting is spontaneous, and too violent, it should be checked by a large dose of solid opium, and a mustard poultice to the epigastrium. But the principal remedy seems to be arsenic, which has long been popular for these accidents, in the East Indies. It is usually administered there in the form of a nostrum, called the Tan- gore pills, each of which contains a grain of it, combined with certain unknown acrid plants. The efficacy of this mineral was also fully established in the West Indies, by Mr. Ireland, surgeon to the 16th regi- ment, who employed it with perfect success, in five cases of the bite of a serpent, which had previously killed several officers and men, some within six hours, and all within twelve. He combined f 5ij of the liquor arseni- calis with gtt. x. of tinct. opii (to prevent vomiting), f 3iss of peppermint water, and fsss of lime juice. This draught, which contains a grain of the arsenious acid, was given every half hour, for six or eight doses, till it produced copious purging (which was encouraged by clysters), or till the symptoms were ameliorated. The swelled parts were well rubbed with a liniment of olive oil, turpentine, and liquor ammonia;—and the patients, although for a time greatly debilitated, were soon able to return to their duty." "If the local symptoms are very slight, stimulating embrocations, and hot fomentations, with leeches, may be sufficient. But if the swelling is rapid and extensive, or the constitution is much affected by the poison, free and extensive incisions into the swelled parts are indispensable. " The constitutional treatment of the second stage must be regulated by the symptoms actually present; it will most likely require a combination of cordials, opiates, and tonics."]1 1 Druitt's Surgery. 105 CHAPTER IV. BUKNS. A burn is an injury inflicted on the body by a degree of heat higher than is compatible with healthy action in the part affected. Burns are produced either by actual contact with flame or heated bodies, or by radiation of caloric from them; and their severity depends on the proximity and intensity of heat, the length of time it has been applied, and the nature of the heating agent, as also that of the injured part. Thus, flame, which can exist only at a very high temperature, and which speedily induces combustion of the tissues; steam, whose latent heat becomes sensible on condensing; metals whose density and conducting power are great; and oil, which maintains a high boiling point, and adheres to the skin;—all produce severe burns, which, cceteris paribus, are most severe on those parts where the epidermis is thin and delicate. This condition, when produced by heated liquids or vapours, is usually styled a scald, the term burn being then restricted to those cases where a dry body has been the agent of injury. As the heat of solid bodies is frequently much greater than that attained by fluid substances, except metals in a state of fusion, the former may produce very deep burns; while liquids, by flowing over a large surface, cause more extensive, though comparatively superficial lesions. The Classification now generally employed, as being the most scien- tific and convenient, is that of Dupuytren, who arranged all burns into six classes or degrees; the tissues involved, and the amount of lesion being made the basis of classification. The first degree consists of a superficial inflammation of the integuments, wwattended by vesication. The second, in addition to the rubefaction, is accompanied by vesicles. The third exhibits the skin partially disorganized, the cuticle, together with the papillary surface of the cutis, being destroyed and converted into a thin eschar. In the fourth degree, the whole thickness of the skin, including, sometimes, the subcutaneous cellular tissue, is carbo- nised. The fifth degree only differs from the preceding in penetrating more deeply; an eschar being formed which comprehends the several soft tissues beneath the integument, down to a variable depth, perhaps even to the bone itself. In the last or sixth degree, the whole thick- ness of the limb or part is carbonised. Consequences of Burns.—If at all severe or extensive, this kind of injury is liable to be followed by many serious consequences, which, though generally more or less combined in practice, may, for better description, be divided into two orders—namely, Local and General; or, into Inconveniences and Dangers; the former being hostile to the pre- 106 burns. servation of the comfort or limbs of the patient—the latter being dan- gerous to life itself. By a due knowledge and consideration of these, the treatment and prognosis must in every case be regulated. Ihe first order, which consists of those local effects not directly dangerous to life, consists, with a single exception, of various conditions attend- ing cicatrization, and productive of functional lesions, partial or com- plete. They have been enumerated under the heads of adhesions, deformities, and mutilations ; to which may be added disfigurements, and affections of the cicatrix. The disfigurements consist of those unseemly cicatrices, especially on the face, neck, and other exposed parts, which merely affect the appearance rather than entail any serious discomfort. They are produced principally by burns of the third degree, by slight cases of the fourth, and sometimes also by severe instances of the second, when the epidermis forming the vesicles has been torn off, exposing the cutis to the stimulus of the atmosphere, to irritation and subsequent suppuration. The adhesions imply those conditions in which, during cicatrization, contiguous tissues or surfaces, which in their natural state move freely on each other, have become mutually adhe- rent, thereby abridging voluntary motion, as when a cicatrix adheres firmly to a muscle, tendon, or aponeurosis beneath; or these latter to one another. Deformities are constituted by any considerable altera- tion in the shape of an organ, or in the relation which one part naturally bears to another. They may be produced in two ways ; either by con- traction of the cicatrix, or by destruction of muscular antagonism. The cicatrix following a burn is said to have a greater tendency to con- tract, than after any other species of injury. Like all new, and lowly- organized structures, it is very liable to absorption, which makes the contraction and puckering of the tissues around go on long after the sore has healed. Wherever a portion of skin has been destroyed in this manner, as in a burn of the fourth degree, its place is eventually supplied, not altogether by a new and permanent structure, but to a very considerable extent by the uninjured integument in the neighbour- hood, which, by the steady drag exercised on it by the gradual contrac- tion of the cicatrizing ulcer, or the cicatrix, is drawn together towards a central part, which is at last occupied by the cicatrix, now much dimi- nished in size, shrivelled, and sometimes almost of a horny texture. The surrounding integument stretches to a certain extent, more espe- cially in those parts where it is loosely connected with the tissues below: but if the loss has been very extensive, the requisition on the integu- ment around will be proportionately large, and this demand may prove more than its extensile qualities can supply. Accordingly, if a burn be so situated, that flexion or other posture of a neighbouring articulation will relax the skin around the seat of injury, the steady drag on the integuments, added to the natural tendency of the limbs to preserve a slightly flexed position, will produce, if not guarded against, a perma- nent flexure of the joint. The same remarks apply with still more force, when the deeper-seated parts have, as well as the skin, been destroyed. Inus the fore-arm has been immovably bent on the arm, the latter bound to the side, the lower jaw dragged down to the sternum, and the head drawn back between the shoulders. When the injury is BURNS. 107 situated on the extensor aspect of an extremity, the tendency, above mentioned, of the limbs to sustain a slightly bent position, is in general sufficient to counteract the extending force of the contracting cicatrix. This is not, however, always the case, for the fingers have frequently been bent backwards upon the metacarpus, and the foot has been so twisted and deformed that all trace of its original conformation has been destroyed. Deformities from this cause, and to this extent, are now, however, much less frequently met with than formerly; though, in injuries of such a nature, the motions of the joint almost always remain more stiff and constrained than natural, and are farther restricted by the abnormal adhesions formed between the cicatrix and the subja- cent parts. Again, in those cases where the tissues beneath the integu- ment are destroyed, as in a burn of the fifth degree, in which the con- tinuity of muscles, tendons, or aponeuroses has been interrupted, the contractions of the cicatrix, together with the unnatural adhesions, fre- quently cause deformity, fixation, and even dislocation of a neighbour- ing joint. As in other injuries, when the solution of continuity affects a nerve, loss of voluntary motion or of sensation must ensue in the parts supplied by it on the peripheral side of the injury, by which occurrence the antagonism of two sets of muscles may be destroyed, and deformity produced. Mutilations consist in the partial or complete loss of an organ. They are immediate in all burns of the sixth degree, and in those of the fifth, in which the possibility of saving a useful limb is at once rendered hopeless. They are consecutive, when caused subse- quently either by the violence of inflammatory reaction inducing exten- sive gangrene, or where the limb, as it remains, is so utterly useless as to necessitate amputation; an operation which is also sometimes neces- sary to save life when it is endangered by hectic from the exhausting effects of profuse and prolonged suppuration. The affections of the cicatrix are chiefly excessive contraction, fissure, ulceration, and irrita- bility. As it is less highly organized than the original integument, it is peculiarly liable to the first three of these conditions, in conformity to the general law, that newly-formed and lowly-organized structures are much more prone to absorption, to inflammation, and other diseases, than older and more highly constituted tissues. Irritability of the cicatrix may be the result of a nervous filament or trunk being impli- cated in it, as occasionally happens after an ordinary amputation; or it may occur without any such apparent cause. The second order of consequences, comprising the general or constitu- tional effects, are those which more immediately endanger life. They may be arranged, chiefly according to the periods at which they occur, into six groups. First,—when a large extent of surface is burnt though but superficially, and more particularly when to the third degree, a shock is communicated to the nervous system, either by intense pain excited in the wide expanse of integumentary nervous web which is injured, or by the sudden destruction of the functions of the integument. It is believed that this shock occasionally causes instantaneous death by asthenia, or the asthenic form of syncope—the heart ceasing to act from its irritability or contractile power being annihilated. The same result may take place when the burn, though of less extent, has penetrated 108 BURNS. more deeply and injured some vital or important organ; but, with this exception, it is a well-ascertained fact that burns are more dangerous from their extent than from their depth. Second,—more frequently it happens that death is not immediate. There is great depression and collapse of the vital powers, which gradually sink in a few hours. The immediate cause of the fatal issue in this instance may be, as in the for- mer, asthenic syncope, with this difference, that here the functions of the heart are slowly and gradually suspended, instead of being instantly arrested. Females, children, and persons of a nervous and irritable temperament, are most liable to sink in this manner. In other cases, death is preceded by typhoid symptoms, low muttering delirium, and coma. When the functions of a large portion of integument are suddenly suspended, the healthy balance between them and those of the lungs is destroyed ; the latter become, with the other internal organs, greatly congested, and soon cease to effect proper aeration of the blood. This leads to more retarded circulation in the pulmonary system; the brain is supplied with imperfectly purified blood; coma ensues, which still further retards the flow of blood through the lungs ; and death results at last, from apnoea, accelerated by coma. Third,—In other cases, the collapse goes off, and is succeeded by an imperfect and feeble reaction, attended with great irritability and excitement of the nervous system, under which the patient may sink exhausted. Constitutional debility and irritability predispose to this termination. Occasionally, death has occurred about this period from tetanus, or from convulsions. Fourth, —On the disappearance of collapse, vigorous reaction may ensue. When this is confined within proper limits, it is the first step towards recovery; but when excessive, and accompanied by very high symptomatic or in- flammatory fever, it is equally perilous to life, as would be its deficiency. Sometimes, accordingly, the patient dies during the stage of excessive reaction. At this period, also, congestion and inflammation are very apt to occur in the mucous membranes, and several internal organs, more especially the lungs, the intestines, and the brain. These serious complications render the prognosis much more unfavourable, and fre- quently prove the chief causes of death. The upper portion of the duo- denum is the part of the intestinal canal which is most frequently affected. Sometimes the inflammation here leads to ulceration, especially in young persons; and, occasionally, during the ulceration, a small artery is opened, hemorrhage ensues, and the patient generally dies, either from a single profuse loss of blood, or from a more sparing dis- charge, frequently repeated. Death in this instance takes place by that form of syncope in which the heart primarily ceases to act, from the want of a sufficient volume of blood to excite its contractions ; the ner- vous system being consecutively affected by the deficiency of the nutri- ent fluid. This mode of death is accordingly called, by Dr. Watson, anaemia. Of hemorrhage from the above cause, about'a dozen cases are on record. Gangrene, from excessive inflammatory reaction, may prove fatal by a combination of asthenic syncope and coma. Any of the serous membranes, or the organs which they invest, may, in like man- ner, be attacked by inflammation. As a general rule, 'those internal parts are most apt to suffer, which are nearest to the external lesion. BURNS. 109 Apoplexy occasionally occurs from the fifth to the seventh day. Du- puytren considered this to be owing to idiosyncrasy, but it is more sim- ply explained by referring it to vascular excitement in a person, the arteries of whose brain are already in a state of disease. Confirmed drunkards have been attacked, about this period, with delirium tremens ; and in pregnant females, the premature expulsion of the foetus is said to have occurred. Fifth,—During, and after the detachment of sloughs, new dangers arise. In bad constitutions, or where the powers of life are much enfeebled, the separation of the eschar by ulcerative absorption may not have been preceded by a sufficient effusion of plastic lymph on the layer of living tissue next to the dead mass; accordingly, if any considerable artery, or even vein, has been involved in the slough, dangerous or fatal hemorrhage may take place from its open mouth, which has not been sealed up, as, under a more favourable state of the system, it would have been. The same result may ensue from an artery being denuded at this period, and afterwards ulcerating. The possibility of such an occurrence suggests the propriety of using no force in re- moving the sloughs, lest the blood-vessels be not yet prepared for the separation. When the eschar has been very extensive, persons have occasionally died soon after its separation without any very obvious cause, unless it has been owing to the sudden exposure of a large ulcera- ting surface to the irritation of the atmosphere, inflicting a second shock on the system, which, though it was able to withstand the primary effect of the injury, succumbs to this second attack in its now enfeebled state. If this be the true explanation, then the raw surface, when of large extent, should be exposed only partially, as seldom as possible, and for as short a time as practicable, at each dressing. During suppuration, phlebitis and pyaemia have sometimes occurred, and destroyed life with the most urgent typhoid symptoms. After all the preceding dangers are past, if the process of cicatrization, over a large surface, be tedious, and suppuration very profuse, the exhausting effects of this drain on the system, combined with long confinement, tend to induce hectic fever, under which the patient may sink. The fatal issue is sometimes much accelerated by the development and rapid progress of phthisis pulmo- nalis. A more common adjunct of the hectic, is colliquative diarrhoea, from irritation and ulceration of the intestinal mucous membrane, par- ticularly in the vicinity of Peyer's glands on the lower part of the ileum. Sixth,—Even the period of cicatrization, according to Dupuytren, is not exempt from danger ; for he mentions that when this process has been nearly or entirely completed, persons have sometimes died suddenly and in a manner unaccounted for, even on dissection. This singular occur- rence may be supposed to be connected with the suppression of the purulent discharge, which, though not natural, yet from its long con- tinuance before cicatrization was effected, had become a habit—and, in fact, necessary, in some degree, to the constitution. Post-mortem Appearances.—The local effects of burns have already been sufficiently described to enable any one to understand what condi- tions may be expected on examination of the parts with the scalpel, when opportunity offers for so doing. In persons who have died imme- diately, or shortly after extensive burns, from the primary shock, 110 BURNS. Dupuytren says, the intestinal mucous membrane presents, in many places bright 'red patches of variable size, and other marks of great congestion,—the fluids of this canal, especially in the stomach, being deeply tinged with blood. Other observers, however, have not found the preponderance of congestion in the mucous membranes to be so great, or so constant, as Dupuytren in such cases has represented it. The cerebral sinuses are gorged with blood ; the brain and its mem- branes very much injected, its ventricles filled with a pinkish serum; and a similar fluid is found within the peritoneum, pleura, and pericar- dium,—these being in some parts dotted, or streaked with red points and lines of vascular injection. When the patient dies during reaction, many of the above-mentioned appearances will be present. The symp- toms during life will assist in pointing out which organ, if any, will be found the principal seat of inflammation or of congestion. The prognosis of burns, except of those which are very trifling, is always uncertain in the early stages; not only from the possibility of any of the preceding fatal terminations occurring ; but also from the circumstance that it is frequently impossible, till an advanced period, to predicate the amount of lesion. In some instances it is doubtful at first how far the destruction has extended; and in others the immediate injury is followed by a secondary sloughing of the tissues, consequent on the violent inflammatory reaction in these parts, the vital powers of which were considerably lowered, though not entirely destroyed at the moment when the injury was inflicted. In forming a prognosis, we must be influenced by a consideration of these points, and of the sex, age, constitution, previous habits, and present sanatory condition of the patient; as also of the extent of the burn in superficial area, and in depth ;—of its relative situation, and the nature of the part. Females, children, and persons of a weak, nervous, and irritable temperament, are, as might be expected, more liable to the dangers attendant on this kind of injury than males, adults, and those of a stronger, and less ex- citable constitution. Old age again, which by its accompanying debility is exposed to the dangers of the former class, and is little able to survive the shock, or to support the tedious suppuration, is, however, less liable to those congestive and inflammatory attacks which so often complicate the injury in younger and more full-blooded individuals. Previous per- nicious habits, present disease, or any circumstance which tends to weaken the general health, increase the danger. Intemperance in alco- holic liquors, is a strong predisponent to a fatal issue in this, as in other serious injuries. These various conditions do not all agree in producing danger in the same manner. Thus a weak and nervous individual, be the weakness from whatever cause, whether from the extremes of age, from disease, or from previous irregularities, is peculiarly liable to sink under the primary shock. To a strong plethoric adult the period of reaction, with its internal congestions, and it may be inflammations, is the most dangerous. Asthenic persons again, if they have survived the preceding stages, are, especially when of the strumous diathesis, prone to succumb during the period of suppuration and hectic. It was before stated that the danger of a burn is more proportioned to its extent of surface than to its depth, except when in the latter case vital or im- BURNS. Ill portant organs have suffered. The depth, on the other hand, more than the superficial area, regulates the amount and nature of the local se- quelae. The influence of relative situation is shown by a burn, which in one place would be comparatively unimportant, producing, in another site, very serious consequences. With regard to the local results, it may be considered a general rule, that, other things being equal, a burn will produce an amount of defor- mity directly proportional to the freedom of action naturally enjoyed by the part which is the seat of injury. Thus, when in the neighbour- hood of a joint, its fixation;—when near the mouth, hideous distortion ; close to the eyelids, their eversion, ectropium, adhesion of their margins to one another—are conditions easily induced. The influence of rela- tive situation in causing danger, is exhibited by otherwise insignificant burns of the scalp, exciting inflammation in the brain or its membranes ; of the thorax and abdomen, in inducing the same morbid action in the serous linings of these cavities, and in the latter situation, when deep, predisposing to hernia or protrusion of some of the viscera, from weak- ening of the abdominal parietes. Again, when situated near the orifices of mucous canals, the transit through them may be materially interfered with, whilst their natural secretions, coming in contact with the sore, may deteriorate its action, and retard its healing. Thus in a scald of the mouth, fauces, and pha- rynx, from an attempt to swallow a boiling fluid, dysphagia or difficulty of deglutition will ensue, which, if the injury be severe, may not pass off with the inflammation, but may continue permanently, through con- traction or stricture of the upper part of the oesophagus. But there is here a more immediate source of danger : the scalding liquid may pene- trate into the larynx as far as the glottis, and excite acute inflammation of it and the epiglottis; or the same result may take place by propaga- tion of the action from the pharynx, without the fluid passing below the epiglottis into the larynx at all. This condition will produce dyspnoea, or even death by apnoea if not relieved. In these instances it is believed that the liquid does not pass into the oesophagus, or farther down the larynx than the rima glottidis; the spasmodic muscular action, in both these parts, effecting closure of their respective canals. Occlusion of the puncta lachrymalia may ensue from a burn in their neighbourhood. Dysuria results when the genitals are implicated; and, in the female, the contact of the acrid urine may aggravate the injury. When close to the anus the pain experienced during defecation induces the patient to perform this as seldom as possible, and constipation is the natural sequence. The situations, then, on which burns are most dangerous, are the head and neck ; the geuitals, particularly in children ; and the trunk generally. When on the hands and feet, tetanus has followed this, as well as other injuries of the same parts. It has been stated that a fatal result will almost certainly take place from a burn of the first or second degree, which involves half of the entire surface of the body; from one of the third grade, affecting a quarter; and from those of the fourth, fifth, and sixth degrees, in which the eschar comprehends more than a square foot. No doubt, these points will frequently be found to be correct; but from what has been 112 BURNS. said above, it will be evident that under particular, though by no means unusual, circumstances, a very much smaller amount of injury may lead to death. The First Degree is most commonly caused by contact with heated liquids or vapours, or by radiation. The four common symptoms of inflammation are present,—namely, redness, heat, pain, and swelling; while the absence of vesication distinguishes this from the next degree. The redness is of a bright rosy hue, diffused—not circumscribed, disap- pearing momentarily under pressure, and very similar to that of ery- thema, of which this may be considered a traumatic form. The pain is acute, of a smarting, or burning character, and it generally lasts as long as the rubefaction remains. The swelling is but slight, except when on mucous membranes. These symptoms disappear by resolution in a few hours, or at most, in two or three days. In more severe cases, a slight desquamation of the cuticle ensues in the form of light furfura- ceous scales. A degree of tenderness in the part frequently remains for a few days longer. When the shock has been very great, collapse is present; marked by a weak, fluttering, and irregular action of the heart, and a pulse almost imperceptible at the wrist. The person is scarcely conscious, his sensa- tions are impaired, and his gaze is vacant. When reaction is established, symptoms of any of the complications already enumerated, may exhibit themselves. Local Treatment of First Degree.—In burns of the first degree, the objects of local treatment are to mitigate pain and prevent effusion. When an extensive surface is affected, the whole should not simultane- ously be exposed to the atmosphere ; and any necessary exposure should be as brief as possible. In slight burns, local treatment may alone be requisite, consisting in the steady application of cold for several hours, either by simple immersion or wet cloths. Immersion is of course only applicable when the surface involved is small and suitably situated, and when no collapse is present. The water employed must be kept cold by frequent renewal. When the part is not conveniently situated for immersion, it should be closely, but at the same time lightly, enveloped with a single layer of soft linen or cotton kept constantly wet with some cold liquid. Simple water may be employed, with the addition, if thought necessary, of a little alcohol, to increase the evaporation and the consequent cold. Dupuytren used an acetate of lead lotion, which he considered sedative and astringent:—it is a very excellent applica- tion. After the incipient inflammation has been thus checked in the onset, the part, if of any extent, must be defended, alike from the stimu- lus of the atmosphere, and the depressing influence of cold; one or both of which might injure it in its present delicate condition. This may be variously accomplished, either by rolling fine carded cotton or wadding around the part; or by varnishing the surface with a thin layer of some bland adhesive substance, which will, for a time, perform the part of an insensible cuticle. For this purpose, mucilage of gum arabic, or traga- canth, or the ethereal solution of gun-cotton known by the name of collodion,—may be employed. The collodion, and probably the muci- lage also, seem to act in two ways ;—first, by protecting the surface BURNS. 113 from contact with the atmosphere; and—second, by contracting to a certain extent as it dries, which, together with its close adhesion to the cuticle, tends to keep up a degree of pressure or compression, that proves beneficial to the weakened part, as well by affording it support, as by favouring the absorption of any slight interstitial effusion. The varnish may be removed, when the vascular action in the subjacent integument has quite subsided to its natural standard. If applied, however, over a large surface, it might prove injurious by mechanically obstructing the cutaneous transpiration of the part; and this would favour the occur- rence of vesication. Such an objection does not apply to cotton. For a like reason, the aqueous mucilages are less objectionable on the large scale, than collodion, which is quite impervious to moisture; while the former readily imbibe a little from the surface below, which not only relieves the subjacent integument, but also prevents undue desiccation of the protective layer, and its consequent cracking and peeling off. But, where a very large surface is burnt, and when the depression is considerable, the continuous application of cold cannot be had recourse to, as it would tend still farther to lower the system. In this case, a warm opiate fomentation may be employed, which will greatly mitigate the pain; and, subsequently, the cotton or varnish may be employed as before. Some persons employ the cotton in the first instance ; and this will be the most judicious treatment in many burns of the first and second degrees, where, from the great extent of injured surface, neither cold nor warm lotions can be conveniently employed. The cotton, more- over, has this obvious advantage, that when once applied in such cases, it need not soon to be disturbed; while liquid appliances, on the contrary, require frequent or constant supervision and renewal. This peculiarity is a decided recommendation for its employment in those distressing cases of great severity, in which all hope of life is at once destroyed; and in which, therefore, the treatment ought from the first, to be chiefly directed to soothe the suffering of the last moments. A popular appli- cation, which deserves mention as a ready substitute for the cotton or varnish, after the vascular action has been repressed,—is flour, dusted thickly over the reddened surface. It is applicable to burns of the first degree; but not when the injury has caused, or is likely to induce vesi- cles ; for, on the bursting of these, the effused fluid cakes the flour into a mass, which hardening, irritates, instead of protecting the skin. Stimulant applications have been recommended from the commence- ment ; but, in the early stages of all burns, they tend to increase the vascular action, and so carry the injury to a higher degree than it would otherwise have attained. Turpentine has been considered to exercise a constringing action on the vessels of the integument, and thus to prevent effusion; but this substance on many skins, even when in the healthy condition, is itself a very powerful rubefacient. In slight burns of the face, from explosions, by which the eye is injured by par- ticles of gunpowder stuck on, or into the conjunctiva, all the large grains should be removed at once ; after which, linen cloth, kept very wet with cold water, or a cold, light, very moist, bread-and-water poul- tice enclosed in a cloth, forms the best application, and is to be laid across the eyes, the patient lying in bed. The water here dissolves 114 BURNS. and carries off the nitre of the powder; while its remaining constituents, sulphur and charcoal, are washed away. Those particles which remain after a day or two, should be carefully picked out by any fine-pointed instrument. The operation, which has been advised, of picking out with the point of a needle, all particles of gunpowder that have lodged in the skin, would be, in many instances, where the whole face and head are thus tattooed, as impossible to execute as it would be danger- ous and cruel to attempt. The treatment of pharyngitis, or laryngitis, following an attempt to swallow boiling water, does not differ materially from that proper for acute idiopathic cases of the same nature ;—it must be instant and energetic. It consists chiefly of depletion, local or general according to circumstances, counter-irritation, the exhibition of antimonial or mer- curial medicine, and the employment of a tepid demulcent gargle. Bronchotomy, as a last resource, should be performed as early as the necessity for it clearly exists, because the ultimate success of this ope- ration as of that for strangulated hernia, depends very much on the period at which it is instituted. The Second Degree of burn is characterized by the presence of vesi- cation, in addition to the erythematous rubefaction observed in the first. The vesicles form where the heat has been most intense, or longest ap- plied. Though generally formed immediately, or very soon after appli- cation of the caloric, they will continue enlarging, or new ones may be formed during the next twelve or eighteen hours, if the part has not been properly protected from irritation. The contained serum may be either clear or opaque, colourless or tinged with various shades of yel- low and red. Around them for some distance, the first degree of burn prevails, but the swelling and pain are here greater; the latter, when the phlyctenae are large and full, being accompanied with a feeling of tension. Such is the state of matters, when, as is most commonly the case, a hot liquid has produced the injury; but, when it is occasioned by actual contact with a heated solid, the epidermis frequently adheres to it, and is torn off along with it on its removal. When this happens, the pain experienced from exposure of the denuded surface to the atmo- sphere, is exceedingly acute, and slight suppuration is almost inevitable. This suggests the propriety of not lacerating the vesicles; or if, to relieve their tension, it be necessary to evacuate part of their contents, of making the_ opening as small as possible, and then preserving the cuticle otherwise entire until the surface beneath shall have no need of such protective covering. Under favourable circumstances, the detached cuticle dries, and shrivels up in a few days; it then falls off, or may be removed, its place being supplied by a new layer of similar structure, as yet, indeed, more delicate, and of a reddish hue, but which soon assimilates its appearance to that of the original tissue. Even if slight suppuration occur, no mark is, after a time, discernible; but if the purulent secretion be from any cause protracted, a scar or slight dis- figurement will ensue, which, however, with time and appropriate treat- ment, will ultimately disappear. The Local Treatment of the Second Degree of burn differs from that proper for those of the first grade, in so far only as the appliances to BURNS. 115 the vesications are concerned. When produced, as this grade usually is, by scalding fluids, some parts covered by the clothes are generally more or less injured; and in the removal of these the greatest possible care is requisite to prevent laceration of the vesicles, or the tearing away of the detached cuticle. If the vesication be slight, the treatment for the first degree may be instituted, taking every care that the elevated epidermis be preserved from injury. But if the subcuticular effusion be very great, the vesicles, as they become large and tense, should be punctured with a small needle. The evacuation of their contents in this way affords much relief; and if the fluid reaccumulate, it may again be discharged in a similar manner. Cold astringent lotions offer the most probable means of limiting the effusion; but these may be counterindi- cated by various circumstances, which have already been sufficiently explained while speaking of the treatment of the first degree. Glyce- rine, mingled with an equal quantity of water, has lately been recom- mended as a topical application in burns of the first and second grades. It certainly has the property of keeping the part soft and moist for a long time. If the cuticle has been torn off, the raw surface, when large, is most effectually soothed and protected by the Linimentum Aquae Cal- cis ; or when small, by forming an artificial crust over it with mucilage, collodion, or the nitrate of silver, which being applied gently to the moist surface, coagulates the secretions, and thus forms a protective layer. Over the thin crust produced by the lunar caustic, a piece of gold-beaters' skin should be applied, to prevent its cracking and prema- ture detachment. The method of healing by incrustation is preferable when the prevention of scars is an important object, as it is when the face, neck, arm, or hand, especially in a female, is the seat of injury. The Linimentum Aquae Calcis, or Carron Oil, as it is popularly termed, has been employed indiscriminately over the whole of the burnt surface, whether blistered and denuded er not; but its employment in this man- ner is attended, in some degree, with the same objection formerly offered, as prohibiting the application, over a large area, of a varnish imperme- able to aqueous moisture, namely, the checking or prevention of the cutaneous transpiration, which effect is, with justice, believed to increase the subcuticular effusion. The common turpentine liniment, composed of turpentine and resinous ointment, is objectionable on the same account, and is, besides, much too stimulant an application to the blistered sur- face. If the effusion in the vesicles become decidedly puriform, the raised cuticle must be freely incised, and the surface treated as an ordi- nary ulcer, should it continue to suppurate; or the incrusting process may be tried, if the secretion of matter be scanty. The Third Degree of burn consists of cauterization of the epidermis, and the papillary or superficial layer of the dermis. Gunpowder explo- sions are said frequently to produce this grade; and the skin in these cases is permanently tattooed, in many places, by the lodgment of black particles driven into it. In this grade, the part is usually charred at once, or it dies very soon. The eschars, in the slighter cases, are so thin as to resemble mere stain; but in other instances, they may be half a line or more in thickness. They vary in colour, from grayish- yellow to dark-brown; and, in consistence, from a moist and soft state, 116 BURNS. to a dry and hard though pliant condition. When the consequence of a scald, they are usually of the lighter hue, and softer consistence; and as, under these circumstances, the vitality of the part has not been in- stantaneously destroyed, the slough is frequently covered with dark vesications, the fluid contained in which is sanguineous, and of a red or brown colour. These are seldom found over an eschar which has been produced immediately by a solid of high temperature, because the slough thus formed is usually dry and hard. It is in that case also depressed, while the surrounding integument is corrugated and drawn in around it. When present, however, Dupuytren regarded these dark-coloured vesi- cations as extremely characteristic, indeed diagnostic, of this degree of burn. Occasionally, when produced by a solid body which has re- mained for some time in contact with the skin, or by a metal in the state of fusion, the cuticle, together with a thin layer beneath it, is torn off at the time, leaving the dermis exposed, and of a grayish colour, part of which dies subsequently, so that nearly its whole thickness is de- stroyed. Immediately around the charred portions of integument, the skin will be found to have suffered to the second degree, as exhibited by the limpid vesicles; and still further off, to be merely affected with the erythema of the first. Dupuytren remarked that, while in every burn the pain is acute, it is much more inte'nse when the skin is burnt only on its surface, than when the injury extends more deeply. Accord- ingly, the third degree of burn is found to be the most painful of any; though some writers have stated it to be less so than the two preceding varieties. The danger to the constitution, also, is proportionately greater here than in these,—primarily, because the shock is greater and the pain more intense; and secondarily, because the reparative powers of the system will be more largely taxed in this, than in the more superfi- cial injuries. So soon as the parts are quite dead, there is a remission of the pain for a few hours, until inflammation be established, and the process of separation commenced; yet even during this interval, though the eschar itself be insensible to the touch, yet, from its thinness, a very gentle pressure on it, by being transmitted to the living and sensitive structure beneath, will excite acute pain. Upon the supervention of inflammation, there is a reaccession of pain, and it now continues very severe, until a short time after the sloughs have been thrown off; the period of which occurrence varies according to their thickness and the vigour of constitution, from four to fourteen days after the infliction of the injury. The removal of the sloughs must not be hastened by force, on account of the pain which such treatment would occasion. The re- maining sore is superficial, and generally cicatrizes rapidly. The result- ing cicatrix is at first redder than the surrounding integument; but sub- sequently it becomes preternaturally white; its surface depressed, smooth, and imperfectly papillated; or sometimes, when suppuration has been prolonged it is marked by irregular lines, ridges, and corru- gated knots. The local result is, therefore, disfigurement The Local Treatment of the Third Degree of burn, will be related along with that proper for the fourth, as the same case usually presents the characters of each. It will be sufficient, at present, merely to men- tion the formation of an artificial crust, by some of the methods already BURNS. 117 described, as being very applicable when the eschar is thin, and most desirable when it is on exposed parts, as the cicatrix, obtained in this way, is much more perfect and similar to the original integument than that resulting from ordinary granulation. The Fourth Degree of burn is generally produced by the actual contact of a solid body at a high temperature. In this case an eschar is at once formed, comprehending the whole thickness of the skin, and frequently, also, the subcutaneous cellular tissue. It is here dark brown, or black in colour; dry, hard, and leathery, yet brittle, in consistence; and is quite insensible, pressure producing little or no pain, even in structures naturally the most sensitive,—the dermis being completely destroyed. Owing to the fluids having been thus almost instantaneously expelled from the carbonized integument, diminution of its bulk necessarily en- sues, both in its thickness, and its superficies. The eschar is conse- quently depressed below the level of the surrounding skin, and the latter, still more than in the third degree, is drawn in around it, exhibiting numerous puckered folds or corrugations radiating from the margin of disorganization. When the part dies more slowly from the violence of inflammatory reaction, the slough is softer and less depressed. Its thick- ness varies from one to three lines, being, for the same depth of destruc- tion, thinner in the hard and dry "variety, because of its greater density and compactness, than in the soft and moist form, which is more loose and flabby in its texture. Receding from the point where the heat has been most intense, the three minor grades of burn are generally observa- ble ; that of the most superficial character occupying the most distant site. The pain is severe so long as the application of the cauterizing agent is continued; but upon its removal it ceases, at least in that spot, for a few hours, during which time, little more than uneasiness may be felt in the part which bears the characters of this degree, because the structure which would have been most acutely sentient, had its vitality been preserved, has been at once destroyed. If, however, the neigh- bouring surface be affected in a more superficial manner, then the pain, already described as attendant on burns of the first three degrees, will be experienced. Even if the latter condition should not exist from the first, it will ensue, in the course of a few hours, and severe pain will then become developed from inflammation attacking the integument around. In three or four days, the parts beneath the slough have, from the same cause, become painful; and both cause and symptom increase in severity during the first week, at the expiration of which period, or about the ninth day, their intensity begins to decline, and afterwards suffers a gradual diminution, which is contemporaneous with the establishment of the process of separation between the dead and living structures. The process of ulcerative absorption by which this is effected, having been described in another part of this work, need not be related here. The separation is effected during the third week after the infliction of the injury. Granulation now proceeds, in some cases, with sufficient activity; but very often it assumes the indolent character, and is attended with profuse suppuration, when the surface is of large extent. The cicatrix, when at last completed, is, as before explained, much smaller than the 118 BURNS. original destruction of integument; it is permanently depressed, of a fibrous appearance, smooth unless cicatrization has been irregular; pos- sessed of little common sensibility, and very liable to chafe and ulcerate. Thus by its appearance it constitutes, at least, a disfigurement; while by its contraction, or adhesion to parts beneath, serious deformities may be produced, attended probably with much loss of motion. Previous to separation of the slough, or at least until that condition be considerably advanced, it is often difficult, if not impossible, to pronounce with certainty whether a burn be of the third, fourth, .or even of the fifth degree; especially in situations where the bones are but thinly covered by soft parts ; because the secondary sloughing, con- sequent on the inflammation, which attains its height about the ninth day, is frequently so extensive and profound, as to make an eschar, which at first seemed inconsiderable, become subsequently of very formidable dimensions. A knowledge of the manner in which the injury was pro- duced as regards the nature of the agent, and the mode and duration of its application, will assist in forming an idea as to how far the caloric may have penetrated. The following remarks will usually enable the primary amount of destruction to be ascertained. The present degree is distinguished from the third, by observing that in this grade, severe pressure on the eschar at an early period produces little pain; while in the more super- ficial lesion, gentle pressure produces intense agony. As before ex- plained, there may be here also very acute pain from the commence- ment, owing to a superficial inflammation of the surrounding skin, and until pressure be actually made on the primary slough, the patient's sensations may not be so well defined as to inform him, that under it at least, there is little or no pain. From a burn of the fifth grade, the present degree is distinguished by its comparative want of sonoriety or resonance on percussing the eschar, which property, if present at all, can, from the thinness of the slough, exist only in a very slight degree; while in a burn of the fifth grade, a distinctly sonorous sound is elicited from the eschar. Of course, in any case, where the slough is of the soft and moist description, percussion is useless, and could produce no distinctive sound. The Local Treatment of the Third and Fourth Degrees of burn com- prises four indications; namely—to regulate the amount of inflamma- tion ; to favour separation of the sloughs ; to assist the processes of granulation and cicatrization ; and to prevent, or in some cases, to modify, deformity. The first indication, which is to regulate the amount of inflammation, requires that its activity should be repressed when excessive ; and that when defective, local reaction should be promoted, because a certain amount of vascular action is necessary to effect the detachment of the eschar, and the subsequent cicatrization of the sore. To limit the inflammation, an elevated and relaxed condition of the part should be preserved. If it prove excessive, so as to threaten extensive secondary sloughing, local depletion may be required • in estimating the necessity for which, the character and degree of'the general symptoms of pyrexia will render valuable guidance. In robust and plethoric adults, in whom, from the injury being of small extent BURNS. 119 the system has been little depressed, the early abstraction of blood by leeches, may limit very considerably the impending destruction of tissue. These should be applied, when the collapse has quite worn off, as near as possible to the threatened part. Perhaps in a few rare cases a moderate general bleeding may be advisable, in order to restrain the local action ; but either form of depletion must be employed with the utmost caution, and in as sparing a manner as will suffice for the attain- ment of the immediate object in view; more especially when the amount of destruction has been great, because, as will afterwards be mentioned when describing the constitutional treatment, the powers of the system may be injudiciously weakened, when ere long it will have need of all its energies to carry on the work of reparation. On the other hand, when local and general reaction prove very tardy and defective, stimulant applications must be resorted to, in order, first —to excite a sufficient amount of local inflammation to throw off the slough; and, secondly—through this medium to assist in rousing the system from collapse. For this purpose, the liniment composed of resinous ointment and turpentine, may be applied, and its stimulant properties regulated by varying, when necessary, the quantity of the latter ingredient. The manner of fulfilling the second indication, which is to promote separation of the slough, may vary a little under different circumstances. The warm water-dressing, consisting of cloths dipped in warm water, and covered with oiled silk to prevent evapora- tion and cooling, is usually the best appliance; and if there be much pain the water may be medicated with opium. Light poultices answer the same purpose, but if large, they prove, from their weight, especially when on the trunk, distressing to the patient. If the inflammatory action be very weak the applications may be rendered stimulant by the addition of a metallic salt. No mechanical force must be employed to detach the eschars ; but if a large piece be loose except at one point, the greater portion of it may be cut off near the point where it is still attached. Occasionally matter forms under a part of the eschar, and, accumulating, gives rise to pain and tension. Fluctuation is perceptible at the part, and free incision of the slough is requisite to permit the escape of the purulent collection. The third indication, which is to promote granulation and cicatrization, comes into play immediately subsequent to the separation of the eschar; when the usual treatment of granulating sores, as described while treating of the results of inflam- mation, is to be instituted. If there be much foetor, a weak solution of the chloride of zinc, or of soda, may be advantageously employed. If the sore lose its vigorous character, and become indolent, the part, especially when on an extremity, should be encircled with a lightly- applied bandage, which not only affords support, but, by the gentle pressure which it exerts, tends to prevent that flabby exuberance of granulation which is so liable to occur, and so certain, if it do occur, to retard cicatrization. It is proper here to mention that these injuries have been, and are sometimes at the present day, treated differently, by means of unctuous applications, by cotton, &c. The former of these are, however, by no means so cleanly as the water-dressing. The Unguentum Calaminae, 120 BURNS. and Oleum Palmee, are probably the least objectionable of them ; and it is advised to spread them thinly on lint, in which a number of small apertures have been made, so as to permit the free escape of matter from beneath the immediate dressing. The surface is also dusted over with vegetable charcoal by some surgeons, with the intention of thereby sopping up the profuse discharge. This is certainly not a seemly appli- cation ; and its use, when possible, had better be avoided, as the washing, required at each dressing to remove this substance, cannot be beneficial to the tender granulating surface. With regard to cotton, the application of which has been recommended in numerous layers, Professor Miller justly remarks, that in these severe burns, it " would speedily become soaked with the discharge, and either require frequent renewal or else prove a very hotbed of pestilential putrescence." The fourth indication, which is to prevent, or, in some cases, to modify deformity arising from the centripetal tendency of the structures around the burn, during and after cicatrization, is accomplished chiefly by pre- serving the parts in such an attitude that the tissues must be approxi- mated longitudinally as regards the long axis of the body, rather than in the transverse direction. For it will be observed that contraction of the cicatrix in the former way, will rarely produce deformity, though it may cause a degree of tension and stiffness ; while in the latter direction, serious impairment of motive function may readily be induced, from fixation of a joint even in a convenient attitude, or, what is more com- mon, in an extremely awkward and sometimes an absolutely dislocated position. In order to obviate this, the position of the part during the progress of cicatrization, and for some time after its completion, must be so ordered that it will oppose any such malposition of the joint impli- cated. The period of complete cicatrization may be thus somewhat deferred; and if, during this delay, hectic should supervene, or prove more urgent, all opposition to Nature's own manner of cure must be desisted from, and subsequent measures trusted to, for the palliation or removal of any deformity which may have accrued from it. The con- traction can be moderated, and its direction regulated, in many situa- tions, where bandages would have no effect, as on the face, neck, and some parts of the limbs, by strips of isinglass plaster. As there is at the angles of commissure of the fingers and toes a great tendency to union of the opposed surfaces, the dressing must be carefully inserted between them up to the top of the fissure, and a turn of a bandage brought above, so as to exert a steady pressure on the part. Natural orifices must be kept, by appropriate mechanical means, from closure or constriction, during cicatrization in their neighbourhood. To prevent fixation of a joint, either from contraction of the tissues or from its long continuance in one attitude, passive motion must, in the latter stages, becautiously instituted, and the exact position of the articulation varied a little from day to day. But in many cases the destruction has been so profound, or so extensive, that partial or complete loss of motion must inevitably ensue. In these instances, the joint, during treatment, must be preserved in that condition, as to flexion and extension, which will render the limb most useful if spurious anchylosis occur. This position, in the elbow, will be semiflexion, the forearm being bent nearly BURNS. 121 to a right angle with the arm, and, in the knee, almost complete ex- tension. Amputation can seldom, if ever, be requisite in burns of the fourth degree, except in rare cases of very profuse and obstinate discharge from an extensive surface, in which the hectic proves imminent; or when the soft structures over the bone are exceedingly thin, and are destroyed all around it, which occasionally happens in the fingers and toes, a burn of the fourth class in these situations being locally as se- vere as one of the fifth grade in better protected parts. The Fifth Degree of burn consists of a disorganization—not only of the skin, but also of the subjacent soft parts to a variable depth, occa- sionally down to the bone itself. In this case the primary eschar when produced instantaneously, or at least rapidly, by incandescent or burning bodies, is black, depressed, and dry; hard and sonorous on percussion. When the part dies more slowly, in consequence of the heat having been less intense, or applied for a shorter time, the slough is softer and more moist. It is quite insensible to pretty severe pres- sure until inflammation has set in, around and beneath it, when of course pain accompanies the vascular action, and is aggravated by pressure. During the violence of this reactional process, secondary sloughing of the tissues is very apt to occur. Arteries and nerves sometimes pre- serve their vitality in midst of the disorganization, for several days. More commonly, however, they perish at the same time with the other tissues, and if they happen to be large or important trunks, gangrene of the distal parts supplied by them may possibly be the result. The minor degrees of burn will usually be observed in more or less regular gradation, receding from the point where the heat has been most in- tense ; but independently ^>f this source, pain becomes developed in a few hours after receipt of injury, from inflammation arising in the super- ficial parts immediately around the eschar; and owing to the same cir- cumstance, during the second week, pain on pressure is elicited, gradu- ally extending from the circumference to the centre of the slough, as the vascular action increases beneath it. At the expiration of that period it begins partially to separate; the most highly organized struc- tures being the first thrown off. In persons of bad constitution there is at this time danger of hemorrhage from arteries which have suffered solution of continuity, and which, owing to the vitiated state of the system, have not been occluded previous to the exposure of their extremities. Pieces of tendon remain frequently for several weeks undetached if not cut away ; and if bone have become necrosed, the exfoliated portions may not be thrown off for a much longer period. After an extensive injury of this severe character, the system requires some time to rally; and it is not, in general, until two or three days after its occurrence that reaction is fully established. During, and for a considerable time after the sepa- ration of the slough, the suppuration is very foetid and abundant. Owing to the depth of the sore, healing advances very slowly. Muscles, tendons, and aponeuroses become adherent to each other, and contribute to form the cicatrix, which, when at last completed, is uneven and irre- gular, and effectually prevents any motion of the parts which have assisted in its production. The local results of this degree of burn may 122 BURNS. be any of the different varieties of deformity or mutilation, attended by corresponding impairment or loss of function. The Local Treatment of the Fifth Degree of burn is precisely simi- lar to that already indicated as proper for like injuries of the fourth grade. Amputation is requisite in burns of this degree under the fol- lowing circumstances:—First, when upon separation of the slough, the interior of a large articulation, such as the knee or ankle, is laid open. Second, when the same result follows inflammation and abscess in its interior. Third, when a large portion of bone is exposed on the de- tachment of the eschar, a condition which would induce extensive necro- sis. Fourth, when the loss otherwise is so great as to hold out little expectation of the sore healing; or, if that should take place, of the limb, thus preserved, proving anything but an incumbrance to its pos- sessor. Fifth, at a later period, amputation may be called for to save the system from sinking beneath the hectic consequent on profuse and prolonged suppuration. The Sixth Degree of burn, which consists in the complete charring of the whole thickness of a part or limb, is easily recognised by the part thus incinerated being shrunken, hard, totally insensible to the severest pressure, brittle and distinctly sonorous on percussion. This primary eschar is black in colour; and when produced at once by the limb being enveloped by metal in a state of fusion, the line of destruction pro- ceeds from the surface almost directly down to the bone; but when the carbonization has been more slowly effected, the eschar proceeds more obliquely through the tissues, gradually penetrating more deeply as it approaches the point of actual contact with the burning body, at which part everything, including the bone itself, is involved in destruction. The secondary sloughing, however, brings bofix cases nearly to the same condition in this respect, and when the eschar is thrown off an irregu- lar and conical stump remains, of which the bone forms the most pro- jecting part, destined, ere cicatrization be effected, to die and exfoliate. The inflammatory reaction and separation of the slough go on here in a similar manner; but the latter requires a longer period for its accom- plishment than in burns of the fifth degree. Mutilation, the most severe of the local results, is the inevitable consequence of this grade. The Local Treatment of the Sixth Degree of burn consists usually of amputation. As the detachment of so thick an eschar is necessarily a work of considerable time, and as the stump then left is a very undesi- rable one, it is proper, unless counterindicated by the existence of some unusual circumstance, to amputate in every burn of this grade. This is to be done so soon as the collapse has gone off, and before the super- vention of the inflammatory, or, it might be, of the irritative fever, which otherwise would occur. The Constitutional Treatment of Burns comprises five indications; namely—to promote reaction; to control and regulate its intensity; to watch for and treat inflammatory affections of the internal organs; to support the system under hectic and its complications; and lastly, to remove mechanically, under certain circumstances, the cause of the hectic. The first indication then of general treatment is to promote reaction. BURNS. 123 It is said that reaction is mainly brought about by the severity of the pain; but this must only be when the pain is under a certain degree of intensity, for it is well known that this symptom, when excessively severe, itself exercises a powerfully depressing influence upon the heart's action. In many cases nature is able herself to rouse the system ; but if not, reaction is to be promoted, when the patient can swallow, by the admi- nistration of some of the diffusible or more permanent stimuli, such as ammonia and brandy, in small and frequently-repeated doses. When the general surface and the extremities are cold, warmth should be applied, and, if practicable, sinapisms to the feet and pit of the stomach ; but the effect of these must be closely watched, lest they induce slough- ing. Opium has been recommended in large doses to diminish the pain, but this will tend to increase still further the cerebral congestion, which dissection has proved to be so common at this stage ; while, on the other hand, small doses will have no effect. The pain should in these cases be relieved, as far as possible, chiefly by topical remedies. When the collapse remains long, a warm and slightly stimulant enema may be ad- ministered, and repeated if necessary. This stimulant treatment, during collapse, must not, however, be car- ried too far; and it is to be suspended so soon as signs of approaching reaction appear ; for otherwise, when that stage is fairly established, the persistent effects of a superabundant stimulation, or, in other words, its surplus would exaggerate the reaction, which would now require as active treatment in the opposite direction, and when subdued, if indeed not fatal, the system would be much more enfeebled than it would necessa- rily have been, had nature been left a little more to her own resources during her efforts to institute reaction. When, as stated before, premature and asthenic reaction comes on, marked by great irritability and nervous excitement, with a rapid, throb- bing, but feeble pulse, the exhibition of opium, in large doses, is attended with the most beneficial results. The second indication is to regulate the intensity of the reaction. When it proves excessive, without apparently any internal organ in particular being attacked, the antiphlogistic regimen will in general be sufficient. In very few burns is bloodletting in any form required, or, indeed, in hospital practice, admissible; but it may possibly be de- manded, in a few cases, to relieve the general inflammatory state of the system; and at the same time, to moderate the local action, and thus limit the amount of secondary sloughing. In having recourse to these depletive measures, however, it must never be forgotten that, in all burns, except those of the first and second degrees, the powers of the system may at no distant day be taxed to their utmost to support suppuration, perhaps large in quantity, prolonged in duration, and secreted by an extensive surface. Accordingly, the slightest unnecessary lowering of the system will entail a still more profuse and protracted suppuration,— a still more tedious and possibly imperfect cicatrization. The third indication relates to the inflammatory affections of various organs which may occur. Their onset is often very insidious, and so must be watched for. They are to be treated in accordance with the ordinary medical principles applicable to each particular complication. 124 BURNS. Bloodletting, when necessary, should be as moderate as possible, for the reason already specified; and also on account of the well-established principle, that depletion cannot be borne to the same extent in secon- dary inflammations after a shock or injury, as in a primary or idiopathic affection of the same nature. The fourth indication is to support the system against hectic, and its complications. The appropriate treatment has been described when speaking of Hectic Fever. Over-stimulation must be guarded against, as this, equally with debility, impedes cicatrization by inducing flabby and exuberant granulation. The bed-sores, resulting from long-con- tinued pressure on the salient points of the back, sacrum, nates, and heels, exercise a very depressing effect. When threatened, a strong spirit- lotion is an excellent application; or, if already formed, the part may be pencilled with nitrate of silver. Under the crust thus produced, the part, if relieved from further pressure, will readily heal. Arnott's water-bed, or a Mackintosh air-cushion, affords great relief by equaliz- ing the pressure over the whole decumbent surface. The fifth indication is to remove mechanically, when necessary, the cause of the hectic. Amputation, though frequently performed to fulfil a merely local indication, namely, the removal of an useless limb, is sometimes necessary for the sake of the constitution. Thus, if hectic be extremely urgent, the suppuration continuing very profuse, with a large surface still remaining for cicatrization, while the amount of the former is not satisfactorily diminished, nor the rapidity of the latter materially increased by remedies, then amputation must be performed in order to save life. Suppuration may be prolonged, and cicatrization delayed—from de- bility of system—from an extensive surface being involved—from bone having become necrosed—and from the opening of a large articulation, either by the sloughing of the tissues, or subsequent to inflammation and abscess in its interior. Affections of the cicatrix.—This structure is very liable to excessive contraction, to chafing, fissure, ulceration, and irritability. With regard to the first of these conditions, Professor Syme remarks that the cica- trix, when recent and still soft, may be gradually stretched. In an instance on the upper extremity, the successful extension was conve- niently effected by a strong iron-wire splint, which can be made in a few minutes, of any form, and when covered with soft washed leather is extremely useful. _ This splint admits of being straightened a little daily; while it has sufficient rigidity to overcome the resistance of the cicatrix. When, however, the latter has become hard and unyielding, it cannot thus be stretched; and attempts to do so have led to great pain, inflamma- tion, and even gangrene of the lately-formed structure. Sometimes a few incisions, made through it, transversely to the desired line of exten- sion, may relieve the contraction; but in many cases, nothing but a plastic operation will succeed. This consists in making an incision in the cicatrix, so arranged, as to permit the limb to be placed in an ex- tended and unconstrained position, in which it is to be maintained: a flap of integument, corresponding in form with the surface exposed by separated edges of the incision, is then dissected from some convenient BURNS. 125 part in the neighbourhood; preserving, however, at one part its con- nexion undestroyed, by which it is to be nourished until fairly attached in the new situation to which it is now transferred, retention till that time being effected by sutures and plaster. The wound occasioned by its removal is treated on common principles, and the connecting slip divided, if necessary, so soon as perfect adhesion has occurred. An- other operation, which has been practised with success, consists in making two incisions in the form of the letter V, in the line of required exten- sion, embracing the scar and meeting at a point on the sound integu- ment below. The flap, consisting of the cicatrix with a narrow border of sound integument, is dissected up, from its apex towards the base; till the limb can be extended, and is then laid down on its now somewhat altered situation ; the edges of the whole wound being brought together laterally. They are secured in the usual mode, and the lines of inci- sion are now found to resemble the capital letter Y. As the cicatrix, like all newly-formed structures, is very susceptible of absorption, the hard prominences, occasionally presented by it, can usually be removed by the steady pressure of some smooth and unyield- ing substance lightly applied; but if this fail, they may be cut out. The chafing, cracking, and ulceration to which the scar is liable are fre- quently very distressing. Slight injuries suffice to abrade its surface ; it frequently cracks when much over-stretched during motion of the part; and ulceration may follow either of these conditions. To guard against these states, all of which may likewise be induced or aggravated by cold, the cicatrix should if possible be kept well defended from exter- nal influences by a warm, soft, and fleecy covering, and by strict atten- tion to cleanliness. But the same conditions sometimes arise spontane- ously, as it were, or from some constitutional cause, which, if discovered, is to be rectified. When the fissures proceed from cold or other external irritation, glycerine, if it prove equally serviceable here, as in common cases of "chopped hands," will speedily effect a cure. The cicatrix, though little sensible to touch, is often morbidly sensitive to atmospheric changes, and is frequently the seat of uneasy sensations, which sometimes are so severe as to merit the name of neuralgia. These symptoms occasionally depend on the trunk or branch of a nerve being involved in the cicatrix; but much more frequently no such cause can be discovered. In the former case, an operation for the excision or dis- entanglement of the implicated nerve could alone be expected to afford relief; and in the latter instance the usual treatment for neuralgia must be instituted. 126 CHAPTER V. FRACTURES. GENERAL DOCTRINES. A fracture, of solution of continuity of a bone, is said to be trans- verse, oblique, or longitudinal, according as it is at a right or an acute angle with, or parallel to, the long axis of the part of the bone in which it is situated. Where the condition of the bone, and that of the sur- rounding parts, is made the basis of arrangement, fractures may be divided into the following classes, namely—Simple, Compound, and Complicated fracture, Fracture with wound, Impacted, and Partial frac- ture. A fracture is said to be simple, when a bone is broken at one part without any coexisting injury of soft parts; compound, or open, when there is an open wound of the superimposed parts, communicating with the fracture; comminuted, when the bone is broken into several fragments; complicated, when, together with the fracture, there is serious injury of the adjoining structures, as laceration of vessels, or of other important parts, or serious contusion of the superimposed tissues; frac- ture with wound, when the wound does not communicate with the frac- ture; impacted, when one fragment is lodged in the other; a,nd. partial, when the continuity of only part of the osseous fibres is interrupted. This last variety has been called by some bending with partial fracture, and by others green-stick fracture. Bending sometimes takes place without fracture; but I have seen cases which I am convinced were cases of bending with partial fracture. The principal symptoms of fracture are pain, obvious deformity, preter- natural mobility, crepitus, and inability to move the affected limb; but as the symptoms and causes of the particular fractures will be minutely described, it is unnecessary to refer to them under the head of general doctrines. The mode of ^ union.—Baron Dupuytren made many experiments in dogs, rabbits, birds, and other animals, and, as the result of those expe- riments, he arrived at the conclusion that nature never accomplishes the union of a fracture without two successive deposits of callus, the one of which he names the provisional, the other the permanent. The first he believed to be perfected in from thirty to forty days—the production and complete organization of the other, he believed, required eight, ten, or twelve months. Dupuytren arranged the phenomena, from the occurrence of the frac- ture to the exact and complete reunion, into five different periods or stages. FRACTURES. 127 In the first stage, comprehending a period of eight or ten days, blood is extravasated into the medullary canal, between the fragments, and under the periosteum, raising up the latter from the bone for some dis- tance above and below the fracture. The medullary membrane becomes swollen and separated from the bone, and the periosteum is not only raised up from the bone, but it also becomes red, soft, swollen, and pre- ternaturally vascular. The fragments of bone may thus be said to be surrounded with blood, which not only fills the medullary canal and the space between the fragments, but also separates the latter from detached periosteum. This blood becomes absorbed, and liquor sanguinis is effused into the parts at first occupied by extravasated blood. In the second stage, comprising the interval between the tenth or twelfth day to the twentieth or twenty-fifth, the tumour of callus, as it is called by Dupuytren, is formed. The substance between the perios- teum and bone is converted into a structure like fibro-cartilage, and within the medullary canal there is also developed a fibro-cartilage, but the substance between the fragments retains the appearance of coagula- ble lymph. In the third stage, extending from the twentieth or twenty-fifth to the thirtieth, fortieth, or sixtieth day, according to age and strength, the fibro-cartilage between the periosteum and bone, and that within the medullary canal, are both converted into bone, the external forming a ring, or ferule, or clasp, and the internal a plug, or peg (cheville), filling up the medullary canal, and together constituting what Dupuy- tren calls the provisional callus. The external ring, embracing both fragments, and the plug within the medullary canal, constitute nature's provision for keeping the fragments in apposition and at rest. The substance between the fragments is, during this stage, changed into fibro-cartilage. In the fourth stage, extending to the fifth or sixth month, it is con- verted into bone, constituting what Dupuytren called the permanent or definitive callus. The fifth stage extends from the fifth or sixth month to the tenth or twelfth, during which the provisional or temporary callus, being no longer necessary, disappears, and the medullary canal is restored. Such are the views *of Dupuytren on this interesting subject; and, until lately, they were generally received as the correct explanation of the successive changes that take place, both in man and in the lower animals, from the occurrence of fracture until the injury is completely repaired. Mr. Paget, in his " Lectures on Repair and Reproduction," after in- juries, has brought forward different views from those which formerly prevailed regarding the repair of a fractured human bone, and has sup- ported his opinions by most conclusive evidence. His views on this sub-. ject are in accordance with those of Mr. Stanley. An interesting and full account of them will be found in Mr. Paget's very instructive lectures, delivered at the Royal College of Surgeons of England, and published in the Medical Gazette for 1849. In reference to the description given by Dupuytren and others, of the examination of fractures in dogs, rabbits, birds, and other animals, Mr. 128 FRACTURES. Paget remarks:—"All that is written in these accounts of external and internal, provisional callus and definitive callus, of the formations of cartilage and bone within the medullary tube, and beneath the peri- osteum° can be traced only, as it were, in rudiment in the fractures of the human bones. There is scarcely a specimen in the Museum of such provisional callus formed in the repair of a fractured human bone; in nearly every case of such fracture, the material of repair is only inlaid between the broken surfaces, or between the adjacent parts of the frag- ments, and unites them by being fixed to both. In favourable conditions, this appears to be the usual mode of repair, even though the fragments of the broken bone be very much displaced. I have examined many more specimens, and find the same rule true ; namely, that in the ordinary repair of simple fractures in the human subject, the reparative material, or callus, is merely inlaid between the several fragments; it fills up the interspaces between them and the angles, at which one fragment over- hangs another, but it does not encircle or ensheath them in the manner explained in the description of provisional callus; nor is it in any con- siderable quantity, if at all, deposited either beneath the periosteum or within the medullary tube. In birds, dogs, and other ordinary subjects of experiments, the formation of a provisional, or, as it may perhaps be better called, an ensheathing, callus is usual." In evidence that the reparative material is placed not within and around the fragments, as an ensheathing, but between them, as an in- termediate callus, Mr. Paget not only adduces many fractures long after they have been completely healed, but as these might be deemed in- sufficient, he refers also to many recent specimens, at four, five, six, eight, nine, eleven, twelve, and sixteen weeks, and many others at un- known dates after the fracture. The only exceptions to the difference in the mode of repair of human bones and those of the lower animals, the only instances in the human subject in which, under ordinary cir- cumstances, provisional callus is formed, are in fractures of the ribs, and, although much more rarely, of the clavicfe. According to Mr. Paget, other remarkable differences between the reparative process in man and in the lower animals, are—that in man no change of any importance occurs for a week or ten days," and the periosteum remains without being raised up or in* any way particularly changed, except that it becomes slightly thickened and more vascular. The first new material produced is liquor sanguinis, which, according to Mr. Paget's observations, sometimes passes into perfect fibrous tissue, sometimes into fibro-cartilage, and, occasionally, although very rarely, into true cartilage. On this subject Mr. Paget remarks:—" In different specimens, or sometimes in different parts of the same, the reparative material may display—in one, fibrous tissue, with a few embedded cor- puscles, like the large nearly rounded nuclei of cartilage cells; in another, a less appearance of fibrous structure, with more abundant nu- cleated cells, having all the character of true cartilage cells; and, in a third, a yet more perfect cartilage." Treatment—The local treatment of simple fracture may be said to consist in fulfilling the four following indications :—first, bringing the fragments into a proper position, which is technically called reduction,— FRACTURES OF THE FOREARM. 129 this should be done as soon as possible; second, maintaining the parts in this position, or preventing any displacement; third, preserving the parts at rest until union be accomplished; and fourth, obviating any untoward symptoms. The proceedings to be adopted for fulfilling these indications will be minutely explained in the description which will be given of the treatment suitable for each particular fracture. SPECIAL FRACTURES. FRACTURES OF THE FOREARM. Fractures of the forearm are more frequent than those of any other part of the body. Desault found, in the record which he kept of such cases, that they occupy the first place. Baron Dupuytren arrived at the same conclusion, as the result of his experience at the H6tel Dieu; and Mr. Lonsdale also, who gives a table of nineteen hundred and one cases, found these to be the most frequent, and to form one-fifth of all fractures. In treating of these fractures, it is proposed to consider—First, The Classification, or arrangement of them ; Second, The Comparative Fre- quency of Cases belonging to each Class ; Third, The Symptoms and Nature of the Displacement peculiar to each Fracture; and, Fourth, The Treatment proper to each Class. # I. CLASSIFICATION. Fractures of the bones of the forearm may be divided into three classes:— 1. Fractures of the radius, 2. Fractures of bcfth bones, and 3. Fractures of the ulna. II. COMPARATIVE FREQUENCY OF CASES BELONGING TO EACH CLASS. From the following statistics of the Hotel Dieu, it appears that the cases belonging to the first class are more numerous than those of the second; and the second more numerous than the third. Baron Dupuy- tren records, that in 1829, there were brought to the Hotel Dieu one hundred and nine fractures, of which twenty-three were of the forearm, and of these sixteen were of the radius alone, five of both bones, and two of the ulna alone: and that,'in 1836, there were ninety-seven fractures, of which twenty-two were of the forearm; and of these, six- teen were of the radius, four of both bones, and two of the ulna alone. These results are in accordance with the experience of most surgeons. But Mr. Lonsdale has given a table exhibiting a different result as to the comparative frequency of cases of the second and third classes. He found that of three hundred and eighty-six fractures of the fore- arm, one hundred and ninety-seven were of the radius alone, ninety-six of the ulna, and ninety-three of both bones. These statistics show that by far the greater proportion of fractures of the forearm, are fractures of the radius only;—a fact not difficult to be accounted for, when it is remembered that the radius may not only be broken by direct violence 130 FRACTURES OF THE FOREARM. applied to itself—to which it is also more exposed by its position as the outer bone,—but also by violence applied to the hand, which is sup- ported by the radius. Fractures of the right radius are more frequent than of the left. Baron Dupuytren found that of ninety-seven cases, fifty-nine were of the right, and thirty-eight of the left radius. III. SYMPTOMS AND NATURE OF THE DISPLACEMENT PECULIAR TO EACH FRACTURE. FRACTURES OF THE RADIUS. 1. Situation.—Fractures of the radius may take place in any situa- tion ; they occur more frequently at the lower, than at the upper extre- mity, and still more frequently about the middle of the bone. M. Vel- peau states that fracture of the ulna is found more frequently below than above, and of the radius, on the contrary, more frequently above than below. This he probably inferred from the circumstance that the lower extremity of the ulna is smaller than the upper, while the reverse is true with regard to the radius. Most surgeons, however, maintain that fractures of the radius are not so frequent at the upper as at the lower extremity. Fracture at the neck is an exceedingly rare accident. Sir Astley Cooper says :—" This fracture I have heard mentioned by surgeons, as being of frequent occurrence, but there must be some mistake in the statement, for it is an accident which I have never seen; and if instances ever present themselves, which I do not mean to deny, they must be very rare." M. Velpeau's statement with regard to the ulna agrees with general experience. 2. Causes.—The radius is fractured by violence, applied either directly to the bone itself, or indirectly through the hand ; for instance—when a person falls on the hand, the radius receives the shock from the hand, the upper part receiving the whole momentum of the body from the humerus, while the lower part rests against the hand upon the ground; the radius bends, and, if the force be sufficiently violent, gives way— generally near the middle. This fracture is more frequently occasioned by a fall on the palm than on the back of the hand. Out of fourteen cases, Baron Dupuytren found that three were owing to falls on the back of the hand, and eleven to falls on the palm. Cruveilhier, therefore, was mistaken in believing that the radius could not be fractured by a fall on the back of the hand. 3. Symptoms.—Pain, loss of the power of voluntarily effecting the movements of pronation and supination, and the prone position of the hand, are indicative characters of this injury. There are also other symptoms which deserve attention, namely, a motionless condition of the head of the bone during pronation and supination, crepitus, a diminu- tion of the transverse measurement of the forearm occasioned by the fractured portions falling into the interosseous space, and projection of the fractured ends on the back of the forearm, when the hand is very forcibly bent. If the fracture be in the middle, or in the lower two- thirds, it may be felt by the finger. The motionless condition of the head of the radius may best be ascer- tained by the surgeon grasping the upper part of the forearm with one FRACTURES OF THE FOREARM. 131 hand, having his thumb firmly pressed on the head of the bone, while with the other hand he takes hold of the hand of the patient on the sus- pected side, and forcibly performs pronation and supination. A motion- less condition, under these circumstances, indicates fracture—mobility is a proof of integrity. This is a most useful guide to diagnoses when the fracture is in the upper part, in which case, from the bone being covered by muscles, the other symptoms are more obscure. Crepitus, which can best be discovered during the above method of examination, is a sure symptom of fracture. It has been called crepitus, or hard crepitus, to distinguish it from a soft crackling sensation some- times produced by effusion into the soft parts. The absence of crepitus, however, will not prove the non-existence of fracture ; for crepitus may be prevented altogether by the presence of muscular fibre between the broken extremities, or it may be rendered not very perceptible, in the first instance, by the effusion of blood, or, at a much later period, by the secretion of lymph. Diminution of the transverse measurement of the forearm, occasioned by the fractured portions falling into the interosseous space. This symptom is most apparent when the fracture is near the middle; it can be increased by pressing the bones near the fracture, or by forcibly bending the hand to the radial side of the forearm. When the fracture is in the upper third, this symptom is not very perceptible. When the fracture is very near the wrist, the fractured portions often occasion such a pressure upon the tendons as to prevent the motions of the fingers, and sometimes the swelling from effusion into their sheaths gives the appearance of a dislocation. The accompanying sketch, from Liston, is very characteristic of fracture near the wrist. 4. Position of the fractured portions.—If the fracture be near the middle of the bone, the part above the fracture remains in its natural position; the part below is drawn too far backwards or forwards, follow- ing the movements of the hand when pronated or supinated, and can only be kept in a line with the upper part when the hand is midway between pronation and supination; it is also drawn too near the ulna by the pronator quadratus muscle; hence arises the diminution of the interosseous space. When the radius is fractured at its neck, the infe- rior part is drawn upwards, inwards, and forwards, by the biceps mus- cle, while the head and fractured neck are drawn slightly outwards by the supinator radii brevis. FRACTURE OF BOTH BONES. Causes.—Fracture of both bones may be caused by a blow, or by a 132 FRACTURES OF THE FOREARM. heavy body passing over the forearm,—in which cases the bones are usuallv fractured in the same situation; or by a fall on the hand, when the radius, which in the first instance receives the whole shock, is frac- tured, and the ulna, to which the shock is thus transferred, gives way likewise. In the latter case the bones are not necessarily fractured in the same situation. There is a difference of opinion among surgeons respecting the usual situation of the fractures, when both bones are broken ; some supposing that they are generally in the same situation, while Velpeau and others maintain the contrary opinion. In explanation of this difference it may be stated, that the fractures, if produced by violence applied to the hand, will not be in a line, as the weakest part of each bone will give way; but if the fractures be the result of direct violence, they will in every probability be in the same situation. Symptoms.—The symptoms are,—pain increased on moving the parts, loss of the power of pronation and supination, tumefaction or some un- natural appearance, for the most part an apparent decrease of the dia- meter of the forearm from side to side by the diminution of the inter- osseous space, and increase of the antero-posterior diameter by the muscles being forced out from between the bones ; angular deformity, apparent on raising the forearm; mobility in a part which ought to be inflexible; and crepitus, which can generally be made very perceptible by the surgeon giving a rotatory motion to the hand. The inter- osseous space may be still further diminished by compressing the bones. The forearm is generally semi-flexed, and there is but little shortening of the limb. State of the parts.—The pronator quadratus muscle draws the under parts of the two bones towards each other, and the pronator radii teres draws the part of the radius into which it is inserted towards the ulna; this diminishes the transverse diameter, while the consequent pressing out of the muscles from between the bones occasions the increase of the antero-posterior. Fig. 18. The parts of the bones 'below the fracture can be made to point towards the parts above, only when the hand is in a straight line with the forearm, and midway between pronation and supination. FRACTURE OF THE ULNA. Three fractures of the ulna are met with, namely, of the shaft, and of the olecranon, and coronoid processes. Fig. 18. From Liston. FRACTURES OF THE FOREARM. 133 Fractures of the processes present peculiar symptoms, and require particular methods of treatment; we shall, therefore, delay the consi- deration of them, until after the description of the treatment proper for the other fractures of the forearm. FRACTURE OF THE SHAFT OF THE ULNA. Causes.—This fracture is almost always caused by violence directly applied to the bone, as by a blow or a fall on the inner side of the fore- arm. Symptoms.—The existence of this fracture can be easily discovered, by drawing the finger along the inner part of the ulna, when, from the superficial situation of the bone, an irregularity caused by the fracture is perceptible. There is a depression at the seat of the fracture, and the part below it is too near the radius. Crepitation is usually perceptible on moving the under part backwards and forwards; and sometimes the long axis of the hand is not in a line with the long axis of the forearm, but is drawn inwards. State of the parts.—The fracture is generally in the under part of the bone, where it is most slender, and exposed to injury from its superficial situation. The position of the fractured parts is as follows :—the part above the fracture is preserved in its natural situation by its connexion with the humerus, whereas the part below is drawn towards the radius by the pronator quadratus. IV. TREATMENT OF THE THREE CLASSES OF FRACTURES OF FOREARM. The treatment of all these fractures consists of two parts; the pro- curing and maintaining coaptation. This is procured by bending the forearm at right angles to the arm, and placing the hand midway be- tween pronation and supination ; then using slight extension, if neces- sary, and pushing back the protruded muscles between the bones. To maintain coaptation, we must call in the aid of both attitude and mecha- nism. Attitude.—In each class of fractures the forearm ought always to be at a right angle with the arm, that the muscles of the arm may be uni- formly relaxed; and the hand ought always to be placed midway be- tween pronation and supination, that is, with the thumb upwards and the little finger downwards. If this be neglected, the fractured portions will unite so as to form an angle with each other; and the consequence will be the loss of the power of supination, if the hand be kept in a state of pronation, and of the power of pronation, if it be supinated. The only variation of attitude in the different classes of fractures is in the relative position of the hand and the long axis of the forearm: in frac- tures of both bones the long axis of the hand should be in a line wTith the long axis of the forearm; in fractures of the radius, the hand should be depressed; and in fractures of the ulna slightly elevated. The object aimed at in these peculiarities of position is to prevent the diminution of the interosseous space ; which is accomplished, in fracture of both bones, by uniformly extending the muscles connected with the radius and ulna; in fracture of the radius, by extending the muscles attached to the outer side of the radius, and in fracture of the ulna by 134 FRACTURES OF THE FOREARM. the extension of those on the inner part of the bone; and these condi- tions of the muscles are produced by the above-described attitudes of the hand. The following directions exhibit at one view the attitudes to be observed:— 1. Bend the forearm at a right angle with the arm. 2. Keep the hand midway between pronation and supination. 3. In fractures of both bones, keep the hand in a line with the long axis of the forearm. 4. In fractures of the radius, depress the hand. 5. In fractures of the ulna, raise the hand. Mechanism.—Various appliances have been used to preserve the parts at rest, and in apposition. Some surgeons use paste-board splints, softened in hot water, and then moulded to the forearm ; some employ splints composed of several parallel pieces of wood secured together by a piece of linen or leather, while others make use of two wooden splints, slightly concave on one side and convex on the other. Baron Boyer recommends that a small oblong pad should be applied between the con- cave surface of each splint, and the forearm, in order more effectually to press in the muscles, and to preserve the interosseous space. But if the splints be applied closely, the pressure in the direction of the antero- posterior diameter will be sufficient; nor will any padding be requisite, except a little cotton to prevent the pressure from irritating the skin. In fracture of a single bone the splints should extend only to the wrist; but when both bones are broken, one of the splints should reach to the fingers, that the hand may be kept in a line with the long axis of the forearm;—the longer is usually applied to the front of the forearm. To preserve the mechanism in its proper situation various means have been employed. The common roller and starch-bandage are both ob- jectionable, inasmuch as they tend, by pressing the radius and ulna toge- ther, to dimmish the interosseous space ; besides which they keep up a degree of heat about the part, and create trouble in taking off the splints, which must occasionally be done to ascertain whether the part presents the desired appearance. The loop-bandage is not liable to the same ob- jections, but the most convenient and elegant manner of treating these fractures is to use the wooden splints, retaining them in the proper posi- tion by the buckle-bandage. Two or three may be used, and the fore- arm should be kept in a sling. DIRECTIONS AS TO MECHANISM. 1. In fractures of one bone, apply two splints of equal length, not extending beyond the wrist. 2. In fractures of both bones, use two splints of unequal length, the larger being applied to the front of the forearm, and reaching to the ends of the finger; the other need not be extended beyond the wrist. The objects aimed at by treatment in these fractures are to obtain coaptation, to preserve the interosseous space, and to keep the parts at rest in a proper position. For the attainment of these ends, attitude and mechanism are both necessary; the former should be used from the very beginning of treatment; but the application of mechanism should FRACTURES OF THE FOREARM. 135 be delayed until either the danger of inflammation supervening is over, or the inflammation, if it has already taken place, has been subdued. [Dr. J. R. Barton, of this city, has called the attention of the profes- sion to the treatment of fractures at the lower end of the radius. Two splints are recommended, which should reach beyond the ends of the fingers. But previously to this application, one compress should be adjusted upon the lower fragment, and another against the lower extre- mity of the upper fragment. Owing to the proximity of this fracture to the wrist, it is found that the stiffness of the joint is very great; and tjiat notwithstanding the surgeon's efforts at passive motion, considerable inconvenience frequently results. Dr. Henry Bond, of Philadelphia, has recently read a paper before the College of Physicians, giving an account of a new splint for this fracture.1 He objects to the present mode of treatment of this fracture, on the grounds that the muscles are rendered tense, and that, in order to pre- vent derangement of the fragments, the hand must necessarily be tightly bandaged in a constrained position, and that pressure on the bursae of the tendons of the fingers must increase the danger of that protracted or permanent rigidity that often renders the hand and fingers unsightly, inconvenient, or useless. " The muscles that act on the hand are least tense, or most in repose, when the hand is inclined backwards, so that the metacarpe forms a considerable angle with the forearm,2 when it is also inclined inwards towards the ulnar side of the arm, and when the fingers are moderately flexed. In this case, it will be perceived that the longitudinal axis of the forearm, if prolonged, would not correspond with that of the hand, but would pass through, or very near, the point where the thumb and index finger most easily and naturally meet. Thus, in the innumerable manipulations with the thumb and fingers (as with a pen, pencil, button, needle, money, &c, &c), their points most easily and natu- rally meet in this axis of the forearm. This will be found to be the position of the hand, when it hangs by the side with all the muscles re- laxed. "But if the hand can be placed and retained in the unconstrained natural position above mentioned (to say nothing of the better chance of escaping permanent stiffness), in the first place, the unsightly deformity will be avoided; and in the next place, the hand will not entirely have lost its uses. For the hand, thumb, and fingers being placed very nearly in the position of their most frequent uses, the interossei, the lumbricales, and the several short muscles of the thumb will, by causing only a very limited motion, enable the hand to perform very many of its useful functions." In order to fulfil these indications, Dr. Bond has devised a splint and dressing. A splint is cut out of a light thin board, of the shape of that represented in Fig. 19. The particular size and form can be obtained from the profile of the sound forearm and hand, when placed in its natural situation, the hand inclining towards the ulna. The lower end 1 Trans. Coll. Physicians, Jan., 1852. 2 Malgaigne calls this, "laflexion habiluelle de la main en arriire.u 136 FRACTURES OF THE FOREARM. Fig. 19. of the splint should be cut obliquely and reach to the second joint of the fingers, so as to allow them to be flexed. This splint is then to be carefully covered with muslin or sheeting, which is to be fastened by tacks or glue, so that the roller can subse- quently be applied with little danger of its slipping, and if necessary pins may be used to prevent its derangement. A carved and rounded block (B, Fig. 20) is nailed or screwed to the extremity of the palmar surface of the splint, of such a size and form as to retain the hand in its habitual inclination backwards, and to give the fingers Fig. 20. that moderate flexure which most relieves the muscles from tension; and also that position, which, if stiffness should result, will not only save the hand from a most inconvenient and ungraceful deformity, but will reserve to it the power of performing very many of its most frequent and useful functions. A piece of binders' board, wider than the splint, is to be tacked to its palmar surface, and the projecting edges (D, Fig. 20) bent up so as to form a kind of box for the lodgment of the arm. The pasteboard is not an essential part of the splint, but may contribute to the comfort of the patient. The splint is then to be lined with flannel, which should also cover the block. Two compresses, of the proper form and material, constitute the remainder of the dressing, unless the fracture be far above the Avrist, and then a dorsal splint may be necessary to preserve the interosseous space.—Ed.] FRACTURE OF THE OLECRANON PROCESS. Causes.—This, which is by no means an uncommon fracture, is usually caused by a blow or a fall upon the elbow, and sometimes, although very rarely, by violent contraction of the triceps extensor cubiti muscle. Varieties— This fracture may be, in direction, either transverse or oblique, and in situation, at the base, middle, or apex of the process. Transverse fracture in the middle of the process is the most frequent, both as to situation and direction. FRACTURES OF THE FOREARM. 137 Symptoms.—An unnatural hard swelling, caused by the olecranon, in the under and back part of the humerus, sometimes half an inch above the joint, and sometimes two inches from the part from which it is broken off; the distance is increased by bending the forearm, or by a voluntary effort on the part of the patient to accomplish extension of the joint. This swelling can easily be moved from side to side, but it cannot be pressed downwards without difficulty, especially if the extre- mity be in such a position as to keep the triceps on the stretch. Bulging of the triceps above the hard tumour is a good diagnostic symptom. An interspace on the back part of the joint between the olecranon, and the extremity of the ulna; this space is increased by a voluntary Fig. 21. effort on the part of the patient to extend the elbow, which merely draws up the broken fragment; or by the surgeon taking hold of the forearm and bending it, and it is diminished by extending the forearm. The surgeon, on pressing his finger into the interspace, feels as if it were sinking into the joint. Loss of the power of extending the limb is another symptom; and the voluntary effort to do so causes pain, and merely draws up the ole- cranon. In some cases the power of extension is not entirely lost. This can only happen when the expansion of the triceps is not so completely destroyed as to disconnect the process from the rest of the bone. Sir James Earle has recorded a case in which the loss of exten- sion did not take place until the sixth day, when it was sudden, and attended with sudden flexion of the forearm. Crepitus may be discerned, if the extremity be very violently ex- tended, and the parts pressed together with considerable force; but attempts to do this occasion great pain. The forearm is usually half bent, and there is often great swelling about the joint, from increased secretion of synovia, and frequently ecchymosis to a considerable extent; but these last two symptoms will vary according to the degree of violence by which the accident was oc- casioned. Mode of union.—Reunion in this fracture is almost always by a ligamentous substance, the length of which will vary according to the distance of the broken parts from each other. It is very desirable to Fig. 21. From Liston. 138 FRACTURES OF THE FOREARM. have it as short as possible, because, in proportion to its length, the arm will be weakened. When the interspace is short, the ligamentous substance is firm, strong, and short; but if it be long, there may be openings through it, so that the reunion will be kept up by ligamentous cords. On account of the difficulty of preserving the parts in apposition, no other than a ligamentous union is generally to be expected. In some cases, however, when the fracture had happened very near to the shaft of the ulna, Sir Astley Cooper has known the union take place in the living subject by bone ; but it is so rare an occurrence that it is scarcely to be hoped for. It seems evident from the following experiments, made by Sir Astley Cooper, that the difficulty of preserving the parts in ap- position, is the obstacle to osseous union. " The integuments having been drawn laterally and firmly over the end of the olecranon in a dog, I made a small incision, and placed a knife, on the middle of that pro- cess, in a transverse direction; on striking it with a mallet, the bone was readily cut through, a separation directly took place by the action of the triceps muscle, adhesive matter was effused, and, when I examined the limb about a month after, I found the bone united by a strong liga- ment. I broke the olecranon in the same way in several rabbits ; blood was, in these experiments, first thrown out, and then adhesive matter filled up the space of separation, which subsequently became ligamen- tous, and gradually firmer and firmer, as the time was protracted between the experiment and the time of the examination. As I found the liga- ment was formed in each of these experiments, I was anxious to learn whether the olecranon could be made to unite by bone, if a longitudinal fracture were produced with but slight obliquity, so that the broken por- tions might still remain in contact; and I found that, under these cir- cumstances, the osseous union speedily took place. Therefore this bone, like the extremity of the os calcis, when it is broken off, is detached by the action of the muscles, and ligamentous union ensues from want of adaptation." Treatment.—The principal indications in the treatment are— First, If there be much inflammation and irritation at first, to delay all mechanical applications, until they are subdued by leeches, evapo- rating lotions, purgatives, and other remedies, which should be employed with activity proportioned to the violence of the symptoms. Secondly, To maintain the fractured surfaces as close together as possible by the judicious position of the limb, and the absolute inaction of the triceps muscle aided by mechanical appliances. The extremity must be kept very much extended, and for some time this can best be done by keeping the patient in bed. It is necessary not only to keep the forearm extended, but also to bring back the arm, that the shaft of the ulna may be brought as near as possible to the attach- ments of the triceps, both to the humerus and scapula, so that the least obstacle may be offered by that muscle to the bringing down of the olecranon. Sir Astley Cooper recommends that the parts be kept in apposition, by placing tape or slips of linen longitudinally on each side of the joint, and applying over these a roller round the arm, immediately above and below the fracture only, and then tying the ends of the slips above the fracture to those below, so that the rollers, under which they pass, are FRACTURES OF THE FOREARM. 139 brought nearer to each other, and the detached fragments may be thus kept in the desired position. Thirdly, to preserve the joint at perfect rest; and for that purpose a straight splint should be applied in front, and retained by a suitable bandage. Fourthly, To begin passive motion of the joint in the course of a month, and for this purpose the splint is to be removed; but as there is great danger of weakening and lengthening the newly-formed bond of union, all attempts at motion must be made with the greatest care. The above plan of treatment, in which the extended position and straight sjplint are employed, is that which is recommended by Sir Ast- ley Cooper, and practised by most British surgeons ; but it is objected to by Desault, Camper, and others, who recommend that the forearm should be kept midway between semiflexion and complete extension, and that this position should be preserved by means of an angular splint. Desault and Camper, the advocates of this method, give the following reasons for preferring it to that usually practised by British surgeons. 1st. The method which they recommend will bring the fractured parts more in a line with each other. The brachialis anticus, in its way from the sides of the deltoid impression to the coronoid process, passes over the eminence formed by the lower extremity of the humerus; and they say that the muscle, being put violently on the stretch, will draw for- ward the ulna, if the olecranon be fractured near its base, and, conse- quently, the ulna and the broken fragment will not be in a line with each other, the shaft of the bone being brought too far forward. This objection does not apply to the method recommended by the French. 2dly. They also state that in the attitude recommended by the Bri- tish surgeons, the broken parts can only be made to touch each other posteriorly, so that they form a retiring angle opening into the joint, into which, therefore, the substance effused for uniting the fractured portions will be thrown, and thus the future movements of the joint be permanently impeded; whereas, in the attitude of Desault, the two portions will meet in front, and form a retiring angle directed back- wards, and thus the future movements of the joint will be unaffected by the new formation. FRACTURE OF THE CORONOID PROCESS. Causes.—This is a rare accident, but two cases are recorded by Sir Astley Cooper, and one by Mr. Liston. Of the two instances recorded by Sir Astley, one was the case of a gentleman, who fell on his hand while the arm was extended. The coronoid process, being driven against the humerus, received the shock, and gave way. The other instance was found in a subject brought to the dissecting-room at St. Thomas's Hospital, and the cause was unknown. The case mentioned by Mr. Liston, was that of a boy eight years of age, and the fracture was occa- sioned by his hanging for a long time by his hands, from the top of a high wall, being afraid to drop down. Symptoms.—The forearm is extended, and the ulna projects back- wards ; but when the forearm is bent and brought forward, which is easily done, the deformity^ disappears; the limb, however, again becomes extended, and the deformity returns, when the force employed to bend 140 FRACTURES OF THE HUMERUS. and bring forward the part is removed. The isolated process is felt in front of the joint, or higher up, according to the state of contraction of the brachialis muscle inserted into it. Treatment.—The objects to be aimed at by treatment are,—to relax the brachialis anticus muscle, to preserve the parts at rest, and to keep the isolated fragment as much as possible in apposition with the part from which it has been detached. These objects may be best attained, by keeping the forearm very much bent, and applying angular wooden splints, very well padded, or pasteboard splints moistened in hot water, and moulded to the elbow. This treatment should be continued for about a month, and passive motion should then be employed; but this must be done with the great- est caution, lest the ligamentous substance, which reunites the parts, should become weakened and lengthened. FRACTURES OF THE HUMERUS. These injuries, according to Mr. Lonsdale, form about one-sixteenth of all fractures, so that they occur less frequently than the correspond- ing injuries of some of the other bones. Of one hundred and eighteen cases of fracture of the humerus, mentioned by Mr. Lonsdale, eighty- nine were of the shaft, sixteen of the condyles, and thirteen of the sur- gical neck. That the description of the different fractures of this bone may be more distinct, it will be cbnvenient to arrange them in the following classes :— 1. Transverse fracture of both condyles. 2. Oblique fracture of either condyle. 3. Fracture of the under third of the shaft. 4. Fracture at the middle of the humerus. 5. Fracture below the insertions of the three muscles into the margins of the bicipital groove. 6. Fracture above the insertions of the three muscles into the margins of the bicipital groove, or, as it is called, fracture of the surgical neck of the humerus, a name given to all that part between the insertions of these three muscles and the tuberosities. 7. Fracture of the anatomical neck of the bone. The bone may be broken in any part of its length, but all its fractures may be included in one or other of the above-named classes. I. TRANSVERSE FRACTURE OF BOTH CONDYLES. Symptoms.—The symptoms of this fracture are, an unnatural promi- nence behind the joint; immediately above this, an unnatural foss or depression; and preternatural shortening of the front of the forearm. These three symptoms are common to this fracture and dislocation back- wards of the radius and ulna; but there is in fracture, the following sure diagnostic guide; if the arm be fixed, and the forearm be drawn in the line of displacement, the symptoms disappear; but they return, as soon as the extending force is removed. If the arm be fixed, and the forearm pressed backwards and forwards, or if it be rotated, crepitation may be perceived ; and, if the arm be raised, and the forearm forcibly depressed, an angular deformity will be observed. FRACTURES OF THE HUMERUS. 141 Desault and others mention frequent cases of this fracture, in which the condyles were not only broken off by a transverse fracture from the rest of the humerus, but also separated from each other by a vertical fissure. In these instances, we have in addition to the before-named symptoms, a still greater mobility of the parts, increased deformity, the bulging out of the joint laterally augmented by pressing in the direction of the longitudinal fissure. State of the fractured portions.—In simple transverse fracture, the condyles are drawn backwards; in transverse fracture of both condyles with a longitudinal fissure between them, they are drawn backwards, and very slightly separated from each other. In this latter case the humerus is separated into three pieces. Treatment.—Bend the forearm at a right angle to the arm, draw it forward until the parts be brought forward into their proper places and into apposition, and preserve them in this condition by applying a few turns of a roller round the lower part of the arm and the upper part of the forearm, and by employing two wooden splints,—one, straight, to be placed in front of the humerus, the other composed of two parts at a right angle with each other, the upper part to be placed behind the hu- merus, and the lower part below the forearm; both splints to be retained by buckle bandages. Evaporating lotions should be applied, and the extremity kept in a sling. The above is the treatment recommended by Sir Astley Cooper; it should be continued in the case of an adult for about a month, and with a younger patient for nearly three weeks, after Avhich time passive mo- tion should be tried, that the joint may recover its power of moving. I have treated this fracture very successfully by means of Weiss's splint, which is a most convenient apparatus for the purpose, inasmuch as it admits of the elbow being slightly moved when that is thought to be judicious, without the necessity of taking off the splint. Desault has recommended two angular splints with joints, and some Italian surgeons apply two angular splints, the one before and the other behind the joint. If the condyles be separated, care must be taken to keep up lateral pressure. Although in some instances this injury is so seriously complicated with laceration and contusion as to make it necessary to remove the limb, yet, from the small size of the joint and the accessible situation of all the parts with regard to surgical treatment, it is—except in cases of extreme complication and disorganization—comparatively safe in its results, and amputation is unnecessary. II. OBLIQUE FRACTURE OF EITHER CONDYLE. Before describing this fracture of the condyles, it may be proper to state, that modern anatomists have named the articulatory surfaces at the lower part of the humerus, the trochlea, and condyle, the former being the inner, the latter the outer articulatory surface, whilst the prominences beyond, or the eminences of attachment for the muscles, are named the epicondyle and the epitrochlea. The old nomenclature, however, is that followed by surgeons, namely, external and internal condyle, each condyle furnishing an articulatory surface and an emi- nence of attachment for muscles. 142 FRACTURES OF THE HUMERUS. Fracture of either condyle may be either slight, as when the emi- nence of attachment only is broken off; or extensive, as when the arti- culatory surface is detached. • FRACTURE OF THE INTERNAL CONDYLE. Symptoms.—When the fracture detaches but a small portion, the symptoms are a slight unnatural prominence, with crepitation and mobility, perceptible on grasping the part and bending the fore-arm backwards and forwards. When the fracture is extensive, the forearm is bent, and the hand drawn a little inwards, and inclined to pronation; when the forearm is extended, the broken condyle projects backwards, and with it the ulna, occasioning the appearance of dislocation of the ulna, which, how- ever, resumes its natural position when the forearm is bent. Additional symptoms are, mobility, crepitus, and pain on grasping the condyles and bending and extending the forearm ; and slight projection forward of the condyle in front of the ulna, if it be very violently extended. The nature of the displacement must be evident from what has been already stated. FRACTURE OF THE EXTERNAL CONDYLE. Symptoms.—When the fracture is slight, the symptoms are,—some degree of swelling about the external condyle, attended with pain; cre- pitation and mobility, perceptible on grasping the condyles and per- forming pronation and supination of the hand. When the fracture is extensive, in addition to the above symptoms, the condyle is a little drawn backwards, and the radius with it; the forearm is slightly bent; and the hand is drawn outwards and inclined to supination. Treatment of slight and extensive fracture of each condyle. 1. In both fractures of each condyle, preserve the forearm at a right angle with the arm. 2. In extensive fracture of each condyle, apply a few turns of a roller round the joint, and then a wooden splint, the parts of which are at a right angle with each other, placing one part behind the humerus and the other below the forearm, and retain it by buckle bandages. 3. In slight fractures of each condyle mould pasteboard splints to the joint, and retain them by a few turns of a roller or buckle bandages. 4. In both fractures of the internal condyle pronate the hand and bend the fingers. 5. In both fractures of the external condyle supinate the hand and extend the fingers. III. FRACTURE OF THE UNDER THIRD OF THE SHAFT OF THE HUMERUS. Symptoms.—Fracture in this situation is easily detected bY inability on the part of the patient to raise the arm; by unnatural mobility at a part, which in the sound state is inflexible; by angular deformity on taking hold of the upper part of the humerus, and raising the arm' FRACTURES OF THE HUMERUS. 143 and by crepitation on grasping the bone above and below the fracture, and moving the parts on each other. Relation of the fractured portions.—In this situation there is little or no tendency to displacement, the parts above and below the fracture being equally embraced by the triceps behind and the brachialis anticus before. In fact, there is no tendency to displacement backwards, for- wards, or to either side, and seldom any in a longitudinal direction, unless the fracture be very oblique, when, as the resistance offered by the bone to the contraction of the muscles is removed, there is a tendency to shortening of the arm. Treatment.—This fracture is treated by applying two wooden splints, the one before, the other behind the humerus, and retaining them by means of buckle bandages, at the same time keeping the extremity in a sling, which should not be so short as to press up the elbow, but merely to support the weight of the limb. If the elbow should be pressed up by the sling being too short, and if the fracture should be oblique, the pressing of the fractured parts against each other may cause a shorten- ing of the arm. IV. FRACTURE OF THE MIDDLE OF THE HUMERUS. Symptoms.—The same as in the preceding injury. Nature of Displacement.—The displacement is rather more than in the fracture of the under third, the part below the fracture having a tendency to be drawn a little outwards. Treatment.—The same as in the preceding injury, except that the splints should be applied to the outer and inner sides of the arm. Some surgeons employ four splints in this fracture, one to the outside, one to the inside, one to the back, and one to the front of the arm. V. FRACTURE BELOW THE INSERTIONS OF THE THREE MUSCLES AND ABOVE THE INSERTION OF THE DELTOID. Symptoms.—In addition to the symptoms exhibited by the two pre- ceding injuries—mobility at a part naturally inflexible, inability to raise the extremity, crepitation, and angular deformity on raising the upper part of the humerus—this fracture has two symptoms peculiar to itself, namely, an unnatural swelling on the outside of the arm below, and another on the inner side above the fracture. These swellings are ex- plained by the nature of the displacement. Nature of Displacement.—The muscles which cause displacement are four, namely, three inserted into the margins of the bicipital groove, the pectoralis major, latissimus dorsi, and teres major, which draw the upper part inwards, and the deltoid inserted below the fracture, which draws the lower part outwards, and, if the fracture be oblique, upwards:—in this case there will be slight shortening of the forearm in addition to the other symptoms. Treatment.—The first object of treatment is to obtain coaptation, which is easily effected by extension and counter-extension; then to preserve the extremity in the proper attitude, that is, with the arm by the side and the forearm at a right angle with the arm; and to keep the parts at rest and in apposition. Desault's apparatus for preserving 144 FRACTURES OF THE HUMERUS. the extremity at rest in the proper attitude, and maintaining apposition, consists of two long rollers—a wedge-shaped pad which will extend the whole length of the arm,—three splints, two of which should be the length of the humerus, the third shorter, and a sling, not too short, otherwise it will, especially if the fracture be oblique, produce displace- ment of the fractured portions by raising the elbow and forearm too high. Method of application.—Desault's directions are the following. Hav- ing damped one of the rollers with a little lead lotion to prevent its slipping, apply two or three turns round the forearm, then along the whole of the arm as far as the axilla, lapping the edges well over in order to keep up equable pressure; then take one or two turns of the roller under the axilla of the opposite side; place the short splint on the front, one of the long splints on the back of the arm, and the other long one on the outer part; taking care that the latter two extend along the whole length of the arm ; and secure the three splints in their respective places by bandaging the arm from the top downwards with the same roller, finishing on the forearm where it commenced. The wedge-shaped pad should then be placed between the arm and the thorax, having its base upwards in the axilla, that it may prevent the three muscles from drawing inwards the part above the fracture ; and then the second roller should be applied round the arm and chest to bandage them together, especial care be taken to apply it loosely above the fracture, that it may not press inwards the upper fragment; but very firmly below, that it may prevent the lower portion from being drawn outwards. The fore- arm should then be supported by a sling, which, however, must not be so short as to press the elbow too much upwards. The above, which is Desault's treatment, answers very well, and is generally preferred. A simpler plan, which is also found to be successful, is, after obtaining coaptation and placing the extremity in the proper position, to apply four splints, one to the inner side, one to the outer, one to the front, and one to the back of the arm, and to retain them by means of buckle bandages; then, after placing between the arm and chest a pyramidal pad with its base upwards, to bandage the arm and chest together, being careful, as in the other method, to make the bandage loose above and tight below the fracture; and, lastly, to support the forearm by a sling, which must not be too short, for the reasons before stated. VI. FRACTURE ABOVE THE INSERTIONS OF THE THREE MUSCLES INTO THE BICIPITAL GROOVE, AND BELOW THE TUBEROSITIES; OR, AS IT IS OFTEN CALLED, FRACTURE OF THE SURGICAL NECK. Symptoms.—The symptoms differ from those of the last-described injury only in this, that the unnatural swelling on the outside of the arm is above the fracture, and that on the inner side below it. Nature of Displacement.—This is the very opposite of what is ob- served in the former injury ; the part above the fracture is drawn out- wards by the three muscles inserted into the greater tuberosity, namely, the supra spinatus, the infra spinatus, and the teres minor; and the part below is drawn inwards by the three muscles inserted into the FRACTURES OF THE HUMERUS. 145 borders of the bicipital groove, namely, the pectoralis major, the latissi- mus dorsi, and the teres major. Treatment.—The treatment differs from that of the former fracture in only two respects:—the apex of the pyramidal pad should be up- wards ; and the roller which is put round the arm and chest to bandage them together, should be applied loosely below the fracture, that the lower fragment may not be drawn inwards, and very firmly above, to prevent the upper fragment from being drawn outwards. VII. FRACTURE OF THE ANATOMICAL NECK, OR BETWEEN THE BALL AND TUBEROSITIES. The possibility of fracture in this situation is no longer a matter of doubt. Bichat saw, in the possession of Larbaud, the humerus of a young man, seventeen years of age, the ball of which was broken off from the rest of the bone. Delpech records an instance proved by dissection. Professor Samuel Cooper refers to the case of a boy shown to him with a fracture of the neck, and Sir Astley Cooper's work contains several interesting cases. I have in my museum an interesting specimen of this comparatively rare fracture. The injury is almost always caused by direct violence. It is most frequently met with in youth, sometimes in old age, but very rarely in the middle period of life. Sir Astley Cooper's work contains the description of a case in an old person, where the existence of the fracture was proved by dissection. Symptoms.—Acute pain is experienced, and sometimes at the moment of the accident a sound is heard as of something breaking. There is sudden inability to move the limb, which lies powerless by the side, though it yields in the freest manner to any motion communicated to it. When the limb is moved, crepitation is generally very perceptible, but every movement creates great pain. On examining the shoulder near the outer part of the coracoid process, a projection of bone is usually felt, which disappears on extending the arm, but returns when the extending force is removed; and immediately below the acromion pro- cess it is observed that there is no vacuity, in consequence of the ball remaining in the glenoid cavity. This is a diagnostic symptom between fracture of the neck of the humerus and dislocation of the shoulder. There may be a flatness of the arm on the outer side farther down, occasioned by the drawing in of a part of the deltoid by the upper extremity of the portion of bone below the fracture. If there be not very great swelling, it may be possible to feel the ball motionless in rotating the arm. Fig. 22. United fracture of anatomical neck of Humerus. From a preparation in my museum. 10 146 FRACTURES OF THE SCAPULA. Nature of Displacement.—The ball remains in the glenoid cavity, and the shaft is drawn forwards and upwards to the front and outer side of the coracoid process. Treatment.—On this subject Sir Astley Cooper says, lhe best mode of treating these accidents consists, in the young, in applying a splint on the fore and back part of the arm, binding it on by a roller, placing a pad in the axilla, and using a clavicular bandage, supporting the hand, but not the elbow, in a sling, since, if the elbow be raised,_the broken end of the bone is pressed forwards. In old persons the injury is more severe, and the force producing it is violent; it therefore becomes neces- sary to reduce inflammation, and to apply leeches and evaporating lotions, to observe perfect rest at first, and after some time the same treatment as to bandages may be pursued as in the young. In both the old and the young, passive motion is to be employed so soon as the union is effected, which in youth is in a month, but it requires from two months to twenty weeks in old age. In all fractures about the upper part of the arm and shoulder, it is judicious to support the vessels of the hand and forearm by a bandage. If this precaution be neglected, the pressure on the axillary and cephalic veins will be apt to produce engorgement of the more distant parts, for the removal of which it is sometimes necessary to take off for a time all retentive apparatus, and to confine the patient to the recumbent posture." FRACTURE OF THE SCAPULA. The comparative frequency of fractures of the scapula is thus stated by Mr. Lonsdale. Out of one thousand nine hundred and one cases of fractures generally, eighteen were of the scapula, and of these eight were of the acromion process, eight of the body, and two of the cervix. Fractures of the scapula may be divided into five classes:—fractures of the acromion process—of the inferior angle—of the body—of the coracoid process—and of the cervix. The first two classes are of most frequent occurrence. The body of the bone from its depth, covered position, and mobility, is by no means very liable to fracture, and the coracoid process and cervix are very seldom broken; hence Boyer remarks, they generally require great violence to break them, and then the contusion of the soft parts is a worse injury than the fracture; for example, he has seen the coracoid process broken by the blow of the pole of a carriage, and the patient lose his life by the violence inflicted on the soft parts about the shoulder. —(Mai. Chir. t. iii.) FRACTURE OF THE ACROMION. Symptoms.—The patient feels as if the shoulder were falling down, complains of a great sense of weight, and has little power to raise the arm. On tracing the spine from its base to the acromion process, it is observed that the part between the fracture and the clavicle is depressed, from being drawn down by* the weight of the extremity, and the con- traction of the deltoid muscle. The roundness of the shoulder is lost; the ball of the humerus falls as far down into the axilla as the capsular ligament will permit; and the measurement from the sternal end of the FRACTURES OF THE SCAPULA. 147 clavicle to the extremity of the injured shoulder, compared with the sound side, will be found to be diminished. On placing one hand over the acromion, and pressing up and rotating the humerus with the other, crepitation will be perceptible. When the humerus is raised, the deformity of the shoulder disappears ; but it returns when the arm is allowed to fall down. Nature of Displacement.—The scapula and the remaining portion of the acromion ar,e drawn upwards and a little backwards by the trapezius and levator scapulae; while the fractured part is drawn downwards and a little forwards by the weight of the extremity and the deltoid muscle. Treatment.—The objects to be attained in this case are,— First, To raise up the broken fragment, and keep it in its proper position. This can best be done by raising up the elbow, and keeping it raised by a short sling; the ball of the humerus is thus pressed up, and made to act as a splint in keeping the fractured parts in apposition. Secondly, To relax the deltoid muscle. This is best effected by placing a cushion between the elbow and the side. Thirdly, To keep the arm at rest in rather a backward position. This is easily done by bandaging it to the chest with a roller. And, Fourthly, To exert some pressure over the acromion, by which close coaptation may be secured ; and this may be effected by a few turns of the roller by which the arm is bandaged to the chest. It is quite possible to treat this fracture in a satisfactory manner by means of a cushion and a single roller, the latter being applied so as to bandage the arm to the chest, to raise up the elbow, and also to exert pressure over the acromion. Mr. Liston proposes the same simple apparatus as he recommends in fracture of the clavicle, which shall be described in treating of the fractures of that bone. FRACTURE OF THE INFERIOR ANGLE. Symptoms.—In this injury the detached angle can for the most part be felt to be too far forwards; but the most diagnostic mark is, that it remains stationary, if motion be communicated to the scapula; or, if the angle be moved, the scapula is unaffected by that motion. Nature of Displacement.—The body of the scapula remains in its natural situation, and the inferior angle is drawn forward,—a displace- ment caused, if the fracture be very near the angle, by the fibres of the serratus magnus; and if it be higher up, by the same fibres. and the teres major and latissimus dorsi muscles. Treatment.—The angle is too small to be easily kept back, and coap- tation is attempted by bringing the scapula forwards and downwards, and by keeping it in that position. The arm is pressed downwards, for- wards, and inwards, and in that situation bandaged to the chest, while by means of the roller by which the arm is secured, and one compress behind the body of the scapula for pressing it forwards, and another before the angle for keeping it backwards, the parts are maintained in apposition and at rest. 148 FRACTURES OF THE SCAPULA. FRACTURE OF THE BODY OF THE SCAPULA. Fig. 23. The fractures in this situation may be either transverse or longitudinal; the latter, which is the less frequent, can generally be distinguished by crepitus, to which will be added, in transverse fractures, • an irregularity of the posterior costa of the bone. There is little tendency to displace- ment, because all the parts surround- ing the fracture are embraced by muscles, both on the outer and inner aspects of the bone ; and all that is necessary in the way of treatment is to keep the arm in a sling, and the scapula forward by a few turns of a roller round the chest. If the frac- ture be completely transverse, then the under parts will be drawn for- wards, and the same treatment will be required as for fracture of the angle. FRACTURE OF THE CORACOID PROCESS. The distinctive characters of this injury are,—pain, which is increased by stretching back the arm, or by any voluntary effort to raise it; and mobility of the coracoid process when the scapula is rendered immovable. This unnatural mobility is very perceptible on fixing the scapula, and moving the arm backwards and forwards. When the arm hangs by the side, the apex of the coracoid process can be felt lower than on the sound side. The fracture is easily discoverable. Nature of Displacement.—The scapula remains in its natural position, but the coracoid process is drawn downwards by the coraco-brachialis, and biceps muscles, and downwards and inwards by the pectoralis minor. Treatment.—The great object is to relax the coraco-brachialis, biceps, and pectoralis minor muscle, so as not to keep up the displacement. For this purpose the forearm should be bent on the arm, and the arm placed across the chest, and the scapula pressed downwards and forwards; the parts being maintained in that position by bandages. Gentle compres- sion by a pad placed below the coracoid process is also useful for keeping the fragment in a proper position. Another important part of treatment is to keep the patient for some time in bed, with the shoulders bent downwards and forwards by means of pillows. There seems to be no reasonable prospect of osseous reunion. The new connexion is formed by a ligamentous substance. Fig. 23. Union of fracture of body of Scapula. From a preparation in my museum. FRACTURES OF THE SCAPULA. 149 FRACTURE OF THE NECK OF THE SCAPULA. By this injury is not to be understood fracture of the anatomical neck of the scapula, which is situated beyond the glenoid cavity, and before the coracoid process, but fracture of what has been called the' surgical neck ; that is the narrow part of the bone, into the formation of a part of which the semilunar notch enters, and which is behind the root of the coracoid process. In this fracture the glenoid cavity and the coracoid process are both broken off from the rest of the bone. This is, comparatively, a very rare injury; so that some excellent authorities have doubted the possibility of its taking place as the result of direct violence; but its occurrence has now been proved by dissection. I have seen three examples of this fracture. One was in a woman up- wards of forty-five years of age—another, in a man upwards of fifty— and a third, in a'lad of sixteen. They were all caused by falls on the upper and back part of the shoulder. That in the case of the lad hap- pened in consequence of falling over a deep embankment. The symp- toms were exceedingly well marked, and all the patients became per- fectly well: but in the case of the female not until the lapse of four months. Symptoms.—The signs of this injury are—flattening and falling down of the shoulder; an unnatural depression under the acromion, and an unnatural tumour in the axilla caused by the head of the humerus; symptoms which can all be made to disappear, by pressing up the arm, but which return as soon as the support to the arm is removed. The same appearances are presented in dislocation downwards of the humerus; but the fracture is easily distinguished by observing with what facility the arm can be raised, and the symp- toms be made to disappear, and how FiS- 24- immediately they return when the arm is left to itself. Besides these pecu- liarities, which are not found in dislo- cation, there is another symptom which clearly indicates fracture, namely, crepi- tation. Sir Astley Cooper remarks, that the best method of discovering the crepitus is, for the surgeon's hand to be placed on the top of the shoulder, and the point of the fore-finger to be rested on the coracoid process; the arm being then rotated, the crepitus is directly perceived, because the coracoid process being attached to the glenoid cavity, and being broken off with it, though it remains itself uninjured, the crepitus is communicated through the medium of that process. Nature of Displacement.—The body of the bone remains in its natural posi- 150 FRACTURE OF THE CLAVICLE. tion, and the broken fragments is drawn downwards and inwards by the weight of the extremity. Treatment.—-In the treatment of this fracture, three things are to be done : first, the head of the humerus is to be kept outwards ; secondly, the glenoid cavity and the neck of the scapula are to be raised by elevating the humerus ; and thirdly, the parts.are to be kept at rest. The appliances necessary for these purposes are,—a pad in the axilla for keeping out the head of the humerus; a short sling for maintaining the arm in a raised position; and a roller to preserve the parts at rest by bandaging the arm to the chest. In the adult, the time required for recovery from this accident is about three months.. FRACTURE OF THE CLAVICLE. As the clavicle is unprotected by soft parts, unsupported in its middle, is of considerable length in comparison with its thickness, and from its position between the scapula and sternum, has to sustain any shock received on the shoulder, or on the glenoid cavity of the scapula—as when a person falls on the hand with the arm extended—it is very liable to fracture. According to Mr. Lonsdale, of all fractures that occur in the vicinity of the Middlesex Hospital, one-seventh are frac- tures of the clavicle. Causes.—This fracture may be occasioned by direct violence, as by a blow; or by striking against a hard substance in a fall; or by indirect violence, or counter-stroke, as by a fall on the point of the shoulder, when the clavicle has to sustain the force of the shock, or by a fall on the elbow or hand, when the extremity is extended. Situation of Fracture.—The fracture, if caused by directly concen- trated force, may be at any part of the bone to which the force is applied; but it may be stated as a general rule, that fractures take place most frequently in the middle of the bone, and in the scapular more frequently than in the sternal extremity. On this subject Mr. T. Wilkinson, King's Lecturer on Comparative Anatomy and Physiology at Guy's Hospital, remarks :—"I have under my immediate observation twenty-two examples of broken clavicles repaired. Of these, fifteen have been divided close to the middle, or very slightly external to this point; but two of the same have also been divided at about one inch from their outer extremities. Four other specimens have been broken transversely in the situations last named. The remaining three have been fractured about an inch from their sternal ends. One of the cases said to have been broken near the middle has had about three-fourths of an inch isolated by a double transverse fracture, which is also split longitudinally into two parts. The proportions stand thus :— Clavicles broken at the middle simply, . . . .12 " " at the middle twice, ... 1 " at the middle and outer end, . . .2 " at the outer end only, ... 4 " " at the inner end only, ... 3" Thus it is very evident, that the strong cylindrical arch formed by the inner half of the collar-bone, is very little susceptible of fracture, FRACTURE OF THE CLAVICLE. 151 although much exposed to direct blows. As a general rule, it may be stated that fractures take place in large proportion towards the outer end of this arch, and but rarely near its middle. With respect to the outer half, fracture is still uncommon, and almost confined to a trans- verse division about one inch from the outer point. For facilitating the description of fractures of the clavicle, it will be convenient to divide them into those on the scapular and those on the sternal side of the attachment of the coraco-clavicular ligaments to the outer tubercle of the bone. FRACTURE ON THE SCAPULAR SIDE OF THE CORACO-CLAVICULAR LIGAMENTS. Symptoms.—On very careful examination it will generally be found, that the part of the bone on the outer side of the fracture is drawn very slightly downwards. This symptom, never very perceptible in this fracture, can sometimes scarcely be discovered; but it will be made more obvious by pulling down the arm, and on pressing the arm up- wards the fragment will be replaced, so as to be on a line with the rest of the clavicle. On placing one hand over the fracture, and with the other alternately elevating and depressing the shoulder, crepitus will be perceived. Sometimes the parts remain so nearly in their natural position, that the usual motions of the arm can still be performed. Nature of Displacement.—There is very little displacement, the part on the outer side of the fracture being retained in its position by its attachment to the acromion process by the acromio-clavicular ligaments, and the part on the inner side by the coraco-clavicular ligaments. This connexion of the parts on each side of the fracture with the processes of the scapula, prevents any further displacement than a very slight depression of the outer fragment, occasioned by the weight of the ex- tremity. Treatment.—If there be no displacement, all that is necessary in the way of treatment is to preserve the parts at rest by keeping the extre- mity supported by a sling, and the arm bandaged to the side. If there be displacement, the same treatment answers as for the fracture next to be described, excepting that the pad in the axilla should be very small, the fragment not having the same tendency, as in the next case, to fall towards the chest. FRACTURE ON THE STERNAL SIDE OF THE CORACO-CLAVICULAR LIGAMENTS. Symptoms.—The broken clavicle being no longer able to sustain the weight of the extremity, or to keep off the scapula from the chest, the arm falls down, drawing with it the part on the scapular side of the fracture, and thus occasions an unnatural depression, which, together with the prominence caused by the sternal end remaining in its natural situation, clearly points out the nature of the injury. The scapula being no longer kept back by the broken clavicle, the shoulder and arm fall inwards and forwards, rendering the distance between the sternal end of the clavicle and the apex of the shoulder, less on the affected than on the sound side, and the arm is drawn forward towards the breast. By press- 152 FRACTURE OF THE CLAVICLE. ing the head of the humerus very forcibly upwards and outwards, the symptoms may be made to disappear, but they immediately return when the force is removed. The patient inclines the head and neck to the shoulder, and takes off the weight from the broken clavicle when standing, by supporting the elbow with the opposite hand : and when sitting, \v resting the elbow on the knee. He is unable to raise the hand to his head in consequence of the humerus no longer having a fixed point of support. There is swelling from extravasated blood over the bone, and crepitation may be perceived by raising the arm and carrying it backwards so as to bring the fractured surfaces in contact; but attempts to discover this symptom occasion great pain. Nature of Displacement.—The part on the sternal side of the frac- ture, though it appears to be drawn upwards from the falling down of the remaining portion, is in its natural situation, being retained there by the power of the sterno-cleido-mastoideus muscle above, and of the costo-clavicular ligament, and pectoralis major muscle below. The scapular portion is displaced in three directions, namely, downwards, inwards, and forwards; downwards, chiefly by the weight of the extre- mity, assisted perhaps by the contraction of the deltoid,—and inwards and forwards by the pectorales muscles, the broken clavicle being no longer able to keep the shoulder outwards and backwards. The scapu- lar part of the clavicle is thus drawn under the sternal portion, so that the one part rests upon the other. Treatment.—The parts are to be brought on a level with each other, and the fractured ends into apposition, and to be preserved in this situa- tion. To effect this the outer portion of the bone must be raised up- wards, and also drawn outwards and backwards ; which may be done by pressing the humerus very forcibly upwards, and keeping it raised by a short sling ; and then placing a thick pad beneath the axilla, drawing the arm backwards, and bandaging the elbow firmly to the trunk. The pad acts as a fulcrum, the humerus as a lever, and the bandage as the power; and thus the upper part of the humerus, and with it the scapula and the outer portion of the clavicle, are drawn outwards and backwards. In the treatment of this fracture many different kinds of appliances have been used. At one time it was the practice of many, when the shoulders had been drawn back, and were held fixed in that position, to place one end of a roller in the axilla of the injured arm, then to apply the roller obliquely across the back over the shoulder of the opposite side, and afterwards to wind it through the axilla of that side, and from that obliquely upwards over the shoulder of the affected side, and having made this figure-of-8 turn secure, to make several other turns succes- sively in the same manner. The shoulder having been thus bandaged back, the arm was placed in a sling. This is what was called the treatment by the figure-of-8 bandage. One objection to this treatment is, that the roller is apt to become roped, and to excoriate the edges of the axilla. To remedy this inconvenience, Brasdor suggested as an im- provement, the bandage which bears his name. It consists of a back- piece of stout leather softly cushioned, with two well-padded straps attached to the sides, and a belt running along its lower margin to sur- FRACTURE OF THE CLAVICLE. 153 round the waist, and to fix the bandage in its proper position. One of the straps is passed under each axilla, and returns over the shoulder to be buckled to the upper part of the back-piece : the back-piece is^ divided down the middle, and the two portions are connected by a lace, in order that it may fit persons of various sizes. The object of this appliance, is to draw back the shoulder; but this alone is insufficient. In treatment of fracture of the clavicle, three things are requisite:—to elevate the shoulder, to carry it out from the chest, and to throw it backwards so as to produce extension of the cla- vicle, and bring its overlapping ends into contact. With these views, and to effect these purposes, Desault constructed his bandage, which consists of two single-headed rollers, each nine yards in length, and a wedge-shaped pad for the axilla. The pad is placed in the axilla, and retained by two ribands attached to it, which are tied over the opposite shoulder; the elbow7 is brought forward, lifted up, and pressed inwards against the chest, thus making the humerus act as a lever upon the pad in the axilla, for the purpose of extending the fractured clavicle. The arm being supported in this position, with the elbow bent at a right angle, one of the rollers is carried round the chest and upper arm, being drawn more tightly as it approaches the elbow; a compress, dipped in camphorated spirits, is next laid upon the fractured bone, and the second roller, commencing in the opposite axilla, is carried across the chest, and over the compress and shoulder; then, passing down behind the arm and under the elbow, it is again taken across the chest, and over the sound shoulder to the axilla, where it commenced; and the same course is repeated till the roller terminates. The turns are secured by pins or stitches, and the hand is supported by a sling. Brunninghausen recommended for the treatment of this fracture, a leather strap, put on like the figure-of-8 bandage, with two pads fixed upon it, to prevent excoriation of the axilla. Of these four plans of treatment, the first two, together with Brun- ninghausen's, act on the same principle, namely, that of keeping back the shoulder; but they leave unfulfilled the other indications, which are no less important. They are also liable to the following objection:—if any of the three different appliances be drawn tight to fix the shoulder, the shoulder will be drawrn towards the chest, and, in consequence, the fractured parts will not be in apposition. On the other hand, the method of treatment recommended by Desault, is scientific and excellent; but as his manner of bandaging is rather complicated, and in the case of females very inconvenient, it has never been very generally adopted in this country. The following plan of treatment, recommended by my late friend, Mr. Liston, is simple, judicious, and unobjectionable. " When the patient is seen immediately after the accident, the bones are, without delay, and before inflammatory swelling has come on, to be placed in apposition and retained. No complicated apparatus is required. A pad, firm, though of soft material, and large enough to fill the armpit completely, is rolled in a shawl, and placed in the axilla; it is retained by tying the shawl over the opposite shoulder, a soft pad being interposed between the knot and the skin to prevent excoriation, and is further secured by 154 FRACTURE OF THE CLAVICLE. tying the ends under the axilla of the uninjured extremity, which should also be protected by a small cushion. " A few turns of a roller, or a handkerchief, are placed round the arm and chest, so as to secure and fix the limb, and the retentive apparatus is completed. The shoulder is thus raised, and removed from its un- natural position, and the fractured extremities of the clavicle, previously placed in accurate contact, are prevented from being again displaced. The elbow and the forearm should be supported by a sling, otherwise the unsupported weight of the limb dragging on the shoulder will cause considerable pain, and subsequent displacement will be apt to occur. The apparatus should be looked to occasionally, adjusted and tightened; and the cushions should be replaced by fresh ones, to prevent excoria- tion and uneasiness. The bone will be found to be quite smooth, to remain of its proper length, to unite generally within twenty days, and that without any unseemly exuberance of callus. No compress or splin- ters need be applied over the bone ; no evaporating lotions are necessary. If the patient be bruised in other parts, and become feverish, it may be requisite to abstract blood, and to exhibit antimonials, purgatives, &c. But all inflammation, arising from the fracture, subsides on the accom- plishment of reduction, adaptation, and retention of the portions. If the fracture be compound, the edges of the wound should be brought together, and retained, so as to favour immediate union." [The apparatus of Dr. Fox, of the Pennsylvania Hospital, is the one generally used in that Institution, and in this city. It is simple in its construction, easily applied, and fulfils all the indications. It consists of a collar, pad, and sling. The collar is made of muslin, and is merely a stuffed ring encircling the sound shoulder, and its use is to afford a firm point of resistance, to which the other parts of the appa- ratus may be attached. The pad is wedge-shaped, and should be sufficiently large at its upper extremity to act as a fulcrum when placed in the axilla, whilst the humerus is used as a lever. Broad tapes are attached to the two cor- ners of the thick end of the pad; one tape is brought across the chest and tied to the collar, the other tape is brought across the back, and tied to the collar behind, and thus the pad is firmly secured in the axilla. The sling is made of strong linen or muslin, sufficiently large to con- tain the forearm and elbow. Cords or tapes are fastened to the sling near the elbow and wrist. When the sling has been applied, it is to be secured by bringing the tape from the humeral portion of the sling across the back, and tying it to the collar. The tapes from the carpal corners of the sling are to be carried up in front of the chest, Fig. 25. FRACTURES OF THE THIGH-BONE. 155 and also fastened to the collar. By these means the shoulder can be drawn upwards, outwards, and backwards, and the fragments retained in coaptation.—Ed.] FRACTURES OF THE THIGH-BONE. FRACTURES OF THE NECK OF THE THIGH-BONE. Fractures of the neck of the femur may take place in any point of its extent; and they often extend outwards through the trochanter major, but very seldom inwards, so as to traverse the articular surface. The articular surface presents a remarkable difference, as to its ten- dency to disease, and its liability to injury from fracture. It is very prone to disease; it is scarcely ever the subject of fracture. Arrangement.—Fractures of the cervix femoris are divided into three classes:— 1st. Intra-capsular transverse fracture, so named from its being within the capsular ligament, and nearly forming a right angle with the long axis of the neck of the femur. 2d. Extra-capsular transverse fracture, when the fracture is without the capsular ligament, and the neck is broken off at its junction with the trochanter major. 3d. Oblique fracture of the neck, extending through the trochanter major. This fracture may be partly within, and partly without the capsular ligament. INTRA-CAPSULAR TRANSVERSE FRACTURE. Symptoms.—I. Shortening of the extremity of the affected side. This symptom may be discovered by placing the patient straight on his back, and comparing accurately the two limbs, knees, and ankles; or by comparing the measurement, between a fixed point of the pelvis and one below the sup- Fig. 26. posed fracture with the measurement between the corresponding point^on the opposite side of the body. In the entire state of the bone, the muscles extending from the pelvis to the femur are kept somewhat on the stretch by the resistance which the neck and head of the bone offer to their contraction ; but when the neck is fractured, the resistance is diminished, and the femur is consequently drawn up by the contraction of the muscles. When the patient is in the recumbent posture, the shortening is caused entirely by the action of the muscles; but in the erect position not only is the part external to the fracture drawn up by the muscles, but also the part of the neck internal to the fracture is pressed down by the weight of the body. This symptom is usually less apparent immediately after the injury 156 FRACTURES OF THE THIGH-BONE. than at a subsequent period, some time being required for the complete contraction of the muscles. As shortening is a symptom of some of the dislocations of the hip-joint, it is of the greatest importance for the purpose of diagnosis to attend to all the distinguishing peculiarities of the shortening from fracture. In addition to the peculiarity already stated, namely, that the shortening is not so apparent immediately after the injury, until the muscles have had time to contract, it may be re- marked that for some time the injured limb may, by being drawn down, be easily made of the same length as the other, but it returns to its former position as soon as the extending force is discontinued. After a very considerable period, however, the muscles become so permanently contracted, that they are capable of resisting a force which was pre- viously sufficient to bring down the limb. The degree of shortening varies much in different kinds of fracture. In intra-capsular fracture there is a difference of opinion on the subject among surgical authorities. Sir Ast- ley Cooper states,1 " The leg be- comes from one to two inches shorter than the other, for the connexion of the trochanter major with the head of the bone by means of the cervix being destroyed by the frac- ture, the trochanter is drawn up by the muscles as high as the capsular ligament will permit, and consequently rests upon the edge of the acetabulum, and upon the ilium above it." The degree of shortening here specified is greater than has been found in the experience of Boyer, and some other continental authorities, or in that of Messrs. Liston, Stanley, Samuel Cooper, and R. W. Smith. Mr. Smith states as the result of his observation that the shortening in this fracture varies from a quarter of an inch to an inch, and in this opinion most surgical authorities now agree. Mr. Smith refers to fifteen examples of fracture of the neck of the femur in the Museum of Richmond Hospital, thirteen of which were taken from patients who died in the hospital, and in each case the degree of shortening was carefully observed. In one in- stance only did it exceed an inch, and in that it was an inch and a half; « New edition of Sir Astley Cooper's Treatise on Dislocations and Fractures, by Mr. Bransby B. Cooper, p. 149, Am. edition. FRACTURES OF THE THIGH-BONE. 157 but the accident had happened some years previous to the measurement, and the neck of the bone had been absorbed. In two instances I had the opportunity of measuring the degree of shortening, and of verifying by dissection that the fractures were entirely within the capsular ligament. The one case was that of a woman, seventy years of age, and the shorten- ing was three-quarters of an inch. Death took place two months after the accident, and on dissection the fracture was found to be within the cap- sular ligament, which did not appear to have been lacerated. The other case was that of a man, whose precise age could not be ascertained, but who appeared to be considerably above forty years : he met with this frac- ture, together with that of several ribs, and other serious injuries, by falling from the top of a house upon the pavement. The shortening equalled one inch. Death took place ten days after the accident; and on dissection it was found that the fracture was entirely within the capsular ligament, which in this instance was rather extensively lace- rated, especially above. The extent of retraction seems to depend very much on the circumstance whether or not the capsular ligament over the neck of the bone be torn; for although, as Boyer remarks, it yields a little without being torn, yet if it remains entire, or nearly so,1 retrac- tion may be almost completely prevented. This was found to be the case by Smith, Stanley, and others, and Mr. Liston remarks with regard to the same point, " In fracture within the capsule, and where the fibrous envelope of the neck of the bone is not completely torn, there can be but slight displacement; and by the most attentive comparison of the two limbs, abbreviation of the one which has sustained the injury may not be detected." Sabatier, Dupuytren, and others, have found in many cases that there was no shortening for many days after the injury, and that then it took place very suddenly on the patient making some exertion, or during some movement in the examination of the limb. This sudden shorten- ing at a period remote from the injury is accounted for by Dupuytren on the supposition that the fracture is within the capsular ligament, and by reason of some irregularity in the fractured surfaces the one fragment is wedged into the other, or the displacement of the one prevented by the position of the other, but that during some movement of the limb, the relations of the fragments become so altered as to admit of retraction. Mr. Smith and others agree with Dupuytren in viewing it as a sign of the fracture being within the capsular ligament, but they attribute it to the ligament suddenly giving way at the moment of the retraction. II. Eversion of the Foot and Knee is a frequent, but not an invariable symptom of this fracture. There is great difference of opinion as to the cause of this symptom. Sir Astley Cooper considered, and most British surgeons agree with him, that it is occasioned by the rotator muscles. Bichat and Boyer thought that it is produced by the weight of the foot. Dupuytren ascribes it to the direction of the fracture, and the relations of the fractured portions to each other; and Mr. Liston says, " The position would appear to depend upon chance in a great measure, and upon the way in which the limb has bent under the patient, or has been placed on his being taken up. The position may be altered 1 Louis has asserted that the displacement may be considerable, but he has not sup- ported this assertion by facts or reasoning. 158 FRACTURES OF THE THIGH-BONE. during the examination of the limb; it may first be inverted, and after- wards, by the weight and inclination of the limb and foot, and the action of the powerful rotators outwards, the toes may become everted." In explanation of the more general outward direction of the toes, Sir Astley Cooper remarks,—" This state depends upon the numerous and strong external rotatory muscles of the hip-joint, which proceed from the pelvis to be inserted into the thigh-bone, and to which very feeble antagonists are provided; thus, the obturators, the pyriformis, the gemini and quad- ratus, the pectinalis and triceps, all assist in rolling the thigh-bone outwards; whilst only a part of the glutseus medius and minimus, and the tensor vaginae femoris are the principal agents in rotation inwards. It has been denied that this eversion is caused by the muscles, and it has been attributed to the mere weight of the limb; but any one may satisfy himself that it arises chiefly from the muscles, by feeling the resistance which is made to any attempt at rotation of the thigh inwards. This difficulty of rotation inwards is also in some measure attributable to the length of the cervix femoris, which remains attached to the tro- chanter major, because in proportion to its length which rests against the ilium, the trochanter is prevented from turning forwards." In ad- dition to the tensor vaginse femoris and anterior parts of glutseus medius and minimus, the two ischio-tibial muscles, namely, the semi-tendinosus and semi-membranosus muscles should be enumerated as rotators in- wards. When the foot is advanced, they prevent the heel from being so much turned inwards as to obstruct the other foot; but since they are more relaxed than usual by the shortening of the extremity, they can in this fracture have no effect in counteracting the powerful rotators outwards. Eversion does not take place to its full extent for some hours, as the contraction of the muscles is gradual. Bichat and Boyer, as it has been already stated, attributed the ever- sion to the weight of the foot, and thought that if it were caused by muscular contraction, there would be more difficulty in turning the foot inwards. Bichat also objected, that if the eversion were occasioned by the action of the rotators outwards, this position of the foot would be invariably met with, which is not the case ; an objection which applies as strongly to his own explanation as to that which he rejects ; and he further states, that in consequence of the fracture, the external rotator muscles, going from the pelvis to the part of the thigh-bone beyond the fracture, have, with the exception of the quadratus femoris, their ex- tremities approximated, and are, consequently in a state of relaxation. In answer to this it has been stated that the general influence of the muscles is to draw up the trochanter, and thus to operate against the relaxation of the rotators, and even to augment their influence. Baron Dupuytren suggests that the position of tile foot may depend on the direction of the fracture, and the relative situation of the frag- ments : that if the outer fragment be in front of the inner, the foot will be turned outwards, but if the outer be behind the inner fragment, the foot will be inverted. Although eversion is the usual position of the foot in fracture of the neck of the thigh-bone, it is necessary to remember that inversion is occasionally found. The following case, recorded by Mr. Stanley, is a striking instance of this, while it also shows the importance of correct / FRACTURES OF THE THIGH-BONE. 159 Fie. 28. diagnosis :—" A middle-aged man fell in the street, and his hip struck the curb-stone. The immediate consequences were, that the limb was inverted and shortened to the extent of an inch, and no crepitus could be discovered. It was presumed that a dislocation had occurred, and accordingly an extension of the limb was made, and so great was the constitutional irritation occasioned by the repeated trials to reduce the supposed dislocation, that the man died about five months from the time of the accident. In the dissection of the hip, a fracture was found, extending obliquely through the neck of the femur, but entirely within the capsule. A portion of fibrous and synovial membrane on the anterior side of the neck of the bone had escaped laceration." The surgical authorities of this country record many cases of inversion, in addition to the above-mentioned example given by Mr. Stanley. Sir Astley Cooper, at page 158 of his work on Dislocations, mentions the case of Mrs. Whateley, sixty years of age, in which the toes were turned inwards, and on dissection the fracture was found within the capsular ligament. Mr. Guthrie, in an interesting paper in the Med. Chir. Trans. vol. xiii., refers to a case of Mr. Langstaff's, in which there was inversion, and on dissection there was a diagonal fracture through the trochanter major. He also mentions a case in which the limb, having been in the first instance everted, suddenly turned inwards when the patient began to use it. Some French authorities refer to inversion in fractures of the neck of the femur as a more frequent symp- tom than it is admitted to be by surgeons of this country. Pare' and Petit describe the derange- ment inwards, as they call it, of the foot, as having taken place in all the cases of this kind which came under their notice. Desault concluded from his Fig. 28. Case of fracture of Cervix Femoris, accompanied with much shortening of the limb, but unattended with either inversion or eversion. From a patient in my wards in the Royal Infirmary. 160 FRACTURES OF THE THIGH-BONE. experience that the cases of rotatory derangement inward were to those outward in the proportion of 1: 4. As to the occasional occurrence of inversion, there is now no doubt, but much difference of opinion exists as to itscause. Some have supposed that the capsular ligament remaining entire in the front of the joint, and re- taining an attachment to the bone beyond the fracture, might cause inversion; but although this condition might possibly prevent^eversion, and even that is doubtful, it could have no effect in causing inversion. Others agree with Baron Dupuytren, who attributes the direction of the foot in every fracture of the neck to the relative positions of the frac- tured portions ; and if this explanation be not correct, the cause of inversion in fracture, entirely within the capsular ligament, remains still undiscovered. Mr. Guthrie has explained, in a most satisfactory manner, the cause of inversion in some fractures, without the capsular ligament. If the fracture be so situated, that the attachments of the rotators outwards inserted into the digital cavity, are connected with the fragment between the fracture and the joint, and the attachments of the anterior fibres of the glutaeus medius and minimus, to the ante- rior part of the trochanter major, are connected with the bone beyond the fracture, then the anterior fibres of these muscles will produce rota- tion inwards. This explanation, however, though most satisfactory in certain fractures without the capsular ligament, will not apply to frac- tures entirely within it. III. Another distinguishing peculiarity of fracture, is the absence of a fixed condition of the limb. It cannot usually be moved by the volun- tary efforts of the patient, but it can be lengthened, or turned inwards or outwards by the surgeon, on the application of very slight force, but it returns to its former position as soon as the force is removed. This is a good diagnostic symptom, for distinguishing a fracture with the rare symptom of inversion from dislocation, in which the extremity is fixed, and cannot be restored to its former position, without very great force, and when restored, it remains in the proper position, and the natural mobility returns. IV. Crepitus is another symptom. If the patient be placed in the horizontal position, and the limb, if retracted, lengthened so as to bring the fragments to a level with each other, it may be readily discovered, by placing one hand over the trochanter major, and giving to the limb a quick rotatory motion with the other. V. The degree and kind of revolution performed by the trochanter under the hand, when the limb is rotated, is an evidence of the existence of fracture, and of its proximity to the trochanter. When the neck of the bone is entire, the trochanter during rotation describes a segment of a circle, the centre of which is in the joint; but in fracture it seems to turn on its own axis, or to describe an arc of greater or less extent, ac- cording to the distance or proximity of the fracture to the trochanter. VI. The other symptoms are, pain, which is less in this than in the other fractures of the neck, and is not much felt, except when the limb is moved; and some unnatural appearances near the injury, such as the trochanter being less prominent than usual, and too near the crista of the ilium; and there being an unusual fulness of the hip caused by the FRACTURES OF THE THIGH-BONE. 161 bulging out of the muscles between the ilium and trochanter, and a swelling, more or less conspicuous, at the upper and fore-part of the thigh. The only injuries for which this fracture could be mistaken, are dislocation forwards of the hip-joint, when the fracture, as is usual", is attended with eversion (the diagnosis between them will be pointed out when the dislocation is described); and dislocation upwards or back- wards, when the fracture is attended with the rare symptom of inversion. In the dislocations the shortening is greater; the inversion is much more than even in the rare instance of its being found in fracture ; the knee is brought forward; there is immobility of the whole limb, and the absence of crepitus ; whereas in fracture with inversion the shortening and inversion are less; the limb is so movable, that by a very slight force it may be rotated, or bent backwards and forwards, which, how- ever, causes great pain, and there is crepitus and the peculiarity of the revolution of the trochanter. EXTRA-CAPSULAR TRANSVERSE FRACTURE. Symptoms.—Shortening. According to Sir Astley Cooper," this varies from half to three quarters of an inch; but, according to Mr. Smith, with whom most surgeons agree, it is usually from one inch and a half, to two inches and a half. Smith, Boyer, Stanley, and Earle, have all found the shortening greater in this than in the former fracture, there being nothing to prevent the muscles from drawing up the outer frag- ment, while the inner fragment is pressed down by the weight of the body. Eversion of the foot. Inversion also sometimes, though rarely occurs, as has been stated under the same symptom in the last fracture. There is always, as some term it, rotatory derangement of the limb, and for the most part, outwards. Fig. 29. Crepitus is another symptom, which can gene- rally be elicited without difficulty, as in the former fracture. Mobility of the limb, which though immovable by the voluntary efforts of the patient, nearly to the same extent as in dislocation, can be bent, extended, lengthened, or rotated outwards and inwards by the surgeon by slight force, but it returns to its former position when the force is discontinued. Pain, to a greater extent than in intra-capsu- lar fracture, even when the limb is at rest, and always exceedingly severe, when it is moved by the surgeon. The severity of suffering is much greater than in the former fracture, and there is sometimes, in consequence, considerable irritative fever. It may also be remarked, that the trochanter is less prominent than usual. If the hand be placed over it when the limb is rotated, it will seem to move on its own axis, instead of describing an arc; it is too near the crista of the ilium. The hip is altered in form, as in the last- 11 162 FRACTURES OF THE THIGH-BONE. Fig. 30. mentioned fracture. There is swelling at the upper and fore-part of the thigh; and ecchymosis and tenderness to the touch are often ob- served. This fracture, though it may take place in old age, is often met with under fifty, and sometimes in early life, and is usually occa- sioned by much greater violence than is necessary to produce intra-cap- sular fracture. OBLIQUE FRACTURE OF THE NECK, EXTENDING THROUGH THE TROCHANTER MAJOR. Symptoms.—If there be any shortening of the limb (which is not always the case), it is usually to a less extent than in the other fractures. The extent of surface of the fractured part, and the direction of the fracture, often prevent this kind of displacement. Crepitus is usually perceptible, and generally the foot is turned outwards, but seldom to the same extent as in the other fractures; in some instances it is turned inwards, the rationale of which, as explained by Guthrie, is given in a for- mer page under the head of Symptoms of Intra- capsular Fracture. The foot is benumbed, the patient is unable to sit, and any attempt to do so causes great suffering, nor can he turn in bed without much pain; great tenderness is felt on pressure, and ecchymosis may often be discerned. In some cases the upper part of the trochanter does not obey the motions of the limb, but remains at rest; sometimes it is drawn upwards, and a separation is perceptible between it and the rest of the bone; and if the fracture be very oblique and below the attachments of the principal rotator muscles, the bone may be drawn up by the glutaeus maximus, and a considerable shorten- ing of the limb be thus occasioned. This last symptom, however, is more characteristic of oblique fracture of the trochanter major, not ex- tending, or very slightly extending, into the neck. This fracture is usually the result of very great violence applied to the trochanter. PERIOD OF LIFE AT WHICH FRACTURE OF THE NECK MOST FREQUENTLY OCCURS. The patients under Baron Dupuytren with fracture within the liga- ment, were almost all above fifty years of age; and Sir Astley Cooper says, " I have now been thirty-nine years connected with St. Thomas's and Guy's Hospitals, and for thirty years have enjoyed no inconsidera- ble share of the surgical practice of London. In the two hospitals there are one thousand and fifty patients, and I believe eight cases of fracture of the upper part of the thigh-bone occur in each year; but in order to avoid exceeding the average number, I will consider them only as five per annum; thirty-nine multiplied by five produce one hundred and ninety-five; adding to these one case only in each year in my private practice of thirty years, they will collectively amount to two hundred FRACTURES OF THE THIGH-BONE. 163 and twenty-five cases. Now in that time I have only known two cases of fracture of the neck of the thigh-bone within the capsular ligament occur under fifty years of age; one was in a.patient aged thirty-eight years, who had an aneurism of the iliac artery; and the other was kindly shown to me by that excellent anatomist and surgeon, Mr. Her- bert Mayo." Mr. Stanley has recorded a case in a boy aged eighteen years ; and in the museum of Guy's Hospital there is a specimen of fracture of the neck, which, however, involves the trochanter, taken from a child nine years of age. Fracture within the capsule is almost exclusively con- fined to persons above fifty years of age ; it is very seldom met with in adults below that age, and is still more uncommon in children : women of advanced age are more liable to it than men. The causes of these differences will be explained below. The other two varieties of frac- ture of the neck may take place in advanced life; but they occur under fifty years of age more commonly than intra-capsular fracture, and are usually the result of great violence, whereas a very slight accident is sufficient to occasion fracture within the capsular ligament. Causes.—The causes may be divided into exciting and predisposing causes. The exciting causes of the several fractures have been arranged by Dupuytren in the following order, according to their frequency :— 1. Falls on the trochanter. 2. Direct violence, such as that of a gun- shot wound. 3. Falls on the foot or knee. 4. Muscular action, as recorded to have taken place once in tetanus. According to Desault's experience, in twenty-four cases out of thirty, the accident was occa- sioned by falls on the trochanter; whereas Sir Astley Cooper found the most common cause to be a slip off the edge of the foot pavement. He remarks with reference to fracture within the capsule: " In London the accident most frequently occurs when persons walking on the edge of the elevated footpath, slip upon the carriage pavement; though the descent be only a few inches, yet being sudden and unexpected, and the force acting perpendicularly with the advantage of a lever in the cervix, it produces a fracture in the neck of the thigh-bone; and as a fall is the consequence, the fracture is imputed by ignorant persons to the fall and not to its true cause. Other trivial accidents may also produce this fracture. I was informed by a person, that being at her counter, and suddenly turning to a drawer behind her, some projection in the floor caught her foot and prevented its turning with the body, by which the neck of the thigh-bone became fractured. A fall on the trochanter major will also produce it; but I have dwelt particularly on the slight cause by which it is occasioned, that the young surgeon may be upon his guard respecting it; as he might otherwise believe that an injury of such importance could scarcely be the result of a slight accident, and that excessive violence is necessary to break the neck of the thigh-bone : but such an opinion is as liable to be injurious to his reputation as the error of confounding this accident with dislocation. Sir Astley Cooper found the other two varieties of fracture to result generally from a vio- lent blow, or a fall on the trochanter. In fracture within the capsule, when caused in the manner already described, the fall is often the con- 164 FRACTURES OF THE THIGH-BONE. sequence of the accident; in the others, the accident is generally the consequence of the fall. When a person falls oil the great trochanter, the neck of the femur is acted on by that eminence, which has a point d'appui on the ground, and by the weight of the body, which acts immediately on the head of the femur. By this action and reaction a force is exerted on the neck of the femur, which tends to make it parallel with the rest of the bone. In falling on the feet, on the contrary, the tendency of the fracturing cause is to force the neck of the femur to form a right angle with the bone, and if this force be exerted on the bone beyond its natural exten- sibility, a fracture must ensue. According to the two last-mentioned views of the mechanism of these fractures, they are not direct, that is, not produced by a cause acting immediately on the part, but the effect of a force communicated to that part by contre-coup, or transmitted reaction. If, however, the fracture be the result of a severe contusion or fall, and be through the trochanter or without the capsule, the fracture is so near to the part to which the violence is applied that its influence may be said to be direct. The different degrees of frequency with which these fractures occur at the different periods of life, and in the two sexes, may be explained by anatomical and other considerations. In the child, the trochanter is concealed under the prominence of the os innominatum ; the trochanter projects but slightly, and the axis of the neck approaches that of the shaft. These circumstances, together with the diminished breadth of the pelvis, the great flexibility of the neck, and the adipose and cellular tissues which are all protective, account for the extremely rare occur- rence of these fractures in childhood. In adults the pelvis is broader, the trochanter is more prominent, the neck is longer, and its inclination to the shaft is at a greater angle; consequently there is more liability to fracture in mature age than in childhood, and there would be still more than there is, but for the great strength and solidity of the bone at that period. In advanced life the pelvis is still broad, the trochanter is prominent, and often but little protected, in consequence of the dimi- nished size of the muscles and the decrease of the adipose and cellular tissue ; and the neck of the thigh-bone, besides being nearly at a right angle with the shaft, is also rendered exceedingly brittle by the diminu- tion of cartilaginous matter and the increase of phosphate of lime; also by a peculiar process of atrophy, which has been admirably described by Sir Astley Cooper. To these circumstances is ascribed the greater liability to fracture in old age. Dupuytren states, that the frequency of this accident bears a direct ratio to the prominence of the trochanter major, the length of the neck, and its angle with the shaft, and he ascribes the greater liability to it in women to the circumstance that the neck of the femur is longer and the trochanter more prominent, while the size and prominence of the muscles which would protect the bone, are often less in this sex than in the other. The very liability to fall in old age must also increase the frequency of fracture. The observations of Sir Astley Cooper, above referred to, are as follows. " The neck of the thigh-bone in persons of middle age has a close cancellated structure, and is covered by a shell of FRACTURES OF THE THIGH-BONE. 165 considerable thickness; but in old subjects the cancellated structure degenerates into a coarse network, loaded with adipose matter, and the shell which covers it becomes so thin that when a section is made through the middle of the head and cervix, it is found diaphanous. Of this I have several specimens. As the shell becomes thin, ossific matter is deposited on the upper side of the cervix, opposite the edge of the acetabulum, and often a similar portion at its lower part, and thus the strength of the bone is in some degree preserved. This state may be frequently seen in very old persons. When the absorption of the neck proceeds faster than the deposit on its surface, the bone breaks from the very slightest causes, and this deposit wears so much the appear- ance of a united fracture that it might easily be mistaken for it. Before the bone thus alters we sometimes meet with a remarkable but- tress shooting up from the shaft of the bone into its head (formed of strong cancelli), giving it additional support to that which it receives from the deposit of bone upon its external surface. " But another change is also produced, of which the following is the history. Old, bedridden, and fat persons, generally females, often used to be brought into our dissecting-room with some of their bones broken, and more frequently the thigh-bone than any other, in being removed from the grave. If the cervix femoris of such persons be examined, it will be found that the head of the bone is sunk down upon its shaft, and that the neck of the thigh-bone is shortened, so that its head is in contact with the shaft of the bone opposite to the trochanter minor ; and at the point at which the ligament is united with the neck of the bone the phosphate of lime is absorbed, and a ligamento-cartilaginous sub- stance occupies its place, either extending (as a plane) entirely through the neck of the bone, or partially, so that one section exhibits signs of it, and in another it is wanting. The bone in some cases is so soft and fragile, both in its trochanters and head, that it will scarcely bear the slightest handling; and the motion of the thigh-bone in the acetabulum is almost entirely lost, so that the persons must have had but little use in their lower extremities. In examining the body of an old subject very much loaded with fat, in the dissecting-room of St. Thomas's Hos- pital, I found that the gentleman who had dissected one limb had cut through the capsular ligament of the hip-joint, and tried to remove the head of the thigh-bone from the acetabulum, but the neck of the bone broke on the employment of a very slight force, and, upon a farther trial to remove it, the bone crumbled under the fingers. As the other limb was not yet dissected, I requested Mr. South, one of our demonstra- tors, to remove with care the upper part of the other thigh-bone, but, although he used great caution in doing it, he could not remove the bone without fracturing the upper part of its shaft; but he succeeded in removing the upper part of the bone, so that it might be preserved; and of this I have given plates. We have here then a case in which the neck of the bone was absorbed, so that the head was brought in contact with the trochanter; in which, most decidedly, there had not been a fracture, although it had in some parts the appearance of one, and in which the disease occurred in each hip-joint. " Another case of the same kind was examined by Mr. South, which, 166 FRACTURES OF THE THIGH-BONE. so far as it relates to the softened state of the upper part of the thigh- bone, was similar to the former ; the heads were spongy, the necks were shortened, so that there was scarcely any remaining ; each trochan- ter was light in weight and very large ; and there was little, if any, motion in either of the hip-joints, so that both limbs appeared, at first sight, as if dislocated on the pubes. But the best specimen of this state is°the following, which I preserve with the most assiduous care, and value in the highest possible degree. I have had, for twenty years, in the collection of St. Thomas's Hospital, the thigh-bone of an old person, in which the head of the bone had sunk towards its shaft. I have been in the habit of showing this bone twice a-year, as a specimen how bones sometimes become soft from age and disease, and from the absorption of their phosphate of lime; and I have frequently cut with a penknife both its head and its condyles, to show the softened state. On sawing through its cervix, the cartilage, deprived of its phosphate of lime, had dried away in several parts; and the appearance was such, that a person ignorant of the change would have declared it to be a fracture, only that in some sections the cartilage has taken different directions (as a thin plane between the head and neck), and in some, the bone was not yet entirely absorbed." MODE OF UNION. In two of the three kinds of fracture of the cervix femoris, namely, extra-capsular transverse fracture, and oblique fracture through the tro- chanter major, the reunion is, as in other parts of the body, by bone ; but this mode of union is extremely rare in intra-capsular fracture. It was at one time a question about which there was much difference of opinion, whether reunion by bone could ever take place in fracture entirely within the capsular ligament, and where the head of the bone is completely in- sulated, except at its attachment to the acetabulum by means of the round ligament. The French surgeons believed that it could, and affirmed that preparations in their museums in Paris demonstrated that mode of union. Several British surgeons were of the same opinion. M. Roux of Paris sent a specimen of what he believed to be reunion by bone, to Sir Astley Cooper ; but Sir Astley was not satisfied, because the traces of reunion in that preparation were such as to indicate a frac- ture where the internal fragment retained a connexion with the capsular ligament. Mr. Cross of Norwich, in the account of his visit to the French hospitals, states that he examined the preparations in the museums of Paris, which were believed to demonstrate union by bone, but that he did not consider them satisfactory. No one in this country has devoted more attention to the investiga- tion of this subject than Sir Astley Cooper; and to show how rare an occurrence union by bone is in fracture entirely within the ligament, he enumerates not fewer than forty-three specimens of this fracture in different collections in London, and states that during his practice of forty years he had seen but two or three cases which militated against the opinion that union by bone cannot take place, and only one in which a bony union had taken place, or which did not admit of motion of one bone upon the other. Sir Astley Cooper never denied the possibility FRACTURES OF THE THIGH-BONE. 167 of bony union; he states that it would be presumptuous to maintain that there could be no exception to the general rule; but he has proved that such exceptions are rare. Several cases are recorded, in which bony union unquestionably took place; and we may therefore conclude that it may occur in very favourable cases, and under good treatment. Of various instances on record, I shall only refer to three. Mr. Longstaff's museum contained an unquestionable specimen of ossific union. The preparation is now in the Museum of the Royal College of Surgeons of England, where I have examined it. The par- ticulars of the case are recorded in the " Medico-Chirurgical Transac- tions." The patient died about two years after the accident. The ossific union is perfect in the shell, and all round the circumference of the bone; the centre of the fissure is united by a fibrous substance. Another instance of bony union occurred in the case of Dr. James, an English physician, who met with this fracture by a fall from his horse, while riding in the neighbourhood of Bordeaux. He recovered from the accident, but died seven months after it, of visceral disease; and, on examination by Dr. Brulatour of Bordeaux, it was found that the fracture was entirely within the capsule, and that the union by bone was perfect. In the second edition of Mr. Liston's "Elements of Surgery," p. 717, there is a drawing of complete bony union, which, Mr. Liston says, he is enabled to produce by the kindness of Sir Astley Cooper. The possibility of bony union is thus clear- ly demonstrated, but still it cannot be looked for except in very favourable cases, and what has been already de- scribed as the frequent condition of the neck of the thigh-bone in aged persons, must render it in many in- stances hopeless. In the majority of cases of intra-capsular fracture, no union takes place, and the broken surfaces become smooth and polished from being covered over by what has been called the ivory deposit, or they may become joined to each other, or to the inner surface of the capsular ligament by fibrous bands, the capsular ligament and surrounding tissues become very much thickened and strengthened, and thus the unnatural motion is limited. The neck of the femur disappears by interstitial ab- sorption, and the diminished head rests between the two trochanters. These conditions, or some combinations of them, are the appearances which present themselves where bony union has not taken place. CAUSES OF THE WANT OF UNION. 1. One circumstance which prevents bony union of the fragments is Fig. 31. Intra-capsular transverse fracture of cervix femoris, followed by absorption of the neck, and conversion of part of capsular ligament into exceedingly thick bands. From a preparation in my museum. 168 FRACTURES OF THE THIGH-BONE. the want of proper and constant apposition. This is only in accordance with what is observed in other parts of the body, when fractured bones cannot be kept in contact. Under such circumstances ossific union rarely takes place, as may be clearly seen from the various cases and experiments recorded in the last edition of Sir Astley Cooper's work on "Fractures and Dislocations," beginning at page 139. 2. Various proofs may be adduced that a certain degree of pressure of the fractured parts against each other is favourable to union. In the present case that pressure cannot easily be maintained, and this is another circumstance which contributes to prevent union. 3. The atrophy of the cervix femoris, already described, not only predisposes to fracture, but also diminishes in a very great degree the power of reparation. This, and the want of vigour belonging to old age, even if no other reason could be assigned, would be sufficient to account for the want of union. • 4. A fourth reason is the feeble circulation through the head and neck on the inner side of the fracture, for, there being no periosteum, its circulation and vitality are kept up entirely by the vessels of the round ligament; nor can the separated portion of the bone receive nu- trition from any other source. 5. Another reason which has been assigned is, the circumstance of the synovial fluid being poured into the injured cavity; but the effect of this is doubtful. Treatment.—The first question is,—Are we justified in subjecting the patient to the long and hazardous confinement to his bed necessary for a chance of union ? The answer to this will depend on the degree of probability that union will take place. It will now be evident that the in- quiries into the changes which the neck of the bone undergoes in age, the circumstances under which reunion takes place, and the causes which prevent it, are of great practical importance. In intra-capsular transverse fracture in advanced life, when there is little if any chance of reunion, it would be injudicious to run the risk of ruining the general health by long confinement to one position, and incur the danger of ulceration and sloughing of the integuments of various parts from the weight of the body, and the application of apparatus for adapting and retaining the parts in apposition. Sir Astley Cooper remarks, " Baffled in our various attempts at curing these cases, and finding the life of the patient occasionally sacrificed under the trials made to unite them, I should, if I sustained this accident in my own person, direct that a pillow should be placed under the limb throughout its length, and that another should be rolled up under the knee, and that the limb should be thus extended until the inflammation and pain be subsided. I should then dairy rise and sit in a high chair, in order to prevent a degree of flexion which would be painful, and, walking with crutches, bear gently on the fobt at first, then gradually more and more, until the ligament became thickened, and the muscles increased in their power. A high- heeled boot should be next employed, by which the halt would be much diminished." In extra-capsular transverse, and in oblique fractures through the trochanter, and even in intra-capsular transverse fractures in very favourable subjects, the following treatment may be adopted. FRACTURES OF THE THIGH-BONE. 169 The patient being placed on a hard mattrass, in an extended position, with the trunk, thigh, and leg in a straight line, a common bandage being applied from the toes to above the knee, to prevent oedema, and coaptation having been obtained by extending the extremity, and placing it in a proper position', with the toes not too much turned inwards or outwards, a wooden splint of sufficient strength and breadth, and long enough to extend from the last rib to three or four inches beyond the foot, with two holes at its upper, and two notches or retiring angles at its lower, extremity, should be well padded and applied to the outer side of the limb, care being taken to protect the ankle by a suitable adjust- ment of pads. The leg and foot should then be fixed to the splint by a roller, from the foot to above the knee; and if the roller, after some turns of it have been applied to the ankle, be passed through the notches, it will fasten the foot to the extremity of the splint, and prevent it from moving. A broad bandage should be applied around the pelvis, and carried down the thigh so as to include all the part above the former roller, and by the turns of this bandage, or by a very broad band, the splint should be fastened to the trunk, by which means the fractured parts will be kept in contact. A large handkerchief or shawl, with a little tow or hair wrapped up in it to prevent its galling the skin, should be applied with its centre in the perineum, and one end behind the hip and the other in front, and these ends passing through the openings in the upper part of the splint, should then be well secured. The pelvis acts as a fulcrum, and the perineal band as the power, by tightening which the splint and the lower part of the limb previously fixed to it can be kept down, the extension be preserved, and the extremity be kept of the proper length. Great care should be taken that the splint be well padded with cotton, wool, wadding, or tow, to prevent the painful effects of pressure; the bandages should be reapplied occasionally during the treatment, and the perineal band frequently tightened. The apparatus will require to be continued for at least seven or eight weeks; but this will vary in different cases, according to the time necessary for procuring union. As satisfactory cures are obtained by this method as by any that can be adopted, and it has the recommendation of being simple and the least annoying of any to the patient. It has been strongly advo- cated by Mr. Liston, Professor Samuel Cooper, Mr. Fergusson, and others. The indications of treatment to be fulfilled are, to preserve the extre- mity elongated, and at perfect rest, to prevent eversion, and to keep up pressure upon the trochanter. Some recommend a different plan of treatment, namely, to keep the 170 FRACTURES OF THE THIGH-BONE. body slightly elevated, and the limb on a double-inclined plane. This treatment can be more conveniently practised by means of Amesbury's bed than by any other apparatus. The first and third indications above stated are fulfilled by the footpiece of Amesbury's bed; the bed itself accomplishes the second; and the fourth and last is effected by a ban- dage or belt around the trunk, and a splint extending between the pelvis and the knee. I have treated cases satisfactorily by each of the above plans; but my decided impression is that the former is to be preferred. Dupuytren recommended the double-inclined plane, and kept the extre- mity elongated by means of two belts, one of which he passed along the perineum, and attached to the upper bed-post; the other he fixed to the knee, and fastened to the lower bed-post. FRACTURES OF THE SHAFT OF THE FEMUR. Symptoms.—These are so conspicuous as at once to satisfy the sur- geon of the nature of the injury. Acute pain at the moment the injury takes place,—inability to sustain the superincumbent weight,—angular deformity in raising the limb,—sudden inability to move the limb by the voluntary action of its owrn muscles,—and preternatural motion of the lower part of the thigh-bone when otherwise acted on,—are inva- riable symptoms; and the following, though not always, are generally present. There is shortening of the extremity, if the fracture be oblique, vary- ing in extent according to the obliquity. To ascertain the extent of shortening, or longitudinal displacement, as it is sometimes called, take the anterior superior spinous process of the ilium and some prominent point at the under extremity of the femur, or head of the tibia, and compare the measurement with that between the corresponding parts on the opposite side of the body. Shortening of the limb may be prevented by the bone being splintered, and the two fractured extremities being locked into each other. This symptom may not appear immediately, the contractions of the muscles by which it is produced being gradual. If the fracture be transverse, there may be no shortening, unless the violence which produced the injury was so great, or applied in such a manner, as to force the lower fragment from resting at any point against the upper. Crepitation may be generally elicited, more especially if the fracture be transverse, by performing rotatory motion. If the fracture be oblique, this symptom may not be perceptible, until the limb has been elongated. The presence of crepitus is an indubitable proof of the existence of frac- ture, although its absence cannot be taken as an indication of the con- trary ; for it will sometimes be altogether prevented by the interposition of muscular fibres between the fractured portions. Tumefaction to a considerable extent may be present, the foot is for the most part turned a little outwards, and the femur is most accessible to the fingers along its sides. Nature of Displacement.—U the fracture be oblique, and if it be not very near either of the extremities of the shaft,—in which case there are some modifications of the displacement which will afterwards be stated,— FRACTURES OF THE THIGH-BONE. 171 the part above the fracture has generally two, and the part below four peculiarities of displacement. The upper fragment is drawn too far for- wards by the psoas magnus and iliacus internus muscles; which, in their way from the iliac fossa and lumbar division of the spine to the trochanter minor into which they are inserted, describe an arc, the convexity of which is forward. There being no longer the usual resistance offered to the contraction of these muscles they draw forward the upper fragment. It is also generally drawn a little outwards by the glutseus maximus muscle. Of course the upper part of the bone can undergo no retraction. The part below the fracture is displaced in the four following directions: — 1st. It is displaced backwards, chiefly perhaps by its own weight, and by being overlapped by the upper part. 2d. It is drawn too near the mesial plane. The course of the ad- ductor longus, brevis, and magnus, is from within outwards, and thus these muscles draw, or as their very name imports, they adduct, the lower fragment too near the mesial plane. 3d. It is rotated outwards, thus occasioning eversion of the extremity. Some attribute this eversion to the mere weight of the limb, but as many of the fibres of the adductor muscles have the planes of their insertion farther back than the planes of their origin, it is probable that they assist in producing rotation outwards, and they will have a greater ten- dency to do so on account of the falling back of the lower fragment, which makes the plane of their insertion farther back than usual from those of their origin. 4th. It is drawn upwards, producing shortening of the extremity. This displacement is occasioned chiefly by the muscles which go between the pelvis and the leg, namely the biceps, semi-tendinosus, semi-mem- branosus, rectus, and gracilis, assisted, no doubt, by the muscles inserted into the fragment below the fracture. If, however, the fracture be transverse, it may happen, on account of the breadth of surface of the fracture, that some part of the lower fragment presses against some part of the upper, in which case there will be no shortening; but if the frac- ture be oblique, the contraction of the muscles will not be prevented by the position of the fractured portions, and consequently, shortening will take place. According to Mr. C. Aston Key, the displacement in fracture of the femur is not to be attributed to the action of the muscles inserted into the upper fragment; but chiefly to that of the muscles which go to the lower fragment. He supposes that the muscles surrounding the frac- ture and inserted into the lower fragment become the subject, first of effusion of blood, and subsequently of serous infiltration in consequence of slight inflammation, and that they are thereby irritated, swelled, and excited to contract; and the lower fragment being movable is thus drawn up. The direction of the upper fragment, according to Mr. Key, will then depend upon the direction of the plane of the fracture. If the fracture go from above downwards, and from within outwards, the lower fragment by being drawn upwards, presses the upper fragment forwards and outwards. If the plane of the fracture be from before backwards, and from without inwards, the effect of drawing up the lower fragment 172 FRACTURES OF THE THIGH-BONE. will be to displace the upper fragment forwards and inwards. Accord- ing, therefore, to this authority, the displacement of the upper fragment is not so much caused by the action of its own muscles, as by the lower fragment, and the direction in which the upper fragment is displaced, by the drawing up of the lower, depends on the direction of the plane of the fracture. If the fracture be situated at the upper extremity of the shaft, the psoas magnus and iliacus internus draw the upper frag- ment directly forwards, producing a tumour in the groin; and if the fracture be transverse and immediately above the condyles, the lower fragment is drawn downwards and backAvards by the gastrocnemius ex- ternus, plantaris, and popliteus, so that the lower extremity of the upper fragment appears as if it were the part displaced. Treatment.—After coaptation of the fractured portions, which should be obtained as speedily as possible, the object of treatment is to pre- serve the parts at rest and properly adjusted ; which can be done by attention to attitude and application of apparatus. Attitude.—Various attitudes have been recommended. Desault ad- vises that the patient be placed on his back on a hard unyielding mat- trass, with the trunk, thigh, and leg in a straight line with each other; this attitude he employed partly with a view of giving ease to the pa- tient, but chiefly that the muscles might be equally relaxed; and appa- ratus be easily applied for keeping the limb extended, and at rest. A second attitude, now however completely abandoned, is that recom- mended by Pott, in which the patient is placed on the affected side with the trunk slightly inclined forwards, and the leg moderately backwards. For a description of this method of treatment see Pott's Surgical Works, vol. i. p. 318. A most decided objection to it is that it does not admit of extension, so that shortening and deformity of the limb, and eversion of the foot, are extremely apt to result from it. It is also exceedingly irksome to the patient. A third attitude is that proposed by Sir Charles Bell, in which the patient is placed on his back with the trunk raised, the thigh slightly bent on the pelvis, and the leg bent on the thigh. Mechanism.—This is, likewise, very various. The splint of Desault and also that of Boyer are appliances which were successfully employed by these celebrated surgeons, and although very complicated and cum- bersome, and not now employed in this country, yet they were useful on the very same principle as the apparatus now in most general use, and no doubt led to its introduction. The apparatus to which I allude is, in fact, the mechanism of Desault simplified; it has been very strongly recommended by Mr. Liston, and is now generally approved, and adopt- ed in all fractures of the shaft, except those at its very extremities. This plan of treatment being the same as that recommended for frac- ture of the neck of the femur, with the single exception that in addition to what is there used, a short wooden splint should be applied to the inside of the thigh, it is unnecessary again to describe it. It is of all methods the easiest to the patient; it prevents eversions, shortening and defor- mity ; and the mechanism is so applied that the pelvis, thigh, leg, and foot constitute one rigid body, which may be moved entire, but the va- rious parts of which being immovable inter se, preserve the same mutual FRACTURES OF THE THIGH-BONE. 173 relation. Some surgeons object to the treatment above described, if the fracture be at the upper extremity of the shaft and immediately below the trochanter minor, on the ground that—1st. The psoas mag- nus and iliacus internus muscles having no antagonists, and being put on the stretch by the straight position, will draw the upper part too far forward; and 2d. The perineal band, if made very tight,—and if it be not made tight it cannot answer the purpose for which it is employed, —will tend to assist the two muscles in increasing this displacement of the upper fragment. In consequence of these objections to the straight position, they advise that the patient be placed in the attitude recom- mended by Sir Charles Bell for the treatment of fractures of the shaft, but with this peculiarity, that the trunk should be so much raised as to make the patient sit erect for the purpose of relaxing the psoas magnus and iliacus internus muscles; and that four wooden splints be applied, one to the front, another to the back, and one to each side of the limb. If the fracture be so nearly transverse that the upper fragment by pressing against the lower, may prevent its retraction, this treatment may answer; but if the fracture be at all oblique, I would recommend the former plan, which I have employed, even in this fracture, with the most satisfactory result. This fracture can be very conveniently and satisfactorily treated in the bent attitude, referred to above, by means of Amesbury's admirable apparatus or fracture-bed, for fractures at the upper part of the femur, along with four wooden splints, firmly applied to the front, back, and two sides of the thigh. This apparatus renders it unnecessary to move the patient's body for any purpose, and it has also the great advantage of making it practicable and easy to keep up extension, and thereby to prevent shortening of the limb. In transverse fracture, immediately above the condyles, or in the under third, the preferable attitude is to have the leg slightly bent, to relax the gastrocnemius externus, plantaris, and popliteus muscles, which draw backwards the lower fragment. The most elegant apparatus for the treatment of fracture in this situation, is M'Intyre's splint, which consists of a sandal, and leg and thigh-pieces; the latter two forming a double inclined plane with each other. The thigh-piece is double, the one portion sliding on the other, and can be lengthened or shortened, and firmly fixed by means of a screw. By lengthening the thigh-piece, which can be done without removing it from the patient's body, exten- sion of the thigh can be kept up. The leg and thigh should be included in a roller along with the splint; three short wooden splints should also be applied to the lower part of the thigh, namely, one in front and one on each side, and the roller should be carried up to the upper part of the shaft. By the above means the fractured portions will be kept in apposition and at rest: the whole of the extremity may be moved along with the splint, but the fractured portions will be preserved in contact, and their proper relations to each other effectually maintained. In oblique fracture in the under third, notwithstanding the action of the muscles above referred to, I prefer the straight position, as that in which extension can be most effectually kept up, and shortening and deformity consequently prevented. [In this country fractures of the thigh are generally treated by an 174 FRACTURES OF THE THIGH-BONE. apparatus which retains the limb in an extended position. The princi- ple of Desault's splint is the basis of numerous inventions, but the modi- fication of it by Dr. Physick is perhaps the most preferred. The pieces which compose Desault's apparatus, are, 1st. Common junk-cloth, accommodated to the size of the limb and the splints; 2dly. A bandage for the body, and one passing under the thigh, to secure the first on the side opposite to the fracture ; 3dly. Three stiff splints, an inch and a half wide, the external one of which being very strong, must be long enough to extend from the spine of the ilium to the distance of four inches below the sole of the foot. This splint is hollowed out or notched at its lower end, and has a mortice in it a little higher up. The upper splint occupies the space included between the fold of the groin and the upper part of the knee; and the internal one, which reaches from the upper and internal fold of the thigh, to the sole of Fig. 33. the foot; 4thly. Three bolsters, an external, an internal, and an upper one, consisting of small bags of chaff; 5thly. A ban- dage of strips, accommodated, as to number, to the circum- stances of the case, separate from one another, each three inches broad, and long enough to go twice round the limb, arranged from below upwards, and overlapping each other, about one-third of their breadth; 6thly. One long and two cir- cular compresses, intended to be applied immediately on the limb, next to the skin; 7thly. Two strong rollers, intended for extension and counter-extension, at least an ell and a half long; 8thly. One long and thick compress, and a sufficient number of bits of tape.1 In this apparatus the line of the counter-extension is very oblique, owing to the perineal band being attached to the upper end of the splint, and the obliquity has a tendency to produce deformity, by inclining the upper fragment outward. Dr. Physick elongated the upper end of the splint so as it should reach to the axilla, and thus the line of the counter-ex- tending band was rendered very nearly parallel to the axis of the body; and at the suggestion of Dr. Hutchinson, a small notched block is attached to the inner surface of the lower extremity of the splint. The extending bands passing over this notch neces- sarily act in a line parallel with the splint. In other respects Physick's apparatus is the same as that of Desault, although the third or anterior splint will not be found necessary in many cases. In applying this apparatus great care is requisite to render it effectual, and at the same time as comfortable as pos- sible. Much will depend upon the accuracy of the adaptation of the bran-bags, and upon the character of the material used for the extending and counter-extending bands. The great ground of complaint which has been urged against this dressing has arisen from a liability of excoriation at the perineum, and at the ankle. The perineal band should be made of soft yet firm muslin, and padded or stuffed in that part which presses against the perineum. The skin should be carefully examined 1 Caldwell's Translation of Bichat's edition of Desault's Surgery. FRACTURES OF THE THIGH-BONE. 175 every day or so, and bathed with soap liniment. The extending band applied at the ankle may consist of a handkerchief or a gaiter to which strong tapes have been fastened, and benefit will result from changing the means of extension and counter-extension. Hagedorn s apparatus is the least liable to objection on the ground of excoriation, there being no perineal band, and the counter-extension being made at the acetabulum of the sound side. Prof. Gibson, of the University of Pennsylvania, has modified this splint, and this apparatus is well known in this country. Dr. Gibson thus describes the original apparatus, and his improvement: " This method consists in extending the patient's limbs upon a mat- trass, and confining both feet, by gaiters or a handkerchief, to a foot- board, which is firmly secured upon the ends of two splints passed through mortices near its edges. These splints extend from the arm-pit, 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 ban- dages passed around the limbs, pelvis, chest, &c. " The principle upon which extension and counter-extension are effected by this contrivance will instantly be understood. The sound limb being extended serves as a splint to the broken one. Counter- Fig. 34. extension then is made upon the acetabulum of the sound side, and ex- tension upon the ankle of the injured limb, which, so long as the two feet are kept on the same level, cannot be shortened, provided rotation of the pelvis be prevented. This purpose is answered by extending the splints to the arm-pits, and not with a view, as might be supposed, of producing counter-extension at these points. Finding that the patient, in the original machine of Hagedorn (which consists of a single splint merely, and a foot-board, independently of leather straps, &c), could incline the pelvis towards the affected side, and thereby shorten the limb by causing the superior fragment to descend and overlap the infe- rior, the additional splint was added, and has been found to answer completely the end designed." (Gibson's Surgery, Vol. I.) If both thighs are fractured, the best plan of treatment is that recom- mended by Dr. Gibson. It consists in securing the feet to the upper extremity of a single inclined plane, by means of gaiters attached to a foot-board. The extension is made by the weight of the body.__Ed.] OBLIQUE FRACTURE OF EITHER CONDYLE. Symptoms.—This injury may be recognised by the crepitus which is felt on taking a firm hold of the condyles of the femur, and producing 176 FRACTURES OF THE THIGH-BONE. flexion and extension of the knee-joint. The mobility of the condyle is caused by the alternate contraction and relaxation of the gastrocnemius. When the leg is very much bent, a fissure may sometimes be detected. From the extension of the fracture into the joint, it is sometimes fol- lowed by inflammation of the knee-joint, and by that means has been known to give rise to serious consequences. [When both condyles are fractured, the symptoms are usually still more distinct. There is usually great mobility Fig. 35. 0f the parts, and crepitation would be very dis- tinct. Upon flexing the knee, its breadth is greatly increased by the separation of the con- dyles, and the patella sinks deeply in the space between them. It is possible, however, that a fracture of both condyles may occur, and yet the most striking symptoms be wanting. A case of this kind has been reported by the editor in the July No. of the American Jour- nal of Medical Sciences, 1849. The injury was produced by jumping from the third story window of the Almshouse Hospital. There was neither crepitation, mobility, nor twisting of the limb. Passive flexion and extension of the leg was readily effected. There was no increased breadth at the knee-joint. The de- formity resembled a partial dislocation of the knee backwards. The leg was thrown back- ward, and the patella was very prominent. The patient recovered rapidly without a bad symptom, and about a year after died of typhus fever. The specimen, as can be seen from the wood-cut, shows but slight shortening and no increase of breadth at the articular extremity. The fragments were probably impacted, the structure being cellular, and the force of the counter-stroke in a fall from such a height being very great.—Ed.] Nature of Displacement.—The vasti muscles passing around the con- dyles, to be inserted into the patella, prevent great displacement. The fragment, however, has a tendency to be slightly drawn backwards by the gastrocnemius externus, and if the fracture be of the inner condyle, besides being slightly drawn backwards, it is also drawn a little upwards by the adductor magnus. Treatment.—The same treatment is pursued, whether there be frac- ture of the external, or internal condyle. The extended position is by all preferred, because the head of the tibia, acting as a splint, resists displacement. Pasteboard or gutta-percha splints, moistened in warm water, should be applied by means of a roller. In these injuries, inflam- mation within the cavity of the joint is much to be dreaded ; the use of pressure, therefore, by the above mechanism must be deferred until all inflammation has subsided. The rule to be observed is to keep the pro- per attitude from the commencement, but not to apply the mechanism until all danger of inflammation is past. [In fractures of either or both condyles it may be necessary to make FRACTURES OF PATELLA. 177 extension and counter-extension, which can readily be effected by Phy- sick's modification of Desault's Splint. At the end of four or five weeks, passive motion should be commenced, to prevent stiffness of the joint.—Ed.] FRACTURES OF THE PATELLA. Fractures of the patella are either tranverse or longitudinal; the for- mer are more frequent than the latter, the exciting causes being more numerous. Fractures of this bone may be either simple or compound; but the compound fracture is fortunately of comparatively rare occur- rence. Fig. 36. Fig. 37. Transverse fracture.—This injury may be produced by direct violence, such as a fall or a blow, or by violent contraction of the four strong extensor muscles of the leg attached to the patella. Persons have been frequently known to meet with this fracture from the last-mentioned cause, while ascending a stair; and the reason of this may be easily understood. The ordinary action of the rectus femoris and triceps exten- sor cruris is to bring the leg forward; this they do by having their fixed points of attachment above, and they then extend the leg by drawing up the patella, which, through the medium of the ligamentum patellae, brings the leg forward. In ascending a flight of stairs the action of the muscles is exactly the reverse. When the leg is raised on the step to be ascended, the patella is made the fixed point of the attach- ment of the muscles, and in the half-bent position in which the leg is placed, the patella rests only by a small part of its posterior surface on the femur, its two extremities, and especially its apex, being unsus- tained. The four muscles, by their contraction, then raise up the femur, so as to be in a line with the leg, and while they do so, it is evident that the patella has to sustain the whole force of muscular action, together with the weight of the body. The apex of the bone has a tendency to V^e drawn downwards, and the upper part backwards, by the extensor muscles, so that while the middle part rests on the femur, and has to sustain the whole superincumbent weight and muscular action, if these be too much for the strength of the bone, it snaps, and the muscles having thus lost their under-fixed attachments, can no longer support the body, which consequently falls backwards. It is a popular mistake that the fall is the cause, whereas it is in fact the consequence, of the accident. This explains the reason why this accident frequently hap- pens to an individual ascending a flight of stairs with a burden on his back. This fracture has also been known to take place during an attack of convulsions, while the patient was stretched on his back ; and a case 178 FRACTURES OF PATELLA. is on record in which it was produced by placing the body of an indi- vidual in the position necessary for performing the operation of litho- tomy, and the straining of the muscles during the operation. Symptoms.—The fracture may be easily known by the two projec- tions formed by the fragments, and the unnatural depression between them, into which the fingers may be pressed down towards the femur, as far as the integuments will permit. The extent of the depression will depend on whether the ligamentous expansion covering the anterior surface of the patella be lacerated or not. The two fragments are easily movable, but any lateral movement of them is attended with pain. On bending the leg on the thigh, the space between the frag- ments is increased; it is diminished in bending the thigh and extending the limb. The patient has not the jpower of extending the leg, nor of supporting the weight of the body on that leg, as the knee bends for- wards when the weight is placed upon it, from the loss of action in the extensor muscles. The manner in which the patient attempts to bring his leg forwards is also diagnostic; he leans the body forward, and then swings forward the whole of the extremity by calling into action the muscles which bend the thigh upon the pelvis. The nature of the vio- lence, and the tumefaction which quickly follows from the extravasation of blood and secretion of synovia, are indicative of the character of the injury. Nature of Displacement.—The lower fragment remains in its natural position, and follows, together with the ligamentum patellae, the motions of the leg ; the upper fragment is drawn upwards by the four extensor muscles. The distance of the fragments from each other is increased by the bent position of the leg ; but it varies, according as the tendinous expansion from the muscles over the bone is more or less lacerated. If the aponeurosis escape with very little laceration, the separation of the fragments may be limited to a very small extent; whereas, if it be com- pletely lacerated, they may be removed some inches from each other. Fig. 38. Sir Astley Cooper says the upper portion may be drawn up five inches, and others have referred to a specimen in the museum of St. Thomas's Hospital, in which the two fragments are connected by a broad structure fully five inches in length. Mode of Union.—Transverse fractures of the patella are very rarely united by bone, but in almost all cases by a ligamentous substance. It FRACTURES OF PATELLA. 179 was long supposed that there was something peculiar about the structure of the patella which was unfavourable to the fresh formation of bone. Baron Larrey was the first who questioned the existence of this sup- posed peculiarity : he ascribed the rarity of bony union to the difficulty of keeping the fragments in immediate apposition; and the correctness of his view, both as to the possibility of union by bone, and the cause of its rare occurrence, is now completely proved. That after fracture of the patella the union may take place by bone, can no longer be denied. In longitudinal fracture of the patella, it is even acknowledged to be the usual mode of union,—so frequently does it occur. In transverse fracture, though it is rarely met with, yet its possibility is incontestably proved. Sir Astley Cooper says :—" In a patient of my kind friend, M. Copart, of Paris, I once saw a case which appeared to me to be united by bone; and Mr. Fielding, of Hull, has published a similar case." Sir Charles Bell, in his work " On Injuries of the Spine and Thigh-bone," says, p. 57:—" This very week a woman goes out of the Middlesex Hospital with a fractured patella united by bone, and you can feel the ridge of union. Admitting that we may be deceived in this, there can be no deception in the preparation, which I place in your hands; you have the patella shattered and reunited by • bone, and you perceive the fragments are united with perfect regu- larity." At p. 58, he says :—" I have besides, eight specimens of frac- tured patella reunited by ligament, and two by bone. The ninth speci- men decides the matter. You see that the fracture has not only been across, but that there has been a rent longitudinally." M. Lallement records an unequivocal specimen of union by bone in transverse fracture. It was proved by dissection of the part, after the death of the patient, from another affection. Mr. Wilson has found in dissection, specimens of union by bone in transverse fracture, and the collection of Dr. William Hunter is said to contain a well-marked example. On the possibility of bone being formed in fracture of the patella, there is now no differ- ence of opinion; and that the cause of its extreme rarity in transverse fracture is the want of correct apposition, appears evident from the following considerations:— 1. Bony union is very common in longitudinal, and very rare in trans- verse fracture ; and it seems difficult to assign any explanation of the difference, except the comparative facility in the one case, and the ex- treme difficulty in the other, of preserving the parts in apposition. 2. If in longitudinal fracture the soft parts be so lacerated that it is difficult to preserve the fragments in apposition, then ligamentous union is the usual result. This seems to show clearly that the obstacle to bony union is the want of apposition. 3. In the case recorded by Sir Astley Cooper of Mr. Marryatt, who was thrown from his gig as he was passing along the Strand, there was transverse fracture of the patella, and the lower fragment was also broken perpendicularly, so that the bone was divided into three pieces. The transverse fracture united by ligament, but the perpendicular by bone. 4. In several instances Sir Astley Cooper divided the patella trans- versely in rabbits, by drawing the integuments to one side, and then 180 FRACTURES OF PATELLA. placing a knife upon the bone, and striking the knife lightly with a mallet. He states, that in no instance in which he performed the ex- periment, either in the rabbit or in the dog, did he ever succeed in ob- taining bony union. He performed the experiment of dividing the bone longitudinally both in the rabbit and in the dog ; and when the precau- tion was taken not to divide the tendinous fibres above, nor the ligament below, so that the fragments were preserved in close apposition, bony union was readily obtained; whereas, if these precautions were not attended to, the union was ligamentous. 5. Mr. George Gulliver has, in the " Edinburgh Medical and Surgical Journal," related a series of experiments on transverse division of the patella, in which he took care to divide the bone without destroying or in- terfering with the fibrous expansion in front of it; and, except in one in- stance, in an old dog, where the union was ligamentous, the division was followed by perfect ossific union. The fibrous expansion, being un- injured, kept the parts in apposition. 6. I had a case in which there was a crucial fracture of the patella in consequence of a contusion from the explosion of a stone in a quarry. The lateral fragments united by bone, the superior and inferior by ligament. T^xe medium of union is almost uniformly ligamentous : and since the • limb is as useful as when the union takes place by bone, and less liable to disruption, bony union being for a long time very susceptible of frac- ture, it is perhaps the most desirable result. Treatment.—The principal indications in treatment are to relax the four extensor muscles, to subdue inflammation of the joint, if it should occur, and to keep the fractured surfaces as close as possible together by means of mechanism. Attention to the first indication is essential to the fulfilment of the third. It is of the greatest importance carefully to attend to the period at which it is proper to commence the use of means for the attainment of these three objects: for the first, means should be taken as soon as the surgeon has an opportunity of seeing the injury; for the second, as soon as symptoms of inflammation appear; and for the third, not on any account at first, nor for several days, lest inflammation should come on, which would be aggravated by the pres- sure ; or, if inflammation has already occurred, not until it has subsided. For the purpose of relaxing the muscles, the trunk should be raised to the sitting posture to relax the rectus, the thigh should be bent on the pelvis, and the leg extended on a line with the thigh, having the heel elevated a little, so as to be higher than the knee, but not much raised, lest the position should be painfully constrained. In this attitude the parts of the skeleton, to which the extensor muscles are attached, are approximated. For subduing inflammatory symptoms of the joint, leeches, evaporat- ing lotions, and purgatives should be employed; and if the symptoms be violent, venesection, antimonials, and low diet, to an extent propor- tioned to the age and constitution of the patient. While the above re- medies must never be withheld when necessary, they ought always to be used as sparingly as possible, otherwise the energy of the reparative powers will be diminished. For preserving the fragments as closely in FRACTURES OF PATELLA. 181 apposition as is practicable, various kinds of mechanism are employed, together with the attitude described above. For my own part, I prefer the simple means recommended by Mr. Liston, which I have used in this fracture with as favourable a result as could be reasonably wished. They consist of a simple roller applied from the foot to a little below the knee, to prevent swelling of the leg and foot from infiltration, and a straight wooden splint, hollow at its two extremities and well padded, extending along the back of the limb from a little below the tuberosity of the ischium to a little below the middle of the leg, and retained by a roller, not tightly applied. The fragment of bone connected with the rectus and triceps muscles should be pressed towards the fragment attached to the ligamentum patellae, before the under part of the thigh is included in the roller. Sir Astley Cooper recommends, as the best mechanism for this injury, a broad leather strap, buckled round the thigh just above the knee, from which a long strap descends, passes under the sole of the foot, and is brought up to a buckle on the opposite side of the thigh belt. The leg is enveloped in a roller, and the limb kept extended by a long splint behind the knee. Mr. Amesbury devised an apparatus for transverse fractures of the patella, which has been called the uniting bandage, and consists of two pieces of leather softly padded on the inner surface, and long enough to pass half way round the limb ; these are buckled firmly above and below the patella, by straps passing behind the limb. Two short straps, attached to the lower margin of the upper belt, are brought down one on either side of the patella, and buckled to the upper margin of the lower belt, tightly enough to approximate the opposite edges of the pads, and at the same time the two portions of the patella. A long strap is then carried down the outside of the leg from the upper pad, under the sole of the foot, and up the inside of the leg to meet a buckle on the inside of the same pad. A long splint is then applied to the back of the limb. The plan commonly adopted to bring the fragments towards each other is, to apply a circular bandage both above and below the fractured patella, drawing it together by tapes placed between the bandage and the limb. The tapes are tied over the rollers, and the upper fragment is thus kept down. It has been very justly objected to this common method of treatment,—and the objec- tion applies equally to Mr. Amesbury's, and to some others, which it is unnecessary here to describe, that all belts and bandages tightly applied above and below the fragments must press the extensors attached to the upper fragment towards the femur, and the ligamentum patellae back- wards, so as to sink towards the joint, and thus the upper and lower ex- tremities of the patella are pressed backwards, and the fractured sur- faces, instead of being in the same plane, are raised forwards, so as to form an angle with each other. As the under fragment has no tendency to displacement, no advantage whatever can result from pressure below it; but it must be drawn downwards by pressing back the ligamentum patellae, besides having its broken surface inclined forwards instead of upwards. Mr. Lonsdale has contrived a very ingenious, but rather com- plicated apparatus, for preserving the fragments in apposition without circular constriction of the limb. A description of it will be found in his excellent work on Fractures. It is of the greatest consequence to 182 FRACTURES OF PATELLA. have the medium of union as short as possible; for if it be of great length, there will be proportionate retraction of the muscles, and conse- quently diminution of their power, and the patient, after his recovery, will not be able to walk quickly without a halt:—hence the importance of preserving the parts as nearly as possible in apposition. LONGITUDINAL OR PERPENDICULAR FRACTURE. This injury is caused by direct violence, and may be easily detected by careful manipulation. Progression is difficult and painful, but not impossible, and reunion by bone is readily effected. Treatment.—The joint is to be kept extended and at rest, the usual precautions to be taken against the occurrence of synovitis, and the ordinary methods to be adopted if it should occur. After all risk of synovitis is over, a slight lateral pressure is to be kept up, which can be conveniently done by pasteboard splints and a roller, or more ele- gantly by a pad on each side of the patella, and a laced knee-cap. As a precautionary measure, a straight splint should be applied behind the joint. COMPOUND OPEN, OR EXPOSE* FRACTURE OF THE PATELLA. This is a very serious injury, and always gives rise to the greatest anxiety in the mind of the surgeon, not merely on account of its being open, which is in itself an unfavourable circumstance, but because the patella being a part of the knee-joint, that large articulation is laid open, and the danger is from the synovitis and its consequences, and the great constitutional irritation, which are apt to result. A wound extending into a joint is at all times a serious injury; and when, as in open frac- ture of the patella, the joint is not only exposed, but the accident is complicated with injuries of the bone and soft tissues, which must give rise to inflammation, the accident is of a very dangerous character. Such injuries often prove fatal in a very short time, and when this hap- pens, it is usually in consequence of violent irritative fever caused by inflammation of the joint. The inflammation of the joint may prevent any opportunity of performing amputation, which should, on no account, be attempted, except after the patient has recovered from the collapse caused by the injury before the inflammation has commenced ; or after the active inflammation and constitutional irritation have subsided. At one time the regular practice was to amputate in all cases of com- pound fracture of the patella, the limb being sacrificed to save the life; but now many limbs are saved which formerly would have been removed. The circumstances which justify amputation are,—an irritable or debili- tated constitution, and more especially, if debilitated in consequence of bad habits, extensive laceration, or severe contusion, or the probability of the occurrence of sloughing of the soft parts. On the other hand, if the patient be of a healthy constitution, and not irritable ; if the wound be small, and sloughing not likely to take place, an attempt should be made to save the limb. For this purpose it should be laid at rest in the position proper for fracture of the patella, the edges of the wound should be brought together as speedily as possible, and every means taken to prevent violent inflammation, and to secure adhesion. When inflamma- FRACTURES OF THE BONES OF THE LEG. 183 tion occurs, it must be combated by the vigorous employment of the ordinary antiphlogistic remedies, namely, venesection, purgatives, anti- monials, and low diet, together with the local use of leeches, and either cold or warm applications as may be found most grateful to the feelings of the patient. In all cases in which debilitating remedies are required by the character of the injury or disease, the judicious practitioner will always be careful not to employ them to a greater extent than seems absolutely necessary ; but in the treatment of inflammation supervening on fracture of the patella, it is especially necessary for the surgeon to remember, that while it is indispensable to use these remedies to an extent proportioned to the urgency of the symptoms and the age and constitution of the patient, care must at the same time be taken that the strength of the patient be not unnecessarily brought down, other- wise the power and energy of the reparative process will be diminished. Some patients recover with an anchylosed joint, and others, even after a severe injury, with the perfect use of the limb. Sir Astley Cooper has recorded five cases which were successfully treated. In one of these the recovery was with an anchylosed knee, and in the other four with the perfect use of the joint. One of the cases, a very fortunate one, occurred in the practice of Mr. Ward, of Nottingham :—although the opening into the joint was large, yet, as the patient was young and of good constitution, and as the tibia and femur, and their cartilages, were uninjured, and the soft parts around the wound were not lacerated nor contused, so that there was little proba- bility that extensive sloughing would take place, Mr. Ward resolved on endeavouring to save the limb, and the patient recovered with the per- fect use of the joint, Mr. Ward having afterwards seen him dancing quadrilles at a ball in Nottingham. There is a case recorded by Pro- fessor Samuel Cooper, which he saw in St. Bartholomew's Hospital, under Mr. Vincent, where the bone was much fractured and the wound extensive; yet, after the formation of abscesses and the separation of several fragments, the patient recovered with a stiff joint. When I was an apprentice to my friend Dr. Ewing, I had the dressing of a very for- tunate case under his care, where, in consequence of the explosion of a stone in a quarry, the patella was broken into several pieces, and the joint extensively opened; but as the person had an uncommonly good constitution, amputation was not performed, and after long confinement and the discharge of a considerable number of small fragments, he recovered with the perfect use of the joint. FRACTURES OF THE BONES OF THE LEG. These fractures are very common, as will appear from the following statistics. Dr. George W. Norris, one of the surgeons of the Pennsyl- vania Hospital, states that during the ten years from 1830 to 1839 inclusive, there were treated in that Hospital nine hundred and forty- six fractures, of which two hundred and ninety-three were of the leg. Dr. Wilkinson King states that of two hundred and twenty urgent cases of fractures admitted into Guy's Hospital in one year, sixty-six were of the leg; and according to Mr. Lonsdale, of one thousand one hundred and one fractures which indiscriminately presented themselves at the 184 FRACTURES OF THE BONES OF THE LEO. Middlesex Hospital, two hundred and eighty-nine were of the leg. They are the most common of all fractures, except those of the forearm, which according to Mr. Lonsdale and most authorities are somewhat more frequent. There is not entire agreement among surgeons as to the comparative frequency of the different fractures of the leg. Accord- ing to Baron Boyer they occur in the following order of frequency : — 1. Fractures of both bones. 2. Fractures of the tibia alone. 3. Fractures of the fibula alone. This order of frequency, given by Boyer, seems to accord with the experience of Professor S. Cooper ; but Mr. Lonsdale found that of two hundred and eighty-nine fractures of the leg, one hundred and ninety- seven were of both bones, fifty-one of the fibula alone, and forty-one of the tibia alone. According to this statement, therefore, the following is the order in which the three classes of fractures of the leg most fre- quently occur:— 1. Fractures of both bones. 2. Fractures of the fibula alone. 3. Fractures of the tibia alone. Fractures of the fibula seem to have occurred more frequently than usual in the experience of Dupuytren, who expresses his belief that they are more common than is generally stated, and that fractures of the lower third of the fibula form a third of all fractures of the leg. Fig. 39. FRACTURES OF BOTH BONES. Causes.—These, which form more than half of all the fractures of the leg, are produced in various ways:—sometimes by a heavy body striking or falling upon or passing over the leg, in which case the frac- turing cause acting simultaneously on both bones, it is generally found that they are both broken at the same height; or, by the body falling while the foot is fixed, or by the foot and under part of the leg becoming fixed, while the body is in rapid motion. Another cause of fracture of both bones is a fall or leap from a great height, the person alighting with the extremity ex- tended, and the body erect. The tibia, having to sus- tain the whole shock, first gives way, and almost always obliquely, and the fibula then receiving the force next becomes fractured. In these circumstances the fractures are not necessarily at corresponding parts of each bone ; for the force being applied to the ends of the bones, each gives way at its weakest part, the tibia frequently about the commencement of its under third, and the fibula within a short dis- tance of its upper extremity. Symptoms.—The symptoms which denote a fracture of both bones are,—some change in the direction and shape of the limb, pain, inability to walk or sustain Fig. 39. From a preparation in my museum. FRACTURES OF THE BONES OF THE LEG. 185 the weight of the body, mobility of the fractured pieces, irregularity perceptible on drawing the fingers along the anterior angle and inner surface of the tibia, crepitus on rotating the foot, and angular deformity on raising up the leg. If the fracture be oblique, the heel may be drawn upwards, and angular deformity may be perceptible in front; the cause of which will be explained, when the position of the broken fragments is described. The manner in which the accident occurred will afford pre- sumptive evidence as to the nature of the injury; but the above are characteristic symptoms. Nature of Displacement.—The displacement may be longitudinal, angular, or rotatory. The longitudinal displacement producing short- ening of the leg, is extremely rare in transverse fracture ; indeed, it can scarcely take place, inasmuch as the drawing up of the under fragments is prevented by the upper portions of the bone ; but if the fracture be very oblique, the under fragments may be drawn upwards by the mus- cles of the back of the leg, and thus slight shortening may take place. Angular displacement may be produced by the action of the extensor quadriceps muscle, by the action of the muscles on the back of the leg, or by the weight of the foot; and in each case the salient angle will be in front. When the bones are fractured near the upper ends—a com- paratively rare occurrence, which can only take place as the result of direct violence, the upper fragment of the tibia is drawn forwards, there being no antagonist to the quadriceps, which is inserted immediately above the fracture. If the knee be bent, the quadriceps muscle will be put more on the stretch, and thus the upper fragment will be still more drawn forwards ; hence arises the great importance, in the treatment of this fracture, of keeping the leg extended. The above is the opinion gene- rally entertained regarding the cause of the displacement forwards of the upper fragment in this fracture, but it is objected to by Mr. C. Aston Key, who remarks, " It is not easy to understand why muscles situated far above the fracture, and sustaining no injury, should be dis- posed to act on the offensive, while those muscles that act in the oppo- site direction should be wholly passive on the occasion. It is still more difficult to comprehend, why the extensor quadriceps, lying upon the femur, should be disposed to such inconvenient action as that of per- versely drawing the upper portion of a broken tibia forwards; the site of the fracture having no apparent connexion with the muscles to which the displacement is attributed." He supposes that the muscles sur- rounding the fracture, becoming distended by infiltration, are thereby put upon the stretch and irritated to contract, and that the lower frag- ment obeying that contraction is drawn upwards, and thus pushes the upper fragment forwards. The angular deformity may be caused, as has been stated, by the contraction of the muscles on the back of the leg, or by the wTeight of the foot, and in either case the projection or sa- lient angle is forward. Under such circumstances, the upper or the lower portion of the bone will project farthest, according to the direction of the plane of the fracture. If the plane of the fracture be from above downwards, and from before backwards, the projecting point will be the upper extremity of the lower fragment; if the plane of the fracture be from above downwards, and from behind forwards, the lower fragment 186 FRACTURES OF THE BONES OF THE LEG. will be drawn upwards by the powerful muscles of the calf, and will push forwards the lower extremity of the upper fragment, which in that instance forms the projecting point. Oblique fractures are very difficult to be managed, and the integuments are very apt to be torn by the pro- jecting points of the fragments. Rotatory displacement, called by some authors derangement in the circumference, arises from the inclination of the foot inwards or outwards, but most commonly in the latter direc- tion. To avoid repetition, the treatment of all fractures of the leg will be described under one head, after the peculiarities of the other two classes of these fractures have been explained. FRACTURES OF THE TIBIA. Causes.—This bone may be fractured by direct violence applied to itself, or by a fall on the foot. The tibia is fractured by a fall on the foot in the same way as the radius by a fall on the hand, and the injury in each instance is most likely to take place if the extremity be extended. As the radius receives on its lower part the whole of the shock from the hand, and on its upper part of the whole momentum of the body from the humerus, in the same way the lower part of the tibia receives from the foot the whole shock, and the upper part receives from the thigh- bone the whole momentum ; and as in each instance a single bone sus- tains the whole shock, it is easy to understand how the radius in one case, and the tibia in the other, may be fractured without a correspond- ing injury of the ulna or the fibula. In the lower third it may also be fractured by indirect violence, or by what is called by the French, contre- coup. Symptoms.—Since the fibula, by acting as a splint, prevents shorten- ing, or any particular deformity or alteration in the appearance of the limb, and the extent of the fractured surfaces tends also to prevent shortening and displacement, and since the difficulty of moving the frac- tured portions on each other renders crepitation less distinct than when both bones are fractured, and the patient has sometimes been known to be capable of supporting his body on the injured limb, diagnosis is more difficult in this than in the former fracture. The manner in which the injury was produced, and the pain for some time constant, continuing much longer than that from mere contusion, and increased on moving the limb, are presumptive signs. If the parts be minutely examined, some inequality will be perceived on moving the finger along the ante- rior angle or inner surface of the tibia ; and on taking hold of the ends of the bone and pushing them in opposite directions, some unnatural mobility, and generally slight crepitation also, will be perceptible. Nature of Displacement.—If the fracture be near the upper end of the bone, the upper fragment will, for the reason before given, be drawn forwards, especially if the knee be bent; but if the foot be kept in a proper position, it is evident, from what has been already said in de- scribing the symptoms, that there will be little tendency to displace- ment of the fractured portions. The treatment will be afterwards described. FRACTURES OF THE BONES OF THE LEG. 187 FRACTURES OF THE FIBULA. Causes.—Fracture of the fibula in its two upper thirds, while the tibia remains uninjured, can only be the result of direct violence, and the situation of the fracture will be the part to which the violence has been applied. The deep situation of the bone, the manner in which it is covered by the peronei muscles, and its elasticity, allowing it to yield until it receives considerable support from the muscles between it and the tibia, render the bone capable of sustaining a somewhat powerful force directed against its two upper thirds, without its being fractured. The lower extremity of the fibula may be fractured by direct violence, or by the outward or inward twisting of the foot, or by the body falling to either side, while the foot is confined in a deep cleft; as occurred in the case of Sir Astley Cooper, who says, " I broke my right fibula by falling on my right side, whilst my right foot was confined between two pieces of ice, and I could with difficulty support myself to a neighbour- ing house by bearing on the inner side of the foot." When the fibula is fractured in its lower third by direct violence, the situation of the fracture is the part to which the violence was applied; and when the fracture has been caused by the inversion or eversion of the foot, it is found to be from two to four inches above the lower end of the external malleolus. The fibula is not only useful for affording attachment to muscles, and assisting to form the ankle-joint, but especially, as it has been particularly pointed out by Boyer, for preventing dislocation of that joint, in a forced abduction of the foot. It descends along the outer part of the astragalus, and he remarked that in every step that is made on uneven ground, the foot presses against the inferior extremity of the bone. By this action of the foot on the external ankle, the fibula is pressed upwards, and as the nature of its articulation with the tibia does not allowT it to ascend in any perceptible degree, it is compelled to bend more or less in proportion to the force applied. The elasticity of this bone enables it for some time to resume its natural direction, when the force is removed. But as the same force acts frequently, and is never intermitted except for short intervals, the bone insensibly acquires a permanent bend, instead of being perfectly straight, as it is in the in- fant. The bend becomes more evident in proportion as age advances and the limb has been used. Climbing animals, such as the squirrel, whose feet are always in a very forced abduction, have the fibula very strong; and it has been observed by Cuvier and Dumeril, that in the three-toed sloth, the inferior extremity of the fibula is inserted into a socket on the superior surface of the astragalus in such a manner that the foot must be considerably strengthened by it, and secured against dislocation, by the extreme abduction which this animal is obliged to make in grasping the trunks and branches of the trees on which he climbs. Of the two causes of fracture of the fibula from indirect violence, namely, violent eversion or inversion of the foot, it is stated by Sir Astley Cooper, Mr. Liston, and Professor Samuel Cooper, that eversion is the more frequent; and in this most surgical authorities seem to be agreed; but Baron Dupuytren, in his experience at the H6tel Dieu, found inversion 188 FRACTURES OF THE BONES OF THE LEG. to be more frequently the cause of the fracture. It appears that of two hundred cases of broken fibula, a hundred and twenty arose from inver- sion or rolling the foot inwards, sixty from eversion or rolling the foot outwards, and twenty from direct violence applied to the bone itself. When the foot is twisted outwards, the weight of the body, instead of following the direction of the axis of the tibia, crosses the lower part of the fibula, the ankle-joint, and the malleolus internus in an oblique direction; so that, under such circumstances, it has to be sustained on the outer side and above the. joint, by the under part of the fibula, and on the inner side and below by the malleolus internus, and the internal lateral ligaments, while the under part of the fibula is violently pressed outwards by the astragalus. When fracture is caused in this manner, it is frequently combined with fracture of the malleolus internus, or rupture of the internal lateral ligaments. When the foot is twisted inwards, the weight of the body, instead of following the long axis of the tibia, passes obliquely across the lower part of the tibia, the ankle joint, and the malleolus externus, the inner aspect of which has the outer part of the astragalus pressed against it, while its under extremity is forcibly drawn inwards towards the outer part of the foot, by the powerful external lateral ligaments :—the rationale of the occurrence of fracture, under such circumstances, may be easily understood. Symptoms.—There is sometimes considerable difficulty in detecting a fracture in the two upper thirds of the fibula, from the bone being covered with muscles, and there being no shortening of the limb ; besides wdiich, the swelling from infiltration often increases the difficulty of tracing the bone, and of detecting crepitus. If the characteristic sign of crepitus be perceptible, either on pressing the bone towards the tibia, or on pressing the foot violently outwards,—by which means it is some- times discovered, or if another characteristic sign be present, namely, an unnatural yielding, or mobility of the fibula on pressure, there can be no difficulty in forming a diagnosis. In the absence of the above characteristic signs, the surgeon will be guided by the following pre- sumptive symptoms:—the circumstance of the patient having been sub- jected to the only cause of fracture in this situation, namely, direct force; a fixed pain at the situation of the injury ; a crack, or sensation of snapping or giving way of the bone having been perceived at the time when the injury was sustained, and a difficulty in walking, some- times amounting to inability. Pain at the part is generally increased on pressing the foot outwards. Fracture of the lower part of the fibula is easily discovered. In addition to the presumptive signs of fracture, the nature of the injury is manifested by an inequality of the bone at the broken part, and unna- tural mobility of some portion of the lower end of the fibula; crepitus, perceptible on grasping the leg with one hand, and pressing the foot inwards and outwards with the other; an angular depression at the situation of the fracture; distortion, with some unnatural mobility of the foot from side to side, and a change in the point of incidence of the axis of the limb upon the foot. Many of these symptoms disappear, FRACTURES OF THE BONES OF THE LEG. 189 when reduction is effected by force applied to the foot, but they return when the force is discontinued. Nature of Displacement.—In fractures caused by direct violence, or by eversion of the foot, the lower extremity of the upper fragment, and the upper extremity of the lower fragment, are both drawn inwards towards the tibia, so as to diminish the interosseous space; but in frac- tures caused by violent inversion, while the lower extremity of the upper fragment is drawn inwards, as in the other varieties, the upper extre- mity of the lower fragment is drawn outwards, partly from the manner in which the fracture is produced, and partly from the lowest part of that fragment being kept inwards by its attachment to the outer side of the foot by the external lateral ligaments. A fracture caused by inver- sion is usually nearer the malleolus externus, than one occasioned by eversion. TREATMENT OF FRACTURES OF THE LEG. All fractures should be reduced as quickly as possible. To make the description of the treatment of these fractures more clear, they may be divided into two classes:—first, fractures, whether of the tibia, or of both bones, in the upper third; and secondly, fractures of either or both bones, below the upper third. I. In fractures of the tibia, or of both bones, which occur in the upper third, or even nearly as far down as the middle of the leg, the pelvis should be raised, and the limb placed in a straight position. If the leg be bent, the quadriceps muscle, by being put on the stretch over the articulation, will cause the under part of the upper fragment of the tibia to press against the common integument; and if this should not be obviated, there will be great risk of a simple becoming an open or com- pound fracture, by ulceration of the integument. In this class of frac- tures, therefore, the straight is the preferable attitude. The necessary appliances are very simple, and consist merely of a roller to the foot and lower part of the leg, to prevent swelling from infiltration ; a hollow straight splint of wood, extending from the middle of the thigh to near the heel, and two pasteboard or gutta-percha splints for the sides of the leg, together with a bandage for retaining the splints in their proper place. II. In fractures of either or both bones below the upper third, the treatment must be different, both as regards attitude and mechanism. Attitude.—The preferable attitude, is that in which the leg is bent on the thigh, the degree of flexion being greater or less, as is found most conducive to the easy retention of the fragments in apposition, and in their proper relations to each other, the foot being very slightly extended, and neither inverted nor everted. In this attitude, it will be more easy than in any other, to prevent the various kinds of displace- ment formerly described. Mechanism.—Various kinds of mechanism have been invented for the treatment of these fractures. The double inclined plane of the late Mr. M'Intyre of Newcastle, is an ingenious, elegant, and excellent apparatus, and so also is that of Mr. Amesbury, and by means of either of them, all the indications to be fulfilled by mechanism, can be readily 190 FRACTURES OF THE BONES OF THE LEG. accomplished ; but a much cheaper and equally useful apparatus, is the splint recommended by Mr. Liston, than which a more convenient piece Fig. 40. of mechanism for the purposes for which it is intended, could not be desired. It consists of a foot-board of wood, and leg and .thigh pieces of sheet iron joined to each other by a couple of hooks and a screw. The screw was in use centuries ago, and is represented in the surgical works of Jerome of Brunswycke, published in the sixteenth century. By it the thigh and leg pieces may be set to any angle, at which it may be desirable to bend the knee, and the foot-piece may be moved upwards or downwards, to suit the length of the limb, and fastened by a side screw, in any position that may be desired. The splint having been Fig. 41. adjusted and well padded, the pads being secured by bits of tape, and a sock with a piece of tape opposite to the ball of the great toe, having been put upon the foot, the limb is placed on the apparatus, and the piece of tape attached to the sock is fixed to a knob on the surface of the foot-board. The broken ends of the bones having then been placed in perfect contact, and in the desired position, the foot, leg, and thigh should then be secured by a roller commencing at the toes, and carried up so as to embrace the whole of the extremity and apparatus, and also to make some turns round the loins. This will prevent the danger of displacement from any slight motion of the trunk, and although the whole extremity may be moved as one piece, the fragments will always preserve the same relations to each other. The bandage should be made to pass between the screw and the apparatus, and in carrying it round the limb, the greatest care should be taken to adapt it neatly by Fig. 40. Liston's cradle. Fig. 41. Liston's splint applied FRACTURES OF THE BONES OF THE LEG. 191 reverses, where inequalities of the limb would cause it to lie unevenly. For favouring the return of blood, and diminishing the danger of swell- ing, the extremity should be raised a little above the level of the trunk, while the patient remains in bed. In general, it is unnecessary to con- fine the patient for more than eight or ten days; after this he may be allowed to sit up during most of the day, with the heel on a level with the pelvis. The treatment thus goes on pleasantly, without danger of the general health being injured by long confinement to bed. By occa- sionally turning the screw very slightly, passive motion is given to the knee, and the danger of stiffness is obviated. In six or eight weeks, as consolidation has advanced, the time for which varies according to the age, strength, and constitution of the patient, the apparatus may be removed, and the patient allowed to move on crutches: he must be careful, however, not to put any weight on the limb for several weeks, otherwise, however straight the leg maybe, on the removal of the appa- ratus, it will become bent and deformed. After the removal of the appa- ratus, gentle support should be given to the leg by means of the starched bandage, or by pasteboard splints and a common roller. A more con- venient or successful method of treatment than the above, need not be desired. In the absence of the more perfect apparatus, the fragments may be preserved in their proper relations to each other by means of the com- mon wooden splints for the leg, retained in their position by loop or buckle bandages. In fractures of both bones, each splint should have a foot-piece; but in fracture of a single bone, it will be sufficient if a foot-piece be attached to the splint on that side to which the foot has a tendency to turn. The splints should be well padded with wadding, cotton-wool, or tow, to prevent painful pressure on the soft parts. [Perhaps the simplest apparatus for fractures of both bones of the leg, with the exception of those occurring in the lower third of the fibula, is the fracture-box which is used in the Pennsylvania Hospital. It consists of a long, narrow box, reaching from above the knee to the FiS- 42- sole of the foot. The sides are movable, being attached by hinges to the bottom, and the end of the box is longer than the foot, and answers for a foot-piece. The sides of the box are to be opened, and a small pillow laid on the bottom, which, when the sides are closed, answers the purpose of junk or bran bags, adapting itself to the inequalities of the limb. The foot is to be secured by a bandage to the foot-board. The pressure required to retain the coaptated fragments can be regulated by tying several tapes more or less tightly around the box.—Ed.] Fractures of either malleolus, or of a single bone, near its lower extremity, can be conveniently treated by the simple apparatus so strongly recommen- ded, and successfully employed by Baron Dupuytren. When slightly modi- fied, it consists of a straight wooden splint, a pad, thicker at the end nearest the ankle, and a roller. The splint should be long enough to extend from the head of either bone of the leg to three or four inches beyond the foot, and have two retiring angles or notches at its extre- 192 FRACTURES OF THE BONES OF THE LEG. mity, and perforations at its upper end to admit pieces of tape, by which a pad is affixed to it, and also to receive the split end of the roller. It should be applied to the side of the leg opposite to that to which the foot has a tendency to turn, the one extremity extending up- wards to near the knee-joint, the other to three or four inches beyond the foot. The pad should be between the leg and the splint, with its thicker end between the latter and the foot; and the roller should be fixed to the upper extremity of the splint by passing the two parts of Fig. 43. its split end through the perforations, and securely fastening them together. This will prevent the splint from being pressed upwards. The roller then, embracing the leg and splint from above downwards, should, during its convolutions round the foot, be made to pass through the retiring angles or notches in the extremity of the splint, whereby it will keep the foot from being displaced in the direction in which it is turned by the accident, and the thick end of the pad acting as a ful- crum, and keeping the splint removed from the foot, will enable the bandage to act with greater effect. In this method of treatment sug- gested by Baron Dupuytren, the bandage offers the resistance to dis- placement of the foot, and the splint should always be placed on the side opposite to that to which the foot has a tendency to turn ; whereas, in the treatment with the common splints for the leg, which some British practitioners still employ, the splint with the foot-piece offers the resis- tance to displacement, and it should always pe on the side to which the foot is displaced. In the latter method the resistance to displacement is offered by the splint with the foot-piece, in the former by the ban- dage ; in the latter the splint with the foot-piece is always applied to the side to which the foot is displaced, in the former the single splint is always placed on the opposite side. A most satisfactory way of treating simple fractures of the leg is by means of pasteboard splints, together with starch bandage, or by starch bandage alone. The period for application is after the subsidence of the swelling and slight inflammation that usually follow the injury. A great advantage of this method is, that such an incasement is formed round the limb as serves to remove all danger of displacement, and makes it unnecessary to confine the patient for any great length of time to the recumbent posture. Nothing could answer better than this mode of treatment, when resorted to at the period mentioned above. Fig. 43. From Liston. FRACTURE OF THE RIBS. 193 Of the practice, recently adopted in Belgium, of applying the starch bandage immediately after the occurrence of the injury, and thus form- ing an incasement for the limb, I have had no experience; but the results are said to be satisfactory, and individuals who have in that country witnessed this mode of treatment have given very favourable accounts respecting it. OPEN OR COMPOUND FRACTURE OF THE LEG. Compound fracture of the leg is more frequently met with than any other kind of compound fracture. If portions of bone be completely detached, they should be removed ; and if the extremity of a fragment project through the wound in the soft parts, it should be reduced; but no general rule can be given as to any uniform mode of reduction. Sometimes it may be best accomplished by enlarging the wound in the soft parts, sometimes by cutting off a portion of the projecting bone with a saw or cutting pliers, and occasionally it may be necessary to employ both these methods to a certain extent. The surgeon should in every instance be guided by the particular circumstances of the case; but in general, if the projecting part of the bone be short and of consi- derable thickness, the more judicious procedure is to enlarge the wound; whereas if it be a long slender portion, it wrould be more advisable to cut part of it off. It is only, however, when reduction cannot be other- wise accomplished, that the surgeon should have recourse to either of these plans. The wound should be cleaned, and its edges brought toge- ther, and dressed as the circumstances may suggest; pressure on the part should be carefully avoided, and if abscesses form, they should be opened without delay. The local and constitutional treatment must be regulated according to the symptoms at the time. FRACTURE OF THE RIBS. Fractures of the ribs happen almost as frequently as those of any other bone in the body. From the statistics of Mr. Lonsdale, it appears that, out of one thousand nine hundred cases of fractures admitted into the Middlesex Hospital, thirty-five were fractures of the ribs. The middle ribs being the longest and most exposed to violence, are most liable to fracture. The upper ribs being the strongest, and protected by the clavicle and the pectoral muscles, are rarely fractured. The lower ribs generally escape injury in consequence of their being short, mobile, and free at their anterior extremities. Exciting causes.—This accident is produced in one or other of three ways :—either by direct violence, as a blow, or fall; or by the applica- tion of force to the sternum or anterior extremity of the rib; or by muscular action, as in coughing, in persons of a cachectic habit of body. If a rib be fractured by direct violence, the part where the violence was applied, is the site of the fracture. If the second exciting cause men- tioned produce fracture, the rib gives way at its most convex point—a little anteriorly to its angle. Symptoms.—A fracture of a single rib, unattended with any internal lesion, is an injury of little moment, the patient commonly recovering in the course of four or five weeks; but when several ribs are broken, 13 194 FRACTURE OF THE RIBS. and there is, connected with the injury, one or more of the complications hereafter specified, the case is one of a very serious nature, and such as often terminates fatally. A simple fracture is often capable of detection by merely passing the finger over the suspected part. The more elegant mode of examination, is to place the hand upon the injured part, and to desire the patient to make a full inspiration, or to cough; when, if a fracture be present, a crepitus will be perceived, and the patient will experience great pain, from the ends of the bone grating upon the soft parts. This latter symptom is much increased by any exertion of the respiratory organs, as sneezing, coughing, &c. Absence of Thoracic Respiration.—On account of the pain which attends the motion of the rib, the patient avoids thoracic respiration, and calls into action the diaphragm and abdominal muscles. Fig. 44. Fig. 45. Nature of Displacement.—It is necessary to attend to the direction of the salient, or pointed angle. It is obvious that the displacement of the ends of the fractured rib can only be either inwards or outwards, for the intercostal muscles preclude the possibility of their assuming an upward or downward direction. If a rib has been fractured by direct violence, the direction of the retiring angle will be outwards, and of the FRACTURE OF THE RIBS. 195 salient angle inwards ; on the contrary, if the injury has been produced by violence, applied to the sternum or anterior extremity of the rib, the direction of the retiring angle will be inwards, and that of the salient outwards: in fact, the disposition of parts is just the reverse. The former kind of displacement is the more dangerous, because the pleura and lungs are apt to be wounded. If there be a mere fissure, there is no displacement. Treatment.—This consists in keeping the rib at rest as much as pos- sible, by means of a broad bandage of calico or flannel, applied round the chest so tight as to stop thoracic respiration, and to make the dia- phragm and the abdominal muscles aid in the performance of the respi- ratory action. If the ends of the fracture project into the cavity of the chest, a large compress is to be applied in front of the sternum, and in this manner the convexity of the rib is increased. If they incline outwards, the modification of the treatment consists in placing two large compresses, one on each side of the fracture. It is convenient, in order to prevent the broad bandage from slipping down towards the loins, to attach a split cloth, or a scapulary, to its central part posteriorly, and, passing it over the shoulders, to secure it in front. Instead of the ban- dage already described, a belt of webbing or girth, furnished at one end with four or five buckles, and at the other with as many straps, as also with two shoulder-straps to prevent displacement, is sometimes employed to suspend the movements of the chest in respiration. It is more com- pact and effective than the common bandage, and is called a fractured rib bandage. To prevent the occurrence of inflammation within the chest, it is expedient, if the patient be very plethoric, to take blood from the arm. PARTICULAR COMPLICATIONS. General Emphysema, or inflation of the subcutaneous cellular tissue of the body. Symptoms.—These are,—difficulty of breathing, a preference of the erect attitude to the horizontal, great distension of the cellular mem- brane, pitting and crackling on pressure of the swelling, and, if the emphysema be very great, a hissing noise on cutting the skin, arising from the escape of the air. Condition of Parts.—Rupture of the pleura and a portion of the lung, from the ends of the fractured rib projecting into the cavity of the chest, is necessary to produce this condition. The air is effused into the chest, escapes into the cellular tissue around the fracture, and by the contraction of the chest in respiration is forced into the general cellular tissue, because the air has no outlet, the skin being entire. We say, therefore, that general emphysema, in fracture of the ribs, is the result of an unnatural communication between the air-cells of the lung and the cells of the subcutaneous cellular tissue. If this condition prove fatal, it is by way of asphyxia, the great distension of the cellular mem- brane mechanically compresses the thorax, so that the muscles of respi- ration being overpowered are incapable of dilating the chest. The difficulty and imperfection of respiration are indicated by the lividity of 196 FRACTURE OF THE RIBS. the face, lips, and eyelids, the dilatation of the nostrils, and the coldness of the extremities for some time previous to dissolution. Treatment.—A few deep scarifications should be made over the ster- num and the ribs, when the air will escape, and the swelling gradually disappear. Pneumathorax, or accumulation of air sent from the air-cells of the lung into the cavity of the pleura. Symptoms.—In a well-marked case, on looking at the thorax, it will be observable that the affected side of the chest is longer, from the ribs being more or less separated, larger, circular, and almost motionless during respiration. Auscultation supplies another symptom, namely, the complete absence of the respiratory murmur, except at the roots of the lungs, that is, between the scapula and the spine. On percussion the affected side yields a clearer sound than the other. This symptom, together with the greater size of the affected side, might lead one to consider that as the sound, and the healthy as the diseased side. Treatment.—Generally a slight degree of inflammation takes place, which seals up the air-cells, and the air is absorbed. The circulation of the lungs should be kept as low as possible, and antiphlogistic remedies had recourse to. Sometimes, however, the operation of paracentesis is necessary. Interlobular Emphysema, or infiltration of air into the cells of the cellular tissue of the lung. Condition of Parts.—This affection is produced by rupture of some of the proper air-cells, and the consequent extravasation of the air con- tained in them into the cells of the cellular substance of the lung. The cells of the cellular tissue thus distended with air compress the air-cells and vessels of the lung, in consequence of which the circulation of air through the air-cells, and blood through the pulmonary vessels, becomes interrupted, and the portion of lung is rendered incapable of performing its function. The air in the cellular tissue does not undergo change; consequently it can have no beneficial effect upon the blood in the lung, and by means of the distended cellular tissue, septa form, which isolate a portion from the rest of the lung. These septa, by rasping against the parietes of the thorax, produce the friction of ascent and that of descent, which are indicative of this condition of lung. Symptoms.—On exposing the thorax we observe, that the affected side is less movable during respiration, not contracting and dilating as in the normal state. If the affection be very great there will be a slight increase in the length and size of the affected side. On percussion over the site of the emphysema, the chest sounds some- what more clearly than natural, but not to such extent as in pneuma- thorax. The nearer the injury is to the surface of the lung the more distinct the resonance will be. Auscultation furnishes another sign completely pathognomonic of this affection, namely, the crepitus ronchus with large bubbles. This sign, which is more marked during inspira- tion than expiration, resembles the noise produced by filling a dried bladder with air. Connected with this sign we usually perceive the friction of ascent, and the friction of descent, the former accompanying FRACTURE OF THE STERNUM. 197 inspiration, the latter taking place during expiration. The impression communicated to the ear is that of some hard dry body, rising and falling, and rasping against the thoracic parietes, and is particularly discernible just as expiration ends, and before inspiration commences. Sometimes this sound is perceptible in the under part of the thorax in the neighbourhood of the diaphragm, sometimes in the situation of the mediastinum. In some instances this sound is continuous during inspi- ration and expiration, in other cases there is a succession of sounds. Besides the symptoms already mentioned, there are others of a general and local kind, as dyspnoea, more particularly on making any exertion, slight lividity of the countenance, coldness of the extremities, and occa- sionally emphysema. Treatment.—This affection is attended with danger, and all that can be done is to preserve the circulation of the lungs as quiet as possible. With this view, lay the patient in bed, enjoin low diet and the usual antiphlogistic remedies. Sometimes nature seals up the cells with lymph, and the air is absorbed and the cellular substance surrounding the lobules assume their healthy condition. HiEMATHORAX, or effusion of blood into the cavity of the pleura from rupture of some of the intercostal vessels, and perhaps of those in the substance of the lung. Symptoms.—Impeded respiration from obstruction to the motion of the lungs, is one of the most marked symptoms of this affection. Percussion yields the dull sound, from blood being interposed between the thoracic parietes and the lung. The stethoscope indicates the ab- sence of the respiratory murmur, except at the root of the lung; and before the effused blood be coagulated, there is sometimes heard a silvery sort of echo of a sharp and shrill tone, termed segophony, the impression communicated being that of a voice heard within the thorax. The voice is reverberated in the bronchial tubes, and is conveyed to the surface of the chest by the compressed lung and the extravasated blood. The pre- sence of a fluid seems to be one of the most essential conditions for the production of this phenomenon, consequently it can exist 'only before the blood is coagulated. The features become pale, and all the symptoms of internal hemorrhage appear. FRACTURE OF THE STERNUM. The sternum is sometimes fractured, but not so often as might be ex- pected from its exposed situation. It is enabled from its position be- tween the elastic cartilages of the ribs to avoid any ordinary violence. A fracture of the sternum is sometimes followed with serious conse- quences, as necrosis, or abscess immediately behind it. Symptoms.—This injury is easily detected by the crepitation which is felt on applying the hand to the front of the chest, and desiring the patient to make a full inspiration. The function of respiration is prin- cipally performed by the diaphragm. Treatment.—The patient should be placed in bed, with the head bent forwards and the pelvis slightly elevated in order to relax the sterno- mastoid and the abdominal muscles. If this be not attended to, an an- gular deformity, having the salient angle directed forwards, will result. 198 FRACTURES OF THE SPINE. With the view of keeping the fragments at rest as much as possible, some apply a large soap plaster over the ribs, others employ a broad bandage, as in fracture of the ribs, which is unquestionably the right proceeding. FRACTURES OF THE PELVIS. These are of rare occurrence, on account of its peculiar shape and the great thickness of several of its bones. Exciting Causes.—Falls from a great height upon the pelvis, the passage of heavy bodies, as a cart or wagon over it, and falls from or under a horse, are the ordinary exciting causes. Of three cases I have seen, one was produced by a fall over the ballusters of a staircase from the second to the ground-floor; a second arose from a fall from an em- bankment upon a heap of stones ; and the third was a complicated case, in which there was dislocation of one of the thigh-bones produced by an explosion. Fractures of the ossa innominata, especially if deep-seated, are with difficulty detected, but the nature of the injury can generally be ascertained from the history of the case, and the inability of the patient to support himself in the erect position. There is also a feeling of lace- ration at the seat of the injury on the patient making any exertion. It often happens as a serious consequence of fractures of the pelvis, that the bladder is lacerated and the urine escapes. If the laceration be in particular situations, the urine escapes into the peritoneum, speedily producing peritoneal irritation and death; and at other times, and more frequently, the urine is effused into the cellular tissue about the pelvis, giving rise to sloughing of the parts and extensive abscesses. Fracture of the sacrum is often attended with compression of the sacral nerves, and consequently with paralysis of the lower extremities. Fracture of the os coccygis can be ascertained by careful manipulation, or by intro- ducing the finger into the rectum, by which means apposition of the parts may be also produced. Treatment.—With respect to treatment of fractures of the pelvis, one precaution never to be delayed, is the introduction of a catheter into the bladder, wnich should be allowed to continue there a considerable time, in order to diminish the danger of extravasation. The patient should be placed in a very soft bed, in the easiest position, and the lower extremities tied together to prevent any motion. If inflammation succeed, it must be combatted by the strictest anti- phlogistic treatment the powers of the patient will permit, and after some time a broad belt may be placed around the pelvis, so as to keep the parts at rest. In the union of a fracture of the sacrum, there is sometimes a con- siderable quantity of callus thrown out, which may prove inconvenient. FRACTURES OF THE SPINE. It very rarely happens that one vertebra is broken: two or more are generally involved in the injury. The vertebral column contains and protects the spinal cord, which gives off the nerves that preside over sensation and voluntary motion. Exciting Causes.—These are two: direct violence to the vertebral column, and falls from a great height upon the head, the head being at FRACTURES OF THE SPINE. 199 the time bent forwards. When the latter is the exciting cause, the appearance presented by the spine is the same as in excurvation, or posterior curvature of the spine. Symptoms.—These vary very much, and depend upon the situation of the fracture and its effects upon the spinal cord. If a fracture take place in the lumbar region, and if, in addition to the fracture, there be pres- sure upon the spinal cord, arising from displacement, effusion, or extra- vasation, there will follow loss of sensation, involuntary expulsion of the faeces, retention of urine, together with a sense of pain and weak- ness, and a degree of irregularity at the seat of injury. The inability of the patient to retain the faeces arises from the sphincter muscle, which receives its nerves from the spinal cord, being paralysed. Rationale of the Retention of the Urine.—The bladder being para- lysed cannot pass off the urine; hence the retention. This retention of urine, as pointed out by Desault, if the patient do not die, is fol- lowed by a sort of dribbling, or incontinence of urine. The explanation of this latter circumstance is, that the bladder becomes so enormously distended, that the urine forces open the com- mencement of the urethra to such an extent as to allow a small quantity to dribble off, yet not sufficiently to relieve the retention or obviate the necessity for the introduction of a catheter. A symptom which occa- sionally takes place at the time of the injury, is priapism, and even emission of the semen, which Mr. Lawrence remarks, has never been satisfactorily explained. Notwithstanding the presence of these symp- toms, the functions of organic life, as heat, secretion, and circulation, still continue. If a fracture with compression occur at the upper part of the lumbar region, the whole of the symptoms already mentioned will be observed, with the addition of a tympanitic condition of the abdomen, produced by the sudden distension of the intestines with gas. If the patient do not soon die, this symptom sometimes disappears after a smart purging. If a fracture happen in the upper part of the dorsal region, together with pressure upon the spinal cord, the additional symptom is, absence of thoracic respiration, arising from pressure upon the spinal cord above the origins of the intercostal nerves. If the fracture be as high up as the sixth cervical vertebra, and attended with pressure upon the spinal cord, there is paralysis of the superior extremities. When a fracture, attended with compression of the cord, takes place above the third cervical vertebra, it is instantly fatal. The phrenic nerves supply the diaphragm, and instant death is the result of pres- sure upon the spinal cord above their origins. The period at which the patient dies, varies according to the different situations of the accident, and the extent of pressure upon the cord. Death is not the immediate result of fracture, even above the third cervical vertebra, unless it be attended with displacement. When a fracture is lower down, between the fourth cervical and the first dorsal, the patient generally lives from three to ten days. When the dorsal region is the seat of fracture with compression, the patient may live from two to three weeks. If a fracture occur in the lumbar region, the 200 FRACTURES OF THE SPINE. patient may perhaps live from three to eight weeks, occasionally some months, as in a case recorded by Mr. Harold, of Cheshunt. Treatment.—Little can be done. The patient should be placed in the easiest attitude, and the broken ends of the column preserved at rest. Antiphlogistic treatment, both general and local, especially local depletion by leeches, may be necessary to prevent and subdue inflam- mation. The state of the bladder must be particularly attended to, and the catheter introduced, if necessary. If the immediate effects are not fatal, counter-irritants may be locally applied, but their use should be delayed for some time. Concussion of the spinal cord may lead an individual to suppose that compression exists when it really does not. Here counter-irritation in the chronic stage is very beneficial. The application of strychnine is then often attended with the happiest results. The best mode of using it is to apply blisters, about the size of a crown-piece, and, when the cuticle is removed, to throw one quarter or one half a grain of the powder of strychnine over the blistered surface. The operation of tre- phining for the purpose of removing pressure from the spinal cord, has been proposed and performed: success, however, does not seem to have attended the operation, or to encourage a repetition of it. Upon this point Sir A. Cooper remarks, " Mr. Henry Cline was the first person who attempted to give relief in this accident. Being an excellent anato- mist and a most able surgeon, he saw no reason why cases of this kind should not be treated as cases of fracture with depression of the skull. Accordingly he cut down upon the arch of the spinal marrow, where the compression was greatest, and with a small trephine of his own inven- tion, he sawed through the arch of the spinous process, and took off the pressure on the spinal marrow by raising the depressed portion of the arch. "it is well known that in cases of fracture, where the displacement has been slight, union of the bone has been produced. There would be no difficulty in producing this union, supposing the pressure on the spinal marrow to be removed. There is a preparation in Mr. Brooks's collec- tion, from a case of fracture with depression, where the person lived long enough for the fracture to be united; and in the College of Sur- geons there is a preparation, presented by Mr. Harold of Cheshunt, from a case where union of the bone took place after fracture with dis- placement. There is no danger, therefore, as to the restoration of the arch of the bone, if the pressure on the spinal marrow could be removed; and it was with this view that Mr. Cline sawed through the arch. It is right, however, to mention that, in many of these cases the spinal mar- row is itself torn through. In some cases of fracture, with displace- ment, it is completely torn; in others, partially, and in some not at all. In cases where it has not been torn, there would be hope from such an operation; and it is in these cases that the operation has been performed. Mr. Tyrrell has attempted the operation since Mr. Cline; but both cases have terminated unfavourably. Whether future experiments may be attended with better success, it is impossible to say. The proposal was plausible ; the operation was easily performed; and as to the result if the spinal marrow were not torn, there seems no reason why a person FRACTURES OF THE SPINE. 201 should not recover after such an operation. We are obliged, however, to speak doubtingly on this subject, since the first experiments have been unsuccessful. If you could save one life in ten, ay, in a hundred, by such an operation, it is your duty to attempt it, notwithstanding any objections which some foolish persons may have urged against it. Sup- pose any one present were in this state himself; suppose him put to bed with a paralysis of his lower extremities, and fully acquainted with the inevitable result if nothing were done; would he not be glad to have an attempt made to save him ? Would it not be foolish and unmanly to say he would rather die than have such an attempt made ? The opera- tion is not severe; it cannot add to his danger; and as to the pain, no man is a man who would regard it. In the two cases in which the attempt was made, the operation did not shorten life; on the contrary, there is reason to believe that it prolonged it. You will be justified, therefore, in making the attempt. Though I may not live long enough to see the operation frequently performed, I have no doubt but it will be occasionally performed with success. There is no reason why it should not; and he who says that it ought not to be attempted is a blockhead."—Sir A. Cooper's Lectures on Surgery, pp. 152, 153. "It has been proposed," Mr. Liston observes, "to treat the spine, in cases of severe and alarming fracture, in the same manner as the cra- nium, by trephining; and some have recommended this in almost all kinds of injuries. I allude to the practice, only to condemn it. The spinal cord is generally displaced and compressed by the lower portion of the fractured body of the bones. One cannot easily comprehend what an operation is to effect in such cases: further notice of this pro- ceeding is unnecessary, seeing that, as far as I know,, it has been unani- mously discarded by the profession from amongst the list of surgical operations."—Liston's Elements of Surgery, second edition, p. 697. "The great objection," says Mr. Lawrence, " to this proceeding is, the uncertainty respecting the precise seat of injury, and the precise mode in which the spinal cord has been injured, or continues to suffer pres- sure. This operation of exposing and taking away part of the vertebral column, is really a very serious, and I may say, a very delicate affair; it is an operation which, if it were done when the contents of the spinal canal were perfectly uninjured, would, I think, be likely to be followed by inflammation of the membranes and cord; it would be likely to pro- duce mischief, even if no mischief had existed before. For these various reasons it appears to me that the proposal of taking out the spinous processes of one or two of the vertebrae ought not to be entertained." 202 CHAPTER VI. INJURIES OF THE HEAD. FRACTURES OF THE CRANIUM. Causes.— From the manner in which the different bones of the cra- nium are arranged, an ovate or spheroidal box is formed, which resists external violence, after the manner of arches, according to Bertin, and of spheres according to Be'clard; yet it is frequently fractured, and in the majority of instances these fractures are produced by the direct application of force to the injured part, as when a person is struck, or falls upon the head, and the bone is broken exactly where the blow or fall was inflicted. The cranium, however, does not always give way where it was struck, but sometimes at a distant part, forming the frac- ture by counter-stroke of the British, the fracture par contre-coup of the French authors. Fractures of the base of the cranium, in the great majority of in- stances, are caused by counter-stroke; the reason of which is easily explained. If a great weight fall upon the top of the head while the body is erect, or if the top of the head be struck by an obtuse body, the force thus applied above has a tendency to produce expan- sion of the lateral parietes, and to force the base of the cranium against the apex of the spinal column. It is evident that in such circumstances the cranium is acted upon by two forces : the violence applied to the top of the head acting downwards, and the resistance offered by the vertebral column acting upwards, so that a fracture of the base is often the result. In like manner, when in falling from a great height, the top of the head or vertex comes to the ground, the resistance of the ground acts on the top of the head, and the whole momentum acts through the medium of the spinal column on the base. The cranium, being thus included between two forces, gives way at its weakest part, that part being the base. Sometimes, however, fractures of the base are produced without a fall or blow on the head itself, as when a person falling from a great height alights upon the nates ; the spinal column being thus brought suddenly into a state of rest, offers Fig. 46. Fracture across whole base of the skull, produced by a fall on the crown of the head. The patient was admitted into my wards in the Royal Infirmary. From a preparation in my museum. Fig. 4G. FRACTURES OF THE CRANIUM. 203 resistance to the head, which being still in projectile motion, has its base forcibly driven against the spine, and a fracture may be the result. In each of these three cases, the head is acted upon by two forces with greater or less violence. Sir Benjamin Brodie, in a very interesting paper on Injuries of the Brain, in the fourteenth volume of the Medico-Chirurgical Transactions, says at p. 329,—" It has been observed to me, however, by Mr. Earle, that he has not known a fracture of this kind (i. e. by counter-stroke), to take place, except when the blow seems to have operated in such a manner as to impel the occiput forcibly against the atlas, the line of fracture passing through the former bone, where it rests on the latter. My own experience corresponds very nearly with that of Mr. Earle. The only well-marked cases of fracture of the cranium, in which the fracture could be attributed to the effects of contre-coup, which have fallen under my observation, were similar to those he has mentioned. I do not, however, mean to assert that such fractures absolutely never occur, independent of the reaction of the atlas. Among the cases re- corded in the Prize Memoirs of the French Academy of Surgery, there are some which show that the thing does happen; and Mr. Bell has afforded an ingenious and scientific explanation of the mode in which it happens. It is, however, worthy of remark, that the only two cases which Mr. Bell has adduced in illustration of what he has advanced, are those in which the fracture extended across the occiput, in the one passing through, in the other close to the foramen magnum of that bone." Fractures of the base of the cranium are not invariably caused by counter-stroke. Sometimes, when violence is directly applied to the occiput or the lateral parts of the cranium, it is not only sufficient to produce fracture of the part to which it is applied, but also to extend the fracture to the base. Of this I have seen two instances:—one, in which the fracture extended forwards to the body of the sphenoid bone, in consequence of a fall on the occiput, and the other, in which it ex- tended along the whole base of the skull, in consequence of a kick from a horse on the mastoid process. Of fractures of the cranium it may be observed, that those of the base in most instances result from counter-stroke, while those in other situa- tions are invariably occasioned by direct violence. ARRANGEMENT OF FRACTURES OF THE CRANIUM. These fractures present every possible variety of form, from the most simple fissure to the most complicated fracture extending in many direc- tions, and accompanied with depression. The ancient writers divided fractures of the cranium into many different varieties, distinguishing each by an appellation descriptive of its form, or of some peculiarity in the relation of the fractured parts; but these appellations, as they bur- dened the memory without leading to any useful practical results, are now abandoned. To show clearly the views now entertained respecting the nature and treatment of these injuries, it will be convenient to arrange them in the following six classes. First, Simple fissure, or fracture unattended with depression. Second, Simple fracture with 204 FRACTURES OF THE CRANIUM. depression. Third, Punctured fracture. Fourth, Compound or open fracture. Fifth, Fracture of the external table alone; and Sixth, Fracture of the internal table alone. I. SIMPLE FISSURE, OR FRACTURE UNATTENDED WITH DEPRESSION. As in this injury there is no wound in the soft parts, and the broken pieces preserve their proper level or equality of surface, and as the simple interruption to continuity of the bone produces no symptom de- noting its presence, it often escapes detection, and continues during life a matter of uncertainty. Simple fracture, considered in itself, is by no means a dangerous injury, and when its existence is suspected, and there is no accompanying injury of the parts within the cranium, it is not necessary to do more than enjoin every prudent precaution against the occurrence of inflammation. The violence which breaks the bone may give rise to separation of the Fig. 47. dura mater, laceration of the brain, extravasation of blood within or upon the brain, or above or below the dura mater, or to simple fissure of the outer table and fracture with depres- sion of the inner; and in con- sequence of some of these ac- companying conditions within the head, there may be con- cussion immediately after the injury, or the symptoms of compression or of inflammation of the brain or its membranes may appear, with all their usual consequences, to a dangerous or even fatal extent. The treatment of these conditions will be afterwards described. II. SIMPLE FRACTURE WITH DEPRESSION. The local signs of this injury are,—an inequality of the surface of the cranium, varying in extent according to the amount of depression, and usually the appearance of a bruise of the scalp. Sometimes the fragments are movable; in other instances the depressed portion is quite unyielding. There is a condition of scalp, frequently presenting itself after a contusion, more especially if inflicted by a flat body, which is very deceptive, and apt to make the inexperienced observer suppose that the depression of bone is to a much greater extent than it really is, and even to produce the impression that the bone is driven in, when no fracture really exists. I refer to the swelling caused by extravasa- tion. Into the cellular tissue surrounding the contusion blood becomes extravasated, and this raises up the soft parts to a considerable extent, whereas, at the bruise itself, if the contusion has been severe, the soft parts remain compressed in consequence of the cellular tissue having been deadened and the vessels paralysed by the bruise. The swelling Fig. 47. Simple fissure of cranium, produced by a fall on the side of the head. The case occurred in the experience of my colleague, Dr. Dyce. From a preparation in my museum. FRACTURES OF THE CRANIUM. 205 is remarkably firm, and the impression given to the finger by the extra- vasated blood so closely resembles that given by the margin of a frac- tured portion of bone, that it is very likely to deceive an unguarded observer. This condition of the soft parts should be al- ris- 48' ways kept in mind, lest the surgeon be deceived, either into the supposition that there is depression where none exists, or into the opi- nion, when it is present, that it is to a greater extent than is really the case. If the injury be not inflicted by a flat body, the whole of the scalp may be elevated at the injured part. Extravasation may be found in three dif- ferent situations, namely, between the integument and the tendon of the occipito-frontalis muscle, between the occipito-frontalis muscle and the pericranium, or between the latter and the bone. Besides the local appearances here described, fracture with depression may be attended with the usual symptoms of compression of the brain ; for an account of which I must refer the reader to the chapter on Com- pression. In regard to these symptoms, the intelligent surgeon will not only keep in mind the different conditions on which they depend, but in order to arrive at a correct diagnosis, and to ascertain from which of the various different conditions the symptoms in any particular case may proceed, he will inquire very minutely into the history of their appear- ance. Compression of the brain, proceeding from external injury, may be occasioned by a depressed portion of bone, or extravasation of blood, or the formation of purulent matter. The time when the symptoms made their appearance, will be found the surest guide in determining to which of these three causes they are to be attributed. When a depressed portion of bone occasions the compression, the symptoms present them- selves from the very occurrence of the injury ; when extravasation of blood is the cause, the symptoms do not appear immediately, except sometimes in a very slight degree, and it is not until a considerable quantity of blood has collected, that they show themselves very deci- dedly. When a patient, having been stunned by an injury of the head, recovers from the stun, and symptoms of compression afterwards appear and gradually increase, there is then reasonable ground for supposing that they arise from effusion of blood. When the compression is caused by the formation of matter, it does not appear for several days, and is preceded by the symptoms of inflammation of the brain, or its mem- branes. Thus the history of the symptoms is a useful guide in deter- mining the cause on which the compression depends. It is important Fig. 48. Fracture of cranium with depression. From a preparation in my museum. 206 FRACTURES OF THE CRANIUM. to remember that the injury of the one table scarcely ever corresponds with that of the other, the inner being almost always fractured to a greater extent than the outer, and the actual depression of the inner table being much greater than would appear from the examination of the outer part of the cranium. It is a remarkable fact, but one of which the records of surgery furnish many examples, that there is no certain correspondence between the symptoms of compression, and the extent to which a portion of the bone may be depressed. In some instances where the depression has not been to a great extent, the symptoms have been decidedly marked; in others, the symptoms have been very slight, when the depression has been manifest and considerable. Hence the statement of an eminent modern writer, "It is extraordinary and unac- countable, but it is not less true, that no calculation of the bad effects can be made, by the degree to which a part of the skull is depressed." Several very interesting cases confirmatory of this fact will be found in Thomson's Observations made in the military hospitals in Belgium. Treatment.—The object to be aimed at by treatment varies accord- ing to the presence or absence of the symptoms of compression. In the absence of these symptoms, the indication of treatment is to prevent the occurrence of inflammation, and for that purpose the strict antiphlogistic regimen, consisting of low diet, rest, and quietude, should be enjoined. It is also advisable to shave the head, to keep it cool by means of cold applications, to administer some smart purgative, and in some habits of body, it is prudent, even as a precautionary measure, to have recourse to depletion, provided there be much reason to apprehend inflammatory action. It would, however, be extremely injudicious to have recourse to depressing treatment in the period of collapse wThich immediately suc- ceeds such an injury; and after this period is passed by, the extent to which this treatment ought to be carried should be regulated by the age, habits, and constitution of the patient, and the particular circumstances of the case. If symptoms of depression be present, then the immediate object to be aimed at, is to relieve the brain from pressure; and the means to he taken, in the first instance, for that purpose, will depend on the extent of the depression, and the urgency of the symptoms. If the bone be not depressed to a very great extent, and if the symptoms be not ex- tremely urgent, the attempt should first be made to relieve the pressure of the brain by bleeding, purging, and the constant application of cold to the head after it has been shaved. Under this alleviating treatment, the brain sometimes becomes accommodated to its new condition, and the symptoms disappear. If after the proper measures have been em- ployed for a moderate period, the symptoms still continue, then the de- pressed portion of bone must be elevated. But if the depression be not only manifest, but also to a great extent, and the symptoms of compres- sion be very strongly marked, then the surgeon is justified in elevating the depressed portion of bone without waiting to ascertain the effect of the alleviating treatment recommended above. It appears, then, that in this variety of fracture, the circumstances under which the surgeon is warranted in proceeding to operate, are,—either when the symptoms continue unabated after the judicious employment of bleeding, purging, FRACTURES OF THE CRANIUM. 207 and the constant application of cold to the head; or, without waiting for the employment of these remedies, when the symptoms are alarm- ingly urgent, and the bone depressed to such an extent as to leave no hope of the brain becoming accommodated to its unnatural condition. When, in either of these cases, the surgeon has resolved to elevate the depressed portion of bone, he should first expose the fracture by making a crucial incision, and then raise up the bone by means of some of the different forms of elevators used for that purpose. If, as is often the case, it should be impossible to introduce the elevator underneath the depressed portion, the surgeon is justified in trephining, his object being, not to saw out the depressed portion, but to remove a part of the Figs- 49-54. bone which is not depressed, so as to admit of the introduction of the elevator, by which the depressed part may be raised to a level with the surrounding parts of the cra- nium. I cannot conclude this chapter without referring to a most extra- ordinary case, which shows, that at a very distant period from the ac- cident, the symptoms of compres- sion may be removed and the patient restored to his ordinary powers of body and mind. The case seems to have produced a deep impres- sion on the mind of Sir Astley Cooper, who records it in the fol- lowing words :—" The other cir- cumstance which I shall mention, is one, which, whether we regard it in a physiological or surgical point of view, is perhaps one of the most extraordinary that ever oc- curred; and, as connected with surgery and physiology, I am sur- prised it has not made a greater impression on the public mind than it appears to have done. A man was pressed on board one of his majesty's ships, early in the late revolutionary war. While on board this vessel in the Mediterranean, he received a fall from the yard- arm, and when he was picked up he was found to be insensible. The vessel soon after making Gibraltar, he was deposited in an hospital in that place, where he remained for some months still insensible, and some time after he was brought from 208 FRACTURES OF THE CRANIUM. Gibraltar on board the ' Dolphin' frigate to a depot for sailors at Dept- ford. While he was at Deptford, the surgeon under whose care he was, was visited by Mr. Davy, who was then an apprentice at this hospital. The surgeon said to Mr. Davy, ' I have a case which I think you would like to see. It is a man who has been insensible for many months; he lies on his back with very few signs of life; he breathes, indeed, has a pulse, and some motion in his fingers; but in all other respects he is apparently deprived of all powers of mind, volition, or sensation.' Mr. Davy went to see the case, and on examining the patient found that there was a slight depression on one part of the head. Being informed of the accident which caused this depression, he recommended the man to be sent to St. Thomas's Hospital. He was placed under Mr. Cline, and when he was first admitted into this hospital, I saw him lying on his back, breathing without any great difficulty, his pulse regular, his arms extended, and his fingers moving to and fro to the motion of his heart, so that you could count his pulse by this motion of his fingers. If he wanted food he had the power of moving his lips and tongue; and this action of his mouth was the signal to his attendant for supplying his wants. Mr. Cline, on examining his head, found an obvious depres- sion ; and thirteen months and a few days after the accident he was carried into the operating theatre and there trephined. The depressed portion of bone was elevated from the skull. While he was lying on the table, the motion of his fingers went on during the operation; but no sooner was the portion of bone raised than it ceased. The operation was performed at one o'clock in the afternoon. And at four o'clock as I was walking through the wards, I went up to the man's bedside, and was surprised to see him sitting up in his bed. He had raised himself on his pillow; I asked him if he felt any pain, and he immediately put his hand to his head. This showed that volition and sensation were returning. In four days from that time the man was able to get out of bed, and began to converse ; and in a few days more he was able to tell us where he came from. He recollected the circumstance of his having been pressed, and carried down to Plymouth or Falmouth; but from that moment up to the time when the operation was performed (that is, for a period of thirteen months and some days) his mind remained in a state of perfect oblivion; he had drunk, as it were, the cup of Lethe; he had suffered a complete death, as far as regarded his mental, and almost all his bodily powers, but by removing a small portion of the bone with the saw, he was at once restored to all the functions of his mind, and almost all the powers of his body. It appears, therefore, that in cases of depression we should not be prevented from trephining, however distant the period may be at which the accident occurred, and the patient may, after any interval, be restored to the powers of body and mind." III. PUNCTURED FRACTURE. When a fracture is caused by a sharp body, such as a corner of a stone, or by any pointed instrument, such as a bayonet or a pitchfork, or by a sharp-pointed body of any kind, which applies force with con- centrated effect, it usually presents the appearance of a cavity, or mere FRACTURES OF THE CRANIUM. 209 puncture, and is hence called a punctured fracture; and because there are often numerous fissures radiating on every side from the centre, it is also called star-like or radiated fracture. From the man- ner in which such a fracture is oc- casioned it is often attended with a wound of the soft parts. The in- ternal table is, on account of its brittleness, injured to a greater ex- tent than the external, and there is one circumstance in this form of fracture which renders it so exceed- ingly dangerous as to require imme- diate recourse to an operation, even in the absence of compression, or of every bad symptom. This circum- stance is, that spicular portions of the internal table are always driven inwards, and if these be not removed, it is almost certain that inflamma- tion will be excited, and if so, the ordinary remedies will have no effect, while the exciting cause continues; and if the operation be delayed until inflammation has taken place, it will then be too late to, save the patient. In short, the very existence of this form of fracture impera- tively calls for an operation. On exposing the fracture the depressed portions should be raised; and if it be impossible to introduce the ele- vator or forceps, it will be necessary to remove a small part of the sound portion of the cranium for the admission of the instrument. After the cause of irritation has been removed, and the edges of the wound been approximated, the treatment will consist of the rigid institution of anti- phlogistic regimen to prevent inflammation, and to subdue it in case of its occurrence. IV. COMPOUND OR OPEN FRACTURE WITH DEPRESSION. On this important subject, Sir Astley Cooper remarks, " Compound fracture is followed very generally by inflammation of the brain, and it will be of no use to trephine, when inflammation is once formed. It might be thought that it would be time enough to perform this operation when inflammation had appeared; but this is not the case; for if inflam- mation comes on, the patient will die, whether you trephine or not; and you will be so far from arresting its final progress by trephining that the operation will add to the danger of the inflammation. When inflamma- tion of the> dura mater and membranes has been excited by depression of the bone, you cannot retard the progress of death by performing the operation." Sir Astley Cooper enforces these principles by cases, and concludes by saying, " The elevation of the bone is never followed by any mis- chief; but if you do not raise it, and inflammation follows, it will be Fig. 55. From Liston. 14 210 FRACTURES OF THE CRANIUM. too late to attempt to save the life of the patient." In reference to this doctrine laid down by Sir Astley Cooper, Sir Benjamin Brodie, after referring to the fact that many persons undoubtedly have recovered, in whom there was at the same time a wound in the scalp and a fracture with depression of the cranium, although no operation was performed, and after referring to examples published by Mr. Abernethy, and various cases which occurred at the battle of Talavera de la Reyna, and were communicated by Mr. Rose, Surgeon to the Coldstream Regiment of Guards, goes on to say, " I have conversed also with other surgeons, whose experience has compelled me to doubt the accuracy of Sir Astley Cooper's conclusion. The question, however, is not to be decided merely on these premises. Many persons may do well without an operation, who suffer from what Sir Astley Cooper denominates a compound frac- ture of the cranium, and yet it may remain to be determined what is the probability of suppuration taking place in these cases as compared with those in which the scalp remains uninjured. For many years I have preserved notes of a large proportion of the cases of injury of the head, which it has fallen to my lot to witness. Among them, of course, are many in which there was fracture with or without depression, fol- lowed by suppuration between the dura mater and the bone. On refer- ring to these for further evidence on this interesting subject, I find that the cases in which suppuration takes place where the scalp is entire, have been comparatively rare; bearing a very small proportion indeed to those cases in which suppuration has followed a fracture complicated with a wound of the scalp. Such is the result of my own experience during a considerable period of time, and which I am enabled to give, not merely from a general recollection of what I have seen, but on the authority of written notes, made at the bedside of the patients, and, for the most part, before the question which they illustrate had ever pre- sented itself to my mind. Taking all these facts into consideration, and endeavouring to give its proper value to what may be urged on either side of the question, I cannot but acknowledge, whatever may have been my first impression on the subject, that it appears to me at this moment that the views of Sir Astley Cooper are well founded, and that in those cases in which a depression of bone exists, without any symp- toms, or with only very trifling symptoms, arising from it, the surgeon can follow no better general rule than this ; if the depression be exposed in consequence of a wound of the scalp, let him apply the trephine, and elevate the depression; but if there is a depression without a wound of the scalp in consequence of the accident, let him not make such a wound by an operation." From the above, it will be evident that the views of Sir Astley Cooper, as to the necessity of trephining in compound fracture with depression, in the absence of any symptoms of pressure, received, after much deliberation, the decided approval of Sir Benjamin Brodie. A different opinion, however, is maintained by many surgeons; and Pro- fessor Samuel Cooper, as will appear from the following extract from his lectures, seems inclined to agree with those who do not recommend an operation, except when symptoms of compression are present. In speaking of the doctrine laid down by Sir Astley Cooper, he says, " I FRACTURES OF THE CRANIUM. 211 cannot say that the observations which I have had opportunities of making on this point of surgery, would have led me to adopt this opi- nion." Sir Philip Crampton remarks on this subject, "In Dublin we conform in general to the rule of practice originally laid down by Dease, who preceded Desault by many years, namely, in fractures of the skull with depressed bone, whether complicated by wound of the scalp or other- wise, no attempt should be made to raise the depressed bone, unless very decided symptoms be present of compressed or irritated brain." Sir P. Crampton mentions that he has seen many cases terminate very favourably without the trephine, and refers to some in the very interesting paper in which he states the above views. On this point it will be evident that Sir P. Crampton and Professor Samuel Cooper are agreed, and that their opinion is opposed to that of Sir Astley Cooper and Sir Benjamin Brodie. Some surgeons are of opinion that in the absence of compression, trephining is justifiable only when the compound fracture partakes of the nature of punctured fracture ; and others, that the surgeon should be guided by the extent of the depression, the con- dition of the fragments, and the possibility of elevating them without increasing the wound of the scalp. For my own part, as Sir Astley Cooper's opinion is given with so much decision, and is founded on so extensive an experience, I should very much hesitate to advise any different procedure. V. FRACTURE WITH DEPRESSION OF THE EXTERNAL TABLE. Fracture of the external table, with depression into the diploe, can- not take place either in early life or frequently in old age, as the skull is, at both these periods, comparatively thin and without diploe; but that it has taken place in the middle period of life, is no longer a matter of uncertainty. This condition of the external table, the internal remaining at the same time perfectly entire, has now been demonstrated by many specimens, in which the occurrence of reunion proves that the patients must have lived for some time after the injury. The possibility of this condition suggests the propriety of caution in forming a diagnosis, and furnishes a reason why mere depression of a part of the cranium does not, if unaccompanied with compression, warrant the performance of trephining. If unattended with concussion, this injury is not likely to lead to any serious consequences, nor does it require any treatment beyond the precautions proper to be attended to, after every kind of injury about the head. VI. FRACTURE WITH DEPRESSION OF THE INTERNAL TABLE. The records of surgery furnish various examples of this fracture every instance of which, attended with unfavourable symptoms, must form a case of great anxiety and difficulty to the surgeon. Professor Samuel Cooper records a case of this kind, with urgent symptoms in which he performed the operation of trephining at Brussels, after the battle of Waterloo. The external table was perfectly entire, but a large splinter of the inner was driven more than an inch into the brain, and on its removal the patient's senses and power of voluntary motion 212 FRACTURES OF THE CRANIUM. returned. The part of the skull to which the trephine was applied, did not, of course, present any depression, and it was selected because the appearance of the scalp showed that there the external violence had been inflicted. In Dr. Hennen's Military Surgery, a case is recorded in which the external table was entire, and the internal splintered and driven more than half an inch into the brain. If a patient has been struck, or has fallen upon a certain part of his head, and if the external table be entire, and the symptoms of compres- sion supervene, the difficulty of diagnosis is sometimes very great, for the history of the symptoms is almost the only guide to the surgeon in forming a conjecture as to whether the symptoms be caused by depres- sion of the internal table, by extravasation of blood, or by matter ; and yet it is sometimes impossible, from the history, to arrive at a decided opinion, because although it is true that in depression the symptoms which indicate the state of the brain come on immediately after the injury, and in extravasation, some time elapses before they appear, and they become more distinctly marked as the blood is effused from the ruptured vessels; still, in a case of extravasation, the patient may have been insensible in the first instance from being stunned, or from the concussion of the brain, and before the insensibility from this cause has worn off, insensibility from compression may have come on; in such a case, the patient having been insensible from the very occurrence of the injury, it would be impossible to determine whether the compression has been caused by extravasation, or by fracture with depression ; and accordingly we find that in some successful cases, in which trephining was performed, in the expectation of finding the cause of pressure to be blood extravasated under the cranium, it turned out to be fracture with depression of the inner table. But supposing the injury of the internal table has given rise to extravasation of blood, or the formation of matter, although the surgeon should think that there is little doubt which of these is the cause of the symptoms in any particular case, still he has no certain guide as to the precise seat of the collected matter; he has no decided and unequivocal symptom to enable him to determine whether the blood be above or below the membranes of the brain, and consequently the real nature of the case, and the exact condition of the patient, must be very uncertain, and the indications of treatment ex- tremely doubtful and precarious. It would be saying too much to affirm that in every instance the surgeon should confine himself to the use of the alleviating remedies for pressure, formerly enumerated, and that what has very appropriately been called " exploratory trephining" should never be performed in any case. The case in which the indica- tion of treatment would be most clear, and the operation, if ever ad- visable, most warranted, is where symptoms of compression come on after an injury in the situation of the middle meningeal artery. On this subject Sir Benjamin Brodie remarks:—" Where no fracture is discovered, yet if there is other evidence of the injury having fallen on that part of the cranium in which the middle meningeal artery is situ- ated, the use of the trephine may be resorted to on speculation, rather than that the patient should be left to die without an attempt being made for his preservation. I cannot indeed adduce any particular CONCUSSION OF THE BRAIN. 213 experience of my own in favour of what is here recommended; but I con- ceive that the instances which have been recorded, in which the middle meningeal artery has been ruptured without any fracture of the bone, and the known fact that there is sometimes a fracture of the inner table, sufficiently justify such an experiment in desperate cases, or even in those in which there is much danger." On the very important and interesting subject of fractures of the cranium, I must limit myself to the above observations ; but at the con- clusion of the chapter on Compression of the brain, will be found an enumeration of the conditions, in which, according to the views now entertained regarding the treatment of injuries of the head, the opera- tion of trephining is considered advisable. CONCUSSION OF THE BRAIN. Causes.—The injury which is termed by British authors " Concussion of the Brain," by French, " Commotion," and in common parlance " stunning," is produced by one or other of the three following causes : —a blow, or a fall, on the cranium itself, or a fall from a considerable height on some other part of the body, as the buttocks, or the feet, by which a sudden shock is communicated to the brain, through the medium of the vertebral column. I lately had under my care a mason, in whose case there were strongly-marked symptoms of concussion, caused by his falling from the second floor of a house on his buttocks; and I am at present attending a female, who, in consequence of the horse becoming restive, jumped from the top of a cart loaded with hay, and alighting on her feet sustained fracture of one leg, and concussion of the brain. The spine in these circumstances is suddenly brought into a state of rest, and the head being still in projectile motion, is forcibly struck against the summit of the vertebral column : the sudden jerk thus com- municated to the brain occasions "concussion." Symptoms.—For facilitating the description of the symptoms of con- cussion, it will be convenient to adopt Mr. Abernethy's arrangement of them into three stages; an arrangement not only advantageous for pro- moting a clear understanding of the symptoms, and for reconciling by accurate discrimination some of the various descriptions of them given by previous writers, but valuable also, together with his other observa- tions, as having led to more correct and scientific views of practice than formerly prevailed. By referring to his Surgical Observations on injuries of the head, it will be found that he arranged the symptoms into three stages, which he called the first, second, and third. The first stage, which immediately follows the injury, is one of collapse, in which there is insensibility, with derangement of bodily powers ; the second is one of reaction, in which there is, to a greater or less extent, some return of sensibility, and restoration of bodily powers ; and the third is one of inflammation of the brain, indicated at first by increased excitement of that organ, and increased vascular action ; and this stage is certainly not the least important of the series of consequences which result from concussion. In well-marked examples the different stages are characterized by the following symptoms. 214 CONCUSSION OF THE BRAIN. In the first stage, the operations of mind are in many instances sus- pended, and often to such an extent, that consciousness is entirely lost for the time ; the functions of the brain and of the organs of sense are also suspended, so that there is complete insensibility to all external impressions. Common sensation and voluntary motion are also lost for the time; and often the loss of sensation is so great, that the patient gives no indication of being pained, on pinching or irritating the skin ; in short, he does not feel any injury inflicted on him; and with regard to motion, it does not so much seem to be the power of contractility that is lost, as the power of voluntarily combining the action of the muscles, so as to perform any particular movement. The operations of mind, and the powers of sensation and of voluntary motion, are usually sus- pended together, but I have seen instances in which the loss of the one is greater than that of the other ; and Sir Astley Cooper records a well- marked example in a gentleman, who at one .time, in the absence of his attendant, got out of bed, bolted the door, passed water, and went to bed again, and yet he was so insensible, that every attempt to get a word from him was ineffectual, and Sir Astley Cooper says, he does not believe the noise of an earthquake would have succeeded in rousing him from his lethargy. The countenance is pale and collapsed ; the surface, especially at the extremities, cold; the respiration is by some observers said to be easily and naturally performed ; in slight cases, certainly, it is almost natural, but in such as are well marked, it is very feeble and without stertor. The pulse is weak, slow, fluttering, and often inter- mittent, and in the extremities scarcely perceptible. The pupils con- tract on the application of light, showing that the retina is not perfectly insensible, and as regards the size of the pupil, in the cases of which I have kept notes, it was usually contracted when the concussion was slight, and dilated when it was very severe. Some authors have occa- sionally found one pupil contracted and the other dilated, and in the first instance, not dilating in darkness, nor contracting farther when the light was suddenly increased. Vomiting is an early symptom, and is referred to that well-known sympathy between the brain and stomach, of which so many examples could be given; a sympathy maintained through the pneumogastric nerves. If the concussion be severe, and the symptoms continue long, there may be the same condition of the urinary organs as in compression, the rationale of which condition will be explained in the chapter on Compression. The above symptoms may be changed into those of the second stage, or into those of compression, or they may terminate fatally without passing through any further change. In the second stage, the operations of mind are not so completely sus- pended as in the first, and the insensibility is diminished, although still so great, that ordinary impressions produce little effect, and the powers of attention and perception are still in a great measure lost; the func- tions of sensation and volition are also in a considerable degree restored. In consequence of this alleviation, although the patient lies as in a kind of sleep,it is possible to rouse him for an instant. By putting a ques- tion to him in a loud, sharp tone of voice, an answer is obtained in a monosyllable, and in such a manner, as if his attention were taken up CONCUSSION OF THE BRAIN. 215 about something else, and he instantly relapses into his former state. Such questions seem to be more readily answered, if they refer to the patient's state. The pupil is usually contracted, and the sensibility of the retina is evinced by the patient drawing his head from the light, when the eyelids are opened. The functions of the organs of sense, though much less acute than naturally, are not entirely suspended; and sensation and power of motion are in a great measure restored, as will be shown by his drawing away his limbs when they are pinched. Although the patient lies in a comparatively insensible state, and gene- rally in the position in which his body happens to be placed, yet there are occasional fits of restlessness, and in this respect concussion differs from compression, inasmuch as in the latter state, there is uniform and permanent insensibility with total loss of the power of motion. The circulation and respiration are more vigorous in the second stage than in the first; and in consequence, a natural warmth is diffused over the body. The pulse is firmer, fuller, and stronger; and if the patient be so far recovered as to be able to raise himself up, or to make any exer- tion, a condition of pulse will be perceptible, which is quite characteristic of concussion;—I refer to its very great acceleration when the patient rises up, or makes exertion of any kind. Sometimes when the pulse is not more than from seventy to eighty in the recumbent posture, it is so greatly accelerated by the patient's rising, as to reach from one hundred and twenty to one hundred and thirty in a minute. There is also in general, an unusually strong beating of the carotid vessels, especially on making exertion; and when the patient is able to describe his feelings, he generally complains of headache. I lately had under my care a lady with concussion of the brain, in whose case great throbbing of the carotid vessels, and great acceleration of the pulse continued for a very considerable time after all other traces of the injury had disappeared. The above symptoms may gradually subside, or they may pass into those of compression, or into those of the third stage. The third stage is one of pure inflammation of the brain, and is indi- cated by great pain in the head, increased heat and throbbing of the vessels about the head, full and flushed countenance, intolerance of light and sound, of light, sometimes even through the eyelids, suffusion of the eyes, watchfulness, restlessness, and delirium, together with great quick- ness of pulse, heat, and dryness of skin, diminution of secretion, and in short, all the usual symptoms of irritative fever. These symptoms may yield to remedies, or they may pass into the symptoms of compression, and prove fatal in the way of coma. Such are the symptoms of concussion in well-marked examples, when the disease runs its course; but, as in other injuries, the symptoms vary according to the violence of the concussion, so that between slight, tran- sient stunning, which wears off in a few minutes, and the state described above, there are many intervening shades. Sometimes, the patient appears merely to have received a slight stun, and in a few minutes he is quite well; in other instances, the symptoms are more marked and of longer duration, yet they wear off without being succeeded by any signs of the inflammatory stage ; and in other instances, the disease runs its course, and the patient falls a victim to it, death taking place in the 216 CONCUSSION OF THE BRAIN. way of coma. Sometimes concussion and compression exist together, and the phenomena of these two states, are so intermingled, that the surgeon is occasionally at a loss to determine on which condition chiefly the symptoms depend. CONSEQUENCES OF CONCUSSION SOMETIMES OBSERVED. Some patients recover from even very severe forms of concussion, without having in after life any trace whatever of the injury; but others are found to suffer various affections resulting from it, for a considerable time after their recovery, or even through their whole life. These con- sequences may affect either the mind or the body. The power of con- tinuous attention is often lost, or very much diminished; slight weak- ness of intellect, and even complete mental imbecility have sometimes been occasioned; but of all the mental powers, the memory is most fre- quently affected, the injury being attended with this peculiarity, that all recent events and impressions are forgotten, while those of an earlier period are remembered. For example, it has been found that a patient, who before concussion, conversed in a language recently acquired, had on his recovery entirely forgotten it, but that he was still able to speak a language which he had acquired long before. In some cases, the recollection has been lost of almost all impressions of a late date, while those of early life are distinctly remembered. This affection of the memory has been compared to that which takes place in old age, and it has been said, that in this respect, patients appear, as far as memory is concerned, as if they had suddenly grown old. In some instances, the affection of the memory has a different character, and the patient is unable to remember the proper word to be used for naming an object, or for describing its quality. Desault mentions a curious case of a man, who after concussion, could remember only recent events, but after- wards lost the recollection of everything recent, and could only remem- ber what had occurred in his early life. It is sometimes found that some of the organs of the external senses are permanently affected; thus, the use of one ear, or of one eye, may be altogether lost, or the sight considerably impaired. In some instances, the sight is affected in a peculiar way, so that only part of an object can be seen at one time, and the patient must move his head in order to obtain a view of the whole object. To such an extent has this been observed in some cases, that the patient has been unable to see all the letters of a word at the same time. Severe vertigo, or pain of head, on making any exertion, and great muscular weakness, are very frequently consequences of con- cussion. DIFFERENT WAYS IN WHICH CONCUSSION PROVES FATAL. It would be quite foreign to the object of this work to give any detailed account of the experiments made by physiologists to ascertain the effect produced on the organs of circulation by injuries on the brain and spinal cord ; but the following results of experiments on the ner- vous centres, and the conclusion drawn from them, as bearing on the interesting subject under consideration, may be here given. 1st. Legal- lois. and Dr. Wilson Philip, in their experiments, carefully removed the CONCUSSION OF THE BRAIN. 217 whole of the brain and spinal cord, and when artificial respiration was kept up, the action of the heart did not cease for some hours ; from which experiments, the conclusion is drawn, that the action of the heart is independent of the brain or spinal cord. 2d. In the experiments of the same physiologists, it was found that when any sudden and exten- sive injury, as a violent concussion, was produced on part of the brain or spinal cord, an immediate and great depression, or complete suspen- sion of the action of the heart, was the result; from which it is con- cluded that a sudden injury of the nervous centres, such as a violent and sudden concussion, suspends the action of the heart, and thus proves fatal; that, in short, death occurs by syncope, or begins at the heart. The vital power of the heart seems to be destroyed; for, when the chest is opened immediately after death, it is impossible to excite any contraction, and in that respect, as will afterwards be shown, the condi- tion of the organ is not the same as in death by coma, where the imme- diate cause of death, as will be seen in the chapter on Compression, is asphyxia, or suspended action of the lungs. 3d. From the experiments of Chossart and others, there appears to be some variety as to the part of the circulation chiefly affected by certain injuries of the nervous centres. Chossart found in some of his experiments, that in certain injuries of the brain and spinal cord, the circulation in the capillaries appeared to be for some time more affected than the action of the heart; but still it is by failure of the circulation that such injuries ultimately prove fatal. It is only by a knowledge of the dangers which threaten in different stages that we can be guided to rational and scientific principles of treatment. When concussion proves fatal in the first stage, it is by failure of the action of the heart; sometimes this failure is instantaneous; sometimes it goes on gradually increasing to a fatal termination; and sometimes there is a very partial reaction, and then a second failure of the organs of circulation, which proves fatal. It is evident, therefore, that the state of the circulation must, in this stage, be watched with much anxiety by the skilful practitioner. When concussion has proved fatal by failure of the heart's action, the heart is in some cases, particularly in those which have been very suddenly fatal, found to be quite empty, a circumstance the cause of which, as Dr. Alison remarks, is not easily explained. In other cases it is distended; but the distinguishing peculiarity is, that there is no difference in the quantity of blood in its right and left sides: in this respect, also, the state of the heart is different in death by asphyxia, as will be shown in the chapter on Compression. Another way in which concussion proves fatal, is by compression of the brain. This may take place soon after the injury, when blood from the vessels of the lacerated portion of brain has had time to accumulate in some quantity; or after reaction has taken place from extravasated blood; or in the third stage from serous effusion, or the formation of purulent matter, as results of inflammation. APPEARANCES AFTER DEATH. The appearances within the head vary according to the length of time between the injury and the fatal event. Separation of the dura 218 CONCUSSION OF THE BRAIN. mater from the inner surface of the cranium, when the blow on the head was severe, is a very common condition. In cases which almost instantly, or very quickly prove fatal, laceration of a portion of the brain is often observed; but it has long been ascertained by the investi- gation of surgeons that concussion often proves fatal, and that very suddenly, without any perceptible unnatural condition either of the cerebral substance, or of the vessels within the head; in short, without any discernible injury of the brain, its vessels, or its membranes. In cases rather more advanced, small specks of blood in some parts, or laceration of the brain are met with ; and in cases still further advanced, besides some of the above appearances, various traces of inflammation are observed, such as a turgid condition of the vessels, increased vascu- larity in the membranes or brain, or various kinds of inflammatory effu- sion, as serous, gelatinous, or purulent, or sometimes of lymph, or different combinations of some of the above results of inflammation. Surgeons have been anxious to determine in what way concussion sus- pends to a fatal extent the function of the brain in those instances, in which no derangement of its organization is discernible on dissection. Some suppose it may be by the sudden shock disturbing the circulation of the brain, but others think it more probable that the structure may be injured, although the injury may not be discovered by dissection. Sir Benjamin Brodie seems to be of fhe latter opinion ; he remarks, " If the brain is on so minute a scale that our senses are incapable of detecting it, it is evident that there may be changes and alterations of structure, which our senses are incapable of detecting." Some sur- geons, again, seem to think that the fatal suspension of function may be caused by condensation of the brain. Mr. Liston says, " When a blow is inflicted on the skull, only a slight commotion of the brain is induced, the cranial contents are, as it were, slightly jumbled, and a temporary and trifling effusion of its functions follows. When, however, the stroke is more severe, the brain is separated from its cranial attach- ments, both at the point struck, and at the part directly opposite; it is thrown upon itself towards its centre; its substance is thereby con- densed, its diameter in the direction of the impulse diminished, and a separation between the brain and cranium is formed at each extremity of that diameter. By post-mortem examinations, it has been ascertained that condensation of the substance of the brain does exist in cases of severe concussion. Such condensation may be sufficient to cause instant extinction of life, or the brain may gradually resume its former condi- tion, or with only such slight incited action as may be required to reunite the dura mater with the inner table of the skull." Such are the opinions which have obtained on this subject, but it appears very evident that our knowledge of it is still very imperfect. Treatment.—There are few points on which greater diversity of opinion has prevailed than on the treatment of concussion; indeed, two directly opposite methods have each had their advocates. Some sur- geons, from a supposed analogy between insensibility in fainting and insensibility in concussion, have advised stimulants and cordials; while others inculcate the necessity of bleeding and other antiphlogistic reme- dies. Pott in England, and Boyer in France, insisted on the necessity CONCUSSION OF THE BRAIN. 219 of bleeding; the latter to an extent unknown in this country. From the arrangement of the phenomena of concussion into three stages, from the condition on which the symptoms depend, and from what has been ascertained regarding the different ways in which it proves fatal, and the dangers of each stage, rational and scientific principles of treatment have been deduced. The treatment proper for each stage is a subject of great practical importance. In the First Stage, when the symptoms of depression of the powers of life are so urgent that there is danger of death from failure of the circulation, it would certainly be extremely injudicious still further to depress the system by bleeding; for this would be almost to take away the patient's chance of life: but, on the other hand, it would be hazar- dous to administer wine, stimulants, or cordials, as the occurrence of phrenitis, the condition on which the third stage depends, would be ren- dered more certain, and its severity, if it should occur, be in all proba- bility increased. Such means should therefore be employed to restore the circulation as are not calculated to have a permanently stimulating effect. With this view the patient should be laid in bed, covered with warm blankets, and having heat applied to the surface of the body, more especially to the extremities and abdomen. When the circulation is restored, the heat should be withdrawn. When the power of swal- lowing is regained, if the above means should not have produced the desired effect, and the patient be evidently in a very dangerous state, the surgeon may venture upon the use of some of the diffusible stimulants, such as ammonia. Since ammonia and other diffusible stimulants have not any permanent effect on the circulation, there is not the same objection to their use as to that of brandy, wine, or any such powerful stimulants. The state of depression is generally but temporary, and the reaction usually proportioned to the depression; hence the danger of giving any powerful stimulant. If there should happen to be lacera- tion of the brain, which, as has been already stated, is a condition often existing in concussion, then the period of depression of circulation tends to diminish the danger of internal hemorrhage; and this furnishes an additional argument in favour of the practice of avoiding stimulants: whereas, if the circulation be artificially excited, there is greater danger of compression from internal hemorrhage, and of phrenitis; and it has been already mentioned that these are two of the ways in which concus- sion proves fatal. In the Second Stage, the object to be aimed at is, to moderate the reaction, and thus to prevent, if possible, the occurrence of the symp- toms of the third stage. The patient should be placed in a cool, quiet, dark room, and every external source of excitement avoided; the shoulders should be a little raised; the head shaved, and cold applica- tions applied to it; the bowels should be freely purged, and the diet of the most unstimulating kind. If there be any evidence of increased vascular action, it may be advisable to bleed from the arm; but on this point the surgeon must be guided entirely by the state of the pulse, and not by the insensibility, which cannot be removed by bleeding. After the proper restoration of the circulation, if there be evidence of increased vascular action, a moderate bleeding may prevent phrenitis; and, if there be laceration, it may tend to arrest extravasation of blood on the 220 COMPRESSION OF THE BRAIN. brain. When recourse is had to bleeding in this stage, it is chiefly as a precaution. In the Third Stage, the treatment is the same as in ordinary cases of phrenitis, namely, depletion both general and local; the efficient appli- cation of cold to the head by means of cloths out of evaporating lotions, or of water rendered very cold by ice, or of ice itself and water in a bladder; smart purging of the bowels, with low diet, and attention to all necessary precautions for avoiding light, noise, and everything which could prove a cause of excitement or irritation. Care, however, must be taken that bleeding be not carried too far. The following reasons suggest the necessity for caution. 1. If there be laceration of the brain, the amount of inflammation necessary for obtaining reunion may be prevented. Sir Astley Cooper records a case which occurred in the practice of another surgeon, where depletion was carried too far, and on dissection there was found lacera- tion, without any attempt at reunion. 2. Phrenitis is an inflammatory disease, in which it is well known that patients do not bear depletion to the same extent as in some other inflammatory attacks. 3. Repeated copious bloodletting produces of itself confusion of mind, pain of head, a hardness and jerking condition of pulse, giddiness, and other symptoms, which an inexperienced observer may mistake for the symptoms of the injury. When the powers of life in this stage seem to be failing, recourse may be had to stimulants; and it is surprising how patients sometimes rally under them in instances where the symptoms are very unpromising, and death seems very near. Throughout all the stages the state of the bladder must be carefully attended to, and the catheter used, if necessary. COMPRESSION OF THE BRAIN, OR COMA. Symptoms.—In sanguineous apoplexy we have a good illustration of the symptoms of compression of the brain. In well-marked cases there is complete suspension of consciousness and of all mental operations. From the brain being incapable of receiving impressions from the nerves, there is suspension of the functions of the external senses, and of common sensation: and from its being unable to transmit the influence of the will through the nerves to the muscles, there is loss of voluntary motion. The muscles are relaxed, and the body remains in any position in which it may be placed. Both in compression and in concussion, sensation and voluntary motion are suspended; the cha- racteristic difference is, that in the former the suspension is constant and uniform while the compression continues; in the latter there are, even during the continuance of the concussion, occasional fits of rest- lessness, and the symptoms have a tendency to wear off. The retina is perfectly insensible; if the eyelids be opened and a candle be placed near, no perception of light is evidenced; the iris is motionless, and the pupil dilated. This is the condition of iris gene- rally found, and, therefore, regarded as a symptom of compression, COMPRESSION OF THE BRAIN. 221 though sometimes the pupils have been found at first contracted and fixed, and afterwards dilated and fixed. The respiration is slow, difficult, and stertorous. The relaxation of the velum pendulum palati, and of the muscles of the larynx and pha- rynx, prevents the free passage of the air, and gives rise to the noise in breathing called stertor. In very bad cases the air puffs out the cheeks and lips, and elevates the latter in passing out: this is always viewed as an unfavourable symptom. In consequence of the insensibility, the uneasy sensation in the chest caused by the presence of venous blood in the lungs, which under ordinary circumstances excites respiration, is not felt; and in addition to this, the muscles of respiration are paralysed. It is this condition of the respiratory apparatus which is the immediate cause of death; in other words, death is caused by asphyxia; and, therefore, the condition of respiration is watched by the surgeon with the utmost anxiety. The pulse is for the most part slow, full, and labouring. It has already been stated that, although the action of the heart is independent of the brain, inasmuch as the whole of the brain of an animal can be removed, and if the respiration be kept up, the action of the heart will continue for some hours, yet it is disturbed by a sudden injury of the nervous system;—in concussion for example, the heart's action is dimi- nished to a very great degree in the manner already described; in com- pression, however, the pulse is affected in a different way. In concus- sion, it is weak, small, and fluttering, whereas in compression it is slow, full, and labouring. The action of the heart is diminished, weakened, and sometimes entirely suspended by concussion, as by a sudden injury of the nervous system; whereas in compression it does not seem to be at all affected directly, but to become impeded and interrupted from the obstruction of circulation through the lungs, caused by the tendency to asphyxia. In the one case the effect is produced directly on the action of the heart, in the other directly on the action of the lungs, thereby rendering it more than ordinarily difficult for the heart to perform its function. Experiments of sawing out a portion of the cranium, and applying pressure to the brain, have been performed on the lower ani- mals, to ascertain the effect on the pulse; and the result observed has been, that the pulse becomes slower and labouring when severe pressure is applied, and rises when the pressure is removed. The same effect is observed in injuries of the human body; when the brain is severely compressed by a depressed portion of bone, the pulse becomes slow, and it is observed to rise, and often very suddenly, when the pressure is removed. This effect, as has been already stated, is believed to be occa- sioned by the condition of the lungs. Some cases are recorded in which the pulse became exceedingly slow. Dr. John Thomson mentions a case of compression from fracture with depression, where it fell to thirty-six in a minute; and I had an opportunity of watching a case where it became as low as thirty-two. Though compression is usually charac- terized by the condition of pulse here described, some instances have occurred where the other symptoms have been well marked without any perceptible change of circulation. Intermission of pulse, though observed in concussion, is not met with in compression. 222 COMPRESSION OF THE BRAIN. The symptoms affecting the alimentary canal are, that there is loss of the power of swallowing from paralysis of the muscles of deglutition; the bowels are constipated, and from the sphincter ani being paralysed, the faeces are passed involuntarily. Vomiting, which is usual in con- cussion, is very rare indeed in compression, it is only present under one or other of the following circumstances, namely, at the commencement of slightly marked cases, where it is probably owing more to concus- sion than compression; and in severe cases of compression on the sud- den removal of the cause of pressure, as on the removal of the depressed portion of the bone. Vomiting indicates a greater degree of sensibility and irritability than are generally met with in compression. The bladder being paralysed cannot pass off the urine. Unless death soon follows, this retention of urine, as pointed out by Desault, is suc- ceeded occasionally by a dribbling or sort of incontinence of urine; for the bladder becomes so enormously distended that the urine forces the sphincter to such an extent as to allow a small quantity to dribble off, yet not sufficient to relieve the distension, or to obviate the neces- sity of the introduction of the catheter. Convulsive twitches are sometimes met with in individuals suffering under compression of the brain; but, according to Bichat and Brodie, they are not indications of compression, but are believed to be more frequently connected with laceration or wound of the brain than with any other condition. Manner in which Compression proves Fatal.—In describing the symp- toms of compression it has been already stated that it proves fatal by failure of respiration, or in other words by asphyxia. All sensibility being destroyed, the sensation caused by the presence of venous blood in the lungs, which is the stimulus to respiration, is not felt; the muscles of respiration are also paralysed. After death, the veins leading to the right side of the heart, the right side of the heart itself, and the trunk and branches of the pulmonary artery, are found greatly distended with venous blood, and the left side of the heart is empty. These condi- tions depend on the obstacle to the transmission of blood through the lungs caused by the failure of respiration. This is a different state of parts from what was described in cases where concussion proves fatal by failure of the heart's action. There is another circumstance in which the state of the heart differs very much in death from compression, and death from concussion. In concussion, the heart's action seems to be completely destroyed, so that it cannot be excited to contract, although the chest of an animal be opened immediately after death, the irritability of the organ being destroyed; whereas in compression, if the heart, whose action in this form of death by asphyxia continues for a few seconds even after the last breath, be exposed immediately after death, it may be excited to contract, either by allowing some of the contents of the right side to escape, or by irritating it; thus showing that its irritability is not destroyed, as it is in death by concussion beginning at the heart. In compression, the action of the heart ceases at last, the right side being unable to contract from over-distension, and the left from the want of its ordinary stimulus, the blood. INJURIES OF THE HEAD. 223 Causes and Treatment.—The causes of compression from injury are three: fracture with depression, extravasation of blood, and the formation of matter. For a description of the symptoms, diagnosis, and treatment of these three different conditions, I beg to refer to the sections on fracture with depression, and fracture of the internal table. I think it necessary here only to add, that extravasation may take place in any of the five following situations : first, between the cranium and dura mater; second, under the dura mater into the cavity of the tunica arachnoidea ; third, between the tunica arachnoidea and pia mater; fourth, between the pia mater and the brain; and fifth, into the substance of the brain itself. There does not seem to be any difference in the symptoms, whatever be the situation of the blood; and it is only when in the first-mentioned situation that relief can be given by trephining, because, in addition to other reasons, it is then only that its situation is circumscribed. I am aware of some extraordinary cases, where relief has been afforded by puncturing the dura mater ; but notwithstanding these exceptions, the above, as a general rule, will be found to be correct. When suppura- tion takes place, it may be in any of the above-named situations. Ac- cording to Pott, when the matter is between the cranium and dura mater, its existence is indicated by a puffy tumour of the scalp, and a separation of the pericranium from the outer table of the cranium. This condition does occasionally present itself, but it certainly is not an invariable symptom, as cases have occurred in which this condition was not present, and yet on dissection matter was found between the cranium and dura mater. That such is the case, Bichat says is proved by daily experience at the Hotel Dieu. CONDITIONS WHICH JUSTIFY THE OPERATION OF TREPHINING. From what has been stated regarding injuries of the head, it will appear that operative interference is thought to be justifiable under the following circumstances:— 1. In simple fracture with depression, provided the symptoms persist after the use of depletion, purging, and the other alleviating remedies. 2. In compound fracture with depression without symptoms of com- pression. 3. In punctured fracture without symptoms of compression. 4. When the symptoms are very urgent, and the surgeon thinks he has good reason to believe, that they are caused by blood or purulent matter underneath the cranium and above the dura mater, or by fracture with depression of the inner table. In each of the first three conditions, it is considered necessary to adopt proceedings for raising the depressed portion of bone to its proper level. If, on exposing the fracture, it is found that this cannot be done by means of the elevator, which is often the case, in consequence of the fractured portions being so related that it is impossible to insinuate the extremity of the elevator underneath the depressed portion, then it is advisable to remove a small portion of the cranium by means of the trephine, for the purpose of allowing the introduction of the elevator, by which the depressed part is to be raised. The instrument used by the ancients was the trepan, and the operation was called trepanning; 224 INJURIES OF THE HEAD. the instrument now used is called the trephine, and the operation, trephining. Such are the views now entertained in these later and better times of surgery, as to the conditions which justify and require the operation of trephining. We find, however, from the history of surgery, that a very different doctrine prevailed in former days ;—that so great was the rage for trepanning among the ancients, that the very slightest fissure, or even the mere suspicion of one, was considered to be sufficient warrant for the operation;—that they trepanned in all fractures, whether attended by depression or not, whether accompanied by symptoms of compression or otherwise;—that they operated when bad symptoms were present, to remove them,—when absent, to prevent them ; so that they elevated every depression, trepanned every fracture, and, in ope- rating on a longitudinal or a radiated fracture, they trepanned along the whole of its course, so as to saw it out; and did not allow a single fissure of it, or rima, as they called it, to escape. In operating for the removal of a coagulum, they made as many openings as would uncover, if possible, the whole of it; and, says Ravaton, " I have seen surgeons so infatuated, so desperately bent on discovering abscess on the dura mater, that, after applying six crowns of the trepan, they would, and I verily believe have, pulled away all the remaining bones of the cranium, had not their patients been delivered by death from such operations." All this was done, they said, to remove danger. It is almost incredi- ble to what a disgraceful extent this passion for trepanning was allowed to outrage common sense; and it is difficult to imagine how they could believe a fracture to be so dangerous, and their operations so safe. To show the extent to which trepanning was carried, Mr. John Bell gives the following quotation :—" Godifredus, Chief Surgeon to the States of Holland, mentions with particular exultation the performance of this operation by his friend, who trepanned the cranium of the Count of Nassau twenty-seven times, and that the fact might be established on indisputable authority, he made the said Count of Nassau, after he was recovered, write the following curious certificate, on the 12th day of August, 1664:—' I, the underwritten, Philip Count Nassau, hereby declare and testify, that Mr. Henry Chadborn did trepan me in the skull twenty-seven times, and after that did cure me well and soundly.' " These practices, and the numerous inventions of instruments for cutting the skull, are sad monuments of the surgery of past ages. In later times the Royal Academy of Surgery in France revived and defended the doctrine that all fractures of the cranium ought to be trephined. It does seem surprising that this body of men, convened for the purpose of ascertaining the principles which ought to regulate the practice of our science, and to whom surgery is in other respects so greatly indebted, should, by giving the sanction of their high authority to so dangerous a doctrine, have led the younger members of our profession to adopt very dangerous rules of practice. The unfortunate results of the operation were so numerous, that the celebrated Desault, one of the greatest orna- ments of surgery in France, forming his opinion from what he saw at the Hotel Dieu, strongly condemned the practice, and, in the latter part of his life, entirely discarded it. The doctrine of the French Academy FRACTURES OF THE FACE. 225 met with a most powerful advocate in this country, in the late Mr. Pott, who, with all the great talent and decision for which he was so eminently distinguished, maintained the doctrine of trephining in almost every fracture, to prevent as well as to remove bad symptoms. He states that fracture of the skull in many cases is not attended with any symp- toms actually demanding this operation at the moment; but that although there maybe no symptoms denoting affection of the mem- branes, or of the brain itself, yet inflammation of those parts will, in consequence of the fracture, come on at a more or less remote period, and that, therefore, recourse ought to be had to the operation. Mr. Pott, in speaking of the doctrine of trephining, says, " I am as much convinced of this as of any fact which repeated experience may have taught me," and throughout his writings on that subject, he gives his opinion with so much decision, supporting it by cases and arguments, that his views cannot fail to have produced a very decided impression. Notwithstanding, however, all the eloquence and talent with which he supported his views, the doctrine he taught is now abandoned; and in these later and milder times of surgery, operative procedure is considered justifiable only under the circumstances mentioned at the commencement of this section. [FRACTURES OF THE FACE. FRACTURE OF THE BONES OF THE NOSE. Causes.—Owing to the prominence of the nose, the nasal bones are much exposed to fracture. It generally requires considerable force to break the arch formed by the articulation of the nasal with the superior maxillary bones. Direct blows, or severe falls, are the most common causes of the accident. Symptoms.—In many cases the contusion of the neighbouring soft parts is so great as to produce great swelling, and diagnosis is not always easy immediately after the fracture ; but even if crepitus cannot be distinguished, the mobility of the parts will often be characteristic. Bleeding from the nose, and injury of the brain, may also be present. The injury of brain is apt to be from concussion, rather than from com- pression. If the inflammation be great, there may be exfoliation of the bones of the nose, or the inflammation may extend to the dura mater which will produce deep-seated pain in the neighbourhood. Nature of the Displacement.—If the fracture is simple, the displace- ment would be slight, and but little deformity would result; but if the bones are crushed, the bridge of the nose will be destroyed. Treatment.—This will depend upon the amount of inflammation and the displacement. Should the fracture be simple, antiphlogistic mea- sures may be all that is necessary; but if the bones are crushed and pressed in, they must be adjusted by a large probe, or a female catheter. Compresses applied on each side of the nose, may be of use in retaining the fragments in apposition. Stopping up the nostrils with plugs of lint, or any other material, will be found of no service ; on the contrary, they will be more likely to do harm by increasing the inflammation. 226 FRACTURES OF THE FACE. FRACTURE OF THE MALAR BONE. Causes.—This bone is rarely fractured, unless from great violence, which will also produce great contusion of the soft parts. It is easily recognised, unless the swelling be very great. Treatment.—The swelling and inflammation are to be removed by appropriate remedies. The jaw must be kept perfectly quiet, which can be best effected by Barton's bandage for fracture of the lower jaw. The patient should not speak nor masticate. Should fragments of broken bone be driven into the temporal muscle, which would inter- fere with chewing, it might be necessary to cut down upon the fracture and elevate the pieces of bones. When small portions are split off from the edges of the malar bone, they are frequently reduced in size, by absorption, previously to their uniting. FRACTURE OF THE UPPER JAW. The superior maxillary bone is sometimes fractured at its nasal pro- cess, in connexion with fractures of the nose. Its alveolar processes are also liable to fracture, though the injury is not a serious one, unless it is the result of a gun-shot wound, involving the antrum Highmorianum. Fragments of alveolar processes will sometimes unite if properly pressed to their place, and the jaw be kept at rest. Fracture involving the antrum, would be attended with great swelling and pain, and the inflammatory symptoms would require antiphlogistic remedies. FRACTURE OF THE LOWER JAW. This results from direct violence, which must be very considerable to pro- duce a fracture in a bone which is so strong and at the same time so mobile. The seat of fracture may be in the body, rami, or processes, and it may happen that the fracture will occur at the symphysis, although this is rare even in children. The direction of the fracture may be either vertical, horizontal, or oblique. A portion of the alveolar process may be broken, without any serious inconvenience. The most frequent situation of the fracture is between the symphysis and the insertion of the masseter muscle. Symptoms.—There is no difficulty in the diagnosis. The history of the case, the pain upon moving the jaw, the unevenness of the base, the irregularity of the teeth, and the Fls- 56- crepitus, are sufficient. The larger fragment, to which the chin is at- tached, will be found to be drawn downwards. If the fracture is double, the displacement will be greater, and the middle portion, or chin, will be drawn downwards. The gums are frequently lacerated, and bleed. When fracture occurs in the neck of the condyloid process, it is not so easily recognised. In the accompanying wood-cut, taken from Fergus- FRACTURES OF THE FACE. 227 Fig. 57. son, there is represented a fracture of both condyles. It is to be dis- tinguished by the pain near the ear, by crepitation, and by the condyle being drawn forward by the action of the pterygoideus externus muscle. Treatment.—The fragments are generally coaptated without difficulty in single fractures; but in double fractures, more care is required. In either instance, the great object is to keep the lower jaw firmly pressed up against the upper, which acts as a splint. A simple dressing con- sists of a moistened piece of pasteboard, moulded to fit the jaw, and secured by a four-tailed bandage, which has a slit in its middle, into which the chin is placed. The two upper tails are to be tied behind the neck, and the two lower ones tied upon the crown of the head. In young persons, and in double fractures, it will sometimes be found convenient to fasten the teeth together with strong silk, or fine silver wire. In many cases it will be sufficient to place a large, thick compress under the chin, and apply Barton's bandage. It consists of a roller, five yards long and two inches wide. " Place the initial extre- mity of the roller upon the occiput, just below its protuberance, and con- duct the cylinder obliquely over the centre of the left parietal bone to the top of the head ; thence descend across the right temple and the zygomatic arch, and pass beneath the chin to the left side of the face; mount over the left zygoma and temple to the summit of the cranium, and regain the starting point at the occiput by tra- versing obliquely the right parietal bone; next wind around the base of the lower jaw, on the left side, to the chin, and thence return to the occiput along the right of the maxilla; repeat the same course, step by step, until the roller is spent, and then confine its ter- minal end." If the parts are kept perfectly quiet, union takes place readily in four or five weeks, there being abundant vascular supply; and usually no deformity results. The patient is to be nourished by fluids, and there is usually room enough for soups and gruels to find their way into the mouth through the interstices of the teeth. Some surgeons recommend the introduction of thin pieces of cork on each side between the molar teeth, leaving an aperture between the iilcisors sufficient for the introduction of food or medicine by a small spoon.__Ed.] 1 Sargent's Minor Surgery. Fig. 58. 228 CHAPTER VII. DISLOCATIONS. By a dislocation is meant the removal of the articulatory surface of a bone from the part with which it is naturally in contact. For rightly understanding and successfully treating dislocations, it is absolutely necessary to have a thorough acquaintance with the form and relations of the bones at their extremities, the position of the ligaments, and the attachments and actions of the surrounding muscles. As to the impor- tance of anatomical knowledge in order to understand these injuries, two great surgical authorities have thus expressed themselves :—" There is necessary," says Sir Astley Cooper, "a considerable share of anato- mical knowledge, to detect the nature of these accidents, as well as to suggest the best means of reduction, and it is much to be regretted that our students neglect to inform themselves sufficiently of the structure of the joints. They often dissect the muscles of a limb with great neat- ness and minuteness, and then throw it away without a proper exami- nation of the ligaments, the knowledge of which, in a surgical point of view, is of infinitely greater importance ; and from hence arise the numerous errors of which they are guilty, when they embark in the practice of their profession ; for injuries of the hip, shoulder, and other joints, are scarcely to be detected but by those who possess accurate anatomical knowdedge." Mr. Percival Pott, in his works, observes, •' In both fractures and dislocations a perfect knowledge of the disposi- tion, force, attachments, and uses of the muscles, at least those of the limbs, is absolutely and indispensably necessary; and if the young stu- dents would be careful in attending to the plain and obvious parts of anatomy ; if they would with their own hands dissect the muscles, ten- dons, blood-vessels, and nerves ; if they would examine minutely the structure, dispositions, and connexions of all the parts which form the various joints, with their ligaments, and attend to the effects which the actions of the muscles and tendons connected therewith must necessarily have on them, they would have much more precise and adequate ideas of luxations than many of them have ; they would have ideas of their own, not taken upon trust from writers, who for ages have done little more than copy each other; and they would act with much more satis- faction to themselves." There are few bones in the body that may not be displaced by the application of enormous force ; but there are some,—as, for example, the vertebrae, and the bones of the pelvis, carpus, and tarsus, so firmly joined together, that although by extreme violence the ligaments and DISLOCATIONS IN GENERAL. 229 other structures by which they are so powerfully tied together and maintained in their natural relations, may be injured to such an extent as to admit of the bones being displaced, yet the application of extreme force in such cases produces other effects of so dangerous and destructive a character that the separation of the bones is a matter of inferior im- portance. The articulations which are principally subject to dislocation are the ginglymoid, and the orbicular; more especially the latter. The reason of this difference will at once be perceived on observing in the ginglymoid joints the mutual correspondence of the eminences and de- pressions of the bones, the number, strength, and firmness of their liga- ments, and the configuration of the parts, which, like a hinge, admits of motion only backwards and forwards in a single plane ; whereas, in the orbicular joints, the very shape of the bones, the comparatively loose condition of the ligaments, and the formation of the joints so as to allow very extensive and diversified movement, all contribute to increase the liability to dislocation. Dislocations may be complete or incomplete, accidental or spontaneous; that is, the articular surfaces may be either completely, or only par- tially separated from each other; they may be caused by external violence, when they are called accidental, or, in consequence of disease in a joint, the bones and ordinary ligamentous restraints may be so destroyed, that the common actions of the muscles produce the displace- ment of the bones without any external violence. This spontaneous dislocation is met with in the hip and in the knee ; but, as in this part of the work we are considering the separation of the ends of bones caused by external violence, we shall defer any further reference to spontaneous dislocation until we come to describe the phenomena con- nected with the diseases of joints. An incomplete dislocation is of comparatively very rare occurrence in the orbicular joints, but in the ginglymoid it is frequent, from the very great breadth of articulating surfaces. Another arrangement, which in a practical point of view is of great importance, divides dislocations into two classes, simple and compound. A dislocation is said to be simple, when the articulation is not laid open, and compound, when the head of a bone is not only dislodged from its articular cavity, but forced through the integuments, or complicated with a communicating wound of the soft parts extending into the joint. In treating of simple dislocations we shall consider— I. The causes of dislocation. II. The symptoms. III. The general indications of treatment. IV. The consequences of an unreduced dislocation. I. The Causes of dislocation may be arranged into predisposing, and exciting. To the former belong shallowness in the form of a joint; great looseness of its ligaments ; great latitude of motion ; weakness of surrounding muscles, whether from emaciation and debility, or from paralysis; weakness and relaxation of the soft parts from previous dis- locations ; unusual distension of a joint from an inordinate accumulation of synovia; and destruction of the ordinary organs of relation from dis- 230 DISLOCATIONS IN GENERAL. ease. The exciting causes are external violence and excessive mus- cular exertion. Of these many examples might be given. External vio- lence may be applied directly or indirectly; for an example of each we may mention two ways in which the shoulder is dislocated. Dislocation downwards of the shoulder is sometimes produced by violence applied to the upper part of the humerus, by which the head of the bone is di- rectly forced down into the axilla; and sometimes by the indirect ap- plication of violence, as when by a fall, or by other means, the elbow is forcibly raised upwards, and the head of the bone is thus driven against the under part of the capsular ligament. The displacement of the pa- tella will furnish an illustration of the manner in which excessive mus- cular action may give rise to dislocation. The natural position of the patella is such that it prevents the fibres of the rectus muscle from going in a straight direction from their origin at the pelvis to the anterior tuberosity of the tibia, into Avhich they may be considered as being in- serted through the medium of the fibrous covering on the front of the patella and the ligamentum patellae. The bone, preventing these fibres from going in a straight direction from the pelvis to the leg, causes them to describe an arch, the convexity of which is inwards. When the muscle is violently called into action, it will have a tendency to draw the patella outwards, in its endeavour to pass straight to the tibia, and thus a dislocation outwards is often produced. If the muscle be violently called into action while the knee is bent inwards, a dislocation will be still more likely to ensue. At the temporo-maxillary articula- tion, a dislocation is often caused by muscular contraction, as will be afterwards explained. II. Symptoms.—One of the most constant and characteristic symp- toms of dislocation, and one which seems to distinguish this injury from fracture, is the fixed condition of the limb. In some cases there is abso- lute immobility of the limb, so that it can neither be moved by the volun- tary efforts of the patient, nor even by the surgeon. This complete immo- bility is usually found in joints which move only in a single plane ; for example, it is particularly observed in dislocation backwards of the elbow. In other instances, although the muscles about a joint cannot excite motion, the limb may be very slightly moved in one particular direc- tion ; for instance, in some cases of dislocation downwards of the hume- rus into the axilla, the arm can be raised upwards to a certain extent by the surgeon, while it may be perfectly immovable in every other di- rection. But slight mobility in one direction, though occasionally ob- served, is not found in many instances, and therefore a fixed condition of a limb may be considered as a general symptom of dislocation. Sometimes the mobility is not entirely lost for two or three hours, or even longer, after the accident. This is believed to arise chiefly from the muscles requiring some time to shorten and accommodate them- selves to their altered condition, and partly from the irritation and in- flammation caused by the unnatural position of the bone. The patient feels more pain and tenderness in consequence of the irritation and in- flammation, and, therefore, naturally offers greater resistance to any moving of the limb. A second symptom particularly deserving notice, is the unnatural direction of the axis of the bone. This is a striking DISLOCATIONS IN GENERAL. 231 symptom, and to be especially observed. As a good example we may mention dislocation downwards of the shoulder, in which the axis of the humerus is directed into the axilla, instead of being in its natural posi- tion. This symptom presents itself immediately on the occurrence of dislocation, and remains until reduction is effected. A third, and very frequent symptom, is some alteration in the length of the limb. The dislocated extremity is in most instances shortened, but is sometimes lengthened; as, in dislocation downwards of the shoulder, and disloca- tion downwards of the hip. In the under extremity, the presence or absence of this lengthening is a good diagnostic symptom between dislo- cation and fracture; for it is found in dislocation downwards of the hip- joint, but never occurs in any fracture of the under extremity. A fourth symptom is some unnatural appearance about the joint, by which its shape is changed. These alterations of form differ, of course, in different dislocations. A fifth symptom is slight, soft crepitation, or a simulation of crepitus. This is a symptom of which the practitioner ought to be well aware, lest he be deceived by it, and led to mistake a dislocation for a fracture. The crepitation in dislocation is of a soft, crackling, oozy, sloppy character, easily distinguished from the hard grating crepitus of fracture, and is supposed to arise from the escape of synovia, and serous effusion, into the surrounding cellular tissue. Sometimes, however, there is in dislocation a hard crepitus, in conse- quence of small osseous scales being torn off from the bone, where the muscles are inserted into it. In addition to the above symptoms there are sometimes great swelling, pain about the joint, great pain at the ex- tremities of the nerves, the trunks of which may be pressed by the head of the bone. There may also be numbness, or even paralysis of the limb, if the pressure on the nerves be to a great extent, and oedema, if the pressure be on the vessels returning blood from the extremity. III. Treatment.—In the treatment of dislocations the indications are three:— 1. To restore the bone to its natural situation:—this is termed re- duction. 2. To preserve the parts reduced in their natural position, until the lacerated ligaments have had time to unite. 3. To prevent unfavourable symptoms, or, if they have already oc- curred, to remove them. The first and paramount indication is reduction, which should be im- mediately attempted; for it becomes increasingly difficult with the length of time from the occurrence of the dislocation, and is, after a long interval, altogether impracticable. It is universally agreed that the chief impediment to the reduction of a recent dislocation is muscular action. Some muscles, having their extremities brought nearer to each other than is natural, become permanently contracted, and accommodate themselves to their new condition. The proofs of this are found in the facility with which reduction is accomplished, when the accident has happened in a limb affected with paralysis, or in a weak, relaxed, and emaciated person; or when the muscles are incapable of making much resistance through any great temporary weakness, or extreme prostration, or collapse, or through the patient being faint or debilitated by bleeding, 2o*2 DISLOCATIONS IN GENERAL. nausea, or other means. Additional proof that muscular action is the chief impediment to reduction, is given in the fact, that if the mind of the patient be diverted from the accident, and be directed to other sub- jects, while attempts are being made to accomplish reduction, the surgeon's design is more easily effected, the muscles are then taken, as it were, by surprise ; but if the attempt be made while the mind of the patient is on the watch, the muscles will resist with their utmost power, and great difficulty will be experienced. These facts furnished useful hints in practice, and suggested the property of various means employed in diffi- cult cases to increase the efficiency of the methods adopted for accom- plishing reduction. The condition of the parts about the joint differs at different periods, if it be long before reduction is attempted. Immediately after the acci- dent, the muscles are relaxed from the depression of the system, prin- cipally caused by the shock of the injury, and this condition is very favourable for reduction; soon, however, they become spasmodically rigid, and ultimately, if reduction be not accomplished, they become completely adapted to their altered condition; the laceration of the ligaments is gradually filled up by the effusion of adhesive lymph, and if the ligament be a capsular one, with a rent, through which the head of the bone has escaped, the diminished size of this opening from the effusion of lymph will, in time, present a further obstacle to the return of the bone into its natural situation. To overcome the contraction of the muscles, extension and counter-extension are employed. It must be manifest that simply drawing or extending the limb would not have much effect on the muscles around the joint, but that to make the whole force bear upon them, both extension and counter-extension are to be used. For instance, when you have to reduce a dislocation of the shoul- der, you first fix the scapula ; in other words, you use counter-extension. You next apply the extending force to the arm ; but this, without coun- ter-extension at the same time, would answer no useful purpose, for the extending force, instead of acting on the muscles around the joint, would act on the whole body ; so that counter-extension, that is, the fixing of the body, is obviously just as necessary as the application of force to the bone which has been dislocated. By British surgeons, extension and counter-extension are applied as near as possible to the dislocated joint: for example, in dislocation of the hip, the counter-extension is applied to the pelvis, and the extension to the thigh ; because the whole force is thus directed against the mus- cles, which oppose the reduction. In France, this practice is objected to, on the ground that the muscles which have to be stretched, must, in extension, be irritated by the pressure, and excited to contract, thereby offering increased resistance to the accomplishment of reduction. The French apply extension at a distance from the dislocation ; for example, in reducing a dislocation of the hip-joint, the extension is applied to the leg, not, as in this country, to the thigh. A point of considerable importance is, the best method of using extension; whether short and violent efforts should be made, or whether the force should be continued even and uninterrupted. On this subject Professor Samuel Cooper remarks :—" The invariable maxim in reducing DISLOCATIONS IN GENERAL. 233 dislocation is, not to make the extension with sudden and considerable violence, but gradually, and, at the same time, steadily and unremit- tingly. It is safer to tire out the opposition of the muscles by gradually- increased uninterrupted force, than by resorting to short efforts of great violence. In this latter practice you run the risk of producing considerable mischief; you may rupture arteries and veins ; you may contuse and injure important nerves ; or you may lacerate the soft parts. But with all these objections, you will gain nothing, for you would have less chance of getting the bone into its place, than by a milder and more judicious plan. The principle, I repeat, then, is to make the extension slowly and gradually, and at the same time unremittingly; for no muscles, however powerful they may be, can resist force thus employed against them, beyond a certain time, and they must, eventually, become tired out." The manner in which extension and counter-exten- sion are employed, varies in different dislocations, as will afterwards be observed, when the dislocations are described. In employing extension, the greatest care is necessary so to apply it that the injury to the soft parts may be as little as possible. With this object, various means are taken to avoid bruising or excoriating the part to which the force is applied; a few turns of a roller, wetted, that it may be less apt to slip, or a portion of soft wash-leather, or a damp towel, may for this purpose be put round the part to which the extension is to be applied. This having been done, let a loop, or noose, formed by doubling a band of linen, or, which answers as well, of stout worsted, be fixed on the part of the limb thus protected, and the ends be drawn through the noose ; to these ends the force employed, which is usually the muscular power of assistants, is applied. The preferable way of applying the noose, is to fix it by means of what is called the clove-hitch ; the advantage of which is, that while it holds firmly enough, it cannot be tightened by the pulling so as unduly or dangerously to constrict the limb. Instead of a noose, a circular band, tightened by a screw, is sometimes used, but the former is more convenient and efficient. The force should be thus applied, while counter-extension is being employed above the joint. The different ways of using coun- ter-extension suitable to special dislocations will be afterwards de- scribed. In some dislocations the muscular power of assistants is insufficient; and in such cases the necessary force is applied by means of pulleys. These, being so constructed as to afford great mechanical power, enable the operator to carry the extension to any degree he may think judi- cious, without the risk of any relaxation or diminution of the force. When they are employed, a well-padded belt is fixed round the limb, having two straps with rings attached to them ; the hook of one set of pulleys is fixed to the rings, while the hook of the other set is fixed to some ring, staple, or other resisting object in the room, and an assistant pulls the cord, to which in this method of reduction the whole power is applied. [Dr. Gilbert, Professor of Surgery in the Pennsylvania Medical College, has suggested a very simple yet effective means of applying an extending force in dislocations. He thus describes it: " Place the 234 DISLOCATIONS IN GENERAL. patient, and adjust the extending and counter-extending bands as for the pulleys ; then procure an ordinary bed-cord or a wash-line, tie the ends together, and again double it upon itself, pass it through the ex- tending tapes or towels, doubling the whole once more, and fasten the distal end, consisting of four loops of rope, to a window-sill, door-sill, or staple, so that the cords are drawn moderately tight; finally pass a stick through the centre of the doubled rope, then by revolving the stick as an axis or double lever, the power is produced precisely as it should be in such cases, viz., slowly, steadily, and continuously."1—Ed.] The obstacles to reduction are sometimes so considerable that it is necessary to employ some previous measures to diminish the power of the muscles. This is usually required in attempting to reduce disloca- tions of long standing or in robust persons, and in dislocations of the hip-joint, where the resistance is always very considerable. The means formerly employed for this purpose were, venesection, or nauseating doses of antimony, or the warm bath. Of these the former two are the most powerful. When the patient is faint or sick, reduction is much more easily accomplished ; and if the patient be robust, or the resistance very great, there is much less risk in having recourse to either of these means than in employing the greater force, which would otherwise be necessary. Of all the auxiliaries to extension and counter-extension, chloroform is the most powerful, and it is now invariably preferred. It prevents pain, facilitates reduction, renders comparatively little force necessary, thereby diminishing the danger of injuring texture, and it leaves no permanent weakness of system. When extension and counter- extension are being employed, the surgeon should use the dislocated bone as a lever, and endeavour to press the extremity of it in the direc- tion most calculated to promote reduction ; but this should not be attempted until extension and counter-extension have been used for some time. For fulfilling the second indication, that is, to prevent the recurrence of dislocation until the ligaments have had time to unite, the joint should be kept at rest, in the attitude in which a return of the dis- location is least likely to occur in some instances, and with a degree of support, which, however, must depend on the situation of the articu- lation. The ligaments are more or less lacerated, and require time to heal; and the surrounding muscles, being not unfrequently torn from their insertions, must be kept at rest until they regain their attachments, otherwise the joint will remain weak in after life. The third indication is to prevent, or remove unfavourable symptoms; for the former purpose, rest of the joint and the antiphlogistic regimen are required ; for the latter, antiphlogistic remedies proportioned to the age and strength of the patient, and the violence of the symptoms. IV. The Consequences of an Unreduced Dislocation are important, and in some instances the resources of nature in forming an artificial joint are considerable. They seem, however, to be much more effective in some articulations than in others ; in the orbicular, for example, than in the ginglymoid. In the one case, the power of motion is often 1 Amer. Jour. Med. Scien., No. II. COMPOUND DISLOCATIONS. 235 regained to a considerable extent, whereas in the other, it is almost, or sometimes even entirely lost. In orbicular joints the very form of the bone gives a facility of moving, and if the displaced head rests on a mus- cle, the muscle becomes dense, hollow, ligamentous, smooth, lubricated, and of a suitable form for its reception. If it rests on a bone, as, for example, on the ilium or scapula, a cavity is formed to receive it, partly by absorption of part of the bone on which it rests, and partly by the deposition of new bone; and the cavity is either lined with a dense ligamentous matter, or covered with a porcellanous deposit. A cup is thus formed for the reception of the head of the displaced bone, which loses its cartilage, and generally becomes covered over by the porcellanous deposit, which gives a smoothness to the movement of the parts on each other. The surrounding cellular tissue becomes condensed, and, although less dense and firm than the original capsular ligament, yet it serves to connect the parts of the new articulation with each other, and assists in preserving them in the necessary relations. Sub- sequently, but always after the lapse of a considerable period, the ori- ginal cavity for the reception of the head of the bone becomes changed and ultimately very much diminished by the disappearing of its cartilage, the gradual filling up of its centre, and the rounding off by absorption of its edges. These changes take place earlier, if the new cavity be so situated as to encroach during its formation on the old one. In some cases the new cavity has been found so completely to surround the head of the bone, that it was impossible after death to remove the head without fracturing some part of the artificial joint. The resources of nature in remedying the effect of an unreduced dislocation are by no means so great, when the accident occurs in a ginglymoid articulation. The configuration of the bones is such, that the displaced bone cannot play so easily on the parts with which it is brought into contact; and the bones are held so firmly by their connexions as not to admit of much motion; hence, more or less of bony anchylosis has been found, on dis- section, to be the general result. It is evident, therefore, that the con- sequences of an unreduced dislocation materially differ according to the nature of the articulation to which the accident has happened. COMPOUND DISLOCATIONS. When a bone is not only displaced from the articular surface with which it is naturally in contact, but is also protruded through the external coverings, or when, in addition to displacement, laceration exposes to view the cavity of the joint, the injury constitutes a com- pound dislocation, which bears the same relation to simple dislocation as compound fracture bears to simple fracture. A compound disloca- tion may also be complicated with fracture or severe contusion of the bones, extensive laceration of the soft parts, rupture of blood-vessels or laceration of, or pressure upon, nerves. These complications are very formidable, and excite the greatest anxiety in the mind of the surgeon. At one time these were considered cases for amputation; but now a surgeon would not think himself justified in advising amputation from the mere circumstance of a dislocation being compound. Petit and Pott inculcated the necessity of immediate amputation, and the 236 COMPOUND DISLOCATIONS. practice was for a long time almost invariably adhered to, both in this country and in France ; but the experience of Sir Astley Cooper, the late Mr. Hey of Leeds, Mr. Lawrence, and of almost every practical surgeon of eminence in the present day, justify a different procedure. In determining on the necessity of amputation, the surgeon is guided by the extent and nature of the complications, the situation and size of the articulation, and the constitution of the patient. The circumstances which warrant amputation are,—very serious complications, such as dangerous contusion, and extensive, and more especially comminuted, fracture ; rupture of important arteries; very great laceration of soft parts, so that the joint is to a great extent laid open; and a weak or irritable constitution. The case is also more unfavourable, if the arti- culation be in a part of the body where, by reason of the distance from the centre of circulation, the process of repair must be feeble. Such are the general considerations to be taken into account in judging of the propriety and necessity of amputation ; but in every particular instance, the surgeon must be guided by the particular circumstances, as it is impossible to lay down such a general rule, as would enable him to determine in every case that may arise. When amputation is deemed necessary, the proper time for its performance is immediately after the patient has recovered from the collapse caused by the injury, and before inflammatory symptoms and accompanying irritative fever have com- menced. The only other period at which it can be performed is not only much less favourable, but is also one which may never arrive; namely, when the above symptoms have subsided. The question, there- fore, whether or not a limb is to be preserved, is one which calls for an early decision. When such cases terminate fatally, it is usually either at an early period by gangrene, or by irritative fever, or, at a later period, by hectic fever from the continuance of local suppuration and irritation. After the subsidence of the irritative fever, while the patient is hectic, amputation may be performed: but after the constitution has been weakened by the previous symptoms, it is with much less prospect of a favourable result. The two dangers which the surgeon has to consider in determining the treatment in the first instance are, on the one hand unnecessary mutilation if the limb be amputated, and on the other, the risk of life from gangrene and irritative fever, if amputation be not performed. In persons of sound constitution compound dislocation is often treated successfully, and sometimes they recover from very formi- dable injuries of this description with very considerable motion of the injured joint. When an attempt is to be made to save the limb, the bones should be reduced, the edges of the wound brought together, and preserved in apposition by strips of adhesive plaster, applied in such a manner as not to excite by any irritation by pressure ; every effort should be made to obtain adhesion of the soft parts, and the local and constitutional symptoms be combatted by the appropriate remedies. PARTICULAR DISLOCATIONS. 237 PARTICULAR DISLOCATIONS. DISLOCATIONS OF THE LOWER JAW, OR TEMPORO-MAXILLARY ARTICULATION. The temporo-maxillary articulation is formed of two bones, an inter- articular cartilage, and two synovial capsules; it is furnished with three ligaments; it admits of motion upwards, downwards, backwards, for- wards, and to either side. The two bones are the temporal and lower jaw, the condyloid fossa of the former, and the condyloid process of the latter. Each bone, where it forms the joint, is covered with a cartilage of incrustation; be- sides which there is an interarticular cartilage dividing the articulation into two compartments,—one between the condyloid fossa and the carti- lage, the other between the cartilage and the condyloid process; and each division is furnished with a distinct synovial membrane. The ligaments are three,—the external lateral, which is in contact with bones forming the articulations, and by its deep surface adheres to the interarticular surface and synovial apparatus, thus helping to preserve the cartilage in its proper situation; the internal lateral, and the stylo-maxillary; the last two not being in contact with the articulation, but completely separated from it by several important structures. The jaw is drawn upwards by the temporal, masseter, and internal pterygoid muscles; downwards, by the platysma-myoides, digastricus, mylo-hyoideus, genio-hyoideus, and genio-glossus muscles; forwards, by the combined action of the two external pterygoid, and one of the portions of the masseter; backwards, by the masseter, and when the os hyoides is fixed, by the digastricus, the genio-hyoideus, and genio-hyo- glossus, and perhaps very slightly by some of the fibres of the mylo- hyoideus ; and laterally, as in the grinding motions of the jaw, by the alternate actions of the two external pterygoid muscles assisted by the oblique motion forwards given by the internal pterygoid. The articulation is liable to three dislocations, namely— 1st. Complete dislocation on both sides ; 2d. Complete dislocation on one side ; and 3d. Partial dislocation of the temporo-maxillary articulation. COMPLETE DISLOCATION ON BOTH SIDES. Causes.—This dislocation may be caused by a blow upon the chin when the mouth is widely opened; by yawning; by spasmodic action of the external pterygoid muscles, while laughing ; by spasmodic action of the same muscles, during the extraction of a tooth,—of which the celebrated Mr. Fox, the dentist, met with an example; or by violently or suddenly opening the mouth very wide to receive too large a body, —of which Sir Astley Cooper records a case,—two boys were struggling for an apple, and the one, in attempting to force it into his mouth, dis- located his jaw. When the condyloid process is in its natural position, it rests behind the inferior root of the zygoma, which forms the anterior part of the condyloid fossa ; but it may be drawn over this root by the external pterygoid; and this is more likely to happen, if the mouth be 238 PARTICULAR DISLOCATIONS. wide open, when the external pterygoid contracts. The rationale of this must at once be evident to every Fig. 59. one who knows the action of the ptery- goid muscles. Symptoms.—The patient is unable to close the mouth. At first there is a considerable distance between the front teeth of the upper and lower jaw-bones, sometimes as much as an inch and a half; but afterwards the jaws can be brought closer, although the mouth still remains open, in con- sequence of the mechanical obstruction presented by the relation which is produced between the coronoid pro- cess of the lower jaw, and the under part of the malar bone. The func- tions of speech and of deglutition are interrupted; and the salivary glands being irritated by the pressure, there is consequently a great secretion of saliva, which, from the loss of deglu- tition, dribbles over the chin. If the lower teeth could be brought up, they would be found much in advance of the upper. The pain in some instances is not very great; in others excessive. The cheek is stretched and flattened; the angle of the lower jaw is too near the mastoid process of the temporal bone, and a preter- natural depression may be felt in front of the external auditory foramen, occasioned by the removal of the condyle from its natural situation. State of the parts.—The condyloid process, instead of being in its natural situation, that is, in the FiS- 60- condyloid fossa, the articular cavity of some writers, behind the inferior root of the zygoma (called , by some the articular eminence), i is brought forward in front of this eminence; and as the combined action of the external pterygoid muscles, which have one of their insertions into the pterygoid fossa immediately beneath the condy- loid process, is to bring forward the jaw, it is easy to perceive how the dislocation may be produced by the spasmodic contraction of these muscles. The coronoid process of the lower jaw is inferior to the under part of the malar bone, and pressing against it, presents the mechanical ob- stacle to the closingof the mouth, which has been already referred to. Treatment.—Various methods of reduction have been adopted. One PARTICULAR DISLOCATIONS. 239 is to introduce the thumbs, and with them to depress the molar teeth, while the chin is elevated by the fingers: by this means the condyles are depressed, and sent backwards into the cavities in which they are naturally situated. Another method is that employed by Mr. Fox, who placed a piece of wood about a foot long upon the molar teeth; then raising the end which he held in his hand, and using the teeth of the upper jaw as a fulcrum, thus depressed the end which was on the teeth, thereby accomplishing reduction on one side; and afterwards, in the same manner, he reduced the dislocation on the other side. A third, and by far the most elegant method, is that recommended by Sir Astley Cooper, namely, to place a cork on each side, between the molar teeth of the upper and lower jaw-bones as far back as possible, and then to press up the chin with the hand. The corks act as fulcra, the lower jaw as a lever, and the hand applied to the chin as the power. By raising the chin, the condyles are pressed downwards and backwards, and are thus sent over the articular eminences into their natural situa- tions. COMPLETE DISLOCATION ON ONE SIDE. By this is meant a dislocation in which the condyloid process advances over the inferior root of the zygomatic process, or articular eminence, on one side. In this dislocation the mouth cannot be closed, but it is not so widely opened as in dislocation on both sides; the chin is generally twisted to the opposite side, and the incisor teeth are not in a line with the axis of the face. From a consideration of the structure of the parts we should expect, that in every instance of this injury the chin would be evidently turned towards the opposite side; but Mr. Hey, of Leeds, says (at p. 325 of his "Practical Observations on Surgery," third edi- tion), " I have repeatedly seen the disease when I could discern no alteration in the position of the chin. The symptom which I have found to be the best guide in this case, is a small hollow, which may be felt behind the condyle that is dislocated, which does not subsist on the other." The other symptoms, the state of the parts, and the treatment, are precisely the same as in the preceding injury, except that in reduc- tion, the cork, or lever of wood, or pressure with the thumb, should be used only on one side. To depress both condyles is found, as was first mentioned by Mr. Hey, to have a tendency to prevent reduction ; and this, no doubt, explains what several surgeons have experienced, namely, that reduction is more easily accomplished by using the lever of wood, than by other means when the injury is on one side. After reduction, the jaw should be for some time supported by a bandage, and the patient should be careful not to open the mouth wide for a considerable period. Care, indeed, will be ever afterwards necessary in opening the mouth; for when the injury has once happened, a very slight cause will be suffi- cient to reproduce it. PARTIAL DISLOCATION, OR SUBLUXATION OF THE JAW. The signs of subluxation are, a sudden locking of the jaw, the mouth being opened slightly and more widely in general on the affected side, 240 DISLOCATIONS OF THE CLAVICLE. and pain at the articulation. The symptoms do not depend on the dis- placement of the bones from each other, but on the interarticular car- tilage slipping from its proper relation to the condyloid process in consequence of relaxation, especially of the external lateral ligament. It is met with in persons of a relaxed habit of body, and is usually removed by the natural efforts to open or shut the mouth ; but when these do not succeed, the back part of the jaw should be pressed directly downwards, so that the condyloid process being depressed, the cartilage may be replaced in its proper relation to it. In one instance, after this plan had failed, remembering the attachment of the external pterygoid muscle to the interarticular cartilage as well as to the pterygoid fossa, I desired the patient to make an effort to bring forward the lower jaw, and the effort very speedily removed the subluxation. Young women of relaxed habit often experience a painful snapping at the joint while opening and closing the mouth. This, it is believed, is occasioned by the ligament failing from relaxation to preserve the parts in their due relations ; and the best remedies for its removal are the means most likely to increase the tone of the parts, and to improve the general health and strength. The shower-bath, preparations of iron, together with other treatment for the general health have been useful, and in obstinate cases, a blister in front of the ear has been found to produce the desired effect. DISLOCATION OF THE CLAVICLE AT ITS STERNAL EXTREMITY. We have here two bones, the sternum, which is fixed, and the cla- vicle, which is so connected with the sternum that its inner extremity projects above it, and four ligaments, namely, the anterior sterno-cla- vicular, the posterior sterno-clavicular, the interclavicular, and costo- clavicular, together with an interarticular cartilage connected more closely with the clavicle than with the sternum. Of this articulation four dislocations have been known ; but two of them are so extremely rare, that of one, Sir Astley Cooper, in his own vast experience, never met with an example, although he records a case occurring in the prac- tice of another surgeon, in which the dislocation was caused, not by external violence, but by disease ; and of the other, so far as my reading extends, I have found but one example. The four dislocations are arranged in the following order, according to the direction of the cla- vicle. 1. Dislocation forwards, in which the clavicle is thrown forwards on the sternum. 2. Dislocation upwards. 3. Dislocation backwards. 4. Dislocation upwards and inwards. Symptoms.—In dislocation forwards there is an unnatural tumour, or obvious deformity in front of the sternum, which may be made to disappear by drawing the shoulders backwards; but it returns as soon as the force is removed; the distance between the acromion process and the mesial line is diminished; the head is drawn forwards, and turned from the affected side to relax the sterno-cleido-mastoideus muscle; and there is inability to raise the upper extremity. The clavicle rests on DISLOCATIONS OF THE CLAVICLE. 241 the front of the sternum. A partial dislocation in this direction has been met with, in which the clavicle is not removed from its articulation with the sternum, the ligaments not being sufficiently lacerated to admit of complete displacement; but it projects unnaturally forwards. In dislocation upwards the symptoms differ from those of the last dislocation merely in the situation of the unnatural swelling, which in this instance is in the under part of the neck; in the other on the front of the sternum. In dislocation backwards there is an unnatural depression in the ordinary situation of the sternal extremity of the clavicle. It may also be accompanied by dyspnoea from pressure on the trachea, by dysphagia from pressure on the oesophagus, and by impeded circulation and pain from pressure on the vessels and nerves. This dislocation is so very rare, that Sir Astley Cooper says he never met with a single case as the result of injury, but refers to a case which occurred in the practice of Mr. Davie, surgeon at Bungay, Suffolk, in which the dislocation was caused by the bone being pressed forward at its outer extremity, arising from deformity of the spine. In this case, Mr. Davie was obliged to saw off the inner extremity of the clavicle, in order to relieve the dyspnoea and the other distressing symptoms caused by the pressure on the parts at the under portion of the neck. It has, however, been since ascertained that this injury may be produced by violence, and in the "Medical and Surgical Journal" for October, 1841, several cases are recorded. The ligaments in this dislocation are more or less ruptured. Treatment.—In dislocation forwards, the surgeon should endeavour to bring forwards the outer extremity of the clavicle, at the same time pressing backwards the inner extremity. In many instances the clavicle has been drawn off the sternum by pulling the shoulder backwards. In dislocation backwards, it is necessary to draw the shoulders very much backwards, and as far as possible from the sternum. In all these dislocations the clavicle may be drawn outwards by drawing the shoulder outwards. In dislocation upwards, after the shoulder is drawn out- wards the surgeon should raise the outer and depress the inner extre- mity of the clavicle. For preserving the bone in its normal situation, and at perfect rest, the best retentive apparatus is that used in fractures. The cure is seldom so complete as in dislocations of other joints, and often some deformity remains, in consequence of the ligaments not pro- perly uniting. Professor Samuel Cooper gives the following particulars of the dislocation upwards and inwards. He says, "My friend, Mr. Morton, of University College, has favoured me with the particulars of an unusual dislocation of the sternal extremity of the clavicle, the dis- placement of it being upwards and inwards. Etienne Careron, get. 39 mason, admitted into the hospital of La Charite-, on account of an in- jury which was caused by his having been violently squeezed between a wall and a cart, in such a manner that the left shoulder was thrust in- wards with great force. On examination, the sternal extremity of the clavicle, was found to have been displaced from its natural situation, and was now placed above the upper edge of the sternum, producing a slight deformity in the contour of the lower part of the front of the neck. It seemed from the description of the accident which was given by the 242 DISLOCATIONS OF THE CLAVICLE. patient, that the force producing the injury had acted in such a direc- tion as to push the sternal extremity of the dislocated bone upwards and behind the sternal portion of the sterno-cleido-mastoid muscle. The articular surface of the internal extremity of the dislocated clavicle lay opposite to that of the clavicle of the sound side, and was supported by the superior border of the sternum. The attachment of the sterno- cleido-mastoid muscle to the first bone of the sternum did not appear to have suffered any laceration. M. Velpeau considered it to be very pro- bable, that the dislocation was in the first place backwards, but that the force continuing to act, the end of the clavicle was afterwards driven upwards and across the front of the root of the neck, and behind the sterno-cleido-mastoid muscle. The dislocation was reduced in the usual manner, and the apparatus of De'sault for fractured clavicle employed to retain the bone in its proper place. The bandages used were steeped in a solution of ' dextrine,' which when dry rendered the whole immo- vable." DISLOCATION OF THE CLAVICLE AT ITS SCAPULAR EXTREMITY. The external extremity of the clavicle articulates with the acromion process of the scapula. The ligaments which more immediately bind these bones together are two; the superior and inferior acromio-clavi- cular ligaments. The two portions of the coraco-clavicular ligament, though not attached to the parts forming the articulation, still contri- bute much to prevent the frequent occurrence of dislocation by causing the two bones to follow each other in their motions. The scapular ex- tremity of the clavicle is liable to only one dislocation, namely, upwards, in which it rests on the acromion process of the scapula. Symptoms.—Diminution of the space between the apex of the acro- mion process and the central point of the sternum ; an obvious defor- mity produced by the outer extremity of the clavicle, which, according to Sir Astley Cooper, may be best ascertained by tracing the spine of the scapula from within outwards; in doing which the finger will be in- terrupted by the outer extremity; inability of the patient to raise the arm; and unnatural flatness of the shoulder. By drawing the shoul- ders very forcibly backwards, these symptoms may be made to disap- pear for the time. State of the parts.—The superior and inferior acromio-clavicular liga- ments are ruptured. The peculiarity of the displacement is, that when the two portions of the coraco-clavicular ligaments are ruptured, the falling down of the shoulder is greater than if the two proper ligaments be ruptured. Treatment.—The object is to bring the shoulders backwards. Sir Astley Cooper recommends the surgeon to place his knee between the shoulders of the patient, and forcibly draw them backwards and out- wards. According to Mr. Liston, the best retentive apparatus is the same as for fractured clavicle; and which must be continued for many weeks, as the ligaments are slow in uniting. In dislocation of either extremity of the clavicle, even when treated by the most experienced surgeons, some deformity will almost always remain; but the patient will recover the motion of his arm. DISLOCATIONS OF THE SHOULDER JOINT. 243 DISLOCATION OF THE SHOULDER JOINT. The scapulo-humeral articulation is formed of portions of two bones,— the glenoid cavity of the scapula, and the head of the humerus. The ligaments entering into its formation are three—the capsular, the ac- cessory of some, the coraco-humeral of other anatomists, and the glenoid. An intimate knowledge of the anatomy of this articulation, and of the dis- position of the muscles for effecting its movements, is of the utmost im- portance ; for experience has proved that, in consequence of its varied and extensive movements, the shoulder joint is more frequently disloca- ted than any other of the articulations, and even, as some maintain, than all the others collectively. The number of dislocations to which it is liable, though usually stated to be four, we shall find to be five, three of which are complete, and two partial. The direction of the hu- merus is made the basis of the nomenclature. 1. Dislocation downwards, or downwards and inwards, or into the axilla. 2. Complete dislocation forwards. 3. Partial dislocation forwards. 4. Dislocation backwards. 5. Partial dislocation upwards. . With regard to the comparative frequency of these dislocations, it has been ascertained that the first occurs most frequently; the second and third are not so common; the fourth is very rare; and of the fifth, not more than one or two cases are recorded. I. DISLOCATIONS DOWNWARDS. Exciting Causes.—A fall from a great height upon the top of the shoulder; a blow upon the upper part of the humerus, when the arm is extended ; or the forcible and violent upraising of the hand or elbow, by which the head of the bone is pressed against the under part of the cap- sular ligament. It has also been caused by the violent contraction of the deltoid, as in raising a heavy body; for while the deltoid raises the arm, the capsular ligament is made the fulcrum ; and if this gives way, dislocation downwards may be produced. Symptoms.—The natural roundness of the shoulder is lost, owing to the head of the bone no longer supporting the deltoid muscle; the acro- mion process is unusually large and prominent; and a very striking symptom, which cannot fail to be perceptible on examination, is a vacuity under the acromion. There is also a want of that depression or hollow at the insertion of the deltoid, which is very conspicuous when there is no dislocation. The fibres of the deltoid, instead of giving the round- ness to the shoulder, and going in a convex direction over the head of the humerus, in their way from their origins to their insertion into the del- toid eminence, go in a straight direction; and if they be felt through the integuments, it will be found that they are not only flat, but also exceedingly tense,—a condition which, as will afterwards appear, offers one of the obstacles to reduction. The rationale of these symptoms will be easily understood, when it is remembered that the head of the bone, instead of resting, as it naturally does, in the glenoid cavity, is sent 244 DISLOCATIONS OF THE SHOULDER JOINT. down into the axilla, and consequently the distance between the inser- tion and the origins of the deltoid is greater than natural, and its fibres are therefore put violently on the stretch. Fig. 61. All the above-mentioned symptoms are observable about the upper and outer portion of the shoulder. On the opposite aspect of the joint, namely, in the axilla, there is an unnatural tumour caused by the head of the bone, which is rendered more perceptible by effecting abduction of the elbow. The surgeon may not be very sensible of this symptom while the patient holds his elbow as near as he can to his side : but the moment the elbow is pressed outwards, the head of the bone sinks in the axilla, and can be very distinctly felt. Elongation of the affected arm is particularly well marked; for ascertaining which, take the apex of the acromion and the outer condyle of the humerus, as two fixed points for measurement. The forearm is at a right angle with the arm and the elbow, the situation of which should be particularly observed, as it serves for a diagnostic symptom in distinguishing the different dislocations of the shoulder from each other, is neither directed back- wards nor forwards, but is in a line with the long axis of the body, and removed from the side. The patient cannot, by a voluntary effort of the muscles of the affected arm, bring the elbow to the side ; and if the surgeon forcibly press it inwards, the patient complains of great pain from the head of the bone being pressed against the nerves of the axilla, and when left to itself the arm hangs away from the trunk. The patient has an inclination to support the elbow by the hand, when standing; and when sitting, to rest it on the knees. A very striking symptom is an alteration in the direction of the long axis of the hume- rus. In the natural state of the parts when the arm is by the side, the axis of the humerus is parallel to the side, and the arm seems to come DISLOCATIONS OF THE SHOULDER JOINT. 245 down from the glenoid cavity; whereas in this dislocation the axis is placed obliquely in regard to the side, and the humerus seems to come out from the trunk instead of from the glenoid cavity. The patient has lost the power of performing the ordinary movements of the joint, and not only is he unable, by voluntary effort, to raise his arm: but it is also, in a great measure, immovable to the surgeon, especially up- wards and downwards, remaining stiff in its unnatural position ; and the patient, when he wishes to alter its situation, moves the whole trunk and extremity in mass. Sometimes the surgeon can move it slightly backwards and forwards, while in other directions, motion is difficult and attended with great suffering. It is proper, however, to add, that in very old persons, or in relaxed feeble habits of body, the immobility of the arm to the surgeon may not be so perceptible. In addition to the above symptoms, there is often tingling at the points of the fingers, with numbness of the whole limb, and oedematous swelling arising from the compression of the axillary plexus and interruption of the circula- tion. On moving the limb a slight crepitus is sometimes perceived, but on continuing the motion it ceases to be perceptible. The crepitus is, probably, owing to the effusion of serum, and the escape of synovia into the cellular tissue. This soft crepitus is easily distinguished from the hard crepitus of fracture, which, however, has been sometimes met with in dislocation of the shoulder, and is believed to depend on one or more of the tendinous attachments of the muscles having, during their disruption, torn away a portion of their osseous attachments. Many of these appearances, although very distinctly marked at first, frequently become obscured for a time by extravasation of blood and inflammatory swelling, which often supervene; but when these symptoms subside, they again become distinct and decisive. State of Parts.—For conveying to the reader an idea of the state of the parts, I shall give the result of two dissections by Sir Astley Cooper, one by Sir Philip Crampton, and one by myself. Sir Astley Cooper says,—" I have dissected two recent cases of this dislocation. A sailor fell from the yard-arm on the ship's deck, injured his skull, and dis- located the arm into the axilla; he was brought into St. Thomas's Hospital, and expired immediately after he was put to bed. On the following day I obtained permission to examine his shoulder, which I removed from the body for the purpose of obtaining a more minute ex- amination, and the following were the appearances which I found. On removing the integuments, a quantity of extravasated blood presented itself in the cellular membrane, lying immediately under the skin, and in that which covers the axillary plexus of nerves, as well as in the interstices of the muscles, extending as far as the cervix of the humerus below the insertion of the subscapularis muscle. The axillary artery and plexus of nerves were thrown out of their course by the dislocated head of the bone, which was pushed backwards upon the subscapularis muscle. The deltoid muscle was sunken with the head of the bone; the supra and infra-spinati were stretched over the glenoid cavity and inferior costa of the scapula. The teres major and minor had under- gone but little change of position; but the latter, near its insertion, was surrounded by extravasated blood. The coraco-brachialis was un- injured. In a space between the axillary plexus and the coraco-bra- 246 DISLOCATIONS OF THE SHOULDER JOINT. chialis, the dislocated head of the bone, covered by its smooth articular cartilage, and by a thin layer of cellular membrane, appeared. The capsular ligament was torn on the whole length of the inner side of the glenoid cavity, and would have admitted a much larger body than the head of the os humeri through the opening. The tendon of the sub- scapularis muscle, which covers the ligament, was also extensively torn. The opening of the ligament, through which the tendon of the long head of the biceps passed, was rendered larger by laceration, but the tendon itself was not torn. The head of the os humeri was thrown on the inferior costa of the scapula, between it and the ribs, and the axis of its new situation was about an inch and a half below that of the glenoid cavity from which it had been thrown." The second case which Sir Astley Cooper had an opportunity of examining, was one in which the dislocation had existed for five weeks, and Sir Astley believed that the poor woman died from violence used in the unsuccessful efforts to accomplish reduction by extension. Sir Astley says, " The capsular ligament had given way in the axilla be- tween the teres minor and subscapularis muscles; the tendon of the subscapularis was torn through at its insertion into the lesser tubercle of the os humeri, and the head of the bone rested upon the axillary plexus of nerves, and the artery. Having determined these points by dissection, I next endeavoured to reduce the bone, but finding the re- sistance too great to be overcome by my own efforts, I became very anxious to ascertain its origin. I therefore divided one muscle after another, cutting through the coraco-brachialis, teres major and minor, and infra-spinatus muscles; yet still the opposition to my efforts re- mained, and with but little apparent change. I then conceived that the deltoid must be the chief cause of my failure, and by elevating the arm I relaxed this muscle, but still could not reduce the dislocation. I next divided the deltoid muscle, and then found the supra-spinatus muscle my great opponent, until I drew the arm directly upwards, when the head of the bone glided into the glenoid cavity. The deltoid and supra-spinatus muscles are those which most powerfully resist reduction in this accident." Sir Philip Crampton records an examination which he made by dis- section, of a recent dislocation downwards in a labouring man, who was brought to the Dublin Infirmary in 1808 in a dying state, owing to injuries received by the fall of a wall. The dislocation was of the right shoulder, and death took place in about two hours. The head of the humerus was lodged on the neck of the scapula and upper part of the inferior costa, and surrounded by cellular tissue extremely ecchymosed. The head of the bone had pressed down the teres minor, and in its descent had passed through the subscapularis muscle, the fibres of which embraced the neck of the bone. The fibres of the subscapularis were also partly torn up from the scapula. The triceps crossed the neck of the humerus on its dorsal side, and the coraco-brachialis and short head of the biceps described a curve on its sternal side. The tendon of the long head of the biceps remained in its groove, but its sheath was partially lacerated. The tendons of the supra and infra- spinati, and of the teres minor, were completely torn off from the humerus, and along with them the surface of the greater tubercle. The DISLOCATIONS OF THE SHOULDER JOINT. 247 capsular ligament was torn from the lower part of the neck of the hu- merus to the extent of half its circumference, and the axillary vessels and nerves were made to describe a curve backwards, by the presence of the head of the bone which was in contact with them. When I taught anatomy in this University, a body, apparently that of a labouring man, was brought to the dissecting-room, which pre- Fig. 62. sented all the appearances, of a dislocation downwards of the shoulder. I made a careful dis- section of all the parts, and the preparation is still in my posses- sion. The dislocation must have been of very long standing, as the glenoid cavity was a good deal filled up, and a new shallow cavity formed on the neck and upper part of the inferior costa of the scapula for the head of the hume- rus, which had lost its cartilage, and was covered over with porcel- lanous deposit. The cellular tissue was thickened about the ball, to form a capsular ligament; and the precise position into which the head of the humerus was pushed, in escaping from its socket through the under part of the capsular liga- ment, was behind the subscapularis, in front of the teres minor and long head of the triceps, and upon the teres major and latissimus dorsi Fig- 63- muscles, with the axillary vessels and nerves to its inferior and inner aspect. As the body was brought to the dissecting-room at the period when subjects were pro- cured by exhumation, I found it impossible to procure a history of the case. Treatment. — Various methods are employed for accomplishing reduction. By the Knee in the Axilla.— If the dislocation be recent, and in a thin, attenuated subject, let the patient be seated on a low chair, and let the surgeon, placing himself beside him with his foot resting upon the chair, put his knee into the axilla, and while with one hand he presses upon the acromion, with the other let him depress the elbow, thus making his 248 DISLOCATIONS OF THE SHOULDER JOINT. knee a fulcrum, and the humerus of the patient a lever. I have often reduced dislocations by this method with the greatest ease. By the Keel in the Axilla.—This is a mode which has been very strongly recommended by Sir Astley Cooper, and is often attended with success. The patient is placed in the recumbent posture on a couch, and the surgeon having applied a wetted roller round the lower part of the arm, and having tied a handkerchief or towel round the arm above the wetted roller, places himself on the same seat with one foot resting on the floor, and the heel of the other in the axilla, and then extends the arm by pulling the towel or handkerchief." In this method of reduction there are various ways of applying the extending force. One is that just described ; another is to apply the handkerchief to the wrist; a third is for the surgeon, having put a skein of worsted round the arm, to pass his head through the double of the worsted, and make it rest on the back of his neck, and while pulling the arm to raise up and draw back his own body, by which means he Fig. 64. will be able to exert a much greater extending force than by either of the two former ways; and a fourth plan, which may be adopted in cases of considerable difficulty, is to make the assistants give additional ex- tending force by pulling the ends of the towel or handkerchief fixed round the arm. It has been remarked that a great advantage of this method of reduction is, that the surgeon, both at the long end of the lever and at the fulcrum, has his sense of touch to appreciate the effect produced by the force, and is able, therefore, at once to modify its application as circumstances may require ; and as soon as the heel detects the slightest change in the position of the bone, he can imme- diately direct the humerus towards the glenoid cavity. By Manual Extension.—The patient being placed in a chair, the first object is, to fix the scapula so as to afford the necessary counter- extension. This may be done by applying the double of a sheet under the axilla, carrying it over the opposite shoulder, and fixing it to some post or resisting object on the opposite side of the patient to that on which the injury is situated. If the sheet be not very much pressed up to the axilla, and its extremities be raised up so as to be on a level with DISLOCATIONS OF THE SHOULDER JOINT. 249 the opposite shoulder, it will fix only the body and under angle of the scapula, and leave the parts near the glenoid cavity to be drawn from the chest by the extending force applied to the arm. The more elegant method of affording counter-extension is by a well-padded ring of leather, having attached to it two belts, by which it may be fastened to a post or any resisting object; and the trunk and scapula being thus fixed, the necessary counter-extension is obtained. The next object is to employ extension; and, for this purpose, a few turns of a wetted roller should be applied to the arm above the elbow, and a band of worsted, or a piece of linen, fastened upon it by the clove-hitch knot; for this knot, while tight enough to prevent slipping, cannot become so tight as to produce dangerous compression. The arm should be elevated to the horizontal position, to relax the deltoid and supra-spinatus muscles ; and extension should be afforded by assistants drawing the ends of the worsted, or towel, or linen, gradually, slowly, and steadily; and after the extension has been kept up for several minutes, and while it is still so, the surgeon, placing his foot upon the chair in which the patient sits, should put his knee into the axilla, and with one hand press the acromion downwards and inwards, and with the other slightly press down the elbow, pushing the head of the bone upwards by means of the knee, which can be done by raising the foot so as to rest it on the toes. During the whole time the surgeon, before the introduction of Chloro- form, used to divert the patient's attention by engaging him in con- versation ; but with such an invaluable auxiliary, that practice is no longer needful. By means of Pulleys.—If it be probable, from the muscular strength of the patient, or from the time that has elapsed since the occurrence of the dislocation, that very considerable extension wall be required, it is advisable to afford it by means of pulleys. Previously to their use, the surgeon will diminish the degree of resistance to be overcome, by bring- ing the patient fully under the influence of chloroform. The necessary counter-extension can be very conveniently afforded by the plan recom- mended in the description of the former method of reduction. The ex- tending force may be applied to the lower part of the arm, by placing round it a few turns of a wetted roller, over which a belt of leather is fastened, with two straps extending from it, at the extremity of each of which is a ring, to which the hook at one end of the pulleys is fixed, while the hook attached to the other set of pulleys is affixed to a ring in some resisting object, care being taken that the ring is on a level with the line of counter-extension. Extension is then produced by pulling the cord of the pulleys. This method is useful for allowing the applica- tion of considerable extending force, which, however, might be afforded in the ordinary way, by increasing the number of assistants; but the prin- cipal advantage of the pulleys is, that by them the force can be applied steadily and gradually; whereas, when extension has to be long kept up by the usual method, the assistants become wearied, and the extension is unequal and accompanied with sudden jerks. The pulleys so greatly in- crease the force, that few assistants are required. The proper method of applying extension by the pulleys, is to draw the cord slowly and steadily, until the extension becomes considerable, to keep up the same degree of extension for several minutes, and then to increase it again gently. When 250 DISLOCATIONS OF THE SHOULDER JOINT. considerable extension has been employed, the surgeon should, by placing his knee in the axilla, with one hand on the acromion, and the other on the lower part of the arm, endeavour to replace the head of the bone in the manner described in the last section. In this method the surgeon, although sensible of the return of the bone into its natural situation, seldom finds it return with a snap, as when reduction is accomplished by the other methods. II. COMPLETE DISLOCATION FORWARDS. Symptoms.—In this dislocation, there is the absence of the natural roundness of the shoulder, the acromion more pointed, and the vacuity greater than in the former dislocation. There is an unnatural flatten- ing of the shoulder behind, and an unnatural tumour, caused by the head of the bone, below and to the sternal side of the coracoid process, and below the middle of the clavicle. The elbow is removed from the trunk, and drawn a little backwards; and the long axis of the humerus, instead of being parallel with the trunk, and directed upwards to the glenoid cavity, inclines towards the trunk, and extends upwards to a point underneath the middle of the clavicle. The forearm is at a right angle with the arm. The pain is less than in the former dislocation, but the motions of the joint are much more restrained; for any move- ment of the arm backwards is prevented by the resistance of muscles, movement outwards by the clavicle opposing the head of the bone, and motion forwards by the head of the bone striking the coracoid process. With regard to another symptom, namely, whether the arm be short- ened or lengthened, surgical authorities are divided. According to Sir Astley Cooper, the arm will be somewhat shortened, but he does not, in any of the cases recorded in his work, mention the state of this symp- tom, although it must no doubt have been from what he observed in those cases that he arrived at the above conclusion. In a very interest- ing case recorded by Sir Philip Crampton,—a case well worthy of atten- tion, inasmuch as it settles another disputed point, which will presently be mentioned, the axis of the head of the bone was nearly a quarter of an inch higher than that of the glenoid cavity : the arm, therefore, must have been shorter than natural. On the other hand, Desault and Malgaigne maintained that there would be elongation; and Baron Dupuytren, although at one time of opinion that the arm could be elongated only in dislocation downwards, afterwards agreed with Desault and Malgaigne, and stated, that after dissecting the ligaments in a recent joint, and producing dislocation, he found the arm had lengthened as much as half an inch. There is a point, concerning which, for a considerable time, there existed much difference of opinion, namely, whether complete dislocation forwards be a primary or consecutive dislocation,—that is, whether the bone can be sent out at once by violence from the glenoid cavity to the situation which it occupies in this dislocation ; or whether it be first dislocated downwards, and suffer a secondary displacement upwards, by the muscles drawing it upwards and inwards, as far as the clavicle will allow. Some have gone so far as to say, that the head of the bone can- DISLOCATIONS OF THE SHOULDER JOINT. 251 not get into the position it occupies in this dislocation, except by suffering a secondary displacement, after having first been forced downwards. Others, for example, Desault, Petit, Dupuytren in France, and the late Fig. 65. Mr Hey, and Professor Samuel Cooper in this country, did not deny the possibility of its being primary, but they believed, as will be seen by a perusal of their writings, that it is in fact very seldom primary, and almost always consecutive to dislocation downwards. It is very evident that Sir Astley Cooper considered this a primary dislocation. The case recorded by Sir Philip Crampton, which will be described in mentioning the state of the parts, very clearly proves that, in some cases at least, this dislocation is primary. State of the Parts.—In the third volume of the " Dublin Journal of Medical Science," there is a case of undoubted primary dislocation recorded by Sir Philip Crampton, which is interesting, not only as set- ting at rest the long-disputed question above-mentioned, but also as being the first recorded dissection of the parts in an example of recent dislo- cation forwards. " The head of the humerus was lodged on the inner side of the neck of the scapula, to the sternal side of the root of the coracoid process, and extending up nearly as far as the notch in the superior costa. The capsular ligament was perfectly entire in the direction of the axilla, showing that the bone could not have been sent first to the axilla and afterwards to the situation here described. The opening in the caspular ligament was on its inner side, and was caused by its being torn from the glenoid cavity, the rent extending from the supraspinatus muscle above to the under part of the subscapularis muscle below. 252 DISLOCATIONS OF THE SHOULDER JOINT. The supra and infra-spinati were much on the stretch, but not lacerated, and the subscapularis muscle Fig. 66. was partly detached from the upper and the anterior parts of the subscapular fossa, and pressed downwards, so that its fibres in a curved manner embraced the neck of the bone. The axis of the head of the bone was scarcely a quarter of an inch above the centre of the glenoid cavity, and the vessels and nerves were on the sternal side of the humerus." Mr. Key made a dissection of a shoulder which had long been dislocated inwards. The glenoid cavity was completely filled up by liga- mentous matter, and the head of the hu- merus was situated under the clavicle to the sternal side of the root of the cora- coid process, in contact with the venter of the scapula, from which the subscapularis muscle was at that part torn off, and separated from the ribs by that muscle and the serratus magnus muscle. A new socket and complete capsular ligament had been formed. I believe that in complete dislocation inwards, the head of the bone will generally be in the position described above, with the pectoral muscles before it, and the axillary vessels and nerves to its sternal side. Treatment.—The reduction is to be effected by the means recom- mended in describing the methods by manual extension, and by pulleys, in the former dislocation, with the two following peculiarities:—First, that the extension should be made downwards and outwards, in the line of the unnatural direction of the axis of the humerus, until the head of the bone be below the coracoid process; then the extension should be continued with the arm raised to the horizontal position. Second, that after extension has been applied for a considerable time, and while it is still being continued, the surgeon should endeavour to replace the head of the bone, by employing the humerus as a lever, pressing the lower part of it forwards, and its head backwards in the direction of the glenoid cavity ; and while doing so, he should also rotate the arm. This can be most effectually done by using the forearm as a lever, having it bent at a right angle with the arm, in order to prevent stretching of the biceps, which would be an obstacle to reduction. In attempting replacement in this, as in every other dislocation, the extension and counter-extension must always be in a line with each other. III. PARTIAL DISLOCATION FORWARDS. Symptoms.—The head of the bone is drawn forward against the coracoid process, where there is an unnatural tumour, whilst there is a depression opposite the back part of the shoulder joint. The posterior half of the glenoid cavity is perceptible to the fingers, whilst the long axis of the humerus is in front and in a line with the coracoid process. The elbow is slightly removed from the side, and is in a line behind the DISLOCATIONS OF THE SHOULDER JOINT. 253 long axis of the body. The arm can partially perform such movements as do not require its elevation, but it cannot be raised. State of the Parts.—The head of the bone is on the scapular side of the coracoid process, and rests against it and the edge of the glenoid cavity, where, in an unreduced dislocation, a new cavity has been found formed for its reception. It seems possible for this dislocation to occur without the capsular ligament being torn through ; but in dissecting an old dislocation, it was found that the ligament had been ruptured and become attached to the coracoid process. The latissimus dorsi and two teres muscles are put upon the stretch, and the pectoralis major, except some of its inferior fibres, is relaxed. The spinati muscles are slightly on the stretch, and the posterior fibres of the deltoid are extended, while the anterior are relaxed. Treatment.—Reduction is accomplished in the same manner as in the preceding injury, namely, by counter-extension, extension, and a lever- like motion of the humerus; less force, however, is required. IV. DISLOCATION BACKWARDS. Dislocation of the head of the humerus on the dorsum of the scapula is so rare an accident, that Desault had never seen an instance of it; Baron Boyer met with it but once in the living body; only two cases occurred at Guy's Hospital in thirty-eight years; in the same number of years Sir Astley Cooper met with two cases, and not more than four cases occurred in his practice during his whole professional career; and Mr. Lawrence, in his lectures, delivered at St. Bartholomew's Hospital in 1830, states that at that time he had never seen the humerus dislocated backwards. Two cases are reported from the Middlesex Hospital; one from the North London Hospital; Mr. Toulmin of Hack- ney met with a case; Mr. C. M. Coley of Bridgeworth, with two ; I have met with two examples, and there are on record a very few other cases, to the particulars of which I may have occasion to refer. Causes.—In one of the cases seen by Sir Astley Cooper, the injury was produced by pushing a person violently with the arm elevated. Of the two cases which occurred at Middlesex Hospital, the one was caused by a heavy box from the top of a bedstead falling on the hand of the person while the arm was elevated; the other, in a woman ninety-four years of age, was occasioned by a fall on the front of the shoulder, in consequence of having trodden on some orange peel. Mr. Toulmin's case was in an unusually muscular gentleman, and was caused by a fall from his horse. Of the cases narrated by Mr. Coley of Bridgeworth, one was caused by the man being pulled down by a calf which he was driving, a cord which he held fast in his hand being tied to one of the animal's legs; the other by the person being dashed from his horse against a tree, the shock being received on the front of the shoulder. In a case of this dislocation, of long standing, in which Mr. Key had an opportunity of making a minute examination of the state of the parts after death, the injury was caused by spasmodic contraction of the muscles during an epileptic fit. The exciting causes of the other cases recorded are not mentioned. Symptoms.—The injury is characterized by the absence of the natural roundness of the shoulder, unnatural prominence of the aero- 254 DISLOCATIONS OF THE SHOULDER JOINT. mion process, with depression under it; unnatural flatness of the ante- rior part of the shoulder, together with a stretched appearance of the skin at that part, and an unnatural tumour on the dorsum of the sca- pula underneath the spine, caused by the head of the humerus, which can be very distinctly felt. As to the precise direction of the long axis of the arm and the position of the elbow, surgeons are at variance. In the cases mentioned by Mr. Coley and Mr. Toulmin, the elbow was for- ward and close to the side. In one of the cases admitted into Middlesex Hospital, the arm was close to the side, and in a line with the long axis of the body. In the other recorded cases the precise position of the elbow is not stated. In one of the cases which I had an opportunity of seeing, the elbow was directed forwards ; in the other, it was merely removed from the side of the body. The long axis of the humerus is of course directed to the dorsum of the scapula, and the position of the arm and elbow, as might be expected, from considering what muscles would thus be put upon the stretch, is for the long axis of the arm to extend downwards and forwards, with the elbow removed from the side, and in a line before the long axis of the body. Some surgical autho- rities give this direction of the long axis of the arm, and this position of the elbow, as symptoms, without stating whether they do so from reason- ing on the unnatural condition of the muscles, or from observation. It is not more difficult to explain an occasional deviation from this attitude in this dislocation, than it is to explain how in some very rare instances the elbow is nearly close to the side in dislocation downwards, although, in by far the greater number of examples, it is removed from the side to diminish the painful tension of the deltoid muscle. State of the Parts.—The head of the bone lies on the dorsum of the scapula, the capsular ligament is ruptured, the muscles in front of the joint are stretched, and the infra- Fig- 67- spinatus and teres minor are torn up from the scapula, before the head of the bone can arrive at its unusual situation. In the case in which the injury was caused by spasmodic con- traction of the muscles in an epileptic fit, and of which a dissection was made by Mr. Key, the gentleman lived for seven years after the acci- dent, but the dislocation could not be kept reduced, and he never re- sumed the use of his arm. On in- spection after death, it was found by Mr. Key, that the explanation of the impossibility of keeping it re- duced, was laceration of the tendon of the subscapularis muscle, and its adhesion to the edge of the glenoid cavity with very imperfect union. The anterior part of the capsular ligament was torn at the insertion of the subscapularis, and the posterior part was carried back with the DISLOCATIONS OF THE SHOULDER JOINT. 255 bone, which, instead of resting far back on the dorsum of the scapula, rested on the posterior edge of the articular surface, and on the inferior costa close to the articulation. Treatment.— In two of the recorded cases of this injury, Sir Astley Cooper accomplished reduction by raising the hand and arm, and turn- ing the hand backwards behind the head. In another instance this method was tried without success, and the bone was replaced by exten- sion of the arm, the scapula being fixed by placing the heel in the axilla. In another, reduction was effected by extension from the wrist in the direction of the displaced bone without the heel in the axilla; and in the remaining cases, with the exception of one which remained unreduced, the bone seems to have been replaced by extension and counter-extension, and in some of them with very little difficulty. The general principles already mentioned as applicable to reduction of dislocation downwards, in the description of the methods by manual extension and by pulleys, are applicable to this luxation; but the ex- tension should be made forwards and outwards, with the arm raised to a horizontal position; and while the extension and counter-extension are being applied, the surgeon should endeavour to direct the head of the bone upwards and forwards by employing the humerus as a lever, pressing the knee against the upper and back part of the humerus, and drawing the elbow a little backwards. V. PARTIAL DISLOCATION UPWARDS. This is an accident so extremely rare, that it is not mentioned by many surgical authorities. The possibility of its occurrence is proved by a case which came under the observation of Mr. John Soden, Jun., of Bath, and also by a preparation, to which reference will be found in another page. An account of the case referred to was drawn up by Mr. Soden, and read before the Royal Medical and Chirurgical Society of London, and published in their Transactions for the year 1841. A description of the case will also be found with an engraving in Sir Astley Cooper's work on " Fractures and Dislocations," edited by Mr. Bransby B. Cooper. The following are some of the particulars. Jo- seph Cooper died in the Bath United Hospital in November, 1839, in consequence of a compound fracture of the skull, and his death afforded an opportunity of examining an old injury of the right shoulder, caused by receiving the whole weight of his body on his elbow in falling back- wards. After the subsidence of the inflammatory symptoms which super- vened, a difference was perceived between the two shoulders. When the man stood erect with his arms dependent, the bone appeared to be drawn too much up in the glenoid cavity. The power of abduction was very limited, because the humerus came against the acromion pro- cess ; and when the arm was moved, on placing the hand on the shoulder a sensation of crepitus simulating fracture was experienced, which how- ever, was merely the rubbing of the humerus on the acromion process. The head of the humerus appeared unnaturally prominent in front • the man could move his arm backwards and forwards, but was unable to raise the smallest weight; and any exertion or motion which could ex- cite the action of the biceps, caused severe pain, and could not, there- fore, be performed. The capsular ligament was but slightly ruptured, 256 DISLOCATIONS OF THE ELBOW JOINT. but the tendon of the biceps was dislocated from its groove, and placed on the lesser tubercle of the humerus,—a position which accounted for the pain experienced where any force was used which called the biceps Fig. 68. muscle into action. The head of the humerus was sent upwards, and where it was in contact with the acromion process, ulceration had com- menced on the head of the humerus. This case shows how greatly the tendon of the biceps contributes to the strength of the joint, and how useful it is, when in its proper situation, for preventing dislocation upwards. In the museum of the Medico-Chirurgical Society of Aberdeen, there is a preparation of an unreduced partial dislocation upwards, which, in all respects, very closely agrees with the description and figure of the above case. It was taken from the body of a subject brought to one of the dissecting-rooms in Aberdeen. DISLOCATION OF THE ELBOW JOINT. This articulation is formed of three bones, the humerus, the ulna, and the radius. It is furnished with four proper ligaments, the anterior, posterior, external lateral, and internal lateral; and it is liable to six dislocations; of which three include both bones of the forearm, and three are dislocations of single bones. They are named thus— Dislocation of both bones backwards. Dislocation of both bones inwards. Dislocation of both bones outwards. Dislocation of the ulna backwards. Dislocation of the radius backwards, and Dislocation of the radius forwards. I. DISLOCATION OF BOTH BONES BACKWARDS. This is the most frequent of the dislocations at the elbow, and is caused sometimes by a wrench, but more generally by a fall on the hand, when the forearm is not perfectly extended. Under such cir- cumstances the radius and ulna come suddenly to a state of rest, and the humerus by the weight of the body is thrown forwards on them. Symptoms.—There is an unnatural prominence behind the joint DISLOCATIONS OF THE ELBOW JOINT. 257 caused by the extremities of both bones, but more especially of the ulna, and an unnatural hard swelling in front of the elbow produced by the extremity of the humerus. The anterior aspect of the forearm is pre- ternaturally shortened. In some cases, the forearm is at a right angle with the arm, while in others it is midway between extension and semi- flexion. The hand is between pronation and supination, but more in- clined to the latter. The motions of flexion and extension, as well as those of pronation and supination, are suspended, or at all events very difficult, limited, and painful; but an unnatural lateral motion can be produced. The accompanying figure from Liston, represents an unre- duced dislocation of seven years' standing, in which case the movements of the hand were considerably regained. Fig. 69. State of the Parts.—The coronoid process of the ulna occupies the olecranon fossa, the head of the radius is lodged behind the external condyle, and the Fig. 70. lower end of the humerus rests on the an- terior surface of the radius and ulna. All the four ligaments are ruptured, though some of the fibres of the internal lateral are preserved. The triceps muscle is much re- laxed from the approximation of its points of attachment; the brachialis anticus and the biceps are either very much put upon the stretch or lacerated, and the former has been found occasionally to tear away a portion of its osseous attachment to the coronoid pro- cess. All the muscles originating from either condyle of the humerus, except the supina- tor radii brevis, are in a state of relaxation. Figs. 69 and 70. From Liston. 17 258 DISLOCATIONS OF THE ELBOW JOINT. Treatment.—Sir Astley Cooper recommends the surgeon, having seated his patient on a low chair, to place his knee in front of the el how joint, against the front of the radius and ulna, and after having for some time attempted, by pressing backwards with his knee, to dislodge the coronoid process from the olecranon fossa, then forcibly but slowly to attempt flexion of the forearm, when reduction will be soon accom- plished. The object of pressing with the knee is, as already stated, to displace the coronoid process from the olecranon fossa ; and the object of the forcible flexion is to bring the bones forward to their natural po- sition. Baron Boyer effected reduction in another manner. In accor- dance with his mode, an assistant is to take hold of the middle of the humerus, and thus afford the necessary counter-extension, and another assistant to make extension at the wrist, keeping the forearm at a right angle with the arm, while the surgeon grasps the elbow with both hands, having his fingers in front of the humerus, and his thumbs on the ole- cranon process, against which he directs pressure downwards and for- wards. According to Sir Astley Cooper's method, the surgeon endea- vours to displace the coronoid process from the olecranon fossa, by pressing the knee against the front of the forearm ; in Baron Boyer's, by pressing with the thumbs the olecranon process downwards and for- wards. In the former plan the bones are brought forward by flexion of the forearm; in the latter, by an assistant pulling at the wrist. I have, with great ease and readiness, effected reduction by employing two assistants,—one for fixing the humerus, the other for effecting extension, which can be best done by grasping the middle of the fore- arm with both hands, and pulling forwards—and while extension and counter-extension are being used, by placing the fingers of one hand in front of the forearm, as near as possible to the elbow, and the other upon the olecranon process, and pulling forcibly with both hands, as if the object were to draw the heads of both bones of the forearm away from the humerus. By this means the coronoid process is very speedily dislodged from the olecranon fossa, and the extension then brings the bones forward to their natural situation. The advantage of affording extension, by grasping with both hands the middle of the fore- arm, is, that the force thus acts as much on the ulna as on the radius; whereas, if extension be applied at the wrist, the force is in a great measure lost, for the ulna, which offers the chief obstacle to reduction, being small near the wrist, and having little connexion with that arti- culation, is acted upon only indirectly through the medium of the struc- tures by which it is connected with the radius. According to Mr. Liston, reduction is thus accomplished:—" The arm and forearm are extended, and the limb is brought well behind the trunk, so as to relax the triceps ; the surgeon performs extension and counter-extension, pulling the forearm with one hand, whilst he pushes with the other, placed on the scapula. If the force thus employed prove insufficient, as it seldom will in recent cases, the patient may be placed on his face on a couch, and on the limb being brought into the favourable position already noticed, counter-extension may be made by the heel planted against the inferior costa of the scapula, whilst the wrist is pulled with both hands." DISLOCATIONS OF THE ELBOW JOINT. 259 II., III. DISLOCATION INWARDS, AND DISLOCATION OUTWARDS. The radius and ulna may be dislocated laterally, that is, they may be drawn to the one side of the humerus or the other; but these disloca- tions are extremely rare, and never complete, on account of the great breadth of the articulating surfaces. They are readily detected by the unnatural prominence along the plane of the joint, either internally or externally, according to the nature of the dislocation, and by the in- ability to flex the forearm; and they are easily reduced by fixing the arm, pulling the forearm, and pressing the bone, either outwards or in- wards, as the case may demand. IV. DISLOCATION OF THE ULNA BACKWARDS. The distinguishing marks of this dislocation are, the projection of the olecranon process behind the humerus, the hand and forearm being twisted inwards to the ulnar aspect of the forearm, and the impossibility of bending the forearm to more than a right angle. In some instances it has been found impossible to bend it even to that extent, and any attempts to do so have caused excessive pain. In one recorded dissec- tion of this dislocation, the coronoid process was lodged in the olecranon fossa; the coronary, oblique, and part of the interosseous ligaments, were torn; the triceps muscle was much relaxed, and the brachialis mus- cle stretched under the humerus. Treatment.—Press the knee against the front of the elbow joint; then with one hand attempt to bend the forearm over the knee, drawing it at the same time forwards, and with the other hand, the olecranon process downwards and forwards. In a case occurring in the practice of Mr. Gosset, in which the coronoid process rested on the internal con- dyle instead of the olecranon fossa, and the pain on bending the arm was insupportable, owing it was supposed to the pressure of the coro- noid process against the ulnar nerve, reduction was accomplished by extension and counter-extension applied by two persons pulling in oppo- site directions, and by the pressure of the olecranon process downwards and outwards, while the forearm was suddenly flexed. V. DISLOCATION OF THE RADIUS BACKWARDS. This must be an extremely rare injury, since Baron Boyer has met with it only twice, and Sir Astley Cooper saw it only once in the dead subject, but never in the living body. Mr. Lawrence has seen the ac- cident, and Mr. Bransby B. Cooper gives a short description of one case complicated with fracture of the ulna, which came under his obser- vation ; but the most minute account I have seen of this dislocation is by Professor Lagenbeck, of Gottingen, who met with two examples, the one in a man twenty years of age, and the other in a child of five years. In these cases, which are published in " The Lancet," the hand was prone and could not be brought into a state of supination ; the forearm was moderately bent, and admitted of neither flexion nor extension ; the skin was lax along the inner side of the internal condyle, and the head of the radius could be felt behind the external condyle ; the articulating cavity of the head of the bone could be felt in the child, but its circum- 260 DISLOCATIONS OF THE ELBOW JOINT. ference only in the adult. In both these cases, replacement was accom- plished by applying counter-extension to the arm, and extension to the forearm, and pressing the head of the bone inwards. Strong and long- continued extension was necessary in the one case, while very moderate extension with pressure was sufficient in the other. In this injury, ex- tension should be made from the hand, and when it has been employed for some time, and is still being continued, it would be judicious, be- sides pressing the head of the bone inwards, to supinate the hand for- cibly, which would assist the pressure in sending the head of the bone forwards, because in supination, while the under extremity is sent out- wards, the superior is directed forwards. In the example which Sir Astley Cooper met with in the dead subject, the account of the state of the parts on dissection is as follows :—The head of the radius was found behind the external condyle, the coronary and oblique ligaments were torn, and the capsular ligament—by which I suppose is meant part of the external lateral, and anterior ligaments,—had partly given way. [Dr. Gibson, of the University of Pennsylvania, states, in the first volume of his Surgery, that he has seen several cases of dislocation backwards of the head of the radius, and that he considers it more common than dislocation forwards. In 1826, he exhibited to the class " a case in which both radii were luxated at the same moment, from the patient being precipitated suddenly before a hogshead of sugar, whilst in the act of rolling it."—Ed.] VI. DISLOCATION FORWARDS OF THE RADIUS. Baron Boyer never met with this dislocation, and says, that no authentic example exists of the bone being thrown forwards on the exter- nal condyle. Many cases, however, are recorded : Sir Astley Cooper met with six examples; Mr. Bransby B. Cooper with two ; and instances have occurred in the experience of Mr. Lawrence, Mr. Tyrrel, Mr. Gosset, and many other surgeons. I have met with two examples, the one in a girl of eleven, the other in a boy of about thirteen years of age: the symptoms were nearly the same in both cases. The forearm was about midway between complete extension and semiflexion, the hand slightly supinated, making an angle of about forty-five degrees with the plane of complete supination; the movements in the direction of prona- tion and supination, as well as those of flexion and extension, were ex- tremely limited; and on attempting to bend the forearm, I was particu- larly sensible of a sudden check to further flexion by an obstacle which left a decided impression of its being caused by one bone striking against another. There was a perceptible alteration of the direction of the long axis of the radius, which, instead of leading up to the under part of the external condyle, was directed in front of it, where the head of the radius could be distinctly felt, forming an unnatural tumour. There was an unnatural depression perceptible below the external condyle, and in one of the cases the patient complained of great pain in the upper part of the interosseous space, which pain was much aggravated by pressure. In each case, I accomplished reduction by making one assistant fix the humerus, and another effect extension from the hand, by which means the force acts on the radius alone; and when extension DISLOCATIONS OF INFERIOR RADIO-ULNAR. 261 and counter-extension had been employed for some time, and were still being used, with the arm as straight as could be made, I then with the thumb of one hand forcibly pressed the head of the bone backwards, making at the same time with the other hand, a forcible attempt at pro- nation, when the head of the bone was tilted back into its proper situa- Fig. 71. Fig. 72. tion. In one of the cases, reduction was accomplished with great diffi- culty, in consequence of its having remained for four days unreduced, during which the case was treated as a sprain by a practitioner, who mistook the nature of the injury. The head of the bone rests above the external condyle, and it is the resistance offered by the humerus which prevents flexion of the forearm. The external lateral, and anterior ligaments of the elbow-joint are lace- rated, as are also the coronary, the oblique, and part of the inter- osseous ; otherwise the radius could not get into its unnatural situa- tion. _ The two dislocations last described are as properly accounted disloca- tions of the superior radio-ulnar articulation, as of the elbow-joint — both articulations being involved in the injuries. ' DISLOCATIONS OF THE INFERIOR RADIO-ULNAR ARTICULATION. These injuries, which consist of the displacement of the one bone with respect to the other at the inferior radio-ulnar articulation, are Fig. 72. From Liston. 262 DISLOCATIONS OF INFERIOR RADIO-ULNAR. not to be confounded with dislocations of the wrist-joint. The writers, who have described these rare accidents, have not all employed the same nomenclature, some making the direction of the radius, others that of the ulna, the basis of arrangement. There are only two of these dislocations. They are described by some authors as dislocation for- wards and dislocation backwards of the radius; by others, as dislocation backwards and dislocation forwards of the ulna. As the two bones are driven in opposite directions, it follows, that the dislocation forwards of the radius of some authors is the dislocation backwards of the ulna of others, and that dislocation backwards of the radius of some is the dis- location forwards of the radius of others. In the following description the direction of the radius is made the basis of arrangement. These dislocations are generally produced by the hand being carried too far round in the directions of pronation and supination; and of the two, dislocation forwards is the more frequent, partly, because the motion of pronation is more extensive than that of supination, and partly, because violent and immoderate force, which is often required in efforts accompanied with pronation, can seldom be necessary in any offices which the hand has to perform in a state of supination. Desault records the case of a laundress who, by a violent pronation of her hand in wringing a wet sheet, produced dislocation forwards of the radius. The dislocation backwards of the radius has not in every case been caused by supination. Dupuytren mentions the occurrence of an ex- ample in one of the gendarmerie, where the injury was occasioned by his horse falling, and his forearm being crushed between the horse's head and the ground. The dislocation forwards seldom occurs; and the dislocation backwards is so extremely rare, that in a long experience Desault never met with it in the living body, and only once in the dead subject; Dupuytren saw but two cases, Boyer but one ; and Sir Astley • Cooper has not recorded a single example. In dislocation forwards the forearm is bent, the hand being carried beyond the natural extent of pronation; there is an unnatural promi- nence at the posterior and inner part of the wrist, caused by the ulna; and the motions of pronation and supination are suspended. Replace- ment is easily accomplished in the following manner :—The arm is fixed by an assistant, and the surgeon, with the fingers and thumb of one hand, separates the bones from each other, pressing the one backwards and the other forwards, and with the other hand, he at the same time forcibly turns the hand into a state of supination ; by which movement the radius is sent back to its proper position. The injury is caused by violent pronation : it is reduced by forcible supination. In dislocation backwards the hand is carried beyond the natural ex- tent of supination; the motions of pronation and supination are sus- pended; the natural prominence formed by the ulna at the back of the wrist disappears; and an unnatural projection in front of the wrist is caused by the under part of the ulna. In the example of the officer, whose case is recorded by Dupuytren, and where violent supination was not the cause of the injury, the hand was not supinated, but midway between pronation and supination. The direction of the ulna was too far forward, the lower extremity coming in front of the radius; there DISLOCATIONS OF THE WRIST JOINT. 263 was an unnatural depression at the back, and an unusual prominence in front of the wrist. Replacement may be accomplished by fixing the arm, and with one hand separating the bones from each other, pressing the one backwards and the other forwards, and with the other hand forcibly producing pronation; by which means the hand, and with it the radius, is carried forward. The dislocation may be caused by supi- nation being carried to too great an extent, and it may be reduced by forcible pronation. Violent pronation may cause dislocation backward of the upper, and forward of the under extremity of the radius ; and forcible supination is a principal means of reducing these dislocations. Supination carried beyond the proper extent may induce dislocation forward of the upper, and backward of the under extremity of the radius ; and forcible pronation is of the greatest consequence in reduc- ing these dislocations. DISLOCATION OF THE RADIO-CARPAL ARTICULATION, OR WIRST-JOINT. This articulation is formed above, by the radius and triangular fibro- cartilage, and below, by the first three bones of the carpus, namely, the scaphoid, semilunar, and cuneiform bones. It is furnished with four ligaments, and is liable to five dislocations. Both bones of the forearm may be thrown forwards, backwards, inwards, or outwards, and the radius alone may be driven forwards on the front of the carpus. The dislocations forwards and backwards are exceedingly rare, especially the former. The celebrated Dupuytren went even so far as to say, " that there was not a single unequivocal instance on record of a dislo- cation of the radio-carpal articulation, and that he invariably found these pretended accidents always turned out to be fractures of the radius near the articulation." It is now, however, quite certain that these dislocations, though rare, do occasionally take place. I. DISLOCATION FORWARDS. The dislocation forwards is produced by a fall on the palm of the hand during extension, and may be detected by a swelling on the fore part of the wrist, produced by the radius and ulna, and another on the back part, caused by the carpus ; by an unnatural depression above the last-mentioned swelling ; by the styloid processes of the radius and ulna not presenting their natural relation to the carpus, and by the hand being extended and fixed. II. DISLOCATION BACKWARDS. The dislocation backwards usually occurs from a fall on the back of the hand, while the hand is fixed. It is characterized by two unnatural swellings,—one on the back of the wrist, caused by the radius and ulna, the other in front, caused by the carpus; and by the hand being vio- lently bent and fixed. These dislocations may be distinguished from sprains by the existence of two swellings ; whereas in sprains there is only one; and that does not appear immediately, but, when it does, gradually increases. For distinguishing between dislocation of the wrist, and fracture of the radius 264 DISLOCATIONS OF THE THUMB. near the wrist, when the inflammatory swelling renders it difficult to detect the real nature of the case, it is of importance to take hold of the hand, and move it, observing at the same time whether or not the styloid processes of the radius and ulna be movable. If the injury be a fracture, they will change their position ; but if it be a dislocation, they will remain fixed. III., IV. LATERAL DISLOCATIONS. The lateral dislocations are never complete, on account of the breadth of the articulating surfaces ; in consequence of which some part of the under portion of the articulation still rests against some part of the upper. A projection of the carpus on the one side of the wrist, and of the radius or ulna on the other, with a fixed condition of the hand, are symptoms sufficiently diagnostic to make these injuries easy of detection. The deformity of parts is so distinct, that there can be no difficulty in recognising these accidents, and their replacement is equally easy by the following means. While the forearm is held firmly by an assistant, so as to afford the necessary counter-extension, and another assistant makes extension from the hand, the surgeon should press the displaced bones towards their proper situation. When extension and counter-extension have been used to a sufficient degree to prevent the bones from pressing against each other, the contraction of the muscles will powerfully aid in accom- plishing reduction. After reduction, antiphlogistic remedies, of rather a smart character, are frequently necessary to subdue the very considerable tumefaction and inflammation which sometimes result from the injury to the soft parts; and recourse must be had to the cautious use of a splint, to prevent any motion of the hand which would be apt to cause a recurrence of the dislocation, and hinder the union of the ligaments ; but care must be taken so to apply it, as not to produce any pressure, which would aggravate the local inflammation, if it should supervene. V. DISLOCATION FORWARDS OF THE RADIUS ALONE, ON THE FORE PART OF THE CARPUS. This is quite a different dislocation from that of the radius forwards at the inferior radio-ulnar articulation. In this dislocation the styloid process is no longer in a line with the radial side of the carpus ; the under extremity of the radius forms a protuberance on the front of the carpus; the hand is fixed, and its outer border is twisted backwards, and its inner forwards. These symptoms are sufficiently diagnostic of the nature of this injury, the reduction and after-treatment of which are the same as when both bones are displaced. DISLOCATIONS OF THE THUMB. The first metacarpal bone of some anatomists, the first phalanx of the thumb of others, is capable of being dislocated in four directions, namely, inwards, outwards, forwards, or backwards; but, in general, it is^ dislocated only forwards or backwards. Mr. Lawrence is of opinion that a dislocation backwards is the only dislocation of this bone that can take place. In many cases seen by Sir A. Cooper, the metacarpal bone was thrown inwards, between the os trapezium and the DISLOCATIONS OF THE THUMB. 265 metacarpal bone of the fore-finger, so as to form a protuberance towards the palm of the hand. The thumb was bent backwards and did not admit of being brought towards the little finger. The unnatural protuberance, formed by the articular end of thg bone, is so very con- spicuous, that the nature of the accident is immediately recognised. Much pain and swelling are produced by the accident. For facilitating reduction, Sir A. Cooper advises extension to be made with the thumb inclined towards the palm, in order to relax and diminish the resistance offered by the flexor muscles. After steady extension for a considerable time, the bone should be forced into its place by making pressure with the fingers on the head of the bone. When reduction is impracticable, Sir Astley deems it preferable to leave the case to the degree of recovery which nature will in time produce, rather than run any risk of injuring the nerves and blood-vessels by dividing the muscles or ligaments. Dislocation of the first Phalanx.—A more frequent, and at the same time more troublesome dislocation, because of the difficulty of its reduc- tion, is the dislocation of the first phalanx from the metacarpal bone. The deformity of the parts reveals the nature of the injury. The extremity of the first phalanx forms a prominence on the back of the head of the metacarpal bone, and the lower part of the metacarpal bone is equally perceptible on the palmar side. In reducing it, which it is comparatively easy to accomplish in the recent state, the thumb should be inclined towards the palm; and during straight extension of the thumb, pressure should be made with the finger on the head of the extremity of the first phalanx. But after a little time has elapsed, there is often very great difficulty in effecting reduction,—so much so, that Sir A. Cooper considered dislocations of the thumb as the most difficult to reduce. " In order to relax the parts as much as possible, the hand should be soaked for a considerable time in warm water; a piece of wetted wash- leather is to be as closely wrapped round the first phalanx as possible; a tape, about two yards in length, should be fastened on the leather with a knot that will not slip, such as the sailors call the clove-hitch. An assistant should now firmly press on the metacarpal bone, by putting his middle and first fingers be- tween the fore-finger and thumb of the patient, and thus make a counter-exten- sion, whilst the surgeon, assisted by others, draws the first phalanx from the metacarpal bone, inclining it at the same time a little towards the palm of the hand. If the efforts made in this way, after having been con- tinued ten or fifteen minutes, should not succeed, then it will be necessary to adopt another plan, which is this,—in addition to the apparatus already employed, let a strong worsted tape be carried between the metacarpal bone and fore-finger, bend the forearm round a bed post, and let the tape be firmly tied to it, so as to prevent the Fig. 73. 266 DISLOCATIONS OF THE HIP JOINT. hand yielding when extension is made. To the tape surrounding the first phalanx a pulley is to be applied, and extension made, which will generally succeed."—Sir A. Cooper, Lectures on Surgery, pp. 638, 639. ♦ The proposal has been suggested of dividing one of the lateral liga- ments with a couching needle, or a very small knife, when reduction is impossible by ordinary means. The best authorities, in general, unite in condemning this practice on account of the frequency with which tetanus is induced by injuries of tendons and ligaments connected with the thumb. Mr. Syme, however, says: — "In cases where the difficulty proves insuperable, one of the lateral ligaments may be cut, which would certainly be better than leaving the bone unreduced, as has sometimes been the case." Sometimes the dislocation takes place in the other direction, the metacarpal bone being forced behind the extremity of the first phalanx. Here there is less difficulty in accomplishing reduction. The phalanges of the fingers are sometimes dislocated backwards. The accident cannot be mistaken, and reduction by means of extension is accomplished with facility. DISLOCATIONS OF THE HIP JOINT. The ilio-femoral articulation, or hip joint, is formed by the cotyloid cavity of the os innominatum, and the head of the femur. It is fur- nished with a large synovial membrane, and five ligaments, namely, the capsular, the accessory, the cotyloid, the transverse, and the ligamen- tum teres or round ligament. The direction in which the ball of the femur is sent from the acetabulum is the basis of arrangement of its different dislocations. It will facilitate the description of the various dislocations of the hip joint to arrange them in two grand classes, the regular, and the anoma- lous. Of the former class there are four different kinds, and the same number of the latter class have been recorded. REGULAR DISLOCATIONS OF THE HIP JOINT. The head of the thigh bone may be thrown from the acetabulum in the four following directions, constituting the four regular dislocations:— 1. Upwards, upon the dorsum of the ilium. 2. Backwards, into the ischiatic notch. 3. Downwards and forwards, into the foramen ovale. 4. Forwards, upon the pubes. With regard to the proportionate frequency of these several disloca- tions, Sir Astley Cooper says, that in twenty cases, you may have twelve of the first kind, five of the second, two of the third, and one of the fourth. I. DISLOCATION UPWARDS ON THE DORSUM OF THE ILIUM. Symptoms.—When the bone has been displaced in this direction, the dislocated limb is more or less shortened. This symptom appears im- DISLOCATIONS OF THE HIP JOINT. 267 Fig. 74. mediately, but, after the muscles have had time to contract, it increases so much, that the point of the great toe of the affected side does not extend beyond the tarsus of the other foot. The shortening will be best seen by supporting the patient in the erect posture, and comparing the position of the toes, or of the inner ankles. The thigh, leg, and foot are all in- verted, so that the great toe of the dis- located extremity rests on the tarsus of the opposite foot. The knee is very slightly bent, and a little in advance of the under part of the other thigh. The limb is perfectly immovable to the voluntary efforts of the patient, nor can it be moved by the surgeon in the direction of abduc- tion or of extension; and if it can be slightly moved in the direction of ad- duction or of flexion, such movements are attended with great pain. There is an unnatural swelling of the hip, caused by the upper part of the femur, and the bulging out of the glutei mus- cles. If the patient be thin, and the bone be not concealed by extravasa- tion of blood and the general tume- faction of the hip, which may soon follow such an injury, the head of the femur may be distinguished on the os innominatum, with its ball directed backwards, and its trochanter major forwards, and much nearer than natu- ral to the anterior superior spinous process of the ilium. Another symp- tom is, the absence of the natural projection of the trochanter major. The distinctive marks of this injury are so unequivocal that an attentive observer can be at no loss to recognise it. They may be stated briefly to be,—Shortening of the extremity; inversion; the knee slightly bent, and a little in advance; the limb immovable to the voluntary efforts of the patient, and to the surgeon in the direction of extension or abduction; absence of the natural projection of the trochanter; an unnatural swell- ing of the hip ; and the trochanter major raised upwards and forwards, so as to be too near to the anterior superior spinous process of the ilium. State of the Parts.—The capsular, accessory, and round ligaments must be ruptured, and the muscles torn up from the dorsum ilii, before the bone can occupy its unnatural situation. The upper extremity of the femur rests on the dorsum ilii, the ball being directed backwards, and the trochanter forwards. It has often been a subject of inquiry, why the ball is always directed backwards, and the trochanter forwards, and why it is not thrown into the attitude in which the principal muscles 268 DISLOCATIONS OF THE HIP JOINT. of the limb would place it. In France, the explanation proposed by Baron Boyer is considered satisfactory. He ascribes it to the strong anterior portion of capsular ligament, which proceeds from the upper and anterior part of the acetabulum to the anterior intertrochanteric line. When the bone is driven upwards, these fibres draw the trochan- ter towards the acetabulum, and prevent the bone from being twisted outwards as the rotators would direct it. Treatment.—It is not advisable to attempt reduction, without having previously weakened the muscular power. The means formerly em- ployed for that purpose consisted of copious bleeding, followed by a dose of antimony, or small doses of half a grain every ten minutes until nausea was produced. Or, when it could conveniently be done, the patient was first bled, then placed in a warm bath, and afterwards got doses of antimony until nausea came on, when the muscles were less able to resist reduction. The patient was, in all probability, much less injured by these debilitating remedies, than by the much greater exten- sion which would otherwise have been necessary. Instead of any of the above-mentioned proceedings, the auxiliary now employed is chloroform, which not only has the advantage of being more powerful, but also of preventing pain, and has, besides, no permanently weakening effect on the system. An assistant being in readiness with a set of pulleys, the patient should be placed on his back or opposite side on a table of con- venient height, particular care being taken that he be in such a position as to have the long axis of the thigh-bone in a straight line between two rings or staples fixed in some resisting objects in opposite sides of the room. To afford the necessary counter-extension to the pelvis, a strong well-padded leather belt or girth should be passed round the limb, so as to press on the side of the perineum (to prevent the chafing of which the padding is necessary), having its extremities directed out- wards and upwards, so as to be in a line with the long axis of the thigh- Fig. 75. bone, and fixed to one of the staples or rings before-mentioned. For affording the necessary extension, a few turns of a wetted linen roller should be tightly applied to the thigh, above the knee, over which should be very firmly buckled a leather belt furnished with two straps at right angles to itself, each having a ring at its extremity. The one set of pulleys should be fixed to the rings, and the thigh being DISLOCATIONS OF THE HIP JOINT. 269 directed a little forwards across the under third of the opposite thigh, and the leg of the affected side bent nearly to a right angle, the other set of pulleys should be fixed to the other ring or staple in the room. The direction of the axis of the thigh being carefully preserved in a straight line with the extending and counter-extending forces, the extension is to be applied by the surgeon himself, or by an assistant under his direction, by drawing the cord of the pulleys. The manner of doing this is, however, of the greatest importance; it ought not to be done suddenly, or violently, but slowly, steadily, and gradually; the cord should be drawn until considerable extension be produced, when the force should not be increased, but steadily kept up ; and when the muscles have had time to stretch, it should then be increased; and after another interval, during which the same degree of extension is preserved, the force should be again increased. When the ball of the femur is brought near to the acetabulum, it will be necessary for the surgeon to employ an assistant to keep up the extension; while he himself, taking hold of the femur, endeavours with one hand to raise the head of the bone from the ilium, by pressing upwards with the hand placed under the thigh,—the object being to diminish the resistance offered by the margin of the acetabulum to the ball of the bone gliding over it; and with the other hand he endeavours to rotate the thigh outwards for the purpose of inclining the trochanter backwards and the ball of the bone downwards and forwards. The advantage of attempting rotation must be evident from what has been stated regarding the position of the bone in this dislocation. The bone seldom returns with a snap when the pulleys are employed, from the muscles being so much worn out that they are not able to exert that sudden and powerful contraction which commonly accompanies reduction of a dislocation. The surgeon must, therefore, determine by the absence of the symptoms of dislocation that the reduction has been accomplished. Fig. 76. The above are the best appliances for the application of the extending .d counter-extending forces: but if they cannot be obtained, a sheet 270 DISLOCATIONS OF THE HIP JOINT. Fig. or tablecloth, with a quantity of tow or linen placed so as to diminish the danger of chafing, may be used for the latter purpose, and a skein of worsted, to which the pulleys may be fixed, for the former. [The extension may be effected in a very simple manner, by the con- trivance of Dr. Gilbert, already described in the first part of the chapter on Dislocation. As will be seen in the wood-cut (Fig. 76), the patient is placed as is usual, and the counter-extension is made in the ordinary way : but the extension is made by twisting by means of a strong stick, a rope which had been twice doubled, and the extremities of which had been properly secured to the limb and to a staple.—Ed.] II. DISLOCATION BACKWARDS INTO THE ISCHIATIC NOTCH. Symptoms.—In this, as in the last dislocation, we have shortening, inversion, an advanced position of the knee, and a fixed condition of the limb; but the three first mentioned symp- toms are to a less extent than in the former case. The shortening and in- version are such, that the point of the great toe rests upon the ball of the great toe of the op- posite foot, instead of upon the tarsus. The knee is less advanced, and is slightly bent: and when the patient is placed in the erect at- titude, the toes only touch the ground.— There is an unnatural projection on the back part of the hip ; the tro- chanter major is too far forward; and the natu- ral projection formed by it is lost. State of the Parts.— The capsular, accessory, and round ligaments are ruptured, and the head of the femur rests on the pyriformis muscle, above the sacro-sciatic ligaments and at the edge of the notch, with its ball directed back- wards and the trochan- ter forwards. DISLOCATIONS OF THE HIP JOINT. 271 Treatment.—Reduction is exceedingly difficult, but it is to be effected in the same manner, as in the former dislocation, with the following peculiarities, which require careful attention. The direction of the ex- Fig. 78. tending force should be across the middle, instead of across the under third, of the opposite thigh ; and as the extending and counter-extend- ing forces must always be in a line with each other, the direction of the mechanism for fixing the pelvis, although upwards and backwards, should be more directed backwards than in the reduction of the former injury. The sciatic notch, where the ball of the bone rests, is posterior to the acetabulum, and from the oblique position of the pelvis in the human body, a little higher up; and as the object of extension is to draw the ball forwards and a little downwards, the reason of the pecu- liarity in the direction of the traction must be obvious. While exten- sion is being made, which ought to be done with the patient placed on his opposite side, the ball of the thigh bone should be raised out of the ischiatic notch, and over the edge of the acetabulum. With this view some recommend that a round towel be placed under the upper part of the thigh and over the shoulders of an assistant, who at the same time resting both his hands on the patient's pelvis, obtains a great power over the dislocated bone. As a symptom, the knee is less advanced than in the former disloca- tion ; but in reduction, it requires to be raised further forward, and crossed over the other thigh, higher up than is necessary, or proper, in replacing the bone in dislocation upwards. 272 DISLOCATIONS OF THE HIP JOINT. III. DISLOCATION DOWNWARDS AND FORWARDS INTO THEFORAMKN OVALE. Fig. 79. This dislocation has been known to occur in consequence of a fall from a horse, with the thigh under the body of the animal. It has also been sometimes occasioned by the fall of a heavy weight on the thigh, while the limbs were separated. I once saw an instance of this disloca- tion caused by the person jumping in great haste out of bed, and while the left foot reached the floor, the right was entangled by the blankets in bed, and in consequence, the ball of the femur was driven against the anterior and under aspect of the joint, thus occasioning a dislocation downwards and inwards. Symptoms.—The limb is elongated and violently abducted, nor can it without great pain and difficulty be brought near to the other limb. If the patient be raised to the erect attitude, he leans to the affected side; or, if the trunk be kept per- fectly erect, the knee is very much in advance ; the rationale of which is, that the psoas magnus, and iliacus internus, are put very much on the stretch, and the patient endeavours to diminish the painful tension, by inclining the trunk to the affected side, or, if that be prevented, by bringing the thigh forward. The toes usually are neither inverted nor everted ; the trochanter major is less prominent than usual, and there is an unnatural hollow below Poupart's ligament. State of the Parts.—The ball of the femur is in front of the foramen ovale, resting on the obturator ex- ternus muscle; and it is important to observe that the ball is directed inwards, and the trochanter major outwards. There is rupture of two of the five ligaments of the hip joint, namely, the capsular, and the round. On this last point, however,—the rupture of the round ligament, a dif- ference of opinion exists. Sir Astley Cooper believed that in every in- stance it must be ruptured, and re- cords a dissection of a dislocation in which he found it so, whereas the celebrated Delpech, although he admits that it is sometimes ruptured, asserts that this is not always the case, and relates some cases in which he found it unbroken. Some found their opinion, that the ligamentum DISLOCATIONS OF THE HIP JOINT. 273 teres is not necessarily ruptured, on the fact, that in the dead body, the ball can be placed on the front of the foramen ovale, without rupture of the ligament. I have often in the dead body, after removing all the muscles, and cutting the capsular ligament, placed the ball of the femur in this situation ; but it can only be done with the trochanter directed inwards and the ball outwards, in short, by turning backwards the part of the femur which is naturally directed forwards, and leaving the part of the ball to which the round ligament is attached, very near to the margin of the acetabulum. This, however, is not the position of the femur in the dislocation; on the contrary, the ball is directed down- wards and inwards, and it will be found impossible in the dead subject, to place it in that position without first cutting through the round liga- ment. As has already been stated, Sir Astley Cooper is of opinion, that the round ligament is always ruptured; and that the accident cannot occur to a living person, except when the limb is in a state of abduction, in which position the ligamentum teres is upon the stretch, and therefore if the force applied go so far as to dislocate the joint, the ligamentum teres must first give way. Treatment.—The ball of the femur is too low down, and too near the mesial plane. It may be reduced in one or other of the four following ways. Fig. 80. 1st. The patient is laid on a table on his uninjured side. The pelvis is fixed by a belt placed round it, and secured to the table. Extension is made by another belt placed under the thigh, the edge of which touches the perineum, and pulleys are attached directly above the patient. It is necessary for the surgeon to press down the ankle of the affected side. 18 274 DISLOCATIONS OF THE HIP JOINT. Fig. 81. 2d. Place the patient on his back. Counter-extension is made by a belt or girth, placed round the pelvis, the concavity of the belt being in contact with the injured side, and secured to a staple or some resist- ing object. The extending force is directed upwards and outwards. After extension has been continued for some time, the surgeon should pass his hand behind the ankle of the sound limb, and grasping the other ankle, should draw it inwards, towards or beyond the mesial plane of the patient's body. While this is being done, the belt in the perineum acts as a fulcrum, the femur as a lever, and the hand as the power; and by bringing the under part of the femur inwards, and a little back- wards, the ball is sent upwards and outwards. This is Sir Astley Cooper's method. (See Fig. 80.) 3d. Mr. Hey, of Leeds, reduced this dislocation in the following manner. He desired the patient to sit upon the front of the bed, astride of the bed-post, and to grasp it; he then fixed two towels to the injured limb, and two assistants made exten- sion. While the extension was con- tinued, he crossed the injured thigh over the sound one, and at the same time rotated the limb. 4th. Mr. Hey, in another case, flexed the thigh to such an extent as to form an acute angle with the trunk, and then by a rotatory motion of the thigh effected reduction. IV. DISLOCATION FORWARDS UPON THE PUBES. Symptoms.—The limb is shortened) usually to the extent of an inch- The knee and foot are turned out- wards, and the knee is drawn for- wards and away from the other. The limb cannot be moved at all by the voluntary efforts of the patient, and but very slightly by the surgeon; nor can it be rotated inwards, al- though it may be pressed a little forwards and backwards. The head of the thigh-bone may be distinctly felt in the groin, giving rise to an unusual protuberance. The round- ness of the hip is lost in consequence of the trochanter major being drawn too near the mesial line, and the space between the trochanter DISLOCATIONS OF THE HIP JOINT. 275 major and the anterior superior spinous process is diminished. There is frequently numbness or pain, from pressure on the anterior crural nerve. From these symptoms, compared with what has been stated as to the symptoms in fracture of the neck of the thighbone, the diagnosis may be easily made out. State of the Parts.—The ball of the femur rests on the anterior part of the pubes, with the trochanter directed backwards. The ball is on the horizontal part of the pubes, superior to the obturator foramen. In some cases it is sent up so high as to be hooked into the pelvis. The capsular and round ligaments must be ruptured, and the accessory may be injured. In a dissection mentioned by Sir Astley Cooper, the head and neck of the femur were driven under the psoas magnus and iliacus internus muscles, which, together with the anterior crural nerve, were thus put much upon the stretch on their way downwards. In a practical point of view, it is of great importance to remember that the trochanter Fig. 82. is directed backwards, and the ball forwards,—this being the very reverse of the position of these parts in the dislocations upwards and backwards. Treatment.—The knee should be pressed a little downwards. The counter-extension should be made over the trunk of the patient, and the extension in a line with it, so as to draw the thigh downwards and backwards. While extension and counter-extension are being employed a towel should be placed under the upper part of the thigh, and an assistant should lift up the head of the bone over the pubes and the edge of the acetabulum, the surgeon at the same time endeavouring to send the ball backwards by effecting rotation inwards of the thigh. ANOMALOUS DISLOCATIONS OF THE HIP JOINT. The following anomalous dislocations are recorded :— 1. Dislocation upwards, with the ball below the anterior superior spinous process of the ilium, the neck against the ridge between the anterior superior and anterior inferior spinous processes, and the tro- chanter directed backwards. An instance of this dislocation occurred 276 DISLOCATIONS OF THE HIP JOINT. in the experience of Mr. Gibson of New Lanark, and was successfully treated by him and Dr. Cummins. The symptoms were the following:—the limb was shortened fully three inches, and so fixed that it could not be lengthened in any degree; the limb and toes were everted, rotation inwards was impossible, and any attempt to effect it caused great pain ; adduction and abduction were exceedingly painful and difficult, but very limited flexion could be performed with less pain. There was a tumour under the anterior superior spinous process, obedient to the motions communicated to the thigh, the trochanter major could not be felt, and the hip was flattened. The position of the bone was believed to be that which is here described; and, for the accomplishment of reduction, nausea was induced by means of tartar emetic; and then, while counter-extension and extension were being made by means of pulleys, Mr. Gibson raised the thigh-bone, by means of a round towel placed under the thigh and over his own shoul- ders, at the. same time pressing the knee towards the opposite thigh, and forcibly rotating it inward. 2. Dislocation upwards, with the ball between the anterior inferior spinous process and the junction of the ilium and pubes, the trochanter being directed backwards. A case of this dislocation is recorded by Mr. Morgan in Guy's Hos- pital Reports. The following were the symptoms:—shortening of the limb to the extent of twTo inches, extreme eversion of the foot, and a tendency on the part of the injured limb, when left to itself, to cross the sound one, the heel of the former resting on the instep of the latter. The ball of the bone could be discovered under Poupart's ligament; the trochanter could not be felt; and the limb could be moved to a certain extent in any direction except rotation. The bone wras believed to be in the position above described. Mr. Morgan accomplished reduction by counter-extension and extension with- out pulleys, employing at the same time forcible rotation inwards of the limb. In order to obtain a greater power in effecting rotation, Mr. Morgan bent the leg at a right angle to the thigh, and rotated the thigh by holding the knee with one hand, and the foot with the other. 3. Dislocation downwards on the tuberosity of the ischium with ever- sion of the foot. Mr. Keate was called to attend a gentleman wrho had suffered this dislocation by his horse falling backwards upon him into a narrow ditch, in which position he remained for some time, with his heels directed upwards and the horse's back next to his thigh. The limb was elongated more than three inches ; the leg was bent on the thigh, and the thigh bent on the pelvis ; the thigh was carried very far away from the other, the knee and foot were much everted, and the tro- chanter exceedingly depressed. The ball of the bone was on a level with the tuberosity of the ischium, and it was believed that it had been brought into this situation by the struggling to get released from under the animal, after it had first been dislocated in front of the foramen ovale. In short, it was supposed that it had been first sent in front of the foramen ovale, and afterwards from thence to the tuberosity of the DISLOCATIONS OF THE KNEE JOINT. 277 ischium ; and, therefore, in accomplishing reduction it was first brought from the tuberosity of the ischium to the front of the foramen ovale, and afterwards from thence to the acetabulum. 4. Dislocation of the ball on the tuberosity of the ischium, with shortening of the limb, and violent inversion of the foot. A maniac became the subject of this dislocation, in consequence of leaping from a window in a third story. In falling, his thigh struck against the railing, and was violently driven upwards. He died in about an hour, and as he was evidently sinking from other injuries, the dislocation was not reduced. The limb was shortened and inverted; the thigh was bent and immovable, crossing the pubes obliquely to the opposite side. On dissection, the head of the femur was found to be above the quadratus femoris muscle, and opposite to the upper part of the tuberosity of the ischium. The ramus of the ischium and the ilio- pubic symphysis were fractured, in consequence of which the injury cannot strictly be considered a simple case of a new anomalous dislo- cation. The ball of the femur has been found in some other situations than those mentioned above ; but so far as my reading extends, in almost all such recorded cases, other injuries, such as fractures, have accompanied the displacement, so that these cases cannot properly be considered as examples of new dislocations, but rather as showing how the combina- tion of other injuries with dislocation may affect the position of the bone. DISLOCATIONS OF THE PATELLA. The patella is liable to three dislocations, two of them common, and the third, of which there are some varieties, extremely rare, and difficult of reduction. The common dislocations are inwards and outwards, the latter being much the more frequent. They may be complete or partial. In the third dislocation, the bone undergoes a semi-revolution on its long axis, so that only one of its edges is in contact with the femur. Each lateral dislocation may be the consequence of direct violence, but the dislocation outwards is often occasioned by muscular contraction. See causes of dislocations in the section on Dislocations in general. Symptoms.—The knee is immovable to both the patient and the sur- geon ; there is an unnatural depression in front of the joint, and an un- usual swelling on the inner or outer side of the femur, according to the direction of the dislocation. Treatment.—Reduction if effected by raising the trunk to the erect posture, elevating the leg so as to relax the rectus and triceps muscles, and then pressing the patella inwards or outwards according to the nature of the injury. Dislocation outwards has sometimes been reduced by elevating the limb and producing forcible flexion of the knee-joint. The dislocation in which the patella makes a semi-revolution on its own axis, so as_ to have one of its margins in contact with the femur and the other with the integument, is so very rare that, as far as I know, there are only three cases recorded. One case, that of a private of the 2d Life Guards, was successfully 278 DISLOCATIONS OF THE KNEE JOINT. treated by Mr. Mayo and Mr. Broughton. The injury was caused by a stroke on the right knee from the knee of another soldier, as the two opposite lines rode through each other. One edge of the patella rested on the outer surface of the external condyle, the other was directed out- wards, and the fore part of the patella was directed forwards and in- wards. Various methods were tried without success to effect reduction, which was at length accomplished by suddenly bending the knee so as to carry the heel back to the hip, when the patella returned to its proper situation. In this case, one edge of the bone was in contact with the outer part of the external condyle; but in each of the other two cases, the one edge was in contact with the trochanter of the femur, and the other directed forwards. Of these two cases, one occurred in the experience of Mr. Welling, surgeon, at Hastings, and in that instance the integu- ments were very much elevated in front of the joint by one edge of the bone, the other edge resting against the femur. Replacement was effected by pressing the edges in opposite directions while the leg was extended. The other case is published in a German journal, " Rust's Magazin," and is quoted in the " London Medical Gazette." The accident hap- pened to a young hussar, who was riding without -stirrups, and was occasioned, as in the case first mentioned, by the knee having been for- cibly struck by a soldier in the opposite rank. The patella was half turned on its axis, so as to have one edge directed backwards and rest- ing on the outer edge of the trochlea of the femur, while the other edge projected directly forwards ; the posterior surface was directed outwards, and the anterior inwards. The surgeon, finding it impossible by any force to restore the patella to its proper situation, had recourse to the expedient of cutting through the quadriceps tendon, where it is attached to the patella, but not even then could he effect replacement. Unhappily the incision extended into the joint, and was followed by suppuration, in consequence of which the patient died about eleven months after the accident. DISLOCATIONS OF THE TIBIA FROM THE FEMUR. The tibia may be dislocated in four directions,—inwards, outwards, backwards, or forwards. The last two are complete ; the other two, or lateral dislocations, are partial. THE LATERAL DISLOCATIONS. The two lateral dislocations are easily distinguished by the appear- ance of the deformity, and the immovable condition of the joint. They are reduced by extension and counter-extension, and by pressing the tibia inwards or outwards, according to the direction of the dislocation. The external condyle of the femur, in the dislocation outwards, rests on the internal condyle of the tibia; in the dislocation inwards, the internal condyle of the femur rests on the external condyle of the tibia. In both dislocations the tibia is a little twisted. DISLOCATIONS OF THE ANKLE JOINT. 279 DISLOCATION FORWARDS. Symptoms.—The symptoms of this dislocation,—are a great swell- ing in the popliteal region, caused by the under extremity of the femur, and another in front of the femur, caused by the tibia, patella, and fibula being driven upwards and forwards upon it; a shortening of the leg, to an extent varying according to the distance that the tibia is sent up upon the femur; a very slight flexion of the leg upon the thigh, so as to form a very obtuse angle; and the extremely unnatural appearance caused by the deformity. In some cases, the pain has been very severe, and from the pressure of the femur against the popliteal artery, the pulsation of the anterior tibial artery has been found in some examples to be interrupted, in others the condition of the vessel has not been observed. Reduction.—Reduction is easily accomplished by counter-extension applied to the thigh, and extension to the leg, in the direction of the long axis of the displaced tibia; and while these are being employed by assistants, the surgeon, placing one hand on the popliteal space against the extremity of the femur, and the other in front of the joint against the tibia, presses in opposite directions so as to send the femur upwards and forwards, and the tibia downwards and backwards. After reduc- tion, the limb should be laid straight, and precautions taken to prevent inflammation. If, notwithstanding these precautions, inflammation should occur, active remedies must at once be employed to subdue it. DISLOCATION BACKWARDS. Symptoms.—A shortened state of the limb, the leg bent very much forward, a swelling in the popliteal space caused by the tibia, another in front, caused by the femur, and a great depression below it, in the situation of the ligamentum patellae, are the symptoms of this disloca- tion. Reduction.—The method of reduction is the same as in the last dis- location, except that the surgeon should press the extremity of the femur upwards and backwards, and the head of the tibia downwards and forwards, while extension and counter-extension are being made. DISLOCATIONS OF THE ANKLE JOINT. The ankle joint, which is formed by three bones, the tibia, fibula, and astragalus, and strengthened by five ligaments, the two tibio-tarsal and the three peroneo-tarsal, is liable to five dislocations. The tibia may be displaced from the astragalus, inwards, outwards, completely for- wards, partially forwards, and backwards. DISLOCATION OF THE TIBIA INWARDS. Symptoms.—This dislocation may be readily distinguished by the great projection of the malleolus externus against the common integu- ment, by the foot being turned outwards, by its inner edge being directed downwards, and by the depression about two or three inches above the malleolus externus, where crepitus may be easily detected. The pain is very great, and the swelling considerable; the foot can be moved by 280 DISLOCATIONS OF THE ANKLE JOINT. the surgeon without difficulty, and when the patient is in the erect atti- tude, the inner edge only can be applied to the ground. Fig. 83. State of the Parts.—The tibia is drawn inwards, and before it can be brought into this position the tibio-tarsal ligaments must be ruptured, and the fibula fractured. This fracture takes place about two or three inches above the joint, and furnishes an explanation of some of the symptoms above mentioned. The under part of the fibula remains at- tached to the tarsus by the peroneo-tarsal ligaments which are entire. Besides fracture of the fibula Fls- 84> and rupture of the tibio-tarsal ligaments—conditions which always exist in this accident, there is often oblique fracture of the tibia, directed so as to break off from the shaft of the bone that part of the tibia which enters into the forma- tion of the inferior tibio-fibular articulation. The fragment thus broken off remains con- nected with the malleolus ex- ternus, while the tibia, entire along the whole of its inner aspect, is carried inwards along with the part of the fibula above the fracture. DISLOCATIONS OF THE ANKLE JOINT. 281 Treatment.—For accomplishing reduction, the surgeon should direct the patient to be placed upon his back, with the thigh raised perpen- dicularly, and the leg bent back so as to make a right angle with the thigh. In this position the gastrocnemius muscle will be relaxed, and the extremity will be conveniently placed for applying the necessary extension and counter-extension. Surgeons have sometimes experienced difficulty in accomplishing reduction, from attempting it when the limb is extended, and the gastrocnemius thereby put upon the stretch. One assistant should afford the necessary counter-extension by holding the thigh, and another the necessary extension, by drawing the foot in a line with the long axis of the leg, preserving the foot, at the same time, midway between flexion and extension of the ankle joint, while the surgeon endeavours to press the tibia outwards, so as to bring it into contact with the upper surface of the astragalus. After reduction, the limb should be placed upon the posterior part, with the leg a little bent on the thigh, and the foot midway between flexion and extension,—a position which will be favourable to the uniform relaxation of the muscles. Until the fibula becomes entire, and the tibio-tarsal ligaments unite, appliances must be used for preventing the foot from being drawn outwards ; for which purpose, two splints, each having a foot-piece, may be employed, or one splint without a foot-piece, applied to the inner, and one, with a foot-piece, applied to the outer side, to compensate for the want of resistance naturally offered by the fibula to the foot being drawn outwards. The most suitable means for keeping the splints in their proper position are loop or buckle-bandages. Some cotton-wool should be used to prevent the splints from pressing unpleasantly against the limb and foot. A point of the very greatest importance is to apply the splints so very loosely at first, as to make it impossible for them to prove injurious by producing pressure upon the affected parts, which often swell to a very considerable extent, in consequence of inflamma- tion supervening. After what has been stated regarding the different varieties of apparatus for retaining the foot in its proper position in fractures, it is unnecessary here to refer to other appliances for the treatment of lateral dislocations of the ankle; for a description of them, and their mode of operation, I beg to refer to the section on Fractures of the leg. DISLOCATION OF THE TIBIA OUTWARDS. Symptoms.—The malleolus externus projects against the common integument, forming a remarkable swelling in that situation, the foot is turned inwards and its outer edge rests upon the ground. State of the Parts.—The tibia cannot be sent to the outer side of the astragalus, the position which it occupies in this dislocation, without the malleolus internus being fractured. The dissevered malleolus remains attached to the tarsus by the tibio-tarsal ligaments. The fibula is sent outwards from the tarsus, and the peroneo-tarsal ligaments are usually ruptured ; sometimes they are entire, but in that case the fibula is frac- tured above the malleolus, and the under part of the fragment remains at- tached to the tarsus, while the upper part of the same fragment is bent 282 DISLOCATIONS OF THE ANKLE JOINT. Fig. 8" outwards. The condition of the parts, therefore, may be stated to be,—that the malleolus internus is broken off from the tibia, and remains attached to the tarsus by the tibio-tarsal ligaments, and the peroneo-tarsal ligaments are ruptured; or, the two malleoli are fractured, and the peroneo- tarsal ligaments are entire. That such are the conditions in this dislocation I am fully satisfied. Treatment.—The method of reduction differs from that in the former dislocation only in this respect, that the surgeon presses the bones inwards instead of out- wards. After reduction, the at- titude and the treatment are precisely the same, except that if one splint only have a foot-piece, it must be applied to the inner instead of the outer side ; because the object of the foot-piece is to preserve the foot in its proper position, and in this dislocation the foot has a tendency to be drawn inwards. This dislocation may also be very conveniently treated by the different appliances mentioned in the description of the treatment of fractures of the leg. In the two lateral dislocations, if Dupuytren's splint be used, it must always be fixed to the side opposite to that towards which the foot is in danger of being drawn ; because, in this case, it is not the splint that prevents displacement, but the bandage, which fixes the foot to the splint. DISLOCATIONS FORWARDS. These, as has been already stated, are two, the complete, and the partial. Symptoms.—The heel is lengthened, fixed, and drawn upwards, the part of the foot before the leg is proportionally shortened, and the toes are depressed. These symptoms in the two dislocations differ merely as to their extent. In the complete dislocation, there is an evident de- pression in front of the tendo Achillis, and the foot is even more rigidly fixed than in the partial dislocation. State of the Parts.—In the complete dislocation, the fibula is frac- tured, and the fragment remains attached to the tarsus by the peroneo- tarsal ligaments, the tibio-tarsal ligaments are ruptured, and the tibia rests on the os naviculare, and the os cuneiforme internum. In the partial dislocation, also, the fibula has been found fractured, the tibio- DISLOCATIONS OF THE ANKLE JOINT. 283 tarsal ligaments ruptured, and the tibia resting partly on the astragalus, and partly on the os naviculare. Treatment.—Reduction is accomplished as in the lateral dislocations, except that the bones of the leg should be pressed backwards while extension and counter-extension are being made, and the extension applied to the foot should be directed so as to bring the astragalus in a line with the long axis of the leg. The limb should be placed in the same attitude as in the former dislocations, and by bandaging the leg and foot to two splints with foot-pieces, it is possible to keep the bones of the leg from slipping forwards; but by far the most efficient and convenient retentive apparatus for the treatment of this injury is Ames- bury's double-inclined plane. By means of it the bones of the leg can easily be kept from sliding forwards, until the fractured portions of the tibia unite, and the ruptured ligaments are restored. DISLOCATION OF THE TIBIA BACKWARDS. This is an extremely rare injury. I once had an opportunity of see- ing an example of it in a girl fourteen years of age. When I saw the patient, about two years had elapsed since the occurrence of the disloca- tion, and no attempt had been made meanwhile, to accomplish reduction; the surgeon who first saw the case after the injury, not understanding the nature of it. The symptoms were,—great lengthening of the foot before the two malleoli; the heel and back of the leg were in a line with each other, so that there was no projection whatever of the foot behind the leg; the malleoli did not appear to have been fractured, but were equally driven backwards, so as to bear their natural relations to each other; and the foot did not present any twisted appearance. When the girl was raised to the erect attitude, and when she pressed with any weight upon the foot, its anterior extremity bent upwards, in conse- quence of which she was unable to use the foot in walking. In this case, the tibio-tarsal and peroneo-tarsal ligaments must have been rup- tured ; the malleoli appeared to be free from fracture, and the tibia rested upon the upper part of the calcaneum. Treatment.—For accomplishing reduction in a recent case, the pa- tient should be placed in the same attitude as in the reduction of the former dislocations; counter-extension should be applied to the thigh by one assistant, and extension to the foot by another; and while the foot is being drawn in a line with the long axis of the leg, it ought, at the same time, to be carried backwards, so as to bring the astragalus underneath the tibia. While counter-extension and extension are being made, the surgeon should endeavour to press the tibia forwards. Ames- bury's double-inclined plane, with a large pad placed between the splint and the back of the leg, immediately above the heel, will be found the most convenient retentive apparatus. COMPOUND OR OPEN DISLOCATION OF THE ANKLE JOINT. Together with displacement of the bones of the leg in any of the di- rections above referred to, there may also be a wound of the soft parts, laying open the cavity of the joint, constituting what is called a com- pound or open dislocation. The cause of the wound may be the protru- sion of the bones through the soft parts, or the tearing of the soft parts 284 DISLOCATIONS OF THE ANKLE JOINT. by some hard body, against which the limb may have been pressed. The former is the more frequent cause, but in whatever way produced, this injury is always of a very serious character. Inflammation of the synovial membrane, and irritative fever, are the consequences of this condition ; and extensive suppuration, destruction of the cartilages, and gangrene of the soft tissues are the local results principally to be dreaded from that inflammation. These open dislocations were at one time con- sidered to be so dangerous, that immediate amputation was deemed not merely expedient, but absolutely necessary to save the life of the pa- tient. But in so many cases, even with serious complications, the limb has been saved, and the treatment been successful, that no surgeon of the present day would think of amputating on account of a dislocation being compound, unless it were attended by other unfavourable compli- cations. In the greater number of cases, the practice to be followed is, to reduce the dislocation, bring the edges of the wound together, and treat the case as the common rules of surgery indicate. There are, however, certain conditions which render amputation ad- visable and necessary, the principal of which are:—an extremely shat- tered conditioruof the bones; a very extensively lacerated wound; severe and extensive contusion of soft parts about the joint, so as to make it probable that sloughing will take place; division of the larger blood- vessels, together with an extensive wound ; a very irritable or debilitated constitution ; or the advanced age of the patient. Such are the chief circumstances which render it judicious for the surgeon to recommend immediate amputation, rather than endanger the life of the patient by attempting to save the limb. When amputation is deemed necessary, the proper period for its performance is before the occurrence of irrita- tive fever: if that period be allowed to pass by, another may not occur in which the operation could with propriety be performed. The above conditions in many instances justify immediate amputation. Sometimes, when attempts have been made to avoid amputation in the first instance, it has been ultimately rendered indispensable by extensive suppuration, or by destruction of portions of the bones keeping up constant irritation in the system, or by gangrene of the foot. When this last condition occurs, it is exceedingly desirable to have the limits of the gangrene fixed before the operation be attempted; although it has been ascer- tained, that it is not so absolutely indispensable to have limits set in gangrene arising from destruction of vessels in a healthy person, as in gangrene arising from a constitutional cause. I shall conclude the subject of compound dislocation of the ankle joint with the following quotation from the work of Sir Astley Cooper. " Persons who are much loaded with adeps are generally- very irri- table, and bear important accidents very ill; indeed they frequently perish, whatever plan of treatment is pursued : to this statement, how- ever, there are exceptions in those who, though corpulent, are still in the habit of taking much exercise, as they will retain some vigour of constitution; and in such persons the limb may be attempted to be saved as in the case described by Mr. Abbot, surgeon, at Needham Market; but in those who have become extremely fat, and who have been addicted to habits of indolence, there is but little chance of pre- serving life but by amputation." 285 CHAPTER VIII. AFFECTIONS OF THE OSSEOUS SYSTEM. PERIOSTITIS. Sir Philip Crampton, of Dublin, who first gave this name to in- flammation of the periosteum, has the merit of being the first person who gave a description of that form of the disease which proceeds from cold or external injury, and is called Idiopathic, to distinguish it from the symptomatic form, which is the effect of scrofula, syphilis, or the injudicious use of mercury. Professor Graves, of Dublin, in his excel- lent Clinical Lectures, divides this disease into two forms,—the diffused and the circumscribed, the former corresponding with the idiopathic, the latter with the symptomatic of Sir Philip Crampton. Periostitis may be either acute or chronic. When it occurs in a person of sound constitution, and is occasioned by cold or external injury, it is usually acute; when it is of the symptomatic or circum- scribed form, it is generally chronic; and when it is excited by external causes in a person predisposed to the disease by scrofula, syphilis, or the too free use of mercury, it often exhibits both the acute and the chronic form. Causes. — The causes of periostitis may be divided into exciting, and predisposing. Of idiopathic periostitis the exciting causes are atmospheric influence, and mechanical injury ; the predisposing causes, a feeble, debilitated state of body, induced by mental anxiety, or long-continued derangement of the digestive apparatus. Of symp- tomatic periostitis, the exciting causes,—although this form of the disease sometimes occurs without any known exciting cause,—are the same as those of the idiopathic form. The predisposing causes are scrofula, syphilis, or an irritable condition of the constitution caused by the prejudicial use of mercury. If in any unfortunate person, the sub- ject of an attack of periostitis, "the triumvirate of scrofula, syphilis, and mercury," as an excellent writer has expressed himself, should chance to meet, the symptomatic form will be, in all probability, of the very worst kind. The causes may be, therefore termed the external or exciting, and the internal or predisposing. Periostitis is most common to. bones situated near the surface of the body, as the cranium, clavicle, sternum, and tibia: the pericranium over the frontal bone, on account of its exposed situation, is frequently the subject of the disease; sometimes also the periosteum of the humerus is attacked by it, and occasionally that of the femur. 286 diseases of the periosteum. Symptoms.—The symptoms in some degree differ according as the disease is of the acute or chronic form. We shall, however, consider the symptoms of both forms together, noticing the differences as we proceed. Deep-seated pain is one of the earliest and most urgent symptoms. It is severe on account of the unyielding nature of the tissue affected, and is of a girding nature, and in some conditions attended with throb- bing. In acute periostitis it is constant, and, like the pain caused by inflammations of the most hard tissues, is characterized by remissions and periodical exacerbations; the exacerbations occurring during the night, when the pain is often most excruciating. In the chronic form, the pain is so much diminished during the day, as to be intermittent; but the nocturnal exacerbations are particularly distressing. Together with pain, there is extreme tenderness on pressure, some- times amounting even to intolerance of touch. This symptom is much greater in periostitis than in ostitis. Swelling is, comparatively speaking, an early symptom, and is also subject to variety during the different stages of the disease. In the first stage, the swelling is of an elastic, tense, doughy feeling, depen- dent on the swollen condition of the periosteum itself; it may afterwards become oedematous, from effusion into the cellular tissue external to the periosteum, but there is always the elastic feeling underneath this oedema. The ultimate character, however, of the swelling will vary, both as to hardness and extent, according as the periostitis is acute or chronic. The varieties and conditions on which they depend, will be understood from the description of the state of the parts given in another page. Often in the very chronic form, the swelling, at first elastic, ultimately becomes quite hard; but it is only in this form, and after long continuance of it, that we find on pressing it firmly with the fingers, that rigid, incompressible hardness which characterizes swelling of the bone itself. The skin is at first pale, and not involved in the disease; but if the disease be acute, the swelling, sooner or later, becomes diffused, and the skin red, tense, tender, and glistening. Constitutional Symptoms.—Periostitis is accompanied with evident constitutional symptoms. In the acute form they are the same as those of inflammatory fever, but of a more aggravated character, and attended with great derangement of the digestive apparatus. In the chronic form the patient becomes pallid, weak, relaxed, and emaciated, from continued irritation and want of sleep, and exhibits the symptoms of hectic fever. In short, the accompanying fever is of the inflammatory type in acute, and ere long becomes of the hectic type in chronic periostitis. There is, however, one condition of the acute form of the disease, in which the inflammatory fever which attends the very commencement, is speedily converted into hectic fever; namely, when suppuration takes place to a great extent. State of the Parts.—One of the earliest pathological changes is in- creased vascularity of the periosteum. In the acute form the periosteum is thickened and softened, while in the chronic it is thickened, and its density increased. Sometimes it is thickened without effusion under it, and then there may be increased adhesion of the periosteum to the DISEASES OF THE PERIOSTEUM. 287 bone, with increased vascularity of the bone; and this, if not relieved, may, after considerable suffering and derangement of the general health, terminate in the conversion of the periosteum into a fibro-cartilaginous substance. This is usually attended at last with some swelling of the bone itself. If there be no subsidence of the inflammation in periostitis, effusion may take place both inside and outside the periosteum ; effusion of serous fluid into the surrounding cellular tissue giving rise to oedema, and secretion of fibrin taking place underneath the periosteum between it and the bone. The secretion of fibrin under the periosteum is more likely to take place in the chronic form, and is termed by some the ge- latinous effusion. "The bone," Mr. Liston observes, "is imbedded in a gelatinous or lymphatic effusion situated mostly beneath the perios- teum." Inflammatory or recent node is the name distinguishing this raised condition of the periosteum caused by the effusion of lymph; and if the inflammation does not go on to a more acute stage, the effusion may be converted into cartilage, and then into bone, forming permanent node. Other products of inflammation may be formed in the acute variety : if the inflammation be great, purulent matter may be formed between the periosteum and the bone, causing separation of the perios- teum. Sometimes the separation is extensive, and necrosis of the bone from inflammation, and from the loss of its nutritive membrane, may be the result. It is when the suppuration is extensive and takes place very speedily, that the inflammatory fever which attends the very be- ginning of the disease may be so quickly converted into the hectic type. There is a form of periostitis termed by some paronychia periostei, or the deep-seated paronychia, or whitlow, and by others the paronychia maligna. This is an example of severe acute periostitis, and affects the phalanges of the fingers and their periosteum. In this variety the pain of the finger is excessive ; it feels as if it would burst; there is great oedema and swelling of the hand, and often the whole finger appears as if affected with erysipelatous inflammation. Suppuration to a conside- rable extent, sloughing of the soft parts, and destruction of some of the bones are sometimes consequences of this form of periostitis. Treatment.—The mode of treatment differs in the acute and chronic forms. In the acute form, the constitutional treatment consists of low diet, general depletion, saline purgatives, diaphoretic medicines, and such means as are capable of procuring resolution. The local treatment in- cludes quiet, an attitude favourable to the reflux of the venous blood, leeches, warm and emollient applications, as fomentations, poultices, and other antiphlogistic means. Free division of the periosteum should be employed, according to some, only when other treatment has failed. Professor Miller objects to free direct division if suppuration be not present, and recommends a valvular division of the inflamed periosteum. Professor Syme says, " The mode of treatment depends upon the inten- sity of the symptoms. When they are very violent and attended with smart fever, the most effectual practice is to make a free incision through the inflamed parts down to the bone. When less severe, no benefit is derived from this proceeding." "Free incisions," says Mr. Liston, "through the periosteum some- 288 DISEASES OF THE PERIOSTEUM. times relieve the pain, and cut short the disease, the distended vessels being thereby emptied ; but such practice is only a last resource, when the action has resisted all other means and threatens an unfavourable termination." If, in the acute form, the inflammation proceeds to sup- puration, free division is the more necessary. But whether suppuration be present or not, the distended vessels ought to be relieved by early free direct incision, if other treatment prove unsuccessful. In the chronic form, the constitutional treatment consists in the ex- hibition of internal alterative remedies, as hydriodate of potass, which, to prove efficacious, must be administered in pretty large quantities, say of about ten grains in divided doses during the day. It may be given in water, or combined with sarsaparilla, which is itself an excellent alterative. Some authors deprecate the employment of powerful alte- ratives, unless all others have failed. Mercurial alteratives are found exceedingly useful in relieving chronic periostitis, and should be tried, if the body be not exceedingly irritable, and if the above treatment have not had the desired effect. It seems strange that mercury, a pre- disposing cause of periostitis, should prove a remedy ; yet that it does so, is an ascertained fact. Bichloride of mercury answers well, and may be given in doses of a tenth of a grain twice or thrice a day, either made into a pill, or in solution in sarsaparilla. " General chronic periostitis, which is produced by exposure to cold, or occurs often during mercurial courses, and is often supposed to be a symptom of syphilis, is relieved by the internal exhibition of bichloride of mercury, or other mercurial preparations, combined with sarsaparilla and diaphoretics. In many instances such an affection will yield to no other treatment, and thus the practitioner is occasionally obliged to have recourse to a somewhat paradoxical practice, that of giving mercury for a disease which seems to have been produced by that mineral." The foregoing passage is borrowed from Mr. Liston's "Elements of Surgery." Upon this point Mr. Lawrence remarks ;—" I have seen, in so many instances, the pain in that disease continue unrelieved, in spite of the pretty active employment of local antiphlogistic means, in spite of mild mercurial treatment, and have so constantly found it yield only to the full in- fluence of mercury on the system, that I own myself to be at a conside- rable loss to account for the opinion entertained by many, that inflam- mation of the periosteum and affections of the bone are actually brought on by the use of mercury. It seems to me to be very inconsistent that one and the same medicine should be capable of decidedly relieving in- flammation of a certain texture, and that when employed for other pur- poses it should actually produce inflammation of that very texture. I think I formerly had occasion to mention that I did not coincide with the opinion of many, that those states were produced by the mercury, and certainly, when speaking of inflammation of the periosteum, whether arising from syphilis or not, I do not know of any means so capable of relieving the disorder as mercury. Local Treatment comprises the use of some of the different forms of counter-irritants. Blisters are sometimes very useful; and in some cases the local application of an alterative, as mercurial ointment rubbed DISEASES OF THE PERIOSTEUM. 289 into the part, or painting it frequently with tincture of iodine, may be found beneficial. NEURALGIA PERIOSTEI. This very* painful affection sometimes follows amputations, or slight injuries of a bone; sometimes it affects the periosteum of the ribs and sternum in cases of spinal irritation or uterine derangement, when a morbid sensibility in the sentient extremities of nerves is by no means an unusual condition; and sometimes it comes on without any known exciting cause. The disease generally affects females of weak constitu- tion, though males of an irritable habit are also subject to it. I have met with many examples of this affection in females of a hysterical habit, and two instances of it I have seen in males, one of the periosteum of the ribs in a young man who died of phthisis, and the other of the peri- osteum of the humerus in a gentleman who never had any complaint beyond derangement of the digestive apparatus, and neuralgic pains about the face. Symptoms.—One of the earliest and most urgent symptoms is severe pain, of a sharp neuralgic kind, sometimes so severe as to deprive the patient of sleep; and like all neuralgic pains, intermitting, and often periodically recurring. Extreme tenderness on pressure is often a symptom, and in some cases the nervous sensibility is so much exalted that the slightest touch is painful. Sometimes, but not always, this tenderness to touch extends to the common integument. In the ex- ample of the affection which I met with in the periosteum covering the ribs, the integuments could be pinched up, and pressure directed against the intercostal spaces without causing any uneasiness ; but the slightest pressure directed against the ribs occasioned great pain. Mr. Thomas Spencer Wells, in an excellent article on diseases of the bones, in the " Cyclopaedia of Practical Surgery," states, that he met with two ex- amples of this affection of the periosteum covering the ribs in two young men who had fallen into phthisis after syphilis and the too free use of mercury; and in both these instances the pain on pressure was entirely confined to the periosteum. The only opportunity I have had of ex- amining the periosteum after death, was in the case of phthisis above referred to. There was not the slightest trace of inflammation, nor any apparent change whatever in either the periosteum or the bone; and though there have been many cases, in which persons who had suffered from this affection, have been examined after death arising from other causes, without the surgeon having been able to detect any trace of vascular hypersemia. The conclusion drawn from hence is, that neu- ralgia periostei depends upon a painful exaltation of the function of the sentient nerves of the periosteum. Treatment.—This disease must be combatted by general and local treatment. The object aimed at by general treatment is to give in- creased tone and strength to the system, and the means to be used for this purpose must be suited to the particular state of the patient. Ex- ercise and free exposure in the open air, a generous diet, and the due regulation of the bowels, together with tonics, such as preparations of iron, and more particularly the carbonate and the saccharated carbonate 290 OSTITIS. of iron, are prescribed with advantage when the patient is not suffering from any other disease, and when no symptoms appear indicating that their employment would be prejudicial. As local applications, different anodyne liniments, and plasters containing opium or belladonna, or both, are useful. I have often prescribed, apparently with advantage, a lini- ment of equal parts of the tincture of belladonna, and the tincture of opium, to be kept constantly over the part; and I have seen plasters containing large quantities of belladonna or opium, or both, very ser- viceable ; liniments and plasters containing aconite, are also very useful. The above are the only local applications of which I have had any ex- perience, with the exception of the endermoid application of nitrate of silver, which I have known to prove exceedingly useful. OSTITIS. Ostitis is the name given to inflammation of bone. It may arise from cold, external injury, periostitis, or neglected or improperly treated phlegmonous erysipelas:—in the latter case, the inflammation spreads from the soft parts to the periosteum and bone, so that they become secondarily affected. It is also often induced by inflammation of the synovial membrane at the extremity of a bone. These may be called the external and exciting causes; and when they induce the disease in a person of sound constitution, it is then said to be simple ostitis; but when the constitution of the patient has been previously affected by scrofula, syphilis, or mercury, wdiich are predisposing causes, the dis- eased action is then modified by the general state of the system, and the ostitis is termed specific. It is of importance to understand how far the inflammation of the specific forms can be distinguished from that of the simple by their effects, and to ascertain as far as they are known, the characteristic appearances of each. Ostitis may not only be either simple or specific, but also like other inflammations, either acute or chronic. Symptoms.—In the acute form, one of the earliest symptoms is deep- seated agonizing pain, which by the patient is referred to the bone. The pain is even more excruciating than in periostitis, and is of a burst- ing kind. It is less aggravated by pressure than periostitis, and, as in that disease, it has nocturnal exacerbations. In the acute forms there are occasional remissions of the pain, but in the chronic form there are often complete intermissions. The pain is increased by motion of the limb, and by the dependent posture. In ostitis, tenderness to the touch at first is slight; in periostitis it is the reverse, so that this symptom is diagnostic at an early stage of the disease ; but afterwards the perios- teum becomes inflamed, and then there is the same acute tenderness as when that membrane is primarily affected. Swelling is long before it makes its appearance, and when it does, it is for some time hard, solid, and diffused, afterwards it becomes oedematous from effusion into the cellular tissue, and the soft tissues over the bone at last present the ordinary local symptoms of inflammation. The constitutional symptoms are those of inflammatory fever, and their violence will depend on the intensity, extent, and duration of the disease, and the susceptibility of the constitution to sympathize with the local action. OSTITIS. 291 In the chronic form, pain is the earliest symptom. Compared, how- ever, with the pain in the acute form, it is inconsiderable; and while it has distinct exacerbations during the night, it is always marked by de- cided remissions, and often by complete intermissions during the day : —this is for a long time the only local symptom. Swelling is long be- fore making its appearance, and when it does, it is much more circum- scribed than in the acute form, and is characterized by an unyielding incompressible hardness. If the periosteum become affected, the swell- ing will at last present the character of the same symptom in chronic periostitis; but it is slower in its progress, and longer in making its appearance, than in that disease. In the early stage, pressure has little or no effect in aggravating the pain, and it is often a long time before the patient complains of tenderness when the bone is pressed. There is very little sympathetic effect produced in other parts of the system until the disease has been of long standing; and when the continuance of the nocturnal exacerbations and want of rest cause constitutional disturbance, the fever is of the hectic type. State of the Parts.—The changes produced in the osseous structure, by acute inflammation, during the period of its activity, and before reaching suppuration, whether external, internal, or general, simple or carious ulceration, or some of the different forms of necrosis, are but imperfectly known. The blood-vessels have been found more numerous and distended than natural. The bone becomes softened, apparently from absorption of part of its earthy matter, its cancellated texture appears unusually open, the lamellae are thinned, and the haversian canals become preternaturally large, as if the distended vessels pressed aside the softened structure. This last-mentioned condition sometimes gives the bone, especially on the surface, a porous appearance. Exuda- tion takes place both into the cells and into the haversian canals. Such are the principal conditions produced, in the first instance, by acute in- flammation in a bone not the subject of any previous unhealthy deposit. After some time, the following changes may take place in acute ostitis. The inflammation may result in resolution, or in one of the varieties of suppuration, which will afterwards be described; or it may lead to simple or carious ulceration, or to necrosis. If the inflammation be of a more chronic character, other changes may take place. Sometimes the bone becomes expanded or enlarged, and, at the same time, espe- cially in syphilitic patients, consolidated, and its weight increased. These changes, caused by the plastic exudation passing into bone, may either affect the entire bone, or be confined to a particular region of it which has been more especially the subject of inflammation. This osseous formation taking place upon the inner surface of the haversian canals, their cavities become more or less filled up, so that in many cases, a section of the diseased part presents a nearly uniform ivory- like texture, in which few orifices appear. Sometimes these deposits are in the cavities of the long bones, making them almost solid through- out ; and often, they are found on the surface, occasioning protuberances rendering the bone rough or uneven, and considerably altering its figure and appearance. In scrofulous subjects, the bone becomes very much lighter than natural, and is filled with a cheese-like substance. In some 292 SUPPURATION IN BONE. specimens in my collection, this substance occupies only part of a bone; in others it extends through almost the whole of a bone, occupying nearly the entire space within the shell, which is exceedingly thin, and in these instances the whole of the earthy matter is absorbed, except that which forms the very thin external shell. In other specimens, this peculiar deposit is equally extended through the whole of a bone, but seems to be diffused through the cancellated structure, which is not entirely ab- sorbed. In some of the specimens, where this substance is general through the whole of a bone, and where the shell is very thin, there are small deposits of bone, forming osseous irregularities, or spicula, on the external surface. The colour of this substance is in some cases pure white, in some, yellowish white, and in others, reddish brown. In many cases, traces of inflammation accompany this cheese-like deposit, while in others, no such traces are apparent. It may result from previous perversion of nutrition, unattended with inflammation; or it may be a transformation of the liquor sanguinis exuded in consequence of a low grade of the inflammatory process, in a person of scrofulous diathesis. The subject of such deposits will be more particularly referred to in the description of tubercle, in the chapter on Tumours. Treatment.—This may be summed up in a very few words. It is both general and local. In the acute form, the treatment is precisely the same as in periostitis, except that there is no necessity for incision. In all cases the treatment should be decided, that the inflammation may, if possible, be prevented from going on to suppuration or caries. The local and general depletion, however, must not be carried to too great an extent, as the consequent debility predisposes to caries. In the chronic form, the treatment consists locally, in the employment of the different counter-irritants; and internally, of the alterative remedies recommended in the treatment of periostitis; but it should be remem- bered that mercury, although often useful, ought to be exhibited with the greatest caution, as the interstitial absorption arising from the free use of this medicine in some forms of ostitis, increases the danger of the occurrence of caries. SUPPURATION IN BONE. Suppuration may be divided into three varieties—namely, external, internal, and general. Of external suppuration, there are two kinds, acute and chronic; each presenting a different assemblage of symptoms, and requiring dif- ferent treatment. Acute External Suppuration, or acute external abscess, is a frequent consequence of periostitis, or ostitis, or both. Symptoms.—Pain of an excruciating kind, attended with the other symptoms of ostitis, if that be ,the cause of the disease—rigors recurring at intervals, and swelling, which has a feeling of fluctuation. The integuments ultimately present the local symptoms of inflammation. Absorption, ulceration, caries, and even necrosis of the bone may be produced, if the purulent matter which burrows beneath the periosteum be not speedily evacuated. SUPPURATION IN BONE. 293 Treatment.— Before the abscess is formed, the surgeon should endea- vour to remove the inflammatory action by the usual antiphlogistic remedies; but after its formation the appropriate treatment is free, direct incision, which affords very great relief to the patient. Chronic External Suppuration, or chronic external abscess, may be the consequence of an attack of chronic inflammation, which may have commenced in the bone, or in the periosteum, or in both of these tissues. Symptoms.—These at first are the same as the symptoms of chronic periostitis, or chronic ostitis, or of both these diseases. After some time a swelling with fluctuation forms, unattended with the symptoms of acute inflammation. The swelling is generally small and circumscribed, just the reverse of what takes place in chronic abscess of the soft parts. Treatment.—The treatment proper to be first tried is the same as in small chronic abscess of the soft tissues ; accordingly all means likely to produce absorption should be employed. With this view it is neces- sary to improve the general health, and to enjoin dry and solid food, and abstinence from liquids; in addition to which, internal alterative remedies, as iodide of potassium, should be given in small quantities,— four or five grains in solution, in divided doses, during the day will often be found beneficial. The local treatment consists in the employment of various applications used to promote absorption. For this purpose it has, in many instances, been found advantageous to paint the part with the tincture of iodine, as frequently as the state of the skin will permit. A lotion of iodide of potassium, iodine, and water, of the pro- portions of 3ii of the iodide of potassium, 3i of iodine, and %'\ of water, is sometimes used in the same manner as the tincture, and with good effect. Some apply blisters, from their well-known effect of sometimes promoting absorption; others use blisters, and dress the part with mercurial ointment. If these means do not effect a cure, a small valvular incision is necessary. If, through improper treatment, the chronic is converted into an acute abscess, free direct incision must be employed. Friction sometimes changes a chronic into an acute abscess. It some- times happens in unhealthy constitutions, that, after injuries or ampu- tations, very extensive collections of pus take place under the periosteum; and in some forms of phlebitis collections of purulent matter form without being preceded by accident or amputation; sometimes they happen as sequelae of fever. They almost always prove fatal; yet, if the patient be healthy, he may recover after necrosis of the bone. INTERNAL SUPPURATION. Of this there are four varieties: namely, diffuse acute internal suppuration ; limited acute internal suppuration ; chronic internal sup- puration ; and scrofulous tubercular abscess of bone. I. DIFFUSE ACUTE INTERNAL SUPPURATION, OR DIFFUSE ACUTE INTERNAL ABSCESS. This follows as an effect of acute ostitis, of which it has the local and constitutional symptoms. If the patient do not sink under the disease, rigors and hectic fever supervene, and sooner or later there is an indis- 294 SUPPURATION IN BONE. tinct undulation or fluctuation beneath the periosteum and the super- imposed soft tissues which become involved. This disease depends upon diffuse inflammation within the bone, the matter occupying in the short bones the cancellated structure, and in the long cylindrical bones the canals, there being no tissue or sac to circumscribe it. The purulent matter destroys the cancellated structure, and some parts of the bone become very much absorbed. The canals for the transmission of vessels become enlarged, and through them and the apertures formed by the absorption of portions of the bone, the matter makes its way to the surface. Treatment.—This is at first the same as in acute ostitis, and should be as decided as the circumstances of the case will admit. As soon as fluctuation is present, recourse must be had to free direct incisions. When hectic fever supervenes, the treatment must be tonic. II. LIMITED ACUTE INTERNAL SUPPURATION, OR LIMITED ACUTE INTERNAL ABSCESS. This usually takes place in the cancellated heads of the long bones, frequently in the head of the tibia, sometimes in its shaft, and sometimes in its under extremity, in persons about or beyond the middle period of life, who are exposed to cold and night Fig. 80. Symptoms.—The principal symp- tom is most excruciating pain. This has been found in some cases to be constant, and in others to be slight, or amounting only to uneasiness during the day, but in all liable to severe nocturnal exacerbations. It is referred by the patient to a par- ticular spot, and is attended with a degree of throbbing and a sensation Fig. 87. SUPPURATION IN BONE. 295 of weight. As the disease advances, tenderness and pain are experienced when pressure is applied to the soft tissues and the part of the bone ex- ternal to the disease. After some time the skin becomes red and slightly hot, but there is no swelling. The symptoms are aggravated by motion of the limb. State of the Parts.—After the disease is fully formed, on making a section of the bone, there is observed a cavity or sac in its interior, having a distinct bony encasement. The interior of the cavity is lined with a vascular membrane, from which the exudation takes place which is transformed into pus. A lower degree of inflammation extends to the textures external to the bony encasement. In the museum of St. George's Hospital, there are several very beautiful and interesting spe- cimens of this disease. Treatment.—Sir Benjamin Brodie has the merit of having proposed the proper treatment, which consists in making a crucial incision of the soft parts, exposing the bone, and by means of a trephine sawing out a portion of it, so as to allow of the evacuation of the matter. Sir Benjamin Brodie has treated cases successfully in this way; Mr. Liston, in his "Elements of Surgery," records a very instructive case, in which the same practice was followed by the desired result; and many other cases have been treated with equal success. Figs. 88, 89, represent a Fig. 88. Fig. 89. case in which the matter made its way to the surface, by its own efforts; but, from the firm nature of the new bony encasement which surrounds the matter, this is a result which can seldom be looked for. III. CHRONIC INTERNAL SUPPURATION, OR CHRONIC INTERNAL ABSCESS. Symptoms.—These, both local and general, are the same as those of chronic ostitis although sometimes at first they indicate acute ostitis Swelling of the bone soon occurs, and if the strength of the patient holds out, so that the disease runs its course, an indistinct undulation or fluctuation depending upon the thin state of the bone, is at last per- wptible to the touch. The constitutional symptoms are ultimately 296 SUP P»U RATION IN BONE. State of the Parts.—As the name of the disease indicates, matter is formed, and it is contained in an indistinct cyst. "The result of the pressure of the abscess is to cause an absorption of the cancellated structure, and in this way the space for the increase of the abscess con- tinues to be enlarged." The matter is thin and unhealthy, and is mixed with the debris of the bone. The cancellated tissue of the bone is dilated, and the integuments over the bone become inflamed. Treatment.—This consists in free direct incision through the soft tissues and the shell of bone, which is, in consequence of disease, gene- rally divisible by a strong scalpel. After the evacuation of the matter, it is advisable to inject sulphate of zinc lotion into the interior of the bone, to employ gentle lateral compression and support, and at the same time to enjoin rest, and adopt judicious measures for supporting the general strength. IV. SCROFULOUS TUBERCULAR ABSCESS OF BONE. Symptoms.—This affection which, as the name indicates, is met with in persons of a scrofulous habit, is at first characterized by a sense of weight and uneasiness in the diseased part, not amounting to pain. This sensation is referred to a particular part, and is increased by pressure and by motion, and sometimes by the heat of bed. Enlarge- ment of the osseous tissue takes place, followed by oedematous swelling of the soft parts, and the integument presents a bluish colour. In the suppurative stage the uneasiness is changed into actual pain, and the enlargement increases more rapidly. The matter, sometimes, makes its way to the surface, in which case, a swelling with fluctuation will be perceptible. On being discharged, it presents the ordinary characters of such collections in scrofulous habits; and the cavity has no tendency to heal, but continues to throw out an offensive discharge. Such col- lections, instead of making their way to the surface, frequently open into the neighbouring articulation; and in that case there is great increase of pain, and of the other local symptoms, together with pretty decided symptoms of irritative fever, which soon change to those of the hectic type. Except when the disease opens into an articulation, it is not accompanied by any strongly-marked symptoms of inflammatory fever; but in all cases it, sooner or later, gives rise to hectic fever. State of the Parts.—The cancellated structure of the bone, especially of the heads of the bones, is filled with scrofulous, or tubercular matter. This substance first fills the cells, and by the accumulation of it, the cancellated tissue of the bone becomes absorbed, and its place occupied by the deposit. The morbid deposit may be the result of previous per- version of nutrition, or the change of liquor sanguinis exuded in conse- quence either of congestion or a slight grade of the inflammatory process. The change of the liquor sanguinis into scrofulous or tubercular deposit, is believed to depend on the constitution or inherent composition of the exudation. The constitution is supposed to be determined by that of the blood; and such being the case, the importance becomes evident of attending to the nature of the food, of promoting the proper performance of the functions of the digestive organs, and of guarding against every- thing calculated to operate unfavourably on the composition and proper- ABSORPTION OF BONE. 297 ties of the blood. In its progress, the disease comes to be^ accompanied with a degree of inflammation, which proceeds to suppuration. Treatment.—This local affection is very much influenced by the state of the general health, which therefore requires to be particularly attended to through all its different stages. The formation of the tubercular deposit in the cancellated structure of the bone is the first deviation from its sound condition. The conditions in which that for- mation is most apt to take place, are believed to be the scrofulous diathesis, together with a weak state of the general health. It is often found in persons of that habit who have been confined to situations where the air is impure, cold, or damp; who have lived on a diet not sufficiently nutritious; who have not enjoyed regular exercise and expo- sure in the open air; or who have been subjected to any particular cause of debility. If the presence of the deposit be suspected, the endeavour must be made to limit its extent, and to delay the suppuration by removing the patient from the influences which excite unhealthy secretion. For that purpose free exposure in the open air, generous diet and the use of such medicines as from the particular state of the patient are most likely to improve the general health, must be strictly enjoined. Tonic medicines, and more especially the preparations of iron, are useful; but as permanent strength can be communicated only by the proper assimilation of nourishment, those remedies should be used which, from the particular state of the patient's health, are most likely to fit the digestive organ for the reception and proper digestion of food. Of all remedies cod-liver oil is the most valuable in this, as well as in other scrofulous affections. Limitation of the tubercular deposit, and prevention of suppuration are obviously paramount indications. When suppuration does take place, the pain should be mitigated by fomentations and rest of the affected part, and the matter should be evacuated as soon as its presence is detected. Sometimes counter-irritation by means of a blister gives some relief from the pain ; but local depletion forms no part of the proper treatment of this affection, as it would only diminish the general strength without helping to remove the local disease. General Suppuration will be considered when treating of Necrosis. ABSORPTION OF BONE. This may take place without any inflammation, and therefore without being accompanied by the formation of purulent matter, or of any se- cretion caused by inflammation. Of absorption of bone without inflam- mation there are two distinct varieties, namely, the continuous, and the interstitial. Continuous absorption is the name given to that process by which a portion of bone is completely removed without inflammation. The con- dition under which this process takes place, is when a bone is subjected to gradual and moderate pressure, without the admission of the air to the compressed part. If there be admission of air to the compressed part, or if the pressure be very severe, inflammation will be induced, and purulent matter formed, and the process by which the bone is re- moved is then called ulceration. If the pressure be gradual and mode- rate, and if the air be excluded, the effect of the pressure is to stimu- 298 ULCERATION OF BONE. late absorption without inflammation, and the process by which the bone is removed is then called continuous absorption. By this process, in some instances, a large excavation is formed in a bone, and in others, the continuity of a bone is so interrupted that it becomes divided into two portions. Examples of this singular change are met with in cases of tumours, aneurism, or chronic abscess. The gradual compression caused by these diseases sometimes produces a depression in a bone, and in some instances, as for example in aneurism within the chest ma- king its way to the surface, portions of some of the ribs are so complete- ly removed that their continuity is entirely interrupted. The only mode of treatment which can stay the progress of continuous absorption, is to remove the exciting cause, by curing the disease from which it arises. Interstitial absorption may affect either a part or the whole of a bone. In the former case it is indicated by dull uneasiness or a sense of fa- tigue, or aching of the part, increased very soon to actual pain on exer- cise ; by slight oedema of the superimposed soft parts, which is also in- creased by exercise; by lividity from passive congestion^ and sometimes also by coldness of the integument. This form of interstitial absorption often occurs in the tarsus and metatarsus, and in the carpus and meta- carpus, and frequently terminates in caries. In this disease the lami- nated portion of a bone is converted into cancellated texture, and the walls of the cells become thinner, so that the cells appear very large. The surface of the bone also presents a very porous appearance. The treat- ment consists in attention to every measure likely to improve the gene- ral health, combined with rest of the part affected, and the constant use of gentle counter-irritation, while the symptoms continue. After the removal of the local symptoms, gentle support of the part is often found to be grateful to the feelings of the patient. Interstitial absorption affecting the whole of a bone is often met with in diseases which affect the articular extremities of the long bones. There is a wasting and absorption of the bone as well as of the other tissues of the limb. To such an extent does this absorption sometimes take place that the shell of the bone becomes extremely thin, and the cancellated structure uncommonly open, so as to present the appearance of large cells with very thin walls, and in some parts the cancellated structure is entirely removed. The removal of the local disease which is the exciting cause of this affection, and the improvement of the general health together with the restoration of the limb to the performance of its usual movements, are the only means by which the unnatural absorption can be checked, and the healthy communication of nutrition to the bone be restored. ULCERATION OF BONE, OR THE SIMPLE AND TRACTABLE ULCER OF BONE. Some writers use the terms ulceration and caries synonymously. By ulceration we mean that condition of bone in which there is loss of sub- stance, together with suppuration, but in which the ulcer has a tendency to heal. In caries, on the contrary, while there is loss of substance, to- gether with suppuration, there is so far from being any tendency to ULCERATION OF BONE. 299 heal, that healing is very difficult to accomplish. This difference as to the tendency to heal depends on the different conditions of the bone at the surface qf the affected part. Mr. Liston observes, " It may tend to prevent confusion of the two different morbid states, if we confine the term ulceration to suppuration in and absorption of bone, whilst the ves- sels retain a considerable power of action, throw out new matter, and procure a reparation of the breach; and this condition of the osseous tissue exists when the disease is situated on the surface of the bone, and when it has been produced by an external cause. On the contrary, the term caries will denote that particular kind of ulceration in which repa- ration is hardly attempted by nature, and is with difficulty obtained by the most active interference; and this disease will be most generally found to affect the cancellated structure." Ulceration is caused by pressure, combined with inflammation. In a portion of bone, excluded from the air, pressure alone, unless carried to such an extent as to excite inflammation, is not sufficient to produce ulceration, but may cause continuous absorption. Some writers there- fore say, that pressure is the predisposing, and inflammation the exciting cause. Pressure may be either external or internal: examples of the latter are furnished by suppurative ostitis taking place within a bone, when the matter may make its way to the surface by ulceration; and of the former many examples are met with, of which one of the most frequent is, pressure on the surface of the bone by collections of matter forming in consequence of inflammation of the superimposed soft tissues in the vicinity. Ulceration of bone is characterized by an ulcer of healthy ap- pearance. Examination with the probe is sufficient to show the nature of the disease. The bone itself, which supports the ulcerated portion, is not diseased, differing in this respect from the state of the bone in caries; for while there is in each disease the removal of part of a bone in consequence of inflammation, in a state of simple ulceration the por- tion of bone forming the surface of the part retains its natural compact- ness and firmness; but the portion forming the surface of a carious part, and to some depth below, is in a state of interstitial absorption. The ac- tion of the vessels is, consequently, very much weaker in the latter case than in the former, and hence arises the difference, as regards the ten- dency to heal, between the two diseases, which in other respects are very similar. ^ Simple ulcer of bone is healed by the bone forming gra- nulations, which, though soft at first, are soon converted by the deposi- tion of earthy matter into bone. By these granulations the surface is to a certain extent elevated, and the edges of the ulcer are lowered by a process of absorption, so that the parts are brought nearly to a level with each other. Owing to the inelastic nature of the bone, the chasm cannot be diminished by the centripetal movement, as in an ulcer of the soft parts; but it is brought nearly to a level, as has just been de- scribed, by the rounding off by absorption of the edges, and the filling up of the centre by osseous granulations. The soft parts coalesce with the granulations, and a fibrous membrane is formed over the latter, on which a cicatrix, having a depressed, white, and firm appearance, is at last developed. This is the appearance of the cicatrix when the ulcer of the bone is perfectly healed, and the cicatrix adheres to the bone; 300 CARIES. but occasionally a cicatrix is formed before the bone has healed, and then it does not adhere to the bone, but is elevated, livid, soft and painful, and is usually soon destroyed, exposing again the^ ulcer of the bone. Treatment.—The constitutional treatment consists in the use of all prudent means for improving the general health, and maintaining the strength, so as to promote the energy of repair ; and the local, in the removal of the exciting cause and the employment of rest, a proper attitude, simple water-dressings, or medicated, if it be necessary to stimulate, together with gentle support by bandages. CARIES. Caries is derived from xeipa, to abrade, and is employed to denote a particular disease of bone. The terms, caries and necrosis, were by the older writers used indiscriminately, although they are two separate and distinct diseases. In caries, part of a bone is removed by the action of the absorbents causing a chasm; in necrosis, part of a bone completely dies; in caries there is very little, in necrosis a very great, effort of nature to form new bone. "The points of resemblance," Professor Samuel Cooper writes, "be- tween caries of bone and ulceration of the soft parts are striking ; each affection is preceded by inflammation; each is attended with the forma- tion of matter; each may be followed by the production of granulations; each may arise from local or constitutional causes; and each may be combined with the total extinction of vitality in certain points of the textures affected. Thus precisely in the same way as we often see ulceration and sloughing exhibited together in the soft parts, we also frequently find caries and necrosis prevailing together in the bones. Some portions of the osseous texture seem to perish and to be detached from the living parts of the bone, while in other places caries is making its attack and producing its usual effects." Caries generally affects the spongy extremities of the long bones, especially the ends of the femur and tibia, the bodies of the vertebrae, the bones of the tarsus and carpus, the sacrum, the sternum, the patella, the lower jaw, and occasionally the bones of the cranium. Necrosis, on the contrary, attacks the compact, lamellated or firm tissue of bone. Sometimes, though rarely, caries does present itself in the lamellated tissue of bone; but before this takes place the bone loses its compact appearance. Causes.—These may be divided into external and internal. The principal external causes are a violent blow, or a wound, and more especially if it be combined with a bruise, as in a gun-shot wound affect- ing a bone, atmospheric changes, extensive injury of the periosteum, continued pressure by long maintenance of one position (as in a tedious illness, or fever, when caries of the sacrum is apt to take place, or of the trochanter major of the femur, or sometimes of both), suppuration or ulceration of the soft parts in the neighbourhood, or in short, any external injury or condition capable of exciting inflammation and ulce- ration of bone. CARIES. 301 The principal internal causes are certain states of constitution, and more especially that condition which we denominate scrofulous, that which is the consequence of infection from the venereal poison, and that which results from the free or injudicious use of mercury. These conditions of sys- tem may be considered predisposing causes; but they seem also capable of acting both as predisposing and ex- citing causes; at all events, when any of them have produced the predisposi- tion, caries makes its appearance from very slight external causes, and in many instances without any known exciting cause at all. The worst forms of caries are those which take place when all the above conditions meet together; that is, in a scrofulous person infected with syphilis, whose constitution has been affected by mercury. Other internal causes, pre- disposing to caries, though not so powerfully, are the conditions of con- stitution which exist in scurvy, rheumatism, and gout. Scrofulous caries, syphilitic caries, scorbutic caries, rheumatic caries, and arthritic caries, are names by which some of the above-mentioned forms of this disease are distinguished. The various forms of caries differ from each other in the parts of bones in which they are most frequently found. Scrofulous caries, the most frequent form of all, usually attacks the spongy texture of bones, as the bodies of the vertebrae, the spongy ex- tremities of the long bones, and the tarsal and carpal bones, beginning in these parts by the deposition of tubercular matter in their cancellated structure ; which deposition is succeeded by inflammation, ending ulti- mately in caries. Syphilitic caries, which is the next in frequency, attacks the compact parts of the bony structure, such as the dense or hard part of the tibia, the compact part of the ulna, and the bones of the cranium. The rheumatic, like the scrofulous, is most frequently met with at the joint ends of the long bones; but it arises from inflam- mation of the ligaments and synovial membrane, extending sometimes to the articular surface itself. The arthritic, like the rheumatic, takes place in the region of the joints, but seems to prefer the external sur- face of the bone, and is generally preceded by a kind of exostosis in which the caries take place, and by the formation of arthritic concre- tions in the neighbourhood. Phlegmonous erysipelas, suppression of customary discharges, and the sudden repelling of profuse eruptions of the skin, have been known to cause caries. Fig. 90. Caries of bones of cranium and face, producing free communication between the mouth, nose, orbits, frontal sinuses, and cranium. Disease commenced by ulcera- tion of soft palate with tubercular syphilitic eruption. From the history it appears that the patient had been subjected to the injudicious use of mercury. From a prepa- ration in my museum. 302 CARIES. Symptoms.—Caries being a result of inflammation, is preceded by ostitis, either acute or chronic, the symptoms of which will vary to a certain extent according to the nature of the ostitis, as will be readily understood from what has been previously stated regarding different varieties of inflammation of bone. Sooner or later the soft parts conti- guous to the bone participate in the inflammation ; and if the affected part be situated near the surface, a swelling is in some little time observable. This swelling is firmly adherent to the bone, and the skin over it be- comes red, tense, and painful. It ultimately becomes soft, indicating the presence of suppuration ; and if opened, or allowed to proceed without interference, the matter which escapes from it is thin and offensive, and rarely presents the characters of wrell-formed pus. After the discharge of the contents of the abscess, either spontaneously or by an opening, the cavity does not heal; but continues to discharge matter which tar- nishes a silver probe, is thin, ichorish, and offensive, and has that pecu- liar foetor by which, without any other symptom, it is possible to deter- mine with considerable certainty that it proceeds from a part connected with a diseased bone. The foetid matter is loaded with a considerable quantity of phosphate of lime. The aperture of the abscess contracts and takes the form technically called fistula, and throws out from its edges granulations, which are spongy, painful, and very apt to bleed on being touched with the probe. The granulations project beyond the margin of the aperture, and the surrounding integument exhibits a livid hue. If a probe be introduced into the aperture, the bone is found to be rough and denuded, its surface irregular, and the osseous texture so much softened, that, with the slightest pressure, the probe will sink into it to a considerable distance. The impression communicated to the surgeon on making an examination with the probe, is not precisely the same in every instance of caries, the condition of the bones being diffe- rent, as was before mentioned, in different forms of the disease. In caries of deep-seated bones, as for example, in scrofulous caries of the vertebrae, the accompanying collection of matter exhibits the characters of a chronic, instead of those of an acute abscess. I have often been struck, in cases of scrofulous caries of the vertebrae and of other bones, with the fact that in many instances, patients would scarcely admit that they had experienced any pain in any stage of the disease. The con- stitutional symptoms vary, in the first instance, according to the nature of the inflammation producing the caries, and the state of the patient's system at the time. In scrofulous caries the patient exhibits the stru- mous habit, and in general symptoms of scrofulous cachexy soon be- come very apparent. During the suppurative stage of caries, and more especially in cases where the caries communicates with an articu- lation, irritative fever comes on, but soon gives place to hectic fever, by which in unfavourable cases, such as when the caries is in inaccessi- ble situations, the disease proves fatal. In some instances the only con- stitutional symptoms observable are those of hectic fever. State of the Parts.—The bone does not in every instance of caries present the same appearance. If the varieties in the state of the bone be made the basis of arrangement, it may be said that caries may exist in one or other of the three following forms :— CARIES. 303 Fig. 91. 1st. That in which there is a regular and distinct excavation of a portion of bone. The extent of the disease, however, is by no means indicated by the extent of the excavation. 2d. That in which the outer encasement or lamella of bone gives way, and the cancellated structure becomes carious without any distinct excavation. In this form the destruction by ulceration is very superfi- cial, being confined to the outer encasement, but the alteration by interstitial absorption in the cancellated structure is very extensive. 3d. That in which the bone has the appearance of having been perforated in innumerable places, termed the worm-eaten caries. This condition is occasionally met with in the external surface of a long bone affected with the first form of caries, the perforations being found in the outer encasement in the neighbourhood of the excavation; but the best examples of worm-eaten caries I have seen, have been in the cranium. In one admirable preparation of this form in my possession, the whole of the upper part of the cranium is occupied with innumerable perforations, and in another, the bones are in some parts bored in hundreds of places, and in others, affected with necrosis. In the first mentioned specimen the bones have in every respect, with the excep- tion of the perforations, a healthy ap- pearance, no traces whatever being observable of any other disease, or of any deviation from the natural and sound condition of the osseous struc- ture. In some other specimens of this form of caries, I have been struck with the absence of any apparent traces of change of structure in the osseous substance, a circumstance in which this form seems occasionally to differ from the other two varieties. In the second specimen mentioned above the disease was in a girl twelve years of age, and was occasioned by a blow. In the first form of caries there may be said to be three different states. First, a part of the bone, where the excavation exists is removed by ulceration. Second, the part which forms the surface of the carious portion is affected to a considerable depth by interstitial absorption, in consequence of which its lamellae are so thin, and its circulation so feeble, that a healthy action rarely takes place. Its circulation is sufficiently weakened to create a great obstacle to the formation of healthy granulations, and yet not so as generally to deprive the part of all vitality and produce necrosis. It is in the presence of this interstitial absorption, that caries differs from simple ulceration Third, beyond the interstitially absorbed part, the bone is often rendered preternaturally dense by the secretion of new osseous matter into its cancellated structure; and its external surface is, from the same action covered over with nodules or spicula of new bone at the parts where 304 CARIES. there is a sound and firm bone underneath. In the second form the ulceration is very superficial, but the interstitial absorption very deep and extensive, and sometimes, as some specimens of it in the tarsal bones in my own collection demonstrate, it extends almost through the whole of the bone. When it is very extensive, the attempts at the formation of new bone in the neighbourhood of the interstitially absorbed part are very feeWe, and in many instances, no traces whatever of such an action can be discovered. Although the interstitial absorption frequently extends to a great depth, it is also certain, on the other hand, that occasionally it is very superficial, and the very limited extent of change of structure is sometimes remarkably disproportioned to the severity and obstinacy of the symptoms. Caries is in every instance a consequence of inflammation, and it may or may not be accompanied by the deposition of tubercular matter in the cancellated structure. When there is a deposit, it may present any of the varieties of appear- ance mentioned in the section on suppuration of bone, and, as is there stated, it may not be a product of inflammation, but a consequence of previous perversion of nutrition in a person of a scrofulous constitution. In some instances this deposit is limited to a small part, in others it is very diffused; in some it is contained in cells of the cancellated struc- ture, and in others, as many of my own preparations evidence, it seems to occupy the whole space included within the shell of the bone, and scarcely any traces of the cancellated structure remain. When the deposit is present, the attempts to secrete new bone in the neighbourhood of the part involved in the caries seem to be in general extremely feeble, and such cases are in consequence exceedingly unpromising. Professor Syme remarks, that after maceration a carious bone looks as if it had been burned, being harder, whiter, and more brittle than natural. I have sometimes been struck with this brittleness and hardness after long maceration and drying in instances where, while the bone remained in the body, it felt so extremely soft, that a probe could with the slightest pressure, and almost without experiencing any resistance, be made to sink through it in any direction. DIFFERENT MODES OF SPONTANEOUS CURE. Nature sometimes accomplishes a cure of caries in one or other of the three following ways :— 1st. By a complete change in the action of the diseased part, in con- sequence of which granulations form, which are converted into bone; and a deposit of osseous matter thus taking place, the cavity is filled up in the same manner as a simple ulcer of bone. 2d. By a process of exfoliation, by which the whole of the ulcerated portion of bone is thrown off, together with the parts rendered weak by interstitial absorption. 3d. By anchylosis, or that process in which sufficient new callus or bone is thrown out to ossify the articulation. Treatment.—-In all inflammations of bone, such treatment should be adopted, as will be most likely to prevent them from terminating in caries. With this view local and general depletion, though necessary, must not be carried too far, as the consequent debility predisposes to CARIES. 305 caries; and as the danger of its occurrence is likewise increased by the interstitial absorption arising from the free use of mercury, this medi- cine, if ventured upon at all, must be exhibited with great caution. Simple ulceration of the bone should be healed as speedily as possible ; unnecessary irritants should never be employed; abscesses must be opened, and " effused pus ought never to be allowed to remain on the surface of the bone, but must be early evacuated." If caries be the consequence of scrofula or syphilis, it is not so much under the influ- ence of local treatment as of the proper constitutional treatment for those diseases. When caries is fairly established, the treatment varies according to the situation of the disease. On this account, the situations of caries are divided into those accessible, and those inaccessible, to the surgeon. To the latter class belong caries of the vertebrae, of the hip-joint, and of the knee. In accessible caries, unless there be great reason to hope for a spon- taneous cure by one or other of the three processes already described, the best treatment is the complete removal or excision of the diseased portion of bone. On no account, however, should any attempt at re- moval be made, while acute inflammation exists in the bone or the neighbouring tissues. Although the carious part could be excised under such circumstance, the operation, instead of being succeeded by a heal- ing process, would, by increasing the inflammation, cause extension of the disease. With regard to the extent of removal, suffice it to say, that a firm, sound base should be left; the whole of the ulcerated and interstitially absorbed portion of bone should be removed. The instru- ments most serviceable for the excision or removal of the diseased part vary according to the situation. In some instances, a scoop may be sufficient; in others, trephines, saws, knives, or the cutting forceps, are required. After removal has been effected, the wound should be treated in the manner proper for a simple ulcer of bone. If the caries has been in parts which form an articulation, the bones must, after the operation, be kept in apposition, and at perfect rest. It sometimes happens that a patient cannot be persuaded to submit to the operation of excision. Under such circumstances, the most advisable procedure is to destroy the diseased part by means of the chloride of zinc, made into a paste, or the red oxide of mercury in powder. For my own part, I prefer the former escharotic, but they both answer very well, and are not, like acids or liquid escharotics, liable to the objection of sinking deep into the substance of the bone, and thereby causing extensive and unneces- sary destruction, or of increasing the disease. The escharotic must be employed so as to insure the object of its application, namely, the com- plete destruction of the diseased part; and after it is taken off, some lint should be introduced into the wound, and poultices employed for alleviating the pain, and promoting the separation of the destroyed parts. When removal has taken place, the treatment proper for a sim- ple ulcer of bone should be adopted. It sometimes happens, that after the surgeon has removed, by instruments, as much of the bone as seems advisable, a part still remains of a suspicious appearance, yet not so circumstanced that it would be judicious to remove it bv excision 20 J 306 NECROSIS. Some surgeons recommend that, in such circumstances, the suspected part should be destroyed by one of the escharotics above mentioned; and the practice is often followed by the most satisfactory results. At one time the actual cautery was much employed for the destruction of carious parts. In regard to this practice I cannot do better than quote the language of Mr. Liston. " The application of the actual cautery may be by some considered necessary; at one time I employed this re- medy very extensively in caries, and occasionally with very good success. I have since, however, been led to change my opinion, and am now inclined to prefer the potential cautery. By the application of the red- hot iron, the diseased portion is destroyed effectually, but at the same time, the vitality of the surrounding parts is often very much weakened, and their power of reparation diminished, so that they are incapable of assuming a sufficient degree of action for throwing off the dead part; their action being increased, while their power is diminished, they may be- come affected with caries, and thus, instead of being arrested, the original disease will either be increased, or extensive necrosis may take place." When the caries is in situations inaccessible to the surgeon, that is to say, where it does not admit of excision, as in the hip-joint, the knee- joint, and the vertebrae, the surgeon should endeavour to obtain anchy- losis. The most important means for this end are,—attention to every measure, judicious in the condition of the patient, for maintaining the general health and strength, perfect rest of the affected parts, and the employment of counter-irritation. If the vertebrae be the subject of the disease, the spine must be kept at rest, and in a reclining position, so as to remove from it the superincumbent weight. The treatment, however, of caries in that situation will be particularly described in the section on diseases of the spine. If the knee-joint be the part affected, the limb ought to be extended, and kept in that attitude by means of a flat con- cave splint, applied behind the joint; if the disease be in the hip-joint, the trunk, thigh, and leg ought to be preserved in a straight line with each other. Counter-irritants are also used with advantage. Those which are most generally preferred, and which are found to prove most beneficial, are blisters, small issues kept open by the occasional applica- tion of potassa fusa, and setons. Experience seems to show that, in some situations, some of the means for producing counter-irritation are employed with more advantage than others; but this will be more fully explained in the description of the diseases of the joints and of the spine. One important point, however, should always be kept in view, whatever be the application employed; and that is, not to produce such a discharge as would affect the general strength; for the maintenance of the patient's general health is fully as important as keeping up coun- ter-irritation. When a collection of pus is perceptible, it must be opened by a small orifice in the most dependent part, and gentle pressure em- ployed to keep the sides of the abscess in apposition. NECROSIS. This term, derived from *(*;«», to put to death, is now, by the consent of surgeons, employed to denote the dead condition of bone. In the soft tissues the state corresponding to necrosis, is called mortification. NECROSIS. 307 Louis, who was the first to restrict the application of the term necrosis to death of bone, applied it only to death of the entire thickness of the bone, and not of the external or internal part, of which, however, there is frequently complete death, followed by removal. The bones most liable to necrosis are, the tibia, the femur, the lower jaw, the cla- vicle, the fibula, the humerus, the radius, and the ulna; occasionally, also, the bones of the cranium are subject to it. While caries, as has been already noticed, is found principally to affect the spongy portions of bone, necrosis, for the most part, attacks those bones which are of a firm, compact'texture. It may occur at any period of life, and in both sexes, yet we more commonly meet with it in young persons from twelve to eighteen years of age; but when it affects the lower jaw, it is seldom before the thirtieth year. The causes of necrosis may be divided into external and internal. Of the former are severe contusions of bone ; bad compound fractures ; the pressure and irritation of tumours, of abscesses, or of a musket ball; acute ostitis ; or the application of strong concentrated acids. It fre- quently results also from severe cold, and occasionally from burns. Destruction of the medullary membrane is found, by experiment on the lower animals, to produce necrosis. The internal causes are such as affect the bone through the medium of the constitution. Scrofula, syphilis, and the baneful influence of mercury on the constitution, seem to produce a considerable tendency to necrosis. If necrosis take place without any known exciting cause, it is said to be idiopathic ; if it be the consequence of a compound fracture, it is called compound ; if it be caused by violence, as by a blow, it is deno- minated traumatic. Varieties of Necrosis.—The different forms or varieties of necrosis are by some arranged into two, by others into three, separate and dis- tinct species. We shall, however, consider four varieties. 1. That form which generally occurs in a person of a scrofulous habit of body, and in which the short bones are affected, as those of the tarsus, metatarsus, carpus, or metacarpus. 2. That form in which there is death only of the outer lamella, that is, in which the disease is superficial, and does not extend through the whole thickness of the shell of the bone. This form sometimes presents itself in the flat bones, as the scapula, and the bones of the cranium. 3. That form which destroys the internal part of a bone, and in which the cortex or outer shell is not affected. This is by some writers called internal necrosis. 4. That form, in which the whole thickness of a bone perishes. The three last-mentioned forms may be distinguished from each other by the names of external, internal, and general necrosis. Symptoms of the First Form.—An indolent swelling first presents itself, unattended with much pain or constitutional disturbance. The swelling is at first hard, after some time oedematous, and at length attended with fluctuation in consequence of a thin ichorish fluid collected in the part. If a probe be introduced, the bone will be felt to be rough, and divested of its periosteum. The aperture has little tendency to heal. In consequence of the continued irritation, hectic fever is pro- 308 NECROSIS. duced. As in this form nature makes no attempt at reproduction, re- moval of the limb is absolutely necessary. Symptoms of the Second Form.—These, in the first instance, depend upon the cause of the disease, which is often an acute abscess, or acute periostitis, or acute ostitis. A small abscess occurs in the soft parts, which, if left to nature, discharges itself. If a probe be introduced, the bone is found to be bare, and a part perhaps loose. The aperture does not heal until the sequestrum or dead portion of the bone is removed, but becomes what is technically called a fistula. The separation of the sequestrum is effected by the absorbents taking up the next layer of bone, and bears an analogy to that process by which sloughs of the soft parts are detached. The aperture now heals by granulation in the same manner as in simple ulcer of bone. This form of necrosis has by some writers been called exfoliation. Symptoms of the Third Form.—There is most excruciating pain, supposed to arise from the resistance offered by the cortex or outer lamella to the swelling of the inflamed part. The inflammatory fever is often so high as to prevent the patient from obtaining repose. The swelling is exceedingly hard and diffused, depending on the swollen con- dition of the bone. It also continues for a very long time, before any- thing unnatural is observed in the soft parts; but in them an abscess gradually forms. The pain is not aggravated, as in other forms of this disease, by pressure or handling of the limb. The other symptoms nearly correspond with those of general necrosis. Symptoms of the Fourth Form.—In this form of the disease the arti- culatory extremities are not generally involved. Pain of a most excru- ciating, girding, bursting character is one of the earliest symptoms. The pain is constant, and is followed by a swelling, which is diffused, presenting no distinct bounds, but generally greater about the middle of the limb than elsewhere. The character of the swelling at first is doughy and elastic, by reason of the effusion between the periosteum and the bone, and the thickening of the periosteum itself. This is followed by a soft swelling, which is less diffused, and ultimately attended with fluctuation, and presents the ordinary local symptoms of an acute abscess, which, if permitted, finds an outlet for itself. If a probe be introduced after the contents of the abscess are dis- charged, the bone will be found to be bare, and ultimately becomes loose. The pus itself is thick, yellow, and of a healthy, purulent cha- racter. After the evacuation of the abscess, there is some diminution of the pain ; but the opening has no disposition to heal, and presents the appearance which is technically called fistula. After the matter is discharged, there is but little subsidence of the swelling, which is gene- ral, presenting no distinct boundary, and of a firm, unyielding kind, de- pending at this advanced stage on the deposition of new bone, and cer- tain conditions connected with that process. Constitutional Symptoms.—Violent inflammatory irritative fever at- tends the first stages of necrosis. If the constitution be good, and not reduced by long-continued and extensive suppuration, hectic fever may not come on ; but there is much reason to apprehend it, if the constitu- tion be feeble, or the disease very extensive, or the articulations affected. NECROSIS. 309 Fig. 92. P Sequestrum.—The sequestrum, or dead portion of bone, is always of an ivory-white appearance, except when it is exposed to the atmosphere through the soft parts, or is situated at the bottom of a large ulcer: it is then of a dark brown, or even black colour, in consequence of the action of the air. In general necrosis, that is, when the whole thickness of the shaft perishes, the sequestrum is situated within the newly-depo- sited bone; in other words, the new bone surrounds or embraces the sequestrum, which is observed to be somewhat reduced in size, in com- parison with the original bone. Some authorities suppose, that the absorbents have the power of removing a portion of the sequestrum, into the system. Mr. John Hunter, Sir W. Blizzard, and Professor Russell of Edinburgh, held this opinion; as do also Mr. Lawrence of London, and M. Velpeau of Paris. Messrs. Gulliver, Stanley, and Liston, maintain, that the sequestrum cannot be acted on by the ab- f sorbents. Mr. Liston observes, "But a dead portion t of bone detached from the surrounding parts, is in ! j every respect an extraneous body, and is not and can- not be, acted on by the absorbents any more than a 1 piece of metal, wood, or stone. Some have gone so far as to affirm that portions of foreign bodies, liga- / tures, &c, are absorbed, but this opinion is altogether V too absurd to require any contradiction; the knots of is ligatures, like portions of glass or other foreign sub- I stance, become surrounded with a dense cyst, and I often remain in the body for a long time; so do por- tions of dead bone, separated by the process here described. A series of experiments were made by Mr. Gulliver, in order to put this question at rest, many of which I witnessed and assisted at, and several also I repeated. Setons of bone were in- serted, and worn for a long time; thin plates of bone were confined on suppurating surfaces, pieces of bone were inserted in the medullary canal of various animals, and kept there for months, and in one instance for more than a year. These foreign bodies were weighed with the greatest care and accu- racy before and after they were so exposed, and were found unaltered in any respect." That the seques- trum is often much less than the original bone, is a fact which is beyond all doubt; but absorption does not, and cannot take place, except through the me- dium of the vessels of the sequestrum, before it has lost all its vitality. Separation.—Respecting the process by which the dead portion of bone is separated from the living, the older writers had very vague Hippocrates stated that separation was accomplished by fleshy Some supposed that it was effected by the pulsation granulations. Fig. 92. Drawing of a preparation in my own collection. 310 NECROSIS. others by the distension of the vessels of the parts ; and Mr. Benjamin Bell thought that the dead bone was separated by suppuration and granulation. The investigations of Wiedmann have set this question at rest. "The parts surrounding the dead portion directly become pre- ternaturally vascular. A groove is next formed all round the seques- trum, which is generally believed to be produced by the action of the absorbents of the adjoining living bone, or, as Mr. Hunter first demon- strated, the groove is formed by the absorption of that part of the living bone which is contiguous to the dead ; its earthy matter being first taken away, and then its animal part, the groove begins on the surface, and extends gradually more and more deeply, until the dead portion is completely undermined and detached."^ Reproduction.—The power of reproduction varies much in the diffe- rent bones of the body, being great in some, and less in others, while there are those in which it is not at all manifested. ^ It is, of course, much greater in young healthy subjects, than in old Fig. 93. debilitated persons. Though the long bones, the lower jaw, the clavicle, and the scapula possess the power of reproduction, to a very considerable extent, the short cuboid bones cannot be reproduced. A case is related by Wiedmann, in which nature effected reproduction of nearly the whole of the lower jaw; and one by Chopart, in which the clavicle was re- produced. An instance is also on record, of the reproduction of nearly the whole of the scapula. Portions of the cranium under particular circum- stances may, to a certain extent, be reproduced; but if both the tables of the cranium be destroyed, to- gether with the pericranium, there will be very slight reproduction; for the dura mater has very little tendency to form new bone. This is the reason why, after the operation of trephining, the pericranium and both tables of the skull being removed, reproduc- tion does not take place to any great extent. From ivhat source is the New Bone derived f— This is indeed a " questio vexata." Different patho- logists give different answers to the following ques- tions, Whether Nature, for the accomplishment of her purpose, employs the vessels of the periosteum—or those of the medullary membrane—or those of the old bone itself? It seems clear that in external necrosis, new granulations spring up from the living bone, and reproduction is effected in the same manner as in simple ulcer of bone. In internal necrosis, it is supposed that the living cortex or outer lamella of the bone, which becomes pre- ternaturally vascular, swollen, and softened, is the source of the new bone. That it cannot be by the vessels of the medullary membrane, is manifest from observation ; for in this form of necrosis the medullary membrane is completely destroyed. In general necrosis, or those cases Fig. 93. Entire regeneration of Tibia. Drawn from a preparation in my own collection. NECROSIS. 311 in which the entire thickness of a bone, and the medullary membrane perish, it is believed that the new bone is derived from the periosteum of the old bone. Duhamel first mooted this opinion, which Troja after- wards supported. Troja produced necrosis by passing a red-hot iron into the medullary canal of various animals, and he ascertained that, when a portion of bone is about to perish, the periosteum becomes detached and raised up from the bone, and the space is occupied by purulent matter. Dr. Macartney had an opportunity of witnessing this separation of the periosteum from the bone in the human body, in consequence of destruction of a small portion of the medullary mem- brane by disease. The periosteum becomes very vascular, and thereby is rendered soft, pulpy, villous, and perfectly red on the surface in contact with the bone, the cellular tissue external to it also becoming swollen. The central part of the periosteum is next converted into cartilage, and afterwards into bone, so that the new bone is formed in the centre of the periosteum. "Some pathologists deny the ossific power of the periosteum, and claim the whole production of new osseous substance for the bone itself. That the process of reproduction may be accomplished in this way, I am not prepared to deny, but that it is not necessarily or always so performed, will I think appear from the following case:—"A girl, twelve years of age, strained her ankle, in the month of March, 1835. Inflammation followed, extending up to the knee, and attended with violent fever. She was brought to the hospital, and placed under my care. Incisions were soon afterwards made to evacuate a large collection of matter, which had formed in the leg ; and the bone being found dead, while the patient's strength was rapidly going away, I amputated the limb above the knee, five weeks after the injury had been received. The girl recovered and is now well. In examining the limb to ascertain the extent to which the bone had died, I found that it was partially surrounded by the commencement of a new one. The shell had already acquired considerable firmness at some parts, but wTas not equally thick throughout, and did not seem fixed to the ends of the old shaft. This observation led to a very careful dissection of the parts concerned: and they are now before the Society. It will be seen that the tibia had died very nearly from end to end, and that the new shell enclosing it had been formed in the periosteum. The new osseous substance may be observed at some parts, in the form of distinct scales. At other parts it looked as if it had originally consisted of separate portions, and been composed by their union. The periosteum connecting these portions to each other, and to the extremities of the bone, was not thickened beyond its natural condition, and where it covered the posterior surface of the tibia, though quite detached from the old bone, had not suffered any further change. There is here then an instance of a bone dying suddenly in consequence of acute inflammation, without anv thickening being previously found in its neighbourhood, and nevertheless succeeded by the production of a new osseous shell, which evidently could not proceed from the old bone, and no less evidently depended on an ossific process resident in the periosteum. As Nature is not capri- cious or variable in her proceedings, I regard this case as sufficient of itself, without any further evidence, to establish the ossific power of the 312 NECROSIS. periosteum. But with the view of making the matter still more clear, I performed the following experiments. I exposed the radius of a dog, and removed an inch and three-quarters of it, together with the perios- teum. At the same time I exposed the radius of the other leg, and removed a corresponding portion without the periosteum, which was carefully detached from it, and left quite entire, except where slit open in front. Six weeks afterwards the dog was killed, and the bones examined. In the one from which a portion had been taken, together with the periosteum, the extremities were found extended towards each other in a conical form, with a great deficiency of bone between them, and in its place merely a small band of tough ligamentous texture. In the other, where the periosteum had been allowed to remain, there was a compact mass of bone not only occupying the space left by the portion removed, but rather exceeding it in thickness. This experiment, when repeated, afforded the same results. " I next exposed the radius of another dog, and separated the perios- teum from the bone, as in the former experiment; but then instead of cutting out the denuded bone, inserted a thin plate of metal between it and the periosteum. The edges of the membrane, and then those of the skin were sewed together, and the wound healed kindly. At the end of six weeks, I dissected the limb, and found a deposition of osseous sub- stance in the periosteum, forming a bony plate exterior to the metal, and not connected to the old bone, except by the membrane. I lastly exposed the radius of a dog, and cut away the periosteum to the same extent that it had been detached in the experiment just mentioned, and surrounded the denuded bone with a piece of metal. At the end of six weeks I found a thick tough capsule formed, enclosing the metallic plate, but having no osseous substance in it. The evidence which has now been adduced seems to me sufficient for putting beyond all question the power of the periosteum to form new bone, independently of any assistance from the old one."—Syme's "Principles of Surgery," pp. 191-3. From the case and experiments published by Professor Syme, it seems warrantable to conclude, that the new bone is formed within the centre of the old periosteum, which first undergoes the various preparatory changes already described. The observations of many other authorities have led them to the same conclusion ; and I have for years exhibited to the Class of Surgery in Marischal College, a beautiful preparation, still in my possession, which most clearly demonstrates the vascularity of the inner surface of the periosteum, the deposition of ossific matter within its centre, and the perfect continuity of the altered portion, in which is contained the new bone, with the periosteum of the neighbour- ing portions of bone which are not involved in the disease. Such seems to be the correct doctrine regarding the source of new bone in general necrosis; but there are some who embrace this opinion only in part. They agree that the new bone is derived from the perios- teum as its source, but consider that it is not developed in the centre, but formed on its inner surface; and affirm that a secretion of lymph takes place between the inner surface of the periosteum and the bone, "which undergoes the preparatory change into a gelatinous or cartila- NECROSIS. 313 ginous tissue previous to its ossification." If this opinion be correct, it is difficult to explain the vascularity of the interior of the new bone.^ Dr. Macartney believes that the new bone is formed from the perios- teum, but seems to think that it is not developed in its centre, as the experiments and case of Professor Syme, and the preparation in my own museum tend to prove, but formed on its inner surface; and he de- scribes the original periosteum as disappearing, not as becoming after- wards attached to the new bone. He remarks that " the first and most important circumstance is the change which takes place in the organi- zation of the periosteum; this membrane acquires the highest degree of vascularity, becomes considerably thickened, soft, spongy, and loosely adherent to the bone. The cellular substance also, which is immediately connected with the periosteum, suffers a similar alteration; it puts on the appearance of being inflamed, its vessels enlarged, lymph is shed into its interstices, and it becomes consolidated with the periosteum. These changes are preparatory to the absorption of the old bone, and the secretion of the new osseous matter, and even previous to the death of the bone which is to be removed. In one instance I found the perios- teum vascular and pulpy, when the only affection was a small abscess of the medulla, the bone still retaining its connexion with the neighbour- ing parts, as it readily received injection. The newly organized perios- teum, &c, separates entirely from the bone, after which it begins to remove the latter by absorption; and while this is going on, its inner surface becomes covered with little eminences resembling granulations. In proportion as the old bone is removed, new osseous matter is dis- persed in the substance of the granulations, while they continue to grow on the old bone, until the whole or a part of it is completely absorbed, according to the circumstances of the case. What remains of the in- vestment after the absorption of the old bone and the formation of the osseous tube which is to replace it, degenerates, loses its vascularity, and appears like a lacerated membrane. I have never had an opportu- nity of examining a limb, a sufficient time after the termination of the disease, to ascertain whether the investment be at last totally absorbed ; but in some instances I have seen very little remaining. During the progress of the disease the thickened cellular substance which surrounded the original periosteum, becomes gradually thinner, its vessels diminish, and it adheres strictly to the new-formed bone, to which it ultimately serves as a periosteum." I have introduced the above extract because it well describes some points, and gives a distinct account of the writer's views ; but from what has been previously stated, it will be seen that I follow the authorities whose views do not altogether coincide with these. Mr. Stanley is of opinion that when necrosis is attended with destruc- tion of the bone and of the medullary membrane, the bone may be re- generated from three sources, namely, from the periosteum which in- vested the old bone, or from the articular ends of the old bone; or if the periosteum be destroyed, from the soft parts which surrounded'it. He states that he destroyed the medullary membrane in a dog's tibia' and removed the periosteum, and yet reproduction ensued from the vessels of the surrounding cellular tissue, which became exceedingly condensed, so as to form a periosteum. The results of some of the ex- 314 NECROSIS. periments of Dupuytren, Breschet, and Villerme', on the formation of callus, in some respects agree with the evidence furnished by the ex- periment of Mr. Stanley. Cloacae.—In the sides of the newly-formed bone arc Fig. 94. observed a number of foramina, called by Wiedmann, Cloacce, and by Troja, foramina grandia, which serve as an outlet for the extraction of the sequestrum, pro- vided it be not too large, and for the escape of the purulent matter confined within the cavity of the bone. The cloacae generally present themselves in the middle or under third of the bone, and are usually of an oval shape, and oblique in their direction. Mr. Davies, and some others suppose that the cloacae are formed by the matter secreted in the interior of the new bone, which, from its great quantity distends, and ultimately bursts the periosteum, thereby giving rise to these apertures. According to Wiedmann, this doctrine is incorrect, for cloacae are observed in situations where matter does not exist. Others attribute their formation to the cor- rosive qualities of the pus; but it seems more probable that they are occasioned by the non-deposition of osseous matter, at certain parts in the centre of the periosteum. In some preparations, the parts where bone has not been deposited, are filled up by periosteum. In a pre- paration in my collection, there are several cloacae filled up by periosteum, which is evidently continuous with that which covers in, and that which lines the outer and inner surfaces of the neighbouring portions of new bone, these portions being clearly deposited in the centre of the periosteum. After the entire removal of the sequestrum, the new bone gradually becomes consolidated and smooth on the surface, by the action of .the absorbents, and is lined by a medullary membrane. Treatment.—Preventive treatment should be first employed with an activity commensurate with the severity of the symptoms, and the strength of the patient. If the ostitis proceed from syphilis or scrofula, in addition to other remedies, the preparations of iodine, especially the iodide of potassium, with sarsaparilla, will be found valuable. As soon as the existence of purulent matter is detected, free direct incision should be made ; which will save much time, alleviate suffering, spare the strength of the patient, and ciroumscribe the extent of the disease. If hectic fever supervene, the strength of the patient must be supported by means of tonics, pure air, and suitable diet and regimen, until the process of separation be completed. In fact, the duty of the surgeon during the process of separation, which is a work of nature, is to keep the limb in a quiescent state, and to combat all untoward symptoms as they may arise. The Process of Extrusion.—The efforts of nature in this process being feeble, the surgeon ought to interfere, and afford the necessary Fig. 94. Drawn from a preparation in my own collection. RICKETS. 315 assistance for the removal of the necrosed part. The proper period for this interference is, when the sequestrum has been separated trom the living portion; but first, the surgeon should consider the course of the cloaca, and endeavour to form some opinion of the size of the seques- trum ; then he should make a free direct incision, generally longitudinal in its direction, not too long, as there is danger of hemorrhage, nor too short, as the difficulty of extraction would be thereby increased, and the operation rendered unnecessarily tedious. When the sequestrum is loose, it may easily be removed by a pair of forceps, if the cloacae be sufficiently large. Sometimes it is necessary to cut a portion of the new bone which confines the sequestrum, or to divide the sequestrum itself by Liston's forceps, or Hey's saw, or some other convenient in- strument. "The instruments," Mr. Liston observes, "and especially those for extraction, ought to be very powerful and suited to the pur- pose ; for in the employment of inefficient means there is much folly and cruelty." After the operation, which is generally attended with a profuse hemorrhage, the wound should be filled with lint, and the limb placed in an elevated position. Antiphlogistic means may be necessary to prevent ostitis. There are certain unfavourable cases of necrosis in which amputation is not only warrantable, but indispensable. If the hectic fever, caused by the long-continued suppuration, threaten to prove fatal; or if the neighbouring articulations become involved in the disease, amputation is the only possible means of saving the patient's life. The bones of the tarsus and carpus, as was previously stated, are never reproduced; and sometimes, in very weak, debilitated persons, there is no reproduc- tion in the long cylindrical bones. In these cases, also, amputation is admissible. " The treatment," Mr. Liston says, " may be summed up in a very few words. Prevent the necrosis, if possible, open abscesses whenever they appear, encourage the patient to move the neighbouring joints, support the strength, remove sequestra when loose, but do not interfere until they are ascertained to be so, give the limb proper sup- port, and rest when a large sequestrum is formed. When fracture has taken place, when the health has been undermined, or when neighbour- ing joints have become diseased, amputate in order to save the life, if it be impossible to save the limb." RICKETS. The spine was by the Greeks called fax's, from which is formed ra- chitis, strictly meaning, disease of the spine; and from rachitis is de- rived the English word rickets. The terms rachitis, and rickets, are not, however, used to denote a disease of the spine, but one in which there is a preternatural softness of the osseous system, affecting the spine in common with other parts ; and these names were originally applied to the disease from an erroneous impression which at one time prevailed, that it originated in the vertebral column. It is a remarkable fact, that this disease appears to have almost escaped observation until the middle of the seventeenth century, there being no distinct account of it given by the ancients, nor by any author of the middle ages. It was first described by David Whisler, in a tract published in 1645, en- 316 RICKETS. titled, " De Morbo Puerili Anglorum dicto The Rickets;" but it was more'fully described in 1671, by Glisson, in his treatise, " De Rachitide, Sive Morbo Puerili." The last-mentioned author states, that it first appeared in England in the middle of the seventeenth century, since which time it has been a well-known disease in these islands, and in many~other parts of Europe. It can scarcely, however, be supposed that the disease did not exist previous to the above period, but merely that it escaped particular observation. Dr. Craigie remarks, " Its oc- currence in infancy only was the cause of its escaping observation; its influence, however, in leaving more or less deformity of the skeleton, must have at all times attracted notice. Deformed dwarfs have been known in all ages; the gibbi, the vari, and the valgi of the Romans must have been more or less rachitic in their infancy. From this cause the deformity of Thersites might have originated. It is also to be remarked, that Fabricius Hildanus delineates the serpentine lateral curvature of the spine in a girl of eight, whose bones were soft as wax, which could be produced by no other cause save rickety softness." Symptoms.—This disease generally attacks children between six months and three years of age; but it is often known to occur at an earlier period, and a few instances are recorded of its taking place in the foetus. Pinel describes the skeleton of a rickety foetus. University College Museum contains a splendid specimen which I have examined; and Soemmering, Bordenan, Loder, and others testify to the fact that the disease is sometimes met with affecting the bones of the foetus. From a state of apparent vigour the child begins gradually to decline in health, and to lose his liveliness; the muscles diminish in size and be- come loose and flabby, causing that diminished appearance of the extre- mities and neck, which contrasts strangely with enlargements perceptible in other parts of the body. In the progress of the disease there is much general weakness; the skin loses its elasticity and becomes pale, and, in aggravated cases, of a dusky appearance ; the digestion is often im- paired; the breath has a sour smell, and the abdomen becomes enlarged, and has to the touch a doughy feeling: this enlargement, for the most part, arises from distension of the intestines with gas. It has some- times been believed to be produced by disease of the spleen, or of the liver, and more especially of the mesenteric glands. There can be no doubt that in patients affected with rickets, these organs are often found diseased; nor is this at all surprising ; but that such disease forms no essential part of the state of the body in rickets, is evident from the fact that, in many instances, there is found no diseased condition of any internal parts except the bones. There is softness of the bones from the interruption of the ossific process; and becoming, in consequence of this softness, flexible and incapable of offering resistance, they yield to the superincumbent weight and to the action of the muscles; and hence result various unnatural conditions observable in the extremities, the spine, the chest, the pelvis, and the head. The upper and lower extremities frequently exhibit a remarkable con- trast of appearance ; the former, from not having to support any weight, are in general proportionate and free from curvature, while the latter are bent so as to become much shorter than natural. The bones give RICKETS. 317 way principally from the effect of the superincumbent weight, and partly also from the effect of the muscles. The form which they assume in the limbs is generally an exaggeration of the natural configuration; by which I mean, an unnatural degree of the curvature proper to the bones. The lower limbs exhibit great varieties of deformity; they are often bent laterally by the action of the muscles, and in such cases they are always bent to the side on which the muscles act most powerfully. The femur may be bent forwards, or laterally, or forwards and outwards; the tibia may exhibit a curvature forwards; or the knees may both fall inwards with the feet thrown outwards; or both the extremities may be together thrown to one side, forming a curvature of the whole length of the extremities with the greatest convexity at the knees, and directed to one side and the concavity to the other. Although, as it has been already stated, the bones of the upper extremities are more rarely Fig. 95. Fig. 96. Fig. 97. affected than those of the lower, yet they do sometimes suffer to a cer- tain degree both as to length and size. The clavicle may be bent un- naturally forwards, partly by the weight of the shoulder, and partly by the action of muscles going from the front of the chest to the bones of the extremity ; and the humerus, radius, and ulna may also become bent in directions determined by the actions of the muscles. The spine ex- hibits in a marked degree the effects of rickets, the weight of the head, and other superincumbent parts, bending it in various directions; and with distortion of the spine is usually associated deformity of the chest, which is sometimes flattened laterally by the ribs falling in on both sides, in which state the sternum is pushed forwards, and the front of the chest Figs. 95-97. From preparations in my own museum. 318 RICKETS. acquires somewhat of the form of that cavity in a bird, and hence the expression " chicken breasted" has been used to describe that peculiarity of form. The chest, in these cases, may be flattened on one side, and rendered very convex on the other, as in lateral curvatures of the spine from other causes. The chest is shortened on the flattened side, and the intercostal spaces very much diminished from above downwards; Fig. 98. Fig. 99. whereas, on the convex side, the chest is lengthened, and the intercostal spaces are larger than natural. This condition of the chest often occa- sions a compression of the thoracic viscera, and thus interferes with the easy performance of their functions; hence arise the difficult breathing and palpitations which are frequently observable in such cases. With respect to the pelvis it was the opinion of the late Mr. John Shaw, that it will be found distorted only in those cases where marks of rickets are found in other parts of the skeleton besides the spine and chest. He made an examination of an extensive series of skeletons in which there were curvatures of the spine, and he found that in some, the deformities were confined to the spine and chest, while in others, he observed marks of rickets in other bones also; but in no single instance of the former class did he find any distortion of the pelvis ; and he therefore concluded that in cases of rickets, although the spine and ribs may be deformed, the pelvis will not be found distorted, unless the disease affect the skele- ton generally. The distortions of the pelvis are various; the bones may be pressed to one side, or the inlet may be diminished from before backwards, or if the softening be very great, and the patient be able to walk, the ossa innominata may, to a certain extent, be approximated towards each other at certain parts by the pressure of the thigh-bones against the acetabula. The head is larger than natural, and has a sin- Figs. 98, 99. From preparations in my own collection. RICKETS. 319 gular appearance from its two grand divisions becoming disproportioned to each other, the facial portion retaining its natural size, while the cranial is much enlarged. It is an observation made by some authori- ties that in rickety patients there has been found a more early develop- ment than usual of the mental faculties. State of the Parts.—In rickets, the earthy matter is deficient, and the bone is light, spongy, and soft, of the consistence of cartilage, and is easily cut with the knife. The vessels of the bone appear numerous and large, and are loaded with dark-coloured blood. The bone is of a red colour varying in shade from pink to brown. The walls of the long bones become very thin, while the bones of the cranium are con- siderably increased in thickness, but are changed in structure so as to become reticulated and spongy. The interior of the long bones presents, as during foetal life, a loose and reticulated arrangement, with some- what of the appearance of a homogeneous substance instead of a distinct medullary cavity and cancellated structure; and instead of being filled with medulla or any oily secretion, as in the healthy state, it contains a reddish or brownish serum. The periosteum is said by Bichat to be generally thickened; other observers have also found it thickened and detached; but Mr. Stanley, who examined an extensive series of bones affected with rickets, did not find this thickened appearance. The con- dition of bone above described may be succeeded by one of growth and strength, in which the bones increase in density and size by a process resembling, with one exception, that by which the natural growth of the bones in a sound state is carried on. A medullary canal is formed ; in- stead of the reddish serum, the natural oily secretion is deposited; and the distinction between cancellated structure and the compact shell becomes perceptible. The great peculiarity is, that the bones become thickest at the smaller curvatures, where the power of resistance is most required, and the deposition not only takes place on the outer surface, but in some specimens extends into the interior, so as to encroach on the medul- lary canal, which has been known in some instances to have been at certain parts even obliterated by it. Treatment.—The proper treatment consists in the employment of all judicious and available means for removing weakness of constitution, and strengthening the general system. For that purpose the most ap- propriate remedies are, residence in a dry and pure air; sleeping in a large, airy apartment; free exposure to the light and to the sun's rays; nutritious and light diet, attention to clothing, and particularly in the cold season wearing enough to keep up free cutaneous circulation ; cold or sea-bathing at the proper season, if the patient be strong enough to undergo the exertion, and if that should not be found advisable, bathing in tepid salt water, or sponging the body ; and the regular employment of friction by means of the hair-glove, or flesh-brush. The state of the digestive system, and particularly the due regulation of the bowels should be attended to ; and, together with the above means which are of the utmost importance for stregthening the general system it is ad- visable to give some tonic medicine. Of the various remedies belonging to that class the preparations of iron seem to be usually employed with the greatest advantage. Exercise to an extent not inducing fatigue is 320 MOLLITIES OSSIUM. beneficial; but after exercise, and occasionally at different other periods during the day, the patient should recline to relieve the weak parts from the pressure of the superincumbent weight. MOLLITIES OSSIUM. The disease known by the names mollities ossium, osteomalacia, ma- lakosteon, and osteo-sarcosis, is extremely rare, and appears to have been unknown to the ancients. The first distinct account of this malady was given by Gabriel in 1688. He met with an instance of it in a lady, whose bones were flexible, and converted into a reddish substance des- titute of fibres. Cases were published in 1691 by Saviard, and in 1700, by Courtial and Lambert; in the " Memoirs of the Royal Academy of Sciences" for 1752, Morand detailed the remarkable case of Madame Supiot, and since that time many well-marked examples are recorded by different observers. From there being so far a resemblance between rickets and mollities ossium, that in both there is softness of bone and deficiency of phosphate of lime, some have supposed them to be the same malady; but they differ so completely from each other in many re spects, that it is very evident they ought to be regarded as entirely distinct diseases. Some of the striking points of difference are the following. Rickets is a very common affection ; mollities ossium is so extremely rare, that, in a period of more than thirty years, no example of it occurred in any of the London Hospitals. Rickets is by no means a dangerous disease; mollities ossium has invariably proved fatal. Rickets is a disease of early life, and is equally common in both sexes; whereas mollities ossium takes place in the middle of the period of life; and all the well-marked examples of it that are recorded, so far as my reading extends, have been in females, with the single exception of the case of Jas. Stevenson, who was attacked with the disease when thirty- five years of age, and after languishing in bed six years died in 1785. In rickets the disease commences while ossification is imperfect, the phos- phate of lime never having been deposited to a sufficient extent; molli- ties ossium takes place after the process of ossification is perfect, and the phosphate of lime, previously deposited, is in a great measure re- moved. In mollities ossium the urine is loaded with a deposit consist- ing of phosphate of lime ; in rickets there is no such deposit. In mol- lities ossium the patient complains of pain in the bones, and is distressed with irritative fever ; whereas, these symptoms are not present in rickets, or if present, they arise from other constitutional diseases. By way of further description of this very remarkable disease, I shall state a few particulars of some of the most extraordinary examples on record. The first case I shall mention is that of Ann Elizabeth Queriot, recorded by Dr. Hosty in the forty-eighth volume of the " Philosophical Transac- tions." This person was attacked at the age of thirty-six, soon after the birth of her first child. She was distressed with fever, profuse perspira- tion, and violent pains in the bones; and the disease was attended with a deposition of a white sediment in the urine. The disease continued about two years, and the bones became so soft that they bent in various directions, and so much distorted that her lower extremities turned up- wards so as to lie in a line parallel with her body. After her death the EXOSTOSIS. 321 bones were found to be so soft, that they could be easily cut with a knife, and so flexible, that although the extremities had assumed a curved direction, they could easily be laid straight. The cavities of the bones contained a reddish blood-like fluid instead of marrow. No cause could be assigned for the disease, and during its progress she was three times pregnant. Another remarkable case is that of Madame Supiot. Her disease was attended with great general weakness, fever, pains over the whole body, and a white sediment in the urine. General softening took place in her bones, so that they yielded to the action of the muscles, and the distortion was so complete, that her lower extremities were drawn up- wards, and her feet lay by the sides of her head. Her disease lasted five years, during which period she was three times pregnant. For some time before she was attacked with this disease, and for two years afterwards, she was addicted to the habit of eating kitchen salt, and it is stated that she used to take a pound and a half a week without mingling it with her food. To this habit some have attributed her disease; a habit, it may be remarked, to which some of the other persons who have been subjects of this malady were addicted. After death, her bones were found to be soft, sectile, and flexible, and loaded with a bloody fluid. As further peculiarities in the state of the bones in this disease, it may be stated, that the cancellated structure disappears, and in its place is found a reddish soft substance, from which on a section being made, a bloody serum exudes; and the place of the marrow is occupied by a substance like clotted blood. FRAGILITAS OSSIUM. In this state the animal matter is comparatively less abundant than the earthy. It occurs in old age as a consequence of the change which takes place in the structure of the bones at that advanced period ; but it is also met with in middle age, in which case it is symptomatic of some other disease, such as cancer, scurvy, or syphilis : in these states it sometimes prevails to a great degree, and is rarely amenable to treat- ment. [exostosis. # Exostosis is an unnatural enlargement of bone, exhibiting various sizes and shapes. The tumour may involve the whole bone, or it may be confined to a small portion. It may form rounded prominences, which are attached by narrow or broad bases; and sometimes the growth has the form of elongated spines terminating in a point. The increased development of bone may arise from the periosteum, the cellular struc- ture, or from the medullary membrane. The structure of the tumour resembles ordinary bone, and may be either laminated, cellular, or compact, in its interior. All bones are liable to exostosis, but it more frequently occurs in long bones particu- larly in the humerus, femur, and tibia. There may be some'constitu- tional peculiarity favouring this bony deposit, but the predisposing causes are generally syphilis, scrofula, and gout. Violence frequently 322 SPINA VENTOSA. Fig. 100. excites inflammation in the bone, by which the equilibrium between absorption and deposit is destroyed, and the excessive deposit takes place in the manner that bones are originally formed and repaired. # . . Symptoms.—Generally there is but little pain, in a healthy constitution, unless the tumour presses on parts particularly sensitive, but if syphilis or scrofula be the cause of the disease, there may be a dull, deep-seated pain. Pain is also more likely to be present when the tumour is of rapid growth; but when the growth is slow, there is but little inconvenience unless it in- terfere'with some important organs. It may press on muscles and impede their action, or it may impede the motion of a joint; when growing from the orbit it may occasion protrusion of the eyeball; or, if from the internal table of the skull it may cause epilepsy. Care must be taken to distinguish those tumours which are dependent upon syphilitic or scrofulous taints from those which are idiopathic, the latter being inconvenient generally from their size and weight, whilst the former may ulcerate and be attended with constitutional disturbances. Treatment.—If syphilis or scrofula exist, the con- stitutional remedies employed in these diseases must be mainly relied on; at the same time pain may be re- lieved by leeches and anodyne applications. True idiopathic exostosis is generally but little diminished by medical treatment, and if it occasions no inconve- nience it should be let alone, but if it mechanically interferes with the function of any part, it is to be removed. The operation will in a great measure depend upon the size and form of the tumour. If it be spiculated, it may be cut down upon, and removed by bone-pliers or a fine saw; but if it has a large base, it may be chiselled off piecemeal. If it be impossible to reach it with instruments, the periosteum should be scraped away, so as to deprive it of its nutrition, and it may exfoliate or be absorbed. The edges of the wound are to be brought together, and inflammation carefully guarded against. SPINA VENTOSA. Spina ventosa is swelling involving the whole circumference of a bone, and of a regular form. It consists of a bony crust, which forms the walls of a cavity divided into compartments, which contain either an ichorous fluid, or a reddish, jelly-like substance ; or a cheesy, lardaceous substance, and sometimes pieces of cartilage or of dead bone. It commences with deep-seated, dull pain, which often is the result ot external violence. The swelling gradually increases, the skin becomes red, and the shell bursts, discharging its contents. Sometimes the walla are formed merely of expanded periosteum. After the contents are evacuated, the cavity fills with fungous excrescences, which protrude through the opening, and which are very sensitive and easily bleed. OSTEO-SARCOMA. 323 The disease probably commences in an inflammation and ulceration of the medullary membrane, which constantly enlarges the tubular cavity of the bone, and fills it with foul matter, at the same time there is going on a deposit from the external periosteum, which becomes ex- panded. At first, it might be mistaken for exostosis; but, in exostosis, the tumour is firm and incompressible, whereas, in spina ventosa, it is a mere osseous shell. It is a disease of slow progress, and very difficult to cure. On the fingers, or metacarpal bones, long-continued pressure may perhaps effect a cure. At the same time, the patient should take iodide of potassium in large doses. Should the tumour burst, and it is recommended by some to open it, the cavity should be cleansed and injected with stimu- lating washes. OSTEO-SARCOMA. Osteo-sarcoma is a tumour formed upon a bone, but consists not merely of bone, but also of flesh, fat, jelly, and cartilage. It is de- pendent upon some constitutional vice, either venereal, scrofulous, or gouty, often excited Fig. 101. by an external injury. Boyer considers that it corresponds to the cancerous affection of the soft parts, and that, after its removal by amputation, it will return in other parts of the body. The tumour becomes large and nodu- lated, and some parts are firm, and others are soft and elastic. Upon dissection, the muscles and tendons will be found to be ex- panded, and of a pearly-white colour. The various coverings will be found much matted together and firmly adherent to the bone. Upon cutting into the bone, it will be found to contain cells filled with medullary or ge- latinous matter, intersected with bony spi- culae. Its growth is attended with severe and lan- cinating pain. The skin is stretched and then inflamed, finally ulceration occurs, which produces hectic and death. Treatment. The treatment in the early stage of the formation is similar to that for exostosis, but amputation will generally be found necessary.—Ed.] 324 CHAPTER IX. DISEASES OF JOINTS. ACUTE SYNOVITIS. Anatomical Characters.—The first effects of inflammation of a synovial membrane are, that the membrane, instead of being pale, thin, smooth, and translucent, as in the sound state, becomes red, preternaturally turgid and opaque, with dulness of its surface. The redness depends on in- creased vascularity, and may present the appearance of crimson or brownish spots, or it may be diffused over the membrane. There is at the same time a preternatural secretion of synovia, which is of a more aqueous character than in the healthy state, and of a less albuminous quality. As the inflammation advances, other changes take place both in the membrane and in the fluid. The membrane becomes considerably thickened by interstitial exudation; it has some degree of pulpiness with redness, and entirely loses its translucency. The absence of the natural smooth glistening appearance is more decidedly observed on its internal surface, to which lymph is often found adherent, giving it a rough appearance ; and if the inflammation be of considerable standing, the lymph may be effused not only on its internal surface, so as to make that surface irregular, and into the substance of the tissue, giving rise to thickening, but also into the cellular tissue external to the membrane, and by which it is connected with the surrounding parts. The mem- brane at this stage is much distended with a fluid of a serous character, having albuminous or curdy flakes floating in it, and hence called sero- albuminous. This is the stage at which adhesion of opposite sides of the membrane may take place, but such an occurrence is comparatively rare, partly in consequence of the great distension from synovia, and partly from the tendency of the inflammation to increase. At a more advanced period the internal surface is more extensively covered by lymph, which becomes in a measure organized, and forms a secreting surface. There are great varieties as to the extent and thickness of the effused lymph, and also of the appearance of its free surface. In many instances it covers the whole of the synovial membrane, so that no part of it can be seen on laying open the joint; in some it is comparatively thin, and in others it forms thick projecting masses. These varieties occasion also a great difference with regard to the surface of the cavity of the joint, which thus exhibits a greater or less degree of irregularity. The adventitious tissue, as it has been called, becomes organized, and secretes purulent matter into the joint, giving rise to great distension. ACUTE SYNOVITIS. 325 At this stage the articulation may be regarded as forming an acute ab- scess ; and if the synovitis should run its course, the matter may sooner or later point, making its way to the surface by interstitial absorption and ulceration, and at length be discharged by ulcerated openings ; an event which, though it gives temporary relief, is soon followed by a de- cided aggravation, much more frequently than by a diminution of the inflammatory action. From the extension of the inflammation to the cellular tissue around the joint, lymph and serum are deposited in it, and, in consequence, a doughy and oedematous swelling becomes percep- tible between the skin and the distended cavity of the articulation. Destruction of a portion of the membrane and subjacent cartilage by ulceration, and of the bone by caries, are frequent results of acute as well as of chronic synovitis. The above are the principal results of acute synovitis in unfavourable cases, where the inflammation attains a high grade; but sometimes the inflammation terminates at an early stage in resolution, and thus struc- tural derangement is prevented; sometimes it goes on to the effusion of lymph, and produces adhesion, to a certain extent, of the opposite surfaces of the membrane to each other, admitting ultimately a limited motion of the joint, but such adhesions, as has been already stated, are rare; and sometimes, when the inflammation has attained a higher grade and produced suppuration, and the matter has been discharged, although such cases generally produce, at length, a total disorganization of the joint, they may terminate in anchylosis. Symptoms.—This disease, very rare in the child, and less uncommon in youth, is most frequently met with in the adult. The knee, ankle, and elbow are more liable to it than the other articulations, but it is most common in the knee. The first symptom experienced by the patient is pain, which though slight perhaps at first, gradually increases, and soon becomes very severe. It may be more intense at a particular part, but it is usually felt over the whole of the articulation; it is aggravated by motion, which is always injurious and often intolerable, and generally by cold, and by the extended position; it is diminished by rest, by heat, and by slightly bending the joint, and thereby relax- ing the structures; hence the patient has an inclination to maintain the parts in this attitude. Almost synchronous with the pain is swelling, which at first depends entirely on the distension of the membrane by synovia. It is as uniform as the ligaments and tendons surrounding the joint will permit, being prominent where the synovial membrane is not confined by these structures. The swelling has very distinct fluc- tuation ; and if the joint be superficially situated, this peculiarity is very evident, and even the fact of its being caused by a very thin fluid is dis- cernible, and thus an impression is conveyed of the stage as well as of the nature of the disease. As the disease advances, the swelling is caused partly by serous and albuminous effusion into the cellular tissue external to the synovial membrane, but chiefly by distension from the fluid within, which ultimately changes so as to become purulent. The serous and albuminous effusions cause the swelling to feel somewhat oedematous and doughy; and though the fluctuation be still perceptible, it is more difficult from the examination alone to form an accurate and 326 ACUTE SYNOVITIS. decided opinion, in every instance, as to the nature of the fluid within the joint. Motion of the joint is not only difficult, but painful, and often attended with a grating sensation, which is supposed by some to be caused at an early period by the change in the character of the synovia, which, becoming more aqueous and consequently less lubricating than in a healthy state, is less calculated to diminish the effects of friction. Whether this supposition may or may not be in part correct, it seems more likely that even at first this symptom depends very much on the swollen state of the membrane ; and at a more advanced period the impression forced on a careful examiner is, that it arises from the irre- gularity on the surface of the lining membrane. The parts external to the synovial membrane being involved in a low degree of inflammation, the skin is preternaturally sensitive, red, tense, and hot. The pain is increased on pressure, and the patient maintains the joint in a slightly flexed position. In many instances, the muscles of the limb are affected at times, and especially during sleep, with spasmodic twitches, which aggravate the symptoms; and the rigidity of the muscles, particularly of the flexors, which maintain the joint slightly flexed, is preternaturally increased, and their bellies and tendons may in consequence be felt unusually tense under the common integument. The severity of the constitutional symptoms varies considerably according to the violence and extent of the inflammation, the grade in which it exists, and the peculiar constitution of the patient. At first the usual symptoms of inflammatory fever appear more or less distinctly marked, but they become more severe, as the disease advances to a higher grade. When the inflammation reaches the suppurating stage, there are frequently rigors, together with a marked aggravation of the symptoms. If the matter be discharged, there is often a diminution of the symptoms, but this is usually of very short duration; and sooner or later the symptoms of inflammatory are changed into those of hectic fever, under which the patient will sink, unless the disease be arrested, or the joint removed. Causes.—The predisposing cause, which also, to a certain extent, modify the character of the attack, are rheumatism, scrofula, syphilis, and the use of mercury; and so powerfully do these conditions operate, that where they exist, a very slight exciting cause, such as a bruise, a sprain, exposure to cold, a wound, or any injury near a joint is sufficient to induce the disease; and, indeed, it occasionally comes on without any known exciting cause. The most frequent exciting cause, however, is cold, combined with damp, which is more apt to affect the more exposed articulations, as the knee, ankle, and elbow. Synovitis frequently takes place in the progress of diffuse suppurative phlebitis, and it is well known that in persons of rheumatic constitution, inflammation of the synovial membrane of various joints is occasionally produced by the excitement caused by gonorrhoea. Treatment.—This is both general and local; the former consists of the early and decided employment of the antiphlogistic regimen and treatment in all their details. Bloodletting, when the general system is affected with inflammatory fever, should be employed to an extent ACUTE SYNOVITIS. 327 proportioned to the age and strength of the patient, and the violence of the disease. The bowels should occasionally be smartly purged ; but the frequent employment of cathartic medicines is not advisable, as it would interfere with a most important indication, namely, to keep the affected joint at perfect rest. When the disease is not speedily arrested, it is of the utmost importance for checking the diseased action, and thereby preventing structural derangement, and for preserving the joint in a fit state for the future performance of its functions, to bring the system under the influence of mercury. With this view calomel and opium are prescribed with advantage. When circumstances render it injudicious to have recourse to mercury, much benefit is often experi- enced from the use of the tartrate of antimony, and in persons of a rheumatic diathesis the exhibition of colchicum, to an extent sufficient to produce in some degree its peculiar effects on the system, usually leads to the happiest results. Such are the principal remedies, as far as regards constitutional treatment in acute synovitis, and they ought to be employed at an early period, and to be carried to as great an extent as may seem necessary and judicious, so as to prevent, if possible, the occurrence of structural derangement. As regards local treatment, one of the most important indications is to keep the joint at perfect rest. The state of complete repose must be strictly enjoined not only during the acute stage, when in conse- quence of the pain caused by motion the patient has little inclination to move it, but also till all inflammatory action has subsided; for when the inflammation has become chronic the symptoms are invariably aggra- vated after motion, although pain may not be felt at the time; and it cannot be doubted that extensive disorganization has often resulted, and many a limb has been lost, from prematurely and imprudently resuming motion. The attitude in which a joint should be kept at rest, must vary according to the situation of the joint; but it may be given as a general rule, that it should be maintained as nearly as possible in that position in which it will be most serviceable and convenient, provided the joint remains stiff, or with great limitation of its motion. The means to be employed for preserving the joint at rest may vary. The limb is often gently bound in the acute stage to a pillow, and at a later period to a suitable splint. Local depletion is important, either by leeches or cup- ping, or, which is often found to answer very well, first by the former, and afterwards by the latter. The efficient application either of cold by means of evaporating lotions, or of heat with moisture by poultices or fomentations will be found useful: in making the choice between these two applications, heat and cold, the best guide will be the patient's feelings; for whichever is most grateful to the feelings will be most beneficial. By the judicious and early employment of the above consti- tutional and local treatment the inflammatory action is in many instances subdued; and with the continuance of. the antiphlogistic regimen and rest of the joint, its effects disappear; and then by gradual and cautious trials the functions of the articulation may be resumed. If however the inflammation does not yield under the above treatment, though carried to as great an extent as prudence will allow, it is advisable to employ some of the forms of counter-irritation, of which one of the most 328 CHRONIC SYNOVITIS. efficient is by blisters. But it is important that care be taken never to apply a blister over a joint in acute synovitis, unless the joint be deeply seated, or the inflammation has become chronic, and depletion has preceded the application. The inflammation would probably be increased by a blister applied over a joint superficially situated, the disease in the acute stage being so susceptible of aggravation and there not being room as when the joint is deeply seated, for the blister to act on the principle of derivation. If it is ascertained beyond all doubt that suppuration has taken place, it is advisable to discharge the matter as in other acute abscesses by free direct incision ; but as nothing could be more injudi- cious than to make an opening into a joint distended with serous or even sero-purulent effusion, the evidence of suppuration should be very clear. If any doubt remain, the nature of the fluid may be ascertained by the introduction of a grooved needle. After such an opening and the discharge of the matter, an attempt should be made to obtain anchylosis, and for this end rest of the joint and attention to all means likely to improve the general health are essential; but as might be anticipated, our hopes are often disappointed, and too generally it becomes needful to remove the limb in order to preserve the patient from sinking under the accompanying hectic fever. CHRONIC SYNOVITIS. Chronic synovitis most frequently occurs in persons who have been affected with syphilis or mercury, or who are of a rheumatic diathesis: it is, however, occasionally met with in others also. It is frequently excited by that kind of injury termed a sprain, or by any local mecha- nical injury, as a blow or a contusion, or by exposure to cold and damp. In many instances it is the form of perverted action ultimately assumed in cases which were originally acute. Anatomical Characters.—The synovial membrane becomes opaque, thick, and pulpy, and preternaturally vascular; and its free surface, instead of being smooth, becomes villous, or granular, and the cavity of the joint is filled with a fluid which at first is serous, but ultimately by mingling with a puriform secretion, becomes sero-purulent; or, from the absorption of the thinner part, entirely purulent. For a conside- rable period the changes are confined to the membrane and its contents, and hence arises the difference in the superimposed parts during the early stages of acute and chronic synovitis; but by a continuation of the morbid action, or by the intervention of an acute attack, the extra- capsular filamentous tissue becomes affected, and infiltrated with a jelly- like substance, and the membrane may ulcerate and the cartilage be destroyed by ulceration ; and this may be followed by destruction of a portion of the bone and the total disorganization of the joint. Symptoms.—If the disease be chronic from the commencement, the early symptoms will differ from those of acute synovitis. There will be no redness of the skin, no particular heat, nor will the pain be very acute, nor much aggravated at the time by motion. On this account, patients have not the same dread of moving the joint as in acute inflam- mation ; but it is no less necessary to preserve it at complete rest, as motion is followed by an increase of the symptoms. The pain is not CHRONIC SYNOVITIS. 329 only less severe, but is felt more at a particular part than over all the articulation. Swelling takes place in the course of a short time, but not so soon as in the acute form; it is not uniform, but bulges out, principally in parts where the synovial membrane is not confined by ligaments or tendons; and as the superimposed tissues are not in the first instance involved, fluctuation is exceedingly distinct. In some in- stances, from the thickening of the membrane itself, and the depositions into the superimposed tissue, which take place during the progress of the disease, the swelling has to a certain extent a doughy or elastic character, and the fluctuation becomes more obscure; but still, on care- ful examination, it can always be discerned. The motion of the joint is followed by pain; the inclination of the patient is to preserve it more or less flexed, and the flexor muscles are found to be tense, the others flabby and relaxed. If the disease be of long continuance, the swelling of the joint becomes very great; and presents a striking contrast to the rest of the limb, which is often greatly emaciated from interstitial absorption of all the structures, both hard and soft. Frequently the veins over the joints are greatly distended, and the skin from its wrinkles being unfolded by the tension, has a shining appearance. If the dis- ease run its course, the matter may point at a particular part, and make its way to the surface by interstitial absorption and ulcera- tion. In some instances the disease is chronic from the very commence- ment, in others it is at first acute and afterward chronic. In some cases the symptoms continue chronic throughout, and in others they are for the most part chronic, but with occasional aggravation from accession of acute symptoms. If the symptoms have been chronic from the commencement, the patient may not have experienced any inflam- matory fever; whereas, if the disease was at first acute, the signs of inflammatory fever are exhibited while the acute stage continues. The constitutional disturbance, however, which sooner or later takes place in every instance where the disease does not come to a favourable ter- mination, is the accession of hectic fever, which will prove fatal unless the joint be removed. Treatment.—As regards the constitutional treatment, which is of very great importance, it may be said that in the absence of any pecu- liar cachexy, the chief points are to enjoin the antiphlogistic regimen, to regulate the bowels, to preserve the digestive apparatus, if possible, in a proper state for the performance of its functions, and to adopt all prudent measures for maintaining the general health. When hectic fever supervenes, the strength should be kept up as much as possible by nourishing diet, and such tonic remedies and other means, as seem most suitable to the particular circumstances of the case. When the disease arises from syphilis, a well-regulated course of mercury is necessary; when from rheumatism, the Vinum Colchici will prove highly beneficial; and when from the abuse of mercury, or from injudi- cious exposure during or after a mercurial course, the happiest effects often result from the use of sarsaparilla, combined with the iodide of potassium. In cases especially where synovitis is combined with in- 330 CHRONIC SYNOVITIS. flammation of the periosteum, the last-mentioned remedies are often highly beneficial. With regard to local treatment, in this as in all cases where joints are diseased, it is most essential that rest be observed ; if this be neglected all other means will be of no avail. Local depletion by leeching or cupping, the latter being generally preferable in chronic synovitis, will be found advantageous in the early stage, not only for checking the in- flammation, but also for rendering it safe to employ counter-irritation. At the same early period the efficient application of cold is usually grateful to the feelings of the patient, and beneficial. But one of the most valuable remedies, both for subduing the inflammation, and also for promoting the removal of its effects, is counter-irritation, which will be most efficiently employed by the repeated application of blisters in the immediate neighbourhood rather than directly over a joint, unless it be deep-seated. These are the principal remedies on which reliance can be placed for checking chronic synovitis. The treatment, therefore, may be said, in the first instance, to consist in the employment of rest, local depletion, cold applications, and counter irritation by means of blisters. At a much later period, when the inflammation is considerably subdued, bene- fit is often derived from some of the other forms of counter-irritation. Some of the principal applications for this purpose are, small caustic issues, or the application of the moxa, in the proximity of the joint. Other excellent modes of employing counter-irritation are painting the joint with the tincture of iodine, or brushing it over with a strong solu- tion of the nitrate of silver, or, after having damped the skin with water, rubbing it very gently with the solid nitrate. These applications must be used with caution, and the surgeon must watch against recurrence of acute inflammatory action; and to diminish that risk, it is prudent to delay the employment of some of the forms of counter-irritation until the acute inflammation has been in great measure subdued. Under the above treatment the inflammation and its effects may dis- appear, and in the course of time, by passive motion and friction, the motion of the joint may be restored, and the patient allowed to use the limb. Often, however, there remains a stiffness of the joint from the thickening of the soft tissues, sometimes hydrops articuli; for the re- moval of which the following treatment is recommended :— Stiffness from Thickening of the Soft Tissues.—The principal remedies are, the repeated application of blisters, so often beneficial from their well-known effect in promoting absorption ; pressure by means of a roller with or without some discutient ointment; friction by the hand with some dry powder; warm water poured on the joint, which is useful not only from the relaxing effect of the heat combined with moisture, but also by causing friction, especially if it be poured from a considerable height; the vapour bath, together with shampooing in the bath, and passive motion. Whenever rubbing, shampooing, or friction is employed, the effects must be carefully watched; and if the treatment should be observed to excite any inflammation, it must be immediately discon- tinued. Of course nothing could be more injudicious than to have re- SCROFULOUS CHRONIC SYNOVITIS. 331 course to rubbing, friction, pressure, or motion, while any inflammatory' action remains. Hydrops articuli is the name given to that condition in which a joint remains distended with synovia, but without pain, redness, or any other symptom than the swelling, and the sense of fulness, and often, of weak- ness, which it occasions. After the subsidence of the inflammation, the fluid is in most instances absorbed spontaneously. When, however, this does not take place, the principal means adopted for promoting absorp- tion are, friction by the hand with any dry powder; or rubbing the joint with the camphorated mercurial ointment; or with the ointment of the iodide of potassium; pressure by means of a roller, or pressure accompanied by the rubbing of the joint with the iodide of potassium ointment, which I have found to produce absorption very speedily. Among the most successful methods, the repeated application of blisters directly over the joint, if it be deeply seated, or in the immediate neigh- bourhood, if it be superficial, and pencilling the joint with the tincture of iodine, with or without its internal use, deserve to be mentioned. In some cases, local acupuncture has been resorted to, either as a prelimi- nary step to drawing off the fluid by means of the exhausted cupping- glasses ; or with a view to allow the fluid to escape into the surrounding tissue, so as to convert the case into one of diffuse oedema. But this procedure, if any inflammation whatever remain about the joint, will be of no avail in accomplishing a cure, since the fluid will be very quickly secreted again, and if there be no inflammation, it is unne- cessary, inasmuch as the disease usually yields to some of the less hazar- dous methods already mentioned; but if, after the employment of other means, the disease should still persist, still, when it is remembered, that the puncturing of a joint is by no means free from the risk of exciting a fresh inflammatory attack, it does appear a matter of very doubtful propriety to recommend, for the removal of an inconvenience, a proce- dure, which, though it has doubtless been frequently adopted without such a result, may possibly excite a serious inflammation. The same treatment has also been proposed as for hydrocele, namely, to draw off the fluid, and inject tincture of iodine into the joint; than which nothing could be more injudicious, or more justly deserving of unquali- fied condemnation. SCROFULOUS CHRONIC SYNOVITIS. This disease, called by some authors the gelatinous degeneration of the synovial membrane, is sometimes attributed to a slight injury, as a bruise, or sprain: but it often presents itself without any assignable exciting cause. It is most frequently met with during adolescence though, certainly, it is not confined to that period. The subjects of it are always of a scrofulous habit; and it is not only accompanied, but also preceded, in most instances, by the symptoms of scrofulous cachexy. Symptoms.—One of the first symptoms is, swelling about the joint, which slowly advances, and is of a doughy elastic nature; but which cannot be said to be characterized by distinct fluctuation. This disease is recognised as much by its negative as by its positive symptoms, and is remarkable for the length of time the skin retains its natural appear- 332 SCROFULOUS CHRONIC SYNOVITIS. ance. There is little or no pain, scarcely any tenderness on pressure, and at this stage none of the local symptoms of inflammation, except swelling, which, with stiffness or diminished mobility and a sense of weak- ness, are the only local signs of the disease. In the further progress of the disease the swelling continues to enlarge, and the rest of the limb becomes wasted. After continuing for months, and often for a longer period, the disease either changes favourably and the swelling dimi- nishes, or it goes on to suppuration of the joint, attended with great aggravation both of the local symptoms and of those of the scrofulous cachexy, and ending in the destruction of portions of the cartilages and bones; and unless some of the forms of anchylosis should occur, which after this stage of the disease is an exceedingly rare event, the only chance of saving the patient's life will be the removal of the affected part. State of the Parts.—In the case of a young man, who was the subject of this disease in the knee, and who died of phthisis, I had an opportu- nity, at a post mortem examination, of making a dissection of the joint. I found the synovial membrane thickened, of a gelatinous appearance, of a grayish white colour, and at some parts considerably injected; the synovial fluid was flaky and much more opaque than is natural; and there was an effusion of a gelatinous character into the cellular tissue, so that it was thickened; and the skin, the synovial membrane, the cel- lular tissue, and the ligaments were all matted together. In another example of this disease in the knee, I lately had occasion to perform amputation, and found the same morbid alterations of structure as in the last-mentioned case, and the same matting together of tissues, with the additional peculiarities that the membrane was much more injected; the part of it which covers the cartilages of the femur was destroyed; the cartilages were removed ; the extremity of the femur was carious; and the fluid in the joint was sero-purulent. Treatment.—Since this disease is connected with scrofula, the treat- ment adapted to that particular state of the constitution is, during the whole of its progress, indispensable ; and, however necessary local treat- ment may be, it is equally important to employ such means as are cal- culated to operate favourably on the general system. The local treatment is nearly the same as in simple chuonic synovitis; but with reference to local depletion, there are two considerations which will prevent the sur- geon from prescribing it, except so far as is absolutely necessary; the one, that it has much less effect in controlling scrofulous than common inflammation; the other, that free depletion is very unfavourable to the state of the general system. The treatment may be stated to consist— in preserving the joint at perfect rest through the entire continuance of the disease; in endeavouring to arrest acute inflammation when it oc- curs, by rest, cold applications and local depletion, the last being em- ployed as sparingly as possible; in attempting to subdue inflammation when more chronic, by rest and counter-irritation, slight depletion as in simple chronic synovitis, preceding the application of the counter-irri- tants ; and after the inflammation has been subdued, in employing means for fulfilling these three indications, namely, to keep the joint at rest, to apply pressure in order to promote absorption, and to use some INTRACTABLE DEGENERATION OF SYNOVIAL MEMBRANE. 333 of the most efficient applications for stimulating the absorbents. These three indications can be effectively combined by Mr. Scott's treatment, which " consists in cleansing the surface of the joint with a sponge, soft brown soap, and warm water, and then thoroughly drying it. The part is then rubbed with a sponge soaked in camphorated spirit of wine, and afterwards covered with cerate made with equal parts of ceratum saponis and the ung. hydr. fort, cum camphor^. This is thickly spread on large square pices of lint, applied entirely round the joint, and supported with broad strips of the emplastrum plumbi. Over these straps is placed an additional covering of emplastrum saponis, spread on thick leather and cut into four broad pieces, one for each side of the joint. Lastly, the whole is secured with a calico bandage, which is not to be applied so as to cause any uneasiness from pressure." In this and in some other affections of joints, the above treatment is often instituted with the happiest results; but it must always be employed with the greatest caution, and its effects constantly watched; otherwise very serious con- sequences may result. It ought never to be adopted while any inflam- mation exists. The pressure should at first be slight, and gradually in- creased at future dressings; and even while it appears to be attended with benefit, the symptoms must be most carefully observed, so that if there should, from any circumstance, be a recurrence of inflammation, however slight, the dressings may be immediately removed, as the pres- sure would be exceedingly injurious. These are the principal precau- tions, and it is important that they be not neglected. Another excellent method of fulfilling the same three indications is, —to excite absorption by applying pieces of lint covered with ung. hydr. fort, cum camphora^, or equal parts of that ointment, and the ointment of the iodide of potassium ; to produce pressure by an elastic cotton roller; and to preserve the joint at rest by a leather or wooden splint retained by suitable retentive appliances. This method I have often employed with advantage ; and it has the recommendation that the dressings can be removed without any trouble, as often as the surgeon wishes to see the appearance of the joint. If, unfortunately, suppuration should take place, the matter must be dis- charged, and the treatment formerly mentioned as proper under such circumstances strictly enjoined. If the desired result should not thus be obtained, but the patient be in danger of sinking under the continued irritation and discharge, the local disease must be removed either by excision of the joint, or amputation of the limb. THICKENING, WITH MORBID ALTERATION OF STRUCTURE, OR BROWN INTRACTABLE DEGENERATION OF THE SYNOVIAL MEMBRANE. This disease, sometimes called the pulpy thickening of the synovial membrane, is characterized by certain marks or appearances, not found in any other disease of the joints. The synovial membrane is converted into a pulpy substance of a brownish, or reddish brown colour, and of a thickness usually varying from a line to half an inch, but sometimes even exceeding an inch. This substance is not of uniform consistence, but is intersected in various directions by a kind of fibrous bands. The disease generally commences in the reflected portions of the 334 INTRACTABLE DEGENERATION OF SYNOVIAL MEMBRANE. synovial membrane, and most frequently occurs in the knee joint; but Mr. Hodgson met with one example of it in the ankle joint, and with another in one of the phalangeal articulations of the fingers. I have in my possession an uncommonly well-marked example of this disease affecting the synovial membrane of the shoulder-joint, which I took from a male subject brought to the anatomical rooms of this University, when I taught anatomy. As at that time subjects were procured by exhuma- tion, I found it impossible to obtain a history of the case. The whole of the synovial membrane is more or less affected; at some parts it is about two lines in thickness, in others more than half an inch. It is of a light brown colour on its articular surface, and of a pulpy appearance, with firm intersections of a fibrous consistence. The cartilages covering the bones seem to be entire; the joint contained a thick opaque fluid, apparently synovia, mixed with pus. No other joints than those already mentioned have hitherto been found affected with this disease. It oc- curs principally in young persons, and in adults ; but is so exceedingly rare after the middle period of life, that Sir Benjamin Brodie has met with only one example. If allowed to run its course, it may terminate either in suppurative inflammation followed by ulceration and complete destruction of the joint, or in malignant tumour. In a beautiful speci- men of this disease, affecting the synovial membrane of the knee joint, which I took from a boy named Bisset, in whose case I found it neces- sary to perform amputation, the whole of the synovial membrane was affected, except the portion which is behind the patella ; but the parts covering the articular cartilages of the femur and tibia were much less affected than that which is situated round the circumference of the joint, where it was in some parts an inch in thickness, and projected into the cavity of the articulation. The articular surface was of a very pale brown colour; and the structure, when cut into, had a pulpy appear- ance, with white intersections of a fibrous consistence, and very much resembling those of carcinoma. At some few spots there were one or two injected vessels, but no vascular or other marks of inflammation could be discovered on the most careful examination; and the impres- sion conveyed to me and also to some friends well qualified to judge was, that the change of structure was the result of some other process than inflammation. The ligaments were entire, and the joint contained a ropy fluid. It is remarked by Sir Benjamin Brodie, to whom we are indebted for first pointing out this particular disease, that, " It would add much to the utility of researches in morbid anatomy, if it were more frequently attempted to ascertain what is the first change in the organization of the affected part which disease produces, and from thence to trace the gradual progress of the other changes which take place, until the de- struction of the natural organization is completed." It is the opinion of Sir Benjamin, that this disease belongs to the same order as scirrhus of the breast, the medullary sarcoma or fungus haematodes of the tes- ticle, and numerous other diseases in which the natural structure of the affected organ is destroyed, and a new and different organ formed in its place, and that although in its progress inflammation comes on, the degeneration into pulpy substance with fibrous intersections is not a INTRACTABLE DEGENERATION OF SYNOVIAL MEMBRANE. 335 result of common inflammation, but of a different kind of morbid action. Some surgeons consider the change of structure to be the result of a chronic form of inflammation. I have not seen a sufficient number of specimens at an early period of the disease to enable me to form a decided judgment; but those which I have seen, and especially the ex- ample of it in the knee joint described above, leave no doubt in my mind that the opinion of Sir Benjamin Brodie is correct. Symptoms.—Stiffness, accompanied with a sense of weakness not amounting to pain, first engages the attention of the patient; and as the disease advances, pain comes on, but usually it is for a long time inconsiderable, and is increased by exercise. Swelling is soon percep- tible, which has a doughy elastic feeling without fluctuation, and is irre- gular in shape. This elastic feeling is often very deceptive, and it is only after a very careful examination, under such circumstances, that the surgeon can satisfy himself of the absence of fluctuation. The stiff- ness gradually increases, and although in some instances a certain de- gree of mobility is retained, the joint in the great majority of cases at length scarcely admits of any motion. • With enlargement of the joint there is also wasting of the limb. The disease begins very gradually, and for a long time its progress is slow; but when it reaches its ad- vanced stages, the pain is often very great, and then its onward course is generally rapid. The disease, as has been already stated, may ter- minate either, as it usually does, in suppurative inflammation, followed by total destruction of the joint, or in malignant tumour, which, how- ever, is comparatively rare. In the former case, there will be the local and constitutional symptoms of suppurative inflammation; in the latter, the articulation becomes much swollen, and communicates to the finger a sensation as if greatly distended with fluid; the skin becomes tense, glistening, and prominently marked by dilated tortuous veins; the pain is severe and shooting, and attended with a sense of great weight; if an incision is made, blood only escapes, and the disease is now evidently of a malignant nature. For a considerable time constitutional symp- toms are not very distinctly marked; but a modified form of hectic supervenes, which, however, becomes much more urgent, when the sup- purative crisis arrives. The patient becomes sallow, greatly emaciated, debilitated, and dispirited, and shows the usual symptoms of the cachexy attendant on malignant disease. Treatment.—As we are not acquainted with any treatment by which the natural structure of any organ after being entirely changed can be restored, a knowledge of the state of the parts would lead us to the conclusion, which the present state of our experience may be said to authorize, that this disease is incurable. In its early stage it may be somewhat palliated, and its progress rendered less rapid, by means of rest, attention to the general health, and cold lotions; and the pain attendant on the suppurative crisis and the destruction of the cartilages may be considerably diminished by warm applications; and thus a cer- tain degree of relief may be obtained. Sir Benjamin Brodie, after referring to the partial benefit derived from this treatment, says, " But no method, with which I am acquainted, is capable of doing more than somewhat checking the progress, and somewhat relieving the symptoms of the complaint. In every case of which I have had an opportunity of 336 FIMBRIATED SYNOVIAL MEMBRANE. seeing the termination, the ulceration of the cartilages, the formation of abscesses in the cavity of the joint, and the consequent disturbance of the patient's general health, have ultimately rendered the amputation of the limb necessary, in order to preseve the patient's life. At this period, therefore, the surgeon is called upon to recommend and urge an operation; but at an earlier period it is a matter of choice with the patient, whether he will live with the incumbrance of a useless limb till the advanced stage of the disease renders its removal indispensable, or whether he will submit to the loss of it, before the absolute necessity for losing it exists." If amputation be deferred until the disease result in a malignant tumour, it will then be too late to derive from it any further benefit, than the doubtful chance of merely, for a short time, deferring the fatal termination. Some surgeons seem to think that at an early stage the disease may be cured, and they speak favourably of the result of treatment similar to that recommended for scrofulous synovitis. For my own part, having found it necessary to amputate in every instance which has come under my observation, I agree with Sir Benjamin Brodie in considering it incurable. FIMBRIATED SYNOVIAL MEMBRANE. In this disease the free surface of the synovial membrane is studded over with innumerable bodies termed fimbriae, of a white or yellowish white colour, and usually varying in size from a millet to a common pea; but some are found resembling, both Fig. 102. in size and appearance, the appen- dices epiploicae of the large intestines. They are smooth and uniform in their outline, and of a glistening appear- ance, as if invested with a capsule of the synovial membrane. They are sometimes broad, sometimes constrict- ed in their base, and connected to the synovial membrane by a narrow pedicle. In some cases, these bodies pervade the whole articulation; in others, they merely fringe the synovial membrane. They usually have the appearance of being formed of a cap- sule of the synovial membrane filled with a fatty substance, and occasion- ally they are somewhat of a cartila- ginous consistence. This being a very rare disease of the synovial membrane, little is as yet understood either of its causes, or of the nature of the morbid action by Which the change of structure is pro- duced. I have seen one specimen of it in the museum of the University of Edinburgh, and three most beautiful specimens in the museum of St. George's Hospital, London ; of one of DISEASE OF ARTICULAR CARTILAGE. 3.M7 the best of which Mr. Hewitt kindly allowed an artist to take a drawing for me, a copy of which is here given. Symptoms.—Pain during and after exercise, and a grating sensation on moving the articulatory surfaces of the bones on each other. The joint becomes swollen and elastic, with stiffness and more or less limita- tion of its motion. DISEASE OF ARTICULAR CARTILAGE. DESTRUCTION OF CARTILAGE. Destruction of the substance of cartilage may take place without the slightest trace of disease in other structures, and as the result of actions confined to the cartilage itself; in which circumstances it is said to be original or primary ; or, it may be the consequence of acute, chronic, or scrofulous synovitis, or of inflammation of the portion of bone to which the cartilage adheres, or of scrofulous degeneration of the joint-ends of bone ; when it is called secondary. The destruction may thus be either original or secondary; it may be extremely rapid or very slow, constituting acute pr chronic destruction; it may be limited or extensive ; it may be superficial and limited, or superficial and extensive, or it may go through the whole thickness of part of the cartilage, and thus penetrate to the bone. Though it most frequently commences on the free surface, it may commence in the middle of the substance of the cartilage, or, if it proceed from disease of the bone, on the attached surface. It may be unattended with the slightest vestige of disease of the synovial membrane or bone; it may even be cured by the unassisted efforts of nature, with- out the occurrence of any new exudation, by the formation of a fibro- nucleated membrane from the substance of the cartilage itself; or, it may lead to disease of the synovial membrane or bone, ending in total destruction of the joint. It is very remarkable that in all these varie- ties, the structural changes in the cartilage are found, on microscopical examination, to be similar, consisting in changes in the structure and arrangement of the cells, and alterations in the hyaline substance. When a thin slice of articular cartilage, in a healthy state, is exa- mined with a microscope, it is seen to consist of an apparently homo- geneous substance called the hyaline substance or matrix, with nucleated cells, named also cartilage corpuscles, disseminated through it with a certain order and arrangement. No blood-vessels are seen in cartilage, nor is there the slightest reason for believing that it contains any. Whatever nutrient fluid it requires, is derived from the vessels of ad- joining textures, and is conveyed, it is believed, through the tissue by imbibition. No nerves have been traced in cartilage, and it is known to be destitute of sensibility. From this brief description of articular cartilage in its healthy state, the following account of its morbid changes will be more intelligible. To Professor Goodsir and Dr. Redfern belong the merit of having successfully investigated the changes in the form, contents, and arrange- ment of the cells, and the alterations in the hyaline substance which take place in the various forms of destruction of articular cartilage, and of having brought forward the views which are at present entertained 338 DISEASE OF ARTICULAR CARTILAGE. ;$v ..... ■& WMm m: 4s ;■ mcL regarding those changes. The principal structural changes observed in the cells and in the hyaline substance are the following. As was first pointed out by Pro- Fig. 103. fessor Goodsir, destruction of car- tilage is always accompanied by enlargement, change of form, and irregular arrangement of the cells. They become " larger, rounded or oviform, and instead of two or three nucleated cells in their inte- rior, contain a mass of them." The enlarged corpuscles at the sur- face burst, and discharge their con- tents, so that the disintegrated sur- face presents a series of cavities. In many instances the contents of the cells, after having been discharged, assist the altered hyaline substance in the formation of a fibro-nucleated membrane on the surface of the dis- eased portion of the cartilage. In such cases the nuclei become elonga- ted and incorporated with the fibres of the split-up hyaline substance ; and this is one of the most remarkable Fig. 104. -'■'8® natb transformations of the nuclei which have as yet been observed. Other changes of the nuclei, of frequent occurrence, are their conversion into Fig. 103. Diseased articular cartilage, showing enlargement of the corpuscles, and the contents of the more superficial thrown out intoth« intercorpuscular substance.—Copied from Redfern. Fig. 104. Vertical section from the cartilage of the central part of the internal glenoid cavity of the tibia, showing the splitting into fibres on the surface.—Copied from Red- fern. DISEASE OF ARTICULAR CARTILAGE. 339 fatty granules, and into fat globules. The conversion of the nuclei into drops of oil was first described by Mr. Rainy. In cases of very rapid destruction of cartilage, it appears that the changes are almost entirely confined to the cells. The alterations in the hyaline substance consist of its losing its natu- ral homogeneous appearance, and in its being split up into bands and fibres, which project into the joint. These bands become incorporated with the liberated and elongated nuclei, and thus constitute a fibro- nucleated membrane, without the aid of any exudation, and by changes in the cartilage itself without any other texture being involved. These fibres constitute processes projecting into the joint, separated from each other at their free extremities, and at their attached extremities, con- tinuous with the hyaline substance. Dr. Redfern was the first to de- monstrate the conversion of the hyaline substance into fibres in disease of articular cartilage. The cartilage, during the whole of this process, Fig. 105. remains non-vascular, and the membrane above referred to, is regarded as the result, not the cause of the destruction. If other textures become involved, exudation may take place from them, and the exuding matter becoming pervaded by vessels derived from the involved texture, con- stitutes a vascular adventitious membrane in contact with the diseased portion of cartilage. This membrane is sometimes formed between the bone and the cartilage; and there can be no doubt that to its formation in that position and its becoming pervaded by vessels derived from the bone, may be attributed the erroneous impression entertained by some observers, that in one form of destruction of articular cartilage the destruction is preceded by the formation of vessels in the substance of the cartilage itself. The usual situation of the adventitious membrane is on the free surface, and its formation is properly attributed to the synovial membrane becoming involved, and giving out an exudation winch becomes pervaded by vessels derived from itself. Dr. Redfern in his work on anormal nutrition in articular cartilage has given the following as the conclusions at which he has arrived in consequence of his investigations. First,—That all the known forms of disease in articular cartilages tTea^oTher ^ * ^ t6XtUre' ^^ ^ essentiaI1V s™ilar Second,—That during the progress of these changes, the cells of the celKnu^ 340 DISEASE OF ARTICULAR CARTILAGE. cartilage become enlarged, rounded, and filled with corpuscles, in lieu of healthy cells ; bursting, subsequently, and discharging their contents into the texture on the surface ; whilst the hyaline substance splits into bands and fibres, and the changed hyaline substance, and the discharged corpuscles of the cells, afterwards form, in many cases, a fibro-nucleated membrane on the surface of the diseased cartilage. Third,—That these changes are referable only to an anormal nutrition as their immediate cause, and in no case to mechanical or chemical actions, such as attrition or digestion in a diseased secretion. Fourth,—That most extensive disease may go on in many joints at the same time, and may proceed to destroy the whole thickness of the cartilage in particular parts, without the patient's knowledge, and whilst he is engaged in an active occupation. Fifth,—That the disease commences most frequently on the free surface; but may proceed from the bone to affect the attached surface, or may take place in the middle of the thickness of the cartilage. Sixth,—That it is, at least, very doubtful if the symptoms which are believed to indicate the existence of ulceration of articular cartilages, are not really dependent on a morbid'change in the bone. Seventh,—That.disease of the whole thickness of an articular cartilage at particular parts, admits of a natural cure, by the formation of a fibro- nucleated membrane from the substance of the cartilage, without the occurrence of any new exudation. Favourable Results.—These vary according to the depth of the destruction. If only a portion of the cartilage be removed, the destruc- tion not extending through the whole of its depth, the diseased part may be healed, on the subsidence of the abnormal nutrition, by a fibro- nucleated membrane, formed entirely from the cartilage itself, in the manner already described. In such cases, the affected part, as will be understood from what has already been stated, presents a villous ap- pearance. If the destruction be superficial, and the synovial membrane be involved, there may be incorporated with the fibro-nucleated membrane a depressed cicatrix formed by exudation from the synovial membrane. When the loss of substance is to a greater depth, exposing the surface of the bone, or when a limited portion of the bone is removed, exuda- tion may take place from the vessels of the bone, and osseous granules, not rising to the level of the cartilage, may occupy the affected part, or the granules may be covered by a depressed cicatrix derived from the synovial membrane. Reproduction of cartilage never takes place, and instead of any of the above favourable results, the place of disintegrated cartilage may be occupied by an amorphous formation, technically called the porcellanous deposit. This substance fills up the cavity, and its smooth and polished surface compensates for the want of cartilage and of synovial membrane. If there happen to be destruction of cartilage and osseous granula- tions on opposite sides of an articulation, the granulations may unite, and a form of anchylosis be produced. Of many fine specimens of anchylosis in my collection, the first of the accompanying drawings represents one of a section of the hip joint, in which the anchy- DISEASE OF ARTICULAR CARTILAGE. 341 Fig. 106. losis is very perfect after the whole of the cartilages have been removed; the cancel- lated structure of the one bone is perfectly continuous with that of the other. The second drawing gives a representation of an- other very perfect specimen of anchylosis, also in my possession. The third represents a specimen now in my collection, given to me by my late friend Mr. Liston: it is represent- ed in his " Elements of Surgery," and in the second edition of Professor Miller's admirable work on the "Principles of Surgery." The above are the favourable results; but in many cases, ulceration and other morbid changes advance so far as to involve the whole of the tissues, and ultimately to pro- duce total disorganization of the joint. ^ Symptoms.—While the destruction is en- tirely confined to the cartilage, and the other tissues are perfectly healthy, the patient may experience no unusual sensation in the joint. When other tissues become involved, a Fig. 107. Fig. 108. ,auK°4 ttToitrnMosis of hip join'' *»*^^ri^"r,™p* of Surgery," .nd now in mv LsennT ' dellneMed >» «'• Listen'. « Elements 342 DISEASE OF ARTICULAR CARTILAGE. deep dull uneasiness in the joint, and diminished power of motion, are the first symptoms. The uneasiness at first is slight, not amounting, perhaps, to actual pain ; it is only occasional, and is often referred to different parts ; but it gradually becomes more severe, constant, and limited to a particular spot. These symptoms are believed to be coeval with the morbid changes in the early stages. While destruction is going on, the pain increases, and as the disease advances, it becomes exceed- ingly excruciating, especially during the night, the nocturnal exacerba- tions and involuntary startings of the limbs being very distressing^ The pain, at this period, is referred to a particular spot, and is often said by patients to resemble the gnawing of an animal. This is supposed to correspond with the period of the formation of matter. Matter never forms, according to Dr. Redfern, until other tissues have become involved, and he supposes that the pain is produced by morbid changes in the bone, and not by the destruction of the cartilage. The pain is aggra- vated by motion, and also by pressure, if directed against the diseased portion of the joint. Sympathetic pains are also felt, which vary in situation according to the site of the disease, and the tenderness, on pressure, is not only at the seat of the disease, but sometimes also, although very rarely, at the parts sympathetically affected. Swelling is a symptom, and for the purpose of diagnosis its characters should be carefully observed. It is long in making its appearance, is slow and gradual in its increase; and deep in situation ; it does not bear handling without pain ; it is nearly uniform in shape, and destitute of that peculiar bulging out at particular parts which is so characteristic of the swelling in the usual forms of synovitis; and fluctuation, though for a long time obscure, becomes distinct in the advanced stage. It differs from the swelling in synovitis in its shape, and the time of its appearance, not being coeval with the pain; and from the swelling in scrofulous gelatinous degeneration, which, however, it more nearly re- sembles in shape, in the lateness of its appearance, and in the pain which is felt on pressure. The swelling proceeds partly from the pre- sence of matter within the joint, and partly from serous infiltration into the external soft tissues. These secretions, as the textures closing in the joint are destroyed, at length communicate, and the fluctuation then becomes distinct. The superimposed muscles become wasted, often giving rise, at an early period, to an unnatural form about the joint; the whole limb becomes emaciated and feeble; its circulation is weak, and there is a tendency to oedema. For a long time the joint is often maintained in a particular position, from the patient feeling in that position some diminution of pain; but in consequence of disorganization of the joint it frequently happens that displacement of the bones ultimately takes place. At first there may be no constitutional symptoms, but as the disease advances, those of inflammatory fever appear, and ultimately change to the symptoms of the hectic type. Symptoms of Destruction of Cartilage of the Hip Joint.— When the disease is seated in the hip joint, and proceeds to an advanced stage, it gives rise to pain with diminished power of motion, tenderness on pres- DISEASE OF ARTICULAR CARTILAGE. 343 sure, change in the form of the nates, alteration in the length of the limb, and ultimately to the local and constitutional symptoms of chronic abscess. These symptoms present the characteristics already men- tioned in the description of the symptoms hitherto usually regarded as denoting ulceration of cartilage; but they have also some peculiarities, which it may be proper to notice. The pain is increased by motion, or by pressure of the trochanter inwards, or of the limb upwards, or by any means which direct the pressure against the diseased portion of the joint; and sometimes to relieve the parts affected as much as possible from the pressure, the patient maintains the limb in a position in which the ball of the femur is made to press least against the acetabulum. The pain is felt in the joint, and also at the knee, principally along its inner side ; and though the knee is only sympathetically affected, the pain is sometimes more severe there than at the hip, so that it is occasionally difficult to con- vince a patient that the seat of the disease is not in the knee. This is an exemplification of what is frequently observed, namely, that when disease exists at one set of terminal expansions of a particular nerve, the pain is often referred to the extremities of other branches given off by the same nerve; for the anterior crural nerve gives branches to the hip and also to the knee ; and the trunk of the obturator nerve supplies the hip joint with nerves, while its anterior and posterior branches give nerves to the knee. Tenderness on pressure is felt at the hip, more especially in front of the joint, and posteriorly on the inner side of the great trochanter. It is remarkable that there is sometimes tenderness at the knee, when the sympathetic pain is experienced. The change in the form of the nates is, that they become flattened by the wasting of the glutei muscles from want of exercise. This is an early symptom, and it makes the nates appear wider than natural; they feel flaccid to the touch, and their under edge is observed to be more loose than in the healthy state. In an advanced stage, the form may be still further changed by the head of the bone being drawn from the acetabulum upon the dorsum of the ilium. The alteration of the length of the limb has this peculiarity, that there is an apparent elongation in the early stage, and an actual shortening in the advanced. The balance of the pelvis being lost, the sound limb sustains the weight of the body, and raises up the pelvis on that side, while on the other, the pelvis not being supported by the diseased limb, falls down, and thus occasions the apparent elongation; but it is only apparent, for if the measurement be taken in the early stage between a given point of the pelvis, and a given point in the limb on the diseased side, and compared with the measurement between the same points on the sound side, they will be found to be the same. The alteration of the po- sition of the pelvis may cause lateral curvature of the spine, which is often a consequence of this disease. It has been stated by some authors that in the first stage, apparent shortening has been sometimes observed in- stead of apparent lengthening. This is to be attributed to the patient drawing up the pelvis on the diseased side, to enable him to steady the 344 DISEASE OF ARTICULAR CARTILAGE. weight of the body on the other limb; and thus the crista of the ilium becomes higher on the diseased than on the sound side. In the advanced stage of the disease, the limb becomes shortened; and in most instances, this is owing to the loss of substance and destruc- tion of the head of the bone, and the corresponding changes of the acetabulum, by which the latter becomes widened, allowing the limb to be drawn up by the action of the muscles, while the head of the femur still remains within the acetabulum. In many cases, however, the short- ening depends on the actual dislocation of the femur, produced by the action of the muscles, after the ordinary organs of relation, the liga- ments, are no longer able to perform their office, owing to the destruc- tion of the portions of bone to which they are attached. The direction in which the femur is dislocated is almost invariably upwards and out- wards, but instances have occurred where the dislocation has been into the ischiatic notch, or in front of the foramen ovale, or upwards and forwards upon the pubes. It has also been found in the cavity of the pelvis, of which I met with an example in a young man twenty-five years of age, in whose case the floor and margins of the acetabulum were completely removed. From the history of the case, I thought there was reason to believe that the destructive process had commenced in the soft parts. When dislocation upwards takes place, the toes are directed inwards; but in other circumstances, I have almost invariably found the foot slightly inverted in the first stage, and, in by far the greater number of cases, when unattended with dislocation, slightly everted in the advanced stage. A general tumefaction takes place about the joint, and afterwards a swelling, which at first presents the peculiarities already described, and at length usually exhibits the characters of an abscess. The abscess is not in all cases found in the same situation, but its appearance is always unfavourable: for, though in children recovery has taken place after the formation of abscess, in adults it is almost invariably fatal;—the limb becoming wasted, and ultimately oedematous, and the constitutional symptoms soon appearing to be those of hectic fever, with its usual train of consequences. The disease has been met with at all ages; but it occurs most fre- quently between the period of puberty and the thirty-fifth year; and it forms, as has been remarked, the majority of cases of hip disease among adults, whereas the disease of the hip most frequently met with among children is that which begins in the cancellated structure of the bones. Treatment of Destruction of Cartilage.—One of the most important indications during the whole progress of this disease is, to maintain the joint at perfect rest; and unless this be attended to, no treatment will prove of any avail. The limb should be placed in the attitude which will be most useful to the patient in after life, and the means employed for obtaining immunity from motion in that attitude will vary according to the situation of the disease. Local depletion, especially by cupping, is employed, but chiefly as a precaution before using counter-irritation, on which the principal hope of benefit must rest. The preferable form of counter-irritation seems to vary according to the period of life, and to a certain extent according to the seat of the disease. In children, the DISEASE OF JOINTS BEGINNING IN THE BONE. 345 best mode is the application of blisters;—and from my own observation, I am of opinion that at the commencement, a succession of small blisters affords the greatest relief, but that afterwards, it is better to keep up irritation of the blistered surface by means of some stimulating oint- ment. When the disease is in the wrist or the ankle, the application of blisters should be continued throughout, as some of the other modes of producing counter-irritation may be injurious to the tendons, which at those joints are so near the skin. In adults, caustic issues are preferable to blisters; they are more serviceable in this than in any other disease of the joints, and the best method of employing them is frequently to retouch the parts with the caustic potass. Moxa and the actual cautery are also employed. The latter is very much praised by some surgeons; but, chiefly owing to the difficulty of persuading patients to submit to it, I have not had sufficient experience to enable me to form a decided opinion from my own observa- tion. Of the good effects of issues I can speak with confidence. There are some precautions, however, which ought to be observed in the use of blisters and issues, namely,—not to apply them directly over the joint, but in its immediate neighbourhood, unless the joint be sufficiently deep for them to have room to act on the principle of derivation,—not to em- ploy them after the complete subsidence of pain,—nor to carry them so far as to induce general debility; and when the symptoms of hectic fever appear to demand the removal of the joint, if it be in an accessible situation, then to discontinue them entirely for some time before ven- turing on such a step, lest the constitutional symptoms should be partly the effect of treatment carried to too great an extent. SCROFULOUS DISEASE OF THE JOINTS, IN WHICH THE CANCELLATED STRUCTURE OF THE BONES IS PRIMARILY AFFECTED. Morbid Changes.—According to Sir Benjamin Brodie, the first de- viation from healthy structure in the cancellous texture of the heads of the bones is, preternatural vascularity. There is also an unusual soft- ness in the bone, from its containing less of earthy matter than in the healthy condition. The cancelli are next filled with a thin, transparent fluid; and, as the disease proceeds, they have a tubercular or cheese- like substance deposited in them. This is followed by inflammation and by absorption of the portion of bone between the morbid deposit and the cartilage, and ultimately by the destruction of the cartilage and syno- vial membrane: so that a communication is thus opened between the joint and the part containing the morbid deposit, and a portion of the deposit is discharged into the joint, leaving a cavern in the bone. Sir Benjamin Brodie says, " the cartilage ulcerates in spots, the ulceration beginning on that surface which is connected to the bone." On this subject Goodsir remarks, " In scrofulous disease of the cancellated tex- ture of the heads of bones, or in cases where the joint only is affected, but to the extent of total destruction of the cartilage over part or the whole of its extent, the latter is, during the progress of the ulceration, attacked from its attached surface. Nipple-shaped processes of vascular texture pass from the bone into the attached surface of the cartilage, 346 DISEASE OF JOINTS BEGINNING IN THE BONE. the latter undergoing the change already described. It may be under- mined for a greater or less extent, or be thrown into the fluid of the joint in small detached portions, or it may entirely disappear." In all these changes, however, according to the views now entertained, the cartilage itself remains non-vascular. The ulceration 'of the cartilage and synovial membrane, and the discharge of the deposit originally con- tained in the bone, are followed by general synovitis, which very rapidly terminates in suppuration; and the contents of the joint, consisting of purulent matter, tubercular degeneration, and the debris of the bone, may ultimately be discharged by ulceration of the external soft tissues. Soon after the disease is fully established, and the communication is opened, as above described, between the diseased cavity and the joint, the changes within the bone are followed by effusion of lymph into the soft parts immediately surrounding the bone, which gives rise to a firm swelling; and at a more advanced period, by effusion of serum into the cellular tissue, which causes slight oedema. There is, at an early stage, a hard swelling from effusion of lymph, and afterwards a swelling with fluctuation from the distension of the synovial membrane by the con- tents of the cavity of the joint. The skin over the swelling remains white, but from its natural wrinkles being unfolded, it presents a kind of glazed appearance; the veins under it become large, and the parts above and below the joint, weak, soft, and emaciated. The scrofulous or tubercular deposit may be the result of previous perversion of nutri- tion, or a change in the liquor sanguinis exuded, in consequence of a slight grade of the inflammatory process ;—the change into this morbid deposit being believed to depend on the inherent composition or consti- tution of the liquor sanguinis itself. It is not regarded, therefore, as a disease necessarily of inflammatory origin, although as it advances, a process of inflammation comes to be connected with it. The above ap- pearances are revealed only by dissection. Symptoms.—Slight pain, or uneasiness scarcely amounting to pain, and felt only at times, and a considerable sense of weakness of the articula- tion, are usually the earliest symptoms. As the morbid changes advance, the pain becomes more severe, and is for a long time referred by the patient to a particular spot about the extremity of the bone. The pain is of a heavy, aching, bursting character, and is generally brought on by the heat of bed, by the dependent posture, and by motion. These symptoms are coeval with the changes in the bone. In the course of time, the pain is followed by a swelling, which at first is firm, hard, and unyielding, and seems to depend on enlargement of the bone; but this is not really the case, for expansion of the shell of the bone rarely, if ever, occurs in this disease. On this subject Professor Samuel Cooper remarks " It was formerly a common notion that in white swellings the heads of the bones were always enlarged ; Mr. Russell, I believe, is the first writer who expressed an opposite sentiment, that he has never heard of an instance in which the tibia was enlarged from an attack of white swelling. The inaccuracy of the opinion was afterwards pointed out by Mr. Lawrence to the late Mr. Crowther, and the subject was mentioned in the earliest edition of the ' First Lines of the Practice of Surgery.' DISEASE OF JOINTS BEGINNING IN THE BONE. 347 " Deceived by the feeling of many diseased joints, and influenced by general opinion, I once supposed there was general, or regular expan- sion of the heads of scrofulous bones. But excepting occasional enlargement which arises from spiculse of bony matter deposited on the outside of the tibia, ulna, &c, and which enlargement cannot be called an expansion of those bones, for a long time I never met with the head of a bone enlarged in consequence of the disease known by the name of white swelling. I was formerly much in the habit of inspecting the state of the numerous diseased joints, which were every year amputated at St. Bartholomew's Hospital, and though I was long attentive to this point, my searches after a really enlarged scrofulous bone always proved in vain, nor was there, at that period, any specimen of an expanded head of a scrofulous bone in Mr. Abernethy's museum." In those instances in which real enlargement of the head of a bone has been found, the disease did not originate in tubercular degeneration of its cancellous texture. In the next stage, the pain is throbbing and extends over the whole articulation, and the swelling is no longer con- fined to the situation of the bone, but is general over the whole joint, and presents the character of fluctuation. These symptoms are coeval with the inflammation of the synovial membrane. Ultimately the skin becomes tense, white and glistening, and is marked with dilated tortuous veins ; and the inflammation extending to the superimposed soft tissues, often gives an oedematous character to the swelling. The disease has already advanced to suppuration, and the matter, together with the debris of the bone, may be discharged through ulcerated apertures. At first, there is little constitutional disturbance. After some time, inflam- matory fever comes on, and is ultimately succeeded by hectic. This, like other varieties of scrofulous disease, is most incidental to young persons, and usually occurs before the age of puberty ; and although it has occasionally been found in persons in the middle period of life, yet it very rarely attacks any one after thirty years of age, who has not previously been the subject of scrofulous disease. Treatment.—In this, as in all scrofulous diseases, the local affection is very much influenced by the state of the general health, the improve- ment and maintenance of which becomes therefore of paramount impor- tance. The formation of the cheese-like deposit in the cancellated structure of the bone takes place at an early period, and the conditions most favourable to its formation are believed to be, the scrofulous dia- thesis, and a weak state of the general health. It is often found in persons of that habit who have been confined to situations where the air is impure, cold, or damp ; who have been excluded from free exposure to the light of the sun; who have lived on a diet not sufficiently nutri- tious, who have not enjoyed regular exercise and fresh air; or who have been subjected to any cause of debility. If the presence of the deposit be suspected, the endeavour must be made to limit its extent and to delay the suppuration by removing the patient from the exciting causes of the unhealthy secretion. For that purpose free exposure in the open air, generous diet, the use of cod-liver oil, attention to the state of the skin, and the use of such medicines as, from the particular state of the patient, are most likely to improve the general health, must 348 DISEASE OF JOINTS BEGINNING IN THE BONE. be strictly enjoined. A complete change of air, scene, and mental occupation, by improving the general health, is often found to produce the mos.t beneficial effect on the local affection; and, on the same prin- ciple, a change of residence to the sea-side, from the bracing air there to be found, has often been observed to lead to very favourable results. Tonic medicines, and more especially the preparations of iron, are useful; but as permanent strength can be gained only by the proper assimilation of nutriment, those medicines are most likely to be useful, which, from the particular state of the patient, are most calculated to fit the digestive apparatus for the proper performance of its functions. As a tonic and alterative, I have often prescribed, and apparently with advantage, the iodide of iron. Of the preparations of iron, the vinum ferri of the old Pharmacopoeia, and the saccharated carbonate of iron, are forms often used in such cases. These means for improving the general health will be found most effectual for limiting the cheese-like deposit, and preventing and repressing inflammation ; for in this, as in all scrofulous diseases, more benefit may be expected from constitutional than from local treatment. For facilitating the description of the local treatment, the disease may be considered in three different stages:— 1. When it is confined to the bone ; 2. When it extends into the articulation; 3. When the abscess bursts. In all these stages, rest is an important part of the treatment. In the first stage, the indications to be fulfilled are—to limit the dis- ease, and prevent its extending into the joint. With this view, in addi- tion to rest of the limb, cold applications are sometimes employed with advantage. Depletion by leeches, and counter-irritants, are at times necessary, but the employment of depletion forms no prominent part of the treatment. In this stage I have frequently prescribed leeches, when, from any circumstance, there seemed to be a fresh accession of inflammation, and the apparent result has been to relieve, for the time, the urgency of the symptoms; but beyond this, I have never been sen- sible of any advantage, and in no case have I ventured on the practice but with reluctance. It ought always to be remembered that depletion has less influence in scrofulous than in common inflammation ; and that if carried so far as to produce an impression on the general health, it increases the danger of the local affection. Mild counter-irritation, to an extent not to affect the general health, may, in general, be resorted to with advantage. In the second stage, rest, with warm emollient applications, as poul- tices and fomentations, are the local remedies most likely to give relief. In the third stage, rest is necessary, lest any of Nature's attempts at anchylosis should be frustrated. Pressure should also be employed so far as to diminish the size of the sinuses, without obstructing the dis^ charge of the purulent matter. If the disease continue to advance, and the hectic fever be to such an extent as to endanger life, amputation may be necessary ; but before determining on this step, the state of the internal organs should be carefully examined, with the view more espe- cially of ascertaining whether or not the patient be free from pulmonic and mesenteric disease ; for it may be found that the tubercular dege- t MORBUS COXARIUS. 349 neration is general, and, if so, there is but little probability that an operation would be followed by recovery. MORBUS COXARIUS, OR SCROFULOUS DISEASE OF HIP JOINT. This disease, most commonly affecting children and individuals under the age of puberty, is occasionally though rarely met with at a later period. It forms the great majority of cases of hip joint disease in children, and begins in the cancellated structure; whereas the disease of the hip joint usually met with after puberty, and most common between that period and the thirty-fifth year, of which a description has already been given, is believed to commence with destruction of the articular cartilages. As the symptoms of this disease are, with certain exceptions which will be afterwards stated, the same as those of the disease of the hip joint beginning in the cartilages, and as the morbid changes are of the same nature as those of scrofulous disease of joints in which the bone is primarily affected—this being an example of that form of disease in the hip,—it will not be necessary to give so length- ened a description of certain points, as would otherwise have been requisite. Symptoms.—These have been divided by some authors into two stages, by Ford and others into three, and some have arranged them into four stages or periods, the first being what they call the period of invasion. In the following description we shall divide them into three stages. First Stage.—This, like some other scrofulous diseases, is of so in- sidious a nature, that often it has made considerable progress before its existence is suspected, the patient complaining for a long time merely of weakness and weariness of the limb, with uneasiness at the knee, but without any pain at the hip. This absence of pain in the affected joint has, in some instances, led unwary practitioners to mistake the seat of the disease. With these symptoms, there is a halt or slight limpino- in walking, and if the extremity be examined at this period, it will be found that the hip is flattened by the wasting of the glutei mnscles, the limb emaciated, and the affected extremity elongated ; which last phe- nomenon arises, as is explained by Hunter, from the pelvis being lower on the diseased side, in consequence of the patient supporting the body on the sound limb. As the disease advances, there is usually pain in the hip Joint, though by no means so great as in the disease origi- nating in the cartilage;—in some instances it is inconsiderable when compared with the pain at the knee. The explanation of the pain at the knee has been given in the section on destruction of the car- tilages of the hip joint. Before the termination of this stage, there is a sense of tension in the groin, and the lymphatic glands in that situation usually begin to swell. Second Stage.—The pain at the knee is much increased, and is almost always considerably greater than at the hip, but in the last-mentioned situation only, is it increased on pressure, which is an excellent guide to the seat of the disease. There is pain at the hip joint on concussion produced by striking the trochanter, the knee, or the sole of the foot 350 MORBUS COXARIUS. The pain is much aggravated by motion; the patient supports his body entirely on the sound limb; the motions of the joint are impeded, so that flexion and extension cannot be carried to their natural extent, and there is also limitation of rotation, especially of rotation inwards, any attempt at which gives rise to great pain. Forcible abduction also causes pain at the hip. There is considerable swelling about the upper part of the thigh, together with the other symptoms, namely, flattening of the hip and its consequent unnaturally broad appearance; a lower position of the trochanter and fold of the hip, than on the sound side; wasting of the limb, and apparent elongation of the extremity. Some surgeons state that real elongation takes place in this stage; but for my own part, though I have given particular attention to this point, I have in every instance found the elongation seeming, and not real. By those who believe the elongation to be real, various explanations have been offered. Some suppose that, from the relaxation of the muscles and ligaments, the thigh bone is partially expelled from its socket, and so falls down; others, that the under part of the acetabulum being de- stroyed, it thus becomes wider, and the muscles relaxed ; while others think that the under part of the acetabulum and part of the head of the femur are simultaneously destroyed. I believe, however, that, in every instance, the lengthening will be found to be only ap- parent, and that if the patient be placed in a horizontal position, and a careful examination be made of the measurements between correspond- ing points of the pelvis and extremities, they will be precisely the same on both sides of the body. With alteration of the position of the pel- vis, there is often found lateral curvature of the spine. Third Stage.—In this stage, the swelling is larger and more painful, it presents the character of fluctuation, and ultimately breaks, the mat- ter which continues to be discharged being of an unhealthy character, and indicating carious destruction. Sometimes the abscess, instead of appearing on the thigh, has made its way into the pelvis through an opening occasioned by the destruction of the bottom of the acetabulum; in some cases it has burst into the vagina, and in others into the rectum; and occasionally it has been found to be discharged into the pelvis, and thence to escape through the ischiatic notch. The appearance of an abscess is always an extremely unfavourable symptom. In this stage, the extremity becomes really shortened, either, as in the disease ori- ginating in the cartilage, from destruction of the margin of the aceta- bulum, whereby the cavity becomes shallower and wider, so as to admit of the limb being drawn up, or from this condition combined with de- struction of the head of the femur, or from actual dislocation. The shortening is sometimes sudden, but more frequently gradual. When dislocation takes place,—which, however, is not always the case,—the head of the femur is usually, although not invariably, drawn upwards and outwards upon the dorsum of the ilium. In this case the trochanter major is drawn upwards near the crest of the ilium, and the hip is pro- tuberant, the swelling being produced by the upper extremity of the femur, and the muscles which are raised up by it. The wasted condi- tion of the limb makes the swelling appear greater than it really is. The head of the bone has been found, although very rarely indeed, dis- MORBUS COXARIUS. 351 placed in other directions; namely, backwards, towards the ischiatic notch; forwards, upon the pubes ; and downwards and inwards in the direction of the foramen ovale, when the extremity has been found Fig. 109. everted and elongated. There is a tendency to flexion of the thigh which increases as the disease advances, and the foot is at last affected with oedematous swelling. With regard to the direction of the toes; I have sometimes found hem inverted m the early stage, but much more frequently everted, so that, judging from my own personal observation, I consider slight ever- sion to be their usual position in this stage; and after shortening has taken place, I have seen them sometimes still everted, with the foot directed nearly as it is in fracture of the neck of the thigh-bone, but much more frequently turned inwards, as in dislocation on the dorsum ot the ilium. According to some authorities, when the destructive pro- cess is chiefly confined to the acetabulum, the head of the bone beinz comparatively little affected, the toes will be rotated inwards? whereas tance to the action of the powerful rotators outwards is in a measure neous dislocation. Vom a paSt T*£!*%2^ * ^ 352 MORBUS COXARIUS. removed, and eversion is the consequence. The age of the patient is to a certain extent a guide to assist in distinguishing this disease from that which commences in destruction of the cartilages, but the less degree of pain in this disease is the principal distinction. In a very few instances Sir Benjamin Brodie found, in the most advanced stage, that, owing to a portion of bone having exfoliated so as to be loose in the cavity of the joint, the soft parts were so greatly irritated as to occa- sion constant suffering. The general health is at first but little affected ; after some time, slight symptoms of inflammatory fever may supervene; but the formation of abscess is followed by hectic, and its usual train of consequences. Morbid Changes.—Opportunities of making dissections in the third stage are unfortunately numerous; Fig. 110. but as in that stage the whole arti- cular apparatus is involved, it is im- possible at that period to discover by dissection which structure was primarily affected. Opportunities of examining the state of the parts in early stages are not numerous, being only met with in those persons who have died of other diseases after the hip joint had become affect- ed. From examinations, however, which have been made in such cir- cumstances, there is reason to con- clude that this disease begins in the bone—that the morbid changes are Fig. 111. Fig. 112. of the nature described in the section on scrofulous disease of joints Figs. 110, 111, 112. Every stage of Morbus Coxarius, exhibiting tubercular deposit in the substance of the bone forming the acetabulum, and in the head of the femur. On the articular surfaces of both bones various irregularities and hollows are observed leading to masses of the deposit. The patient died of inflammation of the brain, which aflForded an opportunity of verifying the diagnosis made during life. From preparations in my museum. MORBUS COXARIUS. 353 beginning in the cancellated structure—that in the majority of cases the os innominatum is primarily and most extensively affected—that it sometimes begins in the femur, and that occasionally the morbid action commences contemporaneously in both bones. The first deviation from the healthy condition is, that, according to Brodie, part of the can- cellated structure becomes preternaturally vascular—that at an early period the affected part becomes unusually soft from a deficient propor- tion of earthy matter, and then a thin fluid is deposited in the cancelli. These changes constitute the anatomical characters at an early period of the disease. As the disease advances, the bone becomes still softer, and, instead of a thin fluid, a cheese-like substance is deposited in the cancelli, and, in many instances all traces of cancellous structure disap- pear, its place being occupied by the cheese-like substance, as several beautiful specimens in my own collection demonstrate. According to the views now entertained, the scrofulous deposit may be the result of previous perversion of nutrition, or a transformation of liquor sanguinis, exuded in consequence of a slight grade of the inflammatory process. In the progress of the disease, the structures between the deposit and the joint undoubtedly become involved in a process of inflammation ; and as a result of this, a communication is established with the cavity of the articulation, and the whole articular surface becomes the subject of the morbid changes described in the section on scrofulous diseases of the joints beginning in the cancellous structure, which changes it is unneces- sary here to repeat. That an inflammatory process occurs in the pro- gress of the disease, all agree; but as to the nature of the morbid action of which the cheese-like deposit is a result, there has been a difference of opinion. Sir Benjamin Brodie, Lloyd, Rust, and others, regard the deposit as a product of inflammation, while others think it may be a result of perverted nutrition or secretion unconnected with inflammation, or a transformation of liquor sanguinis exuded in consequence of inflam- mation. From many facts which have been ascertained, there seems reason to conclude, that in scrofulous constitutions, tubercular deposits in certain textures are results of inflammation, and their increase may be arrested if the inflammation be subdued ; but it seems equally certain from many observations, and from the history of many cases, that when the consti- tutional diathesis is very decided, they may take place wherever there is any congestion of blood, and even sometimes where there is no trace whatever of any congestion, inflammation, or any disturbance of the circulation. In a practical point of view, this is not a matter of very great importance to determine with reference to the cheese-like sub- stance in this disease : for it is generally allowed that depletion has less control over scrofulous than over common inflammation; that when adopted to any great extent in persons of a scrofulous diathesis it is very injurious; and further, that even if the first deviation from a healthy condition were a consequence of a low grade of inflammation it could scarcely be expected that the inflammation within the bone could be much affected by any extent of depletion, which it would be safe or judicious to allow. The scrofulous diathesis of the individuals in whom these depositions occur, is no doubt hereditary, and is believed to 354 MORBUS COXARIUS. depend, in part at least, on a peculiarity in the condition of the blood. The tendency to these depositions is increased by habitual low diet, deficiency of fresh air and exercise, residence in a low damp situation, want of free exposure to the light of the sun, debility from great evacuations or other causes, disorder of the organs of digestion, and habitual mental depression. These considerations are important in a practical point of view, and show how needful it is for individuals who have a tendency to these depositions, to pay attention to diet, to live in a dry bracing atmo- sphere, with exposure to the light of the sun,—to be careful as to the proper regulation of the digestive apparatus, and to cultivate habitual cheerfulness. When the blood is morbidly defective of fibrine, exuda- tion of albuminous matter seems very apt to take place on the occur- rence of local congestion or inflammation; and in many instances it has been found even where no trace whatever exists of any disturbance of circulation. I have, in my own collection, many specimens in which bones are almost entirely filled with cheese-like deposit, where the outer encasement of bone is very thin, and no trace whatever dis- coverable of increased vascularity, but quite the contrary. The diminu- tion of vascularity, after the occurrence of deposit, has been remarked by others. Treatment.—After what has been already stated regarding the treat- ment of disease of joints, beginning in the cancellated structure, it seems unnecessary to give any lengthened remarks on the treatment of morbus coxarius. As the maintenance of the general health is a para- mount indication, every judicious and available means for that object, consistent with the fulfilment of other necessary indications, must be adopted, their use being modified according to the particular circum- stances of the case. The feeble state of the patient's constitution will scarcely admit of antiphlogistic treatment; but antiphlogistic regimen may be necessary until the inflammatory symptoms have been subdued. "Local abstraction of blood," Mr. Liston remarks, "is seldom at all required, and its employment in cases of morbus coxarius in weak con- stitutions, which it generally seizes upon, is very questionable." The most important parts of the local treatment are, the strict observance of rest, and the employment of counter-irritation ; for which latter pur- pose blisters, setons, issues, moxa, the potential and the actual cautery, have all been used. We find that in the time of Hippocrates, counter- irritation by the actual cautery, was employed in this disease, and in modern times some consider it preferable to other means. For my own part, I have followed the method recommended by Sir Benjamin Brodie in disease of the hip-joint, namely, the employment of blisters in children and issues in adults, which he makes by the application of the potential cautery, and keeps open by repeatedly touching the issue with caustic. The best situations for issues are the hollow between the trochanter major and the tuberosity of the ischium, and the outside of the joint near the situation of the tensor vaginae femoris. Issues ought never to be employed to such an extent as to be a cause of debility, and they should be at once discontinued on the appearance of undoubted signs MORBUS COXARIUS. 355 of the existence of abscess. In recent cases, blisters usually give con- siderable relief. With regard to the treatment of abscess in this dis- ease, much difference of opinion prevails. Some surgeons, thinking that the urgent symptoms of hectic come on more quickly when an opening is made than when the abscess is opened by nature, do not approve of making an opening, except when there is uncontrollable pain, with great tension of the soft parts; some recommend that an opening be made at an early period; while others advise that unless there be great constitutional disturbance, it be deferred until the soft parts become thin in consequence of interstitial absorption. When it is evident that matter has formed, and is beginning to make its way to the surface, it appears to be the preferable plan, on the whole, to make an incision, by which means considerable suffering may be prevented, and the extent of disorganization limited. On this subject Sir Benjamin Brodie remarks :—" An abscess connected with any joint, but particu- larly one connected with the hip, does not form a regular cavity, but usually makes numerous and circuitous sinuses in the interstices of the muscles, tendons, and cellular tissue, before it presents itself under the integuments. It is, therefore, less easy to evacuate its contents, than those of an ordinary lumbar abscess, and, indeed, it can seldom be emptied without handling and compressing the limb, in order to press the matter out of the sinuses in which it lodges. But this is often attended with very ill consequences. Inflammation takes place of the cyst of the abscess, and pus is again very rapidly accumulated. Small blood-vessels give way on its inner surface, the bloody discharge of which, mixed with the newly-secreted pus, goes into putrefaction, and exceedingly disturbs the general system. I have seen cases where, after a good deal of pains taken to obtain the complete evacuation of the contents of the abscess, and the puncture having healed, in a few days the tumour has become as large as ever, attended with pain in the limb, and a fever resembling typhus in its character, and threatening the life of the patient. A second puncture having been made, a quan- tity of putrid foetid pus, of a reddish brown colour, has escaped; the confinement of which had produced all the bad symptoms, which have been immediately relieved by its evacuation. The practice which has appeared to me to be on the whole the best, is the following:—An opening having been made with an abscess lancet, the limb may be wrapped up in a flannel wrung out of hot water, and this may be con- tinued as long as the matter continues to flow of itself. In some in- stances, after a short time the discharge ceases, the orifice heals, and the puncture may then be repeated some time afterwards; but when the puncture has not become closed, I have never found any ill conse- quences to arise from its remaining open. On the contrary, I have no doubt that it is desirable that the wound should not heal, until the abscess has contracted, granulated, and healed from the bottom ; and this is one reason for making, not a small puncture, but a free opening with an abscess lancet, or double-edged scalpel. Another reason for proceeding in this manner is, that when the puncture is small the abscess cannot discharge the whole of its contents. Wherever' this happens, the suppuration is much greater than it would have been if 356 ANCHYLOSIS. the matter could have flowed out as fast as it was secreted. A profuse discharge from an abscess is an almost certain indication that there is a lodgment of matter in some part of its cavity. Such a lodgment pro- duces an effect on the secreting surface of an abscess, similar to that which a pea produces in an issue, and it should, if possible, be pre- vented." [anchylosis. Anchylosis is a term now used to imply stiffness of the joint without reference to the limb being straight or bent, though the word *y*uAor signifies crooked. The forms of this affection are various, and numerous divisions may be made, based upon different conditions of the joint. The immobility may be partial or complete; it may depend upon changes which have taken place either in the soft parts or in the bone; it may be that these changes have taken place either within or without the capsule of the joint. False anchylosis is that stiffness resulting from changes in the soft parts, particularly in the fascia, tendons, and ligaments. It is often induced by keeping the joint at rest for a long time, as is frequently the case after injuries. Inflammation in the neighbourhood of the joint is, however, a more frequent cause. Effusion of lymph takes place either in the superficial or deeper structures of the joint, and agglutination necessarily follows. True anchylosis is generally the result of some disease within the capsule of the joint, commencing in the synovial membrane or cartilage. The stiffness is complete, and is owing to a fusion of the articular extre- mities of the bones, which occurrence is often favourably considered by the surgeon, especially if not attended with curvature, since it indicates a termination of the original disease. Rest is also a cause of true anchylosis, and this principle is con- stantly employed in the treatment of those diseases, where the cure is dependent on fusion of the bones, for instance in coxalgia (see Fig. 108), and caries of the spine. Treatment.—The mode of treatment will in a great measure depend upon the nature of the affection. In cases of false anchylosis, attended with bending of the limb, passive motion must first be at- tempted, but if no motion can be produced, machinery must be resorted to. Dr. Mutter's splint, a modification of Stromeyer's screw, will be found a most effec- tual means of making gradual extension and flexion. In the application of this or any other mechanical means, care must be taken that the ex- tension be very gradual, for fear of exciting inflammation. The screw should be turned a few Fig. 113. HYSTERICAL AFFECTION OF THE JOINTS. 357 threads every day, until the limb is straightened, after which its action must be reversed, and the limb brought back to its original position. Flexion and extension should be made every day, and the joint should be rubbed with stimulating liniments. In addition to friction, benefit will also be derived from steam or vapour baths. But should these means prove unavailing, and the rigidity seem to be dependent upon one or more tendons, they may be divided by a narrow-bladed knife subcutaneously. In making the incision, the knife should be so directed as not to cut any important nerve or blood-vessel. After the division, extension is to be made with splints, and gradually increased from day to day, by means of the screw. In cases of true or bony anchylosis no treatment will be necessary, unless the union of the bones is so angular as to deprive the patient of the use of an important limb. In such cases the operation of Dr. J. Rhea Barton is to be performed. It consists in sawing out a wedge- shaped piece of bone, and establishing a false joint, or if that should fail, reunion is to be effected with the bone in an extended position. Dr. Barton successfully performed this operation at the hip in 1827, and on the knee in 1838. Dr. Gibson, of the University of Pennsylva- nia, has also successfully performed the operation at the knee. HYSTERICAL AFFECTION OF THE JOINTS. Hysterical females often complain of great pain in the joints, which might be mistaken for some real and dangerous disease of the part. According to Brodie, " At first there is a pain referred to the hip, knee, or some other joint, without any evident tumefaction; the pain soon becomes very severe, and by degrees a puffy swelling takes place, in consequence of some degree of serous effusion into the cells of the cellular texture. The swelling is diffused, and in most instances trifling; but it varies in degree; and I have known, where the pain has been referred to the hip, the whole of the limb to be visibly enlarged from the crista of the ilium to the knee. There is always exceeding tender- ness, connected with which, however, we may observe this remarkable circumstance, that gently touching the integuments in such a way as that the pressure cannot affect the deep-seated parts, will often be pro- ductive of much more pain than the handling of the limb in a more rude and careless manner. In one instance where there was this ner- vous affection of the knee, immediately below the joint, there was an actual loss of the natural sensibility; the numbness occupying the space of two or three inches in the middle of the leg. Persons who labour under this disease are generally liable to other complaints, and in all cases the symptoms appear to be aggravated, and kept up by being made the subject of constant anxiety and attention." Treatment.—Unfortunately for the patient, this affection is sometimes treated for a diseased or injured joint by antiphlogistic measures which necessarily aggravate the symptoms. Constitutional remedies are those to be relied on. All of the functions are to be restored to a healthy condition, particularly the menstrual and digestive, since these will be usually found at fault. 358 HYSTERICAL AFFECTION OF THE JOINTS. Hygienic remedies are more valuable than local. "The patient should have fresh air, generous living, and plenty of occupation for mind and body; she should be encouraged to take exercise, notwith- standing pain and weakness; and to resume, as far as possible, the habits of a healthy person." The shower-bath and frictions of the skin will improve the capillary circulation. Tonics, such as quinine, valerian, and iron, will be found most valuable where there is debility. Brodie has also found benefit in the use of assafoetida injections, and in the enveloping the joint with a plaster composed of equal parts of ex- tract of belladonna and soap plaster.—Ed.] 359 CHAPTER X. CURVATURES OF THE SPINE. All curvatures of the spine may be comprehended under one or other of the three following heads :— I. That in which the spine presents some unnatural curvature either backwards or forwards; II. That in which there is an unusual deviation from the mesial line, forming one or other of the varieties of mesial curvature ; III. That in which there is a combination of both the preceding con- ditions, which is denominated mixed curvature. The curvatures of the first class are subdivided into three varieties :— 1st. Angular curvature; 2d. Posterior curvature, or excurvation ; 3d. Anterior curvature, or incurvation. Some authors confound the terms excurvation and incurvation. ANGULAR CURVATURE. Though Mr. Liston says—" the lumbar vertebrae are those most fre- quently affected," most authorities agree with Stafford in the opinion that this disease appears most frequently in the dorsal region. " An- gular curvature," Mr. Stafford remarks, " may occur in any part of the vertebral column, in the cervical, the dorsal, and the lumbar vertebrae. It, however, most frequently takes place in the dorsal vertebrae, as they, from the manner in which they are impacted together with their carti- lages, which are much thinner in front than behind, and from their natural inclination to bend forward, are more favourable to it than any other part of the spine; hence, disease of the cervical or lumbar verte- brae may go on to a considerable extent before curvature forwards will take place, the reverse arrangement of the cartilages occurring, and these parts of the column naturally bending backwards, whilst disease in the dorsal vertebrae, from the weight of the trunk being particularly upon them, and the curve being forwards naturally, would proceed more rapidly."1 All agree that the progress of the disease is most rapid, and its appearance earliest in the dorsal vertebrae ; for in the cervical and lumbar regions the vertebrae and intervertebral substances are deeper before than behind, the reverse of which is true of the dorsal regions. In the former, therefore, very considerable destruction must take place before the spine can lose its natural convexity in front and become con- 1 Stafford's Treatise on the Spine, p. 1G4. 360 CURVATURES OF THE SPINE. cave; but in the latter, the spine being naturally concave in front, an- gular curvature will be produced by a destruction much less extensive than in the cervical and lumbar regions, but especially the lumbar. This form of curvature is more frequent in the cervical than in the lumbar region, and more frequent in the dorsal than in the cervical. It may occur at any period of life, though it is much more commonly met with in young persons, and seldom commences after the age of puberty, ex- cept when induced by some particular disease. In treating of many injuries and diseases, we have considered first the causes, next the symptoms, then the state of the parts, and lastly the treatment to be employed ; we shall here adopt a somewhat different arrangement, and refer first to The state of the Parts.—Angular curvature may arise from one or other of the five following causes :— I. It inay be the consequence of scrofulous caries of the spine. The bodies of the vertebrae, from their spongy texture, are peculiarly liable to this disease. It is unnecessary to trace the progress, or explain minutely the nature of the local changes which precede the occurrence of scrofulous caries. According to some authorities, the first deviation from the healthy condition is, that part of the cancellated structure be- comes preternaturally vascular; that at an early period the affected part becomes unusually soft from a deficient proportion of earthy matter, and that a thin fluid is deposited in the cancelli. These changes con- stitute the anatomical characters at an early period of the disease. As the disease advances, the bone becomes still softer, and instead of a thin fluid, a cheese-like substance is deposited in the cancelli. Sometimes the substance occupies only the cells, while the cancellous structure still remains ; sometimes the cancellous structure of a part of the bone is re- moved, and its place occupied by the scrofulous substance, and some- times the whole of the cancellated structure of a vertebra has been found to be absorbed, and caseous matter deposited in its stead. I have in my own collection a vertebra, the whole cancellated structure of which has been absorbed, and replaced by cheese-like matter retained in its place by an exceedingly thin shell of bone. This variety, in the quan- tity and extent of deposit, corresponds with what is observed in other bones affected with this disease. When the disease, for example, is situated at the joint ends of bones, the deposit is usually very limited; but in a long bone the same substance is sometimes found to occupy the whole of its interior. I have specimens in which the whole of the femur is occupied with this substance, contained within a very thin encasement, which is formed by the outer part of the original shell of the bone. That an inflammatory process occurs in the progress of the disease all agree; but as to the nature of the morbid action of which the caseous sub- stance is the result, there is a difference of opinion. According to the views now entertained, the scrofulous deposit may be the result of pre- vious perversion of nutrition, or a transformation of liquor sanguinis exacted in consequence of a slight grade of the inflammatory process. From many facts which have been ascertained, there seems reason to conclude that in scrofulous constitutions, caseous deposits in certain CURVATURES OF THE SPINE. 361 textures are results of inflammation, and their increase may be arrested if the inflammation be subdued ; but it seems equally certain from many observations, and from the history of many cases, that when the con- stitutional diathesis is very decided, they may take place wherever there is any congestion of blood, and even sometimes, where there is no trace whatever of any congestion, inflammation, or any disturbance of the circulation. In a practical point of view, this is not a matter of very great importance to determine, with reference to the cheese-like sub- stance in this disease; for it is generally allowed that depletion has less control over scrofulous, than over common inflammation, that when adopted to any great extent in persons of a scrofulous diathesis, it is very injurious ; and further, that even if the first deviation from a healthy condition were a consequence of a low grade of inflammation, it could scarcely be expected that the inflammation within the bone could be much affected by any extent of depletion, which it would be safe or judicious to institute. The tendency to this deposit is believed to depend, in part at least, on a peculiarity in the condition of the blood, which is unusually serous. When the blood is morbidly defective of fibrine, exudation of albuminous matter seems very apt to take place on the occurrence of local congestion, or inflammation; and in many instances it has been found, even where no trace whatever exists of any disturbance of circulation. I have, in my own collection, many speci- mens in which bones are almost entirely filled with the caseous deposit, where the outer encasement of the bone is very thin, and no trace what- ever discoverable of increased vascularity, but quite the contrary. The diminution of vascularity, after the occurrence of deposit, has been remarked by others. The deposition is succeeded by a low grade of inflammation of the bones and intervertebral substances, which ultimately terminates in caries ; and, in consequence of destruction of the bodies of the vertebrae, as well as of the intervertebral substances, the sound part, above the portion destroyed, falls forward on the part below, and thus gives rise to angular curvature. The commencement of the destruction is almost invariably towards the anterior parts of the bodies of the vertebrae, but sometimes, though very rarely, on their posterior aspect; in this case the parts which naturally furnish attachment to the arches are destroyed, and a separation takes place between them and the remaining portions of the bodies of the vertebrae. In my own collection there is a particularly interesting preparation illustrative of this fact. In this preparation, destruction has taken place of the posterior surfaces of the bodies of certain vertebrae, so that the arches and transverse processes are de- tached, the anterior portions of the bodies remaining entire. There is no breach of continuity along the front of the column, but there is a large chasm in its posterior portion, communicating with the vertebral canal. There was no curvature in this case; for the anterior parts of the vertebrae being entire, there could not have been angular curvature with the projecting angle backwards, nor could there have been angular curvature with the projection forwards; for, though the arches were detached from the bodies, the spinous processes and the arches remained 362 CURVATURES OF THE SPINE. impacted together, and prevented the spine from presenting a concavity along its posterior aspect. There is considerable variety as to the rela- tive position of the two extremities of the diseased portion ; sometimes the upper part falling forward, comes to be directly in contact with the under part; sometimes it is otherwise; but this will depend upon the number of the bodies of the vertebrae destroyed, and the extent of the Fig. 114. Fig. 115. destruction backwards. As the bodies of the vertebrae and the inter- vertebral substances form the part of the column which supports the superincumbent weight, when a chasm or gap is produced in front, the superincumbent weight sends the upper part forward, producing incur- vation in front of the spine, and projections behind of the spinous pro- cesses, and, from the incurvation being of an angular form, the disease is denominated angular curvature. The spinal cord traverses the spinal canal, having its sheath in contact with the arches, and not the bodies of the vertebrae: that is to say, it directs its course along the greater curve. In most cases of decidedly marked angular curvature, complete or partial interruption of the functions of the spinal cord comes on sooner or later; the portion of the cord at the affected part of the spine is as far as possible from the bodies in front of it; but still, the bones do in some cases press upon the cord, and interrupt its functions, espe- cially when the destruction has been rapid, and the curve is very abrupt. This cause of pressure and consequent paralysis may not be permanent. The projecting portions of bone may ultimately become smoothed down by absorption, and in some cases, this no doubt explains the discon- tinuance of the paralysis. The functions of the cord may also be inter- rupted by pressure upon the membranes, produced by matter formed in the progress of the disease. These are the causes, external to the membranes, which may occasion pressure on the cord and interrupt the due performance of its functions. The same interruption, however, is Fig. 114. Remarkable example of angular curvature and anchylosis. From a prepa- ration in my museum. Fig. 115. Angular curvature from caries. From a preparation in my museum. CURVATURES OF THE SPINE. 363 often produced by results of inflammation, with which the membranes or the cord, or sometimes both become affected; and in such cases there is usually found on dissection, a thickened condition of the membranes, or the formation of matter between or within them, or a preternaturally injected state of the cord, or a softened condition of it, which may vary in degree from a slight deviation from the healthy appearance, to that state in which it is almost entirely fluid. Paralysis, however, has been known to exist where none of the above conditions, nor any morbid alteration of structure, was discovered on dissection ; and Stafford and •others suppose that it is sometimes to be referred to longitudinal corn- pressure of the anterior portion of the medulla. " The effect of angular curvation," Mr. Stafford remarks, "is the bending of the medulla and its membranes; which, as I have before stated, causes a greater or less degree of paralysis of the parts below, which, however, does not always arise from pressure of the bones upon it, but from the bending of its own substance, producing pressure upon itself; for instance, the ante- rior portion of the medulla would be compressed, while the posterior portion or back of it would be stretched." It may be regarded as a general law, that of the two functions, volun- tary motion and sensation, the former is almost invariably first removed, and the latter first restored; the rationale of which is, that the anterior columns of the spinal cord, which give off the anterior roots of the nerves, by which they preside over voluntary motion, are nearer to the seat of the disease, and therefore more exposed to pressure than the posterior columns which give off the roots presiding over sensation. Although pressure on the spinal cord is usual in angular curvature, it is surprising how nature, even in some cases where the destruction is very great, and the deviation from the natural form of the spine very remarkable, yet continues to maintain the integrity of the- vertebral canal, so as to preserve the cord from being compressed. Of many examples of this remarkable fact I shall only refer to the following : Mr. Stafford mentions the case of a child in whom, though the bodies of six dorsal vertebrae were destroyed, and the angle of the curve was very acute, paralysis did not occur. Professor Cruveilhier gives the particulars of a case in which the bodies of five dorsal vertebrae were completely destroyed; where the fifth dorsal vertebra rested on the eleventh, the two becoming anchylosed, and at a very acute angle; and yet the medulla was preserved free from pressure. I have at present under my care a girl ten years of age, in whose case the bodies of the fourth, fifth, sixth and seventh dorsal vertebrae must be entirely removed; an abscess is formed, and is pointing about the middle of the seventh rib; and judging from the appearance of the spine behind, the parts above and below the seat of the disease must be for a short distance almost parallel with one another, so abrupt is the curve; and still the patient is as yet quite free from any symptoms of compression of the spinal cord. The only explanation given of such cases is that the process of destruction must have been very slow, and the deviation from the natural form extremely gradual. Mr. Stafford remarks, " The completeness and incompleteness also of the symptoms very much depend upon the rapidity 364 CURVATURES OF THE SPINE. with which the curve takes place. If the destruction of the bodies of the vertebrae has been very quickly effected, the paraplegia is usually more complete; but if it has been slow in its progress, the paralysis below is often very imperfect." In the progress of the disease, a collection of purulent matter forms, as in scrofulous caries in other bones, constituting what in some instances has been denominated lumbar or psoas abscess, but more properly spinal abscess. The appearance of abscess is an exceedingly unpromising symptom ; it is, indeed, generally regarded as fatal. The period at which suppuration takes place differs greatly in different examples of this dis- ease ; in some it occurs at an early period, in others not for many months, or even for a longer period; and indeed an abscess is some- times retained for years by the neighbouring parts becoming thickened and matted together. As a general law it may be stated, that the sup- puration is much earlier when the curvature is induced by scrofulous caries than when it arises from ulceration of the cartilages. The situa- tions in which such collections point are various. When the abscess is connected with the cervical vertebrae, it may present itself among the muscles on the side of the neck, which is most usual, or it may be directed forwards, and burst into the pharynx, of which I have seen one example. When the abscess is connected with the dorsal division of the spine, it may present itself along the lateral part of the thorax, of which I have already mentioned one example, or it may point at other aspects of the parietes of the thorax by running along some of the intercostal spaces ; but usually the matter follows the course of the posterior mediastinum, escapes under the diaphragm, and then descend- ing along the course of the psoas muscle points in the groin. Sometimes an abscess in the dorsal division forms a large swelling on the side of the abdomen, the matter descending between the peritoneum and the other structures which constitute the abdominal parietes; and I had an opportunity of making a dissection in a case of curvature from scrofulous caries of the 7th, 8th, and 9th dorsal vertebrae, in which a spinal abscess, after following the course first of the mediastinum, and then of the psoas magnus, burst at last into the under extremity of the sigmoid flexure of the colon. When the abscess is connected with caries of the lumbar vertebrae, it most commonly points in the groin near the insertions of the psoas magnus and iliacus internus muscles, or somewhere in the thigh below Poupart's ligament. In some instances, the abscess has shown itself in the loins, and in others in the nates, but these are compara- tively very rare occurrences. The only favourable termination which can take place in this disease is anchylosis, to which, however, the soft condition of the bones is by no means favourable. II. Angular curvature may result from destruction of the interverte- bral substances,—the disease thence extending to the bodies of the vertebrae. III. It may arise from chronic inflammation commencing in the vertebrae, followed by ulceration and caries ; the vertebrae being like other bones, liable to inflammation. Such inflammation may be of a common character causing common caries ; or of a scrofulous character CURVATURES OF THE SPINE. 365 producing scrofulous caries already referred to, or of a rheumatic character, which may end in what has been denominated rheumatic caries. Destruction of the intervertebral cartilages is believed to be an early consequence of inflammation of the bodies of the vertebrae. IV. It may originate in the softening and absorption of a vertebra without the production of any chasm. I have in my collection two very striking specimens of this condition, in both of which the curve is very abrupt, and yet there is no chasm or any trace of inflammation dis- coverable ; and I have had under my care for two years a girl with angular curvature in the middle of the dorsal region, which case, from the entire absence throughout of any symptom whatever, except the de- viation from the natural form of the spine and the consequent alteration of the form of the chest, I consider to be one of this nature. V. According to some surgeons, it may arise, from inflammation of the investing membrane of the vertebrae. Mr. Tuson, after referring to some of the more common causes of angular projection, says, " From observations I have made, and numerous cases which have come under my care, I have formed a conclusion, that it may also arise from inflam- mation commencing in the membrane that covers the upper and lower surfaces of the bodies of the vertebrae, connecting the intervertebral substances with the bone, and then extending itself into that substance and cancellated structure." Symptoms.—These are divided into two stages:— 1st. Before curvature; 2d. During and after its formation. In the first stage, the patient complains of a sense of weakness at the part of the back affected, and of weariness, and is unwilling to take ex- ercise. After some time, a dull heavy pain is experienced during and after exercise. The pain, which at first is slight, becomes afterwards more severe, and is increased by exercise, by any sudden jerk commu- nicated to the spine, and generally by percussion, and relieved by the horizontal position. From irritation of the spinal cord, there is often an altered sensation or occasional feeling of pain in the lower extremi- ties ; occasionally spasmodic twitches of the muscles, and at times spasmodic rigidity of the limbs. In the progress of the disease, and before the second stage, the muscles become wasted and lose the power of readily obeying the will, in consequence of which the patient cannot easily and quickly place his foot exactly on the spot where he may wish to place it; and when he walks he is very apt to trip. There is cold- ness of the extremities, and fulness and tightness in the epigastric re- gion ; patients in this state often complain of chilliness, and they are usually found to exhibit symptoms of a feeble condition of the general health. In the second stage there are found the local symptoms of the first stage, often in an increased degree, and together with these, cur- vature, at first slight, but gradually increasing, and in a form very abrupt,—a peculiarity most important to be remembered, as it is one of the best guides for distinguishing angular curvature from some curva- tures which depend on a different condition, and in which, although the spine is bent backwards, the curve, instead of being abrupt and angular, 366 CURVATURES OF THE SPINE. is gradual, resembling a segment of a circle. There is angular projec- tion posteriorly of the spinous Fig. 116. processes, and the spine is bent forwards in consequence of de- struction of the bodies of the vertebrae which support the super- incumbent wreight. As the disease advances, the patient usually loses all sensa- tion and motion in the parts be- low the point of pressure on the spinal cord; in short, he becomes affected with a paraplegia; the power of motion being generally first lost, and last restored, as explained in describing the state of the parts. The patient loses control over the bladder and the sphincter of the rectum, so that the urine and faeces pass off invo- luntarily ; or if the pressure on the cord be very great, there may be complete retention of the urine. Slight difficulty of passing urine has often been found to be an early symptom. The easy performance of the functions of the digestive and respiratory organs is more or less interrupted; the bowels are generally constipated; and the patient complains of a sense of fulness and tight- ness at his stomach, and in many cases of pain. These conditions of the organs of digestion and respiration are supposed to be produced through the connexion between the spinal and ganglionic nerves; and this supposition is probably correct; but there can be no doubt that the function of respiration is often rendered difficult in curvature in some situations by pressure on the intercostal nerves, which are thereby rendered incapable of calling into action the intercostal muscles over which they preside, to assist in enlarging the chest in inspiration. To this point we shall afterwards have occasion to refer. In the progress of the disease abscess may appear, the situation where it shows itself varying, as formerly stated, according to the situation of the disease; its appearance is usually attended with increased derangement of the general health, and under the continuance of the discharge and irrita- tion, hectic fever to a very urgent extent supervenes, and the bowels or some other internal organs becoming infected, death ensues. Such are in general the symptoms of angular curvature, but they differ conside- rably in different cases, particularly as to the local symptoms, which in some instances are as above described, while in others there is no pain or tenderness—the only local symptom being the deformity. If the deformity depend on mere absorption, there may be no pain, but it is an important fact which should always be kept in view, that scrofulous Fig. 116. From a patient. CURVATURES OF THE SPINE. 367 caries of the spine, as is mentioned by some authors, and as I have seve- ral times found, may run its course, and yet the patient may not expe- rience any pain or any local symptom beyond a sense of weakness and weariness of the affected part. So little pain is there, that in many in- stances the curve has been formed before the real seat of the disease has been suspected. In scrofulous caries there is generally less pain than when the disease originates in destruction of the cartilages ; but suppu- ration usually takes place earlier. These differences, the history of the case, and the presence or absence of a scrofulous diathesis, may assist us in forming some opinion ; but we have no sure guide enabling us in the living body to arrive at a certain knowledge, whether the disease has originated in scrofulous caries of bones, or in destruction of interverte- bral cartilages. The symptoms of curvature vary also according to the part of the spine affected. When it occurs in the lumbar region, and more especially towards its lower part, it is not usual, unless the disease be to a great extent, to find the altered sensations and spasmodic twitches in the early stage, or the paraplegia in the latter, as the great size and the form of the bodies render the contents of the canal less liable to pressure. When the curvature is in the dorsal region, the pro- jection, owing to the great length of the spinous processes, becomes very marked, and the chest considerably altered in shape, being flattened laterally, the ribs projecting backwards, following the vertebrae with which they are connected, and the sternum appearing too far forwards. There is at times palpitation, and in some instances difficulty in breath- ing, occasioned by compression of the intercostal nerves, or of the spinal cord above their origins; but this symptom is not so frequent when the curvature is in the dorsal, as when it is in the cervical region. When it is in the cervical region, the head is bent forwards, the prominences behind are not large, unless the seventh cervical vertebra be involved, and the respiration is difficult. In the early stage, there may be pains and twitches of the muscles of the upper extremities as well as of other parts inferior to the seat of the disease. Sometimes when the disease is in the cervical region, especially in its upper part, it proves fatal by producing effusion in the brain, and in some cases the odontoid process having lost, in the progress of the disease, the attachments of the liga- ments which keep it in its proper situation, presses on the spinal cord, and thereby causes immediate death, the seat of the pressure being higher up than the origins either of the phrenic or of the intercostal nerves which preside over the actions of the muscles of respiration. Having thus given a short account of the symptoms of angular curvature of the spine generally, and the additional symptoms peculiar to curva- tures in particular situations, we shall next refer very briefly to the treatment. Treatment.—Any attempt to remove the curvature would be most injudicious. Anchylosis is the only favourable termination to be hoped for, and therefore the object aimed at in treatment should be, to place the patient under the circumstances most likely to conduce to that result. With that view, it is indispensable, first, to keep the patient in a recumbent position, so as to remove from the diseased parts the pressure of the superimposed weight, and to preserve the parts as much 368 CURVATURES OF THE SPINE. as possible in a state of perfect quietude in that position ; and secondly, to use all means, judicious and available in the circumstances of the case, for maintaining the general health. In some cases local remedies are highly beneficial. That it is necessary to confine the patient to the recumbent position, does not admit of question, for it is evident that the superimposed weight pressing on the diseased part, must not only act as a source of irritation, but must also tend to increase the curvature; and it can only be effectually removed by placing the body in the horizontal posi- tion And that any effort which nature may make to effect anchylosis may not be defeated, it is further necessary that the parts should as much as possible, be prevented from being moved upon each other. Another advantage which results from preserving the parts at perfect rest in the horizontal position is, that the removal of the irritation, caused by the superincumbent weight, from the diseased parts, diminishes the danger of the formation of abscess, which (as formerly stated) is a most unpromising occurrence, and must induce the gloomiest appre- hensions as to the ultimate results. One of the best means for ful- filling the above indications is, to place the patient in the supine posi- tion on Earle's bed, which, besides other advantages, rendering it very convenient for this part of the treatment, allows the relative position of the trunk and limbs with regard to each other to be slightly changed, without any risk of moving the diseased parts on each other. Ine slight change thus allowed renders the confinement to the recumbent position much less irksome than otherwise it would be. As an addi- tional precaution for preserving the diseased parts from any movement it is in many instances advisable to apply splints on each side of the spine. The splints in such cases must suit the shape of the parts to which they are applied. Some recommend the patient to be placed in the supine posture, but others give the preference to the prone position, because in that attitude the superimposed weight is more effectually re- moved—there is no risk of heat and irritation from pressure,—it favours the return of venous blood from the bodies of the vertebrae,—and the approach of paralysis, it is thought, may be deferred, as matter will gravitate away from the medulla. This position is also very convenient when local applications are necessary, and in some cases the curve is so abrupt, that it is almost impossible with every precaution to keep trie patient long on his back without producing irritation of the soft parts. But notwithstanding the above-mentioned advantages, I confess 1 nave, in the majority of cases, found treatment conducted in the supine posture more satisfactory, and chiefly, I believe, from the diseased parts being more easily preserved in a state approaching to complete immunity from motion, than is possible when the treatment is conducted witn the patient in the prone position, in which I have often been annoyeu by finding it impossible to prevent the patient from moving the upper part of the spine by frequently moving the head and shoulders; ana as far as my experience goes, the supine position is preferred by patients. Rest, however, of the diseased parts, and the recumbent position, whether the body be prone or supine, are of the utmost importance from the very commencement of the disease, until a cure is effected Dy CURVATURES OF THE SPINE. 369 anchylosis. When it is believed that anchylosis has taken place, and the patient is allowed to resume the erect attitude, it is a judicious pre- caution to employ for some time an apparatus, such as that generally known by the name of the spine supporter, for removing the superin- cumbent weight. The maintenance of the general health is another and equally im- portant indication, but unfortunately some of the best means for ful- filling it are not compatible with the rest and the recumbent position which form essential parts of judicious treatment. The great importance of attending to the general health must be evident, when it is considered under what circumstances scrofulous deposits are most apt to take place in bone. In individuals of a scrofulous diathesis, insufficient nutriment or clothing, living in a damp and cold or impure atmosphere, want of expo- sure to the sun's rays, mental depression, and any cause of debility acting permanently or habitually for a length of time, have unquestionably an influence in exciting scrofulous deposits in bone, as well as in other textures. These considerations suggest the necessity, especially in scrofulous cases, of a generous digestible diet, living in a pure dry atmosphere (the bracing air of the seaside being often highly beneficial), exposure to the light of the sun, the cultivation of habitual cheerfulness, the proper regulation of the digestive apparatus, and the use of such remedies as from the particular circumstances of the case are best cal- culated to improve the general health. The tonic medicines generally found most useful are the preparations of iron. But as far as medicine is concerned, I believe the most important* point is, to have recourse to those remedies which, from the particular circumstances of the case, seem most likely to preserve the digestive organs in a proper state. Besides these means, in some cases, local remedies are neces- sary ; but the employment of them will depend on the nature of the cause of the disease. If the disease depend upon scrofulous caries of the vertebrae, or upon softening with absorption without ulceration or caries, depletion would be worse than useless, and would tend to weaken the patient. In these cases, the surgeon must content himself with advising the recumbent position, maintaining j,he diseased parts in a state of quietude, and prescribing all suitable means for preserving the general health. In scrofulous caries, benefit will often be found to accrue from the early and very cautious employment of counter-irri- tation, along with the treatment here alluded to. If the curve arise from inflammation of the bodies of the vertebrae, of their investing mem- brane, or of the intervertebral cartilages, slight local depletion by leeching or cupping at the commencement of the disease, and afterwards counter- irritation, are known to be highly beneficial. The repeated application of small pieces of blister to each side of the vertebral column at the seat of the disease has been found well suited for children, and caustic issues for adults. Of the various means for producing counter-irritation, Mr. Pott gave the preference to caustic issues. I have used them very frequently, and in some instances with gratifying results. It is im- proper to produce a great discharge, which would tend to weaken the patient, and besides, the long continuance of a profuse discharge and of irritation might induce hectic fever. If abscesses form, the issues 370 CURVATURES OF THE SPINE. should be discontinued. Mr. Pott, whose valuable works contain many cases of disease of the spine, attended with paralysis, successfully treated by the application of counter-irritants, was the first who pointed out to the profession the results of such practice, and many have since followed it with equal success. About two years ago I ceased to attend a patient, in whose case I was much gratified with the result of usin distinguishing peculiarity of which is the absence of that abruptness which is found in angular curvature. If the curve be situated in the cervical re- gion, the chin falls towards the sternum, producing what is commonly called " the stoop." When the whole spine is af- fected, forming a semicircular curve forwards, the patient, when sitting, is disposed to support his trunk, if the dis- ease be not far advanced, by placing his hands upon his knees, and, if it have made con- siderable progress, by placing his elbows upon his knees; and when walking, he has an in- clination to rest his hands on anything which he may be passing, to enable him to bear up under the superincumbent weight, which becomes very overpowering. The local and general symptoms vary according to the state of the spine on which the curvature depends, and the condition of the body in which it takes place. From the gradual form of the curve, the functions of the cord are not interrupted. Treatment.—In considering wdiat kind of treatment is proper, the surgeon must be guided by the nature of the cause of the disease. If the distortion depend on general caries, then the same treatment as in angular curvature is suitable. If it occur as an effect of rickets, or syphilis, a most important part of the treatment consists in the employ- ment of the remedies adapted for these constitutional diseases. When it arises either from a softened condition of the vertebral column itself, or from weakness of the muscles necessary for maintaining it in the erect position, the surgeon should endeavour, by strict attention to the general health of the patient, to invigorate his frame. To effect this, pure air—a saline atmosphere, especially in scrofulous individuals, is often beneficial—generous diet, wine, or any other stimulus that agrees with the patient, tonics, of which the preparations of iron will, in many Fig. 117. Excurvation of spine. From Tuson. 372 CURVATURES OF THE SPINE. cases, be found among the most useful, and sea-bathing, should be en- joined. If sea-bathing be inconvenient, salt ablutions, or sponging the body with salt water, may be substituted for it. The regular and dailv use of friction by means of the hair-glove or flesh-brush, and exercise on foot, should also be adopted. The patient should never take so much exercise as to induce weariness, and he should afterwards assume the recumbent position, until he experiences an aptness or fitness for further exercise. The surgeon should also recommend friction, with some stimulating embrocation, all along the spine, and such amusements as tend to strengthen the muscles of the back. " When a case of stooping is confirmed," Mr. Stafford remarks, " a regular course of the gymnastic exercise is perhaps the best treatment that can be pursued. These, however, must be employed with great caution, as by their too violent use in the first instance, much mischief may arise. In simple cases, very simple means may be resorted to. One plan I am inclined to think would be attended by the greatest success, and which is, a weight being suspended from the shoulders and resting on the abdomen. My reason for thinking this is, from having observed in a regiment of sol- diers that the one who carries the great drum is invariably the straight- est man. For the reason just mentioned, it would be a good plan to make children play at soldiers, and let the one who is disposed to stoop carry the drum in the same manner as the drummer of a regiment. I have little hesitation in saying the habit would soon be cured. Another very good exercise, also, would be to make the individual play at cym- bals ; he would be forced to extend his arms in the air and look up- wards, by which the head and trunk would be thrown backwards, whilst the muscles of the shoulders would be in constant action." Mr. Stafford farther says :—" The use of the dumb bells would be found in some cases of great service; for instance, where the shoulders hang forward, by which the chest is narrowed, and the sternum is forced in by the clavicles; by their employment the shoulders would be thrown back- wards, and the chest expanded. Other methods no doubt might be ad- vised ; as a general rule, however, any exercise which will bring the muscles of the back into action will be of great utility in this description of distortion." In curvature depending upon caries of the spine nothing could he worse than these amusements ; hence the importance of diagnosis. When the curvature arises from bad habits, as constantly leaning forward, allowing the shoulders and arms to hang forward, or from an employ- ment in which the spine is bent forward, the habit must be corrected, and the employment which produced the curvature must for a time be discontinued. In this variety of curvature, mechanical support com- bined with a certain amount of exertion is sometimes useful. Large padded splints are by some applied to the sides of the abdomen, and secured by flannel bandages. Others employ a wooden shield, the con- cavity of which they apply to the convexity of the patient's back ; gra- dually diminishing the concavity by placing in it another layer of flannel or some soft padding. These appliances should not be worn constantly, but for a short time each day. In the few cases where mechanical sup- port during a part of the day is advisable, it may be given by more CURVATURES OF THE SPINE. 373 elegant appliances than those referred to above; appliances which can- not confine the parts or induce injurious pressure in any way. ANTERIOR CURVATURE, OR INCURVATION. This, which happily is the rarest of all the curvatures of the spine, is remarkable for the rapidity with which it proceeds, when it has once commenced. It may happen as the consequence of rickets, mollities ossium, common or scrofulous inflammation beginning in the spine, and primarily affecting either its bones or softer textures; or, it may arise from a softened condition of the vertebral column, or from any state which so deranges the due balance in the action of the muscles main- taining the spine in its proper attitude, as to render the extensor muscles of the vertebral column too powerful for their antagonists. The treatment consists in the application of the principles already laid down for the treatment of these particular conditions. LATERAL CURVATURE. This is by far the most common of all the curvatures of the spine, and is more frequently met with in girls than in boys, and in the chil- dren of the wealthy than in those of the poor, and much more frequently in the females of this climate than in those who live in warmer latitudes. It seldom commences after the age of puberty, except when induced by the excessive action of the muscles of one side. That girls are more liable to it than boys is, no doubt, owing to the serious defects in their physical education. The injudicious means adopted for improving the figure by preventing the proper play of the muscles of the trunk, by retarding the development of the bones and muscles, and by producing more or less absorption of them by compression, cannot but be highly injurious; and to these causes, aided by the want of proper exercise, and of sufficient exposure to the open air, is to be referred the frequency of this disease in girls,—causes which more frequently affect the wealthy than the middle and lower classes. The comparative rarity of lateral curvature as a primary form of disease among the poor, is proved by general experience, and by the statistical fact, that of thirty-two thou- sand nine hundred and ninety-one patients who presented themselves for relief at Middlesex Hospital in five years, there were not more than twenty affected with lateral curvature as a primary disease. As a secondary result arising from other affections, such as disease of the hip, or disease of the knee, lateral curvature is frequently found among the poorer classes. It seems to be the want of attention to this distinction which has induced some to question the fact of the comparatively rare occurrence of lateral curvature among the poor. The comparative ex- emption from this disease in the females of warm climates has been attributed to the loose clothing they are obliged to wear, allowing the due development of their various organs, to the want of stays, and of many injurious restraints, and to their not being subjected to the fatiguing confinement to an irksome position, as the young ladies of this country often are daily for many hours together, in acquiring a variety of accomplishments. _ Causes.—The principal predisposing causes are rickets, mesenteric disease, a softened condition of the bones of the spine, compression of 374 CURVATURES OF THE SPIXE. the thorax from tight lacing, weakness, especially when consequent on measles, hooping-cough, or other infantile diseases, want of proper exer- cise and exposure in the open air, and any circumstance which acts unfavourably on the general system before the various organs have attained their full development. Tight lacing is not uncommonly a predisposing cause of distortion of the spine. This custom, restraining the actions of the muscles, prevents their natural development, so that they become attenuated; the bones also to a certain extent become diminished by absorption, and softened, so as to be unable to sustain the weight they were destined to support; and the cavity of the thorax is diminished, in consequence of which there is not sufficient room for the healthy and easy performance of the functions of the heart and lungs. The immediate exciting causes are, the habit of standing on one leg, standing, sitting, or reclining in a position in which the spine is inclined too much to one side, injudicious confinement of a young person for a long time to one position wdthout support to the back, the consequent weariness and irksomeness obliging the child to lean to one side to obtain relief, the disproportioned use of the muscles of one side, as in the case of persons engaged in certain avocations, or of children to obtain relief from the uneasy sensations caused by ill-made clothes, and lying on a soft bed with a very high pillow. These are the principal exciting causes of lateral curvature, and the rationale of their operation is suffi- ciently obvious. When the distortion arises from the habit of standing on one leg, the first deviation from the proper shape of the spinal column takes place in the lumbar region, constituting what is termed the primary curve; and this will be followed by a curve in the dorsal region; which, to dis- tinguish it from the former, is called the consecutive curve. If the con- vexity of the curve in the lumbar region be to the left side, that of the dorsal region will be to the right: so that if the distortion be to a great extent, the shape of the spine will somewhat resemble that of the letter S reversed : thus giving rise to the appearance of " growing out" of the right shoulder and left hip; but if the convexity of the curvature in the lumbar region be to the left, and the shape of the spine will more or less resemble the letter S, according to the extent of the contortion. The consecutive curve is the result of an effort to maintain the upright position; or, in other words, when a primary curve is formed in the lumbar region, the muscles on the opposite side of its convexity, and higher up, draw the spine in the contrary direction, and the one curva- ture compensating in a measure for the other, allows the centre of gravity still to fall upon the pelvis. The primary curve is always the bolder, and the consecutive curve may occupy the dorsal, and a consi- derable part of the cervical region; or there may be two consecutive curves in opposite directions, one in the dorsal and the other in the cervical region. The same explanation may be given of the operation of several other exciting causes, such as the bad habit of standing, sitting, or reclining in an awkward attitude, or of leaning to one side to obtain relief from the weariness and aching sensations caused by too long confinement to one position. The disproportioned use of the muscles of one side is well CURVATURES OF THE SPINE. 375 known to be an exciting cause of curvature. Examples are occasionally met with in blacksmiths, dragoons, and in persons engaged m peculiar avocations, in whom the muscles on one side, from being frequently called into action, become so strong and so fully developed, as to over- power those of the opposite side, and draw the spine out of the perpen- dicular. Mr. Child records the case of a printer's apprentice, who was in the habit of frequently pulling the press with his right arm, and this gave rise to a curvature in the dorsal region with the convexity to the right side ; the rhomboidei and trapezius muscles being tense, rigid, and prominent. In such cases the primary curve will be in the dorsal region, and will soon be followed by a consecutive curve in the reverse direction in the lumbar region. The improper use of the muscles of one shoulder is sometimes a cause of curvature in females. Mr. Staf- ford remarks, " A girl shall have ill-made clothes ; for instance, one of the shoulder-straps will be constantly slipping off the shoulder; she, of course, will endeavour to replace it; by this effort she is obliged to elevate the shoulder, and thus she not only brings into action the muscles of that side, but at the same time inclines the spine to the one that is opposite. The effect of this position must be obvious, for on the one hand she increases the power of the muscles on one side, which assist in pulling the spine out of the perpendicular ; and on the other, the centre of gravity is destroyed." The above are the principal exciting causes, which acting separately, or two or more of them in combination, give rise to lateral curvature ; but in some instances the spine becomes distorted without any known exciting cause. Sometimes, although rarely, lateral curvature is found to depend on caries : in such a case, whatever excites inflammation about the spine may be an exciting cause of the distortion. I have in my own col- lection a good example of this condition, in which the primary curve is in the lumbar region, and is caused by caries of lumbar vertebrae. The possibility of this form of distortion depending on caries, suggests the necessity of great caution in forming our diagnosis. In such cases the curve will be more abrupt in its form, and more rapid in its progress than in the other varieties of lateral curvature. Symptoms.—The spine exhibits unnatural, but seldom abrupt, deviations from the mesial plane. These are accompanied, more or less, with a sense of weakness and weariness, which, in some instances, increases especially towards night, and after exercise so greatly as to become even pain- ful, and to produce a desire to lie down in order to relieve the spine from the superincum- bent weight. If the distortion depend on caries (which is exceedingly rare), there may be actual pain; but this state sometimes exists, as has been already stated, without the patient being Fig. 118. Fig. IIS. From a patient. 376 CURVATURES OF THE SPINE. sensible of any pain. The local appearances vary according to the ex- tent, direction, situation, and number of the curvatures. If there be two curvatures, the one in the lumbar region, with its convexity to the left side, and the other in the dorsal, with its convexity to the right, there will be a falling-in of the right loin, a fulness in the corresponding part on the left side, and an appearance of projection and elevation of the hip; an alteration, also, in the form of the chest, which will be elon- gated, prominent, and round on the right side, and shortened and flat- tened on the left; the right shoulder will be elevated and project out- wards, and the right mamma will be prominent; the left shoulder will fall down, and the mamma, from the flattened state of the thorax, appear smaller than on the right side. The rationale of these symptoms will be obvious, when the effects of lateral curvature upon the thorax are explained. Two of the most striking symptoms are the "growing out," as it has been called, of the right shoulder, and the prominent and elevated appearance of the hip. The extent of the above symptoms will correspond with the boldness of the curvature. When the convexity of the lumbar curve is to the right side, and that of the dorsal to the left, the appearances which in the former case were observed on the right will be found on the left side, and vice versd. The above are the symptoms of lateral curvature, when there are only two curves, and these situated as described, and not of a very great extent. In an advanced stage, however, of this dis- ease, an alteration is observed in the symptoms ; the breast, like the scapula, does not remain prominent on the convex side of the dorsal curvature, but falls backwards, in consequence FlS-119- of the ribs in front losing their convexity and t becoming flattened as the disease makes pro- gress. If, however, there be three curvatures, \ and if a few of the superior dorsal vertebrae / be, together with the cervical, involved in the uppermost curve, and if the distortion be considerable, the appearance will be different. Besides the symptoms already mentioned in the lumbar region, and the projection back- wards of the scapula on the convexity of the dorsal curvature, there will be flatness of the chest and falling-in of the neck on that side, together with fulness of the neck and breast, and elevation of the shoulder of the opposite side. In this variety the scapula projects backwards at its lower, and falls forwards at its upper part, on the convex side of the dorsal curve ; but it is not raised so much upwards as on the opposite side. The appearance is pe- culiar, from the projection backwards of the shoulder and the falling in of the mamma on the one side, and the rising up of the shoulder, and the prominence of the mamma on the other. The convexity of the uppermost curve produces the fulness on the one side of the neck, and Fig. 119. From a patient in my wards in the Royal Infirmary. CURVATURES OF THE SPINE. 377 the explanation of the other peculiar symptoms is, that, on the side on which the mamma is prominent and the shoulder raised up, the superior ribs are supported by the convexity of the uppermost curve, whereas those on the opposite side are connected with the concavity, and, there- fore, fall in. EFFECTS OF LATERAL CURVATURE ON THE SPINE AND ON THE TRUNK. With reference to the vertebral column, it is observed that the effect of the curvature on the convex side is to separate the transverse pro- cesses from one another, to incline the spinous processes outwards, and to enlarge the bodies of the vertebrae and the intervertebral substances, so that they have the appearance of being expanded. On the concave side the reverse prevails; the transverse processes are brought too near each other, the spinous processes curve inwards, and the bodies of the vertebrae and the intervertebral cartilages are diminished in depth by interstitial absorption. The height of the column is diminished, and if the distortion be considerable, there is rotation of the spine to the same side as the curvature. The muscles which run along the convex side Fig. 120. Fig. 121. are inordinately stretched, and consequently weakened; while those or the concave side are preternaturally contracted and rio-id. These alte Fig. 120. Front view of lateral curvature of spine. From a preparati' museum. Fig. 121. Back view of same preparation. 378 CURVATURES OF THE SPINE. rations are not only to be discovered on dissection, but in the living body also. The surgeon can satisfy himself of the existence of these alterations both before and after dissection. If the curve originate In the use of one shoulder more than the other, the muscles extending from its convexity to the scapula will be preternaturally tense and large, when compared with those of the opposite side. There will lie, on the concave side of the curve, flattening and shortening of the thorax, with diminution of the intercostal spaces ; while on the other side, the thorax will be elongated and rounded in form, and the intercostal spaces enlarged, in consequence of the ribs being removed farther from each other. The condition of the ribs explains the symptoms observable about the shoulders and mammae. The transverse measurement of the thorax is diminished, and, in consequence, the sternum usually becomes preternaturally prominent: and, in many instances, the diminished capacity and changed form of the cavity of the chest interfere with the easy play of the heart and lungs, and thus occasion to the patient annoying sensations within the chest. Treatment.—The treatment of this affection, when dependent on rickets or caries, consists in the application of the principles laid down for the treatment of those particular diseases. If the curvatures arise from the operation of other causes, and are neither of great extent nor of long standing, they may, by judicious management, be completely removed: in this case, the treatment may be termed curative. But when the deviation of the vertebral column is to a great extent, and the bones have acquired their consolidated state, the unnatural configura- tion of the bony structure cannot be removed; and all the surgeon can then do is, to employ remedies calculated to prevent the progress of the deformity. Here the treatment may be denominated palliative. When the deformity is caused by the disproportioned action of the muscles of one side, their action must be discontinued, and the muscles of the oppo- site side brought into exercise. If the curvature has arisen from standing on one leg, or from any of the various improprieties of attitude already referred to, an essential part of the treatment is the discontinuance of the bad habit; for so long as the exciting cause is allowed to remain in operation, no treatment will be of any avail. Another great object will be, to call into use those muscles whose action will tend to bring the spine into its proper posi- tion : these will, of course, be the muscles attached to the concavity of the curvature. This may be done in various ways, by the use of the dumb-bell, turning the wheel, or by such gymnastic exercises as tend to bring into play the muscles of the trunk,—those especially whose con- tractions are calculated to draw the spine to the erect attitude. In the case of children, a simple and excellent plan is, to induce them to play at such games as will call into exercise those muscles by which the ver- tebral column may be restored to its normal form; thus, if the curva- ture has arisen from standing on one leg, Mr. Stafford suggests, that a good way of bringing into action the muscles of the opposite side would be the favourite game of hop-scotch; and when it has been caused by the disproportioned use of the muscles of one shoulder, as in cases of raising up the shoulder to obtain relief from the annoyance of the shoul- CURVATURES OF THE SPINE. 379 der-strap falling down, he advises that the game of battledore and shuttlecock be played with the opposite hand. When the disease has not made great progress, and the bones have not become stiff by anchy- losis, or by great interstitial absorption on the concavity, and growth and expansion on the convexity, of the curve, the means above mentioned will generally be found sufficient to restore the spine to its normal form. When the disease has arisen from general debility, however induced, which has rendered the spine too weak to support the superincumbent weight, the treatment will consist in the use of means calculated to strengthen the general system, and in certain local measures directed to the state of the spine. Some of the most important measures for the purpose of invigorating the system are, the adopting of a generous diet, living in a pure and bracing atmosphere, the use of wine, provided it agree with the patient, the due regulation of the bowels, and the em- ployment of whatever medicinal tonic seems most indicated by the par- ticular situation of the patient. To maintain the right performance of the functions of the digestive organs, and to preserve the bowels in a state neither relaxed nor constipated, are often the only occasions for the employment of medicine internally. Sea-bathing at the proper season is often advantageous; but if this be inconvenient, recourse may be had to salt ablutions, or sponging the body with salt-water. In addition to these, the regular and daily use of friction by means of the hair-glove or flesh-brush, and exercise on foot should be employed, care, however, being taken that the exercise be not to such an extent as to induce weariness. After exercise the patient should rest in a recumbent posi- tion until she experience a fitness for further exertion. To keep patients always in that position would be extremely injudicious, as the debility thereby induced would predispose more strongly to the disease ; but to recline on a couch or sofa for three or four hours altogether in the course of the day, not at once but at different periods, with intervals of gentle exercise or amusement, would relieve the weak part from the superin- cumbent weight, and thus be not only agreeable to the feelings of the patient, but also calculated to be useful. Together with this treatment certain local measures are beneficial, such as friction along the spine with some stimulating embrocation, especially along the muscles which chiefly require to be stimulated. Exercising the muscles of the trunk with the body in the horizontal position, if conducted with judgment and care, is also often highly beneficial; the exertion of muscular action, while the spine is free from the pressure of the superincumbent weight, tends to restore it to its normal position. Such exercises, by calling into play the muscles extending between the ribs and the arm, are also particu- larly well adapted to correct the deformity of the thorax. The appa- ratus employed by Mr. Shaw, and the couch with the exercising frame recommended by Mr. Tuson (a modification of which, in a greatly sim- plified form, I have employed for exercising the muscles while the body is in the recumbent position) are well adapted for the purpose; but all that is required can easily be fixed to the extremity of a couch. It is unnecessary to describe the different pieces of apparatus above referred 380 CURVATURES OF THE SPINE. to, for if the principle is to be adopted of exercising the muscles with the body in the recumbent position, there can be no difficulty in con- triving mechanism for its practical application. Such branches of a girl's education as require sedentary attention, much mental exertion or long confinement to the sitting position, must be suspended. Tio-ht lacing and all mechanical supports, which tend to retard the develop- ment, or prevent the exercise of the various organs, or induce the patient to lean to them for support instead of endeavouring to maintain a proper attitude by the action of her own muscles, are positively inju- rious ; but still, if the patient be unequal to the necessary exercise, some support during part of the time she is in the erect attitude, will be found beneficial. Some of the spine-supporters, which sustain the superincum- bent weight, or rather transmit it to the pelvis without exerting pressure, are best adapted for this purpose. Of late years recourse has been had, for the cure of lateral curvature, to the operation of dividing certain muscles of the spine. This is in some respects analogous in principle to the operation of dividing the sterno-mastoid muscle for the cure of some forms of wry-neck, or of dividing certain muscles for the cure of club-foot; although certainly we have no reason to expect it to be so generally useful as those opera- tions. When the distortion proceeds from disease of the bones, or from any constitutional disease, or from general debility, an operation would be most unjustifiable; and I think it will be evident from what has been stated regarding the causes of lateral curvature that the cases must be exceedingly few, in which there is a reasonable prospect of an operation proving advantageous. In cases of curvature arising from or attended by an excessive exertion of certain muscles, the operation has been per- formed with the view of weakening the muscles to whose overaction the original production, or the subsequent continuance of the curvature, is in part to be attributed. Thus the muscles extending from the con- vexity of the dorsal curve to the scapula have been divided, when the curvature has been caused by an inordinate action of the muscles of that side. In other instances the muscles along the concavity of the curve have been divided; because when a curvature takes place, the muscles attached to its extremities and situated along its concavity have their extremities brought nearer to each other than is natural, and then con- tracting and accommodating themselves to their new position, they not only offer an obstacle to the removal of the curvature, but also tend by their contractile power to increase it. Mr. Child records a case of a printer's apprentice who had curvature in the dorsal region caused by pulling the press with his right arm; the rhomboidei and trapezius muscles were tense, rigid, and prominent. Mr. Child divided the muscles attached to the convexity of the curve, by the overaction of which the distortion had been produced; and the result was favourable. Mr. Whitehead of Manchester, has successfully performed the operation of dividing the muscles along the concavity of a curvature. The two cases are described in the "Medical Gazette," the former in the number of Nov. 27th, 1840, and the latter in that of December 4th, 1840. The operation of myotomy for the cure of distortion of the spine has been CURVATURES OF THE SPINE. 381 performed by M. Genrin of Paris, Mr. Skey of London, Dr. Hunter of Glasgow, and others, with different results; but as yet the impression of surgeons regarding it is decidedly unfavourable. MIXED CURVATURE. As the various conditions on which curvatures depend, and the prin- ciples of treatment suitable to each, have been already explained, it appears unnecessary in reference to mixed curvature to say more than that the important point is, to ascertain the cause of the curvature, and to adapt the treatment accordingly. 382 CHAPTER XL TALIPES, OR CLUB-FOOT. Of this there are four varieties, namely, talipes equinus, talipes varus, talipes valgus, and talipes calcaneus. Symptoms.—Talipes equinus is the most simple, though not the most common, variety of these deformities. It may vary from slight eleva- tion of the heel to that position in which the heel is so drawn up, that the foot is almost in a straight line with the leg. The weight of the body in walking is borne by the anterior part of the foot, and in a pure example,'equally by all the metatarsal bones; but in some cases where the toes incline slightly inwards or outwards, approaching somewhat to other forms of talipes, the anterior part of the sole of the foot cannot be applied evenly to the ground, and the weight is received chiefly by the metatarsal bone of the little or of the great toe, according as the ten- dency to lateral displacement is inwards or outwards. The inward tendency is the more common, owing, it has been supposed, to the circumstance that the natural configuration of the foot admits of more extensive adduction than abduction. In many instances, patients, when they stand carefully upon the affected foot, Fis- 122- appear to tread evenly ; but in walking, as soon as the foot is placed in the extended position, so that the posterior part of the astragalus, which is narrow from side to side, is received between the two malleoli, the foot inclines inwards, and the ball of the little toe principally sustains the superin- cumbent weight. There is great lateral mobility of the foot, especially in the ex- tended position. The muscles of the calf are contracted, and the tendo Achillis is prominent, tense, and unelastic. These con- ditions are rendered still more apparent by any attempt to bend the foot; and the extent to which that can be done, and the amount of resistance offered, vary according to the extent of the distortion. The foot is un- usually convex above and concave below, and in cases of considerable standing, the foot is smaller, and the leg, both in length and thickness, less, than on the opposite side, showing that the parts are less developed in every way. TALIPES. 383 The gait of the patient is peculiar and unpleasing. Pain and a sense of weakness are often experienced at the instep from the strain on the parts in making exertion; and walking is often rendered still more dis- agreeable to the patient by painful corns forming on the parts on which he treads. In many cases the patient can, by a voluntary effort, slightly diminish the deformity ; but when the distortion is caused by paralysis of the flexors of the ankle, he cannot by a voluntary effort bend the foot in any degree; and in such case, if the surgeon place his finger over the belly of the tibialis anticus, or of any other muscle in front of the leg, and desire the patient to endeavour to excite it to contract, no motion whatever will be felt under the finger,—the volition is not followed by any change in the muscles, which the patient desires to call into action. This method of examination it is desirable to institute, before a prognosis be given, as the result of treatment is not likely to prove so satisfactory when paralysis is the cause. The above are the symp- toms which in a greater or less degree, according to the extent of the distortion, characterize this deformity. Talipes equinus congenitus is the name given to it when it exists from the period of birth ; and talipes equinus acquisitus when it takes place at a subsequent period. ABNORMAL CHANGES. The bones which present the greatest deviations from their natural condition are the astragalus, os scaphoides, and calcaneum, but chiefly the astragalus. They are generally somewhat diminished in size, especi- ally the astragalus ; and its natural articular facets for the bones of the leg are roughened and almost denuded of cartilage, while new ones are formed at a greater or less distance backwards according to the degree of the deformity; in the higher grades these surfaces are furnished partly by the astragalus, and partly by the calcaneum. The head of the astragalus is diminished in size, and its articular surface for the os scaphoides is unusually small. The os scaphoides, which is also dimi- nished in size but not altered in form, is drawn downwards; and hence the upper part of the head of the astragalus is prominent on the dorsum of the foot, and an unusual extent of the upper aspect of the bone pre- sents itself, in consequence of the bones of the leg being removed so far backwards. The calcaneum is seldom fully developed. In the higher grades of talipes it furnishes a facet for the bones of the leg. The surface by which it articulates with the os cuboides is contracted in extent, and the upper and anterior part of the bone is prominent on the dorsum of the foot in consequence of the os cuboides being drawn down- wards. The remaining bones of the foot present their natural charac- ters, except that they usually show more or less of deficiency in their development, and all the bones of the tarsus and metatarsus are so arranged, as to give the foot an unusual convexity above, and a corre- sponding unusual concavity below. The toes are extended, but Dr. Little has given a delineation of a' curious specimen belonging to the museum of the London Hospital, in which the toes were unusually drawn downwards towards the calcaneum, which, Dr. Little remarks was owing to the circumstance that the person to whom it had belonged^ had not placed the foot upon the ground, but walked upon the knee! 384 TALIPE?. The articulating facets of the tibia and fibula are roughened in front and denuded of cartilage, from not coming into contact at these parts with the astragalus. The above are the abnormal conditions of the bone in talipes equinus. That which invariably exists, and is regarded as the distinguishing peculiarity, is a greater or less displacement of their articulating facets. The ligaments in this and the other varieties of talipes are changed, being relaxed and shortened so as to correspond with the situation of the bones. These alterations are now considered as consequences, not as causes of the deformity. At page 45 of his interesting book on Club- foot and other analogous deformities, Dr. Little remarks, " The ligaments cannot directly influence the production of the deformity; but its pro- gress may be facilitated by their relaxation ; the restoration of the foot is impeded by their diminished length, the result of long continuance in an improper position." The muscles are, in all the varieties of talipes, invariably affected with abnormal conditions, which are regarded as the causes of these distor- tions. The distinguishing peculiarity is, that the balance between an- tagonistic sets of muscles is interrupted. The disturbance of the equilibrium of the muscles may arise from complete or partial paralysis of the tibialis anticus, or of it and of one or more of the other flexors of the foot, and the consequent contraction and structural shortening of the muscles at the back of the leg; or, it may be occasioned by the spasmodic contraction ; and, if of long standing, the consequent struc- tural shortening of the muscles of the calf, Avithout paralysis of the muscles in the front of the leg; or, it may be unattended by either paraly- sis or spasmodic contraction, and be the result (as is often observed when the whole voluntary power of the limb is diminished), of the organic contraction of the extensors of the foot preponderating over that of the flexors. The gastrocnemii are the muscles chiefly involved in the production and maintenance of this deformity; and although sometimes other ex- tensor muscles are affected, it is comparatively rare that the division of any of the tendons, except that of the gastrocnemii, is necessary. These are the principal conditions of the muscles which cause genuine talipes ; but deformities which in external characters resemble talipes, may arise from contraction of the gastrocnemii excited by abscess of the leg, or by caries or necrosis of either of the bones of the leg; from cicatrization of extensive ulceration ; or, from the maintenance of the foot in a particular position, assumed in consequence of inflammation or other painful affections of the joints. In hysterical females, the signs of talipes are sometimes exhibited, constituting what has been called talipes equinus hystericus; and, in many instances these symptoms have been found to subside under the treatment proper for hysteria. In cases where dissections have been made, the blood-vessels and nerves were found to be, like all the other structures, reduced in size; but from what is stated above, it will be evident, that of all the abnormal condi- tions, that of the muscles most chiefly engage the surgeon's attention, as to that must be referred the existence of the deformity; and to the TALIPES. 385 removal, therefore, of that condition, the remedial measures are to be directed. Treatment.—An improved knowledge of the exciting causes of talipes, and of the abnormal conditions of the parts, has led to the adoption of sounder and more rational principles of treatment than formerly pre- vailed. In all cases of talipes equinus, whether congenital or acquired, whether induced by spasmodic contraction of the muscles at the back of the leg, or by paralysis of some of those in front, if structural shortening has occurred to any considerable extent, the proper treatment consists in the division of the tendons of the shortened muscles, and the restora- tion of the foot to its proper position by means of mechanical apparatus. The nature of the operation and of the mechanical apparatus will be presently explained. In cases for which it is suitable, nothing more satisfactory can be desired than this method of treatment; by it I treated, with complete success, a case of talipes equinus of thirteen years' duration; and of the many successful cases recorded by Dr. Little in his treatise on this subject, the second had existed for fourteen years, the fourth for twenty-nine, and the fifth for thirty-five years, and yet the results were perfectly satisfactory. When the structural short- ening is to a slight extent, the judicious employment of mechanical treatment, without division of tendons, will often prove efficient. In each of the two classes of cases, in that which requires the division of tendons, and in that which will yield to the judicious application of me- chanical treatment alone, the origin of the disease should be minutely inquired into; and if the disturbance of the equilibrium of the muscles arise from paralysis of one or more muscles, the state of the central parts of the nervous system must be attended to ; or if by the reflex and incident functions of the nervous system, it has originated in dis- order of the digestive apparatus, or in derangement of other organs, treatment must be directed to the removal of the cause, unless it has been of so long standing, or of such a nature as to preclude all hope of removal. In many cases, where there is no structural shortening, medi- cal treatment directed to the origin of the disturbance, whether in the nervous system, the digestive apparatus, or in some other organs, will, by removing the origin of the disturbance, cure the deformity. In such cases an operation is not advisable, but it is prudent, together with medical treatment, to employ friction, manipulation, and such mechani- cal appliances as will be most likely to prevent structural shortening while the spasmodic contraction remains. The operation is extremely simple, and may be performed with any very narrow sharp-pointed instrument, such as a small, straight, sharp- pointed bistoury, or with an extremely narrow knife in the shape of a scalpel, or with a narrow-bladed instrument, not more than an eighth of an inch in breadth, the cutting edge of which does not extend more than five or six-eighths of an inch from the point, the remaining part being blunt, so that the instrument can be turned in the wound, and thus the operation be effected without so extensive a division of the skin as would probably be occasioned by an instrument with a cutting-edge of greater length. It is very important that the wound of the integument should be the least possible. In talipes equinus, the tendo Achillis is 386 TALIPES. usually the only tendon that requires to be divided, but in some instances the section of the tibialis posticus and flexor longus pollicis is also needful. The division of the tendo Achillis may be effected in the following manner:—While the knee is extended and held by one assis- tant, and the heel depressed and the toes raised as much as the struc- tural shortening will permit by another, for the purpose of rendering the tendon prominent and tense, the surgeon introduces the flat blade of the knife at one side (usually the inner side) of the tendon, and having passed it under the tendon until the point reaches the opposite side, turns the edge backwards, and divides the tendon in withdrawing the knife. The division is attended with a grating noise, and its accom- plishment is evidenced by the removal of the resistance to the depres- sion of the heel, and by the hollow that is left under the integument. All experienced orthopaedic surgeons prefer the transverse to the oblique section (which some have recommended because a larger surface is thereby formed for the effusion of the uniting medium); and it may be effected, as described above, by carrying the knife before the tendon, and cutting from before backwards, or by pinching up the integument and sending the knife between it and the tendon with the sides of the knife backwards and forwards, and then directing the edge against the tendon, and cutting from behind forwards. By either method, the ope- ration may be performed in a few seconds; not more than a drop or two of blood escapes, and the external wound is extremely small, being not more than the breadth of the instrument, which is carefully with- drawn through the opening, by which it was introduced. A small piece of plaster is placed over the opening, and the foot is allowed to remain in its deformed position until the wounds be perfectly healed, which is usually not more than two or three days. As regards Fig. 123. the operation, there is merely a puncture of the skin, and the division of the tendon is subcutaneous, so that neither the tendon nor its sheath Fig. 123. Stromeyer's apparatus applied. TALIPES. 387 being exposed, the danger of inflammation is greatly diminished ; and that it may be yet further diminished, and the risk of suppuration avoided, no means should be taken to restore the foot to its proper position, until the wound be perfectly cicatrized. Such is the doctrine laid down by Stromeyer, and followed by the most experienced ortho- paedic surgeons, as to the period at which extension should be com- menced. But M. Bouvier and Mr. Whipple recommend that it be com- menced immediately after the section of the tendons. There is also a difference of opinion as to the manner in which extension should be employed. Stromeyer, Little following his example, and most others, bring the foot gradually to its proper position; whereas others endeavour to effect this at once. The directions of Stromeyer, both as to the period for commencing extension and the method of employing it, are those which have met with general approval. The extension having been commenced, should be daily increased, care being taken not to employ it injudiciously, or to apply so great a pressure as to cause abrasion or irritation, which might render continuance of the extension injurious. The extension is necessary for stretching the ligaments, for restoring the bones to their normal position, for elongating the muscles on the back of the leg, and for allowing, by bringing up the toes, the contraction of the muscles on the front of the leg, by which the foot is maintained in its proper position. Together with extension, bathing, fomentation, and friction, should be daily employed, and will be found beneficial. Fig. 124. Fig. 125. Of the many kinds of mechanism contrived for the pupose of accom- plishing extension in the various forms of talipes, Stromeyer's stretching board, and Dr. Little's apparatus, are most generally approved. They Fig. 124. Little's boot applied. One view. Fig. 125. Little's boot applied. Opposite 388 TALIPES. are the only kinds of which, until lately, I have had experience; and they certainly answer most admirably the purposes for which they are intended. The former is the more suitable for talipes equinus, and for some cases of talipes varus; but for others, Dr. Little's apparatus will be found more useful, as fulfilling more indications than the stretching- board of Stromeyer. These pieces of mechanism, and the mode of their operation, may be understood from the accompanying wood-cuts. The apparatus of Dr. Little is a modification, with various improvements, of one originally used by Scarpa. By means of mechanism, the foot is gradually brought into its proper position, and the muscles that are undivided, the ligaments, and the lymph effused between the ends of the divided tendons, are cautiously extended; but the use of the apparatus should be continued after the foot has been brought into its right posi- tion, in order to obviate a tendency to contraction, which continues for some time to exist in the effused lymph. When walking is resumed, care should be taken to place the foot properly on the ground. In this variety of talipes, walking, after the proper period, tends to prevent a return of the deformity and to perfect the cure ; and it may be ventured upon earlier than in some varieties, which will afterwards be described. TALIPES VARUS. Symptoms.—While talipes equinus is the most simple, talipes varus is by far the most common variety of these deformities. "It is that deformity in wdiich the foot," as Dr. Little remarks, " undergoes a three- fold alteration of its position in relation to the leg: extension, adduction, and a rotation of the foot, somewhat analogous to supination of the hand, taking place to a greater or less extent, according to the severity of the disease. The heel is drawn upwards (extension), the toe is turned in- wards (adduction), and the patient treads on the outer edge of the foot only, the inner edge being raised from the ground (rotation). This threefold alteration from the natural position of the foot, occasions the most serious impediments to steady or Fig- 126. comfortable walking; and when the dis- ease reaches the highest gradations, the foot assumes a frightfully distorted ap- pearance." In many instances, the dis- tortion is so great that the sole of the foot is vertical instead of horizontal; and the patient, unable to apply any part of it to the ground, supports the weight on the outer edge of the foot. The patient, when standing, keeps the legs removed from each other to balance the weight of the body; the gait is unpleasing and un- steady, and walking is rendered not only unusually fatiguing, but also very painful by the strain upon the foot, and the swell- ings which form upon the skin on those parts on which the patients tread. The foot is preternaturally small, as well as the limb, from the want of proper development, and it deviates from the natural condition not only in its TALIPES. 389 relation to the limb, but also in its shape; for its dorsum presents an unusual convexity and the sole a corresponding concavity; its inner edge is short and unusually concave; its outer edge is convex, and in many cases has a semicircular outline, on the middle part of which only the patient is able to tread. The patient has no power to bend the foot by voluntary effort; the attempt to do so merely increases the adduc- tion. When the deformity is slight, the foot may be brought into a natural position, but as soon as the force is removed, it returns to its former state. When the deformity is more extensive, the surgeon can- not, by taking hold of the foot, bring it into a proper position, and in the worst cases he can only move it slightly in the right direction. In all circumstances, but especially in attempting to bring the foot to a natural position, the tendo Achillis and inner division of the plantar fascia, and often the tendon of the tibialis anticus, feel tense under the integument. But more particular reference will be made to the struc- tures which are shortened, under the head of the abnormal conditions. These symptoms may either exist at birth or arise afterwards; in the former case, they constitute talipes varus congenitus, in the latter, talipes varus acquisitus. Abnormal Conditions.—In talipes varus there are the same abnormal conditions of the bones as in talipes equinus. This might have been expected, as'extreme extension is common to both deformities. It is unnecessary again to enumerate these conditions; but there are also other changes in talipes varus, produced by the adduction and rotation. The changes, as in talipes equinus, consist principally of alterations in the relations of articulating facets to each other. According to Scarpa and other anatomists, the astragalus undergoes less altera- tion of position than either of the other tarsal bones. Although its articulating facets for the ankle joint are displaced by being pressed forward and outward, the portions of •these surfaces towards the outer side being further displaced than those towards the inner, still some parts of its surfaces are in contact with some parts of the surfaces for the ankle joint furnished by the bones of the leg ; and there is no con- dition calculated to prevent a cure, if the cause of the deformity be re- moved. The posterior extremity of the calcaneum is drawn upwards and a little outwards, and its anterior extremity a little inwards ; and the scaphoid, cuneiform, and cuboid bones not only present the same peculiarities as in talipes equinus ; but they are also, by the adduction and rotation of the foot, twisted inwards and rotated on their own axes; so that their inner edges are in a measure directed upwards, and their outer edges downwards. The os scaphoides has been found so much drawn inwards, as to have its inner extremity articulating with the an- terior part of the malleolus internus, and connected with it by a powerful ligament. The os cuboides, instead of articulating with the whole of the anterior part of the calcaneum, is more or less separated from it above, by being drawn downwards and inwards; and sometimes, when the deformity has been very great, they have been found in con- tact only at the under parts of their articulating facets,—a triangular space, the base of which is upwards, intervening between them. The above are the essential peculiarities of the bones in talipes varus. Pal- 390 TALIPES. letta, Delpech, Cruveilhier, and others, have found the malleolus in- ternus in some instances deficient in size ; and in one case which came under my own observation, it was remarkably small; but this condition does not always appear. The ligaments adapted to the altered relations of the bones, and the stretching of those which are preternaturally short, is one of the causes of uneasiness in the restoration of the foot to its proper position, by the treatment after an operation. The abnormal conditions of the muscles and tendons are considerable and important, since it is by them that the deformity is produced and maintained. Some muscles are shorter, others longer than natural, and their equili- brium is disturbed. This disturbance may be produced in either of the ways mentioned in the description of the abnormal changes in talipes equinus. The number of muscles which are contracted varies in dif- ferent degrees of the deformity. In many cases, especially when the deformity is slight, the gastrocnemii alone are so much contracted as to require division of their common tendon; but in other instances, the tendons of the tibialis posticus, flexor longus pollicis, and tibialis anticus, require division. The tibialis anticus, although naturally a flexor of the ankle joint, has sometimes, in aggravated cases, its tendons so far deflected inwards as to increase the deformity and require division; and in a case in which I lately operated, where the deformity had attained its highest grade, the extensor longus pollicis was so far de- flected inwards, and so tense, that it was necessary to divide it as well as the tibialis anticus, the tendons of the gastrocnemii, the flexor longus pollicis, and the tibialis posticus muscles. When the muscles are spas- modically contracted, their bellies feel firm and hard to the touch, like muscles affected with spasm; but when the deformity is attended with structural shortening, the muscular tissue is in a state of atrophy, both its length and thickness being diminished ; and sometimes (though such an occurrence is now believed to* be very rare), it is converted into a fatty substance, constituting what is termed the fatty degeneration. There is often shortening of the plantar fascia to such an extent as to require the division of its inner portion. This shortening, however, is not, as Maisonnabe believed, a cause of the deformity, although it often presents such an obstacle to the restoration of the foot to its proper position as to render division necessary. The appearance of the limb slightly resembles its appearance in a state of atrophy. Its tempera- ture is often observed to be lower than natural, and on dissection the vessels and nerves, like the other structures, have been found unusually small. Of all the abnormal conditions, however, that of the muscles and tendons especially requires attention. Treatment.—In determining the most prudent method for restoring the foot to its natural position, the surgeon will be guided by the same considerations as in a case of talipes equinus; and, as the principles of treatment were fully stated under that head, it appears unnecessary to do more than to give some short particulars as to the treatment of those cases of talipes varus in which there is so much shortening of tendons, that their division is requisite, in addition to mechanical treatment, for the restoration of the foot, and also to state the most prudent method of procedure with congenital cases in infants until the period arrives at which an operation may be proper. TALIPES. 391 With regard to cases which require an operation and mechanical ex- tension for the removal of the deformity, the first point is to ascertain which tendons ought to be divided; and this can only be done by a mi- nute investigation of the case. As was stated in describing the abnormal conditions, in some instances, section of the tendo Achillis is sufficient, and in such cases, the operation is precisely the same as for talipes equinus. In some of these cases, the difficulty of bringing the foot to its natural position is removed on the division of the tendon ; in others, a certain amount of resistance is offered by the muscles on the back of the leg, but not more than can be removed by mechanical extension. There are many cases, however, in which other tendons, besides the tendo Achillis, must be divided; most commonly the tendon of the flexor longus pollicis, or of the tibialis posticus, or one or both of these tendons belonging to muscles on the back of the leg, together with the Fig. 127. Fig. 128. tendon of the tibialis anticus in front. In a very interesting and satis- factory case, which I treated lately, and from which the accompanying figures were taken, it was necessary to divide all the above-mentioned tendons, namely, three on the back of the leg, and two on the front, that of the tibialis anticus, and that of the extensor proprius pollicis. The two last-mentioned tendons were so deflected inwards and shortened, as to maintain the deformity. Occasionally it is also necessary to divide the plantar fascia before the deformity can be entirely removed. In Dr. Little's interesting treatise, various cases of talipes varus are re- corded, in which a cure was effected by section of the tendo Achillis, followed by mechanical extension, and other cases, in which division of other tendons also was necessary. In the eighth case recorded in his treatise, the deformity was cured by division of the tendo Achillis, and tendon of the tibialis posticus; in the fourteenth case, by division of the tendo Achillis and the tendon of the flexor longus pollicis muscle ; in the eighteenth, it was cured in one foot by division of the tendo Achillis, Fig. 127. Appearance before operation. Fig. 128. Appearance a fortnight after operation. 392 TALIPES. Fig. 129. and in the other, by division of the tendo Achillis and tendons of the anterior and posterior tibial muscles ; and in the twenty-third case, by the division of the same three tendons. More extensive use of the knife than is absolutely necessary is exceedingly reprehensible. The division of the tendons should be subcutaneous, and effected in the same manner as that of the tendo Achillis, and with the least possible injury of the common integument, and the sur- rounding parts. The tendo Achillis may be divided about an inch above the calcaneum, or a little higher or lower, as the circum- stances of the case may indicate; and the most common and advisa- ble situations for dividing the other tendons are, for the tendons of the tibialis anticus and extensor pro- prius pollicis muscles, the dorsum of the foot in front of the ankle joint, where they appear most prominent; for the tendon of the tibialis pos- ticus, about an inch above the un- der part of the malleolus internus; and for the tendon of the flexor lon- gus pollicis in the sole of the foot, where it is found most tense. The foot should be allowed to remain in its unnatural position, until the small wounds are perfectly cicatrized, when extension should be Fig. 130. Fig. 131. commenced, and gradually and cautiously increased, and constantly maintained, until the foot be brought to its proper position. Stro- Fig. 129. Appearance six weeks after. Figs. 130 and 131. Talipes varus before and after operation. talivert. Treated by Aveling's TALIPES. 393 meyer's stretching-board, with a little additional apparatus for more efficiently preventing inversion, will be found a very convenient appli- ance for satisfactorily fulfilling all the necessary conditions. In slighter cases, or after the foot has been brought nearly to its proper position, or when the resistance to be overcome is not very great, Little's appa- ratus will be found to answer all the purposes aimed at by mechanical extension. From the tendency of the foot to turn inwards, patients cannot be allowed to resume walking so soon after the operation as they may after the operation for the cure of talipes equinus, and when they venture to do so, the parts should be for some time supported by a boot with a steel spring or stem on the inner side, and the patient should very carefully endeavour to place his foot evenly upon the ground, as from the laxity of the structures which should keep the foot outwards, there is a tendency in the upper part of the tarsus to turn outwards, and in the toes to turn inwards. As talipes varus is frequently met with in infants, it is important to comprehend distinctly the treatment proper for the deformity at that period. As it is very desirable to avoid the performance of even the slightest operation in an infant, it is fortunate that more cases are curable without operation in infancy than at a later period of life; and, as the difficulties in carrying out treatment by mechanical extension are on many accounts greater, it is a happy circumstance that the resis- tance is less in infants than in older patients. Whether a case of talipes varus in an infant can be cured by mechanical means, can be deter- mined with certainty only by a trial; but an opinion may be formed by observing the amount of resistance offered to the endeavours to place the foot in its proper position. The treatment recommended by Dr. Little, when the infant is under six months, is to apply tin splints to the inner side of the foot, protecting the limb from pressure by the intro- duction of cotton wadding, and then to bandage the leg and foot to the splint. The effect of the bandage will be to press the inner part of the great toe, and the upper and inner part of the leg, against the splint, and to diminish the convexity outwards formed by the interme- diate parts of the limb. The object aimed at in the first instance is to overcome the inclination inwards of the toes, or in other words, to con- vert the talipes varus into talipes equinus; and this having been accom- plished, a tin splint with the foot-piece bent more upwards should be used for the purpose of bringing down the heel. If the child be more than six months of age, he recommends the employment of his own apparatus, a representation of which has been already given, for over- coming the inclination of the toes inwards, and bringing down the heel. It often happens that, while it is possible to overcome the distortion inwards, the heel still remains elevated, and in such cases, when the child is about to walk, the cure may be very quickly completed by section of the tendo Achillis. TALIPES VALGUS. This is much less common than either of the two former varieties of these deformities. 394 TALIPES. Symptoms.—Here, also, the foot undergoes a threefold alteration of its position in relation to the \v<\ Fig- 132. but the alterations are the very reverse of those in talipes varus. The foot is flexed, abducted, and rotated outwards. Walking is very fatiguing, and in the worst cases, the patient can place no part of the sole of the foot on the ground, but treads upon the inner ankle; the knee of the affected side inclines inwards, and the limb presents the same appearance of atrophy as in the deformities al- ready described. This variety also may be either congenital, or acquired. Abnormal Conditions.—I have not had any opportunity of ascer- taining by dissection the abnormal conditions. On this subject, Dr. Little says, " I have been afforded only three opportunities of investigating the morbid anatomy of talipes valgus; these were furnished by Professor Muller, and Dr. Pockels of Brunswick. The subjects from which the preparations were taken were full-grown foetuses. In these, so far as the incomplete development of the osseous structures enabled me to judge, the astragalus was twisted in such a manner that the articular facet, which ought to be applied against the inside of the internal malleolus, did not enter the composi- tion of the ankle-joint, but was turned downwards; the navicular bone and calcaneum followed the astragalus, and together with the internal malleolus, would have touched the ground with their internal surfaces, if the feet had belonged to subjects who could have walked. The external edge of the os cuboides, and fifth metatarsal bone, and external surface of the calcaneum, presented directly upwards ; the latter, there- fore, was in contact with the external malleolus, the prominence of which could not be felt through the skin of the foot." Treatment.—The treatment must be conducted on the same principles as in the two former varieties. If it be thought that mechanical treat- ment alone will be sufficient, a convenient appliance for that purpose is Dr. Little's apparatus with the springs on the inner instead of the outer side; and if division of tendons be also required, the same me- chanism answers all the purposes of a retentive apparatus. In some slight instances, division of the tendo Achillis alone has proved suffi- cient ; in others, that of the tendons of the peronei muscles has been requisite; and in others, it has been necessary to divide all the tendons of the peronei and gastrocnemii muscles. A convenient situation for division of the tendons of the peronei muscles is five or six lines above the under part of the malleolus externus. On account of the extreme relaxation of the ligaments on the inner side of the foot, it is long before the patient can be allowed to walk after the operation. TALIPES. 395 TALIPES CALCANEUS. This appellation was given by Dr. Little to a deformity which he met with in a child four and a half years of age, in whom the fore part of the foot was elevated to the greatest possible extent, and the heel so much depressed as to have the long axis of the calcaneum in a line with the leg, and its posterior surface only touching the ground. The tendons on the front of the leg were tense, and those on the back relax- Fig. 133. ed; so much so, indeed, that the tendo Achillis could scarcely be felt. The foot was easily brought into its proper position, • which proved that there was no structural shortening; and the treatment, which was successful, consisted in the use of a boot for maintaining the foot in its proper position. Dr. Little states, that in a French pe- riodical, a deformity, believed to be of the same kind, is said to have been successfully treated by divid- ing the tendons of the tibialis anti- cus muscle. This is the distortion called by some writers hook-foot; the same principles of treatment are applicable as in the other forms of talipes. Having mentioned the symptoms, abnormal conditions, and treatment of these deformities, it may be satisfactory to state very shortly the views now entertained regarding their origin, and the history of treat- ment now so generally and successfully adopted. The opinions that talipes is caused by an unnatural form of the tarsal bones, or by an alteration of their relative position and connexions, or by an unnatural contraction of some ligaments and elongation of others, or that it is occasioned by undue pressure on the foetal limbs by the uterus, in con- sequence of deficiency of the liquor amnii, or by external pressure to conceal pregnancy, or by the limbs being arranged in an improper position during foetal life, belong only to the past history of surgery. The opinion now generally entertained is, that these affections are 'caused by a disturbance in the equilibrium of antagonizing sets of mus- cles. The writings of Duvernay, Tong, Boyer, Rudolphi, Shaw, Del- pech, Stromeyer, Guerin, Duval, and some others, have been the means of gradually leading to the adoption of this view, to its fuller develop- ment, and more lately to its perfect confirmation, together with its prac- tical application in the treatment of these affections. Rudolphi ap- pears to have held this view more clearly than his predecessors; he contended that congenital talipes proceeds from the disordered Fig. 133. From Dr. Little. 396 TALIPES. influence of nerves on muscles during the period of foetal existence. Delpech at one time believed that talipes originated in malformation of the tarsal bones ; but even then he considered that the muscles contri- buted to increase the deformity ; but he stated in his treatise " L'Ortho- morphie," published in 1829, that he had renounced his opinion as to the origin of the deformity, and that he believed its immediate cause to be a disturbance of the natural and necessary equilibrium of the mus- cles, which disturbance may have resulted from remote influences, as effusion upon the brain or spinal cord, or from hydrocephalus, or from irritation excited in some part of the nervous system, or from direct injury of the nerves leading to muscles ; as, for example, in a case in which the external popliteal nerve was injured, and the injury was fol- lowed by paralysis of the tibialis anticus-, extensor proprius pollicis, extensor longus digitorum, and peronei muscles, and by contraction of their antagonists, and consequent distortion of the foot; or in a case in which talipes varus, in an extreme degree, followed injury of the nerves, induced by necrosis and abscess of the femur. Delpech, however, was of opinion that the gastrocnemii are the only muscles involved in the production of talipes varus, and that the adduction of the foot is caused by pressure in walking. Stromeyer believes the contraction of the gas- trocnemii to be the essential cause of talipes equinus and talipes varus, and the deficiency of the internal malleolus the cause of the inclination inwards in talipes varus. He supposes that if the contraction of the gastrocnemii occur during the early months of foetal life, talipes varus will be the result; whereas, if it take place at a later period, after the malleolus internus is in a measure developed, the deformity will be talipes equinus, with or without slight inclination of the foot; in short, he regards contraction of the gastrocnemii as the essential cause, and all varieties as secondary phenomena ; whereas the opinion now gene- rally entertained is that which the observations of Guerin, Duval, and Little, have established, namely, that the deformity, when superadded to retraction of the heel, is to be referred to the action of other muscles affected similarly with those which occasion the retraction of the heel. Dr. Little has given such a clear exposition of his views in the following sentences, that I cannot forbear transcribing them. " Let us now fully consider those congenital contractions of the feet which depend on derangement of the nervous and muscular systems, and ascertain in what way a permanent deformity arises. In the first place, we will take a case originating from paralysis of the anterior tibial muscle. Here the remote injury, the cause of paralysis, is the same as that of paralysis of other parts of the body, namely, inflamma-' tion and the effusion of blood, or sero-sanguineous or serous fluid, in some part of the brain or spinal cord, which compresses or otherwise injures the delicate texture of that part of the nervous centre, whence the affected muscles derive their nerves. The posterior muscles of the leg (those of the calf in particular) having lost their natural antagonists, become firmly and permanently contracted, by the constant action of their involuntary contractile power, by which the heel is raised from the ground, Talipes equinus. At an early period of the disease, this contraction may be overcome by forcibly bending the foot with the TALIPES. 397 hand ; but thisf after a time, becomes impossible. The other case, that of a Talipes originating from spasm, admits of a different explanation. The remote cause resides either in the central organs of the nervous system (most probably in the spinal marrow), or it is a disease existing in some other organ of the body, affecting peripheral parts of the nervous system; for instance, in some one of the viscera of the chest or abdomen, more probably of the latter. From this an injury is propagated to the central organ, and is reflected to certain muscles of the leg, which become spasmodically contracted. In other words, there may be either some deviation from the healthy state in a part of the spinal marrow, where the roots of the motor nerves distributed to the muscles of the calf are implicated or irritated, causing them to become involuntarily contracted ; or there may exist elsewhere some disease, such as irritation of the mucous membrane of the alimentary canal by improper or undi- gested food, or worms, through which filaments of nerves (named by Dr. Hall incident) are excited. These communicate in the spinal cord with other filaments—the reflex, or involuntary motor nerves, whereby the muscles of the calf are excited to spasmodic action. In this explana- tion of the production of non-congenital Talipes I have confined myself to the most simple and intelligible form of Talipes equinus. The Talipes varus differs only in depending on paralysis or spasm of a larger number of muscles. When paralysis is the cause, the peronei muscles have lost their power, as well as the anterior tibial, and long extensor muscles of the toes. If spasmodic contractions be the cause, the poste- rior tibial muscle, long flexor muscle of the great toe, those of the sole of the foot, and sometimes the tibialis anticus muscle, are partially involved in the production of the deformity. I have here defined the manner in which I consider Talipes to arise after birth. Any cause, whether paralysis or spasmodic, by which the equilibrium, between different sets of muscles that are naturally antagonists, is disturbed, produces the distortion vulgarly called club-foot. Other causes, namely, those which produce a shortening of the muscles and other soft parts upon one side of the leg by disturbing (although in a different manner) the antagonism of the muscles, are capable of producing deformities similar to those belonging to the genus Talipes. "Having thus offered my opinion of the causes of those deformities of the feet, which take place after birth, and stated the identity of their symptoms, and morbid anatomy with those of the club-foot with which children are born, the probability will, I think, appear obvious that the remote causes are the same ; but there are other phenomena connected with the history of these affections, which render the accuracy of these opinions almost capable of demonstration. Foetuses which have suffered some evident derangement in the development of the nervous system, such as those denominated hemicephalous and acephalous, or affected with spina bifida, and those born before the expiration of the natural period of utero-gestation, are particularly obnoxious to this deformity of the feet. The occurrence of the perfectly analogous deformity of the hands, which takes place prior to birth, denominated club-hand, in which the flexors and pronators (analogous to the so-called extensors and adductors of the foot), are likewise contracted, corroborates the 398 TALIPES. opinion that congenital club-foot depends on spasmodll muscular con- traction. In the instances which I have examined of congenital de- formity of the hand (club-hand), both in museums and in the living subject, the feet were also affected with Talipes, proving the operation of a common cause. Other circumstances corroborative of this opinion are the co-existence with congenital club-foot of congenital squinting, and even congenital stammering or mis-enunciation, diseases which evi- dently depend either on increase of the involuntary, or the decrease of the voluntary motor powers of the orbital and laryngial muscles. The importance of these facts is increased by the observation I have made, that non-congenital club-foot is likewise occasionally accompanied with strabismus." The instances are extremely rare in which congenital Talipes is caused by paralysis. From the time of Hippocrates until March, 1784, the treatment of Talipes consisted in the employment of mechanical pressure, and the varieties were merely different contrivances and appliances for facili- tating the adoption of the same principles of treatment; but in 1784, the first step was taken towards the present method, a physician of the name of Thilenius having suggested the division of the tendons affected with shortening; and his suggestion was carried into practice byLorenz, a surgeon at Frankfort, in the case of a young lady affected from infancy with Talipes varus. The heel descended two inches after the opera- tion, and the lady was able to walk on the entire sole. It was the tendo Achillis that was divided, and the operation was performed under the direction of Thilenius. The division, however, was effected by a large wound. The suggestion of Thilenius was also carried into practice at a subsequent period by Sartorius, whose method of operating, how- ever, wTas liable to many objections, particularly because he made ex- tensive incisions of the superimposed parts, exposed the tendon at the part to be divided, and after section of the tendon, immediately at- tempted to bring the foot to its proper position. The consequences were unfavourable, and such as do not follow the operation of section of the tendons as it is practised at the present day. Michalis suggested a different method of treatment, which consisted in a partial division of the shortened tendon, and bringing the foot to its proper position im- mediately after the operation ; he recommended section of the tendon to the extent of one-third of its thickness, by which means its strength would be materially diminished. He performed his first operation in November, 1809. Both Sartorius and Michalis recommended imme- diate restoration of the foot to its proper position, the one after com- plete, the other after partial division of the tendon ; but neither of their methods of treatment met with general adoption or approval. Delpech had the merit of conceiving and recommending some new and important principles of treatment. Having observed that after rupture of the tendo Achillis and some other injuries, the uniting me- dium admits of considerable elongation, it occurred to him that the same elongation could be obtained after section of the tendo Achillis for the cure of Talipes, provided mechanical extension be employed before the uniting medium has acquired great strength and firmness. TALIPES. 399 He recommended that the section of the tendon should be effected with- out division of the common integument over it: and in the instance in which he performed the operation, he made a wound of the common integument an inch in length on each side of the tendo Achillis by passing a scalpel between it and the deeper-seated structures ; and then by a convex edged bistoury, he divided the tendon from before back- wards. He recommended that after the operation, the cut portions should be preserved in apposition, by maintaining the foot in the dis- torted position by mechanism, until reunion of the divided tendon be effected—that careful and gradual extension of the uniting medium should then be made, until the tendon be of sufficient length; and this having been obtained, that the limb be kept in a proper position by means of apparatus until the new substance has acquired sufficient strength. Delpech performed his operation in May, 1816, and although a cure was effected after a long period, and the patient ultimately re- covered, yet there were so many discouraging circumstances, that he never repeated his operation. Although the mode of dividing the ten- don recommended by Delpech is exceedingly objectionable, he certainly has the merit of having suggested some important principles in the after treatment. To Stromeyer, who performed his first operation in February, 1831, the praise belongs of having perceived what was ob- jectional, and appreciated what was valuable, in the views of those who preceded him, and of proposing and performing the safe and successful operation, and the mode of after treatment, which are now so generally approved of, and so successfully adopted. Before concluding this chapter, I may mention that my friend and former pupil, Dr. Aveling, has contrived an admirable apparatus which he calls a talivert, and which I have repeatedly used in private and in public practice. It appears to me exceedingly well adapted for the purposes for which it is intended, and very superior to all kinds of apparatus hitherto employed for the treatment of these deformities. I hope that Dr. Aveling, who is now practising in Kent, will make this useful addition to surgical mechanism known to the profession. 400 CHAPTER XII. DISEASES OF THE ARTERIES. ARTERITIS. Arteritis may be in activity, acute or chronic: and in extent general, invading a large portion of the arterial system, or partial, confined to the trunks and branches of a particular part. Symptoms and Morbid Appearances.—The symptoms vary according to the intensity of the attack, the stage of the disease, and the changes occasioned by the inflammation in the affected vessels. The diagnosis is often, especially at an early period, extremely difficult: for as the disease in some forms presents no signs peculiar to itself, it is not easily distinguished from common inflammation. While the disease is still slight, and no such changes have occurred in the coats or contents of the vessels as to obstruct their canals, the principal symptom is pain along the track of the vessels, which pain is increased by pressure, motion, or extension of the affected part. On laying the finger over the course of the vessel, the pulsation is felt to be weak, and to convey a tremulous sensation. When the Arteritis is more severe, and invades a part of the arterial system, as for example, when it is seated in the arteries of a limb, and the inflammation is so intense as to give rise to changes which will presently be described, the pain and tenderness are much increased; an incompressible hardness is felt in the situation of the principal arterial trunks affected; and the pulsation, at first pre- senting the peculiarity above-mentioned, by and by ceases entirely. Together with these symptoms in the tracks of the main trunks, there will, also, be pain in the limb, accompanied with a purplish red appear- ance, and oedematous swelling : and if the collateral branches be affected the part will exhibit the usual symptoms of gangrene. If the arteritis be but to a slight extent, there may be little or no constitutional dis- turbance ; but when it is intense, so as materially to impede the func- tions of the trunks and collateral vessels, there will, in addition to the local symptoms, be those of irritative fever. Some years ago I met with a striking example of acute idiopathic Arteritis in a female, about thirty years of age, who had previously enjoyed uninterrupted good health, except that some years before, she had suffered from an attack of acute rheumatism ; but from this she had recovered, and had been for years perfectly wTell. I was called to see her in consequence of severe pain in the forearm and lower part of the arm, which commenced very suddenly about three hours before I saw DISEASES OF ARTERIES. 401 her. At first the pain was chiefly along the course of the radial and ulnar arteries, the pulsation of which vessels at the time I saw her was feeble, and that of the humeral artery was labouring. The pain soon became diffused over the under part of the arm, the forearm, and hand, and was of a bursting character, with oedematous swelling, and a pur- plish discoloration of all parts below the commencement of the lower fifth of the arm. In the course of eight hours from the beginning of the attack, the pulsation of the radial and ulnar arteries, and of the humeral artery in the two lower thirds of the arm, entirely ceased, and the parts exhibited the ordinary appearance of what is now usually de- nominated spontaneous gangrene,—the line of demarcation presenting itself at the commencement of the lower fifth of the arm. After some days, it was deemed advisable, by an experienced surgeon and myself, to perform amputation about the middle of the arm. This was done, and the patient recovered, and continued perfectly well for two years, when she left Aberdeen with the intention of residing with her relations in a distant part of the country. The day after her journey she was seized with symptoms in both her lower extremities, similar to those which she had previously had in her arm, and in the course of twenty- four hours nearly the whole of both lower extremities presented the characters of gangrene, and the patient died some hours afterwards. This case furnishes a striking example of the serious consequences which sometimes result from Arteritis; and in the latter part of its history, a remarkable instance of the truth of the observation made by M. Bizot, as to the symmetrical occurrence of arterial disease. Dupuy- tren was the first who ascribed spontaneous gangrene to Arteritis. The same view was supported by Cruveilhier, who from observations on the human body, and from numerous experiments in which he excited Arteritis in the lower animals, by injecting irritating fluids into the arteries of their extremities, came to the conclusion that the essen- tial character of inflammation of an artery is coagulation of the blood within it, and that gangrene is the result of occlusion, not only of the trunks, but also of the collateral branches. The writer of an able article on Arteritis in the " Cyclopaedia of Practical Surgery," speaking of the gangrene produced by Arteritis under the expression " particular form of gangrene," states his opinion, that it is by no means identical with the affection known in this country as Pott's Mortification of the Toes and Feet. I have seen examples of Pott's Mortification corre- sponding most minutely with the description of the disease in the third volume of " Pott's Surgical Works ;" but the distinctive characters of that affection are quite different from those of spontaneous gangrene produced by Arteritis; the latter affection being much quicker in its progress, and, as far as my own experience has given me the opportu- nity of judging, far more painful and dangerous. It is stated, however, by the writer of the article in the " Cyclopaedia of Practical Surgery," that the gangrene from arteritis is less painful than the mortification described by Pott. In the case already referred to, I found, on a careful dissection of the arteries, that their coats presented a red in- flamed appearance, as though some irritating fluid had been injected into them; they seemed to be softer and thicker than natural; the 402 DISEASES OF ARTERIES. canals, which seemed large, wrere filled with coagulated blood, and at many points there was a slight lamella of lymph on the internal mem- brane. No adhesions were perceptible between the coagulum and lymph; but in some examples of this form of Arteritis adhesions arc said to have been observed. That the coagulum was formed at an early period is certain, from the cessation of the pulsation. Such were the symptoms and morbid appearances in a well-marked example of what may be termed acute idiopathic fibrinous arteritis. Treatment.—This form of arteritis should be treated on the same general principles as inflammation of other parts, namely, by general and local depletion, purgatives, antimonials, diaphoretics, low diet, and the occasional use of opiates for relieving the violent pain. Perfect tranquillity of body and mind should be strictly enjoined, as any exer- tion or emotion which would accelerate the circulation, would, by increasing the distension of the vessels, aggravate the disease. The prompt but judicious exhibition of mercury, unless an irritable, shattered, or scrofulous constitution should forbid its employment, is calculated to be highly beneficial by checking inflammation and diminishing fibrinous effusion. In the way of local remedies at an early stage, perfect rest of the affected part, depletion by leeches, attention to attitude, and the use of warm and emollient applications are very important. ACUTE SUPPURATIVE ARTERITIS. In individuals of shattered, or weak, or cachectic constitutions, a very dangerous form of acute arteritis sometimes, though very rarely, takes place, and gives rise to phenomena, which in many respects resemble those consequent on diffuse suppurative phlebitis. It is much more rare than the latter affection, in consequence of the structures which enter into the formation of an artery being less susceptible of inflammation in any of its forms than those which form the coats of veins. The inflam- mation has a tendency to spread from the part first affected. It is extremely acute, and is believed to cause the formation of purulent matter at an early period. This by being mixed with the blood in its circulation, is thought to give rise to the peculiarity of the constitutional symptoms, which often prove speedily fatal before gangrene has taken place. Violent irritative fever attends the very commencement of this disease ; and it very speedily assumes the worst form of atonic or typhoid fever. Some of the most remarkable features attending its progress are, extreme prostration of the vital powers; a weak, quick, and small pulse; a pallid and shrunk countenance, expressive of suffering; a dull, lurid, dirty-looking hue of the surface of the body; a morbid state of all the secretions ; flaccidity of the soft solids ; a dry and encrusted tongue; low delirium; and other symptoms indicative of extreme depression of the vital powers. As there is no fibrinous effusion, and in the extremely depressed state of the vital powers, little or no tendency to coagulation of the blood, there is direct purulent admixture with the blood, in con- sequence of the circulation through the inflamed part not being inter- rupted. The principal peculiarities of this form of arteritis are, its tendency to become diffuse, to go on to suppuration, and if the patient survive any length of time, to terminate in gangrene as its most usual DISEASES OF ARTERIES. 403 local result, and the very early change of the acute irritative fever to one of the typhoid type. The lesions occasioned by acute suppurative arteritis consist chiefly of a dark red, or purple-coloured injection of the walls of the vessel, seen on examining its interior, softening of its more internal textures, and sanious infiltration into them in various situations. Treatment.—The same local treatment should be adopted as in the variety of arteritis formerly described, together with general antiphlo- gistic treatment at the very commencement; but in prescribing remedies of this character it is necessary, even from the very first, carefully to keep in view the peculiarity of constitution possessed by most of those who are attacked by this disease, as well as the danger arising from exhaustion at a more advanced stage. However needful it may be at first to use means which produce a relaxing effect upon the capillary vessels, promote secretion, soothe nervous irritation, equalize the circu- lation, and facilitate the excretory actions, still when the accompanying fever assumes the typhoid type, those adapted to the state of depression and exhaustion, and calculated to support the vital powers, should be actively administered, howTever little hope there may be of averting an unfavourable result. ARTERITIS LIMITED TO A PART OF A VESSEL. This form of arteritis almost always arises from causes which are external and local in their operation, as a wound, or the application of a ligature; and it assumes the sthenic character, and usually gives rise to changes which result from that form of inflammation. The local results are various, being regulated to a considerable extent by the manner in which the injury is inflicted, and the amount of in- flammatory action induced. On this subject, Professor Miller says, " The minor grades will give exudation of a plastic kind, such as we desiderate after deligation ; the coats become turgid and coherent; and the canal is completely obliterated at the part affected. A higher grade of action, reaching the truly inflammatory, gives suppuration, usually conjoined with ulceration; a result which we do not desiderate, but on the contrary take every means to avoid, in operations on the larger vessels; hemorrhage being almost certain to follow. A still higher action, more especially if combined with circumstances tending to im- pair vital power of the tissue, causes gangrene of the vessel, a still more disastrous event; exemplified by the deligation of an artery whose coats have been too rudely manipulated, and too extensively separated from their cellular connexions." Much insight into the nature and results of adhesive inflammation, by which arteries are obliterated, has been obtained by observing the results of that process on the coats and contents of an artery at different periods after the application of a ligature. Two of the most attentive observers of that process were Jones, who investigated it through its different stages, and Stilling, who mentions seventy experiments on animals,—experiments which were judiciously conceived and carefully performed, and by their results as well as by those of Jones's investiga- tions, many important facts have been ascertained and elucidated. Ac- 404 DISEASES OF ARTERIES. cording to Stilling, of whose researches those of others, so far as thev go, are confirmative, some of the most important changes after the deligation of an artery are the following. On tying an artery tightly with a small ligature, its two inner coats are cut through, and the canal of the artery is closed by the apposition of the opposite sides of the outer coat, and immediately after deligation, stagnation ensues to the next collateral branches, with accumulation of blood-globules near the ligature, followed by coagulation of fibrin from the fluid constituents of the blood. The coagulum is, during the first eighteen hours, of the form of a cone, with its apex towards the heart, attached only by its base to the part where the ligature is applied ; of very slight cohesion, and not of uniform colour throughout, being red towards its base, and of a yellowish colour like that of inflammatory crust towards its apex. It next undergoes a change of form, of firmness, and of colour; its form becomes more spindle-shaped, the end nearest to the ligature tapering less than the other; its firmness increases partly in conse- quence of stronger coagulation, and partly from effusion from the pa- rietes of the artery; and its colour becomes an almost uniform pink or red. It by and by becomes attached to the parietes of the artery, the attachment being produced by exudation from the vessel, and the adhe- sions present a filamentous appearance when the plug is detached from the interior of the artery. Stilling, and Dr. Hassie, Professor of Pa- thology and Clinical Medicine in the University of Zurich, both state that when there has been much exudation, the plug exhibits externally several concentric layers. The outer coat being deprived of its nutri- tion ultimately gives way. Exudation of lymph takes place into the cellular tissue surrounding the artery—its different coats can no longer be distinguished, and sooner or later, the thin exudation of lymph exte- rior to the portion of coagulum formed by the coagulation of the blood, the walls of the artery, and the surrounding cellular tissue become con- densed into one mass, in which the original parts can no longer be distinguished. Plastic exudation takes place from the extremities of the middle and inner coat divided at the line of deligation, and the ligature, after severing the outer coat, comes away. The condensed mass formed of the exudation from the coats of the artery on the exte- rior of the coagulum, the walls of the artery, and the infiltrated cellular tissue, are proved by injection to be highly vascular; and that the vessels extend into the coagulum, is demonstrated by the vivid colour communicated to the latter in successful injections,—the appearance being such as, in the opinion of Stilling, to leave no doubt whatever of its being produced by vessels, and not by extravasation. The coagulum at this stage is traversed with innumerable canals which give it a porous appearance, and ultimately it is entirely removed, so that the sides of the artery finally cohere. The cohesion is not only where the coagulum at one time existed, but it extends also a little nearer to the heart. The artery is thus ultimately obliterated. Some observers, in describing the different exudations, name the exudation into the surrounding cellular tissue and around the artery, the external coagulum; that from the extremities of the divided coats, the middle coagulum; and that within, DISEASES OF ARTERIES. 405 the internal coagulum. In interfering with an artery, the utmost cau- tion is necessary, not only that it may not be extensively detached from its surrounding connexions, whereby its coats would be deprived of their nutritious vessels; but also that nothing but the most gentle manipula- tion be employed, so that there may be as little danger as possible of the supervening action going beyond the adhesive grade. CHRONIC ARTERITIS. Chronic arteritis presents no distictly appreciable signs, or they are so slight, and of so equivocal a character that they commonly escape detection, until the lesion with which they are connected has increased so far as seriously to disturb the functions of the part. The question, whether chronic arteritis stands in any casual relation to certain organic lesions, with which at one period of their history it is undoubtedly con- nected, will be considered, when the nature and appearances of those lesions are described. LESIONS OF THE COATS OF ARTERIES. CARTILAGINOUS DEGENERATION: OR, CARTILAGINOUS PATCHES UPON THE FREE SURFACE OF THE INTERNAL ARTERIAL MEMBRANE. These formations occur most frequently before or about the middle period of life, and chiefly in the smaller arteries at a considerable distance from the heart; occasionally they are found in the larger arteries, and in such instances they occur at the point where branches originate. These deposits present considerable varieties as to their transparency, consistence, and connexion with the inner membrane; sometimes they are transparent, of a semi-fluid consistence, and sepa- rable, so that they can be peeled off, leaving the internal membrane entire; sometimes they are less transparent, of the consistence of boiled white of egg, and can scarcely be peeled off without removing that coat; in other instances, they are opaque, of the appearance of cartilage, with the lining membrane no longer discernible, and on the removal of the deposit, the middle coat is brought into view. These varieties are regarded as the"different degrees of the same affection, which commences with albuminous effusion, the effusion gradually becoming more opaque and firmer in consistency, and more completely involving the internal arterial membrane. The only change these patches seem to undergo after assuming a cartilaginous consistency, is increase of thickness. The internal membrane, probably from having lost its elasticity, some- times cracks around these bodies, which consequently hang into the artery, and in such circumstances, fibrinous coagula are apt to be deposited round their margins. Professor Hassie, of Zurich, states that he had twice found this condition in the abdominal aorta. I have, in my own collection, a beautiful preparation of the aorta, which strikingly exhibits this lesion. The opinions which at one time prevailed, that these cartilaginous patches originated between the internal and middle membranes, and that they are occasionally converted into osseous sub- stances—that, in short, they form a preparatory stage to ossification, 406 DISEASES OF ARTERIES. are now believed to be erroneous. These opinions, no doubt, arose from the occasional occurrence of cartilaginous degeneration of the internal membrane, coexisting with osseous formation between the inner and middle coats ; but the latter differ remarkably from the former in their origin, mode of development, and the consequences to which they give rise, as will afterwards be stated. As to the nature of the morbid process, by which cartilaginous degeneration of the internal membrane is produced, pathologists are not agreed. Professor Hassie thinks they are deposited immediately from the blood circulating through the vessels. Hodgson says—" The surrounding parts of the membrane generally exhibit the appearances of chronic inflammation, but I have never seen red vessels on that portion of the internal coat which had been converted into this cartilaginous structure." Bizot, who examined the arterial system in one hundred and fifty-two subjects, and minutely investigated its morbid conditions, gives a clear description of the anatomical charac- ters of this comparatively rare degeneration of the internal coat, and regards it as a product of inflammation of that coat. It may be said to have been proved by M. Bizot, who traced the transformation step by step, that the patches originate in the albuminous exudation of arteritis, which exudation is at first of a viscid gelatinous consistence, but gradu- ally becomes firmer, and eventually supplants the inner membrane, on the free surface of which it was originally effused. STEATOMATOUS DEGENERATION. This disease, named less properly by some atheromatous degeneration, was long overlooked, and seems to have been first noticed by Monro and Haller; but since they drew attention to it, it has been investi- gated with great success by many able pathologists, and its anatomical characters and progress distinctly pointed out. Steatomatous degene- ration commences by minute granules, of a pale yellowish colour, situated between the internal and middle coats. While the disease is in this rudimentary state, the lining membrane is scarcely elevated at all; it is transparent, so that the spots are seen through it; it is unchanged in consistence; and if it be peeled off, the granules being adherent to its surface, come along with it. There is no accompanying redness, or any mark of inflammatory action in the surrounding textures. These granules coalesce into groups or masses, in the next grade of the degeneration, and the inner membrane, though unchanged as to transparency or texture, is scarcely so flat as during the early stage ; and if it be peeled off, part of the deposit comes away with it, and part clings to the middle coat, from which it appears obvious, that the unnatural deposit is deve- loped between them. The middle coat, at the seat of the deposit, is of a light yellow colour, and of a more friable texture than natural, but neither in it nor in the surrounding textures can traces of inflammatory action be at this stage discovered. The deposit has the consistence of suet—feels greasy to the touch—is of a cheese-like opaque appearance, and when broken down by the finger, gives the sensation of minute granules scattered through a fatty substance. Not only has it a fatty appearance, but the researches of Gulliver show that its chemical com- DISEASES OF ARTERIES. 407 position also differs but little from that of ordinary fat; and this being the case, of the two appellations, steatomatous and atheromatous degene- ration, the former is the more correct. Bizot detected shining particles in this deposit; Cruveilhier, small masses resembling the cholesterin scales of small gall-stones. Gluge, on examining these masses with the microscope, found them to consist of fat-globules; and Sivaine, who also repeatedly examined them with the microscope, states that he " found them, on several occasions, to consist of fat-globules merely; generally, however, they were made up of an amorphous granular mass, mingled partly with fat-drops, partly with numerous cholesterin rhom- boids. The shining particles are often very numerous, some having a golden, and some a silvery hue." The steatomatous degeneration, after attaining the grade last described, may undergo one or other of various transformations ; the two principal changes, however, are ulcerous softening and osseous transformation. For the sake of a clearer description, the various changes in ulcerous softening have been arranged into three stages. The first is characterized by the absence of all marks Fig. 134. of inflammation in the surrounding textures, or of any change in colour, transparency, or consistency of the internal membrane. This membrane, how- ever, is slightly elevated, there being more of the deposit than in the former grades of the disease; and the middle coat is still more altered and softened, and of a still brighter yellow colour at the affected spot. In the second stage, the patches are distinctly elevated, like pustules, and when pressed, communicate to the finger of the examiner the im- pression of their containing a semi-fluid substance. After the membrane has been opened and the matter discharged, it is found on examining the place in which the matter was contained, that the middle coat presents an ulcerated appearance; but some part of it still remains between the place in which the matter wTas situated and the outer coat. In the third stage, the internal membrane having cracked allows an escape of the deposit, and falls down towards the middle coat, producing a depression ; or the internal membrane having (as happens in many instances) fallen off, or having disappeared, an ulcer is formed, with the walls of which the sanguineous current is in contact, the edges being irregular, and the walls formed of the outer coat, or of that and the yellowish detritus of some very small portion of the middle coat. The outer coat becomes thickened, and the seat of many injected vessels, but no traces of inflammation are to be seen in the inner and middle coats at the parts surrounding the seat of the degeneration. Such are the characters of the steatomatous degeneration, when it undergoes the ulcerous transformation ; but, as has been stated above, it may undergo Fig. 134. From a preparation in my museum. 408 DISEASES OF ARTERIES. an opposite change, termed the osseous transformation. The term transformation has been objected Fig-135- to, when applied to this last-men- tioned change, as the calcareous matter is merely deposited in the yellow steatomatous substance, which is regarded by many patho- logists as forming its nidus. The calcareous matter assumes the form of thin, brittle scales or plates, of a yellowish-white colour, surrounded at first by steatoma- tous deposit, but not having any fibres or organized structures be- tween them. They are believed to increase very slowly, the sur- face directed to the lining mem- brane more slowly than that directed outwards ; and they evi- dently enlarge more in extent than in thickness. As the calcareous deposit increases, it comes into contact with the lining membrane, from which it is in some instances separated up to this period by a layer of albuminous matter spread over it. The inner membrane in many cases at length gives way, so that the blood is in immediate contact with the calcareous deposit, and the middle coat, after having been attenuated and changed as already described, ultimately disappears, and its place may be said to be occupied by the concretion ; hence has arisen the erroneous opinion that this coat itself is transformed into bone. The calcareous concretions are found in various forms ; they usually consist of plates or scales, varying considerably in extent, and in some rare instances, occupying the whole circumference of the vessel at the affected part, so as to con- vert it into an inflexible tube. Sometimes they consist of minute grains ; and more rarely, they give, on examination with the finger, the sensation of a number of minute bodies, movable on each other, as if jointed together. As cartilaginous degeneration of the inner coat is not very unfrequently found coexisting with the form of calcareous trans- formation just described, the error of ascribing the calcareous deposit to ossification of the previously-existing cartilage is easily accounted for. These subjects of anatomico-pathological investigation have occupied the attention of many pathologists, and in the present state of our know- ledge of them, they are considered, not as different stages of the same Fig. 13-3. From a preparation in my museum. DISEASES OF ARTERIES. 409 disease, but as entirely different diseases—the result of different morbid actions; the one commencing on the free surface of the internal coat, the other in the cellular tissue between the internal and middle mem- branes. Such are the anatomical characters of the ulcerous and calca- reous transformations; the latter, however, may give rise to ulceration, and it may therefore be stated, that, in the progress of steatomatous de- generation, ulcerous transformation may take place, with or without osseous transformation. Sometimes when the steatomatous deposit ex- ists in great quantity, it diminishes the channel of the artery, but it is much more frequently productive of dilatation with or without ulcera- tion, or of rupture, or of circumscribed or diffuse false aneurism—dila- tation being usually the result of the steatomatous deposit, and rupture with its consequences, of that condition when accompanied by calcareous concretion. A variety of the steatomatous deposit has been described by Scarpa, Stentzel, Craigie, and others, in which the secretion is of a yellowish colour, and of a cheesy or wax-like consistency. It commences most frequently in the bifurcations of arteries, and originates between the middle and inner coats; but it differs from the deposit already de- scribed, in being of firmer consistence, and in rarely containing gritty calcareous deposition. To this variety some restrict the term steato- matous degeneration, and give to that already described the name of atheromatous deposit. CALCAREOUS DEGENERATION. Calcareous degeneration has been referred to by authors under the various names of ossification, earthy degeneration, calcareous deposit, and osseous transformation. One variety of this disease, namely, that which is often found to occur as a transformation in the progress of steatomatous degeneration, has already been described; but there is another form, differing from this in many important particulars. Its seat is in the middle coat itself; it appears in the form of plates or spicula, occupying a greater or less extent of vessel, and in some examples, it at last becomes so extensive and complete as to convert the affected part of the artery into an inert tube. This degeneration seldom affects the whole circumference of an artery, except in the lower extre- mities, where it has been found to exist in distinct rings. The middle coat loses its equable aspect, some of its fibres shrivel, and the coat consequently becomes thin. It is yellower than natural, and instead of being elastic, it becomes friable and easily torn. If at this period, the vessel be cut in the direction of its length, the margins of the incision appear irregular, from the change not having been uniform, some fibres having lost more of their elasticity than others. Such are the early deviations from the healthy appearance of the middle coat, the fibres of which are ultimately changed into, and their place occupied by, an osseous formation. In consequence of this change, the external surface of the artery, in many instances, presents an uneven appearance, becoming unequally dilated in some parts, and slightly constricted in others. The internal coat, while the disease is limited and of recent standing, may remain entire, though shrivelled and irregular; but in an advanced stage, the inner surface of the vessel often becomes ragged and irregular—a result of the rupture of the internal membrane at the 410 ANEURISM. margins of the calcareous deposit. The morbid change now under con- sideration is most frequently found in the arteries of the lower extre- mities and of the brain; and the steatomatous degeneration most fre- quently in the aorta. Dilatation and aneurism are more rarely caused by the calcareous than by the steatomatous degeneration. In individuals at an advanced period of life, the calcareous degeneration not unfre- quently produces in the lower extremities gangrene of feet and limbs, and in the vessels of the brain rupture, ending in fatal extravasation of blood and compression of the brain. Another consequence of this degeneration is hemorrhage after the deligation of an artery; the vessel cracks at the part where the ligature is applied, adhesion does not follow, and ulceration and hemorrhage result. The steatomatous dege- neration and its various sequelae are occasionally coexistent with the calcareous. Although the calcareous deposition is a form of ossifica- tion, yet it differs from bone in several essential particulars ; it is desti- tute of fibrous structure and of vascularity ; it presents an irregular homogeneous appearance ; it consists of a larger portion of phosphate of lime and less animal matter; and it is destitute of any obvious arrange- ment. The period of life at which calcareous degeneration usually occurs is after the sixtieth year. Instances, however, are recorded, of its having been met with in infants, in children, and in persons from eighteen to twenty-four years of age ; but such examples are regarded as exceptions, and are extremely rare. As increased vascular action frequently exists without calcareous degeneration, and as that degenera- tion, in its early stage, is unattended with any traces of inflammation (although, when extensive, it may operate as a foreign body, and excite chronic inflammatory action), there appears no reason to regard this disease as a consequence of inflammation; especially as it usually occurs at that period of life at which there is the least tendency to inflamma- tion. It is considered to be a result of an alteration of the process of nutrition, but with what morbid condition of the system it is connected, pathologists have not been able to determine. ANEURISM. By the term aneurism, derived from the Greek *it6e«f\M, signifying a dilatation, is meant a pulsating tumour containing blood, and communi- cating with the interior of an artery. I. Divisions.—Various divisions have been made of aneurisms. Some writers, taking situation as the basis of arrangement, have divided them into internal, or inaccessible; and external, or accessible. By an external or accessible aneurism is meant an aneurism so situated, that it is impossible to include the trunk of an affected artery in a ligature, between the aneurism and the heart: where this is impossible, the aneurism is termed internal, or inaccessible. To the latter class belong aneurisms in the cavities of the body, as in the abdomen, chest, and cranium. Another division is based on the manner in which the aneurism is formed, and the tissue constituting the aneurismal sac. According to this arrangement, which is both ancient and useful, all aneurisms may be arranged into two classes—true and false. Much confusion, however, has arisen from systematic writers attaching different meanings to these terms. By a true aneurism, some authors mean one in which the aneuris- ANEURISM. 411 mal sac is formed by simultaneous dilatation of all the coats of an artery; and by a false aneurism, one in which, after the destruction of the inner and middle coats, and the ultimate giving way of the outer coat, some other tissue forms the aneurismal sac. Other writers, by a true aneu- rism, mean one which results from disease of an artery, and formed by dilatation of all the coats, or in consequence of ulceration from within, or by rupture, or by ulceration and rupture jointly, while some of the coats, remaining undivided, form the aneurismal sac ; by a false aneurism, they understand one in which some other tissue, or tissues, form the aneurismal cyst, all the coats having been divided by a wound, or destroyed by ulceration from without. Another classification, adopted by many writers, divides aneurisms into true, false, and mixed; the true being those in which all the coats are dilated and form the sac; the false, those in which all the coats are destroyed at some part, and the surrounding tissues form the cyst; and the mixed, those in which the coats of the vessel are first dilated and subsequently destroyed, the disease being at first a true, and afterwards changing into a false, aneurism. Cruveilhier, from finding the imperfections of other classi- fications and of the difficulty of ascertaining beyond doubt the state of the arterial coats, by which alone could be formed a classification founded on a pathological basis, proposed an arrangement based entirely on outward form; namely, A. Aneurismes sous l'aspect d'ampoules; 1. Aneurismes Periphe'riques; 2. Aneurismes Se'mipe'riphe'riques ; 3. Aneurismes a Bosselures. B. Aneurismes sous l'aspect de Poches si Collets. TRUE ANEURISMS. II. Mode of Formation.—True aneurisms may be formed in various ways: 1. By Dilatation.—It has been clearly proved by various dissections, in which the true arterial coats have been traced in unbroken continuity through the parietes of the sac, that aneurisms are sometimes formed without any rupture by dilatation of all the coats. This doctrine, advanced by Fernelius, Diemerbrock, Haller, and others, was called in question by Scarpa, who conceived that true aneurisms are always formed by destruction of some of the tunics of an artery. The opinion of Scarpa, however, was successfully combatted by Hodgson, who by minutely examining numerous preparations in the different museums in London, and by carefully dissecting many aneurisms in their different stages of formation, ascertained that although in the majority of instances, especially when aneurisms have attained a considerable size, the coats of the vessel have given way, still many aneurisms are formed by dilatation, and that Scarpa therefore was on this point certainly in error. The dilated coats in some instances appear little altered in thickness, but more frequently they are attenuated in some parts, and thickened in others. The dilatation may affect only a limited portion of the circumference of the artery, constituting what from its form is called a sacculated or sacciform aneurism ; or it may implicate the whole circumference and affect the artery to a considerable extent longitudi- nally, constituting when regular in its outline and abrupt at its extremi- ties, a cylindrical aneurism ; or it may commence and terminate gra- 412 ANEURISM. dually, in which case it is called a fusiform aneurism ; or it may be very irregular, giving to the artery a knotty and tortuous appearance, con- stituting what Breschet has denominated the varicose form of true aneurism. The formation of aneurism by dilatation is often observed in the aorta. 2. By Rupture.—If an artery, affected with any of the forms of degeneration formerly described, be violently stretched, as in leaping, running, or by any violent exertion in walking, then the inner and middle coats may become lacerated, the diseased condition may prevent adhesion, and the result may be the dilatation and ultimately the giving way of the outer coat. The doctrine that aneurism was formed by rup- ture of the coats of an artery was maintained by Sennertus, Hildanus, Severinus, and others. It is usually called, however, the doctrine of Sennertus, and has been ably supported by Scarpa, who contended that aneurism is formed " by a corrosion and rupture of the proper coats of the artery, and consequently by effusion of blood under the cellular sheath, or any other membrane which covers externally the injured artery." Aneurisms formed in this way are not unusual in the extre- mities, more especially at the flexures of the joints ; and they are more frequent in men than in women, probably because the exciting causes of their formation are such as the former are more exposed to than the latter. In most instances, the rupture of the coats is attended with sharp pain, and many patients have stated, that they felt as if they had received a smart blow on the part, and have been able from this circum- stance to date the commencement of the disease. Rupture does not appear ever to take place in a sound artery, and if it did, the experi- ments of Jones prove that it would not be followed by an aneurism, as an effusion of lymph takes place, by which the vessel is strengthened at the injured part. 3. By Dilatation and Rupture.—Cases recorded by Lancisi, Friend, Guatteni, Morgagni, Monro, and many subsequent observers, leave no doubt that aneurism may arise from dilatation and rupture conjointly; and in the opinion of many distinguished pathologists, this is the most frequent mode of its formation. There is first a dilatation of all the coats, forming a true aneurism; but when the expansion reaches a cer- tain point, the inner and middle coats, having less power of extension than the outer, become ruptured or give way, either after or without previous ulceration ; and the outer coat becomes distended and forms a sac which surmounts the primary dilatation. The expansion of all the coats constitutes a true aneurism, which may be termed primary; the dilatation of the outer coat forms a consecutive aneurism. Such cases have been denominated compound or mixed aneurisms. The peculiarity of this mode of formation is, that rupture or ulceration of the internal and middle coats takes place after their dilatation, and is followed by a still farther dilatation of the outer coat. Examples of this form of aneurism occur not unfrequently in the aorta. The above are the prin- cipal changes in the coats of arteries constituting aneurisms; and they may all be said to proceed from pre-existing changes connected with the cartilaginous steatomatous or calcareous degenerations, or with these conjointly; or the pre-existing change may, in some instances, consist only of a low grade of inflammation causing debility and defective vital ANEURISM. 413 cohesion of texture,—common results of inflammation in many other textures of the body. There can be no doubt, however, that the steato- matous degeneration is by far the most frequent predisposing cause of aneurism, and the rationale of its operation may be very easily under- stood from what was stated, in a former section, as to the conditions to which it gives rise. If the degeneration be confined to a particular part, and implicate only one side of an artery, it is easy to conceive how, on the destruction of the elasticity of the inner and middle coats, the column of blood acting with equal force on every side will give rise to a dilatation or pouch on one side, constituting a sacciform aneurism. If the degeneration extend around the whole circumference, and be abrupt at its commencement and termination, the distending force may cause a cylindrical aneurism ; whereas, if the transition from the healthy to the diseased state be more gradual, a fusiform aneurism will more probably be the result. As has been already stated, any of the various degenerations of the coats, or a low grade of inflammation may consti- tute the pre-existing change which predisposes to the formation of aneu- rism. The steatomatous degeneration is by far the most frequent, the true calcareous degeneration of old people comparatively rare. The latter, however, may lead to the formation of aneurism by causing rup- ture or ulceration of the inner coats, or the narrowing of the arterial canal, which it occasions, may be followed by dilatation on its cardiac side, leading to the giving way of the inner and middle coats. The three modes of formation, then, are—by dilatation alone, by rupture alone, or by dilatation and rupture conjointly. III. Varieties.—Besides the differences of form which have led to the appellation of sacciform, fusiform, cylindrical, and varicose, and the differences in the kind of degeneration which may constitute the pre- existing change, true aneurisms (using that expression in the sense already affixed to it) present numerous varieties in the condition of the several coats of the artery and their relation to the aneurismal sac. The principal varieties are the following, the first four of which are illustrated by Wardrop, by the accompanying diagrams. First diagram. 1st. The parietes of the aneurismal sac __________^—-^___________may be formed by the distension of the —Vv— three coats. Second diagram. 2d. They may be formed by the dilata- __________f~\ _______ tion of the internal and external coats, ■=f \ the middle coat having been ruptured. Third diagram. 3d. They may be formed by the dila- y~\ tation of the external coat, the middle and internal coats having been ruptured or destroyed by ulceration, or by rup- ture and ulceration. Fourth diagram. 4th. They may be formed by the dila- tation, or hernia, of the internal coat, ~f~\-----: the external and middle coats having given way. This rare variety, examples of which have been observed by Haller, 414 ANEURISM. Dupuytren, Dubois, Breschet, Laennec, and Liston, has been hitherto regarded by most observers as peculiar to the aorta, the inner membrane of which is more loose and elastic than that of other parts of the arte- rial system; but Breschet conceives that he has proved its occurrence in smaller arteries. It probably arises from the destruction of the ex- ternal and middle coats by disease, and according to Laennec, the inner coat will protrude and form an aneurismal sac while the swelling is small, but will be apt to burst, as the tumour becomes larger. Laennec refers to four examples, in two of which the aneurisms were of the size of cherries, and the inner membrane, though dilated, was entire-; in the other two, they were of the size of walnuts, and the inner coat had given way. Laennec says—" The opinion at present current in the Parisian schools, viz., that in aneurism the internal coat remains entire, and protrudes in the form of a hernia, through the ruptured fibrinous tunic, is more untenable as a general position than that of Scarpa, who main- tains the rupture of the two internal tunics in every case of the disease. Both these opinions are true in certain cases, but not in all." John Hunter, Scarpa, and Sir Everard Home, removed the external and middle coats of arteries in various experiments on living animals, with the view of ascertaining whether the force of the circulating current would dilate the inner coat into an aneurism ; but they found that in- stead of an aneurism resulting, effusion of lymph took place, and the part healed without any change of size in the channel of the artery. 5th. The dissecting is a very rare variety. Laennec has given an account of one example, and Mr. Guthrie of two. In the case men- tioned by Laennec, the aneurism was very extensive; yet the person was not suspected, during life, of having any disease of the vascular system. The aneurism extended from the arch of the aorta to its division into the common iliacs, and is the largest example of this variety on record ;—" The internal and middle coats had been divided by a nar- row transverse fissure, extending over two-thirds of the circumference of the artery; and the blood, instead of extending the external coat into a sac, had insinuated itself between it and the middle fibrous coat, and dissected them from each other, through more than half the circum- ference of the artery, from the arch of the aorta down to the common iliacs." Here the aneurismal sac was formed on one side by the ex- ternal coat, and on the other by the middle and internal coats. In one of the cases recorded by Mr. Guthrie, there was a fissure about half an inch in extent, by which the blood escaped through the inner and middle coats, and effected a separation of the middle and external coats, so as to form a pouch about six inches in length in the anterior part of the descending aorta. In the other example mentioned by Mr. Guthrie, the inner and middle coats of the aorta were divided along half the cir- cumference by a very clean rent, situated opposite to the origin of the arteria innominata, and the separation of the external and middle coats extended on the one side from the rent to the origin of the aorta, and on the other to a point opposite to the origin of the left subclavian. Laennec was the first writer who gave a minute description of this curious variety, and it has been carefully investigated by Rokitansky, ANEURISM. 415 who gives an account of eight cases which came under his own observation. These eight, together with two others, also referred to by Rokitansky (viz. the one described by Laennec, and one by Dr. Stosch), the two described by Guthrie, two by Mr. Smith, one by Nivet, and two by Goddard and Pennock, being seventeen in all, were, until lately, so far as I know, the only recorded examples of this kind of aneurism. In almost all these examples the heart was diseased, and more especially its left side ; in some instances there was dilatation with hypertrophy ; in others dilatation with attenuation; and in many of them there were evident signs of steatomatous and calcareous deposits. According to Rokitansky, it sometimes commences by disease of the middle and • internal coats, in which case the continuity of these coats is destroyed, and the separation of the external coat follows as a later effect; in other instances, it is the consequence of chronic inflammation of the external coat, which gives rise to separation of that coat, followed by rupture of the middle and internal coats. In the one set of cases he considers that the rupture precedes, in the other, that it follows, the separation. 6th. The late Mr. Shakelton described a kind of aneurism previously unnoticed, in which the blood had forced its way through the internal and middle coats, dissected the middle from the external coat to the extent of four inches, and then burst again into the channel of the ar- tery, thus forming a new channel, which eventually superseded the old one,—the latter having been obliterated by the pressure of the tumour. In this case the aneurismal sac was formed by five coats on the one side, and the external coat on the other. 7th. In the body of a man about fifty years of age, who had not been supposed to be the subject of any disease, and who died very suddenly before any medical man had an opportunity of seeing him, I met with a singular variety of dissecting aneurism. In the arch of the aorta, about three-fourths of an inch to the left side of the origin of the left subclavian artery, there was a rent of the inner and middle coats ; from this rent to near the origin of the aorta on the cardiac side, and for upwards of an inch on the capillary side the external coat was sepa- rated from the middle, round nearly two-thirds of the circumference of the artery. There was an opening upwards of half an inch in diameter, by which the aneurism thus formed burst into the pulmonary artery, a little below the place where that vessel gives off its two branches. The aorta was affected with steatomatous deposit in many places, and in this case there were, beyond all doubt, patches of the same kind of degene- ration in the pulmonary artery. There was very slight hypertrophy of the left side of the heart. A true aneurism is invariably limited at first; that is, it is confined within a proper cyst; but, by rupture or ulceration, the cyst may give way, and the blood become diffused through the surrounding textures; in which case, the aneurism is said to be diffuse. IV. Contents of the Sac.—The contents of an aneurismal sac-are not the same at all periods; they vary considerably, according to the length of time that has elapsed since the commencement of the disease. At first the sac contains only fluid blood, and in this stage, by exerting 416 ANEURISM. pressure on the swelling, or on the artery leading to it, the aneurismal sac is readily emptied. In the next stage the contents consist partly of fluid blood, and partly of a solid substance, the nature of which will be afterwards described, bearing but a small proportion to the fluid. In a yet more advanced stage, the sac still contains both fluid blood and coagulum; but the proportion of the latter to the former is greatly increased. When after death an opportunity is afforded of examining an aneurism of some standing, the sac is found to contain what is technically called the coagulum, consisting of two parts, namely, blood more or less firmly coagulated, the coagulation having probably taken place subsequent to death, and a lamellated fibrinous concre- tion. This fibrinous concretion is found to consist of numerous con- centric laminae, varying in firmness according to their situation; those nearest to the blood having usually a soft and somewhat reddish ap- pearance ; those farther removed being more dry, more pale, and more adherent; and the external ones in contact with the sac, having a very opaque, dry appearance, and being of a somewhat friable consistence. A most important change which takes place soon after the occurrence of aneurism, is the commencement of the formation of the fibrinous con- cretion. The blood, after the formation of the aneurism, leaves upon the internal surface of the sac a layer of coagulum, and this being fol- lowed by successive depositions of fibrin, the lamellated concretion is gradually formed. If the form of the sac be such as to admit of the re- tardation of the current of circulation in it, as in a sacculated aneurism, having a narrow communication with the arterial trunk, the coagulum is formed much more readily: and this explains a most important dif- ference in the pathological conditions of an aneurism, and a simple dila- tation of the artery ; for in the latter, where the surface is smooth, and no retardation of the current of blood can take place, there is no fibri- nous concretion, and consequently no means of protection for the weak- ened part. V. The various ways in which Aneurisms prove fatal.—1. Aneurisms frequently prove fatal by making their way to the surface of the body, or to the mucous canals, or to the serous cavities. When an aneurismal tumour, reaches the surface of the body, it never bursts by laceration, Fig. 136. Farther growth of aneurism prevented by coagulum becoming adherent to the artery around the opening of the sac. From Hodgson. ANEURISM. 417 but the attenuated integument sloughs, and on the separation of the slough, an escape of blood takes place. The flow of Fig. 137. blood is for a time arrested by a part of the coagulum forming a plug, but by and by, the hemorrhage returns, and the patient sinks in consequence of repeated at- tacks of it. The process is the same when the disease opens into the mucous ca- nals, or into an organ lined with a mucous membrane, as the oesophagus, intes- tines, or bladder. The part does not give way by lacera- tion, but after being attenu- ated by absorption, it is destroyed by sloughing. I have a preparation of an aneurism of the aorta, in which an opening was made into the trachea by the process above referred to, and the first discharge of blood caused death by suffocation. Aneurisms frequently prove fatal by bursting into some of the serous cavities, as the cavities of the pleurae, that on the left side more fre- quently than that on the right, the peritoneum, the serous cavity of the tunica arachnoidea, or the pericar- dium. Of the last, examples were Fig. 138. seen by Morgagni, Sir Astley Cooper, and others; and I have a beautiful specimen taken from a man who died suddenly, in whose pericardium I found a large quantity of blood, the fatal rent being about an inch in length. In the two former modes of fatal termination, the integument, or mucous membrane, after being attenuated by absorption, gives way by sloughing; in the last the serous membrane gives way by a rent. In the third mode, and sometimes in the second, death results from a single discharge of blood; but in the first, from repeated hemorrhages. 2. Death may be caused by pres- sure on important parts, as the tra- chea, the bronchial tubes, the lungs, the oesophagus, the thoracic duct, Fig. 137. Aneurism of arteria innominata, which proved fatal by bursting into the trachea. From a preparation in my own museum. Fig. 138. Aneurism of the aorta, which induced caries of the vertebrse, and fatal compression of the spinal cord. From a preparation in my museum. 27 418 ANEURISM. of which Laennec witnessed an example, or the spinal cord. I have several specimens of aneurisms which proved fatal by pressure on the spinal cord; in one of them the bodies of two vertebrae, and in another those of three, are entirely absorbed on the left side of the spine. 3. By constitutional irritation, the system sympathizing with the local irritation. This will be most likely to occur when the aneurism is surrounded by unyielding textures, which are capable of offering con- siderable opposition to its integument. 4. Aneurisms may prove fatal in consequence of inflammation at- tacking the sac and surrounding parts, and giving rise to suppuration and the formation of large abscesses. This is by no means a frequent occurrence, but various examples are on record. 5. Death may ensue from the bursting of the aneurism, and the escape of blood into the surrounding textures, that is, from a circumscribed aneurism becoming diffuse. The extravasated blood may so greatly interrupt the circulation as to cause gangrene, or the infiltration may be followed by unhealthy inflammation of the tissues, which are weak- ened by the pressure of the infiltrated blood, and death may be caused by the symptomatic fever, which in such cases usually assumes a typhoid type. Such are the most frequent modes of fatal termination of aneurisms; there are others which, though of extremely rare occurrence, are occa- sionally met with. In an individual not suspected of labouring under Fig. 139. Fig. 140. any disease, who died instantaneously one morning, while rising out of bed, and whose body I was requested to examine, death was caused by an aneurism of the aorta bursting into the right auricle of the heart. This mode of fatal termination has also been seen by others. I have Fig. 139. Front view of aneurism of aorta. From a preparation in my museum. Fig. 140. Back view of same preparation, showing the aneurism, producing absorp- tion of the ribs, and making its way to the surface. Death was caused by part of the coagulum falling into the artery. ANEURISM. 419 in my possession a _ specimen taken from a case in which death was caused by an aneurism of the aorta making its way into the pulmonary artery. In some instances of aneurism of the aorta, it has been found on dissection, that fatal destruction of the circulation resulted from a portion of the coagulum falling from the sac into the artery. VI. Symptoms.—Sir Astley Cooper says, " With respect to external aneurisms, the symptoms may be divided into three stages. When you have an opportunity of seeing aneurism in its early stage, you will find a small tumour pulsating very strongly—much more strongly than in any subsequent stages ; for it may be taken as a general rule that the force of the pulsation is in the inverse proportion of the size of the aneurism. When an aneurism is first formed, it* contains only fluid of blood ; and if you apply your finger to the artery between the aneurism and the heart, you will readily empty Fig. 141. the aneurismal bag. In this state there is scarcely any pain, and no other alteration in the limb than some irregularity of circulation producing spasm in the muscles; and when the patient is going to rest, cramps in the legs and sudden twitchings, which prevent him from sleeping. The next state in which we find aneurism is when the blood is beginning to coagulate in the interior of the sac, the coats of which are very considerably thickened. At this time, if you press on the artery, you may empty the sac in part; you will see the swelling reproduced when you take off the pressure. You cannot completely empty the bag by pressure, for a considerable degree of swelling will still remain. There is some degree of pain in the limb below in this stage of the disease, in consequence of the size of the swelling, and the pressure on the sur- rounding parts. The aneurism becomes a solid swelling, instead of a mere bag containing fluid blood, and the circulation is retarded by the pres- sure on the surrounding parts. In the next stage, the aneurism has acquired considerable magnitude, and the pulsation is, in a great degree, lost. Pulsation may be observed in some one part opposite to the opening from the artery, but it is seldom perceived over the whole swelling. A small portion of the blood still continues in a fluid state but the greater part of it is filled with coagulum." The principal symptoms of external circumscribed aneurism are a swelling, pulsation synchronous with the heart's action, and at each pulsa- tion an elevation of the tumour, a heaving or uniform enlargement, a peculiar thrill felt on applying the hand, and a sound like that of bel- lows perceptible on applying the ear. For the purpose of diagnosis, it is of the utmost importance that the characteristic peculiarities of these symptoms should be clearly understood. 1. The swelling at first is small, but its increase is gradual; " seldom so rapid as the outward bulging of an abscess; seldom so tardy as the enlargement of any tumour not malignant." In the first stage it is 420 ANEURISM. soft, and may be reduced by pressing the tumour or the artery leading to it; in the second stage it is a little harder and less compressible; and in the third stage it is still harder, and very slightly, if at all susceptible of diminution by pressure. To whatever extent the tumour may be compressible, it immediately returns to its former size on the discontinuance of the pressure. By pressure on the trunk, leading from the aneurism, the tumour is increased. 2. The pulsation is synchronous with the action of the heart, and is much more perceptible, both to the touch and the sight, in the first than in any subsequent stage. In the second stage the pulsation, in conse- quence of the deposition of fibrin, may be less distinct in certain parts of the tumour than in others ; hence it is said not to be " equal in all directions." In the third stage the pulsation is still further diminished, and may be limited to certain parts ; and it is scarcely, or not at all, perceptible if the sac be nearly filled with lamellated fibrin. The absence of pulsation, therefore, is no certain proof that a tumour is not an aneu- rism ; nor is the presence of pulsation any proof that it is ; for a tumour or an abscess may have pulsation communicated to it by its being situated over an arterial trunk, and in the case of an abscess so situated, the fluid nature of its contents renders the pulsation very deceptive. It will assist in diagnosis to remember, that the pulsation of an aneurism cannot be changed by any alteration in the position of the limb; but that the pulsation communicated to a tumour in the neighbourhood of an artery, may be diminished or suspended by placing the limb in such a position as may remove the tumour from the artery, or by lifting the tumour off the artery, or pressing it aside. 3. Elevation of the aneurism is perceptible, and is always synchro- nous with the pulsation. 4. A heaving, or uniform enlargement, or distinct expansion at every point, simultaneous also with the pulsation, is quite diagnostic of aneu- rism. The impression communicated to the fingers of the examiner is, that the expansion is caused by the injection of a fluid into the cavity. This symptom differs very much from the pulsation or change of place of a tumour occasioned by an impulse from a neighbouring artery. The presence or absence of this symptom should be minutely inquired into, in the examination of every swelling supposed to be aneurismal. 5. The peculiar thrill or rasping sensation, felt on placing the fingers over the aneurism, is supposed to be produced by the blood rushing over a rough surface. 6. The sound, like that of a bellows {bruit de soufflet), is discoverable either by mediate or immediate auscultation. This sound, however, is no certain proof of the existence of aneurism, as it is well known that it may be produced by a tumour diminishing the calibre of an artery; it may be made perceptible by compressing an artery with the stetho- scope, more especially if the individual be in a state of nervous agita- tion ; and it has often been perceived where, on dissection, no lesion of the coats of the arteries could be discovered. Of all the symptoms, the uniform expansion simultaneous with pulsa- tion, is the most unequivocal. The history of the symptoms often affords valuable assistance in making out the diagnosis in difficult cases. ANEURISM. 421 Fig. 142. The following symptoms, though not distinctive characters, usually in a greater or less degree attend aneurism at some period of the disease. Pain.—If an aneurism arise from dilatation, there is usually no pain at the period of its formation; if there be first dilatation and then rupture, the pain is trivial; but if the aneurism originate in rupture, sharp pain is felt at the formation of the disease ; and in all cases there is ultimately more or less pain or uneasiness, when the swelling attains great size in an advanced period of the disease. (Edema of the extremity, weakness, numbness, spasmodic twitchings, and sensations from compression or stretching of surrounding structures, are symptoms of frequent occurrence. If an aneurism be in the neigh- bourhood of a joint, it usually interferes to a considerable extent with the motion of the articulation. VII. Spontaneous Cure.—Nature sometimes, though very rarely, effects a cure; and an aneurism, therefore, which is not accessible to surgical treatment, does not invariably terminate fatally. The processes by which a spontaneous cure may be effected are the following:— First.—The most frequent manner of a spontaneous cure is, by the sac becoming filled with lamellated coagulum. The various stages of this mode of favourable termination, first minutely described by Hodg- son, and afterwards minutely investigated by many other competent observers, are the following:—the sac becomes com- pletely filled so as to preclude all further entrance of blood. The artery, by depo- sition of coagulum, becomes impervious as far as its nearest considerable branches, and is ultimately converted into a small impervious cord,—the circulation in such cases being maintained by the blood, which is received into the branches given off from the arterial trunk above the aneurism, being discharged into branches given off from the trunks below, and conveyed through the last-mentioned branches by inverted circulation into the trunks from which they originate—both sets of branches becoming much en- larged. Or the artery may remain per- vious, the blood passing over the closed- up sac at the part where its mouth communicated with the vessel. The tu- mour becomes smaller and harder in consequence of absorption. Petit records a case of spontaneous cure, in which the aneurism, at one time as large as an apple, became as small as an olive. Examples of this mode of spontaneous cure are to be found in the writings of most sur- Fig. 142. Spontaneous cure of aneurism of the femoral artery by the sac being filled with coagulum; the vessel remaining pervious. From a preparation in my museum. 422 ANEURISM. gical authorities on this subject. The accompanying drawing is taken from a very good example in my own collection of preparations. Second.—In some examples where the whole circumference of a vessel has become aneurismal, a spontaneous cure has been effected by a canal being left through the centre of the lamellated coagulum, through which the blood continued to circulate. There is reason to believe this to be an extremely rare mode of spontaneous cure. Third.—It occasionally happens that from over-distension, or some other circumstance, inflammation of the sac and surrounding parts supervenes, and goes on to gangrene, the whole of the aneurismal tumour sloughing away, and by that means a spontaneous cure is effected;— hemorrhage from the vessels leading to the part being prevented by the same process as when gangrene takes place in other circumstances. Fourth.—Another mode is by the aneurism pressing on the trunk leading to or from the aneurism, so as to obstruct the circulation. If the size and position of the tumour be such as to cause an approxima- tion of the opposite sides of the artery either on the cardiac or capillary side, there can be no doubt that a cure will be the result. When the pressure is on the cardiac side, the cure is effected on the same prin- ciple as in one of the modes of surgical treatment described in the next section. Fifth.—Pressure on the trunk leading to the aneurism may be pro- duced by other causes than the aneurism itself, as by a tumour not aneurismal, or by another aneurism on a neighbouring artery; and thus a spontaneous cure may result. Mr. Liston records an example of sub- clavian aneurism, which on dissection was found to have been cured by an aneurism of the arteria innominata. Sixth.—The same favourable result will follow, when inflammation takes place in the artery, and fills its calibre with coagulum. Seventh.—Sometimes a portion of lamellated fibrinous coagulum be- coming detached falls into the sac, and thus causes diminution, or com- plete occlusion of the mouth. In the latter case, coagulation of the blood in the sac must take place, and in the former the consequent diminution of the circulation through the sac is much calculated to promote deposition of fibrin, and to accomplish a spontaneous cure. In this mode the artery may or may not become impervious. Eighth.—A portion of the coagulum may fall into the artery and obstruct it, thus effecting a cure. Or, Ninth.—The aneurism may burst and become diffuse. If the presence of the diffusely infiltrated blood do not give rise to the untoward conse- quences formerly described, it may, by its pressure on the cardiac side of the tumour, so weaken the force of the circulation through the aneu- rism, as to promote the deposition of lamellated coagulum, or to arrest the circulation of the fluid parts of the contents of the sac, and thus promote their coagulation. Such are the methods by which nature sometimes, though rarely, effects a spontaneous cure; and it may be a consolation to patients who are subjects of aneurisms in inaccessible situations to know that their case is not hopeless, and that a sponta- neous cure is not impossible. VIII. Treatment.—As the enlargement and ultimate giving way of ANEURISM. 423 an aneurism depend on the force with which the current of blood is sent into the sac, leading principles in the treatment have been, to diminish this force, or to arrest the current altogether. By fulfilling the first indication, the progress of the disease must be retarded, and its cure may be effected, as the diminution in the velocity and force of circula- tion promotes the formation of lamellated coagulum ; by the second in- dication, a cure is effected, for the fluid contents of the sac being set at rest become coagulated. Consolidation induced by coagulation, or by deposition of fibrin, or by both, will be followed by increased hardness, diminution by absorption, and the other favourable symptoms mentioned in the description given of the first mode of spontaneous cure. The medical treatment, which is the only treatment practicable when the aneurism is in the cavities, or in situations inaccessible to the sur- geon, is useful on the principle already stated, that the diminution of the force and velocity of the circulating current increases the tendency to deposition of coagulum. This diminution is effected by lessening the vigour of the heart's action and the quantity of the circulating fluid. For the attainment of these objects, the vigorous employment of anti- phlogistic treatment, to as great a degree as is compatible with the con- tinuance of life, was originally proposed and practised by Albertini and Valsalva. It is designated their treatment of aneurism, and from their experience and that of others it acquired great celebrity, which, how- ever, it has not. maintained. Albertini and Valsalva reduced their patients, by repeated abstractions of blood, to such an extreme degree of debility, that they could scarcely raise their arms from bed ; they enjoined the most perfect quietude both of body and mind ; they directed that their patients should be kept constantly in the horizontal posture in bed, and that their diet should be of the most unstimulating kind; and they gradually reduced the quantity to half a pound of pudding in the morning, and a quarter of a pound in the evening, forbidding every- thing else except a limited quantity of water. When this treatment effected a cure, it was by favouring the deposition of lamellated fibrin- ous coagulum. Its efficiency in arresting the progress of internal aneu- rism and accomplishing its cure, has been proved by the experience of Albertini, Valsalva, Pelletan, and other observers; but there is reason to believe that its effects have been very much overrated. Be that, however, as it may, few persons will submit to its employment to the extent practised by Albertini and Valsalva; and there can be no doubt that it has often been used to a hurtful extent, and that in some persons it is not free from the danger of proving fatal by inducing other dis- eases. Its employment is, therefore, often inadmissible. For these reasons, it is not now adopted in the vigorous manner practised by Albertini and Valsalva, nor with a curative view, but in a very modified form, and with little hope of doing more than checking the progress of the disease. By medical treatment alone, can the progress of aneurisms in inaccessible situations be retarded ; and of the necessity of employing all judicious means for diminishing the circulation, and of endeavouring to preserve the body in a quiescent state there can be no reasonable doubt. Although it may not be prudent to reduce the patient to a state of great debility, there can be no question that it is advisable and 424 ANEURISM. necessary in every case of internal aneurism to enjoin quiet, restriction of diet, abstinence from animal food, and from all stimulants ; to caution patients that they guard against all emotions of mind, and refrain from every kind of exercise by which the circulation could be accelerated; and occasionally to have recourse to bleeding, proportioned in frequency and quantity to the force of the circulation, and the strength of the patient. A precaution which ought always to be observed is, to with- draw the blood slowly from the patient placed in the horizontal position, and never to take away a large quantity at once, lest syncope should be induced, which in internal aneurism, more especially if there be disease of the heart, is attended with the greatest danger. Digitalis, from its effect of weakening the action of the heart, has often been administered ; but its employment is a matter of very questionable propriety, as the extent to which it affects the heart's action cannot be regulated with certainty, and its decided influence is hazardous in such cases. The superacetate of lead has long been used in Germany in cases of internal aneurism ; and Laennec, Dupuytren, and Bertin in France, and some practitioners in this country, state that they consider it to have been used with advantage. Surgical Treatment.—Until John Hunter, in 1785, proposed and practised his operation for the cure of aneurism, the treatment adopted was either amputation, or the employment of pressure, or the perfor- mance of some one or other of the following operations. One of the earliest operations we read of is that which was practised in the time of Celsus, who lived in the beginning of the first century of Christianity, and was the most elegant writer on medicine and surgery among the Romans. In those days the practice was to open the tu- mour, to clear out its contents, and to endeavour to stop the hemor- rhage by thrusting the actual cautery into the wound—a procedure almost invariably fatal, and it would have been very surprising if it had been otherwise. Another operation is that which was practised by Rufus the Ephe- sian, a zealous surgeon who flourished in the beginning of the second century in the time of the Emperor Trajan. He first by means of a ligature secured the artery immediately above the aneurism, and then cut into the tumour and removed its contents. Antyllus, who is generally believed to have flourished in the begin- ning of the fourth century, followed .the example of Rufus in cutting into the aneurismal swelling, and removing its contents ; but he previ- ously tied the artery below, as well as above the swelling, and endea- voured to heal the wound by granulation. Such were the operations practised among the Romans. The Greek and Arabian writers recommended an operation in some measure different from those practised among the Romans, and, in one particular, bearing a resemblance to that in use at the present day. Aetius, a native of Amida, and a pupil of the celebrated School of Alexandria, who flourished in the middle of the sixth century, and the celebrated Paulus iEgineta, also a pupil of the Alexandrian School, who lived about the middle of the seventh century, both practised the same operation. Aetius recommended for the cure of aneurism at the bend ANEURISM. 425 of the arm, to include the brachial artery in a ligature a little below the axilla, and then to evacuate the contents of the aneurism : the peculi- arity of this method was the application of the ligature at a considerable distance from the aneurism. Paulus iEgineta not only practised this operation for the cure of aneurism at the bend of the arm; but adopted it also in aneurisms in various other situations. Such was the practice recommended by the Greek writers. These operations were succeeded by one still more formidable and dangerous, which consisted in opening the aneurismal sac, clearing out its contents, then searching for the artery and securing it by a ligature, both above and below, at its openings into the sac. This horrible and dangerous procedure was always attended with extreme pain and irri- tation, and was for the most part fatal, as might have been anticipated, considering the many hazards which the patient had to encounter. Another operation, practised by Guattani and others, consisted in laying open the sac, removing its contents, and applying graduated compresses tothe extremity of the artery at the mouth of the sac. In performing this operation, some surgeons, among whom was Guattani, endeavoured to arrest the hemorrhage by pressure alone, using com- presses for this purpose; others, retaining the use of compresses,- also applied styptics. After the introduction of the torniquet by Morel, towards the end of the seventeenth century, the danger from loss of blood during the operation was diminished, as hemorrhage could be prevented until the surgeon had accomplished the immediate object of his operation. Whoever reads the description of their operations, as given by Guattani, Deschamps, Pelletan, and others, will readily admit that few things in the history of surgery are more horrible, and that it is not, therefore, very surprising that many surgeons in those days arrived at the conclusion, that until a safer and more successful mode of operation should be discovered, the most advisable procedure was ampu- tation, which, accordingly, was often resorted to. Another operation was, however, before long, suggested, namely__ the method so successfully practised at the present day, of tyino* ar- teries. It seems very surprising that there has been so much difference of opinion as to whether this operation should bear the name of Anel, of Desault, or of Hunter, when, by a careful examination of the then practice, it is so easy to determine the merit which belongs to each of these great men. To Anel, undoubtedly, the merit belongs of having first introduced the important principle of not interfering with the aneurismal sac, but leaving it entire; he tied the artery above the sac, but as close to it as possible. This method he successfully practised on the brachial artery m 1713; the important point in it is the placing of the ligature on the artery, and not interfering with the tumour. The treatment which was practised by Anel for an aneurism of the brachial artery, Desault applied to a case of aneurism of the popliteal artery in the Hotel Dieu, Paris, in the month of June, 1785—the same year in which Hunter performed his first operation. The grand objec- tion to the method practised by Anel and Desault is, that the artery was tied as close as possible to the aneurismal sac ; its recommendation 426 ANEURISM. (as has been already observed) is, its principle of not interfering with the tumour. To John Hunter, undoubtedly, belongs the merit of suggesting the method now so generally adopted, and of establishing its success by experience. In Hunter's method, to which he was led by a considera- tion of the physiological principles applicable to the cure of this disease, the aneurismal sac is not interfered with, and the artery is tied on the cardiac side of the tumour, at a considerable distance from it, where the artery is easily accessible, and where its coats are more likely to be free from disease, the removal of the aneurism being left to the action of the absorbents. Hunter performed his first operation in St. George's Hos- pital, London, in December 1785 (a few months after Desault's operation in the Hotel Dieu, Paris), in a case of popliteal aneurism, for the cure of which he tied the femoral artery; and the desired result was ob- tained. This mode of operation is justly regarded as one of the greatest improvements in surgery, nor can there be any question that Hunter is entitled to the praise of having first suggested it and proved its success. It has been said " that those who render themselves useful to their fellow-men by their important discoveries in the sciences belong to every country, and, that they deserve praise from one pole to the other; but it seems to us, also, that each nation may, without being taxed with egotism, claim for itself, and attach to its own soil the discoveries or improvements which are its property, and which tend to increase its scientific glory." As the effects of a ligature properly applied to an artery, and the various changes which result, have already been minutely described in a former section, it seems unnecessary to do more than to refer to that description, and to add, that the immediate object which the surgeon wishes to accomplish is, to set the fluid contents of the sac in some measure at rest, which will be indicated by the arrest of the pulsation and the bruit; and this will be followed by their coagulation, and, con- sequently, by the entire consolidation of the tumour. Slight contrac- tion of the sac takes place at the moment the force of the blood is arrested by the application of the ligature, and the whole contents of the sac being converted into coagulum, the remaining part of the cure is carried on by the same process as when consolidation takes place in a spontaneous cure. From what has been stated as to the immediate object which the surgeon desires to accomplish, it will be evident, that it must always be a matter of the greatest anxiety that the pulsation be arrested on the application of the ligature; and, as the desired result may be prevented either by the existence of a variety of the arterial system, or by an extremely free communication with the trunk between the ligature and the aneurism by means of anastomosing vessels, the immediate effect produced by the ligature on the pulsation is anxiously observed. It often happens that, although the pulsation is arrested by the application of the ligature, yet in the course of a few hours, or at a later period, on the collateral circulation becoming fully established, it returns in a slight degree. This is, no doubt, occasioned by the blood not being rendered altogether stationary at once, and by some passing into the aneurismal sac from vessels arising above the ligature; but, ANEURISM. 427 although the return of pulsation even in any degree is always a cause of much anxiety to the surgeon, it almost invariably, in such cases, gra- dually diminishes and ultimately disappears, in consequence of the enfeebled force of the circulation being insufficient to overcome the ten- dency of the blood to coagulate. The condition which it is desired to produce by the operation is, the solidification of the tumour. For pro- moting that state, it seems essential that the force of the circulation be enfeebled, and this is accomplished by tying the main trunk, although the blood is not rendered at once perfectly stationary in the aneurismal sac. The tumour is gradually diminished by absorption ; and, with regard to the condition of the main trunk, on which the aneurism is situated, it has been found, in some instances, that it has become oblite- rated from the first branch above the ligature to the first below the aneurism, an example of which is mentioned by Sir Astley Cooper, where the obliteration extended from the origin of the deep femoral artery to the commencement of the tibial arteries. But such an extent of obliteration is extremely rare ; and in most specimens which have been examined and recorded, it has been found, that the trunk has been obliterated in two situations, namely, from the first branch above the ligature to the first branch below it, and for a short distance above and below the aneurism : so that an insulated por- tion of the artery preserves its cavity between the obstructed parts, and a double collateral circulation connected with the insulated portion, assists in maintaining the circulation through the extremity. By one collateral circulation blood is conveyed from the arterial trunk above the ligature, to the upper part of the insulated portion, and by the other, from the insulated portion to the main trunks on the distal side of the aneurism. At the time when Hunter performed his operation, the proper method of applying a ligature to an artery was not known, and to prevent hemorrhage, various plans were adopted which were cal- culated to insure the occurrence of the event they were intended to avert. Some of these methods were, the application of ligatures of reserve, tying the ligature very loosely from a dread of dividing too early the arterial coats, the application of pieces of tape for ligatures, and the introduction of soft bodies, such as pieces of cork, between the ligature and the artery. But the experiments and the investigations of Jones having discovered and established the principles which should be the guide in applying a ligature to an artery, the Hunterian operation has, by the application of these principles, been brought to its present state of perfection. The site selected for the operation should not be so near to the aneurism, as to interfere with the artery where its coats are the subject of degeneration, nor so distant from it as to risk the danger of too free a collateral circulation. The ligature' should be small, round, and firm ; the artery should be exposed as little as possible in front, only so far as to admit the point of the needle into contact with the artery; and laterally and underneath, only by the track of the needle. The ligature should be tied very firmly, so as to divide the inner and middle coats; one end of the ligature should be cut off, and means used to promote union of the wound by the first intention. For some time previous to the operation, as well as afterwards, until the 428 ANEURISM. ligature comes away and the wound is perfectly healed, it is necessary to enjoin the use of the antiphlogistic regimen; and in some cases, where the pulse is very strong, it is advisable before the operation, to have recourse to general depletion for the purpose of diminishing the force of the heart's action. With the same view it is also prudent, in some instances, to bleed after the operation; and when an important vessel in the neck is tied, bleeding is sometimes to be recommended as a prudential measure to diminish the danger of the occurrence of con- gestion of the lungs. After the operation, the limb should be placed in a convenient position, the part where the vessel is situated being relaxed. The temperature of the limb usually falls a little, but it soon rises, and as the collateral circulation becomes established, it rises above the natural standard. While the temperature is below the natural standard, it is extremely injudicious to interfere in any way except by covering the limb with flannel, or some soft cloth; for reaction speedily comes on without interference; and there can be no doubt that in various instances where gangrene has followed, it has been the result of excessive reaction induced by the application of heat and stimulants during the depression which had been occasioned by the tying of the main trunk, and the consequent stoppage of the supply of blood. Until some time after the ligature has come away, it is necessary to enjoin not only that the body be kept in perfect rest, but also that the patient should guard against any mental emotion, or any circumstance by which the circulation might be accelerated. At no period is this more neces- sary than at the removal of the ligature. In some few instances, but it is an extremely rare occurrence, the temperature does not rise above the natural standard at any period after the operation ; the reason of which is supposed to be, that the collateral circulation had become fully established before the performance of the operation. From what has been stated it will be evident, that only one ligature should be used. The only exception to this rule is, when from any circumstance it hap- pens that at the part where the artery is to be tied, it is injudiciously detached from its surrounding relations ; in such a case it is prudent to apply two ligatures, one at each extremity of the detached portion—a practice as ancient as the time of Aetius,—and to divide the artery between them, or to leave it entire, as may seem advisable in the parti- cular circumstances of the case. Of late years, however, three operations have been practised; namely, that of Hunter, that of Brasdor, and that of Wardrop. From what has been stated, the nature and advantages of the Hun- terian operation are, I trust, evident. It consists, as has been already explained, in tying the aneurismal artery on the cardiac side of the tumour, and at some distance from it. Brasdor's operation consists in tying the trunk of the artery on the distal side of the aneurism, and in its near proximity. Wardrop's operation consists in tying one of the two terminating branches of the artery on the distal side of the aneurism. ANEURISM. 429 These different modes of procedure have been illustrated by a diagram similar to the following:— Fig. 143. Fig. 144. Fig. 145. Hunter's mode. Brasdor's mode. Wardrop's mode. Brasdor suggested that his mode of operation might be applicable to some aneurisms so placed, as to render the Hunterian operation im- practicable. Desault also recommended this mode, but neither he nor Brasdor performed the operation. Their contemporary, Deschamp, was the first who performed the operation ; but it was under very un- favourable circumstances, and without success, in a case of aneurism as high upon the common femoral as Poupart's ligament. Sir Astley Cooper was the next who practised Brasdor's method; it was in a case of aneurism of the external iliac; the common femoral was tied, but the patient died of the bursting of the tumour some time afterwards. These are the only two instances on record, in which, during a period of more than forty years, Brasdor's method was performed, and from their unfavourable results it fell into disrepute. To Wardrop belongs the merit of having first proved the success of Brasdor's operation. The subject of the operation was a female, seventy-five years of age, and the case was one of aneurism of the common carotid artery, where it was impracticable to tie the artery on the cardiac side of the tumour. He tied the carotid on the capillary side, and the result was successful. Wardrop performed this operation in 1825, and it has since been prac- tised by Bush and others, in cases of carotid aneurism, and the results have proved that although it is a mode of treatment obviously inferior to the Hunterian method, and not generally applicable, yet a surgeon is jus- tified in recommending it for certain aneurisms, situated so near the trunk as to render it impossible to tie the artery on the cardiac side of the tu- mour. It is obvious that the common carotid presents the most favour- able circumstances for the success of Brasdor'a operation; because, if it 430 ANEURISM. be not absolutely indispensable, there can be no doubt that it is highly desirable that no vessel should originate, either from the sac or between the sac and the ligature. And from this it follows that, as.the number of aneurisms in which that condition can be obtained is comparatively few, the utility of the operation is proportionately limited, and moreover the danger of the operation is increased by making it necessary to include the artery in the proximity of the aneurism. Mr. Wardrop suggested his mode of operation for aneurism, so situ- ated that neither Hunter's method nor Brasdor's can be adopted; as, for example, for the case of the arteria innominata; and he was led to do so by considering, that if the circulation in the sac be diminished in force, though it be not completely stopped, this will be sufficient to promote the formation of fibrinous concretion. Mr. Wardrop was the first person to perform this operation in a case in which he tied the sub- clavian vessel; it has since been performed by Mr. Evans, Dr. Valen- tine, Mr. Mott, Dr. Morrison of Buenos Ayres, M. Langier, Mr. Fearn, and others ; but the statistical results are extremely unfavourable, and there is every reason to fear that in cases treated according to this method, the issue will almost invariably be found unsatisfactory. Cer- tainly this mode of treatment has not gained the favourable opinion of the profession. TREATMENT OF ANEURISM BY PRESSURE. Pressure has long been employed in the treatment of aneurism, and is much recommended by many of the earlier writers ; but its good effects seem to have been much overrated, for although the records of surgery furnish examples of the cure of aneurisms under the employment of pressure, yet there is reason to believe that until of late years, when this mode of treatment has been revived and employed on more scientific principles than formerly, the cures were in great measure owing to the quietude, abstinence, and depletion which were practised at the same time, and which, even though unaccompanied by pressure, would tend to promote a spontaneous cure. The pressure was applied sometimes to the whole limb, sometimes to the aneurism alone, and sometimes to the denuded artery; but the two methods most frequently adopted were, to apply it to the aneurism and the artery leading to it, or to the artery alone on the cardiac side of the tumour. The former of these two methods was adopted by Guattani, who was one of the greatest advo- cates for compression in the treatment of aneurism. He used firm com- presses over the tumour and the artery leading to it, and applied a roller from the under part of the swelling to the upper part of the limb. He applied the roller anew, and somewhat more tightly every eighteen or twenty days. With this local treatment he combined general blood- letting, rest, and spare diet. With regard to the result of this proce- dure, Guattani relates that of fourteen cases, four were cured ; in one, the treatment was discontinued on account of the pain; in one, after the use of pressure for three years, an operation was deemed advisable; in one, the tumour was diminished, but the result is not stated; and in seven, no benefit was obtained. Guattani does not seem to have had an idea, that by this treatment ANEURISM. 431 he obliterated the artery and established a new circulation; but Scarpa conceived that when pressure effected a cure, it was by bringing into contact the opposite parietes of the vessel, and producing obliteration of the cavity of the artery by adhesive inflammation, a process to which the diseased condition of the artery is sadly hostile. In some instances Guattani employed pressure for the purpose of exciting suppuration in the swelling. Pressure on the artery alone at some distance from the aneurism was the mode of treatment often adopted; the limb was left free, and the pressure which was employed with the intention of exciting inflam- mation in the vessel, and rendering it impervious by plastic deposition, was confined to the artery and to the opposite part of the limb. This method was successfully employed by several of the French sur- geons, particularly by Dubois and Dupuytren. Dubois cured several external aneurisms by pressure. In one case of popliteal aneurism, the pressure was applied on the front of the thigh on the 25th of February, and the patient was presented to the faculty of medicine in Paris on the 29th of the next month, completely cured. Other French surgeons tried this method of treatment; and in this country Sir William Blizard, Sir Astley Cooper, Mr. White, and others; but the continued pressure necessary to induce obliteration caused such insupportable pain, that it was often found impossible to persevere with the treatment; and this circumstance, together with the local inflammation, sloughing, and con- stitutional disturbance, which often resulted, led to the abandonment of it in this country as a means of inducing obliteration of the vessel. The treatment of aneurism by pressure has lately been revived, but on new and improved principles ; and the new mode of employing it has been attended with so great success, that it may now be said to be completely established. The ultimate object aimed at being the conso- lidation of the contents of the aneurismal sac, its attainment is sought by weakening the force of the circulation through the aneurism ; and for this purpose pressure is applied to the artery leading to the aneurism at a considerable distance from the tumour, and employed to an extent only to weaken the force of the circulation, and not to produce oblitera- tion of the artery. As this does not require severe pressure, the objec- tions made to the former mode of treatment, that it was impracticable on account of the pain, and that the pressure often gave rise to severe and dangerous local results, cannot be urged against the method which is now employed. Dr. Bellingham, one of the surgeons of St. Vincent's Hospital, Dublin, has the merit of having suggested this new mode of using pressure, and of having proved its success, and brought the subject before the profes- sion. He has treated a considerable number of cases with perfect success, and his method has been tried with equally gratifying results by other surgeons in Dublin, and elsewhere. Dr. Bellingham is said to have stated in regard to the favourable impression entertained of this mode of treatment, " So highly satisfactory has been the result of com- pression in Dublin, that no surgeon of that city would in the present day perform the operation of applying a ligature to the femoral artery for popliteal aneurism." Liston, Cusack, Hutton, Porter, Greatrex, 432 ANEURISM. Newcomb, O'Farrell, and others, have treated aneurisms by this new method with perfect success ; and it may now be said, that this mode of treatment has received the approval of all leading surgical authorities, with the exception of Professor Syme, whose success in treating aneu- rism by Hunter's operation has been so remarkable—he having tied the femoral artery twenty times with perfect success for the cure of popliteal aneurism. In Tuffnell's " Treatise on the Treatment of Aneurism by Pressure," published in 1851, I have seen the following satisfactory report of the results in thirty-nine cases of aneurism which occurred in Dublin during the last eight years :— " Thirty-nine cases in all. " In thirty, cure perfect and complete by pressure. " In one, compression was discontinued, the aneurism not subse- quently increasing in size. "In two, the ligature was resorted to, and the artery tied with success. " In three, amputation was necessary, each instance being followed by recovery. " In one, death took place from erysipelas. " In two, death took place from coexisting disease of the heart." There are many aneurisms beyond the reach of pressure, and there are others in arteries to which it is not adapted; but such facts cannot reasonably be urged as objections against this mode of treatment in cases to which it is applicable, especially as its employment is not at- tended with the slightest risk to the patient, and even though it should be unsuccessful, it will retard the progress of the disease, and interpose no obstacle to the subsequent operation by ligature. When Dr. Bellingham first called attention to this interesting sub- ject, he stated it as his opinion, that it would be unnecessary to employ such a degree of pressure as would cause inflammation and obliteration of the artery at the seat of the pressure; but that it would be sufficient merely to weaken the circulation through the artery and the sac, thereby favouring consolidation by the deposition of lamellated coagulum. In some cases treated successfully by this mode, opportunities have occurred of making post mortem examinations in consequence of the fatal results of other diseases; and it must have been gratifying to Dr. Bellingham to find, that in most of these instances, the main artery was pervious everywhere except at the aneurism. After the Hunterian method, the main trunk is usually impervious at two parts, namely, at the ligature, and at the aneurism, and pervious between them; after treatment by pressure, it becomes closed only at the sac. I am aware of one case treated by Dr. Bellingham's method, in which the artery became im- pervious from the seat of the pressure to the aneurism, but this condition is not believed to be the most frequent. Various contrivances have been employed for applying the pressure. It should be constantly maintained and applied at different points, so as not to cause irritation of the skin ; and it is therefore desirable to have more pads than one in front of the artery. One appliance which has been used, is an arc of iron, with a pad behind, and two or more in ANEURISM. 433 front, movable by means of screws; one pad should be made to press against the artery, and when it causes discomfort, another should be applied against another point, after which the pressure by the former should be slackened. The Signoroni Tourniquet has been found a useful apparatus for fulfilling the required conditions ; namely, for producing a constant, but very moderate pressure, and for applying it at different points, according as it can be conveniently borne. The pressure may be re- newed at the point where it was first applied, when the parts have recovered from the effects of the former application. FALSE ANEURISM. The various forms of false aneurism, which are of traumatic origin, and usually result from unskilfulness in the performance of venesec- tion at the bend of the arm are, circumscribed false aneurism, dif- fused false aneurism, aneurismal varix, and varicose aneurism. Either of the first two varieties, however, may occur in any part of the body, if an artery be wounded ; and either of the last two in any part where an artery and a vein in proximity to each other, are both wounded. Circumscribed and Diffused False Aneurism.—These two varieties differ from each other principally in extent, and this depends mainly on the condition of the surrounding cellular tissue. If, when an artery is wounded, the surrounding cellular tissue or fascia, underneath which the Fig. 146. blood escapes from the vessel, be dense or firm, a circumscribed false aneurism may be the result; whereas, if the surrounding tissue be loose and capable of dilatation, the aneurism which forms, will be diffused. When an artery is wounded, as a grand object of treatment is to prevent the occurrence of aneurism, the energetic employment of pres- sure is most important; and the best means for this purpose are a gra- duated compress and a roller ; a very necessary precaution, however, is the previous bandaging of the limb, without which energetic pressure cannot be safely employed. If an aneurism be formed, the treatment must depend on the state of the parts. If, in consequence of partial consolidation of the contents of the sac, the aneurism be but partly compressible, either the Hunterian treatment may be adopted, or pres- sure according to the improved principles on which it is now applied to the treatment of true aneurism; but if the contents of the sac be en- tirely fluid, the proper treatment for effecting a complete cure consists in tying the artery both above and below the wounded part. Aneurismal Varix.—When, in consequence of a wound, a direct Fig. 146. From Liston. 28 434 ANEURISM. communication is made between an arterial and a venous trunk, a disease may be formed which was first described by Dr. Wm. Hunter, in the year 1756, and for which, at a subsequent period, Dr. Cleghorn, of Dublin, Fig. 147. Fig. 148. suggested the name of aneurismal varix. This disease may occur in any part of the body where an artery and a vein, in proximity to each other, are both wounded; but it most frequently presents itself at the bend of the arm, and results from the transfixing of the median basilic vein, and the wounding of the artery in the operation of venesection. Thus three wounds are made before the disease takes place; one on each side of the vein, and one in the artery. The wound in the der- moid, or superficial side of the vein may heal, but that on the opposite side of the vein, and that in the artery may remain open, and through these open- ings a communication may be established between the two vessels. The effects of this communication and direct ingress of the arterial blood into the venous trunk are, that the implicated vein suffers cylin- drical widening, and becomes infected with sac-like dilatations; the artery, on the distal side of the disease, becomes generally smaller, and its coats thinner, in consequence, no doubt, of the diminished quantity of blood received into it; and on the cardiac side of the wound, the artery is usually widened, eometimes to a great extent, if the disease be of considerable standing. This last-mentioned condition, namely, the widened state of the artery on the cardiac side of the wound, is one which has attracted the attention of various authorities; and before a surgeon ventures to recommend an operation, he must be well satisfied that it does not exist, or only in a very slight degree; because in the event of the artery being very much widened, its inner surfaces can- not be placed closely and uniformly in Fig. 147. From Liston. Fig. 148. Aneurismal varix, following wound of femoral artei-y and vein, the former being enlarged to the size of a portion of small intestine. From a preparation in my museum. ANEURISM. 435 apposition ; but the walls of the vessel will be puckered up by the liga- ture, and when the ligature is removed, hemorrhage will, in all proba- bility, result. If the artery be considerably widened, the pulsation will be felt over a broader surface than usual. The accompanying delineation is taken from a beautiful example of this condition in a preparation in my own collection. The superficial femoral vein and artery were wounded, aneurismal varix was the resut, and the vessels were enlarged as here represented. The symptoms of aneurismal varix are, feeble pulsation of the artery on the distal side, and a swelled and tortuous condition of the vein, in which a peculiar thrill and bruit are very perceptible. The bruit has been compared by some to the purring of a cat, by some to the prolonged articulation of the letter R, by some to the noise of the fly-wheel of a music-box, and by others to the buzzing of a fly confined in a paper bag. The limb beyond the seat of the disease is usually oedematous and cold, and the skin often presents a cyanotic hue in consequence of the pressure causing congestion, and obstructing the free return of the blood. With regard to treatment, as this affection is in most cases merely a source of inconvenience, and becomes stationary, palliative treatment, consisting of pressure applied over the whole limb, and more powerfully over the disease, in all that in such circumstances is deemed advisable; but if the symptoms be so urgent as to demand an attempt to accom- plish a radical cure, the proper mode of procedure is, by cautious dissec- tion, to expose the artery, and to tie it above and below the opening: this course, however, cannot prudently be adopted, if the artery be widened as above described. From what has been stated it will be evident that it is at an early period that an operation is most likely to be useful. Varicose Aneurism.—The difference between this affection and aneu- rismal varix is, that in this the communication between the wounded artery and the vein is not direct, but through the intervention of an aneurismal sac. The blood having escaped through the wound in the Fig. 149 artery passes into the surrounding cellular tissue, which it distends into a sac, and from this sac it is discharged into the vein. The swelling m this instance is formed partly by a circumscribed tumour, and partly by the dilated vein ; the former usually continues to increase, as the blood is thrown out more rapidly from the artery than it is transmitted into the vein. The treatment in such cases consists in deligation of the artery both above and below the wounded part. The first case of this Fig. 149. From Liston. 436 DISEASES OF VEINS. disease which we find in the records of surgery in this island, is one which occurred in the experience of Mr. Park, in the Liverpool Hospital. On opening the dilated vein, an orifice was found in its posterior part, communicating with a sac, which sac on being examined presented an orifice leading into the artery. Since this case was recorded, many examples have been met with, and they have generally been at the bend of the arm, resulting from unskilfulness or-carelessness in the perfor- mance of venesection. DISEASES OF VEINS. PHLEBITIS. This term was first applied by M. Breschet, to denote inflammation in the venous tissue, an affection of which veins are very susceptible. Plebitis may be either traumatic or spontaneous, and may exhibit the characters of fibrinous, of limited suppurative, or of diffuse suppurative phlebitis. FIBRINOUS PHLEBITIS. Symptoms.—Fibrinous phlebitis—the adhesive phlebitis of Cruveilhier —is the mildest form of this affection, and is characterized by pain, by swelling of the limb below the affected part, by oedema of the surrounding cellular tissue, sometimes, although not invariably, by more or less sympathetic fever of the inflammatory type, and, if the affected vein be superficially situated, by linear hardness and redness in the course of the inflamed vessel. The pain is increased by the dependent posture, by stretching the vessel, and by pressing on the affected part, or on the trunk of the vein leading from it. If the inflammation be slight, there may be little or no swelling or oedema of the limb, or any symp- tomatic fever. When the affected vein is superficial, the hardness in its course is very distinct; and so is the linear redness, unless the disease be combined with erysipelas, in which case the redness may not be dis- cernible. State of the Parts.—The local changes resulting from this variety of the disease consist, in the formation of certain unusual conditions of the contents of the vein, and an alteration of the state of its coats and of the surrounding cellular tissue. There is consolidation of the contents of the vein, whereby its calibre is obstructed; the coagulum is formed partly by an inflammatory product which exudes from the coats of the vein, and partly by coagulation of the blood. Gendrin found, that after insulating a portion of a vein by securing it between two ligatures, and after emptying it of its blood, and exciting inflammation by an irritant injection, a plastic substance filling up the whole calibre of the vessel was formed; hence it seems warrantable to conclude, that in this disease coagulum is partly formed by an exudation from the coats of the vein. In some instances, the plug is evidently formed of concen- tric layers, and in many, the centre of the coagulum consists of dark coagulated blood. At first the coagulum is but loosely attached to the interior of the vessel, but subsequently it becomes more strongly adhe- rent. The coats become red and thick, by plastic effusion into them. DISEASES OF VEINS. 437 The surrounding cellular tissue becomes the subject of serous infiltration, and that in immediate connexion with the vein is often affected with plastic exudation, by which means the vein and the surrounding textures become firmly adherent to each other"; and in consequence of this and of the thickened state of the coats, it has been found in some examples, where there has been an opportunity of withdrawing the plug, that the vein had not collapsed, but that its calibre remained open, like that of an artery. Lymph may thus be thrown out around the vein, and so lead to its firm agglutination to surrounding parts ; or into the coats, where it will occasion the thickening of the walls of the vein; or into its canal, producing, if it be to a small extent, a coating along the interior of the vein, or if in greater quantity, leading to its entire ob- struction. The vein may be ultimately converted into an impervious cord, or absorption may take place, and its natural condition be re- stored. While the circulation is interrupted though the inflamed vein, it is kept up by the collateral branches which are in a state of unnatural dilatation. Treatment.—Low diet, the use of aperient and diaphoretic medicines —the free, and, if necessary, the repeated application of leeches, the preservation of the part at perfect rest, and in an attitude favourable for promoting the return of venous blood, and for relaxing the inflamed vein, the employment of warm cataplasms, or of evaporating lotions, or of the local vapour bath, whichever may be most agreeable to the feel- ings of the patient, constitute the chief parts of the treatment. LIMITED SUPPURATIVE PHLEBITIS. The constitutional symptoms are of the same character as in the for- mer affection, being those of sympathetic fever of the inflammatory type ; they are, however, more severe. The local symptoms at first differ from those of fibrinous phlebitis only in being more intense ; but afterwards, in one or two situations, a circumscribed swelling is formed, in which fluctuation and the other characters of a small abscess may be detected. Along with the puru- lent matter there also exists a coagulum both above and below, by which a barrier is presented to the admission of the pus into the general cir- culation, and the character of limitation, so essential for the safety of the patient, is thus maintained. The purulent matter is, in some in- stances, though very rarely, found loose in the vein; it is usually en- veloped in a thin fibrinous layer, and sometimes is actually enclosed in the centre of the clot. To determine the mode in which pus is formed within inflamed veins, is a matter of great difficulty, and different views are entertained on the subject. The opinions of some authorities re- specting it are so distinctly expressed in an admirable article on Phle- bitis, in Dr. Hassie's Anatomical Description of the Diseases of the Organs of Circulation and Respiration, that I cannot forbear transcrib- ing the following passages. " The principal question is, whether the pus formed in the veins be the result of secretion from the inflamed surfaces, or of direct metamorphosis of the blood itself. Gendrin be- lieved that he had observed, by the help of the microscope, a direct change of the blood-globules into pus-globules, and he endeavoured to 438 DISEASES OF VEINS. prove this by the following experiment; having, by means of a double ligature, isolated a portion of an artery or of a vein, he caused it to inflame by injecting an irritant fluid. He then readmitted the current of blood, and afterwards confined it by definitely drawing the ligatures together again. Hereupon suppuration commenced in the vessel, and the blood becoming first coagulated and then deprived of its colour, was by degrees altogether converted into pus. This is the experiment so frequently cited, and by many held to afford incontestable evidence. More recently, M. Donne' has employed the microscope for the purpose of demonstrating the conversion of the blood into pus. Having mingled the two substances in the proportion of eight to one, he traced all the gradual changes wrought in the blood-corpuscles, until after the lapse of twenty-four hours none but pus-globules were discernible. On the other hand, Gluge (as formerly Vogel in opposition to Gendrin), has shown that in water and in every other kind of liquid capable of dis- solving their capsules, the blood-corpuscles undergo precisely the same modifications of form as those described by Donne". Hence it may be reasonably inferred that the blood-corpuscles become destroyed, and that ultimately pus-globules alone are to be met with in the fluid, serving for the experiment, not that the individual blood-corpuscles are transformed into pus-globules. Gluge could not detect any alteration in the blood, in consequence of inflammation, beyond the formation of what, both by himself and by Valentin, were termed ' composite inflam- mation-and-exudation-globules.' It would make a material difference could it be shown that the liquid, resulting from the solution of the blood-corpuscles was, at least partially, capable of conversion into organic elementary cells, which, in consequence of the existing inflam- mation, assumed the form of pus-globules. This view is, however, merely hypothetical, for I have not as yet been able to subject it to the test of experiment. Some light may perhaps be thrown upon the point at issue, by the further prosecution of E. H. Weber's interesting in- quiries concerning the minute globules that slowly revolve along the parietes of the vessels, and which, according to that excellent observer, are blood-corpuscles modified through the progress of nutrition. The assumption that the pus is secreted by the coats of the veins is founded upon analogy. Vogel demonstrated the transition of epithelium-cells into pus-globules, 'and the fact has since been amply confirmed by Henle, who, availing himself of the discovery of Schwann, "that all organic bodies are developed out of nucleated cells,' showed, partly by direct observation, partly by analogical reasoning, that out of these ' primary cells' forms may spring, either normal or pathological, as the case may be. Thus pus-globules would originate as the product of in- flammation. In accordance with these views, the puriform masses generated within the veins, would be developed as follows. First of all, the epithelium lining, discovered by Henle, separates from the in- ternal membrane of the vein, so as to give to the inner surface of the vessel the dull appearance already described, and to render it more susceptible of a morbid tinge from imbibition. The next change affects the passing blood-corpuscles, which assume a spheroid, or else a gibbous appearance, advance with a slow revolving motion or cling to one DISEASES OF VEINS. 439 another, parting with their serum (plasma according to Schultz), and with their pigment. The internal membrane of the vessel generates new imperfect epithelium cells, which mingle with the altered blood, and finally actual pus-globules, which, when congregated in sufficient number, completely arrest the current of the blood, and affect the blood- corpuscles in the manner already pointed out. The simultaneous effu- sion of both fibrin and albumen now serves to complete the formation of a plug, which differs in external character, according to its more or less rapid development, and to the varying proportions of its constituent parts. The plug thus originating, afterwards undergoes farther changes. It ought not, however, to be concealed that this description rests, for the most part, upon analogy only ; the test of microscopic observation having, as yet, demonstrated the above process only in the smallest vessels, and by no means in the larger ones." The treatment consists in the use of general and local antiphlogistic remedies to an extent proportioned to the severity of the symptoms and the particular circumstances of the case. The whole body should be kept at perfect rest, the affected part being preserved in an attitude favourable for relaxing the inflamed vessel, and promoting the return of venous blood; and warm applications should be diligently employed. When abscess forms, early and free opening should be made, followed by the usual treatment for abscess. DIFFUSE SUPPURATIVE PHLEBITIS. Symptoms.—This very dangerous form of the disease sometimes supervenes on the last-mentioned variety, the barrier to the admission of the pus into the circulation giving way in consequence of an increase of the circulation, or of some other cause. In such instances a change is perceptible, both in the local and constitutional symptoms. The local circumscribed swelling subsides, and the constitutional symptoms change very speedily from the inflammatory to the worst form of the typhoid type, the change being often preceded by shiverings. In many instances the characters of the diffuse form are presented from the very commencement of the attack. The local signs in such cases are, pain of a peculiar, oppressive, sickening kind, increased by pressure on the affected vessel, or on its trunk on the cardiac side, by the dependent posture, and by extending the inflamed part; redness, if the affected vessel be superficially situated; diffuse swelling; and oedema. There is great tenderness to the touch along the course of the inflamed vein ; but from the absence, both of the plastic effusion and of the coagulum of blood, so essential in suppurative phlebitis for the safety of the pa- tient, there is neither the linear induration, nor the symptom of a knotted cord along the track of the vein. Should death not take place very speedily, gangrene may ensue. The accompanying fever, especially in a more advanced stage, is of a low or typhoid kind, cha- racterized by great prostration of strength, anxiety, irritability, and restlessness, a sense of weight at the praecordia, a very rapid and feeble pulse, paroxysms of oppressed and hurried breathing, black sordes on the tongue and teeth, frequent nausea and vomiting, especially of bilious matter, the countenance sunk and expressive of anxiety and 440 DISEASES OF VEINS. great suffering, » yellowish or sallow appearance of the body, and before death muttering delirium. Such are the symptoms of this most dangerous disease ; and they are believed to depend on the contamina- tion of the blood by direct purulent admixture, pus or a puriform fluid being formed very early, and meeting with no obstacle to its mingling with the blood. Dr. Arnott, in an interesting article in the fifteenth volume of the " Medico-Chirurgical Transactions," gives the particulars of many fatal cases, and his own conclusions from them. His observations led him to conclude, that there are great differences as to the extent of the vein occupied by inflammation in fatal cases ; that in the great majority of cases pus is found within the veins ; that there is a striking resemblance between this form of phlebitis and diseases arising from the inoculation of morbid poison, and that death does not take place from extension of the inflammation to the heart, such extension being a very rare occur- rence indeed, as the inflammation usually terminates abruptly where a cross current flows into the main trunk through a collateral branch; but that the entrance of pus, or of some other product of inflammation, is the source of the fatal symptoms. Morbid Changes,—As has been already stated, purulent matter is usually found within the vein; which matter not being circumscribed, as in the limited form, finds no barrier to its admission into the circula- tion ; " the fibrinous dykes" (to use the expression of an excellent writer on surgery) being wanting. There are three, situations which the pus may occupy, namely—the interior of the vein, the cellular mem- brane connecting the coats with each other, and the surrounding cellular tissue, which is often infiltrated to a great extent. There are many important sequelae which present themselves in various parts of the body remote from the seat of the phlebitis—but they are all thought to be divisible into two grand classes, the first com- prehending such as are referable to the coagulation of the blood in the large venous or arterial trunks, in the central parts of the vascular system, or even in the heart itself; and the second, certain lesions which have their seat in the capillary system. The coagulation of blood consequent on phlebitis has been met with most frequently in the pulmonary artery. An author, on this subject says :—" It would appear that in such cases, the product of inflamma- tion, be it pus or finely-divided fibrin, follows the course of the blood towards the heart, but advancing more slowly than the uncontaminated blood, accumulates, invests itself again and again with fresh layers of coagulum, and ends by entirely closing up the calibre of individual vascular trunks." The sequelae which have their seat in the capillary system, consist of lesions which have been designated by the appellations " lobular inflam- mations," and "lobular abscesses." These secondary infiltrations are most commonly found in the lungs and liver, especially in the former; they usually present themselves in the form of deposits disseminated through the parenchyma of those viscera, and differ from abscesses in being neither encysted, nor concentrated into one place. In the chest the lungs are the organs most frequently affected, but sero-purulent DISEASES OF VEINS. 441 effusions are also met with in the pleurae, the pericardium, and even on the surface of the heart itself. In the abdomen, the liver is most fre- quently the seat of such deposits; in the spleen, and in the kidneys, they are very rarely found. The cellular tissue, both subcutaneous and inter- muscular, is very liable to become the seat of purulent deposits, the matter being deposited sometimes as in abscess, and sometimes by infiltra- tion. Such deposits are most common in the cellular tissue around joints. Purulent effusions into the synovial membranes of joints, and even destruction of their cartilages, are well known to practical observers as frequent lesions. Phlebitis is adso sometimes attended by inflamma- tion of the membranes of the brain and effusions under them, and even by effusions' into the ventricles ; but deposits into the substance of the brain, as sequelae of phlebitis, are extremely rare results. In va- rious instances the eye has been rapidly destroyed; the cornea becoming swollen, and eventually bursting, or becoming totally disorganized. Veins, also, quite remote from those originally diseased, seem liable to secondary suppuration. In regard to these lesions, Professor Hassie thus expresses himself:—"Another question still presents itself, namely —whether the pus formed within veins at the part originally inflamed be substantively transmitted through the medium of the circulating current to the lungs, the liver, &c, to accumulate at certain points within the latter; or whether it be actually generated in the parenchyma of those organs. The former opinion was at one time zealously main- tained, and numerous observations were adduced in evidence of such metastasis. More recently, however, the latter view has prevailed; and, although in these processes there is still much that remains to be cleared up, yet an unbiassed comparison of the facts has furnished an explanation adequate to the majority of cases. With regard to lobular abscesses, there cannot, at the present day, be any further question of the pus being conveyed to them, exclusively and in quantity, by the circulation. The best authorities have repeatedly asserted that these collections are not at once purulent at the outset, but knots form, of from the bigness of a pea to that of a walnut, become infiltrated with firm coagulated blood, and eventually suppurate. I have had opportu- nities of convincing myself of the correctness of this fact with reference to the lungs, the liver, and the spleen. It may be, therefore, concluded that owing to some obstacle, the blood stagnates at certain points, pro- ducing suppurative inflammation of the surrounding tissues. "The experiments of Leuret, Trousseau, and others, and of Cruveilhier, afford an insight into the cause of such stagnation ; for when putrid and other substances are injected into veins, organic changes perfectly ana- logous to those above described, are developed with the accompaniment of low typhoid fever. The experiments of Giinther are the most striking of all in their results. Having injected pus into the veins of horses, he very shortly afterwards found fully-formed lobular abscesses in the lungs. From these data we may, with some degree of certainty, infer that pus is conveyed in substance by the veins to the heart, and forwarded from thence; but that those pus-globules, which have reached the capillaries of the lungs in their entire state, are unable, from their size, to per- meate the latter. These globules now become a central point of stag- 442 DISEASES OF VEINS. nation (and, finally, of extravasation) in the adjunct branches of the pulmonary artery, and thus determine, eventually, local inflammation and suppuration. "In this manner phlebitic abscesses in the lungs are satisfactorily ac- counted for, as are also those which occur in the liver, in consequence of inflammation within the tract of the portal system. The origin, how- ever, of purulent collections in other organs still remains obscure. Here, indeed, the above explanation is inapplicable, founded, as it is, upon the inability of the pus-globules to permeate the minute capillary vessels of the lungs. Giinther found that these deposits were formed subsequently to those in the lungs, and believed that they originated from pus being taken up from the diseased parts of the lungs by the pulmonary veins, and thus carried into the greater circulation. Were this ex- planation correct, phlebitic abscesses must, necessarily, exist in the lungs, wherever such deposits are found in the capillary system of the greater circulation. To ascertain this, I have compared a large number of cases, observed partly by Balling, Dance, Arnott, and others; partly by myself. Amongst them, however, there are only two (one related by Sasse, of purulent deposits in the liver, and one by Dance, of purulent exudation within the wrist-joint), in which the non- existence of pulmonary abscesses is established by careful examination after death. Four of Arnott's cases—the first, third, seventh, and ninth—would certainly appear to belong to the same class; they are, however, not related sufficiently in detail to admit of any decided infe- rence being drawn. It is singular, indeed, that the seat of the purulent secretion, in those four instances, was within serous sacs—in three of them, within those of different articulations, and in one, within that of the pleura. It may, upon the whole, therefore, be assumed that in some cases the substances commingling with the blood, pass through the capillary system of the lungs, without inducing any changes in the pul- monary parenchyma. Vogel, without, indeed, assigning any reason, considers it not impossible for single pus-globules to pass through the capillaries of the lungs; it is perfectly intelligible, at all events, that the nuclei of ruptured pus-globules may pursue their course, without hindrance, into the greater circulation. This applies equally to fibrin altered by the inflammatory process, finely-divided particles of which will, if hurried along by the circulating current, be, in many cases, pro- ductive of the same effects as pus." Causes.—Phlebitis seldom originates spontaneously, and can, in most instances, be traced to some injury done to the vessel itself, or to the communication of inflammatory action from some contiguous textures. Injuries affecting bones, as has been particularly pointed out by Cru- veilhier and others, often give rise to venous inflammation. A blow, pressure, extension of inflammation from ulcers, cold, suppuration in the shaft of a bone after amputation, are all causes of phlebitis. It is well known that in the Hotel Dieu of Paris, lobular pneumonia, induced by phlebitis, was at one time a frequent cause of death among patients on whom operations had been performed. Other ordinary causes of in- flammation of veins, are wounds of veins by accident, or in venesection, or other operations in which veins have been wounded or tied; and hence VARICOSE VEINS. 443 arises the necessity of avoiding, as much as possible, any interference with veins, and especially of not including them in ligatures, except under the most urgent circumstances. Many fatal examples have resulted from ve- nesection, owing mostly to the use of a dirty lancet in bleeding, or to too free an exercise of the limb before the wound has properly healed; or to an irritable or unhealthy state of constitution, which not only pre- disposes most strongly to an attack on the application of an exciting cause, but modifies, in a great degree, the character of the inflammation. Symptoms.—While the symptoms are of the sthenic type, the local and constitutional treatment formerly recommended should be adopted; but when typhoid symptoms appear, or when the constitutional affection is, from the commencement, of the asthenic character, while the same local treatment, more or less modified according to circumstances, is proper, the object aimed at by constitutional treatment should be, to support the strength and to allay as much as possible the irritative fever; for which purpose the means generally employed are, diffusible stimu- lants, wine, light nourishment, and the use of calomel and opium, or calomel in combination with some of the preparations of morphia. No treatment, however, as yet suggested, is found to have much effect in arresting the progress of the disease, and, consequently, the prognosis in this form of phlebitis is extremely unfavourable. VARICOSE VEINS. CAUSES, ANATOMICAL CHARACTERS, AND TREATMENT. Varix, which has been defined to mean, "a vein preternaturally dilated without the dilatation being instituted to answer any good pur- pose in the animal economy," may originate in any permanent obstruc- tion to the venous return, as for instance, in pressure on the venous trunks above, induced by distended rectum, by diseased liver, by the gravid uterus, by aneurismal or other tumours; or it may arise from some obstacle to the passage of the blood through the heart or lungs, or from relaxation or weakness of the coats themselves. According to some authorities it arises more frequently from weakness of the veins than from any other cause. In some examples, obstruction from inflam- mation in the vein itself has been supposed to give rise to the disease; and, in some, violent and sudden muscular exertion has occasioned it. Varices occur principally in three situations, namely, in the lower extremities, in the spermatic cord, when the disease is termed varicocele; and about the lower part of the rectum, constituting the disease called hemorrhoids, or piles. Varicose veins occur occasionally in other parts of the body, various examples of which are recorded, and in most of them the disease could be clearly traced to some obstruction to the return of the blood by the venous trunks leading from the affected part. It is to varices in the lower extremity that the following observations are intended to apply. It is an extremely rare thing for the deep- seated veins to be the subjects of this disease, in consequence of their coats being supported by surrounding textures. The vessels which afford examples are the vena saphena interna, and the vena saphena externa; but principally the former, the branches of which about the 444 VARICOSE VEINS. ankle and inner part of the leg are often affected. These veins are so situated that their coats receive little support from surrounding struc- tures to aid them in resisting the dilatation caused by accumulation of blood within them. The calibre of a vein affected with this disease is enlarged. The vessel is not only dilated, the dilatation either being nearly equable, or presenting sacculated or knotty protuberances on various parts, but it is also elongated, and thereby becomes tortuous. In many instances the vein exhibits a very irregular aspect, being equably wide at some parts, comparatively narrow at others, and at others dilated into irregularly shaped cavities. The enlargement may be accompanied either by increased or diminished thickness of the coats, or by both states at dif- ferent points. The state of the coats, however, is not the same in the different forms of varix, nor in the same form at different periods. Professor Hassie of Zurich, makes the following observations on this subject. " In persons affected with a morbid preponderance of the venous system, we first of all observe an undue prominence of the veins of the skin. These appear in dense nets of branches, remarkable for their diffuse distribution, and are generally turgid with blood, or liable to become so from the slightest mechanical or dynamical causes—like what, under ordinary circumstances, would be the effect of violent and prolonged muscular exertion. In this condition of the veins their coats have not undergone any absolute change, being everywhere propor- tionate to the width of the calibre ; the vessels are not more than usually tortuous, and cannot as yet be called morbidly altered; after a while, however, the veins become permanently dilated, an occurrence more frequent in elderly than in young persons. This is brought about by a reinforcement of the fibrous texture of their external coat, in the shape of an accession of conspicuous transverse fibres. Meanwhile the internal membrane remains unchanged in structure, merely displaying numerous lines of superficial furrows running lengthwise, and the vessel still maintains its natural course, not assuming a more sinuous, but rather, if anything, a straighter direction than before. It does not collapse when cut through, but remains patent, and is distinguishable from the arteries by its colour, which is of the same pale red as the fibro-felt-like texture constituting the normal external membrane of a vein. The valves remain unaltered. In this condition the saphena is frequently found in old persons; so likewise are certain branches of the vesical plexus, whilst other branches manifest still farther changes. In the greater number of instances, however, the external membrane of the vein is not thickened, but, along with the other membrane, undergoes considerable attenuation, in proportion as the vein becomes more and more dilated. Conformably with their irregular disposition, the inter- mediate fibres give way unequally, allowing the internal membrane to jut out in sac-like protrusions, and to establish so many irregular, constricted, pear-shaped, and often in appearance, pediculated tumours. At the commencement of some of the smaller branches the membrane thus forms pouch-like dilatations, or forces itself between the longitudinal fibres of the external membrane in lengthy protuberances, which exceed in circumference that of the vein in its natural state; or, it may, VARICOSE VEINS. 445 perhaps, distend cylindrically and pretty equably for a considerable length the intermediate fibres before alluded to. Meanwhile the valves become attenuated, and pulled asunder transversely, so as to be rendered useless ; in many instances they become partially or wholly obliterated, and are torn into shreds, or destroyed as far as their free border, which then runs across the diameter of the vessel like a filament or band, attached by the two extremities to the internal membrane. The veins now appear elongated, and their course very tortuous." Professor Andral has described six different forms of enlargement of veins which he has met with in dissection, but many pathologists ques- tion the propriety of classing some of them with varices. They are the following:— 1. Simple dilatation without any other change. 2. Equable dilatation with attenuation of the coats at the affected part. 3. General dilatation, and a tortuous condition, with thickening of the coats. 4. Partial dilatation, with thickening of the coats. 5. Dilatation, with septa within the veins. These septa, as will be understood from what is stated above, are not now regarded as of new formation. 6. Dilatation, with septa and perforations in the coats, by which per- forations the cavities of the veins and the surrounding cellular tissue which is diseased, communicate. The kind of disease of the cellular tissue will be considered under the head of the anatomical characters of hemorrhoids. Varicose veins at first contain blood in a fluid state; but an alteration of the contents, which frequently occurs, is the coagulation of the blood, whereby the vessels become obstructed. The formation of coagula is considered to be a product of inflammation, varicose veins being liable to be attacked by that process, and, as was stated in the description of the anatomical characters of some of the forms of phlebitis, coagulation of the blood is an early result of inflammation when it attacks the venous tissues. In many instances varicose veins create little inconvenience; in others they cause much discomfort and annoyance by pain, fulness, and weakness of the affected part, aggravated by exercise and the erect pos- ture ; but the following results are not unfrequent—phlebitis, hemor- rhage, certain conditions of cellular tissue, varicose ulcers, and inflam- mation of the skin. Inflammation of the vein may be of a low grade, giving rise to coagu- lation of its contents; or it may affect both vein and cellular tissue, and, reaching the suppurative grade, give rise to small abscess in the first instance, and afterwards to varicose ulcer, although this is not, as will hereafter be stated, the mode in which the form of ulcer denominated varicose usually originates. Phlebitis, when a consequence of varicose veins, usually assumes the form of fibrinous phlebitis, producing destruc- tion, or of limited suppurative phlebitis, but very rarely indeed that of the diffuse suppurative variety.' In some instances, the vein and super- ficial parts have become so greatly attenuated as to produce bursting of 446 VARICOSE VEINS. the vessel, followed by serious, and occasionally even by fatal hemor- rhage. The valves being rendered incapable of performing their office the pressure of the column of blood may give rise either to inflammation or to increase of dilatation, and eventually to hemorrhage, which, as there is no obstacle to the descent of the blood from the trunks of the veins, may be excessive. Other conditions of frequent occurrence are, oedema of the cellular tissue, merely from obstruction of circulation ; or oedematous effusion, as a product of a low grade of inflammation of the cellular tissue, when the substance effused is of a less fluid character than when the oedema arises from the obstruction to free circulation; or, if the inflammation be of a rather higher grade, the cellular tissue may be consolidated by effusion of lymph. Such are the more frequent conditions of the cellular tissue surrounding varices in general; but in that variety which constitutes a form of hemorrhoids, a different state of cellular tissue is found, as will be stated in another section. Varicose ulcers are frequent consequences of varices, and they arise either from limited suppurative phlebitis ending in abscess, and the for- mation of an ulcer, or from inflammation of the skin, which either cracks or has a scab formed over an irritated and inflamed part, where an ulcer ultimately forms. Treatment.—The treatment of varicose veins ,is either palliative or radical: the former has now almost entirely superseded the latter, and in the opinion of the writer ought always to be preferred, except when the disease endangers the life of the patient. Palliative Treatment.—One of the most important indications, except in the case of pregnancy, is to remove, if possible, the exciting cause; and for that purpose remedies adapted to the particular circumstances of the case ought to be prescribed. In all cases it is advisable to pre- serve the bowels in a regular state—to enjoin the use of light nourish- ment, but with abstinence from liquids—to direct the patient not to remain long in the erect posture—to remove from time to time from the weakened vessels the weight of the superincumbent column of blood—to recommend that the recumbent posture be frequently assumed in order to favour the return of blood, and that violent or long-continued muscu- lar exertion be avoided; and, except in the case of phlebitis, to support the weakened vessels by means of pressure. For this last purpose, a common roller, or a starched bandage, or elastic bandages of India-rub- ber, are sometimes used; but the two most convenient appliances, as affording a very equal pressure, are an elastic stocking, or an elastic bandage of stocking web. The pressure should be sufficient to afford support, and to diminish the size of the dilated veins, but not to produce any undue constriction of the limb. If the varicose veins be affected with phlebitis, pressure will be ex- tremely injurious. In such cases the treatment consists, in preserving the whole body at perfect rest,—keeping the affected limb in the hori- zontal posture,—applying leeches in the neighbourhood of the vein,— employing either cold lotions or warm applications, as may be most grateful to the feelings of the patient; together with the strict observ- ance of antiphlogistic regimen. VARICOSE VEINS. 447 Radical Treatment.—It would answer no useful purpose to explain all the methods which have been adopted for effecting a radical cure. Among them the following deserve to be noticed :— 1. Puncturing the vein, a plan proposed by Hippocrates, evacuating its contents, and stopping the hemorrhage by means of pressure. 2. Excision, originally proposed by Celsus, checking the hemorrhage either by tying the trunk at each extremity of the cut portion, or re- straining it by pressure. 3. Tying the vein, a proceeding anciently proposed by Aetius and Paulus iEgineta, has been revived and strongly recommended by Sir Everard Home, and adopted (with differences in the mode of tying) by Ricord, Tavignot, and some others. For the cure of varicose veins of the leg, Sir Everard Home tied the saphena interna by dividing the skin over it, and passing a needle armed with a ligature under the vein. The object of his operation was, to produce obstruction of the principal trunk leading from the varix. In some cases it was believed that bene- fit was derived; but several cases having proved fatal, these unfavour- able results put a stop to so hazardous and unjustifiable a practice, which for the removal of an inconvenience, placed a patient's life in the greatest danger. As obstruction of circulation through a venous trunk is often the cause of varix, it is difficult to understand on what prin- ciple the operation of Sir Everard Home can prove useful, except where the venous trunk itself has become so greatly distended that its valves are unable to prevent the weight of the column of blood in the venous trunk from pressing on its branches. Some surgeons think it useful by promoting collateral circulation, so that the blood is returned by different channels. Sir Benjamin Brodie, in stating objections to this operation, remarks, " But still there is another reason against having recourse to this operation. I do not believe, from what I have formerly seen, that it permanently benefits the patients. It is true that they appeared to go out of the hospital much relieved; but where I had the opportunity of seeing them one or two years afterwards, I always found them as bad as ever. Indeed, I am by no means certain that the benefit which the patients seemed to derive, in the first instance, was the result of the operation; and I am more inclined to believe that it arose from their having been necessarily kept for some time in bed in the horizontal posture." 4. Cutting through the vein. Various modes of this operation have been adopted; but of all with which I am acquainted, the safest ap- pears to me to be that proposed and practised by Sir Benjamin Brodie, who used a narrow sharp-pointed bistoury with the edge on the convex side, and when his object was to cure a cluster of varicose veins, he in- troduced the instrument through the skin, carried it flat between the skin and the veins, and then directed the edge against the veins, and in withdrawing the instrument cut across the veins, leaving but a very small wound in the skin; the hemorrhage he arrested by the pressure of a compress. He was induced to try this operation from observing that, although operations on large veins are apt to lead to dangerous results, there is no reason to fear danger from operations on the smaller branches. In reference to this mode of subcutaneous division of varicose 448 VARICOSE VEINS. veins, Sir Benjamin Brodie observes, "As applied to varicose veins, the operation is as easy and as safe as it is on other occasions; yet I scarcely ever have recourse to it now. With my present experience it really appears to me that in ordinary cases it is not worth the patient's while to submit to it, as I always observed that, if I cured one cluster, two smaller ones appeared, one on each side, and that ultimately I left the patient no better than I found him. The operation, however, is proper, where there is a varicose cluster much distended, and liable to burst and bleed. Here you may actually save the patient's life by having recourse to it; and you may do so without considering whether fresh clusters are or are not likely to form afterwards." 5. Pressure by means of a needle and twisted suture in order to effect obliteration of the vein has been practised with considerable suc- cess by M. Velpeau. He introduces a needle underneath the vein, and applies a twisted suture round its ends, and if considerable inflammation supervenes, he withdraws it in a few days, his object being to induce sufficient inflammation to reach the fibrinous grade, and thereby to cause occlusion; but if little inflammation result, he allows the needle to eat its way through. Few serious consequences .appear to have resulted from this operation ; and it is therefore regarded less unfavour- ably than various other modes for attempting obliteration of varicose veins. 6. Cauterization.—The potassa fusa has been applied to different situations, and in different forms, according to the different immediate results through which it is hoped to effect the cure. One method is, to apply the potassa fusa over the venous trunk, and to employ it so freely as to produce a slough of the vein together with that of the surrounding parts. The change desired in this method is the permanent obstruc- tion of the canal of the vein by the destruction of a part of the trunk and fibrinous inflammation in the parts surrounding the slough. Pres- sure is applied to the dilated veins; and when this method proves beneficial, it is believed that this result arises from the blood being forced to return by collateral circulation, by which means the distended vessels become unloaded, and are placed in circumstances more favourable for recovering tone or becoming consolidated. Another method is, to apply the potassa fusa not over the venous trunks leading from the disease, but over the varix itself, and at different points, using it so freely as to induce sloughing of the veins together with the surrounding tissues. A third, method, suggested and practised by Mr. Mayo, consists in applying the caustic over the vein, but not so freely as to induce a slough; the object being to bring on fibrinous phlebitis, and thereby to cause per- manent obstruction. A fourth mode is, the application of the Vienna paste—a compound of five parts of quick lime, and four of caustic potash made into a paste with spirits of wine. It is applied to various parts along the course of the diseased veins, the surrounding parts being protected by some plaster; the diameter of each part to which it is applied should be about one-third of an inch, the number of parts varying according to the extent of the disease; and the length of time during which the application should be continued is about half an hour. Such are the principal methods which have been employed for the VARICOSE VEINS. 449 radical cure of varices, and such the different opinions entertained as to the process, by which each is expected to conduce to the end desired. Division, as practised by Sir Benjamin Brodie, cauterization by means of the Vienna paste, and obstruction by pressure by means of a needle and twisted suture as proposed and practised by M. Velpeau, are the methods most favourably regarded; and of them all, the subcutaneous section of the veins as practised by Brodie, I should think the least hazardous, and consider warrantable and advisable, when the disease gives rise to great discomfort, or threatens dangerous hemorrhage ; but in all other circumstances it appears to me to be a matter of very ques- tionable propriety, to venture upon a proceeding which endangers the life of a patient, merely to relieve him of an inconvenience. I consider that in the great majority of cases, the palliative treatment is preferable to any of the methods proposed for effecting a radical cure. 29 450 CHAPTER XIII. * DIFFERENT KINDS OR CLASSES OF ABDOMINAL HERNIA. Abdominal herniae, or ruptures, are usually divided, if their condition is taken as the basis of arrangement, into three classes ; namely, reduci- ble, irreducible, and strangulated; or, if they are arranged according to situation, into four; namely, inguinal, femoral, umbilical, and ventral It will help to a clearer understanding of the subject, if we consider these two divisions separately, giving under the first, the general doc- trines of hernia, and under the second, the different forms of hernia, as they present themselves in the living body. REDUCIBLE HERNIA. Definition.—A hernia is reducible, when it can be easily returned into the cavity of the abdomen. Symptoms.—In reducible hernia there is a swelling, which presents the following characters:—It is unattended with heat, discoloration, tenderness, pain, or even uneasiness, except when the tumour first takes place, at which period an uneasy sensation of weakness in the parts is in some instances complained of. The swelling begins from above, and gradually descends; it is brought on by the erect posture, coughing, sneezing, pressing on the abdomen, or by any exertion of the abdominal muscles or diaphragm; and it disappears in the recumbent posture, or when gentle pressure is applied. During coughing it becomes larger and tense, and communicates a sudden impulse to the hand of the exa- miner. These symptoms may be observed in every reducible tumour; but there are others, which, although more variable, characterize a hernial tumour, and when present, furnish information regarding its contents. If the swelling be elastic, uniform, and compressible, and if its return be sudden and attended with a peculiar guggling noise (the gargouillement of the French writers), there can be no doubt that the hernia is formed of intestine. The smooth surface of the intestine makes its return easy and sudden, and the mixture of air with other intes- tinal contents gives rise to the peculiar guggling sound. If the swelling be more solid and uneven,—if it feel heavy to the patient,—if it be doughy to the touch, and receive an impression from the fingers of the examiner, and if its return be gradual and unattended with any peculiar sound, there can be no doubt of its being an omental hernia. When omentum forms the hernia, its surface becomes moulded by the surround- ing parts, and in consequence, its return into the abdomen is gradual. If a portion of the swelling be elastic, and return suddenly with a gug- gling noise; and if the remaining part be doughy, and its return more HERNIA. 451 gradual and less easily accomplished, the hernia is in all probability formed of intestine and omentum. These discriminating symptoms, when well marked, as they usually are in hernia of short standing and moderate size, furnish very satisfactory information regarding the con- tents of the hernia; but if the hernia be small, it is often difficult and even impossible to arrive at a decided conclusion as to its contents ; and if it be of long standing, there is frequently the same difficulty, since the thickening of the hernial sac, and the adhesion of the parts of the hernia to each other, and change of structure, diminish the accuracy of any nice discrimination by the touch. When the hernia is formed of intestine alone, it is called an Enterocele ; when of omentum alone, an Epiplocele; when of both intestine and omentum, an Entero-epiplocele; and when of a redundant portion of bowel in the form of a diverticulum, a Hernia Litrica. Treatment.—The treatment of reducible hernia consists in returning it into the abdomen, "and preventing its recurrence by the pressure of a truss. A reducible hernia generally goes up of itself, when the patient is placed in the horizontal posture and more especially if the thigh on the affected side be brought a little upwards and inwards, so as to relax the parts about the hernia. When it does not return of itself, it may be replaced by certain manual proceedings, technically called the operation of the taxis—the manner of performing which varies in some respects according to the situation of the hernia, as will be explained hereafter. Pressure by means of a truss is employed for the purpose of preventing a recurrence of the hernia. While the patient requires to use a truss, the treatment is palliative or preventive; when it has induced such a change as to prevent any tendency to a recurrence of the hernia, the cure is said to be complete or radical. There is no period of life at which a truss may not be used. At one time it was supposed that it could not be applied to a child; but it is now ascertained that if a truss be sufficiently weak, it may be worn by the youngest children without inconvenience; and as a complete or radical cure is readily produced in early life, it is of the greatest importance that the application of a truss should not be delayed. The only condition of parts in early life which forbids the use of the truss is the testicle not having descended through the inguinal canal. The pressure and thickening of parts, under these circumstances, might present an obstacle to the descent of the testicle, and cause its permanent retention in the abdomen; but fortunately this condition of the testicle is of rare occurrence. If, however, it should present itself in a case of reducible hernia, the application of the truss ought to be delayed until the testicle has made its way into the scrotum. In regard to the use of a truss, the following points are highly deserving of consideration:— 1. The different ways in which the use of a truss produces a complete cure of hernia. 2. The precise situation in which the pressure should be applied by means of a truss. 3. The length of time a truss ought to be employed for the cure of a hernia. 4. The chief sources of inconvenience and irritation from wearing a truss. 452 HERNIA. I. THE DIFFERENT WAYS IN WHICH THE USE OF A TRUSS PRODUCES A COMPLETE OR RADICAL CURE OF HERNIA. First.—If a hernia has been very suddenly produced, if it be very small, and if it be very quickly returned, the hernial sac may either return with the hernia, or be gradually drawn back into the cavity of the abdomen. The sac being empty, and no force pressing it down- wards, its ascent will be promoted by the elasticity of the peritoneum lining the walls of the abdomen in the neighbourhood of the protrusion, and by the stretching of the peritoneum in various movements of the body, as well as by the elasticity of the hernial sac itself. After the return of the sac, the pressure of a truss sometimes produces sufficient diminution of the opening by contraction, effusion of lymph, and conse- quent joining of the surfaces, to prevent any future protrusion of sac or hernia. This kind of cure, however, in which the t sac returns, and its future protrusion is prevented by the diminution of the opening, is only to be looked for in small herniae of short standing, and very suddenly produced. If a hernia be of considerable size, and more especially if it be also of long standing, the distension of the hernial sac, and the pres- sure of the surrounding parts excite a degree of inflammation by which those parts and the sac become adherent to each other, so that the sac cannot be returned into the abdomen, and the kind of complete cure already described cannot take place. Second.—After the return of a hernia, the sac being empty contracts by its own elasticity, in accordance with the general law, that membra- nous parts accommodate themselves to the state of their contents. This kind of closure of the hernial sac is analogous to the contraction of the tubular portion of peritoneum, which exists within the inguinal canal for some time after the descent of the testicle. A truss, by approxi- mating to each other the sides of the hernial sac, may assist the natural elasticity in closing up its neck, and in bringing about a radical cure. Third.—Occasionally the wearing of a truss for a long time produces thickening of the neck of the sac, or of the cellular tissue surrounding it, or of both, and thus interrupts the communication between the cavities and the abdomen, and the hernial sac. Fourth.—The pressure of a truss often excites adhesive inflammation in the sac, by which its opposite sides become joined together by coagu- lable lymph, and a recurrence of hernia is prevented. This condition of parts is very frequently found in the bodies of persons who have been subjects of hernia. Fifth.—According to J. Cloquet the opposite sides of the sac some- times become adherent without the intervention of lymph, and without the very slightest traces of any inflammation. He supposes that the membrane ceases to secrete the fluid by which it is naturally bedewed; that it becomes dry, and that the sides become adherent without the intervention of any substance.. In the ordinary form of adhesion of the opposite sides of a hernial sac, effusion of lymph, thickening of the sac, and traces of adhesive inflammation are perceptible, whereas in this method of complete cure there is immediate union, with thinning of the peritoneum, and the entire absence of all traces of inflammatory adhesion. HERNIA. 453 Sixth.—Pare*, Arnaud, and others, record cases in which complete cures were effected by the firm adhesion of the formerly protruded parts to the peritoneum lining the abdomen around the mouth of the hernial sac; and as in these cases trusses had been worn, it was believed that the pressure gave rise to inflammation in the neck of the sac, and that this inflammation, having extended to the membrane lining the cavity of the abdomen, produced the adhesions. Seventh.—Absorption of the neck and part of the body of the sac sometimes produces radical cure. Surgical observers have described this condition of parts, and I lately had an opportunity of demonstrating it to the students at the School of Medicine in Marischal College, in the body of a person who had worn a truss for many years for the cure of a reducible hernia. Almost the whole of the neck and the upper part of the body of the sac were absorbed, but the remaining portion of its body and fundus were entire, and formed a bag in the scrotum in front of the tunica vaginalis. II. THE PRECISE SITUATION TO WHICH THE TRUSS SHOULD BE APPLIED. Since the immediate object which the surgeon desires to accomplish by the pressure of the truss is, to prevent a return of the hernia, and the ultimate object, to induce some of the various changes already de- scribed, by which the tendency to its recurrence may be removed, it must be evident that the precise part to which the pressure should be applied is, that where the hernia first quits the abdomen. This point will vary in the different forms of hernia, and will afterwards be ex- plained; but meanwhile it may be stated that before the various changes in the sac, and in the opening by which it quits the abdomen, were clearly understood, by which changes a complete cure of hernia is effected, a very common error which prevailed was, to apply the truss too low instead of exactly over the opening ; and in consequence, the advantages of the truss were often not obtained, and moreover various inconveniences, which will hereafter be described, were frequently pro- duced. III. THE LENGTH OF TIME A TRUSS SHOULD BE WORN. As the prospect of a complete cure is very different at the different periods of life, it being almost a matter of certainty in young persons, occasionally met with in adults, and not to be expected in elderly per- sons, there will be a corresponding difference in the length of time that the truss must be worn, as well as in the object of wearing it; the ob- ject being at one period merely preventive or palliative treatment, at others palliative treatment and radical cure. In young persons a com- plete cure is often effected in less than twelve months, in adults seldom under two years at least, and in old persons it is not to be expected. In regard to the time a truss should be worn, Sir Astley Cooper re- marks, " You will be asked by the patient when you have applied the truss, how long he is to wear it; tell him to wear it at least two years. He will then ask you whether he is likely to be cured at the end of that time; your answer must be that this must depend upon his age. A young person is generally cured at the end of two years, but it will 454 HERNIA. be advisable for him jto continue to use the truss for three years. If the person be not young, there is not much hope of effecting the cure of hernia by wearing a truss." The truss should be constantly worn, not only during the day, but also during the night, because although the probability of a recurrence of the hernia is by no means great in the recumbent posture, yet it might be induced by a cough, or any sudden change in the posture of the body in bed, and then the cure would require to be commenced anew from that period. It ought also to be kept in mind that the recurrence of the hernia, after the use of the truss has been commenced, is attended with more risk than before, because if thickening about the neck of the sac or around it has commenced, the hernia is more likely to be irreducible from being surrounded by firmer textures. According to some of the best surgical authorities upon this subject, the only ex- ceptions that should be made to the constant use of the truss are, when it is first applied, and before it is to be laid aside, when it is believed that a complete cure has been effected. When first applied, the truss frequently gives rise to irritation, and heat of the skin, with inconve- nience and discomfort from pressure and restraint; and until these unpleasant sensations wear off, which will usually be in a week or two, it may be discontinued during the night, but the patient should even then be careful not to remove it until he is in the horizontal posture, and he ought again to apply it before raising himself from that position. And when it is believed that the cure is complete, the truss may be discontinued at night, before it is entirely laid aside. For some time after the daily use of the truss is discontinued, it is a judicious precau- tion to wear it whenever the body is more than usually relaxed. When the danger of a recurrence of the hernia is greater, or during any un- usual exertion, and during the whole period of wearing the truss, it is proper, on making any violent movement or effort, to afford a degree of support by the hand over the pad of the truss. When it is believed that the cure is complete, the surgeon should make a very careful exa- mination of the part where the hernia came out from the abdomen ; and before he sanctions the discontinuance of the truss, he should endeavour to ascertain that no swelling can be felt, and that during coughing, or any exertion of the muscles of the abdomen, there is no sensation of a hernia striking against the finger when applied to the opening. IV. THE CHIEF SOURCES OF IRRITATION AND INCONVENIENCE FROM WEARING A TRUSS. The chief inconveniences from the use of a truss arise for the most part from its being too strong, or from the pad being placed in an im- proper situation, hence the necessity of selecting a truss of the proper strength and length for a patient. It should be strong enough to prevent any recurrence of the hernia, but not to cause any painful irritation of the soft parts. Labouring people and those who are re- quired to use great bodily exertion need stronger trusses than others. The length of the truss is also a matter of great importance, not only that the pad may rest on the precise spot where the hernia came out from the abdomen, but also that it may not rest upon the side of the HERNIA. 455 pubes, the result of which is apt to be irritation of the soft parts from pressure between the bone and the truss, and swelling of the testicle from compression of the veins of the cord. IRREDUCIBLE HERNIA. Definition.—A hernia is said to be irreducible, when it suffers no constriction, and yet cannot be returned into the abdomen. For facili- tating the description of this form of the disease, it may be useful to attend successively to the causes which prevent reduction, to the dangers and inconveniences which may arise from irreducible hernia, and to the treatment. Causes which prevent Reduction.—First. A frequent cause which prevents reduction, is the bulk of the protruded parts in relation to the opening through which they would have to return. The bulk is some- times, and especially in neglected cases where means have not been used to give a degree of support, owing to the quantity of parts which have come out of the abdomen, but more frequently to the enlargement or growth of the hernial contents. The omentum and mesentery are the parts which when protruded present the impediment to reduction from growth; and their increase is occasioned mostly by the deposition of fat in the portions of these tissues, external to the opening through which they came out from the abdomen. Where they are embraced by the opening, the pressure prevents enlargement in that situation; but from the yielding nature of the textures external to the opening, the increase of volume is often very considerable. In old irreducible herniae the omentum is not unfrequently found to be affected with thickening and hardening, caused by the effusion and organization of coagulable lymph. Second. Constriction of the neck of the hernial sac is occasionally the obstacle to reduction. That this condition of the neck of the sac sometimes exists to an extent sufficient to constitute, without an opera- tion, an insuperable impediment to reduction, is a point regarding which surgeons are agreed, numerous instances having been recorded by the great surgical authorities of this and other countries, and examples occurring frequently in the practice of many surgeons. Not only is the sac necessarily narrower at the neck than in any other situation, from the manner in which it is embraced by the surrounding textures, but it is liable to be still further diminished by changes without and within the sac, and in the nature of the sac itself. For a minute description of these changes, the conditions under which they most frequently take place, and the nature of the action by which they are produced, I beg to refer to the section on the anatomy of the hernial sac, and the seats of stricture in the different species of hernia ; and meanwhile, I shall only remark that thickening and induration of the cellular tissue around the sac, effusion and organization of lymph without, and often also within the sac, and a thickened and indurated state of the sac itself, are the principal conditions which, separately or in various degrees of combination, diminish the canal of the sac, so as to prevent reduction. There can be very little doubt, that these changes are produced by the pressure on the neck of the sac, causing a slight degree of inflammation, 456 HERNIA. which terminates in effusion of coagulable lymph, and that the lymph afterwards becoming organized, occasions the constriction. Although constriction, when sufficient to render a hernia irreducible, is usually, yet it is not invariably, at the neck of the hernial sac ; a fact of little practical moment, if a hernia be merely irreducible, but of the greatest importance, if it be strangulated and require an operation, the object of the operator being to divide the constriction in order to relieve the symptoms of strangulation. Third. Adhesions of the protruded parts to the hernial sac often constitute the impediment to reduction. Of these adhesions there are three varieties;— 1. The protruded parts sometimes adhere to the sac through the me- dium of a layer of coagulable lymph. This form was described by Scarpa as the gelatinous or glutinous adhesion, and as this is a condition of parts which very quickly takes place, the surgeon should endeavour to reduce the hernia as soon as possible, in order to prevent the slight inflammation which gives rise to the effusion. 2. Adhesions sometimes assume a membranous or filamentous appear- ance, varying greatly both in the number and length of the filaments,— in the number, from a single band to several, and in length, from two or three lines to an inch and upwards as a general rule. Adhesions of this form are found only connecting movable parts with each other, as the intestine with the hernial sac, or with the omentum; and they are precisely similar to the bands we often find between serous surfaces in other parts of the body. They are produced by the effusion of coagu- lable lymph, which ultimately becomes organized—therein differing from the last-mentioned form—and which is drawn out into bands or filaments by the movements of the intestines. This accounts for their being found chiefly connecting movable parts with each other, and for their being more frequent in the body and fundus of the sac than at its neck or mouth, where the parts are in a more confined space, and have less motion. This is now the almost universally received opinion of the ori- gin of the membranous or filamentous adhesions. A different theory, however, is held by Scarpa, who says :—"I am of opinion that the for- mation of this filamentous or membranous adhesion is constantly pre- ceded by a slight attack of adhesive inflammation, with immediate union of the intestine or of the omentum with the hernial sac; a superficial union indeed, but in progress of time—especially from the intestine separating gradually from the hernial sac by its own vermicular action, by the considerable distension produced in it by the interruption of the faeces, by its proper contractile power, and that of the mesentery, by the interposition of serum always collecting in the sac—the thin covering of the intestine, corresponding to the points of superficial adhesion with the hernial sac, yields and elongates, so as to form at last one or more filaments, bridles, or membranes interposed between the intestine and the sac of the hernia." In short, Scarpa's opinion was, that they are formed of elongations of portions of the serous coat of the intestine. 3. The third form of adhesion, which usually receives the name of the fleshy, is like the gelatinous and membranous, in being the result of adhesive inflammation, but differs from them, inasmuch as the union is HERNIA. 457 close, firm, and deep, so that the protruded parts and the sac cannot be separated from each other, but form a solid mass, the vessels of which are continuous. In a case of strangulated hernia, the subject of operation, this form of adhesion demands a very different method of procedure from the gelatinous or membranous, as will be explained in the section on that subject. This species of adhesion is very frequently met with between omentum and hernial sac, and then is generally at the body and fundus of the sac; but when it is found between intestine and sac, which is a very rare occurrence, it is usually at the neck. Scarpa has described this form under the name of the unnatural fleshy, to distinguish it from what he calls the natural fleshy, which is of an entirely different character, and will be afterwards described. The three forms of adhesion agree with each other in being caused by in- flammation, and in being attended with effusion of lymph; but they differ, inasmuch as the lymph in the first form is not organized ; in the second, it is organized and elongated into bands or filaments ; and, in the third, although organized, it is not elongated, but effused between the sac and protruded organs, and between the tissues of these parts, so as to con- vert them into a solid inseparable mass, the vessels of which are conti- nuous. Fourth. Adhesion of the protruded parts to each other often forms the impediment to reduction. The parts which form a hernia often glide down separately, and to a great extent, into the sac, and after- wards by pressure and various accidental causes, become adherent to each other, and cannot in mass be returned through the opening by which they separately left the abdomen. Fifth. Membranous bands across the sac constitute an insuperable obstacle to reduction. In reference to these bands, Sir Astley Cooper remarks,—"They appear to be produced in the following manner: during the reducible state of the hernia, inflammation takes place, both in the contained parts and in the inner surface of the sac; but by using proper means, the protruded parts are reduced, and the sides of the sac collapse and adhere together. However, while the adhesions are still recent, a fresh descent takes place from the abdomen, and the hernial contents again disunite the surface of the sac everywhere, except at the points of union of the inflamed parts, the cementing lymph of which instead of bursting asunder, elongates with the fresh pressure, and forms those membranous bands, which are seen passing from one side of the sac to the other. Between these the intestine and omentum get entangled, a circumstance which adds so much to the diffi- culty of reduction, as to make it, in general, considered as impracticable; but unless the hernial contents themselves adhere, there appears no reason why the means already pointed out, may not here also prove successful. After all, there is scarcely a possibility of detecting by the feel, this variety of the disease in the living subject." Sixth. The obstacle to reduction is sometimes furnished by the natural means of connexion between the intestine before its descent, and the peritoneum lining the surrounding part of the abdomen. It is of the greatest importance that the surgeon should have clear and distinct 458 HERNIA. ideas of this condition of a hernia, for if it be not understood, and if an irreducible hernia of this kind should become strangulated and require an operation, the most dangerous errors may be committed. Scarpa gave an exceedingly clear and full explanation of this condi- tion of a hernia; it has also been described by Pelletan, Cloquet, and Hesselbach, and with great distinctness by Mr. Lawrence. Pott, in two parts of his valuable work, refers to the difficulty of reducing certain herniae, where there is reason to believe the obstacles to reduc- tion arose from this condition; but from the manner in which he expresses himself, it is not evident that he understood the real cause of the impediment. The natural means of connexion of the hernia to the surrounding parts, may form the obstacle to reduction on the right side, if the hernia be formed of the ccecum, or head of the colon; or on the left, if it be formed of the sigmoid flexure of the colon. These divisions of the alimentary canal are completely covered by peritoneum, laterally and anteriorly, but are destitute of a peritoneal covering behind; and the peritoneum is reflected from their lateral aspects to the parietes of the abdomen in the ilio-lumbar regions, with which the parietes is con- nected by loose cellular tissue, capable of great dilatation. The natural means of connexion of these divisions of the alimentary canal with the parietes, are short, and formed of peritoneum, between that portion of it which furnishes a serous coat to the intestines, and that which lines the walls of the abdomen. If these portions of alimentary canal descend to form a hernia, they will drag along with them the part of the perito- neum which naturally lines the parietes of the ilio-lumbar region, to form the hernial sac; and if the hernial sac descend into the scrotum, and there form adhesions to the surrounding parts, the portions of perito- neum which, within the abdomen, preserved the intestine in its natural relations to the walls of the abdomen, will now retain it in the sac; and, as through the medium of these portions, the hernial sac and serous coat of the portion of intestine which forms the hernia, are continu- ous with each other, it is evident that the reduction must be impracti- cable. It is as impracticable, under these circumstances, to return the intestine as it would be to return the testicle into the abdomen; the intestine draws peritoneum along with it to form a hernial sac, and the testicle draws peritoneum to form tunica vaginalis; and the serous coat of the intestine has the same relation to the hernial sac, as the tunica vaginalis reflexa has to the tunica vaginalis propria. Such a hernia, when it becomes strangulated, and an operation is to be performed, requires a particular method of treatment, which will afterwards be explained. DANGERS AND CONSEQUENCES WHICH MAY RESULT FROM IRREDUCIBLE HERNIA. The chief dangers which may result from irreducible hernias are, inflammation of the hernia, laceration or injury of the intestine from violence, extreme inconvenience from its size, and strangulation. The chief source of anxiety, however, in irreducible hernia is the risk of its becoming strangulated—a state in which the life of the patient is placed in the most imminent danger. The symptoms of this state, the HERNIA. 459 condition on which they depend, and the treatment requisite, will be explained under the head of Strangulated Hernia. Irreducible herniae, even when left to themselves, do not always attain a great size; and sometimes they give rise to no inconvenience whatever, beyond a sense of weight and fulness in the parts affected. Sometimes they render the subjects of them liable to occasional colic pains, and derangement of the digestive organs, but in other instances these symp- toms do not present themselves. TREATMENT OF IRREDUCIBLE HERNIA. From what has been stated of the causes which render herniae irredu- cible, and of the dangers which may result from them, the indications and rationale of treatment may be very easily understood. In every case the diet should be carefully attended to, and everything avoided which would be apt to produce derangement of the digestive system, and the bowels should be preserved free from constipation, as a loaded con- dition of the alimentary canal would, by increasing the distension, be likely to cause an increase of the protrusion; in short, the intestinal canal should, as much as possible, be preserved in a regular and natural state. The hernial tumour should be carefully defended from any injury by external violence, and the greatest precaution taken to avoid every kind of exertion, by which an addition might be made to the protrusion, or the parts already protruded be injured, or their condition in any way changed. To retard the growth of the hernia, and to diminish the pro- bability of its proceeding to such a size as to cause inconvenience, the tumour should if possible, be supported by means of a suspensory ban- dage ; and if it has already attained great size, by a suspensory laced bag, by which an increase of the hernia is sometimes prevented, and its size diminished by absorption. These precautions may be said to con- stitute the proper treatment of an irreducible hernia; and however little inconvenience a hernia may occasion, they ought never to be disre- garded. As greater risk attends an irreducible than a reducible hernia, various means have been proposed and adopted for removing the obstacles which oppose reduction. Of these the principal are, 1. The diminution of the size of the hernia by producing emaciation. 2. The absorption of part of the hernia by the application of pressure. 3. The application of cold; and 4. An operation. 1. Fabricius Hildanus records an instance of a man who was cured of a hernia of twenty years' standing, by six months' confinement to bed; and Arnaud gives an account of several cases, in which very large hernias had entirely disappeared after the patients had become much emaciated by long confinement with tedious illnesses. Impressed by these instances, Arnaud endeavoured to effect radical cures in certain cases by an imitation of this process of Nature. The means he employed were, confinement to bed, restriction of diet, occasional venesection, and the frequent exhibition of purgatives and clysters; and in numerous 460 HERNIA. instances he succeeded in accomplishing reduction. The late Mr. Hey of Leeds reduced several herniae by the same means, and states that usually the cure occupied six weeks, but in one instance it was accom- plished in a week. . . While a hernia is merely a source of present inconvenience, and little apprehension is experienced of what may be its future consequences, few patients will submit to a method of treatment which is attended with so much discomfort, and requires so much self-denial; besides which, to a patient of advanced age, this method might give rise to serious results, and in such circumstances, therefore, a prudent practi- tioner would hesitate at recommending its adoption. But the great objection to this method of treatment is, that it cannot prove of any service whenever the obstacle to reduction is adhesion in any of its different forms ; and since there is no criterion for distinguishing where adhesions do or do not exist, it is almost impossible in any case for a surgeon to assure his patient that it will certainly succeed. The cases in which this treatment is likely to be attended with a favourable result are, those of omental hernia, in which enlargement of omentum from accumulation of fat forms the impediment to reduction. 2. Pressure is another means which has been employed in cases of irreducible hernia, and it has been recommended in cases where the impediment to reduction is enlargement of the omentum from accumu- lation of fat; but for various reasons which need not be mentioned, it appears to be extremely injudicious to venture on this treatment. 3. By the application of cold, herniae of considerable standing have been returned. . On this subject Sir Astley Cooper, who proposed this method ot treatment, makes the following remarks : " In some cases the applica- tion of ice occasionally procures the return of a hernia which appeared irreducible. I was asked by a physician to examine a hernia which had come down about a fortnight before, and had ever since resisted all attempts at reduction, without being painful. I found it was omental hernia, and ordered ice to be kept upon the tumour for a considerable time. In twenty-four hours it was so much diminished as to encourage a perseverance in the plan, and in four days the hernia was entirely removed. . , " Mr. G., a surgeon in the East India service, called to show me an omental hernia on the right side, which, though not painful, gave him some anxiety, as it could not be returned, and he was apprehensive ot its becoming strangulated at some future time. I ordered him to bea, and put him on the same plan as in the former case, which produced a very gradual diminution of the tumour, and, at the end of five days, its entire removal. It appeared to me in both cases, that the good effects attending the use of the ice, were owing to a consequent contraction ot the scrotum, which thus performed the office of a strong and permanent compression of the tumour." • , v. ff t During the spring of 1841, I was very much gratified with the eoect of the application of ice, in the case of a person named Kelly, a butcher' then sixty-six years of age. For many years he had been annoyed witn a reducible inguinal hernia on the right side, for which he required to HERNIA. 461 wear a truss. He always succeeded in returning the hernia without any assistance, until about two weeks before I saw him, when it came down, he said, to a greater extent than on any former occasion ; but for twelve days it was unattended with pain or any inconvenience, beyond a sense of weight or weakness of the affected part. After it had been down for twelve days, it became, in consequence of some over- exertion, painful and tight; and when I saw him, two days after the commencement of the pain, and two weeks after the descent of the hernia, I found him labouring under the ordinary symptoms of strangulation, which, according to his report, had been much more urgent for the eight hours preceding my visit, than before. The hernia extended down to the middle of the scrotum; and, from the examination, I felt fully satisfied (as did also a medical friend who likewise saw the case) that the hernia consisted partly of omentum and partly of intestine. I instituted the ordinary treatment for strangulation for five or six hours, and thought I should be obliged to have recourse to an operation ; but on making a second careful attempt at reduction by means of the taxis, a small part returned very suddenly, and almost immediately he felt relieved, both from the local and general symptoms, and the bowels were soon opened; but still it appeared impossible to return any more of the hernia. I then ordered ice to be kept over the hernia, and in the course of thirty hours from its first application, the hernia entirely dis- appeared, and the use of the truss was then resumed. I have often successfully used ice, in conjunction with other remedies, in reducing hernia in different states; but in the present instance, the return of the part which remained after the subsidence of the symptoms of strangulation, when the case presented the characters of a simple irreducible hernia, must have been owing solely to the application of ice, as no other means of reduction were used at the same time. From all I have been able to ascertain from recorded experience, from what I have been told in conversation by others, and from what I have seen in my own practice, my decided impression is, that it is only in hernia of very short standing that the application of ice proves to be of ser- vice ; and the same conclusion is suggested, independently of observa- tion and experience, by our knowledge that the cause which prevents the reduction of hernia of long standing, is frequently one or other of the forms of adhesions already described, and that on these the applica- tion of cold by means of ice could produce no beneficial impression. 4. An operation is the only practicable method of accomplishing re- duction, when adhesions are the impediment; and unfortunately, in most herniae of long standing adhesions do exist. It may be laid down as a general rule, that as an irreducible hernia is only a source of inconvenience, and exposes the patient merely to the risk of being thrown into a hazardous situation by its becoming strangulated, or giving rise to some of the consequences described in a former section, the surgeon is not justified in performing an operation which puts the life of the patient into immediate and great danger ; on the contrary, it is his duty to advise the patient to be satisfied with such palliation of his complaint as may be obtained from the means which have been already pointed out. Still, operations have been per- 462 HERNIA. formed; but it appears from recorded experience that they have gene- rally proved fatal. The great size which an irreducible hernia often presents, the extent of adhesions, and the consequent danger of the dis- section, and great risk of inflammation, are considerations which would deter a prudent surgeon from venturing on an operation, unless some very distressing symptoms should demand it. On this subject, Mr. Lawrence, in his valuable work on hernia, remarks :—" Yet an objection must be made to the general rule of not operating in irreducible hernia}, in behalf of those instances where the tumour occasions such essential inconvenience and suffering to the patient, as to induce him, when the dangers he incurs have been fully represented, to submit to the opera- tion. Such was the case of the celebrated Zimmerman; the omentum adhered by a single filament to the testicle; when the former was re- placed, the latter ascended with it, and experienced very painful pres- sure from the ring; if the parts were allowed to protrude again, a por- tion of intestine generally followed, was pressed on by the ring, and occasioned a fear of strangulation. The pressure of a truss occasioned such severe suffering, that it could not be borne. In a patient on whom Mr. Abernethy operated, an adherent epiplocele gave rise to frequent protrusions of the intestine, which were highly distressing. A particular source of danger and inconvenience existed in both these cases, and ad- mitted of no remedy but the operation." STRANGULATED HERNIA. A hernia is said to be strangulated, when the protruded parts expe- rience such a degree of pressure as not only prevents their return, but also, by compressing their blood-vessels, disturbs or in a measure sus- pends or impedes the circulation in them. This condition very speedily produces inflammation in the protruded parts, which extends itself from thence to the parts within the abdomen. Symptoms.—There is pain in the swelling, beginning about the neck, or being at first most considerable there, and propagating itself gradu- ally over the swelling in the direction from the abdomen. The swelling becomes tense, and there is for some time, tenderness on pressure, after- wards pain on pressure, in some instances very acute. In some exam- ples there are heat and redness. Such are in many cases the local symptoms ; and if death do not very speedily take place, they occasion- ally change for a short time before its approach, the swelling becoming flaccid, the pain and tenderness on pressure wearing off, and crepitation being perceptible on examination:—such symptoms denoting the pre- sence of gangrene. The symptoms connected with the alimentary canal are, eructations, nausea, vomiting, and insuperable constipation of the bowels. At a very early period the patient is troubled with eructations, followed by nausea and vomiting. The contents of the stomach are first vomited, and after- wards, in consequence of inverted peristaltic motion, those of the canal between the stomach and the seat of the stricture. Bilious matter is brought up in large quantities, and the contents of the small intestine, and even of part of the large intestine, if any portion of that division of the alimentary canal should be placed higher up than the part included HERNIA. 463 mthe stricture. When the contents of the large intestine are brought up, the vomiting is called stercoraceous. The insuperable constipation is a striking symptom. It may be possible by means of clysters to wash out the portion of canal which is below the hernia ; but it is im- possible while the strangulation remains, to procure any evacuation from the part of the intestine above the hernia; and this is not owing to a mechanical obstruction offered by the stricture, for the constipation is insuperable when the stricture only diminishes the calibre of the intes- tine, as well as when it includes an entire fold ; and it is insurmountable m cases of omental hernia, after the inflammation has extended to the intestine. The constipation is owing to the same cause as in enteritis or ileus of which strangulated hernia is an example, though differing from ordinary cases in being produced by a mechanical cause There are some symptoms connected with the abdomen, which are quite characteristic of strangulation; namely, a sensation as if a cord were tied tightly round the upper part of the abdomen, twisting pains about the umbilicus, and pain diffused over the whole abdomen, but gene- rally more considerable from the seat of the hernia to the umbilicus The abdomen after a certain time becomes tense, and, as the disease ad- vances, tender and painful on being pressed, or stretched; and, therefore the patient lies quite still, with the limbs drawn up to relax the abdomi- nal parietes. After a time, hiccough comes on, and the belly becomes tympanitic. The tongue is white and dry, the countenance pale, anx- ious collapsed, and expressive of great suffering; the pulse, which from the beginning is small and hard, becomes very quick, and extremely small and thready; there is great sense of feebleness, the extremities ultimate- ly become cold, and the surface of the body covered over with a clammy perspiration. When gangrene has actually taken place, the patient may experience a sudden and complete relief from all pain and tenderness in the swelling or abdomen; the former may feel emphysematous, a sure sign of gangrenous mischief; it may feel flaccid, or even return on pres- sure; the abdomen may become free from all tenderness on pressure but it_ still remains tense; the patient may feel himself relieved from all suffering, and in many instances even a few minutes before death, patients have expressed themselves as perfectly confident of recovery; but the pulse is extremely feeble, and usually in this state irregular ; the clammy perspiration remains, and death very soon closes the scene. Such are, generally, the symptoms of strangulation ; but they are not m all cases of equal intensity or rapidity. When the patient is not ad- vanced m life, when the hernia is intestinal and recent, and when the stricture is tight, the symptoms are alarmingly intense, and present thei assemblage already described. In elderly persons, and more espe- cially when the hernia is of long standing, the mouth of the sac proba- bly being widened by the distension occasioned by the protruded parts, the symptoms are usually less urgent and slower in their progress, and for some time their appearance seems to indicate that they are to be referred to obstruction of the alimentary canal rather than to inflamma- tion. There can be very little doubt that in such cases, accumulation of taecal matter from torpor of the intestine is frequently the cause of dis- comfort, and that the inflammatory process is a consequence arising from it. When the hernia is omental, the symptoms of strangulation 464 HERNIA. are less violent and slower in progress than when it is intestinal; the pain and sense of constriction in the tumour are comparatively incon- siderable ; the pain and tenderness of the abdomen not so urgent; the vomiting not so frequent; and the constipation not by any means so very obstinate ; so that the bowels may be moved by enemata until the inflammation has reached the intestine, when, as in a case of ileus, it becomes insuperable. In some cases, but they certainly are extremely few, inflammation in the hernia is the cause of strangulation ; but in by far the greater number of examples inflammation is the consequence of the constriction. Under all circumstances, the symptoms of strangula- tion furnish ground for the greatest alarm. Although cases are often known to go on for several days, others have terminated fatally in a very short time. The works of Larrey, Pott, Cooper, Hey, Wilmer, and others, contain records of cases in which strangulation has been fol- lowed by death in less than twenty-four hours. Sir Astley Cooper al- ludes to a case in which death took place in eight hours after the occurrence of strangulation, and Larrey met with two examples in which only two hours elapsed between the occurrence of strangulation, and the death of the patient. Strangulated hernia has the same general symptoms as ileus and intus-susception, and in addition to these it has its own peculiar local symptoms. The presence of the symptoms above described should always lead to a careful examination of the usual sites of hernial protrusion, and the absence of local swelling in such cases warrants the conclusion that they depend upon a cause which is intra- abdominal. Conditions, however, may exist requiring great care to form a correct diagnosis, namely, the coexistence of ileus with an irreducible hernia, not strangulated, or, the presence of ileus with an ambiguous tumour at any of the ordinary sites of hernial protrusions. The history of the symptoms, the absence of a sense of tension or of pain in the swelling, or of any alteration of the symptoms connected with the tu- mour, and there being little or no tenderness on pressure, render it ex- tremely probable that the symptoms are independent of the local affec- tion, or that the latter has no casual relation to them. The proper view to be taken of a strangulated hernia, I conceive, is, that it is a species of ileus produced by a mechanical cause. Treatment.—Strangulation being caused by compression of the pro- truded parts, an indication of paramount importance is to relieve them from the pressure as speedily as possible. With that view, replacement should in most cases be attempted by a certain manual process, techni- cally called the operation of the taxis. To diminish the tension of the opening, through which the parts are protruded, the patient should be placed in the recumbent posture, with the trunk bent a little forward, and the thigh of the affected side raised upwards and inwards. With the fore-finger and thumb of one hand, the tumour should be embraced at its neck, and replacement attempted by a kneading or pinching movement at that part, while with the other hand the tumour should be subjected to general pressure; the object being, not to push back the hernial contents in mass, but to knead up the tumour, bit by bit; and in doing this, it is necessary to observe the course which the protruded parts must have taken, that the direction of the pressure may be accom- HERNIA. 465 modated to it. Before attempting to press up the tumour, it is often advantageous to draw the hernia downwards, as if the object were to draw the hernial contents farther from the abdomen. By this proceed- ing, the neck is rendered straight, and an obstacle, offered by the hernia being much swollen on the aspect of the stricture farthest removed from the abdomen, is diminished, so that the taxis can be employed under more favourable circumstances. The taxis should be employed gently, steadily, and cautiously, without any force or violent effort, and even when used most prudently, it should not be continued for more than eight or ten minutes, nor should it be persevered with after it has been ascertained that there is no reasonable prospect of its employment being successful. In some cases of strangulation, it would be extremely injudicious to use the taxis at all, or any other means for accomplishing reduction; and in a very few others, it ought not to be employed until the state of the tumour has been changed by appropriate treatment. To the former class of cases belong those in which the hernia has become gangrenous, or in which there is reason to believe that the intestine has become so much softened by inflammation as to be in danger of giving way if re- turned into the abdomen. In such circumstances, faecal extravasation and death would be the consequences of returning the hernia. The proper treatment of such cases will be explained, when describing the operation for strangulated hernia. The cases in which it is not prudent to use the taxis are by no means numerous. In reference to this prac- tical point, it is important to remember what has been stated in the de- scription of the symptoms of strangulation, namely, that although in the great majority of cases, inflammation is the result of the strangula- tion, yet in some exceedingly rare cases, the reverse takes place;—the hernia becoming inflamed and swollen, and in consequence, embraced so tightly by the surrounding textures, that its circulation is impeded, and strangulation produced. The prudent procedure is, to endeavour by the application of leeches around the hernia, by general depletion if necessary, by cold applications and other antiphlogistic remedies, to subdue the inflammation ; and the cause having been removed or modi- fied, the taxis may then be employed, not only with safety, but also with a more reasonable prospect of success. If symptoms be urgent, how- ever, an operation should be resorted to for the purpose of removing the pressure. The direction in which the hernia should be pressed, during the operation of the taxis, varies in the different species of hernia. Fur- ther information on this subject will be given in a subsequent chapter. In the event of the taxis not being successful, recourse should be had to some of the various means, called auxiliaries to the taxis, and then the taxis should be tried a second time. Of these means, the most use- ful are bloodletting, the warm bath, the very abundant application of cold, enemata, and chloroform. Bloodletting is no doubt a valuable auxiliary in certain cases, espe- cially when the symptoms are very acute, and the hernia small, when depression has not come on to a great extent, and when the patient is not at an advanced period of life. It favours reduction, partly perhaps by diminishing the bulk of the hernial contents, though its effect in that 466 HERNIA. way must be very slight; but principally, and indeed almost entirely, by producing relaxation, and thereby increasing the size of the opening through which the parts have to be returned. Such being the principle of its usefulness, it will be desirable to produce fainting by the bleeding, and with this view, the head and trunk of the patient should be raised to the erect position during the bleeding, and the blood should be taken from a large opening. When fainting is induced, the taxis should be used a second time. Bloodletting is also advantageous, by diminishing the tendency to inflammation after reduction. The warm bath is useful on the same principle as bloodletting, and in the same class of cases; and if the two auxiliaries can be used to- gether, that is, if the patient be bled to faintness in the warm bath, the taxis may then be employed under very favourable circumstances. Un- less the bath be sufficiently warm to induce faintness, little or no benefit will result from its use. Delay, however, being so dangerous, this is a remedy which cannot always be employed in private practice, on account of the time which would often be required for its preparation. The abundant application of cold over the hernia is a valuable auxi- liary to the taxis, and in various instances it has produced reduction with- out the taxis. The application must be continued for a considerable time, otherwise it can have no effect. Pounded ice enclosed in a blad- der, is one very convenient way of applying cold, and another is by a mixture of muriate of potash and muriate of ammonia. The cold dimi- nishes the bulk of the tumour, and also induces a degree of constant pressure, by the contraction of the textures covering the hernia. Mild enemata are also useful, more especially in cases of large and old hernia, when strangulation has been brought on by torpor, and a loaded condition of the alimentary canal. The tobacco enema is a very powerful remedy, and in the state of extreme relaxation which it brings on, the taxis has been used with success. But as in the state of depres- sion produced by strangulated hernia, the system has but little power to stand out against the lowering effects of this remedy, and as in some instances it has appeared to sink under them, I have never ventured to employ it, and cannot therefore, from my own observation, say anything of its advantages. It appears to me, that this is a remedy which ought never to be employed. Such, until lately, were the principal auxiliaries to the taxis for ac- complishing reduction; and in regard to their employment it is to be remembered, that it is of the utmost importance not to lose time; that in cases where there appears no objection to the use of the taxis, it should be employed cautiously, but decidedly and thoroughly; that in the event of its being unsuccessful, such auxiliary remedies should be adopted either singly or in combination, as in the particular circum- stances of the case seem most advisable, and then the taxis should be used a second time ; and if it still be without success, that time should not be wasted in the repetition of treatment, which on a full and fair trial has failed, but that the surgeon should then at once recommend an operation. Such were the views entertained, previous to the discovery of the properties of chloroform, regarding auxiliaries to the taxis and the proper HERNIA. 467 modes of employing them. The use of chloroform, however, has now superseded the necessity of bloodletting, the warm bath, and enemata. If the patient be brought well under the influence of chloroform, and if on the decided, skilful, and thorough employment of the taxis, the hernia cannot be returned, the surgeon may reasonably conclude that the constriction is too great to be overcome by any means short of an operation. He should therefore spare the patient the danger resulting from delay and unnecessary handling, and at once proceed to the opera- tion. OPERATION FOR STRANGULATED HERNIA. There are some peculiarities with regard to the forms of the incisions and other important points in the operations for the different species of hernia, which will be referred to when the different species are described; but there are some considerations regarding the operation, in general, a correct knowledge of which is indispensable. Some of the most important of these are— 1. The circumstances under which it is justifiable or necessary to resort to the operation;—2d. The importance of having recourse to operation at an early period, and of abstaining from handling the hernia before the operation, more than is necessary for the fair and skilful use of the taxis, while the patient is under the influence of the most power- ful auxiliary—chloroform;—3d. The indications which are to be ful- filled by the operation ;—4th. The conditions which render it impossible and those which make it improper, to return the hernial contents ;—5th. The mode of procedure in regard to the hernial sac;—6th. The anatomy and treatment of abnormal or artificial anus ; and 7th. The treatment after operation. 1st. The operation is justifiable and necessary, when the patient has been brought fully under the influence of chloroform, and when the taxis has been fairly, fully, and skilfully tried, and failed to produce the desired effect. The conviction being thus produced that by no other means than an operation is there hope of saving the life of the patient, it ought to be resorted to as quickly as possible. 2d. From what has been stated as to the condition of the parts in strangulated hernia, it must be evident that much handling or pressure of the hernia must not only give unnecessary pain, but also increase the risk of hurrying on the inflammation to results, which, even though the operation should be performed, would render it unsafe to return the hernial contents. When, therefore, the taxis and other remedies have been fairly and skilfully tried, no advantage can, but considerable injury may, result from the repetition of treatment already found to be unavailing. So deeply was the celebrated Desault impressed with the injurious effects of pressure and handling, that he confided in other means for accomplishing reduction, and entirely prohibited the taxis in cases brought to the Hotel Dieu, until by other means the parts were brought into a state in which they could be returned with little diffi- culty. 3d. The indications which are to be fulfilled by operation are two— the first, which is essential for the safety of the patient, is the removal 468 HERNIA. of the pressure by division of the stricture, and the second, which when possible and proper, is very desirable, is the return of the hernial con- tents. In many instances, especially when the hernia is small, intes- tinal, and not of long standing, it returns very suddenly on division of the stricture; in other cases, there are some obstacles apart from the stricture which can very easily be removed; for example, of the four varieties of adhesion mentioned, among the causes which render hernia irreducible, the soft recent adhesion formed by coagulable lymph, called by Scarpa the gelatinous or glutinous adhesion, can be broken down by the finger, and the filamentous adhesion can be divided by the knife. 4th. The principal conditions which render it impossible to return the hernial contents after division of the stricture are two forms of adhesion, namely, the adhesion by the natural means of connexion, and the close organized adhesion, described by Scarpa as the natural and unnatural fleshy adhesions. When either of these conditions exists, the stricture should be divided, and then the coverings of the hernia should be replaced, and proper means taken to heal the wound. Another obstacle frequently met with in hernia of great size is, adhesion to each other of the different parts forming the hernia. In such cases, if the hernia consist of omentum alone, part may be cut away, and the rest returned to the mouth of the sac, the hemorrhage being stopped by pinching the vessels with a forceps, or including them in fine ligatures, while great care is taken not to include any part of omentum along with them. Such are the principal conditions which render it impossible to accomplish reduction; the stricture, however, being divided, the principal cause of danger is removed. There are certain states in which it would be extremely improper to attempt reduction, namely, when the hernial contents are gangrenous, or when the intestine has given way, from inflammation having gone on to gangrene, or when it has been torn, or accidentally wounded in the operation. The two last-mentioned conditions can only result from un- skilfulness in the mode of procedure; but should they exist, the hernia should not be returned. From what has been stated it will be under- stood that, in all cases in which it is possible, if the intestine be sound and entire, reduction should be attempted. When the intestine presents such an appearance as to render it doubtful whether it can retain its vitality, or whether its return may be followed by faecal extravasation, the surgeon should content himself with carefully dividing the stricture, replacing the coverings, and using proper means for the healing of the wound. When the intestine is gangrenous, the stricture should be carefully divided, but in doing so the greatest caution should be observed not to disturb any of the adhesions around the neck of the hernia; the gan- grenous portion should be laid open, its contents cleared out as com- pletely as possible, and the coverings replaced; but no attempts made to close up the wound. There is some difference of opinion among surgeons as to the most prudent method of procedure in regard to the stricture when the intes- tine is gangrenous. AYhile they agree as to the propriety of opening the intestine and clearing out its contents, some disapprove of any HERNIA. 469 attempt to divide the stricture, as both unnecessary and injudicious— unnecessary, inasmuch as they suppose that the evacuation of the intes- tinal contents will in every instance sufficiently remove the pressure; and injudicious, from the risk of destroying the adhesions by which the intestine is retained at the mouth of the sac,—a condition essential for diminishing the danger of faecal extravasation into the cavity of the abdomen. But others recommend a careful division of the stricture, lest dangerous pressure should still remain ; and as it is possible to accom- plish division without any risk of breaking down the adhesions round the whole of the neck of the sac, this seems the most advisable procedure, except when the gastric portion of intestine evidently and freely sends down its contents through the wound; in which case division of stric- ture is not so essential. Teale, in his admirable work on Hernia, remarks on this subject: "Louis maintained that the division of the stricture was not necessary for the evacuation of the intestinal canal, after a free incision had been made into the gangrenous portion of the intestine;" and Mr. Travers has strongly objected to the division of the stricture under these cir- cumstances, on the ground of its disturbing the adhesions, and being unnecessary for the evacuation of the bowel; nevertheless, he admits that this rule of treatment may have its exceptions. " If," says Mr. Travers, " the stricture should still be sufficient to retain the matters, which will seldom be the case, a moderate dilatation of it will be re- quired." Mr. Lawrence coinciding with Mr. Travers in opinion that the division of the stricture is generally unnecessary, states that if the stricture be so narrow as to interfere with the discharge, an incision must be made to afford the requisite room. To ascertain this point, as well as to discover if there be any interior constriction, Mr. Lawrence recommends that the end of the little finger, or a female catheter, be cautiously introduced into the bowel. Arnaud and Dupuytren divided the stricture, when the faeces did not freely escape. The general prac- tice of Sir Astley Cooper was to divide the stricture. Mr. Key is of opinion " that the danger of disturbing the adhesions has been exagge- rated, and states that a director may be passed between the intestine and stricture without materially disturbing the adhesions." In all cases in which the intestine is not entire, whether from having been purposely laid open, or from having given way of itself, or from having been torn or cut by unskilful procedure, it should be allowed to remain, so that the faeces passing off by the wound, may form an abnormal anus, and extravasation into the abdomen be thereby prevented. The wound should be left open to facilitate the free discharge of the intestinal con- tents, and simple dressings frequently renewed. The anatomy and treatment of artificial or abnormal anus will be afterwards explained. When omentum forms the hernia, and it is gangrenous, the gangre- nous portion may be removed, and the remaining part returned to the abdominal aspect of the mouth of the hernial sac. These remarks, it is hoped, will be sufficient to point out the proper mode of procedure regarding the hernial contents, when the hernia is sound and reducible, when it is irreducible, and when it is in any of the various conditions in which reduction would be dangerous and improper. 470 HERNIA. 5th. The mode of procedure with regard to the hernial sac. After the other coverings have been divided by incisions varying ac- cording to the situation of the hernia, the sac should be pinched up by means of a forceps, where it is seen to be separated from the hernial contents by some serous fluid, if such separation be perceptible, or where it lies over omentum, if that structure appear to form any part of the front of the hernia, and it should then be opened by holding the knife in a horizontal position. The point of the fore-finger should then be sent up within the sac in front of the hernial contents, and the hernial knife carried up flat upon the finger as a director, care being taken not to al- low the edge of the knife to touch the hernia. The stricture should then be divided through the neck of the hernial sac, the direction of the di- vision being from behind forwards. On the return of the hernial con- tents the sac is usually allowed to remain in the wound, because in most instances it has such adhesions to the surrounding parts as make its return impossible. It is a question of great importance, in reference to the operation for strangulated hernia, which of the two following modes of proceeding in regard to the hernial sac is the more advisable; namely, that of opening the sac, and dividing the stricture, from within, or that of dividing the stricture and replacing the parts without opening the sac. Of these two, technically called the intra-peritoneal and extra-peritoneal modes of division, the former is that, which, except in a limited number of cases, has received the sanction and adoption of most surgical autho- rities in these islands. It appears certain that, in the great majority of cases, it is by that mode alone, that it is possible to accomplish the two grand indications which it is desirable to fulfil by the operation; namely, the removal of the pressure by division of the stricture, and the return of the hernia. The fulfilment of the former, namely the removal of the pressure by division of the stricture, is essential to the safety of the patient: and that of the latter, the return of the hernia, exceedingly desirable when practicable and proper. With regard to the first indication, when the stricture is external to the sac, as is not unusual, it is possible to divide it by adopting either mode; but if formed by the sac, or within it, it is clear, that by intra- peritoneal division alone can the more important indication be fulfilled, or any good effected. Cases belonging to the latter class are by no means of unfrequent occurrence. That the neck of the hernial sac oc- casionally constitutes the stricture, is a point regarding which surgeons are agreed, instances having been recorded by the great surgical authori- ties of this and other countries, and examples occurring frequently in the practice of many surgeons. The sac, necessarily narrower at its neck than in other parts, is liable to be still further diminished by effu- sion and organization of lymph, either on its outer or inner surface, as well as by a thickened and indurated state of its own substance,—condi- tions which, separately, or in various degrees of combination, diminish the canal of the sac. For eighteen years I have availed myself of every opportunity of examining the condition of hernial sacs, and from my dissections I am led to conclude, that, in herniae of considerable stand- ing, thickening of the neck is of frequent occurrence. Although con- striction, when sufficient to render a hernia irreducible, is usually at the HERNIA. 471 neck of the sac, yet it is not invariably so. This fact is of little practi- cal moment if a hernia be merely irreducible; but it becomes of the greatest importance if it be strangulated, and require an operation, as the paramount object of the operation is to divide the constriction, in order to relieve the symptoms of strangulation. The stricture is occasionally found within the sac. In a very few in- stances it has been found to be occasioned by a loop of intestine; in some by a band of omentum ; and in others by a band of lymph effused from the serous coat of the intestine, and surrounding and constricting it as by a ligature. This last-mentioned condition has been described and delineated by Sir Astley Cooper. It has also been met with by other surgeons ; and not fewer than four cases of it have come under my own observation. The first case was that of a female about sixty years of age, of a full habit of body, and the subject of a strangulated umbilical rupture. Her medical attendant, a surgeon of long standing in Aberdeen, found it necessary to have recourse to an operation, and of that I was a wit- ness. The hernia returned very suddenly as soon as the margin of the umbilicus was slightly divided; but the symptoms of strangulation con- tinued, and the patient died in ten hours after the operation. I was requested to conduct the post-mortem examination; and, on opening the abdomen, found behind the umbilicus a swelling about the size of a small orange, formed of intestine, with a neck surrounded by a band of lymph, which embraced and constricted the part as by a cord. The lymph had been effused from the serous coat of the intestine in conse- quence of the inflammation excited by the pressure of the margin of the umbilicus. In this case the hernia returned, but without the stricture having been divided. The second case was that of a female, a patient of my own, about the middle period of life, on whom I had occasion, with the assistance of Mr. Paterson, surgeon in Aberdeen, to perform the operation for strangulated femoral hernia. On carrying up the point of my finger between the hernia and the hernial sac to feel for the stricture, I was struck with the circumstance, that the tightness of what I supposed to be the stricture, bore no ratio to the extreme urgency of the symptoms of strangulation, and that, after dividing some of Poupart's ligament, by cutting from within the hernial sac, the intestine, on being gently pressed, still remained as tense as formerly, and its contents did not seem to be moved by the pressure. I therefore examined the neck of the hernia with my finger, and perceived a band of lymph keeping the part tightly constricted, and, in short, constituting the stricture. I gently drew down the intestine, and cut the band in several different parts, when the contents of the intestine could be easily made to move upwards. On being satisfied that all constriction was removed by dividing the band of lymph in various parts, the intestine was returned into the abdomen, and the patient recovered without an unfavourable symptom. If the hernia had been returned without this band of lymph having been discovered and divided, the object of the operation would have been unaccomplished. The third case was that of a female, about sixty years of age, of a 472 HERNIA. remarkably full habit, and who about two days before I saw her, had been seized with symptoms of strangulation. When I first saw her, the abdomen was tympanitic to a great degree; the vomiting was most dis- tressing ; the bowels had not been moved for five days, and she had every symptom of sinking very rapidly. She stated that she had often on previous occasions had attacks of what she believed to be colic, and imagined at first that the illness from wThich she was suffering was only a return of that disorder, and, consequently, anticipated a speedy recovery. I was also informed that, for a considerable time, she had a disagreeable feeling of tenseness in her left groin, though without swelling so far as she could perceive; and that, some hours before I was called, while drawing up her limbs in a fit of retching, she felt, to use her own expression, as if something had given way in her groin, and from that moment was relieved from all feeling of tenseness. The symptoms of strangulation, however, continued. I made a most minute examination of all the usual seats of hernia, but could detect no symp- tom of such a lesion. I requested my colleague, Professor Macrobin, to attend the patient along with me, which he did, and he was also present at the post-mortem examination. On opening the abdomen, there was at its lower part a small tumour of intestine seen, before any parts had been disturbed beyond merely turning down the abdominal parietes. It was of a livid colour, about the size of a walnut, and with a narrow neck, tightly embraced by a band of lymph, by which it was so constricted as to make it difficult to pass a probe from that part of the intestine which led to the swelling into that which constituted the tumour. The intestine was also twisted over itself in form of a loop. On examining the femoral canal of the left side, a hernial sac was found in it; and the tumour of intestine had, no doubt, formed a hernia, but returned of itself. The stricture, however, formed by a band of lymph, still remained. Sir Astley Cooper records a case in which Mr. Weston returned a hernia by the taxis without an operation; but the symptoms of strangulation continued, and it was found that the stric- ture was caused by a band of lymph which embraced the intestine. In the instance of my patient, the hernia returned without any assistance. The fourth case was that of a female, whom I had never seen during life, but at the post-mortem examination of whose body I was present, in consequence of the request of a medical man who had seen her a short time before death, and who had also often attended her on pre- vious occasions, when in a state of great suffering from disease of the womb. The symptoms, I was informed, were those usually induced by a strangulated hernia; but the medical man could not detect any swelling in any of the usual seats of hernia. On examining the left groin before opening the abdomen, I thought I felt a very small swell- ing, which I suspected to be a hernia, and I therefore made a careful dissection of the parts in presence of the surgeon, who requested me to do so, and of one of my pupils. On cutting through Poupart's liga- ment from before backwards, the contents of a small hernial sac returned into the abdomen without being touched, and were found to consist of intestine strangulated by a band of lymph, embracing the neck of a small hernia. The hernia wras not much larger than a Avalnut. If it HERNIA. 473 had been discovered during life, and made the subject of operation, there would have been great risk of its returning into the abdomen without the real stricture being discovered or divided. From what is stated above, it appears very clear that the extra-peri- toneal mode of herniotomy is quite unsuitable when the stricture is formed by the sac or within it, whatever be the nature of the stricture itself; and the above-mentioned examples of strictures formed by mem- branous bands, suggest very strongly the propriety of great caution in arriving at the determination of adopting the extra-peritoneal division ; as well as, in those cases in which the sac is opened, of examining very carefully before the hernia be returned, whether membranous bands do or do not exist. The second indication which it is desirable to fulfil by an opera- tion, is the return of the hernia. With a view to facilitate the inquiry, as to which of the two modes of procedure is the more suitable, cases may be arranged into the three following classes:— First, Those in which the stricture is external to the sac, in which it is neither impracticable nor improper to return the hernia, and in which no obstacle exists to that return after the stricture has been divided. Secondly, Those in which an obstacle does exist after division of the stricture : and, Thirdly, Those in which the return of the included intes- tine would be practicable, but improper. First, In cases belonging to the first class, either mode is applicable; but extra-peritoneal division being attended with much less danger, is decidedly preferable. Secondly, Tn regard to cases in which, independent of the stricture, an obstacle to reduction exists, it will be proper to consider what are the principal obstacles most frequently met with. These are adhesions of the protruded parts to the hernial sac, the natural means of connex- ion, in some rare cases; adhesions of the protruded parts to each other; and the large size of the hernia. For a description of these obstacles to reduction, the reader is referred to the section on irreducible hernia. If any of these conditions exist, and if the sac be not opened, reduc- tion is in general impracticable. If the sac be opened, .two of them may easily be overcome; namely, the soft recent adhesions, formed by coagulable lymph and the filamentous,-«-the former can be broken down with the finger, the latter divided by the knife. Two of them present an insuperable impediment to reduction ; namely, the natural means of connexion, and the close organized adhesions, if these be to a great extent, and the hernia large. With regard to the two remaining condi- tions, the possibility of overcoming them, and the propriety of attempt- ing to do so, must depend entirely on the particular circumstances of the case; but frequently, it is more judicious not to interfere with them, unless they exist only to a limited extent, and in herniae of moderate size. Most of these conditions, however, are principally met in cases of large and old hernia; and, on account of the risk of injuring the intes- tine in attempts at reduction, as well as that of inducing dangerous inflammation by much handling of the intestine, and the difficulty of 474 HERNIA. maintaining the parts reduced, even should reduction be possible, the majority of surgeons seem now disposed to follow the advice of Sir Astley Cooper regarding such cases. His practice was, to divide the stricture, which fortunately in such cases is, for the most part, external to the sac, and to leave the latter unopened, and the hernia unreduced. The stricture being divided, the principal cause of danger is removed. The coverings of the hernia should be replaced, and proper means taken for promoting the healing of the wound. Thirdly, There are certain states in which it would be extremely im- proper to attempt reduction; namely, when the hernia is gangrenous, or when the intestine has given way from inflammation having gone on to gangrene, or when it has been torn, or accidentally wounded in the operation. The two last-mentioned conditions can only result from unskilfulness in the mode of procedure; but, should they exist, the hernia ought not to be returned. When the intestine presents such an appearance as to render it doubtful whether its return may be followed by faecal extravasation, the surgeon should content himself with care- fully dividing the stricture. In all cases in which the intestine is gan- grenous, or not entire from whatever cause, it ought to be allowed to remain, so that the faeces passing off by the wound may form an abnor- mal anus, and extravasation into the abdomen be thereby prevented. When omentum forms the hernia, and it is gangrenous, the gangrenous portion may be removed, and the remaining part returned to the abdominal aspect of the mouth of the hernial sac. The practice of re- moving a portion of omentum, when from growth it renders a hernia irreducible after division of the stricture, is a proceeding which, in some cases, may be adopted with advantage. For cases belonging to this class, extra-peritoneal division is of course quite unsuitable. These remarks, it is to be hoped, will be sufficient to point out the proper mode of procedure when the hernia is sound, and reducible after division of the stricture ; when it is irreducible after such division—and when it is in any of the various conditions in which reduction would be dangerous and improper; and also to show., that to follow one method indiscrimi- nately in all cases would be unwise; that intra or extra-peritoneal division should be adopted according to the particular circumstances of the case; that in the majority of cases intra-peritoneal division is not only the more suitable mode, but the only one which is safe, or by which any good can be effected; and tfcat the cases in which extra-peritoneal division is suitable are those of very short standing, where there is no reason to apprehend the existence of adhesions, or of an unsound condi- tion of the hernia; and those also of large and old hernia, where the more judicious proceeding is to divide the stricture, and not to attempt reduction. The plan of not opening the sac, although practised in certain cases by Franco and Pare", was first strongly recommended by Petit, and con- sequently has been designated the method of Petit, to distinguish it from the mode in common use. Petit practised this method as early as 1718. It was subsequently advocated by Garengeot; and, at a still later period, adopted and strongly recommended by Bonnet of Lyons. In this country it was introduced by the second Monro, who advocated HERNIA. 475 its adoption in cases of small and recent hernia, and mentioned four cases in which he resorted to that mode of proceeding. In one of them, however, adhesions prevented the return of the hernia, and in two of them he was obliged to cut the neck of the sac. In later times, the same proceeding was adopted by Sir Astley Cooper in cases of large and old hernia, and strongly recommended by him as the decidedly prefera- ble mode in cases of that class. Mr. Lawrence, in his valuable " Treatise on Ruptures," remarks, " The plan of removing the stricture, and re- turning the prolapsed parts without opening the sac at all, ought, I think, to be more frequently adopted than it has hitherto been, although it appears objectionable as a measure of general use, in the operation for strangulated hernia." To Mr. Key, however, the merit undoubtedly belongs of having recommended a more general adoption of Petit's mode than had previously prevailed in this country. In his admirable " Me- moir on the Advantages and Practicability of dividing the Stricture in Strangulated Hernia on the outside of the Sac," published in 1833, will be found much valuable information on this interesting subject. Mr. Luke of the London Hospital strongly recommends this mode, and his success is a decided testimony in its favour. Out of nearly forty patients he has not lost more than two. In October, 1845, when I had occasion to be in London, Mr. Liston showed me a patient in the North London Hospital, in whose case he had adopted this mode; and, in a communi- cation I afterwards received from him, he informed me that he had practised it in a few other instances, and felt convinced of its being the preferable mode when the hernia is small and recent, and when there is no reason to apprehend an unsound state of the intestine. And, judging from the recorded statements of some other distinguished surgeons, this mode seems to be meeting with deservedly increased favour; and I have no doubt will continue to do so, if practised under the limitations already mentioned. There can be no doubt that intestinal inflammation is the most fre- quent cause of death after the operation for strangulated hernia. Some of the advocates of Petit's method have assigned as the causes of that inflammation, when the ordinary proceeding is adopted, the exposure of the intestine to light and air, change of temperature and handling. I agree with Mr. Lawrence in ascribing it not to these agents, but chiefly to the long-continued pressure of the stricture, owing to the operation being too long delayed, and to an injudicious and too frequent use of the taxis previous to the operation. I remember being very much struck with an observation of Desault's ; I have not his works beside me at present, but it is to this effect :—" Think well of that hernia which has been little handled and soon operated on." The operation is justifiable and necessary, when the patient has been brought fully under the influence of chloroform, and the taxis has been fairly, fully, and skilfully tried without producing the desired effect. The conviction being thus produced, that by no other means than an operation is there hope of saving the life of the patient, it ought to be resorted to as quickly as possible. Much handling must not only give unnecessary pain, but also increase the risk of hurrying on the inflammation to results which, even though the operation should be performed, would 476 HERNIA. render it unsafe to return the hernia. When therefore the taxis has been fairly and skilfully tried, on a patient fully under the influence of chloroform, no advantage can, but considerable injury may, result from the repetition of treatment already found to be unavailing. Many con- siderations show that the operation should be performed as soon as possi- ble, after its inevitable necessity has been found to exist. Delay, like undue handling, increases the risk of inducing such a state of the hernia in consequence of inflammation, as would render its return unsafe. From the circumstance that a hernia may speedily prove fatal, and from the depressed state which comes on in consequence of delay, ren- dering the patient less able to stand the shock of an operation, will be seen the importance of being as prompt as possible; but there is another, and a very urgent reason—namely, that, if the operation be. delayed until intestinal inflammation has been induced within the abdomen, it is far from certain that this inflammation will subside on the removal of the hernia which caused it. I have performed the operation for stran- gulated hernia, according to the usual mode, a considerable number of times, I believe twenty-three in all, and except in one case, where death occurred in consequence of an attack of phlegmonous erysipelas which commenced after the patient was considered out of all danger) in every instance with success. This success I attribute to two things—namely, avoiding all undue and useless handling, and performing the operation early. My decided impression is, that the reason why the operation is so frequently followed by death, instead of being one of the most suc- cessful of the great operations of surgery, is too great delay in resorting to an operation, and the undue and the injurious use of the taxis, even after its adoption has proved unavailing. 6th. Abnormal or artificial anus, its anatomy and treatment. When- ever the intestine is unsound, or not entire, it should be allowed to re- main, the safety of the patient in such cases consisting in the formation of an abnormal anus. Lymph is thrown out along the abdominal aspect of the mouth of the sac, by which means the intestine becomes con- nected to the walls of the abdomen, and the danger of faecal extravasa- tion is diminished. The portion of intestine leading to the abnormal anus, that is, the upper or gastric portion, sends down its contents, and they are discharged by the wound; their transmission into the lower or rectal portion, that is, the part leading from the abnormal anus, being prevented partly by the contraction of that portion from being empty, and its retraction ; but principally by the septum formed by the contiguous portions of the bowel. The completeness of this partition (called by some the spur, ldperon), and consequently of the hindrance of the passage of the faeces from the one end of the intestine to the other, varies according as the entire diameter of a loop of intestine, or a part of it only, is included in the stricture. If the whole diameter be included, the portions of intestine will be in a measure parallel, and the partition complete. The danger of abnormal anus varies according to the part of the bowel affected. If it be a portion of the great intes- tine, the only consequences may be discomfort and inconvenience; whereas if it be a portion of the small intestine, and more especially if it be near the commencement of the jejunum, the chyle will run to HERNIA. 477 waste, and death from inanition probably follow. The upper portion remains open, its mucous membrane in some instances projecting, and discharges its contents into a cavity conical in form, the base being round the breach of the intestine, and the apex at the aperture in the abdominal parietes. An excellent writer on surgery says, " In an ab- normal anus of long standing, another phenomenon is observed: the two ends of the intestine retract inwards. Scarpa explained this by a movement of traction exercised on them by the mesentery, which move- ment, we think, is owing solely to the peristaltic motions of the intes- tine. There is then formed a membranous canal from the intestine to the surface, called the funnel (I'entonnoir), which serves as a way of communication between the two ends of the intestine; and when the spur is not very prominent, but strongly retracted, it ends by bringing about the complete return of the faecal matters into the inferior end, and the spontaneous cure of the artificial anus." Nature thus in some cases effects a cure without any other assistance than attention to re- gimen and pressure on the external aperture, for the double purpose of preventing protrusion of the mucous membrane, and of presenting an obstacle to the passage of the faeces outwards. Desault was the first who effected a radical cure of abnormal anus by surgical treatment; but his method, though successful, is not very generally applicable. To Dupuytren the merit belongs of having devised, and successfully prac- tised, an ingenious and more generally applicable mode of effecting a radical cure. His object was the destruction of the septum, which offers the principal obstacle to the restoration of the normal canal; and the plan which he ultimately adopted for that purpose was, to produce a slough of the septum by subjecting it to pressure between the blades of a screw-forceps; the two blades having been introduced, one into each portion of the bowel, are made to approach each other by the turning of the screw, and the partition deprived of its vitality by pres- sure ultimately comes away with the instrument, and the principal ob- stacle is thus removed. Of this method of treatment I have had no experience, but in the hands of Dupuytren it was found to be success- ful. It should never be ventured upon at an early period, lest the surrounding adhesions, which are so essential, should be broken, and lest the irritation should be so great that the extensive sloughing action produced might endanger the life of the patient. And when it is adopted, the utmost caution should be exercised, its effects should be closely watched, and care taken, especially at first, not to employ com- pression to such an extent as to cause distressing symptoms. The blades should not be introduced very far, lest by too extensive destruc- tion an opening be made into the cavity of the abdomen, or lest a loop of intestine be included between the parts. The restoration of the canal is also promoted by the occasional introduction of tents or bougies into the inferior portion of the canal. Dupuytren's method of treatment is clearly most applicable to those cases, in which the two portions of bowel are parallel to each other. 7th. Treatment after the operation for strangulated hernia. After reduction it is advisable in general to give an opiate, and suita- ble means should be employed for promoting the healing of the wound: 478 HERNIA. strict attention to rest, the recumbent posture, and the careful regula- tion of the diet, are indispensable. After some little time, it is advisa- ble to endeavour to procure evacuation of the bowels by means of mild enemata; but on no account whatever, should purgative medicines be given by the mouth for some considerable time after the operation. If inflammatory symptoms should appear, they must be combated by local and, if necessary, general depletion, fomentations, attention to regimen, the exhibition of calomel and opium, and other appropriate remedies. Pressure over the wound should be kept up by means of a compress and bandage; and before the patient is allowed to get out of bed and resume the erect posture, by means of a truss to diminish the danger of reprotrusion. THE DIFFERENT KINDS OF HERNIA, WHEN SITUATION IS MADE THE BASIS OF ARRANGEMENT. When situation is made the basis of arrangement, it is usual to divide herniae in accessible situations into four principal classes—namely, in- guinal, femoral, umbilical, and ventral. I. INGUINAL HERNIA. In the language of surgery, inguinal hernia is a generic term, comprehending five different species—namely, oblique, direct, congenital and encysted congenital inguinal hernia, and hernia infantilis. These species, though all connected with the inguinal canal, yet differ from each other in their anatomy, relations, seats of stricture, &c, and each, therefore, requires to be particularly described. [But before entering into a special description of each, it may be proper to glance at the anatomy of the parietes of the abdomen, and particularly of those parts concerned in inguinal hernia. In the study of inguinal hernia, it must constantly be borne in mind, that the protrusion occurs at a natural weakness in the abdomen, through which the testicle and spermatic cord descend, towards the completion of foetal life; and it will be useful, therefore, to study the relations of the different lamina of the abdomen, to the cord and testicle ; we should not forget, also, in the examination of the parts of a healthy abdomen in which no hernia existed, that the structures would be very much modi- fied by the affection. We might then say; first, that a knowledge of the different layers of the abdomen is most important, for the cord and testicle are covered by a re-presentation of the same; and secondly, that if the coverings of the cord are understood, there can be no difficulty in understanding those of the protrusion of the most common form, oblique inguinal hernia. The parts can be studied most satisfactorily by making two incisions, each commencing in the linea alba, one inch below the umbilicus, one extending to the pubes, and the other directed towards the crest of the ilium. Superficial fascia.—When the skin is removed by the incisions directed, a large portion of the superficial fascia of the abdomen is brought into view. It is composed of cellular tissue and capable of being split into layers. Its thickness varies in different subjects, and in different parts HERNIA. 479 of the abdomen. In fat subjects, the external layer will be found to have much fat contained within its meshes, and in such, therefore, a much deeper incision will be required to divide it. It is continuous with the superficial fascia of the thorax, the thigh and the perineum, and the deeper layer of it will be found to be connected with Poupart's ligament, the crest of the ilium, and the linea alba. Through the layers of this fascia ramify blood-vessels which may be cut in the operation for the relief of strangulated hernia. The principal artery in the lower part of the abdomen, is the arteria ad cutem abdominis of Haller, called fre- quently the external epigastric artery. Branches also of the external pudic arteries, or the veins accompanying, might also be cut, but the hemorrhage would be so slight as not to require a ligature to arrest it. Imbedded in this fascia near the groin we find the lymphatic glands. They will be found most numerous immediately over Poupart's ligament, and in the upper part of the thigh over the saphenous opening of the fascia lata. " When the superficial fascia is removed, the aponeurosis of the external oblique muscle is in view, together with, in the male body, the spermatic cord (in the female body, the round ligament of the uterus), which emerges from an opening close to the outer side of the spine of the pubes. The lowest fibres of the aponeurosis, as they approach the pubes, become separated into two bundles, which leave an interval between them for the passage of the cord or ligament just named. One of the bands, the upper one and smaller of the two, is fixed to the symphysis of the pubes; and the lower band, which forms the lower margin of the aponeurosis, being stretched between the anterior superior spine of the ilium and the pubes is named Pou- part's ligament, or the femoral arch. This latter tendinous band has con- siderable breadth. It is fixed at the inner end to the spine of the pubes, and, for some space outside that process of the bone, to the pectineal ridge. In consequence of the po- sition of the pectineal ridge at the back part of the bone, the ligament is tucked backwards, and its upper surface affords space for the attach- ment of the other broad muscles, at the same time that it supports the spermatic cord. Poupart's ligament does not lie in a straight line be- tween its two fixed points; it curves downwards, and with the curved border the fascia lata is connected. Fig. 150. It is owing to the last-mentioned Fig. 150. The aponeurosis of the external oblique muscle and the fascia lata.—1. The internal pillar of the abdominal ring. 2. The external pillar of same (Poupart's liga- ment). 3. Transverse fibres of the aponeurosis. 4. Pubic part of the fascia lata. 5 The spermatic cord. 6. The long saphenous vein. 7. Fascia lata. 480 HERNIA. fact that the so-named ligament, together with the rest of the aponeu- rosis of the external oblique, is influenced by the position of the thigh, being relaxed when the limb is bent, and the converse. Moreover, the change of the position of the limb exercises a corresponding influence on the state of the other structures connected with Poupart's ligament. " The interval left by the separation of the fibres of the aponeurosis above referred to, is named the external abdominal ring, and the two bands by which it is bounded, are known as its pillars or columns. The space is triangular in shape, its base being the crista of the pubes, while the apex is at the point of separation of the two columns. The size of the ring varies considerably in different bodies; in one case its sides will be found closely applied to the spermatic cord, while, in another, on the contrary, the space is so considerable as to be an obvious source of weakness to the abdominal parietes. It is usually smaller in the female than in the male body. " Between the pillars of the abdominal ring is stretched a thin fascia, named, from that circumstance, * intercolumnar;' and a thin diapha- nous membrane prolonged from the edges of the opening affords a cover- ing (fascia spermatica) to the spermatic cord and the tunica vaginalis testis. The cord passes through the ring over its outer pillar. " Internal oblique muscle.—After removing the aponeurosis of the ex- ternal oblique, this muscle is laid bare. The lower fibres are thin, and Fig. 151. HERNIA. 481 about to escape at the external abdominal ring, passes beneath the fleshy part of the muscle. The fibres in this situation varying consi- derably in direction from those of the rest of the muscle, pass inwards from Poupart's ligament at first nearly parallel with that structure; and, becoming tendinous, they join with the tendon of the transversalis. " Transversalis muscle.—This muscle does not, in general, extend down as far as the internal oblique, so that the latter being removed, an inter- val is observable between the edge of the transversalis and Poupart's ligament, in which the transversalis fascia comes into view; and in which Fig. 152. 482 HERNIA. muscle.' This tendon is fixed to the crest of the pubes in front of the rectus muscle, and likewise to the pectineal ridge. It is thus behind the external abdominal ring, and serves to strengthen the wall of the abdomen where it is weakened by the presence of that opening. "A band of tendinous fibres (Fig. 152), directed upwards and inwards over the conjoined tendon in a triangular form, gives additional strength to the abdominal wall in the same situation, but the fibres of this struc- ture are often very indistinct. "Where the spermatic cord is in apposition with the preceding muscle, the cremaster muscle of the testis descends over it. The fibres which compose this muscle are, from their colour, more easily distinguished than the other investments of the cord; and this is especially the case in robust persons, or when they are hypertrophied, as sometimes hap- pens in cases of long-standing hernia. The outer part of the cremaster is much larger than the portion connected with the pubes; indeed, it sometimes happens that the latter is not to be discerned even with most careful dissection. " When observed in different bodies the lower part of the internal oblique and transverse muscles will be found to present some differences in their physical characters as well as in the manner in which they are disposed with respect to the spermatic cord. Thus:— " a. The transversalis, in some cases, is attached to but a small part of Poupart's ligament, and leaves, therefore, a larger part of the abdomi- nal wall without its support. On the other hand, that muscle may be found to extend so low down as to cover the internal abdominal ring together with the spermatic cord, for a short space. Not unfrequently the fleshy fibres of the two muscles are blended together as well as their tendons. " b. Cases occasionally occur in which the spermatic cord, instead of escaping beneath the margin of the internal oblique, is found to pass through the muscle, so that some muscular fibres are below as well as above it. And examples of the transversalis being penetrated by that structure in the same manner are recorded.1 " c. In his latest account of the structure of these parts Sir A. Cooper described the lower edge of the transversalis as curved all round the internal ring and the spermatic cord. ' But the lower edge of the transversalis has a very peculiar insertion, which I have hinted at in my work on hernia. It begins to be fixed in Poupart's ligament,-almost immediately below the commencement of the internal ring, and it con- tinues to be inserted behind the spermatic cord into Poupart's ligament as far as the attachment of the rectus.'2 With this disposition of its fibres, the muscle would, in the opinion of the last-cited authority, have the effect of a sphincter, in closing the internal ring, and would thus tend to prevent the occurrence of hernia. But the principal object with which the attention of surgeons has been fixed on the muscles in this situation, is in order to account for the active strangulation of hernial protrusion at the internal abdominal ring, and in the inguinal canal. 1 Itccherches Anatoraiques sur les Hernies, &c, par J. Cloquet, pp. 18 and 23, Paris, 1817. Inguinal and Femoral Hernise, by 0. J. Guthrie, plate I., London, 1833. 2 Observations on the Structure and Diseases of the Testis, second edition, p. 36. Ed. by Brnnsby B. Cooper, F.R.S. London, 1841. HERNIA. 483 " Fascia transversalis.—Closely connected with the transversalis muscle by means of the cellular membrane interposed between the fleshy fibres of the muscle, it is united below to the posterior edge of Poupart's ligament, there joining with the fascia iliaca; and on the inner side it blends with the conjoined tendon of the internal oblique and transversalis muscles, as well as with the tendon of the rectus. The fascia possesses very different degrees of density in diffe- rent cases ; in some being little more than a loose cellular texture, while in others it is so resistant at the groin,—towards which part it increases in thickness, and especially at the inner side of the internal abdominal ring—that it is calculated to afford material assistance to the muscles in supporting the viscera. By an oval opening in this membrane the sper- matic cord (or the round ligament of the womb) begins its course through the abdominal parietes. This opening, named the internal abdominal ring, is opposite the middle of Poupart's ligament and usually close above that structure, but occasionally at a distance of three or four lines from it. Its size varies a good deal in different persons, and is consi- derably greater in the male than the female. From the edge of the ring a thin funnel-shaped elongation (infundibuliform fascia; fascia spermatica interna, Cooper), is continued over the vessels of the sper- matic cord. " Epigastric artery.—The position of this vessel is one of the most im- portant points in the anatomy of the inguinal region, from the close connexion which it has with the different forms of inguinal hernia and with the femoral hernia. Accompanied by two veins (in some instances by only one) the vessel ascends under cover of the fascia last described obliquely to the rectus muscle, behind which it then proceeds to its ulti- mate distribution. In this course the artery runs along the inner side of the internal abdominal ring—close to the edge of the aperture, or at a short interval from it. The vessels of the spermatic cord are therefore near to the epigastric artery; and the vas deferens, in turning from the ring into the pelvis, may be said to hook round it. " The Inguinal Canal.—This, the channel by which the spermatic cord passes through the abdominal muscles to the testis, begins at the inter- nal abdominal ring, and ends at' the external one. It is oblique in its direction, being parallel with and immediately above the inner half of Poupart's ligament; and it measures two inches in length. In front, the canal is bounded by the aponeurosis of the external oblique muscle in its whole length, and at the outer end by the fleshy part of the inter- nal oblique also; behind it, is the fascia transversalis, together Avith, towards the inner end, the conjoined tendon of the two deeper abdomi- nal muscles. Below, the canal is supported by the broad surface of Poupart's ligament, which separates it from the sheath of the large blood-vessels descending to the thigh, and from the femoral canal at the inner side of those vessels. " The spermatic cord, which occupies the inguinal canal, is composed of the arteries, veins, lymphatics, nerves, and excretory duct (vas defe- rens) of the testis, together with a quantity of loose cellular membrane mixed up with those parts. The direction of the vessels just enume- 484 HERNIA. rated requires notice. The artery and vein incline outwards from the lumbar part of the vertebral column to reach the internal abdomi- nal ring, where, after being joined by the vas deferens as it emerges from the pelvis, they change their course, inclining inwards along the inguinal canal; at the end of which they become vertical. There are thus repeated alterations in the direction of the vessels; and while at the beginning and ending all are close to the middle line of the body, they are considerably removed from that point where they come toge- ther to emerge from the abdominal cavity. " The coverings given from the constituent parts of the abdominal wall to the spermatic cord and the testis, namely, the cremasteric muscular fibres with the two layers of fascia, between which those fibres are placed (the infundibuliform and spermatic fascige), are very thin in their natu- ral state; but they may be readily distinguished in a surgical operation from the investing superficial fascia, by their comparative density and the absence of fat. " In order to examine the peritonaeum at the groin it will be best to divide that membrane with the abdominal muscles by two incisions drawn from the umbilicus—one to the ilium, the other to the pubes. The flap thus formed being held somewhat outwards, and kept tense> a favourable view will be obtained of the two fossae (inguinal fossae or pouches) with the intervening crescentic fold. This fold is formed by the cord remaining from the obliterated umbilical artery, which being shorter than the outer surface of the serous sac, projects it inwards; and as the length of the cord differs in different cases, so likewise does the size and promi- nence of the peritongeal fold vary accordingly. " The lowest part of the outer fossa will be generally found opposite to the entrance into the internal abdominal ring and the femoral ring, while the inner one corresponds with the situation of the external abdo- minal ring. But the cord representing the umbilical artery, which, it has been stated, causes the projection of the serous membrane into a fold, does not uniformly occupy the same position in all cases. Most frequently it is separated by an interval, from the epigastric artery, while in some cases it is immediately behind that vessel. There is ne- cessarily a corresponding variation in the extent of the external perito- nseal fossa. " Between the peritonaeum and the fascia lining the abdominal muscles is a connecting layer of cellular structure, named the subserous cellular membrane. A considerable quantity of fat is in some cases found in this membrane. " The relative position of some of the parts above referred to may be here conveniently stated, by means of measurements, made by Sir A. Cooper, and adopted after examination by J. Cloquet. But as the dis- tance between given parts varies in different cases, the following mea- surements must only be regarded as a general average:— HALE. " From the symphysis of the pubes to the anter. supr. spine of the ) rl . , ilium, . . ... . . \ °s incD From the same point to the spine of the pubes, . . 1J " to the inner part of the external abdominal") n, (< ring, • . . . . . j, * HERNIA. 485 MALE. FEMALE. From the same point to the inner edge of the internal abdominal }„. , „ , . , ring, . V 3 inches. 3,£ inches. to the epigastric artery on the inner side of 1 93 the internal abdominal ring, . j ? » "From the preceding account of the structure of the abdominal wall at the groin, it will be inferred that the defence against the protrusion of the viscera from the cavity is here weaker than at other parts. The external oblique muscle and the fascia transversalis are perforated, while the two intervening muscles are thinner than elsewhere, and more or less defective. To this it must be added that the viscera are impelled towards the same part of the abdomen by the contraction of the dia- phragm and the other abdominal muscles, which occurs in the production of efforts to overcome resistance; and these are the circumstances under which protrusions actually take place." Quain and Sharpey's Anatomv, p. 1286-1294.—Ed.] F j y' I. OBLIQUE INGUINAL HERNIA. This (called by some writers external inguinal hernia) is a hernia which leaves the abdomen at the internal aperture of the inguinal canal. The points which it is of importance clearly to understand regarding this Fig. 153. form of rupture will be seen by attending successively to its commence- ment—direction—coverings—relations to the inguinal canal, spermatic cord, and internal epigastric artery—its seats of stricture—and the operation, when symptoms of strangulation still continue after the em- ployment of all the measures proper for that state. Fig. 153. Drawing of the parts concerned in inguinal hernia. Taken from a dissec- tion made by me for the surgical class. 486 HERNIA. 1. The commencement, as has been already stated, is at the internal aperture of the inguinal canal, where it begins by pushing the perito- neum before it. 2. The direction varies in the different divisions of its course. While within the inguinal canal its direction is downwards, inwards, and for- wards, so that in using the taxis the pressure should be upwards, out- wards, and backwards. After leaving the inguinal canal, its direction is downwards, inwards, and a little backwards. If such a hernia do not 154. & leave the inguinal canal, it is called a bubonocele; but if it reach the scrotum in the male, it forms what is called scrotal hernia, or os- cheocele; or if the labium in the female, it constitutes a labial hernia:—these ap- pellations being descriptive of the extent of the hernia. 3. The coverings of an oblique inguinal hernia, if it extend beyond the ex- ternal aperture, are six in the male, and five in the female. In the male they are, from within outwards, the hernial sac, formed of peritoneum—the fascia in- fundibuliformis or internal spermatic fascia, derived from the margin of the in- ternal aperture — the cre- master muscle, called by some writers the fascia cre- masterica — the external spermatic fascia—the super- ficial fascia, and the common integument. In the female the cremaster muscle is wanting. 4. The relations of an oblique inguinal hernia to the inguinal canal, to the spermatic cord, and to the internal epigastric artery, are the follow- ing. It comes down through the canal, differing greatly in this respect from direct inguinal hernia. The cord is behind, and the hernia in front, as might be expected, considering the different ways in which the hernia and the cord reach the internal aperture ; and the internal epigastric artery is to the pubic side of the neck of the hernia, but Fig. 154. Hernial sac, showing its usual situation in front of the spermatic cord. From a preparation in my own museum. Fig. 155. Hernial sac, accompanied by varicocele: showing the spermatic cord split, the vessels lying on one side, and the vas deferens on the other. Taken from a prepa- ration in my own museum. HERNIA. 487 Fig. 156. Fig. 157. behind the fascia transversalis, and separated by it from the canal. If the hernia be of considerable standing, the different parts com- posing the cord may be separated from each other, some being bent to one side, and some to the other; and occasionally some have been found nearly in front; but these are deviations from the usual con- dition. The relation which is the most important of all to be kept in view is, that the internal epigastric artery is on the pubic side of the neck of the hernia. 5. The seats of stricture in this species of hernia are three—first, at the external aperture; this, however, is of very rare occurrence, except in cases of large and old hernia, when it is sometimes met with, and may then be formed either by the circumference of the aperture, or by the hernial sac; secondly, between the exter- nal and internal apertures, in which case it may be formed by the under borders of the internal oblique and transversalis muscles, or by the hernial sac, or by being embraced by the fibres of the above mus- cles, the cord and the hernia having in some cases fibres behind as well as in front; and, thirdly, at the internal aper- ture, in which case it may be formed either by the fascia transversalis where it forms the aperture, or by the hernial sac. The correctness of these statements as to the seats of stricture and the parts by which they may be formed, I have had opportunities of testing in my own dissections and operations. 6. The operation. As all the details of the operation for strangulated hernia in general are applicable to the operation for this particular species, I shall here only point out the modifications rendered necessary by the anatomical relations. The incision of the integument should commence about half an inch above the internal aperture, follow the direction of the long diameter of the tumour, and de- scend to near its base. One simple inci- sion suffices. The next step is, to lay bare the hernial sac by the cautious division of the other coverings, and if intraperitoneal division be the prudent mode of procedure, to open the sac, attending carefully to the precautions already mentioned. The her- nial sac having been opened, and the seat of the stricture ascertained by passing the point of the fore-finger upwards within the sac and in front of the hernia, the hernial knife is sent up on the palmar aspect of the 1 488 HERNIA. finger as a director, care being taken to avoid wounding the hernia; and for this purpose it should be sent up with the side resting on the finger until its pointed extremity be within the stricture, when the edge should be turned forwards to the stricture and the division made, during which process the action of the right hand which moves the knife is accommodated to that of the left index finger which to a certain extent guides the knife, and also prevents the hernia from coming against its edge. An important question is, in what direction the stricture should be divided. If the stricture be at the external aperture, or at the under border of the internal oblique and transversalis muscles, there is no artery to be afraid of, and the division can be safely effected by carrying the knife upwards and inwards, directly upwards, or upwards and outwards; but if the stricture be at the internal aperture, there would be danger of wounding the internal epigastric artery if the inci- sion were carried upwards and inwards ; it can, therefore, be made with safety only in two directions, namely, upwards and outwards, or directly upwards. The same proceeding as regards the direction of the incision in di- viding the stricture is adopted in all cases of inguinal hernia. It was first recommended by J. L. Petit, and by Scarpa, and afterwards by Richerand, Dupuytren, and other continental authorities; and in this country it was very strongly advocated by Sir Astley Cooper, who recommended in all cases of dividing the stricture, to cut directly upwards—a practice which has deservedly received general adoption. II. DIRECT INGUINAL HERNIA. In explaining the anatomy of direct inguinal hernia, we shall follow the same order as in the former case. Fig. 158. 1. The commencement of a direct inguinal hernia is opposite the exter- nal aperture, through which it comes usually by pushing the posterior wall of the inguinal canal before it, but in some instances by rupturing a part of it. Fig. 158. From Druitt. HERNIA. 489 9. Its direction before leaving the aperture is directly forwards; after leaving it, it is the same as that of an oblique inguinal hernia in the corresponding part of its course. 3. The coverings of a direct inguinal hernia, from within outwards, are the hernial sac—the fascia transversalis with the conjoined fibres of the internal oblique and transversalis muscles, provided they be not rup- tured—a very imperfect covering from the cremaster muscle—the exter- nal spermatic fascia—the superficial fascia, and the common integument. In the female, as there is no cremaster muscle, there is one covering less. These coverings differ from those of oblique inguinal hernia in two particulars—namely, that formed by the cremaster muscle is in this case less perfect; and the second from within outwards, instead of being formed by the internal spermatic fascia given off from the internal aperture of the inguinal canal, is formed by the fascia transversalis itself assisted by the conjoined fibres of the internal oblique and transversalis muscles, except when they have been ruptured, or separated from each other. 4. With regard to its relations to the inguinal canal, spermatic cord, and in- ternal epigastric artery, we may remark that it does not come down through the canal, but directly through its external aperture; that the cord, instead of being behind it, is on its outer side ; and that the artery, instead of being on the pubic, is on the iliac side of the neck of the hernia. This last peculiarity is most important to be remembered, and it is thus seen that oblique and direct inguinal herniae have opposite relations to the internal epigastric artery. 5. The seats of stricture in this species are only two: namely, at the external aper- ture—which, however, is a rare occurrence, and then the stricture may be formed either by the circumference of the aperture, or by the hernial sac ; and at the under border of the internal oblique and transversalis mus- cles, the stricture being formed by them, or by the hernial sac itself. 6. After what has been stated regarding the operation for strangulated hernia in general, and that for oblique inguinal hernia, it seems unnecessary to do more than add, that when the stricture is at the under bor- der of the internal oblique and transversalis muscles, the knife in Fig. 159. Drawing of the sac of a direct inguinal hernia ; showing the mouth of the sac lying on the pubic side of the deep epigastric vessels, and the spermatic cord split so that its vessels lie behind, and the vas deferens in front of the sac. From a prepa- ration in my own museum. 490 HERNIA. dividing the stricture could be carried directly upwards, or up- wards and inwards, without going in the direction of the internal epigastric artery; but not upwards and outwards. It would be unsafe to cut upwards and outwards in direct inguinal hernia, or up- wards and inwards in oblique; and as it is difficult or impossible in some cases to determine whether the hernia be oblique or direct, from the weight of the hernia having drawn down the internal aperture to be opposite the external, it is proper to adopt the rule already laid down —namely, in all cases of inguinal hernia, in dividing the stricture to cut directly upwards. It may be briefly stated, that the operation is performed by making an incision through the integuments in the direc- tion of the tumour, and extending from its upper to its under part, and cutting through the other coverings until the hernial sac is brought into view. The hernial sac is then opened, strict attention being paid to the precautions before mentioned. The forefinger of the left hand is Fig. 160. then introduced into the sac, and carried up to the stricture, and the palmar aspect of the finger used as a director for conducting the knife up to the stricture, and as a guard to prevent the knife from coming against the hernia. The extremity of the knife having been introduced below the stricture, its edge should be directed towards the stricture, and division effected by cutting directly upwards. The hernial contents should then be returned, if such a proceeding is possible and proper; if not, the treatment formerly described should be adopted. III. CONGENITAL INGUINAL HERNIA. Congenital inguinal hernia—more properly called hernia into the tunica vaginalis, because while it is usually congenital, or met with in young infants, it sometimes, though rarely, presents itself at a more advanced age—differs from the two species already described, in that Fig. 160. From Liston. HERNIA. 491 they, if they descend into the scrotum, are without, as is shown in the ac- companying delineation, but this is contained within the tunica vaginalis. The two accompanying diagrams, though somewhat altered and improved, taken from the works of a writer who was once a great ornament of Fig. 161. the surgical profession, shows the opposite relations of common and congenital inguinal hernia to the tunica vaginalis. The manner in which this species of hernia is formed, may be thus explained. Although the tubular portion of peritoneum, which, for a short time after the descent of the testicle, forms a canal of communication between the tunica vaginalis within the scrotum and the peritoneum within the abdomen, usually becomes very soon occluded, and ultimately quite Fig. 162. obliterated, so that the cavity of the tunica vaginalis is perfectly separated from that of the abdomen, yet in some cases the tubular por- Fig- 161. A scrotal hernia; showing the usual relation of the sac to the tunica vaginalis. Fig. 162. Congenital scrotal hernia ; showing the situation of the hernia within the tunica vaginalis. 492 HERNIA. tion does not exhibit its usual disposition to close and become obliterated and while this state continues, on crying or making some exertion, a portion of intestine may be sent down through the tubular canal into the cavity of the tunica vaginalis, and thus constitute what is called a congenital hernia. As it is only after the inflation of the lungs that the usual exciting causes are applied, this variety rarely occurs till after birth; but sometimes a portion of intestine in contact with the testicle while within the abdomen, adheres to the testicle, and descends with it into the scrotum at the usual time at which the gland leaves the abdomen, and in such cases constitutes the hernia prior to birth. Congenital hernia is almost invariably formed of intestine alone ; the omentum very rarely descending so far as the commencement of the tubular canal. The principal peculiarities distinguishing this from the two former species are, that it has no hernial sac of peritoneum proper to itself, the tunica vaginalis being its immediate investment and forming its hernial sac ; that it is in contact with the testicle, which consequently cannot be so distinctly felt as in the more common species; that the whole swelling is more uniform and firm than in an oblique or direct inguinal hernia, and that the different parts are less easily felt and dis- tinguished. Most of these peculiarities depend on that previously mentioned, namely, its being within the tunica vaginalis, which is thicker and firmer than the peritoneum, which forms the sac in the more common varieties. The descent of this species is usually sudden and complete. For this variety in its different states of reducible, irreducible, and strangulated, the same rules are to be followed as have been already laid down for the treatment of hernia in general. When it is found in adults, and becomes strangulated and requires an operation, the seat of stricture is almost invariably higher up than the external aperture, and the operation is more difficult than in oblique or direct hernia, from the parts being concealed and the parietes being thickened. The incision should not be carried further down than to within about three inches of the under part of the tunica vaginalis, because as that membrane has to be opened, if the incision were carried lower, the testicle would be unnecessarily exposed to irritation. In other respects the operation is the same as for oblique inguinal hernia. IV. ENCYSTED CONGENITAL INGUINAL HERNIA. This variety, which is still more rare than the former, has been more properly termed encysted hernia of the tunica vaginalis ; for though, like the last species, it is within, yet it is not in contact with the tunica va- ginalis, but is separated from it by a hernial sac. That the hernia is within the tunica vaginalis, and that it is contained within a hernial sac, there is no doubt. There has indeed been some difference of opi- nion as to the mode of formation of the sac, but it now seems nearly cer- tain from various dissections that it is formed in one or other of the two following ways. If the tunica vaginalis remain open in every way except at the abdominal canal, and if imperfect adhesions form at that point, and a hernia descend into the part above the adhesions, the ad- hesions becoming elongated and pushed down before the hernia constitute HERNIA. 493 the hernial sac—the sac proceeding from, and adhering firmly to the tubular portion of membrane between the abdomen and the tunica va- ginalis. Or, if the tunica vaginalis remain open everywhere except at one part, and be there imperfectly closed, the peritoneum being pressed down before the hernia into the tunica vaginalis will thus constitute a serous covering for the hernia. V. HERNIA INFANTILIS. This term is applied to a very rare species of hernia, originating in early life, which may be said to consist of a hernia with the usual peri- toneal sac placed behind the tunica vaginalis. The way in which it takes place may be thus explained. The cavity of the tunica vaginalis is unusually large, contains some serous fluid, and ascends high up in the cord, although its communication with the abdomen is occluded. The hernia, with the usual peritoneal sac, is sent down behind the tunica vaginalis, and in consequence, three layers of serous membrane, namely, the front and back of the tunica vaginalis, and the front of the hernial sac, must be cut through before arriving at the substance of the hernia. II. FEMORAL HERNIA. A hernia is called femoral or crural when the descent takes place behind Poupart's ligament, through what is termed the femoral or cru- ral ring ; which ring being much larger in the female than in the male, from the space being greater between the anterior superior process of the ilium and the pubes, femoral hernia, which is in the male a very rare occurrence, is comparatively frequent in the female. The nomenclature adopted in the following description, is that employed by some of our best writers on anatomy, who call the space in which a femoral hernia is situated, the femoral or crural canal, its upper extremity the femoral ring or abdominal extremity, and the other the saphenous opening or femoral extremity of the femoral canal. ["The muscles of the abdomen, beneath the edge of which the femoral hernia escapes, are represented by the aponeurotic band of the external oblique muscle, which is commonly known as Poupart's ligament, but which, in connexion with the femoral hernia, is named the femoral or crural arch. Extending from the an- terior superior spine of the ilium to the pubes, this band widens at its inner end, and, inclining or folding back- wards, is fixed to a part of the pecti- neal line, as well as to the spine of the pubic bone. The small triangular portion attached to the pectineal line is known as Gimbernat's ligament (Hey). The outer edge of this part is concave and sharp; with other struc- Fig. 163. The innominate bone of the left side with, 1. The femoral or crural arch; 2. Gimbernat's ligament. 494 HERNIA. tures, to be presently described, it forms the inner boundary of the aper- ture through which the hernia descends. The breadth and strength of Gimbernat's ligament vary in different bodies, and with its breadth varies the size of the opening which receives the hernia. " The space comprised between the femoral arch and the excavated margin of the pelvis is occupied by the conjoined psoas and iliacus, with the anterior crural nerve between those muscles and the external iliac artery and vein at their inner side. Upon these structures the fascia which lines the abdomen is so arranged as to close the cavity against the escape of any part of the viscera, except at the inner side of the blood-vessels. But the arrangement of the parts situated thus deeply (towards the cavity of the abdomen) will be most conveniently entered upon after those nearer to the surface shall have been examined. To this examination we now proceed. " The general disposition of the superficial fascia met with on removing the common integument from the groin has been described. In con- nexion with the present subject, it will be enough to mention the fol- lowing facts. The deeper layer of this structure adheres closely to the edge of the saphenous opening, and the careful removal of it is neces- sary in order adequately to display that aperture. Where it masks the saphenous opening, the deep layer of the superficial fascia supports some lymphatic glands, the efferent vessels of which pass through it; and the small portion of the membrane so perforated is named the cribriform fascia. The superficial and the deep fasciae adhere together along the fold of the groin likewise, and this connexion between the two mem- branes serves the purpose, at least, of drawing the integument the more evenly into the fold of the groin, when the limb is bent at the hip-joint. " By Scarpa the deep layer of the superficial fascia which covers the abdomen was described as an emanation from the fascia lata, extended upwards over the external oblique muscle.1 But different modes of viewing the continuity of such structures depend very much on the manner of conducting the dissection. In the present case, for example, the fascia may be said to proceed from above or from below, according as the parts are dissected from the abdomen downwards or from the thigh upwards. Such difference, however, is no more than a verbal one, the material fact being merely that the two membranes are connected together along the groin. " The separation of the fascia lata into two parts at the saphenous opening, and the positions and connexions of each part, having been de- scribed in detail, only a few points in the arrangement of this membrane will be noticed in this place. At the lower end of the saphenous open- ing the iliac division of the fascia is continuous with the pubic by a well- defined curved margin immediately above which the saphenous vein ends ; above the opening a pointed cornu (falciform process—Burns2) of 1 A Treatise on Hernia, translated by Wishart, p. 247. 2 Edinb. Med. and Surg. Journal, -vol. ii. p. 263, and fig. 2. In the first edition of Hey's Practical Observations in Surgery, the upper end of this process of the fascia was named the "femoral ligament;" and since then several anatomists have distinguished the same part as " Hey's ligament." But Mr. Hey dropped the desig- nation in the subsequent editions of the same work, and there seems no good reason for continuing it. Compare the original edition (1803), p. 151, and plate 4, with the third edition (1814), p. 147, and plates 4, 5, and 6. HERNIA. 495 the same portion of the fascia extending inwards in connexion with the femoral arch reaches Gimbernat's ligament; and in the interval between the two points nowreferred to (i. e., from the upper to the lower end of the saphenous opening), the iliac layer of the fascia lata blends with the subjacent sheath of the femoral vessels as well as with the superficial fascia. The pubic part of the fascia covers the pectineus muscle, and is attached to the pectineal ridge of the pubes. Immediately below the femoral arch the iliac and pubic portions lie one before, the other be- hind the femoral blood-vessels and the sheath of these. They occupy the same position with respect to the femoral hernia. "The anterior or iliac part of the fascia lata being turned aside the sheath of the femoral vessels will be in view (Fig. 152). The sheath is divided by septa, so that each vessel is lodged in a separate compart- ment^ and the vein is separated by a thin partition from the artery on one side and from the short canal for the lymphatics on the other side. Fig- 164. Fig> 165. Along the thigh the sheath is filled by the artery and vein, but behind the femoral arch it is widened at the inner side. Here it is perforated Fig. 164. The femoral vessels of the left side, with their sheath laid open, and a small hernia displayed.—1. The lower part of the external oblique muscle. 2. The anterior superior spine of the ilium. 3. Iliacus muscle. 4. Sartorius. 5. Pubic part of the fascia lata. 6. Femoral artery. 7. Femoral vein. 8. A small hernia. Fig. 165. The groin of the right side dissected so as to display the deep femoral arch. —1. The outer part of the femoral arch. V. Part of the tendon of the external oblique muscle, including the femoral arch, and also the inner column of the external inguinal ring, projecting through which is seen a portion of the spermatic cord cut. 2. The femoral arch at its insertion into the spine of the pubes. The fibres outside the nu- meral are those of Gimbernat's ligament. 3. The outer part of the femoral sheath. 4. The spermatic cord, after having perforated the fascia transversalis. 5. The deep femoral arch—its inner end where it is fixed to the pubes. 6. Internal oblique muscle. ". Transversalis. Beneath the lower edge of this muscle is seen the transversalis fas- cia, which continues into the femoral sheath under the deep femoral arch. 8. Con- joined tendons of the internal oblique and transversalis muscles. 9. A band of tendi- nous fibres directed upwards behind the external abdominal ring. 496 HERNIA. for lymphatic vessels, and on this account is said to be ' cribriform.'1 This inner, wider part of the sheath it is that receives the femoral her- nia ; and in connexion with the anatomical description of that disease it is designated the femoral canal. At its upper end the sheath of the vessels is continuous with the lining membrane of the abdomen—with the fascia transversalis at its fore part, with the fascia iliaca behind. " When the femoral arch is being removed it will be found that a bun- dle of fibres, springing from its under surface outside the femoral vessels, extends across the fore part of the femoral sheath, and, widening at its inner end, is fixed to the pecten of the pubes behind Gimbernat's liga- ment. This tendinous band is known as the deep femoral arch. Con- nected with the same part of the pubes is the conjoined tendon of the internal oblique and transversalis muscles. The tendon lies behind the attachment of the deep femoral arch. In many cases the last-named structure is not strongly marked; and it may be found to blend with the tendon of the muscles just referred to. Not unfrequently it is alto- gether wanting. "Attention being now directed to the internal surface of the abdo- men :—When the peritonaeum has been removed, it will be observed that the fasciae lining the cavity form, for the most part, a barrier against the occurrence of hernia; for outside the iliac vessels the fascia iliaca and fascia transversalis are continuous one with the other behind the femoral arch. These fasciae are, in fact, but parts of the same mem- brane to which different names are assigned for the convenience of de- scription, just as distinctive names are applied to portions of the same artery. But where the iliac artery and vein occur the arrangement of the fasciae is different. The vessels rest upon the fascia iliaca; and the membranes, instead of joining at an angle as elsewhere, are continued into their sheath in the manner above described.2 "The sheath is closely applied to the artery and vein, so that, in the natural or healthy state of the parts there is no space left for the for- mation of a hernia in the compartments which belong to those vessels; but at the inner side of the blood-vessels will be found a depression which is occupied but partially with the lymphatics. This is the femo- ral ring, the orifice of the femoral canal. " Femoral ring.—After the removal of the peritonaeum, this opening is not at first distinctly discernible, being covered with the laminated cellular membrane (subserous) which intervenes between the peritonaeum and the walls of the abdomen. That part of the membrane which covers the ring was found by M. Cloquet to possess in some cases considerable density; and, from being the only barrier in this situation between the abdomen and the top of the thigh, it was named by that observer the cru- 1 The word " cribriform" being applied to this part as well as to the layer of the superficial fascia stretched across the saphenous opening, the two structures are dis- tinguished in the following manner:—the former is known as the cribriform portion of the sheath of the vessels, while to the latter is assigned the name of cribriform fascia. 2 Some anatomists describe the sheath of the vessels as continued down from the membranes in the abdomen, while others regard it as an emanation from the fascia of the thigh, but continuous with the abdominal fasciae. As this difference in the manner of viewing the structure in question does not alter the facts in any way, it is quite immaterial which of the modes of description is adopted. But it appears to mc most natural to regard the sheath as a production of the fascia lata. HERNIA. 497 ral septum (septum crurale). But this structure is usually no more than loose cellular membrane, and it forms but a very slight partition. On clearing it away the ring is displayed. It is a narrow opening, usually of sufficient size to admit the end of the fore-finger; the size, however, varies in different cases, and it may be said to increase as the breadth of Gimbernat's ligament diminishes, and the converse. It is larger in the female than in the male body. On three sides the ring is bounded by very unyielding structures. In front are the femo- ral arches ; behind is the horizontal branch of the pubes covered by the pectineus muscle and the pubic layer of the fascia lata; on the outer side lies the external iliac vein, but covered with its sheath; and on the inner side are several layers of fibrous structure connected with the pectineal line of the pubes—namely, Gimbernat's ligament, the deep femoral arch, and the conjoined tendon of the two deeper abdominal muscles with the fascia transversalis. The last-mentioned structures— those bounding the ring at the inner side—present respectively a more or less sharp margin towards the opening. " Femoral canal.—From the femoral ring, which is its orifice, the canal continues downwards behind the iliac part of the fascia lata (its falciform process), in front of the pubic portion of the same membrane, and ends at the saphenous opening. It is about half an inch in length ; but in its length the canal varies a little in different cases. " Blood-vessels.—Besides the femoral vein, the position of which has been already stated, the epigastric artery is closely connected with the ring, lying above its outer side. It not unfrequently happens that the obturator artery descends into the pelvis at the outer side of the same opening, or immediately behind it; and in some rare cases that vessel turns round the ring to its inner side. Moreover, an obturator vein occasionally has the same course; and small branches of the epigastric artery will be generally found ramifying on the posterior aspect of Gim- bernat's ligament. In the male body, the spermatic vessels are sepa- rated from the canal only by the femoral arch. "To the foregoing account of the anatomical arrangement of the parts concerned in femoral hernia, may be added certain measurements, showing the distance of some of the most important from a given point. They are copied from the work of. Sir A. Cooper:—1 HALE. FEMALE. From the Symphysis pubis to the anterior spine of the ilium, . 5^ inches. 6 inches From same point to the middle of the iliac vein, . . 2j} " 2| " " " to the origin of the epigastric artery, . 3 " 3j " " " to the middle of the lunated edge of the) g. u 2s „ fascia lata, . • • • / " to the middle of the femoral ring, . . 2\ " 2% " The preceding description of the parts is copied from Quain and Shar- pey's Anatomy.—Ed.] Direction.—A femoral hernia may be said to have three peculiarities of direction, namely, at first, and while within the femoral canal, down- wards ; on arriving at the saphenous aperture, forwards; and afterwards obliquely upwards and inwards; thus describing an arch, the convexity 1 On Crural Hernia, p. 5. 32 498 HERNIA. of which is downwards, and in a measure embracing three of the four aspects of Poupart's ligament—namely, the posterior, femoral, and an- terior ; the neck of the hernia being behind the ligament, the body on its femoral aspect, although removed a very little from it, and its fundus in front. These peculiarities suggest the necessity of straightening the Fig. 166. hernia, or of bringing down its fundus, before efforts are made to return it by the taxis. The first change of direction is caused by the narrow- ing of the sheath, and its close adhesion to the vessels, together with the close adhesion of the iliac portion of the fascia lata to the front, and of the pubic portion of the same membrane to the back of the sheath at the under extremity of the femoral canal—conditions which, by produc- ing constriction, offer an obstacle to further descent in a perpendicular direction; whereas there is little to impede the passage forward through the saphenous aperture. The second change of direction is caused partly by the firm adhesion of the fascia superficialis to the front of the fascia lata, but chiefly by the pressure against the superficial epigastric vessels, by which the forward progress of the hernia is opposed, whereas they offer no obstacle to its passing upwards in front of Poupart's ligament. Coverings.—The fascial coverings from within outwards are, first, the hernial sac, formed of peritoneum. Second, the sub-peritoneal cel- lular tissue which lines the femoral ring, or abdominal extremity of the femoral canal. This substance, called by some authors the septum crurale, is pressed down before the hernial sac, and, together with tne Fig. 166. Drawing showing certain parts concerned in femoral and inguinal hernia. HERNIA. 499 aggregate °? textures, which in the normal condition occupy the femoral canal, constitutes the second covering. This covering is by some named the fascia propria,-—a term applied by others to the third covering, con- sisting of the fascia infundibuliformis, or sheath of the femoral vessels, \ . ^■■^^^^Qf^j^^v^^^f^A. The two last-mentioned coverings %f~^ are, in many instances, so matted together as to form but one. Fourth, the layer of cellular tissue which spreads over the saphenous opening, and which is perforated by various vessels. This is by some called the cribriform fascia, and considered (I think, properly) as the deep layer of the superficial fascia; whereas it is described by others as the middle division of the fascia lata. Fifth, the superficial fascia with some ab- sorbent glands and adipose tissue; and, Sixth, the common integument. There are great varieties with regard to the thickness of the coverings, and it is supposed that in some instances the hernia escapes through some of the openings in the femoral sheath and in the cribriform fascia, in which cases there will seem to be only two coverings interposed between the common integument and the hernial sac. I have been much struck, in my own operations, with the great difference in different cases of the thickness of the fascial coverings, and with the fact, that instead of six different membranes, constituting so many distinct cover- ings, as is the case in inguinal hernia, and as we might expect from con- templating the anatomy of the parts in the normal state, there are some- times found only three ; namely, the hernial sac ; a cellulo-adipose layer, which varies much in thickness in different cases ; and the skin. The greatest number, however, of fascial coverings which can present them- selves, are the six enumerated above. Anatomical relations of the Neck of the Hernial Sac.—The neck of a femoral hernia is related to the boundaries of the femoral ring as fol- lows, namely, posteriorly, to the fascia iliaca, where it covers the linea ilia pectinea; anteriorly, to Poupart's ligament, lined by the prolonga- tion downwards of the fascia transversalis ; internally, to the base of Gimbernat's ligament, at the junction of the fascia iliaca and fascia transversalis; and externally to the femoral vein, from which it is sepa- . a, rated only by the interposition of a_ membranous slip. There is also 7, «£». another relation which sometimes exists, namely, to the obturator artery,'^*-4'* when that vessel, instead of coming off from the internal iliac, arises from the external iliac by a common trunk with the internal epigastric. When it has that irregular origin, the obturator artery crosses the femoral ring as it dips into the pelvis on its way to the obturator fora- men, occasionally passing near to the posterior and iliac sides of the femoral ring, but much more frequently in front and towards the pubic side. In the latter case, if a hernia be present, the artery will embrace about two-thirds of the circumference of the abdominal aspect of the neck of the hernial sac, namely, the front and inner aspect; so that when the stricture is found at the femoral ring, great caution should be used not to make too extensive a division, or to send up the cutting edge of the instrument farther than is indispensable for dividing the tissue which constitutes the stricture. Seats of Stricture.—This is a subject on which much attention has been bestowed; and although in some points a difference of opinion 500 HERNIA. exists, it is certain, from the testimonies of high surgical authorities, that the stricture may be at the femoral ring, the textures constituting the ring forming the stricture; or at the saphenous extremity of the canal, and formed by the crescentic border of the fascia lata ; or at the neck of the sac, and formed either by the sac itself, or by thickened textures around. In my own operations, I have invariably found the stricture at the femoral ring, and the majority of authors agree, that it is found there more frequently than elsewhere ; but it is certain that it is sometimes found in the other situations mentioned. In some instances, a stricture has been found at more than one of the above sites at the same time. Such are the usual seats of stricture, and the constituting textures in this species of hernia ; but in some rare in- stances strangulation has been found to be occasioned by a loop of in- testine, by a band of omentum, or (which is an extremely rare occur- rence) by the circumference of an unusual opening in Gimbernat's ligament. Operation.—The body having been properly placed, the first step of the operation consists in making the integumental incision, various forms of which have been adopted, some making a simple incision which is not the most convenient; some a crucial, which is objected to, as the under part of the vertical portion might interfere with the vena saphena major ; some an incision, composed of two parts, the one oblique and in the course of Poupart's ligament, the other extending down from the former in a vertical direction, so that the incision is formed thus P^, on the right side, and thus "| , on the left; others making an incision thus , and others adopting the same form in- verted, thus . The last-mentioned form is convenient, and may be made without risk of wounding important parts underneath, by transfixing the skin after pinching it up, the vertical portion extending from about an inch and a half above the crural arch, in a line with the centre of the tumour ; and being met below by the transverse portion, which should go from one side of the tumour to the other, parallel to Poupart's ligament, but a little below it. The next step is to cut through the various coverings, and lay open the hernial sac. This having been done, and the fore-finger of the left hand introduced within the sac, and carried up in front of the hernia, and the seat of the stric- ture ascertained, the hernial knife, with its blunt point, should be car- ried up flat upon the finger, until its point be within the stricture, when its edge should be directed against the stricture, and the necessary divi- sion effected, by cutting directly forwards. Great care should be taken not to lacerate the intestine by the introduction of the finger, or to allow it to come against the edge of the knife, or to admit the knife farther than is absolutely necessary for the division of the stricture, lest the unusual disposition above mentioned of the internal epigastric artery should exist, and the edge of the knife should reach the artery. HERNIA. 501 The remaining parts of the proceeding should be regulated by the prin- ciples laid down in the description of the operation in general. By the above proceeding, the operation may be accomplished with as little difficulty and risk, as by any other; but it may be proper to add, that, as regards the direction in which the stricture is divided, the modes adopted are very various. If the stricture be at the saphenous opening, there is no particular danger to guard against, and the surgeon may, in dividing the stricture, cut upwards and inwards, directly upwards, or upwards and outwards, and the operation is comparatively easy; and when it is at the femoral ring, the knife may be safely carried to a small extent inwards, into Gimbernat's ligament, upwards and inwards, directly upwards into Poupart's ligament, or upwards and outwards; but not directly outwards, on account of the femoral vein. The cutting inwards into Gimbernat's ligament has been recommended by Mauchart, Richter, Gimbernat, Boyer, Roux, Hey, Lawrence, and Ferguson, and others have objected to it, because it is more difficult, from the greater depth, to cut into Gimbernat's, than into Poupart's ligament; because there is, from the same reason, greater danger of cutting or tearing the intestine when endeavouring to get at the seat of the stricture, and also because so little additional room would be gained by the division of Gimbernat's ligament. The cutting upwards and inwards, recommended by Heister, Le Dran, Sabatier, Lassus, Chopart, Desault, and others, has been objected to on the ground, that if the hernia be in the male (which, however, is a comparatively rare occurrence), the knife is carried in the direction of the spermatic cord: but this danger seems to have been greatly exaggerated; for the knife ought never to be carried so high as to endanger the cord in the male, or the round ligament of the uterus in the female. The direction of the incision adopted by Pott, Sir Astley Cooper, and many others, was directly forwards, that by Mr. Liston forwards and a little inwards. Sharp cut upwards and out- wards ; and so did Dupuytren, but a very different proceeding; he car- ried the knife from within outwards, and from below upwards; and although in this method, the edge of the instrument is no doubt carried in the direction in which the epigastric artery is found, there is no danger of the artery being wounded, as the knife is not carried so high as to be in danger of reaching it. Scarpa had recourse to multiple in- cision in the under border of the crural arch. III. UMBILICAL HERNIA. The cases of umbilical hernia have been variously arranged by various writers. Scarpa divides them into two classes, namely—the congenital, appearing in the infant at birth, and the adventitious, occurring at any after period: but a more convenient arrangement is that of Mr. Law- rence, who gives three varieties, namely—the congenital, which appears at birth ; the hernia of children, which appears after the navel has been formed; and the umbilical hernia of adults. CONGENITAL UMBILICAL HERNIA. The congenital variety is occasioned by an original deficiency in the formation of the umbilicus; it exists at the period of birth, and is therefore properly called congenital; it forms ' a tumour, conical in 502 HERNIA. form, the contents of which are for the most part intestine sent into the cord between its vessels, the umbilical vein being usually above and the arteries below, or on either side. The external covering of the tumour near the base is composed of integument, but at a farther dis- tance it is formed by an expansion of the substance of the cord, for the hernia is sent through the umbilicus into the cord. The cavity is lined by a small peritoneal covering. The treatment consists in returning the hernia, and preventing a recurrence of the protrusion;—two points of the utmost importance to attain, as in the event of the hernia not being reduced, the separation which must ensue of the expanded portion of the cord which forms part of the coverings, would expose the patient's life to the greatest danger. The method usually adopted in this country to prevent reprotrusion, is compression by means of compresses and a bandage. Another plan, to which reference will be made in the next section, is to use the ligature with compression. THE UMBILICAL HEKNIA OF CHILDREN. In this, which is a very common species of umbilical hernia, the object of treatment is, to return the protruded parts, and to keep them in that condition until the contraction and subsequent obliteration of the um- bilical ring prevents any future reprotrusion. The means adopted for this purpose is compression, or the ligature ; the former is attended with less pain and risk, and has always been preferred by the great majority of British practitioners. Various modes have been employed for pro- ducing the requisite compression. A very convenient method is by a piece of cork covered with soft leather, and kept in the umbilicus by strips of adhesive plaster, the whole being retained by means of soap plaster spread on the leather, and applied in a transverse direction. Another method is, to apply the half of an ivory ball to the umbilicus, retaining it by adhesive plaster, and a bandage, or some other appliance for the same purpose. The treatment by ligature was practised by Desault and Dupuytren, and their example has been followed by some others. An able and successful member of the surgical profession has given the following account of it:—" The infant being laid on its back, and its head bent on its chest, and its thighs flexed on its pelvis, the surgeon reduces the hernia, retains it with his left forefinger, and with his right hand raising the parietes of the hernial pouch, he slides them between his fingers to make sure that no part remains in the sac. Being assured of this, his assistant makes several turns round the sac, at its base, with a waxed thread, each turn being well tightened and secured by a double knot. The tumour thus tied is enveloped in a bed of lint, maintained by a compress and bandage. On from the eighth to the tenth day the liga- ture falls off with the parts it has strangled and killed. A small ulcer results, which is soon healed. It is well for the child to wear a bandage for two or three months, the better to prevent a relapse." This mode of cure, however, has not gained the favourable opinions of the surgical authorities in this country. Various cases are recorded by Desault, and some are mentioned by Soemmering and others, in which spontaneous cures occurred from the HERNIA. 503 natural tendency of the umbilicus, in early life, to close; but such occurrences are so rare that the surgeon is not warranted in leaving cases to the unassisted efforts of nature. UMBILICAL HERNIA IN ADULTS. This is rarely met with in males, but more frequently in females. Pregnancy is one of its most usual exciting causes ; hence its compara- tive frequency in females who have borne many children. In almost all cases of umbilical hernia in adults, omentum forms some part of the hernia, and to this has been attributed the fact that in the greater number of instances in which strangulation occurs, the symptoms are less urgent than in most other species of hernia. An umbilical hernia may be reducible, irreducible, or strangulated; and in each of these conditions the treatment should be conducted according to the principles laid down in the general doctrines of hernia. The coverings are very thin, consisting merely of the cicatrix of the navel, the hernial sac formed of peritoneum, and the very thin layer of cellular tissue by which they are connected together. In performing the operation, it should be remem- bered that these coverings are often exceedingly thin, and that although every umbilical hernia has originally a peritoneal sac, yet when the hernia is large, the sac becomes so thin by dilatation, or absorption, or both, as scarcely to be perceptible. When the peritoneum becomes exceedingly thin and adherent to the skin, the covering is often found to present the appearance of being formed of only one layer. The coverings may be divided by a longitudinal or any convenient form of incision, and the stricture may be divided by cutting upwards and to the left side. IV. VENTRAL HERNIA. By a ventral hernia is understood one through any part of the front of the abdomen, except the inguinal canal, the femoral canal, or the umbilicus. Cases belonging to this class should be treated according to the general principles already laid down. Such are the various classes into which herniae in accessible situations are divided. Occasionally, however, they are found in inaccessible situ- ations,—for example, in the diaphragm, the obturator foramen, or the greater ischiatic notch; constituting diaphragmatic obturator, or ischi- atic hernia. Sometimes cases occur of a mixed class ; for example, a perineal hernia, which consists of a descent between the bladder and the rectum, the swelling presenting itself in the perineum; or a vaginal hernia, in which the tumour projects into the vagina. Examples of hernia in inaccessible situations are, happily, of rare occurrence; they cannot be made the subject of surgical treatment; and their existence only becomes a matter of certainty after death. I shall conclude this section on hernia with the following remarkable case of strangulation, caused by a diverticulum. I recorded the case in the number of the "Edinburgh Monthly Journal of Medical Science," for July, 1849: David White, seventeen years of age, a fine-looking young man, had always enjoyed excellent health until the 22d of April; on which day, 504 HERNIA. while walking in the street, he was suddenly seized with sickness, vomiting, and violent pain in the abdomen; the pain being constant, hut attended with frequent paroxysms of aggravation. At the commencement of the attack the belly was not tumid, nor was there any tenderness on pressure—on the contrary, the patient had an inclination to compress the belly with his hands, especially during the paroxysms of pain, and to turn himself round in bed. In the course of five or six hours, however, the abdomen became tender to the touch, and ultimately so much so that the slightest touch occasioned pain and vomiting ; the belly gradually became tumid ; and the patient was obliged to preserve his body as motionless as possible in order to prevent the aggravation of pain. Such is the history of the symptoms, as given by my friend, Dr. George Morrison, who attended him from the commencement of the attack. My colleague, Professor M'Robin, and I saw the patient for the first time twenty-four hours previous to his death. His symptoms, when we saw him, were—distension of the abdomen ; constant violent pain, with paroxysms of aggravation like the tormina of ileus; tenderness on pres- sure ; sickness, urgent vomiting of a greenish liquid ; no stool after the commencement of the attack ; pulse one hundred and thirty, small and feeble; features collapsed, and the countenance expressive of great exhaustion. These symptoms continued for twenty-four hours, without undergoing any material change, death taking place within sixty hours from the commencement of the attack. The suddenness with which the symptoms appeared, their history, and the absence of swelling in any of the usual sites of hernia, produced a strong impression on the mind of Dr. Morrison, Professor M'Bobin, and myself, that the symptoms were caused either by intussusception, or by internal hernia, or by some internal cause of strangulation; in short, that it was a case of enteritis, occasioned by some internal mechanical cause. I made a post-mortem examination twenty-four hours after death, in presence of the medical gentlemen above mentioned. On opening the abdomen, a small quantity of sero-sanguineous fluid was found in the cavity of the peritoneum; the stomach, and a great part of the small intestine, were greatly distended with flatus ; the distended portion of the intestine was much inflamed, and there were slight adhesions of lymph in some parts. The lower third of the ilium and the whole of the great intestine were collapsed, and of a perfectly healthy appear- ance. On displacing some of the convolutions of the small intestine, a portion of the ilium, twelve inches in length, was found greatly dis- tended, strangulated, and in a state approaching to gangrene; the part of the intestine to the gastric extremity of the strangulated portion being violently distended and inflamed, and that to the rectal extremity being comparatively collapsed, and of a perfectly healthy appearance; the strangulation being effected by a diverticulum of the ilium, having very peculiar relations and connexions. Fig. 167 of the accompanying drawings gives a front view of the HERNIA. 505 strangulated intestine and stricture. Fig. 168 gives a posterior view. Fig. 169 presents an appearance of the natural relations of the diverti- culum, obtained after^ emptying the intestine, and withdrawing it from underneath the diverticulum by which it was strangulated. The diverticulum was an inch and a-half in length, and terminated in a slightly-dilated cul-de-sac ; from the extremity of which a membranous band was sent off, one extremity of which was evidently continuous with the serous coat of the diverticulum, and the other as evidently not merely attached to, but becoming continuous with, the anterior lamella of the mesentery. Through the aperture formed by the diverticulum, mesentery, and the portion of the intestine, from which the diverticulum Fig- 167. Fig. 168. is continued, twelve inches of intestine had passed at the commencement of the attack, and became strangulated. The above cannot but be regarded as a very curious and extremely unusual case—not that it is rendered so by the mere existence of a di- verticulum, which is itself a rare formation, but the presence of a diver- ticulum being the occasion of strangulation. There is on record one case bearing a striking resemblance to the above. I allude to a preparation in the museum of St. Bartholomew's Hospital, of which I subjoin the description as extracted from the pub- lished catalogue of that valuable collection:— " Portion of small intestine, from which a diverticulum is continued.— The extremity of the diverticulum is adherent to the contiguous part of Fig. 167. Anterior view of the strangulated intestine and stricture;—agastric ex- tremity ; b, rectal extremity. Fig- 168. Posterior view of the strangulated intestine and stricture;—a, gastric extremity; b, rectal extremity. 506 HERNIA. the mesentery, so as to form a circular aperture or ring. Through this aperture a portion of intestine, twelve inches long, passed, and became strangulated. The patient, a lad subject to constipation, died four days after signs of strangulation of the intestine." Fig. 169. It will, however, be seen that, in one point at least, the cases differ: in that of St. Bartholomew's Museum, the fundus of the diverticulum is adherent to the contiguous portion of the mesentery—whereas, in the case I have described above the fundus of the diverticulum is con- nected with the mesentery by the serous coat becoming contracted into a membranous band, and expanding into the anterior lamella of the mesentery. In the catalogue of the museum of the Royal College of Surgeons in Ireland, there is a description of a preparation in which a diverticulum, four or five inches long, caused strangulation of several feet of intestine ; but the relations of the diverticulum, as well as the mode in which it effected strangulation, were very different from the case described above. Fig. 169. An appearance of the natural relations of the diverticulum to the intestine: a, gastric extremity; b, rectal extremity. 507 CHAPTER XIV. WOUNDS OF THE ABDOMEN. Although the doctrines respecting the treatment of wounds generally is applicable to wounds of the abdomen, yet as these are particularly dangerous and require certain peculiarities of treatment, it is necessary to give a fuller account of the different sources of danger and of the treatment required in wounds of various kinds in that part of the body. There have been instances in which both the fixed and the floating vis- cera have been wounded, in which balls and sharp instruments have passed through the body, and yet the patient has recovered ; but still when wounds of the abdomen are accompanied by injury of the contain- ed viscera, they are extremely dangerous, and in the majority of in- stances fatal. The chief sources of danger are hemorrhage, fatal depres- sion of the nervous system, extravasation of visceral contents, and peri- tonitis. Hemorrhage may prove fatal, either very speedily from the loss of blood, as when any large vessel in the abdomen is wounded, or when there is an extensive deep wound of such organs as the liver or spleen— such cases presenting the usual symptoms attendant on profuse internal hemorrhage ; or when the loss of blood is not of sufficient extent to pro- duce death, by its occasioning inflammation of the peritoneum, which quickly leads to the most unfavourable results. Depression of the nervous system, although generally attendant in a greater or less degree on wounds of the abdomen as well as on blows on that part, more rarely occurs to a fatal extent in the former than in the latter case; yet sometimes it terminates in death, the sudden shock given to the nervous system causing the failure of the heart's action,— a result which has been supposed by some to occur more frequently after wounds of the stomach and duodenum than of the other viscera. Extravasation of visceral contents does not occur so often as might be expected; indeed, it is astonishing how seldom such effusion takes place in cases of a small wound of the intestine ; extravasation being in such cases prevented, in the first instance, by the constant equable pressure which the abdominal viscera exert on each other, the various surfaces being constantly in close contact, and by the tendency to protrusion of the mucous membrane, which plugs up the orifice, and afterwards by exudation of coagulable lymph on the exterior of the wound, by which and by adhesion to surrounding textures the breach becomes permanently repaired. By this process both hemorrhage and extravasation of intes- tinal contents are often prevented; but if the viscus be full, or the wound very considerable, effusion of visceral contents into the sac of the 508 WOUNDS OF THE ABDOMEN. peritoneum is very apt to take place ; and if so, the result is certain to be fatal—for escape of bile, or of urine, from the great acrimony of these secretions, or of the contents of the alimentary canal, will produce the greatest possible suffering, which very speedily terminates in death. The most prominent symptoms in such cases are—sudden, unremitting, and excruciating pain, great prostration of strength, ghastly anxiety of countenance, extremely feeble pulse, and on the part of the patient, a decided conviction of approaching death. Peritonitis is another source of danger, and one so common that it may be said to be the cause of death in almost all fatal cases of penetrating wounds of the abdomen, excepting those in which death takes place from the great and sudden loss of blood, or from the shock given to the ner- vous system, or from extravasation of visceral contents, in which death occurs so soon after the extravasation, and so little trace of inflammation is discernible, that it appears most probable that the fatal result was oc- casioned by the sinking of the nervous system. For the clearer explanation of the principles to be followed in the management of wounds of the abdomen, it is convenient to arrange them into four classes—1st. Wounds which simply penetrate the cavity with- out injuring any of its contents ;—2dly. Wounds which not only pene- trate the cavity, but injure some of the contained viscera, without pro- trusion of the wounded part;—3dly. Wounds attended with protrusion without any wound of the protruded part; and, 4thly. Wounds accom- panied not only with protrusion, but also with injury of the protruded part. 1st. Wounds which simply penetrate into the abdominal cavity are the least dangerous ; yet if the wound be extensive there is risk of its giving rise to peritoneal inflammation. The great object of treatment, therefore, is to guard against this occurrence, for which purpose abso- lute rest and the sparing use of the mildest ingesta should be strictly enjoined, together with the best local treatment for procuring adhesion, —comprehending attention to position, the use of adhesive plaster for keeping the edges of the wound in apposition, and if necessary, the interrupted suture. Sutures should not be employed unless absolutely necessary ; and when their use is ventured upon, special care is to be taken not to include the peritoneum in the suture. All judicious and available means should be employed to prevent inflammation, and if it should occur, appropriate remedies should be used to subdue it, such as low diet, perfect quiet and rest, venesection, calomel and opium, fomenta- tions, mild enemata, and if it can be conveniently employed, the warm bath. 2dly. Wounds which not only penetrate the cavity, but also injure some of the contained organs without protrusion of the wounded part, are extremely dangerous, and it is in many instances quite impossible to form an idea of the extent of injury received. The healing of the wound in the parietes should be promoted by suitable means, and as searching for the inward viscera would be contrary to all sound princi- ples of surgery, the symptoms arising from the internal injuries can only be met by medical treatment. Important indications are, to guard against all exciting causes of extravasation, either of blood or of visce- ral contents, and against all causes of inflammation; and if inflammation WOUNDS OF THE ABDOMEN. 509 should occur to endeavour to subdue it by proper treatment. It is, there- fore, necessary to abstain from all imprudent exhibitions of stimuli for the removal of the collapse consequent on the injury, to preserve the body in perfect rest in the horizontal position, to enjoin the use of the mildest ingesta, and to abstain from the employment of purgatives, as being calculated, until the injury has been healed, to do harm not only be- cause, by the irritation they produce, they increase the danger of the occurrence of inflammation, and its intensity when it does occur, but also, because by the additional peristaltic motion they increase the risk of extravasation of intestinal contents, and interfere with the process by which nature repairs the injury. These, with all the details of anti- phlogistic regimen, constitute important parts of the preventive treat- ment : and when inflammation occurs, the remedies proper for that state must be promptly applied. If there be reason to suspect injury of the bladder, the catheter should be kept introduced to diminish the chances of extravasation of urine. 3dly. Wounds attended with protrusion without injury of the pro- truded parts. The protruded parts are usually portions of intestine or omentum, or both; and if uninjured, the sooner they are reduced the better; but all proceedings for that purpose should be conducted with the utmost gentleness, so as not to induce the danger of inflammatory accession, care also being taken, as in hernia, to return that part first which was last protruded,—the mesentery before the intestine, and the intestine before the omentum. By these proceedings the parts are more likely to resume their natural position in the belly, and there is less danger of exciting irritation and inflammation, than by attempting to return the whole en masse. For facilitating reduction, the patient should be placed in the most favourable position for the relaxation of the abdominal muscles; the pelvis should be slightly raised, and the chest bent a little forwards. It is an important precaution, to make sure that the reduction is complete, lest if part of the protrusion be not sent into the cavity, but remain embraced by some of the textures forming the aperture, strangulation should ensue. It has happened in some cases where reduction was erroneously supposed to be complete, that the inner part of the wound had so embraced a portion of the pro- trusion, as to cause fatal strangulation. Considerable difficulty is some- times experienced in accomplishing reduction, in consequence of the protruded intestine becoming distended with flatus. Various proceedings have been recommended and adopted for overcoming this difficulty. Pare', Dionis, and many others advised the puncture of the intestine with a round needle to allow the flatus to escape ; some recommend squeezing back the air into the portion of intestine within the abdomen ; but the safer, and indeed, in my opinion, the only justifiable course, when necessary, is, instead of puncturing the intestine, or injuring it by undue and dangerous pressure or handling, to enlarge the opening very slightly. When such a step is absolutely necessary, the incision should be made at the upper rather than at the lower part of the wound, except when the incision in that direction might endanger the internal epigastric artery, or correspond with the umbilicus ; and in all instances it should be as limited as possible. The object of both these recom- mendations is to diminish the danger of ventral hernia afterwards ; as 510 WOUNDS OF THE ABDOMEN. the pressure of the intestines towards the upper is less than towards the lower part of the abdomen. Of course, if by gentle and safe pressure the intestine can be reduced or its contents be so returned as to admit of reduction, no judicious surgeon would venture on the use of the knife. The best instrument for enlarging the opening is the probe-pointed bistoury. Immediate reduction, the greatest gentleness of proceeding, the avoiding all unnecessary and severe handling of, or pressure on, the intestine, the enlarging the aperture when absolutely necessary, the making sure that the reduction is complete, the retaining the parts in the abdomen by suitable treatment until the wound is completely healed, and the guarding by all judicious precautions against the occur- rence of inflammation, are the most important points to be attended to in the management of the species of injury now under consideration. It is curious to observe the opinions which have been entertained regarding Park's proceeding of puncturing the intestine. It was ap- proved of by Dionis, Rousset, Garengeot, Van Swieten, Chopart, De- sault, Richerand, Lowe, Sharp, and others. These all agreed in sanc- tioning the proceeding, but differed among themselves as to the circum- stances in which it should be considered justifiable, and also as to the preferable form of instrument for effecting the puncture; some using a broad triangular needle, some a round needle, and some as Richerand a trocar and canula similar to that employed in hydrocele. The pro- ceeding is strongly objected to by Sabatier, La Faye, Blancard, Cal- lisen, Travers, and almost all the higher surgical authorities in Britain ; some objecting that a small puncture is insufficient to insure the escape of the flatus, in consequence of the tendency to protrusion of the mucous membrane ; and others, that the proceeding is dangerous as well as ineffi- cient. 4thly. Wounds accompanied with protrusion, and also with injury of the protruded parts. Since the special rules applicable to the manage- ment of wounds belonging to this class are precisely the same as those for the treatment of the cases of hernia in which the protruded parts are found, in cutting down upon them, to be in an unfit state to be re- turned into the abdomen, it is scarcely necessary to do more than refer to the section on that subject, and to that on the anatomy and treatment of abnormal anus. The following observations by Mr. Travers will be perused with interest. " If a gut be punctured, the elasticity of the peritoneum, and the contraction of the muscular fibres, open the wound, and the villous or mucous coat forms a sort of hernial protrusion, and obliterates the aper- ture. If an incised wound be made, the edges are drawn asunder and everted, so that the mucous coat is elevated in the form of a fleshy lip. If the section be transverse, the lip is broad and bulbous, and acquires tumefaction and redness from the contraction of the circular fibres behind it, which produces, relatively to the everted portion, the ap- pearance of a cervix. If the incision be according to the length of the cylinder, the lip is narrow, and the contraction of the adjacent longitu- dinal fibres, resisting that of the circular fibres, gives the orifice an oval form. This eversion and contraction are produced by that series of motions which constitutes the peristaltic action of the intestines." WOUNDS OF THE ABDOMEN. 511 If the wound be very small, consisting of a mere puncture, and more especially if it be at a part of the canal usually not much distended, the most advisable course probably is to return the part, and trust to nature's process for closure; in short, the treatment is replacement without mechanical union. If the wound be incised, and small, and the intestine otherwise quite free from injury, the edges should be brought together by a single stitch of silk or fine thread introduced by means of a small round sewing- needle, the edges being slightly turned inwards so as to have peritoneal surfaces in apposition. The ends of the silk should be cut off quite close to the knot, and the intestine replaced ;—experiments on animals, and experience in the human body proving that the small noose finds its way into the intestinal canal by ulcerative absorption, and is voided with the faeces. Permanent closure of the wound, in cases which pro- ceed favourably, is effected by the assistance of surrounding textures, to which the peritoneal coat of the bowel becomes adherent. The ex- ternal wound should not be very firmly closed at first, lest extravasation should take place, and the dressings should be as light as possible. In this variety the treatment consists both of mechanical treatment and replacement. If the wound be not very small, the most judicious procedure is to retain the cut portion at the surface of the wound by one or more stitches connecting the edges of the wound in the intestine with those of the external wounds, and to endeavour to convert the case into one of abnormal or artificial anus;—replacement would be extremely in- jurious, by incurring the danger of extravasation of intestinal contents. It will be seen that, in the first of the three classes into which we have arranged wounds accompanied with protrusion and injury of the protruded parts, the treatment at first consists of replacement without mechanical union ; in the second, of mechanical union and replacement; and in the third, there is neither mechanical union of the edges of the wound nor replacement, but the lips of the wound of the intestine are retained at the margin of the external wound, and the case is converted into one of abnormal anus, to avoid the danger of fatal extravasation into the peritoneum. The above are the proceedings which, on the whole, appear to be the most judicious in the treatment of the different varieties of wounds in the intestine, and they are recommended by the great majority of British authorities of the present day. They are very different, how- ever, from many of the singular modes of procedure adopted formerly by many surgeons, and still practised by some. In some cases, liga- tures have been employed in great numbers; in others, sutures of every possible form have been used ; most extensive wounds of the intestine have been sewed up, and replacement effected; in some instances, the ends of the ligatures have been cut off, the ligatures having been em- ployed only for preserving apposition of the edges of the wound in the intestine; and in others, the ends have been left and kept in the ex- ternal wound, the ligatures being used partly for procuring apposition of the edges of the wound of the intestine, and partly for keeping that wound near the external one. The methods of Reybard, of Palfyn, of 512 PARACENTESIS ABDOMINIS. Jobert, of Ramdohr,1 of Duverger, and of Sabatier, are some among the many which have been proposed; but as they have never gained the favourable opinion of the most eminent surgeons in this country, it is considered unnecessary to describe them. Much valuable information regarding these injuries will be found in the writings of John Bell, Dr. Thomson, Sir Astley Cooper, Dr. Hennen, and Mr. Travers, as well as in the works of many of the best Continental authorities on surgery. PARACENTESIS ABDOMINIS. The usual conditions which warrant the performance of this operation are, either ascites, or ovarian dropsy, when either disease arrives at so advanced a stage, that the pressure on the diaphragm creates a difficulty of breathing,—the object of the operation being to relieve the breathing. The most convenient attitude for the patient to be placed in is the sitting posture, on a chair, or on the side of a bed; and the preferable site for the operation is the linea alba, a little below the umbilicus. At one time the operation was performed in the linea semilunaris, but as there is danger there of wounding the internal epigastric artery, the former situation is to be preferred. In cases, however, of ovarian dropsy, the pointing of an ovarian cyst may render it necessary to select as the site of the operation the part where the bulging of the sac is perceptible. The patient having been placed in the proper position, and a broad bandage or sheet having been applied round the abdomen, and the ends committed to assistants for the purpose of drawing them Figs. 170-172. to keep up pressure while the fluid is being drawn off, the surgeon in- troduces the trocar and canula through the abdominal parietes in the linea alba, about midway between the umbilicus and the pubes, then withdrawn the trocar, and when the fluid has escaped through the ' That of invagination, as it has been called. PARACENTESIS ABDOMINIS. 513 canula, withdraws it also. A piece of adhesive plaster is then placed over the wound, a compress above it, and the whole belly is tightly bound up by the bandage. The bladder should be emptied before the operation^ that there may be no danger of wounding it; and, while the fluid is being drawn off, constant pressure should be kept up by means of the bandage, lest dangerous or fatal syncope should result from the sudden accumulation of blood in the abdominal veins on the removal of the support previously afforded by the fluid ; or lest, from sudden dis- tension through the same want of support, either one of these veins, or some other vessel, should give way. 33 514 CHAPTER XV. CALCULOUS DISORDERS. Of the various morbid conditions of the urine, none are of greater interest to the surgeon than those in which various deposits take place. When a deposit takes place subsequently to the expulsion of the urine from the bladder, it is termed sediment; when previously, gravel. The more remarkable diatheses connected with these deposits are the following:— I. THE LITHIC DIATHESIS. Varieties.—The lithic or uric acid deposit may be said in general to assume one or other of two distinct characters, namely, that of amorphous and impalpable sediment, or that of crystallized or massive concretions. Each of these two general divisions presents three va- rieties. The amorphous and impalpable sediment consists chiefly of lithic acid, in combination with ammonia. The three varieties of this deposit are the yellow sediment, consisting of lithate of ammonia, more or less tinged with the yellow colouring principle of the urine—the red, or as it is often called, the lateritious sediment, consisting of lithate of am- monia, combined with the yellow colouring principle of the urine and the red or purpurate of ammonia—and the pink sediment, the appear- ance presented when the lithate of ammonia is combined with the red colouring principle, with little or no admixture of the yellow. Strongly marked examples of this last variety are extremely rare. The crystallized or massive deposit is found in three varieties,—as crystallized sand or gravel, as amorphous concretions, or as pisiform concretions. Crystallized sand or gravel, consisting of lithic acid with purpuric ad- mixture, is of various forms and colours, according to the Fig. 173. nature of the urine from which it is deposited. These crystals to the naked eye much resemble in size and shape the particles of Cayenne pepper, and in colour, when their presence is accompanied by fever, they are usually reddish; when without fever, they more or less resemble the yellow amorphous sediment. [Under the microscope the crystals present the appearances represented in the wood-cut. —Ed.] The amorphous lithic concretions present two varieties, the coloured and the white. The former, which are the more common, consist almost entirely of pure lithic acid, and are irregular in form, generally rough on the surface, CALCULOUS DISORDERS. 515 and not crystallized within, but appearing as if formed by many different masses being pressed together; in colour being sometimes yellow, some- times of a dark brown or brownish red. The latter or white variety, consisting of lithate of soda, are extremely rare, irregular in shape and size, soft in texture, and presenting neither a crystallized nor lamellated appearance, but amorphous. The pisiform lithic concretions are in most instances generated in great abundance, and vary in size; in form they are more or less globu- lar ; their surface is smooth, in many instances remarkably so; their central parts usually lamellated, and almost invariably crystallized. Their colour varies considerably, being sometimes, although rarely, a dark brown or reddish, but more commonly one or other of the shades of yellow. Both the amorphous and pisiform lithic concretions are usually gene- rated in the kidney, and they are much more formidable than the other varieties of lithic deposits, inasmuch as there is great risk of their origi- nating the formation of calculi. When lithic deposits take place in old age, they are usually the pisiform. Causes.—The tendency to lithic deposit is hereditary. It is usually found either in children and young persons under the age of puberty, or in persons from forty to sixty years of age. The principal exciting causes are, errors in diet, want of sufficient exercise, waste of tissues more rapid than the supply, as in fever, ne- glect to maintain a clean and proper state of the skin, and atmospheric influence. The habitual use of too much food, especially of animal food, the use of wines or malt liquors, or of any kind of food or drink calculated to produce an excess of hydrochloric acid in the stomach, a cold and moist condition of the atmosphere, or such a state either of the atmosphere or of the skin as tends to prevent the customary evolution of free acid or nitrogenized excretion through the skin, and certain cu- taneous diseases, are favourable to the formation of lithic deposits. Free acid generated in the stomach passes off by the urine, and com- bining with an alkaline base precipitates the lithic acid. Dr. Prout remarks, "The lithic acid and its compounds we suppose to be principally derived from the albuminous principles, not only of the chyle and blood, but also of the albuminous textures of the body, in the same sense and mode in which we suppose urea and lactic acid to be principally derived from the gelatinous textures. When, on account of the imperfect assimilation of alimentary matters by the stomach and primary assimilating processes, the chylous principles are not raised to that standard of perfection by which they are fitted to become compo- nent parts of the blood, we suppose that the healthy kidney possesses the power of selecting and disorganizing such imperfectly developed chylous matters, and of converting them into lithate of ammonia. Such is the presumed origin of most of the yellow amorphous sediments occur- ring to healthy individuals from slight errors in diet, &c. " During feverish or other derangements, in which the functions of the hepatic system are particularly involved, the lithate of ammonia is not only supposed to be derived from the imperfectly assimilated chyle, 516 CALCULOUS DISORDERS. and the deteriorated albuminous principles of the blood ; but also from the deranged secondary assimilation of the albuminous textures of the body. The lithate of ammonia thus developed appears in the urine more especially under the forms of the red and pink amorphous sedi- ments ; and is distinguished by the large quantities of colouring matters developed in conjunction with it. Lastly, the massive forms of lithic acid deposits are derived from the same sources as the above ; but when thus deposited, the lithic acid is secreted, either in connexion with acids which combining with the ammonia of the lithates set the lithic acid free; or in connexion with other bases, as soda, &c, the compounds of lithic acid with which are less soluble than the lithate of ammonia." Treatment.—Indolence and inactivity being predisposing causes of lithic deposits, exercise, judiciously proportioned to the strength of the patient, and not sufficient to induce fatigue, should be strictly enjoined. The state of the skin should be attended to, and with that view bathing and friction are useful; the clothing should be sufficiently warm to pre- vent the natural and healthy perspiration from being checked, and if possible, residence in a cold and damp situation should be avoided. Attention to diet is of the greatest importance, and in reference to this part of the treatment, the patient should be cautioned to avoid all kinds of food and drink which are indigestible, or calculated to excite acidity. Malt liquors of all kinds are injurious; wines, especially the sweet and acescent, and hard waters, should be avoided. Animal food should be taken but sparingly; and it is most important that the food generally be not only of the most digestible kind, so as not to excite derangement of the stomach, but also that it be taken in very moderate quantities. Besides, attention to exercise, to the state of the skin, and to the careful regulation of diet, all which are important for diminishing the tendency to the occurrence of lithic deposit, it is advisable to administer alkalies for the purpose of preventing the formation of the lithic acid or of neu- tralizing it, and also for preventing its precipitation and the consequent danger of aggregation, by offering a soluble base for the acid. Of the different alkalies, potass is by much the preferable, as the salts formed by its combination with lithic acid are soluble ; whereas with soda a salt may be formed as insoluble as lithic acid itself. II. PHOSPHATIC DIATHESIS. This term does not imply the mere presence, or any excess, of the phosphates in the urine. In the healthy condition of that secretion, the earthy phosphates are eliminated from the body in a state of solution; but in certain states of constitution the balance of the healthy affinities is broken, and the phosphates become deposited in a visible form. To this condition is given the title of phosphatic diathesis. In the uric acid diathesis, the gravel precipitated is red, whereas in the phosphatic, it is white. In the former, the deposit of lithate of am- monia is determined by an excess of acid; in the latter, by deficiency of acid, or alkalescence of urine. This class of deposits consists of, 1st. The triple phosphate of magnesia and ammonia. 2d. The phosphate CALCULOUS DISORDERS. 517 of lime (an exceedingly rare variety); and 3d. Of a mixture of the two former. The earthy phosphates are readily soluble in urine healthily acid, and, therefore, an excess of them may pass off in acid urine without becoming visible ; whereas the minutest quantity becomes visible in alkaline urine, on account of their not being soluble in alkaline fluids. Urine may be alkaline from the formation of a fixed alkali, such as the carbonate of soda, the carbonate of potass, or the alkaline phosphate of soda; but more commonly from the presence of ammonia, constituting what has been called ammoniacal urine, the ammonia being endangered by the decomposition of urea. Phosphate of magnesia is contained in healthy urine, but it is very soluble. If, however, ammonia be engendered, the triple phosphate of ammonia and magnesia which is formed, is insoluble. This triple phosphate may either be precipitated in the form of white crystals, or it may have an amorphous character. [In Fig. 174 the various forms which the triple phosphate exhibits s' J. _' under the microscope are represented. Generally the crystals are sections of a prism; sometimes they have a stellar, foliaceous, or penniform arrangement.—Ed.] Of the three deposits above mentioned, the first is the least formidable ; the second, as has been already stated, is ex- tremely rare ; the third, consisting of a mixture of the two salts, is by far the most frequent, and is also the most for- midable. Causes.—The predisposition to the deposit of the earthy phosphates is inherited. The exciting causes act, some generally, others locally; the principal are, long-continued over-exertion, de- pressing passions, insufficient food, the habitual or long-continued use of debilitating medicines, such as mercury or strong purgatives, the abuse of the alkaline medicines, injuries of the kidneys, organic disease of the kidney, bladder, or prostate gland, and injuries or a morbid condition of the spinal cord. Any influence which unfavoura- bly affects the body generally may be an exciting cause. It is well known that alkaline deposit is often found in consequence of injury of the back, a fact which was pointed out by Sir Benjamin Brodie, as far back as 18.07. On this subject an excellent authority remarks, "The immediate link in the chain of connexion between the cord and the urine in these cases, seems commonly to be a chronic inflam- matory condition of the mucous membrane of the bladder, the decompo- sition of urea being effected by the altered mucus." When urine is alkalescent from a fixed alkali, no ammonia being present, then instead of the triple phosphate of ammonia and magnesia, the phosphate of lime is thrown down, and may present itself as a fine white sand, or as a film of iridescent appearance on the surface of the urine. Symptoms.—The urine depositing the triple phosphate is generally abundant, pale-coloured, of low specific gravity. That depositing phos- phate of lime has been found in a few instances of a deep colour and acescent when passed, but usually it is of a pale colour, of a low or mo- derate specific gravity, and becomes alkalescent sooner than healthy 518 CALCULOUS DISORDERS. urine. That depositing the mixed phosphates, when unattended with disease of the bladder, usually is exceedingly abundant, of. a pale colour of a low specific gravity; and although it may be clear when passed yet on being exposed to heat it becomes turbid from deposit of the phosphates; when connected with diseased bladder, it is usually alka- lescent on being passed, and invariably becomes so on cooling; it also becomes very offensive, and with the phosphates deposits large quanti- ties of mucus sometimes tinged with blood. Often, and especially in an advanced stage of the disease, the local and constitutional symptoms attending the phosphatic diathesis, resemble those of disease of the bladder, or of some other organic disease. The constitutional symp- toms are subject to considerable modifications; but in all instances where the disease has assumed a permanent character, patients are ca- chectic, weak, sallow, languid, sleepless, and much affected with ner- vous irritability, which is evinced in many different ways. The bowels are flatulent and often irregular, and the peristaltic motion accompanied by borborygmi, and patients complain of a feeling of sinking and of pain and weariness in the back and loins on making the least exertion. Treatment.—In this diathesis the powers of life being in an asthenic condition, the treatment indicated by that condition is what experience has shown to be the most useful, and consists in the use of a generous animal diet, tonics, the mineral acids, such as the nitric or muriatic— both of which in many cases are given with great advantage—the due regulation of the bowels when absolutely necessary, by the very mildest aperients, freedom from care and mental anxiety, and from every kind of exertion calculated to produce an unfavourable impression on the body, exposure to a free bracing atmosphere, and together with these means, the use of sedatives, which are peculiarly indicated by the ner- vous irritability and anxiety with which patients in this state are so often afflicted. Of all remedies belonging to this class, opium is the most valuable, not only from its effects in relieving nervous irritability, but also from its power of rendering alkaline urine acid. In the severe forms of this disease opiates are necessary, and the preparation which experience has shown to be the most useful is the liquor opii sedativus of Battley. The above are the principal indications of treatment; and when they are attempted to be fulfilled, the means must be modified according to the particular circumstances of individual cases. Saline draughts, alka- line medicines, saline or reducing purgatives, mercury, malt liquors, acescent vegetables, hard waters, and fruits, are injurious and ought to be avoided. III. OXALIC DIATHESIS. In this diathesis the preponderating unnatural ingredient in the urine is oxalic acid; and there is a tendency to the formation of calculus of oxalate of lime in the kidney, if a nucleus exist. Symptoms.—The distinctive characters of the urine in this diathesis are, that it is remarkably free from sediment, often bright and clear, but sometimes of a pale citron yellow or greenish hue, and of low or CALCULOUS DISORDERS. 519 moderate specific gravity, and if condensed by evaporation, or examined by the microscope, the characteristic octohedral crystals are discernible. [Occasionally, small masses are found resem- FiS- 175- bling dumb-bells.—Ed.] This diathesis is met with both in the young and the old; but the mulberry calculus is most commonly found in the middle period of life, and in the dyspeptic, and in persons of the sanguine and the melan- ^ p cholic temperaments. The constitutional symptoms vary 2 ^ exceedingly in character and degree, and in some respects *&. are influenced by the peculiarities of temperament of the H| .-, patients ; those of the sanguine temperament being irritable, fj and those of the melancholic desponding and dejected; the |T| mind having a great tendency to brood over the symptoms of the disease. Uneasiness is experienced during the assimilation of the food; flatulence is complained of, the symptoms of dyspepsia are often very troublesome, and in many instances the patient is annoyed by palpitation. When the diathesis is very marked, the skin in some cases assumes a peculiar hue. On this subject Dr. Prout says, "The skin is apt to assume an unnatural appearance difficult to describe, but the colour of which may be said to vary from dull greenish yellow in the sanguine, to dark olive or livid in the melancholic temperament." A nephritic attack occurs, and if the patient get rid of the calculus, he usually remains for years free from all his uncomfortable symptoms. The oxalate of lime calculus, which forms during the continuance of the diathesis, is hard, and bears a striking resemblance in form and colour to the mulberry, and is hence called the mulberry calculus. In some instances small calculi, consisting of oxalate of lime, are found bearing so close a resemblance to hemp seed, that they have been designated hemp-seed calculi. If they be not carried off by the urine, they pass into the mulberry calculus. Although the mulberry calculus is not common, Dr. Golding Bird has found that small crystals of oxalate of lime are extremely common in the urine, and are discoverable by the microscope, although they do not sink or form a deposit. In slight cases there may be no local or consti- tutional symptoms, or none sufficiently marked to attract attention, the presence of the diathesis is then discoverable only by the microscope. Causes.—Some of the exciting causes of this diathesis are believed to be grief, depressing passions, great loss of blood, and residence in a damp and malarious situation. It has been known to follow gout, and to accompany chronic rheumatism. Dr. Prout says, "Diet under all circumstances, but particularly in strongly predisposed habits, has, per- haps, more influence in exciting this diathesis than any other cause. I have seen repeated cases in which the too free use, or rather abuse, of sugar has given occasion to the oxalic acid form of dyspepsia; and sooner or later, under favourable circumstances, to the formation of an oxalate of lime calculus. I have also seen, as before noticed, well- marked instances in which an oxalate of lime nephritic attack has fol- lowed the free use of rhubarb (in shape of tarts, &c), particularly when 520 CALCULOUS DISORDERS. the patient has been in the habit, at the same time, of drinking hard water." Treatment.—The treatment consists principally in attention to diet,— promoting the due performance of the functions of the digestive organs and of the skin, and in the observance of all judicious and proper means for maintaining the general health and strength. The diet should con- sist of animal and farinaceous food, and as the assimilating process is weakened, even those things which are proper, should be taken in very moderate quantities, and in the lightest and most digestible form. The safest drink is distilled water. If, on account of the habits or condition of the patient, some stimulant should be necessary, brandy and water, taken with food, would be preferable to wine. The condition of the bowels must be carefully attended to, and, when necessary, regulated by the mildest laxatives; the function of the skin must be promoted by sponging, friction, and suitable clothing; and all causes of exhaus- tion or depression carefully avoided. Of medicinal remedies, the mine- ral acids, such as the nitric or the muriatic in some tonic infusion, and the nitro-muriatic in some bitter infusion have been found of the greatest service. The effects of the mineral acids must be watched, and their use discontinued wThen they begin to produce a deposit of lithic acid, or of lithate of ammonia in the urine. On this subject, a great authority expresses himself as follows:—"In cases of this diathesis, when the patient lives at a distance in the country, I commonly recommend the use of the muriatic acid, or nitro-muriatic acid, as the case may be, to be persisted in till the lithate of ammonia, or the lithic acid, begins to appear in the urine; or for a month, and by adopting such a course of acids three or four times in the year, and by a carefully-regulated diet, I have seen the diathesis gradually subdued, and at length removed altogether." It is of the greatest importance for persons who have this diathesis, to abstain from sugar, fruits, fermented liquors, all kinds of viands containing oxalic acid, and especially the stalks of rhubarb, and from hard water. By partaking of food containing oxalic acid, and of hard water, which contains the supercarbonate of lime, they would be introducing into their system the very ingredients of the mulberry cal- culus. URINARY CALCULI. Urinary calculi are formed on nuclei of their own substance, or on a clot of blood or mucus, or on some foreign substance introduced into the bladder by the urethra, or in consequence of a wound, or of ulceration. They may be either renal, or vesical. CALCULUS IN THE KIDNEY. The primary nucleus of a renal calculus may be constituted by the simple cohesion of the deposit, or by a clot of blood, or by a particle of the epithelium of the mucous membrane lining the cavities of the kid- ney—this last being a mode of origin believed to be not unusual after injury or inflammatory attacks of the kidney. [Renal calculi are generally composed of uric acid, although occa- sionally they are formed of the oxalate or phosphate of lime. Their size CALCULOUS DISORDERS. 521 and form is very various. They may be as small as a grain of sand, or they may be so large as to prevent their escape from the kidney by the ureter. Remarkable specimens of this kind were obtained by the editor, a few years since, from a little girl twelve years of age. The kidneys were Fig. 176. Fig. 177. much enlarged, and the pelvis, calices, and infundibulse greatly dis- tended by the calculi. The parietes were so thin, and the structure so altered that none of the characteristic appearances of the gland could be observed. When removed from the loins they felt like membranous sacs filled with stones. Upon fitting together the fragments they pre- sented the arborescent figures of the actual size and form represented in the wood-cuts, with numerous stems and buds, forming a cast of the dilated cavities of the kidney. The buds, or the enlargements corre- sponding with the infundibula, were composed of clusters of beautiful shining crystals. Dr. Bridges analysed them, and found them to be composed of the phosphate of lime. Their weight was five hundred and ten grains. The presence of these calculi was not suspected before death, although the sandy and ropy character of the urine, and the pain in the lumbar regions, gave indications of nephritic disease. The child died from hectic produced by inflammation of the kidneys. In some few instances the stone has created an abscess in the kidney, and has been discharged through the loins. Figs. 176, 177. Renal Calculi. From Dr. Neill's paper in the American Journal, July, 1849. 522 CALCULOUS DISORDERS. The affection may be considered a slow and painful one; and if it occur on both sides, producing inflammation of the kidneys, would likely prove fatal. Yet a person may carry a small stone in the kidney for some time and feel no pain; but if, from some exertion, the stone be broken, or change its position, the pain would be severe, and extend to the groin. When the stone is so small as to escape from the pelvis of the kidney and descend the ureter, it gives rise to those painful and distressing symptoms frequently spoken of as a fit of the gravel. The symptoms are more severe when the stone is rough and large, and they continue as long as the stone is passing along the ureter, which may occupy from twelve to forty-eight hours. The pain commences in the loins, and extends to the groin and testicle, which is generally re- tracted. The patient suffers from sick stomach, and often vomits. At the same time there is prostration, the skin becoming pallid and covered with cold perspiration. The symptoms generally subside suddenly, owing to the entrance of the calculus into the bladder, but Sir Astley Cooper records several cases which terminated fatally, owing to the stone completely filling up the ureter, which became much distended with urine and pus. In one instance the ureter burst, and the contents were discharged into the abdomen. Treatment.—Should a stone be diagnosticated in the kidney, it would be important to determine the diathesis of the patient, and to prevent the increase of the deposit by such remedies as have already been pointed out. At the same time its escape from the kidney is to be promoted by diluents and diuretics. But should it be too large to pass, and give pain by exciting inflammation of the kidney, cups should be applied to the loins, and opiate enemata administered. The same kind of treatment would be required when the stone is passing down the ureter. If the patient be robust and vigorous he should be bled freely. Owing to the excessive pain, it may be necessary to give larger doses of opium, as well as to employ the opiate enemata. Relaxation of the ureter, and relief from pain may also be expected from the hot bath and laxative medicines. Should the stone become im- pacted in the ureter, it is possible that it may be discharged by ulcera- tion through the parietes of the abdomen. CALCULUS IN THE BLADDER. The description of urinary calculi in Dr. Gross's "Practical Treatise on the Diseases of the Urinary Organs," is so complete that the editor conceives that he cannot do better than to present a large portion of it to the student. " Stone occurs at all periods of life, from the most tender infancy to the most decrepit old age. Indeed, there is reason to believe that it occasionally exists as an intra-uterine affection. Geyer1 relates the case of a boy who suffered from calculus of the bladder from birth. He was cut in his twelfth year, when the stone had acquired so large a bulk that it had to be broken before it could be extracted. The 1 Miscel. Nat. Curios., Dec. 11, An. V. p. 456. CALCULOUS DISORDERS. 523 whole mass weighed ten ounces. Stahl1 found a calculus of the size of a peach-kernel, in an infant of three weeks, that had suffered great distress from its birth in passing its water. Similar examples are mentioned by Nicolai,2 Armstrong,3 Richel,4 Greding,5 Nosaus,6 and others. " Of 5376 cases mentioned by Civiale, in his treatise on Calculous Affections, 2416 were children, 2167 adults, and 793 old persons; 1946 occurred before the age of ten, 943 from ten to twenty, 460 from twenty to thirty, 330 from thirty to forty, 391 from forty to fifty, 513 from fifty to sixty, 577 from sixty to seventy, 199 from seventy to eighty, and 17 after eighty.7 " Children are more subject to this disease in certain districts than in others, and the same is true in regard to adults. The greater propor- tion of calculous cases in Wirtemberg, in the mountains of Switzerland, the Neapolitan States, and in some of the counties of England, espe- cially Norfolk, occurs in young persons, from causes hitherto unex- plained. In the United States, a larger number of children are affected with this disorder in Kentucky, Ohio, Tennessee, and Alabama, than in any other regions. Pennsylvania, Virginia, Maryland, the two Caro- linas, Georgia, Florida, Louisiana, and Arkansas, also furnish a consi- derable number of cases. The inhabitants of Missouri, Iowa, Wisconsin, Michigan, Indiana, New York, and New Jersey are comparatively ex- empt ; and in the New England States generally a case of calculus of the bladder is so rare as to excite the surprise of the observer. In Canada and the other British Provinces of North America the disorder is also very infrequent: at all events, none of the surgeons of these regions have acquired much reputation as lithotomists, and but few cases of stone are brought from thence into this country. We are justified, therefore, in believing that the malady is uncommon there. The same remarks are applicable to Texas, Mexico, and California, as I have assured myself by repeated inquiries from respectable and intelligent practitioners in those territories. The causes of these differences have not been ascertained ; attempts have been made to trace them to the effects of climate, and to the influence of the water, food, and habits of the people, but without success. " It is not satisfactorily ascertained whether this affection is hereditary. Facts certainly warrant the inference that it is. Thus, Civiale relates the case of a man on whom he practised lithotrity, whose mother had had stone, and one of whose children died of it. He also performed the operation on two brothers, whose grandfather and two uncles had laboured under the disorder. Prout speaks of a family in which the father, son, and grandson were all affected with uric acid calculi. I have not met with any cases illustrative of the present topic. 1 Diss. De Morb. Foetuum in Utero Materno, S. 6. 2 Von Erzeugung der Kinds im Mutter Leibe, Halle, 1746, p. 223. 3Ueber die Gewohulichen Krankheiten Regensb. 1788. • 4 Voistel's Handbuch der Path. Anatomie, 3 B. p. 289. 5 In Ludwigii Advers. Med. Pract. Vol. iii. P. iv. p. 742. c Jour, de Medecine, T. lxxii. p. 369. 7See the Author's edition of Liston's Surgery, p. 531. Philad. 1846. 524 CALCULOUS DISORDERS. " Coloured persons appear to be remarkably exempt from calculous complaints. Whether this is the case in all countries where the negro resides I am not informed, but it is certain that the circumstance obtains, in an eminent degree, in the black population of the Southwest. Duriii" a residence of ten years in Kentucky, I do not recollect to have met with a solitary example of gravel or stone in a coloured person. My impression is that Dr. Dudley in his large calculous practice has never cut more than two or three individuals of this description. To what this immunity is due, our knowledge does not enable us to determine. The circumstance is so much the more surprising when it is remembered that the coloured people of that region are constantly exposed to hard labour, and that their fare is often of the coarsest character. "Urinary calculi are much more frequent in men than women, because they are more constantly exposed to the exciting causes of the com- plaint; and secondly, because the more complicated structure of the urinary apparatus, which prevents the ready discharge of sabulous matter, and thus favours the formation of stone. But for the latter circumstance, the probability is that young girls would suffer nearly as often as boys. " What influence, if any, occupation exerts upon the production of this disorder, we have no statistical facts to determine. In the southwestern states, especially in Ohio, Kentucky, and Tennessee, the great majority of calculous subjects are farmers and mechanics, or the sons of persons of this description ; and the same is true, I suppose, of the calculous cases in the other states. Persons who are habitually exposed to cold and wet are said to be particularly prone to this complaint; the fact, how- ever, if it be one, requires confirmation before it can be received as true. It has been already shown, as it regards sailors, who were formerly supposed to be very liable to stone of the bladder, that they are extremely exempt from it. " Climate, doubtless, exercises no little influence in the formation of urinary concretions. It has been already stated that, in the United States, this disease is most common in Ohio, Kentucky, Tennessee, and Alabama; a circumstance which, so far as is known, does not depend upon any peculiarity of living, and which may therefore be supposed to be owing to some mysterious operation of the climate. In Holland calculous disorders are very common, and the circumstance is the more remarkable, because of the great use that is made of gin, which is a powerful diuretic. That this liquor is not the cause of this occurrence is proved by the fact that the Dutch colonists of Batavia, in the island of Java, whose habits are not at all dissimilar from those of the people of the mother-country, are almost entirely exempt from this affection. Soemmering informs us that the disease is altogether unknown in some situations bordering on the Rhine.1 Calculous affections are, as was stated before, much more common in Norfolk than in any other part of England, and yet the habits of the residents there are the same as in the other counties. In the East Indies, stone is comparatively unusutl, though not so much so as was formerly imagined. We have already 1 Coulson on the Bladder, p. 166. London, 1842. CALCULOUS DISORDERS. 525 seen that it is proverbially uncommon in New England. It is hardly safe, however, to indulge in any remarks concerning a subject which is involved in so much obscurity as the one under consideration. Much of what has been advanced is wholly conjectural, and, therefore, scarcely worthy of serious attention. Patient and multiplied observations in different parts of the world are alone competent to furnish us with any real and substantial light; for these we must wait before we are justified in coming to any positive conclusion." " Many respectable writers and practitioners are of opinion that the production of calculous diseases is promoted by the use of hard, impure water, in consequence of the changes which it is supposed to induce in the renal secretion. The opinion is plausible, and may be true, but how far, or to what extent, nobody has attempted to decide. If it be true that in Kentucky, Alabama, Tennessee, and Ohio, most calculous cases occur in limestone regions, it is equally true that many are found in the freestone districts of those states."1] The most frequent origin of a vesical calculus is the descent of a renal calculus, and its retention in the bladder. This in most instances fur- nishes the nucleus, which, however, sometimes originates in a drop of blood or of mucus. In some cases, calculi are formed on nuclei of their own substance deposited in the bladder; and in others, nucleus is a fo- reign substance introduced into the bladder from without. In the great majority of instances, however, the nucleus is provided by the urinary organs themselves, and aggregation may go on at the original site of formation, or descent may take place into the bladder. The calculi that originate in the kidney, on nuclei of their own substance are the uric acid, and the oxalate of lime, but most frequently the former; whereas those which originate in the bladder, on nuclei of their own substance, are the phosphatic, and the cystic oxide calculi. [" In many instances, however, the concretion is formed round a foreign body, introduced either by the patient himself through design or acci- dent, or in the same manner by a second party. A person shot in bat- tle has been known, at a subsequent period, to suffer from stone in the bladder, in consequence of the ball having lodged in that organ, and thus invited, as it were, a deposit of calcareous matter. A surgeon may become the innocent cause of a similar occurrence. In treating a dis- eased urethra, or in exploring this canal, the bladder, or the prostate gland, the catheter, bougie, or sound which he uses may break off, and afterwards lead to the development of a stone. Many such cases are upon record. A great variety of substances, as nails, tacks, bullets, needle-cases, fruit-stones, peas, beans, pebbles, tents, hairs, small keys, pipe-stems, glass tubes, grass stalks, pieces of straw, pins, and needles, have been accidentally lodged in the bladder, by patients endeavouring to relieve stricture, to procure evacuations of urine, to excite onanism, or create public sympathy. Examples of this kind are, for obvious rea- sons, more common in the female than in the male. O'Brien relates2 an instance in which the nucleus consisted of a human tooth; Liston,3 one in which it was formed by a brass ring; and Malago,4 one in which 'Dr. Gross, on Diseases and Injuries of the Bladder, p. 342-346. 2 Dublin Journal of Medical Science for March, 1834. 3 Edinb. Med. & Surg. Jour., vol. xix. p. 57. 4 Filiatre Sebezio, 1845. 526 CALCULOUS DISORDERS. it was composed of a globule of mercury. In my private collection is a portion of calculus, presented to me by Dr. Jetton, of Tennessee, which contains three of the caudal bones of a squirrel. The man from whom it was removed was thirty-five years of age, and the probability is that he was in the habit of exciting onanism with the tail of this animal, a piece of which broke off, and slipped into the bladder in an attempt of this kind. In the annexed drawing, taken from a preparation in the Fi 178 cabinet of Dr. Sabine, of New York, the nucleus consists of a piece of cork. Dr. Van Buren, son-in-law of Dr. Mott, and one of the surgeons of the Bellevue Hos- pital, informs me that he has a stone, the nucleus of which is formed by the head of a stalk of wheat. It was removed from a man nearly seventy years of age. He had introduced the straw for an improper purpose, and the barbs no doubt prevented its retraction; the consequence was that it passed beyond his reach, and ultimately into the bladder. " The nucleus varies much in its size, colour, form, and consistence. Although generally single, it is sometimes double, triple, and even quadruple: its situation is not always strictly central. The instances in which the concretion is hollow, or the nucleus loose, are rare. " Calculi vary much in their number. In general, there is only one; now and then there are two or three; and sometimes, though rarely, there are several dozens, or even several hundred. The largest number I have ever found was fifty-four, which I removed from the bladder of an old gentleman, upwards of seventy-six years of age, from Oldham County, Kentucky. They were of a dull whitish colour, smooth, irregu- lar in their shape, and from the size of the kernel of a filbert to that of a common marble. Fifty-five were found in the bladder of the cele- brated Buffon. Examples are mentioned of sixty, seventy, eighty, ninety-six, and one hundred. The greatest number ever extracted by Sir Astley Cooper was one hundred and forty-two. Dessault took up- wards of two hundred from the bladder of a priest. Similar instances are mentioned by Kriiger, Dupuytren, and others. Dr. John Kelly,1 of the State of New York, has published a case of two hundred and twenty-eight. Tulpius, Boerhaave, Beauchene, and Ribes each record a case of three hundred or upwards. In the instance mentioned by the latter, this number was found after death in a man who had previously undergone the operation of lithotomy three times. Murat met with six hundred and seventy-eight. Schurig, in his "Lithology," refers to a" case of seven hundred. The most extraordinary example, however, upon record, occurred in the practice of the late Dr. Physick, who ex- tracted from Judge Marshall, of the Supreme Court of the United States, upwards of one thousand calculi, from the size of a partridge shot to that of a bean. They were all of an oval shape, and marked each by a small black spot.2 1 Amer. Jour. Med. Sciences, Jany., 1847, p. 246. 2 Gibson's Institutes of Surgery, xi. p. 220. Fifth edition. CALCULOUS DISORDERS. 527 " The mulberry calculus is almost always solitary; and the same is true, but not to the same extent, of the uric calculus. The phosphatic calculus, on the contrary, is not unfrequently multiple. When the con- cretions are numerous, they are always proportionably small, and more or less smooth on the surface, from the constant friction which they exert upon each other in the bladder. On the other hand, solitary stones are generally rough, and comparatively large. "The volume of urinary concretions ranges between a hemp-seed and a cocoa-nut. In the great majority of instances it does not exceed that of an almond, a pullet's egg, or a walnut, the latter of which in- deed it seldom reaches. In young subjects, and in recent cases gene- rally, the size is usually inconsiderable. I have a number of calculi, extracted from children from three to five years of age, which, in their volume, hardly equal a common marble. The size of a urinary concre- tion, however, does not necessarily depend upon the period of its sojourn in the bladder, or the age of the patient. Occasionally it increases very rapidly, so as to attain a considerable bulk in a very few months; and, on the other hand, it may remain small for many years. In 1844, I operated upon a man twenty-six years old, who had laboured under well- marked calculous symptoms from his earliest infancy, and yet the stone was hardly as big as a hen's egg. "The chemical constitution appears to exert no inconsiderable in- fluence upon the volume of urinary concretions; thus, the ammoniaco- magnesian and the fusible calculi are capable of attaining a very large size, while the uric, oxalic, cystic, xanthic, and fibrinous, are almost always comparatively small, no matter what may be their own age or the age of the patient. This fact is interesting in a practical point of view; because, by ascertaining the calculous diathesis of the sufferer, we shall be able to form a tolerably correct idea as to the volume of the stone under which he is labouring. " It has been already seen, that when urinary calculi coexist in great numbers, they are always proportionably small. In the most remarka- ble case of this kind upon record,—that of Judge Marshall, previously referred to,—the size of none of the concretions, which amounted to upwards of one thousand, exceeded that of a bean, while many of them were not larger than a partridge shot. It is worthy of remark also, that under these circumstances, the individual calculi are generally of un- equal dimensions. " The consideration of the weight of urinary concretions is necessa- rily connected with that of their volume. In general this does not ex- ceed a few drachms or ounces. Out of every one hundred calculi, as they occur in the cabinets of different institutions, or private individuals, few will be found to weigh more than five or six drachms. The smallest probably ever removed by operation was one of ten grains, extracted by Mr. Martineau, of Norwich, England, from a boy thirteen years old. Many examples, however, are recorded of four, six, eight, ten, twelve, fifteen, and even sixteen ounces. Instances of eighteen, nineteen, and twenty ounces, are related by Borellus, Lusitanus, Cheselden, Pauw, Foschini, Wrisberg, and Sandifort. Fabricius Hildanus describes a calculus which weighed twenty-two ounces, and was four inches and a 528 CALCULOUS DISORDERS. half in length, by three and a half in breadth. Examples of from twenty-four to thirty ounces are recorded by Deschamps, Pauw, Paget, Tolet, King, and other authors. In the case mentioned by the latter,1 the patient, who was forty-six years of age, had suffered from his in- fancy, and the stone was seven inches and a half long, by fifteen inches in circumference. Several instances exist in which the concretion weighed thirty-five, forty, forty-five, and even fifty ounces. Mr. Henry Earle,2 of London, has published the particulars of a calculus which weighed forty-four ounces, and was sixteen inches in circumference. It was impossible to break it, and the operator was compelled to leave his task unfinished. Deschamps gives a case of fifty-one ounces; Verduc, one of three pounds three ounces; and, as if to cap the climax, Kessel- ring3 one of upwards of six pounds. "Not a little diversity obtains in respect to the consistence of vesical concretions. As a general rule, it may be said to vary from that of semi-concrete mortar, chalk, or wax, to that of stone or marble. The hardest calculi are the oxalic and uric, which generally emit a clear sound when struck with steel, and cannot be fractured without a con- siderable degree of force. Calculi, on the other hand, composed of ammoniaco-magnesian phosphate and phosphate of lime, are friable, and easily reduced to powder. In extracting such concretions from the bladder, they not unfrequently break under the pressure of the forceps. The cystic and fibrinous calculi are quite soft, the latter scarcely equal- ling that of yellow wax. It often happens that one part of a stone is hard and compact, while another is soft, friable, or even pulverulent. This diversity of consistence is strikingly exhibited in what are denomi- nated the alternating calculi, and seems to depend, in great measure, if not entirely, upon the component elements of the different layers of which such concretions consist. It is not improbable that the age of a stone may exert some influence upon its consistence, though it is impos- sible to estimate the amount or degree of it. " Stones are occasionally composed of a mixture of sabulous matter and hair, more or less intimately matted together. Their consistence re- sembles that of old lath-plaster; they are easily crushed, or pulverized, and they are of whitish, grayish, or pale drab colour. Their formation is of rare occurrence, and they appear to consist principally of phos- phate of lime and magnesia. Where the hair comes from is not ascer- tained. " The colour of these bodies is not less variable than their other physical properties. The most common shades are white, grayish, drab, fawn, reddish, rose, and brown. Concretions of a bluish, greenish, black, or slate colour are rare. In the alternating calculi, a combina- tion of tints is generally observable, and even one part of the surface of a stone may differ essentially, in this respect, from another. The cystic and fibrinous calculi are of a yellow colour, not unlike that of yellow wax; the phosphatic are whitish or grayish ; the oxalic, dark or blackish; the uric, rose, reddish, or brown. 1 London Medical and Physical Journal for 1828. 2 London Medico-Chir. Trans., vol. xi. p. 82. 3 Commer. Liter. Norimb. 1739, hebd. 9. CALCULOUS DISORDERS. 529 " Most calculi, at the moment of their extraction from the bladder, and for a short time afterwards, emit a strong urinous odour, which they gradually lose by exposure to the atmosphere. It may also be completely destroyed by ablution in warm water, and rapid desiccation before the fire. More or less, however, of the animal matter is usually retained, so that maceration at any future time, if not too remote, is apt to be followed by a slight reproduction of the original odour. When sawed, rasped, or rubbed, urinary concretions give out a smell similar to that of bone, horn," or ivory. Fourcroy considered the spermaceti odour furnished by mulberry calculi, thus treated, as characteristic of the species ; this, however, is a mistake. " Vesical calculi are capable of assuming a great variety of forms. The circumstances which are chiefly concerned in producing this result are the action of the bladder, the friction which the concretions, when multiple, exert upon one another, and the nature of the nucleus. One of the most constant symptoms of vesical calculus is a frequent mictu- rition, at the close of which the bladder always contracts violently upon the foreign body. When this contraction is uniform, the concretion will be likely to be of a regular figure; but the reverse when this power is exerted unequally. The attrition which vesical calculi, when multiple, experience from the friction to which they are incessantly exposed, seldom fails to effect a change in their configuration. Such concretions are nearly always smooth, angular, and more or less polished, while, on the contrary, the solitary are generally rough, and comparatively regular in their shape. The influence exerted by the nucleus in moulding the form of the concretion is well illustrated by those cases in which the deposits take place round a foreign body, as a bullet, pin, needle, or bit of bougie, accidentally introduced into the bladder. The configura- tion of the stone, under such circumstances, almost always partakes of that of the extraneous substance. Finally, it is not unlikely that the chemical constitution exerts more or less influence upon the form of the concretion. " Vesical calculi are commonly of an oval form, but occasionally they are round, spherical, or even cylindrical. Other varieties of form are sometimes seen, as the conical, pyriform, cubic, triangular, pyramidal, gourd-like, polygonal, and the tetrahedral. Sometimes the concretion is thin and flat, like a coin, lenticular, semilunar, or in the shape of a mushroom, a kidney, a mulberry, a bean, or a heart. Again, it may be large and bulbous at the extremities, and narrow at the middle, like a dumb-bell. Dr. Mussey, Professor of Surgery in the Medical College of Ohio, has a most singular-shaped calculus, which he removed, many years ago, from the bladder of a man after death. It has a very delicate nucleus, from which a number of slender prongs project, of an irregu- larly cylindrical shape, and some of them upwards of an inch in length. A large concretion will occasionally assume the form of the bladder, and have even prolongations or projections, representing the shape of the urethra, the ducts of the prostate gland, or the ureters. In fact, there is no end to the grotesque appearance of these foreign bodies. Morgagni speaks of a perforated stone, voided by a female. " The shape of a calculus is sometimes materially influenced by that 530 CALCULOUS DISORDERS. of its nucleus. If this is very long, as when it consists of a piece of catheter, bougie, straw, or flower-stalk, the concretion will also be apt to be long and slender, the reverse being the case when the nucleus is rounded, or ovoidal. The fact is interesting in regard to the manner in which the foreign body should be seized with the forceps, with a view to its removal from the bladder, whether this be attempted by incision, or the natural channel. " The surface of these concretions may be smooth or rough. The former is generally the case when several exist together, from the fric- tion which they exert upon each other; when there is only one, how- ever, it is almost always rough. From the cause just mentioned, mul- tiple calculi may not only be smooth but even highly polished, and rendered angular, polygonal, rhomboidal, or tetrahedral. The oxalic concretion derives its common name from the roughness of its surface, which resembles that of fruit of the mulberry. The uric acid calculus is usually finely tuberculated. In some of these foreign bodies the sur- face is scabrous, mammillated, knotty, convoluted, or covered with spines, prongs, or stalactites. " The chemical composition of urinary calculi has attracted much attention during the last fifty years, and the individuals who have parti- cularly distinguished themselves for their researches in this respect are Scheele, Bergmann, Wollaston, Brande, Marcet, Fourcroy, Prout, Ber- zelius, Henry, Scharling, Taylor, and Bird. In this country, the most valuable contribution that has been 'made to this branch of the chemical science is from the pen of Professor Peter, of Kentucky. His paper, which was originally published in the fifth volume of the Western Lancet, is founded upon an analysis of eighty-one calculi in the museum of the medical department of Transylvania University, and is one of deep interest in reference especially to the relative frequency of stone in Lexington, and the probable causes by which it is induced. To this paper, which has since appeared in a separate form, I beg leave to refer the attention of the reader for a large amount of valuable information, having a direct bearing upon the nature and composition of urinary concretions in a region of country where calculous affections are more common than in any other parts of America. It is to be hoped that the labours of Dr. Peter will have the effect of stimulating others to similar investigations; for it is only by the combined researches of chemical philosophers in different portions of the country that the subject can be placed in its true light. " The subjoined account, which is transferred, with little alteration, from my work on Pathological Anatomy, includes the most important species of urinary concretions that have hitherto been described. " The uric calculus, called also the lithic calculus, the most common species of all, was first noticed by Scheele, in 1776. In its colour it is brownish, inclining to that of mahogany, of a flattened oval shape, occa- sionally finely tuberculated on the surface, but most generally smooth, though not polished, unless there are several concretions at the same time, and from the size of a currant to that of a hen's egg. If the uric calculus be divided with the saw, it will be found to consist of several layers arranged concentrically around a common nucleus, the laminae being CALCULOUS DISORDERS. 531 frequently distinguishable from each other by a slight difference in colour, and sometimes by the interposition of other ingredients. Water has but little action upon it; it is perfectly dissolved by caustic potash: and disappears with effervescence in hot nitric acid, the solution affording on evaporation to dryness, a bright carmine-coloured residue; before the blow-pipe, it becomes black, emits a peculiar animal odour, and is gradually consumed, leaving a minute quantity of white, alkaline ashes. Fig. 179 shows the oval shape and finely tuberculated surface of the calculus; Fig. 180 the internal concentric layers. Fig- 179. Fig. 180. " As a variety of the preceding the uro-ammoniac calculus may be here mentioned. It is principally observed in children, and is so ex- tremely rare that several distinguished chemists have been induced to deny its existence. It is generally of small size, with a smooth surface, of a clay colour, and composed of concentric rings, which present a very fine earthy appearance when fractured. Much more soluble in water than the uric calculus, it gives out a strong ammoniacal smell when heated with caustic potash, and deflagrates remarkably below the blow- pipe. This variety of calculous concretion was first described by Four- croy. " Next to the uric calculus, in point of frequency, is the oxalic, which is generally of a dark brown colour, and tuberculated on the surface, very hard, compact, and imperfectly laminated, seldom larger than a walnut, spherical, and always single. Under the blow-pipe, it expands and^ effloresces into a white powder ; it dissolves slowly in muriatic and nitric acid, provided it be previously well broken up. In the alkalies, it is perfectly insoluble. This species of urinary concretion, called by many the mulberry calculus, from its resemblance to the fruit of the mulberry, was first correctly analyzed, in ,1797, by Dr. Wollaston, who proved it to consist essentially of oxalate of lime. Figs. 181 and 182 show the external appearance and internal structure of this concretion. 532 CALCULOUS DISORDERS. Fig. 181. Fig. 182. " A variety of this species of calculus has been described by Fig. 183. the term hemp-seed, from some resemblance which it bears in _ colour and lustre to that substance. Fig. 183. It is always J| J[{| of small size, remarkably smooth, and generally exists in consi- IUf derable numbers, being rarely if ever found alone. " The phosphatic calculus, Fig. 184, described by Wollaston in 1797, is of a pale brownish colour, and of a loosely laminated structure, with a smooth, polished surface, like porcelain. The Fig. 184. shape is mostly oval, and the size, though generally ^gggpgijsssgg^ small, is sometimes very considerable. It whitens ^§ffi§j$S§l^^ when exposed to the blow-pipe, but does not fuse; and readily dissolves in muriatic acid, without effer- vescence. This calculus, composed essentially of phosphate of lime, is extremely rare, as forming entire concretions, but frequently consti- tutes alternate layers with other matters. It is sometimes called the bone-earth calculus, aud occasionally contains small quantities of carbo- nate of lime. " The next species is the ammoniaco-magnesian, so called from its being composed of the phosphate of ammonia and mag- Fig. 185. nesia. Fig. 185. This mixed calculus is of a ©white colour, friable, crystallized on the surface, and looks a good deal like a mass of chalk: its texture being never laminated, it easily dissolves in dilute acids, but is insoluble in caustic potash; before the blow-pipe, it exhales an ammoniacal odour, and at length melts into a vitreous sub- stance. This species of concretion, first noticed by Wollaston in 1797, sometimes attains an immense size. In a case mentioned by Dr. Thompson, the circumference was fourteen inches, and the weight nearly two pounds. "The fusible calculus, the nature of which was first determined by Wollaston, consists of a combination of the last two. It is of a white colour, extremely brittle, leaves a soft dust on the fingers, and is easily separated into layers ; when broken, it presents a ragged, uneven surface. It is insoluble in caustic potash, but gives off ammonia ; and, under the blow-pipe, it is readily converted into a transparent, pearly- CALCULOUS DISORDERS. 533 looking glass. _ This concretion is very common, and sometimes attains a very large size. It is frequently met with as an incrustation of foreign bodies. Figs. 186 and 187 exhibit the outer appearance and internal structure of this concretion. F1g- 186. Fig. 187. " A very rare species of urinary concretion is the Cystic, so called from an erroneous supposition that it was peculiar to the bladder. It consists of a confused, crystallized mass, of a white yellowish colour, with smooth surface. The structure is compact, and the fracture exhibits a peculiar glistening lustre, like that of a body having a high refractive density. It exhales a strong characteristic odour under the blow-pipe, and is very abundantly dissolved in acids and alkalies, with both of which it crystallizes. This species is commonly of an irregular spherical shape, and seldom attains a large volume. Wollaston termed it an oxide, and gave it the name of cystic, from a belief that it occurred exclusively in the urinary bladder. It has since been detected, however, in the kidney. The external and internal appearances of the cystic calculus, are shown in Figs. 188 and 189. Fig. 188. Fig. 189. " The xanthic calculus wras first pointed out by Dr. Marcet, whose account of it is the best that is extant. It is extremely rare. Its 534 CALCULOUS DISORDERS. texture is compact, hard, and laminated : its colour is of a cinnamon brown, its surface smooth, and its volume small. It dissolves very readily in acids and alkalies, and is gradually consumed before the blow-pipe, leaving a minute quantity of white ashes. " There is what is called the fibrinous calculus. ♦ Like the preceding species, this is also extremely rare, and appears to be composed princi- pally of the fibrin of the blood, a property to which it owes its name, and by which it is characterized. Sir Benjamin Brodie1 has described a concretion of this kind, which was about the size of a horse-bean, of an oval shape, and of a yellow transparent appearance, not unlike amber, but less hard. When dried, it shrunk to a small size, and became con- siderably shrivelled. " Finally, there is a concretion recently described by Heller, under the name of urostealith. It is exceedingly rare, and I do not know that anybody else has noticed it. The specimen, analyzed by the German chemist, was obtained from a man of tolerably good constitution, twenty-four years of age, whose chief complaint was pain in the region of the right kidney, with difficulty in micturition. The concretions were of a rounded form, soft, elastic, and from the volume of a hemp-seed to that of a hazel-nut, most of them being as large as a pea. They become brittle on being dried, when they present the appearance of wax, of a greenish-yellow hue when viewed by transmitted light. When heated, they melt, and emit a peculiar pungent odour, similar to that of benzoin. Urostealith is readily dissolved by ether and by solutions of caustic potash, but it is insoluble in boiling water, and nearly so in alcohol. It seems to be composed of a particular kind of fatty matter."2—(Dr. Gross, on Diseases and Injuries of the Bladder, p. 347-359.)—Ed.] SYMPTOMS OF CALCULUS IN THE BLADDER. The leading symptoms produced by a calculus in the bladder are, a frequent, sudden, and urgent desire to pass water, the desire being often irresistible, especially under exercise, or on change of position,—and pain referred to the point of the penis, most severe, just as the bladder is emptied, and after making water, when the contraction of the middle coat brings the mucous coat into distinct contact with the calculus. The pain is sometimes of a burning character ; at other times, it is a severe, but dull pain, with a sensation as of something lodged at the part, and giving rise to a desire to pull and pinch the prepuce, causing it to be- come elongated. The skin of the fore-finger and thumb, especially in children, in whom the inclination to pull the prepuce is often observed, becomes, in consequence of being kept wet by the urine, sodden and white like that of a washerwoman's hands. Sometimes the flow of the urine is suddenly stopped by the stone covering the inner orifice of the urethra, and is restored on a change of posture removing the stone from that position. As the stone increases in size, the symptoms become more and more urgent; the pain at the point of the penis is frequently accompanied by sympathetic pain about the rectum similar to tenesmus; and in most instances, after the disease has been of long standing, the •Lectures on the Urinary Organs, p. 214, second edition. London, 1835. 2 Simon's Animal Chemistry, p. 635, 1'hila. 1846 ; also Markwick on Urine, p. 93, Phila. 1848. CALCULOUS DISORDERS. 535 urine ceases to be so clear and transparent as natural, and deposits on cooling, especially after exercise, a quantity of mucus. Such are the leading symptoms caused by a stone of moderate size ; but, in the course of time, these symptoms become painfully aggravated, other local symptoms supervene, and the general health, at first little affected, becomes impaired, so that the patient's situation is rendered peculiarly distressing. The urine, instead of preserving its natural clear and transparent appearance, becomes at first merely opalescent from the mucus thrown off by the lining membrane; which mucus is seen, as the urine cools, to subside to the bottom of the recipient vessel, and in some cases, is at times tinged with blood. As the disease ad- vances, the congestion of the lining membrane goes on to inflammation, in which state its sensibility is greatly increased, the desire to make water is almost constant, the pain most excruciating, the urine offensive, and loaded with mucus, tinged with blood, its smell foetid and ammo- niacal, and by and by, it contains purulent matter along with the mu- cus. Inflammation of the mucous membrane aggravates all the symp- toms to a very great degree; the pain at the point of the penis is excruciating and attended with the inclination to squeeze the glans penis,—the agony being no doubt caused by the inflamed bladder spas- modically grasping the stone. The sympathetic pains are often very distressing, and are felt shooting down the thighs, and in the soles of the feet. The rectum is not only affected by such pains, but it also becomes irritable, and often liable to prolapsus ani, or to hemorrhoids. The above are the leading and diagnostic symptoms of stone in the bladder; but as some of them are somewhat similar to the symptoms of other affections, such as disease of the bladder, disease of the prostate gland, organic disease of the kidney, renal calculus, and (to some ex- tent) organic disease of the rectum, the surgeon should, before giving a positive opinion, make use of the sound, and when, by means of this instrument, he feels the calculus, he is as fully convinced of its existence as if he actually saw it. VARIETIES AS TO THE DEGREE OF PAIN IN DIFFERENT PERSONS, AND IN THE SAME PERSON AT DIFFERENT TIMES. The degree of pain produced by a vesical calculus varies much in dif- ferent cases, and even in the same person at different times, and in different stages of the affection. The varieties in different persons de- pend chiefly on the size and figure of the stone, on its smoothness or roughness, on the nature of the stone, the quality of the urine, and, when other things are equal, on the condition of the bladder. A small stone occasions less pain than a 'large one, and one that is smooth on the surface less than one that is rough, the rough nodules irritating the mucous membrane; and this is the reason why the mulberry calculus in most instances causes so great pain. But of all the calculi none are so painful as the phosphatic, which is no doubt owing to the greater degree of derangement of the general health, and to the general and local sus- ceptibility being morbidly increased. An unusually acid or alkaline condition of the urine will increase the sufferings of the patient, the fluid being in each case too stimulating for the lining membrane; but the greatest pain i3 experienced in an inflamed condition of the bladder, 536 CALCULOUS DISORDERS. as the sensibility of the bladder is thereby greatly increased. The diathesis itself sometimes varies in the same person, and there is then a corresponding variation in the roughness or smoothness of the surface of the stone—changes which, apart from some of the facts stated above, sufficiently explain why the sufferings of the patient are so much greater at some stages of the concretion than at others. SOUNDING.1 Although a patient may have many or all of the rational signs of stone, nothing can positively convince the surgeon of its presence but feeling it with the sound. A sound is an instrument made of polished steel, shaped somewhat like a catheter. The handle should be smooth, so as s' " to communicate the most delicate impression to the f~^\ fingers, and the point should be rounded, so as not to I ' be arrested in the orifices of the prostatic or seminal \ / ducts. The curve near the point should neither he too long, too acute, nor too obtuse, in order to facili- tate the movements of the instrument when introduced into the bladder, and to bring it more accurately in contact with the stone. Previously to sounding, the bowels should be emptied by a dose of castor oil or an enema. A full rectum may impede the movements of the instrument, and impart deceptive sensations to the hand of the sur- geon. A patient is never sounded with an empty bladder. The patient should be directed to retain his urine, but should he have inadvertently passed it, the bladder is to be distended with three or four ounces of tepid water, injected through a silver catheter, which may then be used as a sound, care being taken to stop its orifice, to prevent the regurgitation of the fluid. During the operation of sounding, the patient should be on his back, near the edge of the bed, with his shoulders elevated, and his limbs flexed, so as to relax the abdominal Fig. 191. __ ^~^J muscles. The instrument is introduced in the same manner as a cathe- 1 Condensed from Dr. Gross' work on Urinary Organs. CALCULOUS DISORDERS. 537 ter, and if the stone is not felt at once the sound must be rotated upon its axis, so as to explore every portion of the bladder. Sometimes the stone cannot be felt on account of its lying in a pouch in the bas-fond of the bladder, just behind the prostate gland. When this is the case the finger should be oiled, and introduced into the rectum, and the stone pushed upwards against the sound. It may be necessary to change the position of the patient, making him lie on his side, sit or stand, bend forward, or raise his buttocks. The stone may be contained in the folds of the bladder, or some abnormal pouch ; or it may be adherent to the walls of the bladder. Small stones have been found imbedded in the parietes of the bladder. Several such calculi are represented in the ac- companying figure. The calculous matter, instead of being collected into a distinct concre- tion is sometimes spread out in the form of a layer upon the bas-fond of the bladder. The crust varies in thickness, and is sometimes difficult to break. It grates under the sound, and when struck emits a peculiar noise, not unlike that of a cracked pot. But the noise produced by striking a free calculus is a click, or a clear metallic resonance, which is more distinct when the stone is hard. The sense of touch is also readily impressed by the contact of the stone, and through it the volume of the calculus can be in some measure ascertained. There is danger in sound- ing patients who have travelled a great distance for surgical relief, be- fore they have recovered from the fatigue. Cystitis and peritonitis may result to such an extent as to endanger the life of the patient. The sounding should always be conducted with the utmost gentleness, and should never be continued beyond a few minutes at a time. A pro- tracted operation of this kind is generally productive of mischief, and cannot be too pointedly condemned. Should severe pain ensue, it must be allayed by a full anodyne; and any inflammatory symptoms that may arise are to be combatted by the usual remedies. In all cases the patient should be directed to make free use of demulcent drinks. "Although sounding is the only certain method of detecting a stone in the bladder, it is occasionally liable to error. Numerous cases are upon record where a foreign body was supposed to be present, and where the poor patients were subjected to all the pains and perils of lithotomy, and yet no calculus was found, either at the time of the operation or after death. Surgeons of the most consummate skill and the most extensive experience have fallen into this error. It is for the purpose of avoiding a repetition of such mistakes, so discre- ditable to those who commit them, that I shall endeavour briefly to point out their sources. Great men may sometimes commit an error with impunity which would bring ruin and disgrace upon a more humble member of the profession. Cheselden,1 the most celebrated lithotomist of his age and country, cut three patients without finding any stone. Blanc,2 Dupuytren,3 Roux,4 and Crosse,5 all operated, expecting to find 'Benjamin Bell's System of Surgery, ii. p. 40. Edinburgh, 1784. 2Dessault's Chirurgical Journal, translated by Gosling, i. p. 125. London, 1794. 3Lecons Orales, T. ii. p. 334. 4 Johnson's Medico-Chir. Rev., April, 1827, p. 549. 5 Essay on Urinary Calculus, p. 50. 538 CALCULOUS DISORDERS. a stone, where there proved to be none. The late Dr. Physick1 came very near committing the same mistake. He sounded a patient, and had no doubt there was a stone. His health, however, was bad, and the operation was postponed. He died some time after, and upon exami- nation no stone was found. " Mr. Crosse,2 who, as we have just seen, was himself unfortunate in one instance, states that he has notes of not less than eight cases in which the operation was needlessly performed, and to several of which he was an eye-witness. The late Mr. Samuel Cooper,3 of London, was acquainted with the particulars of at least seven such cases, at two of which he was present. Velpeau4 says he has a knowledge of four in- stances, where the patients were subjected to the operation without there being any calculi in the bladder. South5 mentions the case of a child, two years and a half old, who was cut for stone, but in whom no stone was found, although he had suffered very severely, and a calculus was supposed to have been felt. I am acquainted with two instances in which the patients were lithotomized without there being any stone. One of these was a child, under four years of age, whose parents resided in Indiana. He was sounded several times, and a stone was supposed to be present, but none was found at the time of the operation. He recovered quickly, and is still living. The other case occurred in Ken- tucky, in an old man, upwards of sixty years of age, who was cut by the same surgeon, under the supposition that he had calculus. He died a few days after the operation, and, upon examination, the bladder was found to contain nothing but a fungous tumour, portions of which had repeatedly come away by the urethra during life. Many similar ex- amples are recorded in the ' Me'moires de l'Acaddmie de Chirurgie' of Paris. It is worthy of remark, that quite a number of the patients in whom no stone was found were promptly and entirely relieved of the symptoms which had been attributed to its presence. On the other hand it is equally certain that some of them perished from the effects of the operation, while others who survived it received no benefit from it. " The circumstances which may lead to the commission of the error above mentioned differ very much in their character, and are dependent for their origin either upon the bladder itself, or upon the surrounding parts. The following are the most important. " I. In the first class are included an indurated and contracted state of the bladder, the development of an osseous cyst, and the formation of a fibrous, encephaloid, or polypus tumour, and a deposit of tubercular matter. " II. In the second division of the subject may be comprised certain affections which involve the parts in the immediate vicinity of the bladder, as the prostate gland, rectum, uterus, vagina, and pelvic bones."6—Ed.] Treatment.—Of the various modes of treatment recommended for the 1 Liston's Practical Surgery, by Norris, p. 310. Philad., 1838. 2 Essay on Urinary Calculus, p. 50. 3 Dictionary of Surgery, vol. ii. p. 134. New York, 1842. 4 Velpeau, Operative Medicine, vol. iii. p. 891. 5 Chelius's Surgery, South's Edition, vol. iii. p. 277. 6 Dr. Gross, on Diseases and Injuries of the Bladder, p. 380-384. LITHOTOMY. 539 removal of calculus, we shall refer to three, Lithotomy, Lithotrity, and Lithotripsy. LITHOTOMY, OR CUTTING FOR THE STONE. In the next section, which gives the history of Lithotomy, will be found the various modes in which the operation has been performed. Of these (several of which are not now in the list of regular and established operations), that wdiich is to be preferred in almost every instance in Figs. 192-195. which lithotomy is justifiable, is the lateral operation. The several acts of this operation are variously performed; but the method of the late lamented Mr. Liston, who, while he lived, was deservedly regarded as the first lithotomist, has brought it to a state of the greatest simplicity and elegance, and has been adopted by the great majority of operating surgeons. The perinaeum having been shaved, the rec- tum having been cleared by a dose of castor oil on the evening before, and an injection on the morning of the operation,—the patient, having retained his urine from half an hour to three quarters of an hour previous to the operation, should be brought under the influence of chloroform, and then a staff of the largest size the urethra will admit, having a deep groove between its convexity and left side, should be introduced, and the stone having been felt, the charge of the staff should be given to the principal assis- tant. The hands and feet of the patient should be tied to each other, 540 LITHOTOMY. and his body placed in the attitude shown by the accompanying drawing. If the staff be of the largest size that can be conveniently introduced, Fig. 196. it will be easily felt after the first incision, and the urethra can without difficulty be opened upon it. The staff should be drawn up under the pubes to keep the prostate gland from being imbedded in the rectum, and held steadily by the assistant in that position throughout the diffe- Fig. 197. rent stages of the operation. The operator should then introduce the fore-finger of the left hand into the rectum to make sure of its being LITHOTOMY. 541 empty, and to excite it to contract, which will diminish the risk of its being injured during the operation. I have always followed the example of Mr. Liston in making the introduction of the finger into the rectum the last thing before the commencement of the operation, in order to diminish the danger of its being wounded, and the first thing after its completion, to make sure of its being safe. The first incision is then made by introducing the knife pretty deeply into the perinseum at the left side of the raphe, and about an inch in front of the verge of the anus, and by carrying it downwards and outwards to rather more than an inch below the anus, and so directing it that the middle of the incision may be about midway between the anus and the tuberosity of the ischium. By this means the skin and superficial fascia are divided. The fore- finger of the left hand is then pressed into the middle of the wound for the purposes of putting aside cellular tissue and thereby enlarging the wound, of keeping the rectum out of harm's way, and of feeling for the staff in the membranous portion of the urethra. Such fibres of the transversus perinei and levator ani muscles as oppose the onward progress of the finger should be carefully divided by the knife. The groove of the staff is easily felt anterior to the deep fascia of the peri- nseum. The point of the nail of the fore-finger should be pressed against the groove, and the knife, carried along the back of the finger, should be made to enter the groove about three lines in front of the prostate ; and it having been surely ascertained that the knife is in the groove of Fig. 198. the staff, it should be cautiously pressed backwards so as to divide that portion of the membranous part of the urethra which is posterior to where the knife enters the groove, the deep fascia and fibres contained within it, the prostatic portion of the urethra, the left lobe of the pros- tate gland, and the dense unyielding fibrous band at the base of the prostate, into which the muscular fibres are inserted. The incision should commence about three lines in front of the gland, and should not extend beyond its circumference,, so that there may be no risk of the 542 LITHOTOMY. ilio-vesical fascia being divided, as such division would admit of infiltra- tion by breaking up the barrier which this fascia constitutes between the external and internal cellular tissues. The edge of the knife should be directed downwards and outwards. If it be held too horizontally, the section of the prostate, so made as not to extend beyond its base, would be too limited, and the planes of the external and internal incisions would not correspond: if too vertically, the section obtained would also be too limited, and the rectum would be endangered. The finger should be so placed as to protect the rectum, and should follow the knife, which is withdrawn as soon as the incision has been made, and immediately afterwards the principal assistant withdraws the staff, the surgeon re- Fig. 199. taining his finger in the section of the prostate. In most instan«es the stone can be felt with the front of the finger; the forceps should then be introduced, the finger being used as a guide. When the forceps reaches the stone, its blades should be opened, the stone seized, and efforts made to extract it, the handles of the forceps being depressed so that the line of extraction may be in the direction of the axis of the pelvis, and the fore-finger of the left hand preventing the descent of the bladder with the stone and forceps. To make the external incision free, facilitates the remaining steps of the operation : but the internal incision should be limited;—the great object being to avoid cutting beyond the circumference of the prostate, so that the ilio-vesical fascia, which is the barrier between the external and internal cellular tissues, may be LITHOTOMY. 543 entire. The prostate, the mucous coat and muscular fibres at the neck of the bladder are so yielding that the wound can be easily dilated without any laceration, and thus a stone of very considerable size can be readily extracted through an incision of very limited extent, perhaps not more than seven or eight lines in length, and not ex- tending into the bladder beyond the base of the prostate. FiS- 20°- If the stone should be too large to be safely extracted through the limited opening now described, the most judicious course then is to introduce a probe-pointed bistoury along the finger, and effect a similar incision on the right side of the prostate; in short, to make what is called the bilateral sec- tion of the gland—a proceeding which may be adopted from the first, if it is certain that the stone is too large to be ex- tracted through a section on one side of the prostate gland. It having been ascertained by the appearance of the stone, or, if necessary, by the use of the searcher, that there is not another calculus, the elastic tube is introduced into the wound to facilitate the escape of the urine, and thereby to diminish the danger of infiltration; and for the promotion of the same object, the patient after being re- moved to bed, is placed on his back with his shoulders a little raised. Such is the simple and safe mode of per- forming lithotomy with the knife, recommended by Mr. Liston, and which I often witnessed with the greatest admi- ration when I was his pupil. [Many operators prefer a probe-pointed knife. Dr. Gross employs a probe-pointed bistoury closely resembling that of Blizard.—Ed.] The structures divided in this operation are the integu- ment, two sets of fasciae, namely, the superficial fascia and the two layers of the deep fascia; the transverse muscle of the perineum on the left side, some of the fibres of the leva- tor ani, and the muscular fibres betwreen the two layers of the deep fascia; the external hemorrhoidal arteries, and the transverse artery with their associate veins and nerves; the cellular and adipose tissue in the ischio-rectal excava- tion ; a few lines of the back part of the membranous portion of the urethra, the prostatic portion of the urethra, the left lobe of the prostate gland, and the dense, unyielding, fibrous band at the base of the prostate, into which the muscular fibres are inserted. If the incisions are properly arranged, the above are the only structures that will be interfered with. The principal dangers to be guarded against are, bruising the soft parts, wounding the rectum, wounding some important artery, as the artery of the bulb, and too extensive division in making the section of the pro- state. The precautions to be adopted for avoiding the first and second of these dangers have been mentioned; the third is avoided by not com- mencing the incision too high up : and the fourth by limiting the extent of the incision so as not to cut the bladder beyond the circumference of the prostate. Some arteries occasionally deviate from their usual arrangement, and are then in danger of being wounded. The artery of 544 LITHOTOMY. the bulb occasionally arises from the pudic near the tuber ischii, and crosses the line of incision. Should it be wounded, it ought if possible to Fig. 201. be secured by a ligature. The pudic artery, even when presenting thai abnormal arrangement in which it lies on the posterior edge of the pro- state, would be wounded only if the incision reached beyond the gland; —an additional reason to that already given for limiting the extent of the section. In old persons there is sometimes venous hemorrhage from the veins around the prostate, which often become enlarged at an advanced period of life. This is most efficiently arrested by pressing some plugs of lint around the tube ; and the same plan is adopted in the case of arterial hemorrhage, when it is difficult to find the artery, and the hemorrhage does not cease on the thighs being brought toge- ther, which, however, it often does from the opposite sides of the wound being then more closely pressed against each other. In the event of lint being introduced, it is necessary to be even more than usually careful that the tube be kept completely pervious. The principal object of the tube being to prevent urinary infiltration, it is retained until it is reasonable to suppose that the cells of the cel- lular tissue are closed by effusion of lymph. In young persons, twenty- four hours will be sufficient for this purpose, the process of effusion being rapid at that period of life ; but in persons of a more advanced age, or of a relaxed habit of body, it should be retained for at least forty-eight or fifty hours ; and the greatest care taken for the first few hours after the operation until the urine become colourless, to observe that occlusion of the tube be not produced by coagulated blood. The important objects [Fig. 201. This engraving, copied from Scarpa, represents the left lobe of the prostate as it is divided in the lateral operation, a, Marks the incision of the membranous portion of the urethra and the side of the gland, b. The left lobe of the prostate, b*. The right lobe of the organ, c. The bulb of the urethra. Close behind are observed CowperV glands, d, d. The legs of the penis, e, e. The seminal vesicles. //. The deferent ducts. g. The ureter of the left side.—Ed] HISTORY OF PERINEAL LITHOTOMY. 545 of attention for the first few hours are, that there be no hemorrhage, that the tube be pervious, and that the urine flow plentifully, and gra- dually become colourless. The secretion having become colourless, and no particular constitutional sympathy having manifested itself, the early and principal dangers are passed. On the withdrawal of the tube, the wound may be dressed with a little lint, and subsequently with a little lint dipped in oil, resinous ointment or turpentine liniment, according to the particular state of the granulations. In many instances no appli- cation whatever is required. The greatest care should be taken to keep the nates free from inflammation and excoriation by the use of the spirit lotion, lard, and the frequent change of sheets, so as to keep the parts as dry as possible; the mind should be encouraged, the strength kept up by all means which in the particular circumstances of the case would be judicious, the frequent error of keeping the patient too low avoided, and the constitutional treatment in other respects conducted according to the common principles of surgery. In the course of eight or ten days a little urine comes by the urethra, generally causing a slight pain and irritation the first time, and the patient seldom feels so well for that day; the quantity gradually increases, and in three or four weeks, sometimes more and sometimes less, the whole comes by the urethra, and the continuity of the parts is restored by the healing of the wound after which the treatment proper for the diathesis should be continued, as reproduction of stone occasionally though very rarely occurs. [With regard to the result of the operation, Dr. Gross states, " It has been calculated that about one patient out of every five that are cut for stone by the lateral method perishes : and this estimate, taking the general average results, is, perhaps, pretty near the truth. Considered, however, with reference to individual operators, it is incorrect. Thus, taking the results furnished by some of our own lithotomists, it will be found that they afford a much more gratifying picture. Dr. Dudley, for instance, is said to have lost only 5 cases out of 180 cut, up to the beginning of 1846; Dr. Mettauer, of Virginia, 2 out of 73; Dr. John C. Warren of Boston, 2 out of 30, of which three, however, were by the bilateral method; and Dr. Gibson of Philadelphia, 6 out of upwards of 50. My own cases, amounting to 24, have all been successful. I in- variably use the knife ; while Dudley and Gibson employ the gorget. In the Pennsylvania Hospital, at Philadelphia, between 1752 and 1848, 83 cases of stone were cut by the lateral method, and except in a few instances of very young children, by means of the gorget. Of this num- ber 72 were cured, and 10 died; 1 being set down as relieved."1—Ed. HISTORICAL SKETCH OF PERINEAL LITHOTOMY, AND THE VARIOUS MODES OP OPERATING. THE METHOD OF CELSUS. This mode of operation, the most ancient on record, and the only one in use down to the sixteenth century, deriving its name of Lithotomia Celsiana from having been described by Celsus, has also been called ■Dr. Norris'sReport on Surgery, Trans. Amer. Med. Assoc, vol. i. p. 163. 546 HISTORY OF PERINEAL LITHOTOMY. cutting on the gripe, and, the operation by the apparatus minor, on account of the fewness of the instruments required,—a knife and a hook and sometimes only a knife having been used. The rectum having been emptied by means of a clyster, and the patient having walked about the room to bring the stone down to the neck of the bladder, he was placed in the lap of an assistant, whose duty it was to hold him, and to keep*the thigh bent and separated so as to expose the perineum. Sometimes, if the patient was not a young person, two assistants were strapped together by the thighs to support him between them, each having "charge of a thigh. The operator, having oiled his fingers, introduced the index and middle fingers of the left hand into the rectum, and endeavoured to get them behind the stone, to force it forwards to the neck of the bladder, and to make it cause a prominence in the perineum. A lunated incision was then made, having its con- vexity forwards to the bulb of the urethra and its concavity backwards to the anus, the extremities being directed to the ischia. The words of Celsus, " cornibus ad ischia spectantibus," show that those writers are mistaken who say that the extremities of the incision were directed to the left hip. The parts between the middle of this incision and the stone were cut through, and the operator then endeavoured to press the stone through the wound, or to extract it by means of a hook. THE OPERATION BY THE APPARATUS MAJOR. The next operation we read of in the history of perineal lithotomy is known by the names of the operation of Johannes Romanus, by whom it was devised,—the Marian operation or the Sectio Mariana, in con- sequence of a minute description of it having been given by Marianus Sanctus, a pupil of Johannes Romanus,—the operation by the apparatus major, from the multiplicity of instruments employed (l'operation par le grand appareil, Fr.), and median lithotomy, from the first incision having been made in the mesial line in the perineum. The reason assigned for the introduction of this mode, and the abandonment of that previously in use, was the declaration of Hippocrates that "wounds of membranous parts are mortal." It was supposed, however, that such parts might be dilated with safety, and it was on the principle of dilata- tion that the operation was founded. The patient having been placed on a table with his shoulders raised, his hands were bound to his feet, and the latter were separated from each other, drawn upwards, and still more firmly fixed by turns of a bandage passed round his neck and shoulders ; and in this attitude he was held by assistants. A grooved staff -was then introduced into the bladder, and an incision made with a razor in the middle line of the perineum extending from behind the scrotum to near the verge of the anus ; by the further application of the knife the bulbous portion of the urethra was opened; and this was all the cutting employed in the operation. The operator having the point of the knife lodged in the groove of the staff, introduced a probe into the bladder, guiding it by the knife into the groove, and by the staff into the bladder. The knife and staff having been withdrawn, the in- struments for dilatation were then used. These were two, called the male and female conductors. The female conductor, which was a long director with a groove, was introduced along the probe, when the latter HISTORY OF PERINEAL LITHOTOMY. 547 was withdrawn, and the point of the male conductor having been placed in the groove of the female, was pressed onward into the bladder. The lithotomist then, by taking the extremity of a conductor into each hand, Figs. 202—207. and separating them from each other, commenced the work of dilating, or rather tearing up the membranous and prostatic portions of the urethra and the neck of the bladder. After all the dilatation that could be effected by the conductors had been accomplished, the grand forceps was introduced between them into the bladder, and employed first in still increasing the dilatation, and then in seizing and extracting the stone. After Marianus, who gave the first description of the operation, his successors contrived many other instruments to be used after the male Figs. 202—107. " Instalments constituting the "Apparatus Major." 548 HISTORY OF PERINEAL LITHOTOMY. and female conductors, in tearing open the neck of the bladder. The principal of these were the gorget of those days, which was in use in the time of Collot, though its employment was not patronised by him ; the simple dilator, which dilated by its handles being brought together ; the dilator of some authors, an entirely different instrument; and the double dilator. By some or other, or all of the above-mentioned instruments, together with the fingers of the operator, the membranous and prostate portions of the urethra, prostate gland, and neck of the bladder, were torn open to make room for the extraction of the stone. The cruelties of this operation could scarcely have been exceeded; but although its results were such as might have been expected, it was still practised from 1520, when it was first proposed, to 1697, when Frere Jacques de Beaulieu taught the surgeons of Paris to despise it, and proposed another mode of operation. Some of the most celebrated operators with the grand appareil, were Marianus, Pargeus, the family of the Collots, who were Lithotomists to the kings of France for several generations (the elder Collot having been appointed Royal Lithotomist to Henry II., and having been the first person on whom that title was conferred), Octavius de Ville, Toletus, and Mery and Marechal, the surgeons-in-chief to the Hotel Dieu and La Charite Hospitals in Paris. OPERATION OF FRERE JACQUES. Freire Jacques, a native of Langsauniere, in Burgundy, devised a method of cutting for the stone, which shall presently be described. Having practised this method with success in various towns on the Con- tinent, he went to Paris, where he had influence enough to obtain from President Harley an order to perform his operation on a dead body in the H6tel Dieu in the presence of the surgeons of Paris. Mery, sur- geon-in-chief of the hospital, was required to report regarding it. On the 7th of December, 1697, Mery received the first order to wit- ness Frere Jacques cut a dead body for the stone in the H6tel Dieu, and on this experiment he gave a most favourable report. On the 14th of the same month he received a second order from the president to witness Frere Jacques make further trials of his operation on dead bodies in the Hotel Dieu; and it is remarkable that Mery, who indeed is supposed to have been influenced by the violent jealousies entertained towards Frere Jacques by the lithotomists and surgeons of the day, and to have become the organ of their party, reported in opposite terms of these further experiments, and condemned what previously he had strongly praised. In consequence of this, Frere Jacques lost the support of President Harley, and being dispirited, left Paris without being allowed to perform his operation on the living body. He went to Fontainebleau, where he was introduced to Daschene, one of the physicians to the court; to Bourdelot, physician to the Duchess of Burgundy ; to Fagon, phy- sician, and to Felix, surgeon to Louis XIV.: and by the influence of these gentlemen an order was given by the court, that he should per- form his operation on a boy from Versailles, then living at Fontaine- bleau, who was afflicted with the stone. He performed the operation in the presence of the above-named gentlemen, and in a manner to com- HISTORY OF PERINEAL LITHOTOMY. 549 mand their admiration, and in three weeks the boy was seen running in the streets perfectly well. The consequences were, that Frere Jacques cut six other persons at Fontainebleau, gained the favour of the court, and the enthusiasm of the people, and returning to Paris, and there operating in private on twelve persons, produced such an impression on the public mind, that President Harley summoned a meeting of the physicians, surgeons, and managers of the H6tel Dieu, together with the magistrates of Paris, and others, at the palace of the archbishop, on the 7th of April, 1698, requiring another report on this operation. The contest at this meeting is said to have been very violent. The operators by the apparatus major finding that all they had been proud of in their method was in danger, with themselves, of falling into neglect, were as strong in their opposition to the new mode as the friends of Frere Jacques were in their approval of it; but the final result of the discus- sion was, that the latter were triumphant, and it was resolved that, in the ensuing season of cutting for the stone, Fr&re Jacques should be allowed to perform his operation in the Hotel Dieu and at La Charite*. He operated accordingly, but unfortunately for him, of sixty-two patients whom he cut in those hospitals, twenty-five died, seven having been carried dead out of La Charite' in one day. This occasioned the renewal of the persecution which had before been directed against him, and it was now carried on not only by the lithotomists and surgeons, but also by the priests, whose violent hatred he had incurred by accusing them of having poisoned his patients and injured their wounds for the purpose of bringing discredit on his operation. A second time therefore he left Paris, but continued to practise his operation in the chief towns of France, in Holland, and in Germany, to the great admiration of those who wit- nessed his proceedings. Up to this period of his career Frere Jacques was perfectly ignorant of anatomy: he was not aware of the danger of wounding parts, the structure of which was unknown to him : and hence he had all the boldness of a man unconscious of danger. In the operation hitherto practised by him, called, in the history of his proceedings, his original uncorrected operation, he introduced into the bladder a large peculiarly-shaped staff, without a groove, and holding it with his left hand, he with the right plunged a long dagger-shaped knife along the side of the tuber ischii of the left side into the bladder ; having made a sufficiently large opening, he next introduced into the bladder a con- ductor through the wound, and having carried a forceps along the con- ductor into the bladder, he then withdrew the conductor and staff, and endeavoured to extract the stone. The staff, as we have already stated, had no groove, nor was it used to guide the knife into the bladder. Fagon, the king's physician, was deeply impressed with the boldness with which Frere Jacques performed his operation, and being himself afflicted with the stone, he formed the resolution of allowing Frere Jacques to operate on himself; and partly perhaps with that view, and partly from admiration of his boldness and benevolence, he invited him to return to Versailles, and kindly inducing him to live in his house, persuaded him to study anatomy, and to make dissections under the direction of the celebrated Du Verney. Frere Jacques operated on the dead body, and the parts were then dissected by Du Verney, who, to- 550 HISTORY OF PERINEAL LITHOTOMY. gether with Fagon and Felix, the king's physician and surgeon, pointed out to him the dangers against which he had to guard; and the result was that they induced him to perform what is called his second, or im- proved operation, which differed from the former in the use of a grooved staff for conducting the knife into the bladder. This operation he practised on the dead body, in the presence of his three friends, until Du Verney pronounced his experiments on the dead body perfect; and his success on the living body was such that he at one time cut thirty- eight persons without losing a single patient. Such is the history of Frere Jacques's improved method, which has always been considered as the foundation of the very superior mode of perineal lithotomy practised in the present day. A celebrated writer gives the following account of an event which occurred about this part of Frere Jacques's career, and exercised great influence on public opinion with reference to his operation. " There were at this moment two men of eminent rank who had re- solved to submit to the operation of Frere Jacques; the one, Mr. Fagon, first physician to Louis XIV., the other the Mare'chal de Lorges; both had taken measures to insure the success of the operation; but in the very moment that Frere Jacques was about to obtain the most dis- tinguished honour, he suffered a sad reverse of fortune. Mr. Fagon had himself taught Frere Jacques, and with the assistance of Du Verney, the celebrated anatomist, and Felix, first surgeon to the king, had made him go through a series of dissections. His operation was reformed according to their desire ; he had forsaken his big round staff, and cut upon a grooved one; he had operated on thirty patients in the Hotel Dieu of Versailles with uninterrupted success ; he had already sounded Fagon, and felt the stone; yet Fagon, though thus far advanced in this generous design, was prevailed on, by the solicitation of his friends, to put himself into the hands of Mare'chal, who had learned to perform Frere Jacques's operation. Mare'chal accordingly performed the opera- tion, and Fagon survived, and in a few weeks went abroad in his carriage. The Mare'chal de Lorges, of distinguished rank and great fortune, pro- ceeded with equal precaution; he assembled in his hotel twenty-two poor people afflicted with the stone, who were cut by Frere Jacques with perfect success: but while the poor patients survived, the Mare'chal himself died in tortures the day following the operation. This was de- cisive of the fate of our operator. The Mare'chal de Lorges lying dead in his superb hotel, while Fagon, cut by Mare'chal, was rolling in his chariot in the streets of Paris, was a triumph for the regular lithotomists, and a mortal blow to the reputation of Freire Jacques, who now departed from Paris never to return." Frere Jacques operated on nearly five thousand patients in all; he was benevolent, candid, and disinterested; he never accepted more money for his services than was necessary to mend his shoes and to sharpen his instruments. He operated with astonishing success in diffe- rent parts of France ; also at Amsterdam, where he was presented with a gold medal for his public services ; at the Hague, where he received a present of gold sounds, which it is said he afterwards had melted to give to the poor: and at Delft, Leyden, Padua, and many other places; after HISTORY OF PERINEAL LITHOTOMY. 551 which he went to Rome to receive the benediction of the Pope, and then returning to his native village, at an advanced period of life, he distri- buted among the poor what little money he possessed, and died, accord- ing to Morand, in June, 1714. RAU'S OPERATION. . Rau, Professor of Anatomy at Leyden, and teacher of the celebrated Albinus, was the next great lithotomist that appeared. He had seen Frere Jacques operate, and had himself operated with great success; but he refused to tell any one his mode of proceeding, and died without leaving any description of it. From the account which Albinus gives of it, it is believed that its peculiarity consisted in cutting into the bladder behind the prostate, and dividing the prostate by cutting from behind forwards, instead of (as in Frere Jacques's improved operation) from before backwards. In this proceeding, a grooved staff was used. CHESELDEN'S OPERATION. The celebrated Cheselden, surgeon to St. Thomas's Hospital, London, being deeply impressed with the success of the operations of Frere Jacques and Rau, resolved to abandon hypogastric lithotomy, or, as he called it, of cutting into the bladder by the highway, and to perform perineal lithotomy. From Cheselden's own description of his proceed- ings, contained in the appendix to different editions of his " Anatomy," and from the account of the operation as he at one time practised it, given by Douglas, who states that he received it from Cheselden him- self,—it is perfectly clear that when he first practised perineal litho- tomy, after making his incision in the perineum, he endeavoured to cut into the under part of the lateral region of the bladder, and then fixing his knife in the staff, he divided the prostate gland, and neck of the bladder from behind forwards. This method, however, he afterwards abandoned, as being not only difficult of performance, but also unsuc- cessful, chiefly from sloughing and infiltration of the cellular tissue. Cheselden's second operation has been uniformly regarded as supe- rior to any adopted before his time ; and, indeed, with slight modifica- tions, it is nearly the same as that practised by most of the best litho- tomists at the present day. On this subject, the lamented Mr. Liston wrote, as his deliberate opinion,—and, in former days, when I had the great privilege of being his pupil, I repeatedly heard him make the same statement,—" Depend upon it that, somewhat modified, it is the best operation that can be performed; it is one I have practised with little alteration for many years, and in not a few cases, and I see no reason to change it for any other." The following is Cheselden's account of his second operation, as I find it given by him at page 330, of the thirteenth edition of his work on Anatomy now before me. " I first make as long an incision as I can, beginning near the place where the old operation ends, and cutting down between the musculus accelerator urinse and erector penis, and by the side of the intestinum rectum. I then feel for the staff, holding down the gut all the time, with one or two fingers of my left hand, and cut upon it in that part of the urethra which lies beyond the corpora cavernosa urethras, and in 552 HISTORY OF PERINEAL LITHOTOMY. the prostate gland, cutting from below upwards, to avoid wounding the gut; and then passing the gorget very carefully in the groove of the staff into the bladder, bear the point of the gorget hard against the staff, observing all the while, that they do not separate and let the gorget slip to the outside of the bladder; then I pass the forceps into the right side of the bladder, the wound being on the left side of the perineum, and as they pass, carefully attend to their entering the blad-« Fig. 208. der, which is known by their overcoming a straightness which there will be in the place of the wound ; then, taking care to push them no further that the bladder may not be hurt, I first feel for the stone with the end of them,—which having felt, I open the forceps, and slide one blade1 underneath it, and the other at top; and if I apprehend the stone is not in the right place of the forceps, I shift it before I offer to extract; and then extract it very deliberately, that it may not slip suddenly out of the forceps, and that the parts of the wound may have time to stretch, taking great care not to gripe it so hard as to break it; and if I find the stone too large, I again cut upon it as it is held in the forceps." Cheselden's success was very remarkable; on this point, he says, " What success I have had in my private practice, I have kept no ac- count of, because I had no intention to publish it, that not being suffi- ciently witnessed. Publicly in St. Thomas's Hospital, I have cut two Fig. 209. hundred and thirteen ; of the first fifty only three died : of the second fifty, three ; of the third fifty, eight; and of the last sixty-three, six. Several of these patients had the small-pox during their cure, some of whom died, but I think, not more in proportion than usually of that dis- temper ; these are not reckoned among those who died of the operation. The reason wbv so few died of the first two fifties was, at that time few HISTORY OF PERINEAL LITHOTOMY. 553 bad cases offered; in the third, the operation being in high request, even the most aged and most miserable cases expected to be saved by it, and besides, at that time I made the operation lower, in hopes of improving it, but found I was mistaken." sir c^sar Hawkins's mode. The next important change in the mode of proceeding among the sur- geons of this country was that introduced by Sir Caesar Hawkins, sur- geon to St. George's Hospital, who, having an edge put upon the blunt gorget of the apparatus major, thereby converted it into a cutting gorget; and after cutting with the knife into the membranous portion of the urethra, he effected an opening into the bladder by dividing the prostate with the gorget. After this method became known, many different forms of gorgets and gorgerets were invented ; which it would answer no useful purpose to describe. Of one of them, Mr. Liston remarks, " It is more like an implement for cutting turf,—a ' flauchter- spade,'—than for performing a delicate surgical operation." Of other instruments invented for dividing the prostate, and cutting into the bladder some of the most celebrated were the bistouri cache'e of Cosme ; the gorgeret cistotome-dilatoire-compose' of Le Cat; and the double lithotome, used by Dupuytren, in his bilateral section. [" The gorget is fast falling into desuetude. Whether this is owing to any intrinsic defect in the instrument itself, or merely to the manner of using it, cannot be easily determined. However this may be, very few operators, either in this country or in England, continue to employ it. Dr. Dudley, of Lexington, has performed all his operations, upwards of two hundred in number, with it; and I am told that he still uses the same instrument with which he commenced his brilliant career as a lithotomist, forty years ago. Dr. Gibson, of Philadelphia, also adheres to the gorget, and so do likewise a few of the other surgeons of that city. Most American operators prefer the knife, which is also the case in England, France, and other portions of continental Europe. The gorget has undoubtedly committed many blunders, the recital of which would form one of the most sickening chapters in the history of surgical wrongs. Nevertheless, it has done, and still continues to do, good ser- vice in the hands of some of our most eminent' men, and ought not, therefore, perhaps, to be spoken of too lightly or severely, for its faults are, perhaps, after all, rather attributable to the surgeon than to the dumb instrument with which he does his bungling work. " The gorget has sometimes slipped into the cellular tissue between the bladder and the rectum, or between this organ and the pubes; thereby bruising and otherwise injuring the parts, and favouring the occurrence of urinary infiltration. Cases are mentioned, where, by a blind and heroic thrust, the instrument completely severed the bladder from its connexions, pierced the rectum, or penetrated the peritoneal cavity, and passed high up among the bowels. Mr. John Bell, in his History of Lithotomy, says, ' I have seen the gorget driven twice, not into the bladder, but deep among the bowels; for although there was a stone, the surgeon never reached the bladder. Not one drop of urine followed ; the stone was not extracted ; and the boy died the second day 554 HISTORY OF PERINEAL LITHOTOMY. from the operation.' Sir James Earle observes that he has more than once known this instrument, though passed in the right direction, pushed on so far, and with such violence, as to go through the opposite side of the bladder. Mr. Benjamin Bell found in two instances, on dissection, that this organ was wounded in three different parts, at its neck, in its side, and towards its superior fundus. The late Mr. Crosse states that he has repeatedly seen the gorget slip between the bladder and the rec- tum ; in one instance he declares that the instrument, after entering the bladder, pierced its coats from within outwards, so as to stop against the pubic bone. Bromfield, in passing the gorget, perforated the opposite side of the bladder, and found, to his horror, on withdrawing the instrument, that the intestine had descended through the opening. The bowel had to be held out of the way while he extracted two calculi, though it was forced out again by the child's screaming before he at- tained his object. * As soon as he was convinced, by his finger, that the bladder was totally free from any pieces of stone, he again returned the intestine into the pelvis, and brought the child's thighs close together; a piece of dry lint was applied to the wound, and a pledget over it; he was then sent to bed with no hopes of his surviving till the next day; but, contrary to expectation, the child had a very good night, and was perfectly well in little more than a fortnight.' It is said that the cele- brated Scarpa thrust the gorget, which was looked upon as the palladium of his fame, between the bladder and the rectum. " The operation with the gorget differs, in no wise, in its early stages, from the operation with the knife. The period for using the instrument is immediately after the incision of the membranous portion of the ure- thra. The surgeon then exchanges the scalpel for the gorget, the beak of which he places in the groove of the staff, guided by the point of the left index-finger. After assuring himself, by drawing the instrument slightly backwards and forwards, that it is in no danger of slipping, he Fig. 210. takes hold of the handle of the staff, and by a simultaneous movementof his hands, he lowers the instrument and the gorget nearly to a level with the abdomen; pushing at the same time the latter onward into the blad- der. In executing this part of the operation, care should be taken not HISTORY OF PERINEAL LITHOTOMY. 555 only that the gorget do not slip out of its place, and thus pass between the rectum and the bladder, but that it is properly lateralized, otherwise there will be great risk of injury to the rectum and the pudic artery. The annexed engraving represents the gorget, as modified and improved by Physick and Gibson." (From Gross on Urinary Diseases, &c.)—Ed.] dupuytren's operation. Sectio-bilateralis.—The bilateral section of Dupuytren consisted in making a semilunar incision, having its convexity forwards, and extend- ing from between the anus and the tuberosity of the ischium on the one side, to the corresponding part on the other; in continuing the dis- section so as to divide all the parts over the membranous portion of the urethra, and opening this membranous portion for a short distance from before backwards; after which, the double lithotSme was fixed in the groove of the staff, and by it conducted into the blad- der ; then, the staff having been withdrawn, the concavity of the litho- tome was directed downwards, the blades were expanded, and in with- drawing the instrument, the double section was effected. A double reason in favour of this proceeding is, that there is no risk of wounding the rectum, nor of injuring the pudic arteries, unless the blades be ex- panded to an unnecessary extent. [" The bilateral operation of lithotomy has never had any distinguished advocates in Great Britain, where the ordinary method seems to be uni- versally preferred to all others. Nor has it, so far as I am informed, received much countenance in Germany, Russia, and Italy. It was first performed in this country in 1832, by Dr. Ashmead, of Philadelphia. It was repeated soon after by Dr. Ogier, of Charleston ; and within the last ten years has been practised by Stevens, Warren, Mussey, Eve, Parker, Watson, Hoffman, Post, May, Pancoast, and other surgeons. It was also, as I am informed, the favourite method of the late Dr. Bushe, of New York. I have myself been so much wedded to the lateral method that I have never felt inclined to employ any other. " Most of the surgeons above named use the knife, both for dividing the perinaeum and the prostate gland. My distinguished friend, Pro- fessor Eve, of Georgia, who is one of the most able and strenuous advo- cates of the bilateral method, informs me that he always employs the lithot6me cache' of Dupuytren. Of fourteen patients cut with this in- strument, only one died, but from no cause connected with the opera- tion. Dr. Stevens, of New York, has devised an instrument, named the prostatic bisector, which he uses for cutting the prostate gland and neck of the bladder. An instrument very much on the same plan had been previously contrived by Dr. Pattison and Dr. Bushe. Dr. Mussey, of Cincinnati, formerly employed the lithotome cache", but of late years, as he has recently informed me, he has given a decided preference to the knife. The last twenty-three operations which he has performed were done in this manner. " The double lithot6me was greatly improved by Dupuytren, and is accurately represented in the annexed drawing. ' It consists of two long, narrow blades, folding upon each other, and concealed in a 556 LITHOTRITY. case, which is slightly curved, and adapted, by its size and shape, to be passed along the groove of the staff into the bladder. Thus, the instru- ment is introduced through the urethra without injury to the parts, while a mechanical contrivance attached to the handle allows the blades to be expanded after it has been lodged in the bladder. They quit the sheath on each side, and, when separated, resemble the blades of a pair of scissors with the cutting edges reversed. In this state the instrument is withdrawn, and cuts its way out. The size of the opening produced of course depends upon the extent to which the blades Fig. 211. have expanded, their degree of separation being indicated by an index.' "* (Gross on Urinary Diseases, &c.)—Ed.] It is hoped that from the preceding account may be clearly understood the mode of performing lithotomy adopted by some of the most distinguished surgeons of the present day, as well as the principal methods we read of in the history of the operation, and their most important varieties. Besides the median, lateral, and bilateral modes of perineal lithotomy, quadrilateral lithotomy has been proposed, in certain circumstances, by M. Vidal de Cassis, but it is unnecessary to describe this proceeding. LITHOTRITY. This term is now used to designate the operation of boring or rubbing a calculus in order to pulverize it, and so remove it through the natural passage. The first person in modern times who adopted proceed- ings with that view, was General Martin, who, in 1800, operated on himself, and, by means of a file, removed part of a stone with which he was afflicted. In 1813, Gruithuisen proposed the use of a canula through which a borer was introduced; and after him, several others who had devoted attention to the subject, made various suggestions, possessing more or less ingenuity. But M. Civiale, in 1823, proposed a more ingenious apparatus than any of his predecessors. This consisted of an outward canula containing three branches, which, when thrust out, after its introduction into the bladder, seized and held the stone, on which, when thus firmly fixed, a drill, sent through the inner canula, was made to act. The result, however, of this, and of all other proceedings on the same principle, was far from satis- factory, and, in consequence, the present practice is to crush the stone, instead of drilling it,—or, in other words, Lithotrity has been superseded by Lithotripsy. 1 Brit, and Foreign Med. Rev., vol. ii. p. 101. LITHOTRIPSY. 557 LITHOTRIPSY. The operation known by this name, for removing calculi by crushing, has now been brought to great perfection. To the late Mr. Weiss, sen., undoubtedly belongs the merit of having invented, and offered to the profession, the first lithotriptor, on the principle of that now in common use; and Mr. Weiss, jun., brought the instrument to its present state of great simplicity and perfection. On the recommendation of Mr. Liston, Mr. Weiss made the handle of metal, instead of wood or ivory, with which it had before been covered,—a change by which the percep- tion of the contact of the instrument with the calculus is rendered much more delicate. At the suggestion, as Mr. Liston informs us, of Mr. Oldham, a gentleman connected with the Bank of England, Mr. Weiss introduced another most important alteration, without which the use of the instrument was more hazardous:—he made the outer blade open, so as to receive the other. The accompanying draw- ing is a representation of the simple and perfect lithotriptor, noAv in Fig. 212. use. Mr. Weiss states that he showed his lithotriptor to many profes- sional men, and among others, to Baron Heurteloup in 1830, who, up to that time, had used the straight drill of Civiale ; he immediately adopted the invention, and merely substituting the hammer for the screw, claimed it as his own, calling it his " Percuteur Courbe a Marteau." ["Another instrument, the merits of which are certainly equal, if not superior, to those of the one just described, is that of Dr. Jacobson, an eminent surgeon of Copenhagen. For simplicity and facility of use, it would be difficult to conceive of anything more perfect or convenient. It consists of a silver canula, about ten inches long by three lines in diameter, the upper extremity of which is furnished with a circular steel rim, an inch in width, while the lower is slightly curved for about two inches, and terminates in a blunt point. Within this tube is a steel rod, calculated to move backwards and forwards at pleasure, and con- nected, inferiorly, with the one just described by means of an articu- lated chain consisting of three links. The superior extremity projects beyond the horizontal rim of the canula, and is furnished with a stout screw, which is intended to work the chain backwards and forwards, during the seizure and comminution of the stone. A graduated scale exists upon the instrument for measuring the volume of the stone. " It has been alleged that the lithotriptor of Jacobson is inferior, in several respects, to that of Heurteloup and Weiss; but, mainly, on account of its greater liability to pinch the coats of the bladder, and 558 LITHOTRIPSY. its inability to grasp so large a calculus. It is also said to be more difficult to seize the concretion so readily when Fi&- 213- it lies behind the prostate in a cul-de-sac of the bladder. These objections, however, are rather imaginary than real. In the first place, it is not an easy matter for a skilful surgeon, in any case, to include the coats of the bladder in the jaws of his instrument; the contingency, at all events, is a remote one, and can scarcely hap- pen if care be taken to round off the margins of this part of the instrument; secondly, no calculus larger than what can be embraced by Jacobson's lithotriptor should ever be attempted to be crushed by this operation; and, lastly, if the stone lies low in the bas-fond of the blad- der, and cannot be readily seized, the difficulty is easily remedied by the introduction of the finger in the rectum. These objections, there- fore, fall to the ground. Fig. 213 represents Jacobson's stone-crusher, as modified by Vel- peau. " With either of the above instruments the operation may, in general, be safely and expe- ditiously performed. The percussor of Heur- teloup, is, I believe, but rarely used anywhere at the present day; it is an awkward and clumsy affair, and ought, in my judgment, to be dis- carded from our armamentarium. " It is not every case of stone that admits of being crushed. There are certain circumstances which imperatively forbid it; and hence much judgment is frequently required to enable the surgeon to make a proper selection. When the operation was in its infancy, there is reason to believe that it was too often employed indiscriminately, both to the detriment of patient and surgeon; and, on the other hand, many per- sons were doubtless subjected to lithotomy who would have made excel- lent subjects for lithotripsy. Fortunately, a better state of things pre- vails at the present day; the jealousy which existed between the stone-breaker, and the knife-man, has ceased; and the consequence is, that more judgment is displayed in the selection of cases for the two operations. In this country, however, lithotripsy is still in its infancy; in fact, it can hardly be said to have received fair play from the hands of the lithotomists. Dr. Dudley, who has operated more frequently for stone than any surgeon in America, has never, I believe, employed litho- tripsy ; and the same is true of some of our other practitioners. Those who have busied themselves most with this operation, in this country, are Dr. Randolph, Dr. Gibson, and Dr. Pancoast, of Philadelphia, and Dr. N. R. Smith, of Baltimore; the first of whom unfortunately died too soon for the cause of surgery, which he was so nobly engaged in cultivating. Many other surgeons have occasionally resorted to it, but comparatively few have made it the subject of their special study and LITHOTRIPSY. 559 practice. The operation was first performed in the United States., by Dr. Depeyre of New York." (Gross on Urinary Diseases, &C.)1—Ed.] When the operation is to be performed, the patient is placed on a couch or bed of convenient height, with a pillow below the pelvis, so as to send the stone into the fundus of the bladder. If the bladder should not contain a sufficient quantity of urine to distend it, so that the stone may be crushed without injury to the lining membrane, tepid water Fig. 214. should be injected by means of a syringe and catheter, until the bladder contains at least six or seven ounces of fluid. The lithotriptor having been then introduced, and the stone seized, the surgeon, after previously ascertaining that no portion of the lining membrane is entangled, brings the stone to the centre of the viscus, and commences the crushing pro- cess by turning the screw; this should be done very gradually, espe- cially at first. The crushing of the stone is felt by the operator very distinctly. If the stone be very small and friable, it may be pulverized at one seizure; but more frequently it happens that, after the first crushing, the fragments require to be seized and pulverized. When one seizure is insufficient, the surgeon must be guided by the susceptibility of the patient in judging how frequently it may be repeated at one time, as, if a very correct judgment be not formed on this point, and if the crushing be carried to too great an extent, very serious con- sequences are likely to result. When the process has been continued as far as may be necessary, or as the state of the patient may render advisable at one time, a large catheter, with a peculiar opening at its extremity, is introduced, through which the urine and some of the detritus are discharged; and if considered at the time desirable, a little water may be injected once or twice, by means of a syringe, before the removal of the catheter, in order to favour the escape of detritus, it being important to bring off as much as possible through the instrument, 1 New York Med. Jour., for February, 1831. Fig. 214. From Liston. 560 LITHOTRIPSY. as the transmission by this means occasions no irritation. Rest and antiphlogistic treatment should be strictly enjoined, and the local symp- toms which supervene, must be treated according to the common princi- ples of surgery. Fragments pass off for some days, and in their trans- mission through the urethra often give rise to great pain and irritation. If another operation be necessary, it may be ventured on after the effects of the first have disappeared. The cases favourable for Litho- tripsy are those of adults in whom the stone is small and compara- tively soft, the kidneys, bladder, prostate gland, and urethra, organically sound and free from any particular irritability, and the general consti- tution not more than ordinarily susceptible. There can be no doubt that in such circumstances lithotripsy, in the hands of a judicious sur- geon, is a very safe and satisfactory operation; and that when these favourable conditions combine, it is to be preferred to lithotomy; but in other circumstances, supposing an operation to be desirable, lithotomy is undoubtedly that which ought to be adopted. If in all cases a cor- rect and unprejudiced judgment be exercised, first as to whether any kind of operation be advisable, and if so, then whether in the particular conditions of each case lithotripsy or lithotomy be the more suitable operations for the removal of calculi in the bladder, will be found suffi- ciently satisfactory in their results. It is only the abuse of these opera- tions that can bring either the one or the other into discredit. 561 CHAPTER XVI. AFFECTIONS OF THE TESTICLE. ORCHITIS. Inflammation of the testis may be either acute or chronic: it may commence in the body of the testicle, or in the epididymis, forming the epididymitis of some authors; and it may be either primary, as when idiopathic, or when excited by external violence, such as a bruise, a wound, or exposure to cold and wet; or, as is far more frequently the case, consecutive, the inflammation being transmitted from the urethra by spreading along the vas deferens, or perhaps by metastasis,—in which circumstances the epididymis is first attacked and most affected, the tunica vaginalis generally becoming soon involved. An example of orchitis as thus induced has been referred to in the enumeration of the consequences of gonorrhoea, a form of the disease usually acute, and known by the names of " secondary gonorrhceal orchitis," or "hernia humoralis." Secondary orchitis may, however, be the result of inflam- mation unconnected with gonorrhoea; it may arise from inflammation caused by violence in the introduction of catheters or bougies, or it may be the consequence of strictures, or of the means used to cure them. Sometimes it is an accompaniment or a consequence of mumps, in which case its production depends on metastasis. acute orchitis. Symptoms.—When orchitis is primary and acute, the symptoms are, excruciating pain in the testicle, great tenderness, especially as the disease advances,—so that in some cases the patient cannot allow the part to be touched, a distressing sense of weight, a swelling of the tes- ticle, which, however, preserves its oval form, pain extending along the back and in the loins, where it is often extremely severe, and a red, hot, shining appearance of the scrotum. The pain and sense of weight are increased by the erect posture. In very acute cases, nausea, vomiting, and pain in the under part of the abdomen are urgent symptoms, which, in consequence of their similarity, have sometimes been mistaken for symptoms of enteritis. The most severe form of orchitis is usually that which arises from wounds of the testicle. Such injuries are therefore very dangerous, especially in individuals of an irritable habit of body. The constitutional symptoms in the acute primary form of the disease are very severe. Consecutive Orchitis, when originating in the transmission of inflam- 36 562 ACUTE ORCHITIS. raatory action by continuity of tissue, is usually preceded by slight pain, weariness, and fulness in the groin, where the cord is found to be ten- der on pressure, and the vas deferens to be enlarged. These symptoms are followed by pain, tumefaction and tenderness of the epididymis, which forms an elongated swelling at the back of the testicle; in many instances this swelling is so great as to render the epididymis as large as the testis, which remains still unaffected. The inflammation soon extends to the tunica vaginalis, when the tumour forms a mass, the different parts of which are no longer distinguishable, and the testis itself becomes involved. The distinguishing peculiarities of this form are the symptoms along the course of the cord in the first instance, fol- lowed by the affection of the epididymis, which invariably precedes that of the testis ;—the cord, epididymis, tunica vaginalis, and testis becom- ing successively affected. In this variety the swelling is usually greater, and forms more rapidly; and although there is much variety in the intensity of the symptoms, the pain and constitutional disturbance are for the most part less severe. In the sympathetic form of gonorrhceal orchitis, namely, that in which the disease presents itself without any previous affection of the vas deferens—a variety sometimes met with, although rare in comparison with the last-mentioned form of the disease—there is an absence of all symptoms indicating any affection of the cord, and the inflammation commences in the epididymis. In by far the greater number of cases of gonorrhceal orchitis the inflammation proceeds along the vas deferens to the epididymis. In seventy-three cases out of one hundred and four noticed by M. Aubry, the inflammation first attacked the vas deferens ; in the remaining thirty-one the disease was sympathetic. Gonorrhceal orchitis may occur at any period of an attack of gonor- rhoea ; but it most frequently commences when the pain and discharge begin to subside. On the connexion supposed to exist between the in- flammation of the testis and the state of the discharge, the under-men- tioned authorities give the following result of their observations. M. Gaussail states, that in sixty-seven cases out of seventy-three, the gonor- rhoea diminished on the first appearance of orchitis ; M. Aubry, that in fifty-eight cases out of eighty-one, there was diminution of discharge at the commencement of inflammation of the testicle ; and M. D'Espine mentions that in only six cases out of twenty-nine the discharge con- tinued unchanged; while in the remaining twenty-three, it was variously modified, being increased in some, diminished in others, and in others entirely suppressed. Late observations have shown the incorrectness of the opinion which at one time prevailed, that secondary orchitis is more frequent on the left side than on the right. Of seventy-three cases mentioned by M. Gaussail, forty-five were on the right side, twenty-four on the left, and four were double ; of twenty-nine observed by M. D'Espine, twelve were on the right side, eleven on the left, and six double; and of thirty-six which occurred in the practice of Mr. Curling, twenty-one were on the right side, fourteen on the left, and only one double: so that of one CHRONIC ORCHITIS. 563 hundred and thirty-eight cases it appears that seventy-eight were of the right testicle, forty-nine of the left, and eleven of both. Treatment.—The local treatment of acute orchitis consists in the use of leeches, rest, recumbency, support of the testicle, so as entirely to obviate the effects of gravitation, and warm fomentations. Opening a vein in the scrotum is often a convenient mode of local depletion. When the tunica vaginalis is involved and much pain is experienced from ten- sion, great relief is often experienced from evacuating the accumulated serum. Cold evaporating lotions sometimes give more relief than warm fomentations or poultices ; the feelftigs of the patient are the surest guide, whether the warm or the cold are preferable. The constitutional treatment consists in the use of low diet, rest, the free exhibition of antimony, general depletion when the inflammatory symptoms and sympathetic fever are urgent, and after the pulse has been lowered by antimony, and other means, resolution is often pro- moted, and structure saved, by the use of mercury. Both in the idio- pathic form, when the testicle is principally involved, and in the conse- cutive, when the inflammation has its seat principally in the epididymis and tunica vaginalis, mercury is exceedingly useful: some surgeons confine its use almost entirely to primary, and others to secondary orchitis. I have used it pretty generally in both classes of cases, and am perfectly convinced that much advantage results from doing so. As inflammation originating in the testicle is not only more painful and at- tended with more constitutional disturbance, but also more apt to endanger the structure and function of the part affected, this form of orchitis requires even more prompt and decided treatment than the others. If suppuration should occur, which is more apt to take place in primary than consecutive orchitis under proper treatment, free incision should be made as soon as there is decided evidence that matter has formed; by this proceeding the tubular portion of the organ will be less endangered, and sinuses and fistulous passages probably prevented. When the disease has become chronic, the greatest benefit is often ex- perienced from the cautious employment of pressure, applied by means of adhesive plaster cut into strips, the testicle being separated from its fellow, and the scrotum drawn off as much as possible from the diseased testicle, to admit of the proper application of the strips of plaster. Of the advantages of this treatment in chronic cases, I can speak in the strongest terms. Dr. Fricke of Hamburgh suggested treatment by com- pression, both in acute and chronic cases, and states as the result of that proceeding, that of fifty-one cases of acute orchitis, eighteen having been treated in the ordinary method, and thirty-three by compression, the average duration of the disease in the former was thirteen days, in the latter only nine days. Ricord, Cullerier, Parker, Acton, Curling, Hamilton, and others, have spoken favourably of the results of this practice; but in acute cases I have had no opportunity of forming a judgment upon it from my own personal observation. CHRONIC ORCHITIS; OR, FUNGUS OF THE TESTICLE. This affection occasionally succeeds acute orchitis, as a result of the inflammation being imperfectly resolved ; but it is much more frequently 564 CHRONIC ORCHITIS. chronic from its commencement. By far the most frequent cause of chronic orchitis is urethral disease, such as gonorrhoea, or stricture, the inflammation being conveyed along the vas deferens to the epididymis. Irritation of the urethra, induced by other affections of the urinary organs, is sometimes the exciting cause. It ought, however, to be remembered, that this disease is not invariably owing to the state of the urethra. Excessive indulgence of the passions, a reduced state of the vital powers, debility resulting from a long-continued course of mer- cury, are all regarded as predisposing causes. It has been sometimes known to come on during attacks of gout and rheumatism; and hence these diseases have been said to be favourable to its occurrence. Anatomical characters.—The principal anatomical character of this disease is a yellow homogeneous deposit which does not become vascular, and which is at first soft, but ultimately becomes more solid and firmly adherent to the parts with which it is in contact. This deposit is the ordinary result of the various forms of the disease, and on it the enlarge- ment depends. Pathologists have been anxious to determine in what textures the matter is originally deposited. Cruveilhier, who has given an interesting description of this disease, illustrated by coloured plates, supposes that the yellow substance is originally deposited in the cellular tissue of the testis, and that it radiates along the fibrous partitions from the corpus Highmori. But although in very advanced cases it may be found in the cellular tissue, yet, from the dissections of Sir Astley Cooper, Sir Benjamin Brodie, Mr. Curling, and many others, it appears certain that it is originally deposited within the tubuli testis, and that it is a secretion in them by the lining mem- brane. It has been found in them, in the rete testis, the epididymis, and the vas deferens. The disease may give rise to serous effusion into the tunica vaginalis, producing fluctuation; or to effusion of lymph, causing obliteration of the sac, or to ulceration of the coats of the testicle, and of the parietes of the scrotum, and to eventual protrusion, through the opening, of a yellowish, firm, comparatively painless fungus, which, being part of the testicle itself, the condition has very properly received the name of Hernia testis. In many cases the surface of the protruded part becomes covered over with a layer of weak granulations, affording a copious dis- charge ; but in many which I have seen no granulations were formed. The tumour consists of the tubuli testis with the yellow deposit, the part being pressed out by the morbid deposit when resistance can no longer be offered by the coats of the testicle, and the parietes of the scrotum, they having given way by ulceration. In some instances, the whole of the organ has protruded. The protrusion may or may not be preceded by slight suppuration, as well as by the yellow deposit, and sometimes pus is deposited in various parts, giving rise to abscesses and sinuses; and creating a necessity for castration. Such are the anatomical characters of chronic orchitis, when it runs its course. Symptoms.—The principal symptoms of this disease are slight pain, or a sense of uneasiness, or weight in the part. The uneasiness, how- ever, is not great, and in some instances is so slight that the disease has IRRITABLE TESTIS. 565 been known to make considerable progress before the patient has been aware of its existence. The testicle feels hard and incompressible. The hardness and pain are both greater before the coats of the testicle have given way, than afterwards. There is slight tenderness or pain on pressure, at the commencement of the inflammatory process; but after the disease has existed for some time, the tenderness on pres- sure is very inconsiderable, and (what is very remarkable), when, at an advanced stage of the disease, protrusion of the substance of the testicle has taken place, it is found to be nearly, if not entirely, insensible. If suppuration precede protrusion, the patient will exhibit the ordinary local signs of inflammation. The suppuration is always limited, as is also the softening which it induces. The general swelling usually dimi- nishes to a certain extent, when the scrotum has given way. Treatment.—The result of treatment is usually satisfactory, if com- menced at an early period. It may be said to consist in the removal of the cause of the disease, rest, a course of mercury carried to an extent sufficient to produce an impression on the system, and the careful employment of pressure by the mode already described. Mercury is the grand remedy, and in few diseases is more benefit derived from its use. Blue pill, alone or in combination with opium, as symptoms may indicate, is one of the best modes of administering it. In many cases I have used the proto-iodide of mercury in doses of a grain and a half night and morning, and with the most beneficial results. During an accession of inflammatory symptoms, local depletion by leeches may be necessary, but depletion forms no prominent part of the treatment of this disease. When protrusion has taken place, the mode of treatment now adopted is that for which we are indebted to Professor Syme. It consists in slightly enlarging the opening through which the protrusion has taken place, removing the hard ring of integument which consti- tutes the margin of the opening, bringing the integument completely over the protruded part, and retaining the opposite sides of the opening in apposition by means of sutures. This treatment has now been fairly tried in many cases, and, as far as I know, has been uniformly attended with the desired result. It is certainly a great improvement on the practice which formerly prevailed, namely, that of shaving off the fungus, or destroying it by escharotics, and endeavouring afterwards to heal the wound;—a treatment, in some instances, so tedious and unsa- tisfactory, that castration has often been deemed more expedient. NERVOUS AFFECTIONS OF THE TESTIS. There are two varieties of nervous affections of the testicle, namely, "Irritable Testis," and "Neuralgia of the Testis." IRRITABLE TESTIS. This affection, which is an increase of the natural sensibility of the organ, is usually met with in weak, irritable, dyspeptic, and hypochon- driacal persons, and is for the most part dependent on some affection of the urethra, or of the genital system, or on disorder of the general health. It sometimes occurs after great indulgence in sexual inter- 566 NEURALGIA OF THE TESTIS. course, or after much venereal excitement; and it has been known to be a consequence of onanism, and of involuntary seminal emissions. The sensibility of the organ is increased to a most painful extent, so that in some cases the part is intolerant of manipulation, and even the contact of the dress is painful. In some instances both sides are affected, a circumstance in which morbid sensibility differs from Neu- ralgia of the Testis. The uneasiness is usually increased by exercise, and by the erect posture, and is sometimes so great as to oblige the patient to abstain from exercise, and to remain at rest in the recumbent posture. As this distressing complaint yields to treatment, castration is not necessary; nor would it be always effectual, as the disease has been found to return in the cord. In some cases in which patients have insisted on castration, opportunity has been afforded of examining the condition of the testis, which, in no instance, as far as I know, was found to differ from the normal state, except that slight dilatation of vessels was in a few instances observed. In the treatment of this affection, the principal indications are, to remove the cause, to improve the general health by such means as are most judicious in the particular circumstances of the case, and to dimi- nish the preternatural sensibility of the parts by local bathing, and the application of anodyne lotions. Lotions containing opium, belladonna, or tincture of aconite, or combinations of these medicines, are often exceedingly useful. In several instances this affection has been cured by complete change of scene, air, and mental occupation, without any other treatment except support of the testis. NEURALGIA OF THE TESTIS. In this distressing affection there is constant uneasiness, sudden, severe, and remittent attacks of pain, occurring in paroxysms of variable duration, and generally at irregular but sometimes at regular intervals, like other neuralgic pains. The pain is most excruciating, and during its continuance the testicle is drawn up by spasmodic contraction of the cremaster muscle, and in some instances the pain is attended with nau- sea and vomiting. This affection possesses the characters of tic doulou- reux, or true neuralgia, and is almost always confined to the spermatic nerves of one side. It is most frequently met with in weak, irritable, and dyspeptic persons, and attended with a disordered condition of the digestive organs; and the intense pain and want of rest in most cases give rise to derangement of the general health. Occasionally this affec- tion has been found to succeed an attack of orchitis, and to recur when- ever the patient's health has become disordered, and in several cases jt has been known to be excited by the morbid condition of the veins in varicocele: but in the great majority of instances the cause of the disease is exceedingly obscure; and when, on account of the severity of the pain, patients have insisted on castration, dissection has not dis- covered anything to account for the pain; for the structure of the testis has almost always been found to present a perfectly healthy appear- ance, except in some examples, in which there was a slight fulness of vessels, the effect probably, and not the cause, of long-continued pain. Castration is not advisable, for although in some instances the result SCROFULOUS TESTICLE. 567 has been favourable, in others the disease has returned in the cord; and moreover, the disease usually yields in time to the treatment proper for neuralgia in other parts, which has been already described. TUBERCULAR DISEASE OF THE TESTICLE, OR SCROFULOUS TESTICLE. This disease sometimes occurs in children, a fact, of which a con- siderable number of examples are recorded, and of which I have seen two, in boys of five and seven years of age; but it has been found ad- vanced to the stage of suppuration at a still earlier period. The most com- mon time for its appearance is at puberty, or between that period and the age of twenty. It is generally found only in one testicle, but some- times both are affected. Symptoms.—The patient feels uneasiness in some part, generally in the epididymis, where, on examination, enlargement and induration may be perceived. The hardness is greater than in common chronic orchitis, but less than in scirrhous affections of the testicle. In most cases un- easiness is afterwards experienced in another part, commonly also in the epididymis, and on examination another swelling with the same characters is discovered. The disease is always slow in its progress, and often ap- pears as if stationary; but after a considerable period the enlargement becomes greater, the uneasiness increases, the integument becomes of a dark livid red colour, and adherent to the large part, and at last an ab- scess forms, from which pus mixed with tubercular matter is discharged. The quantity of matter discharged is not great, the abscess does not readily heal, a fistulous opening forms, through wrhich a thin discharge, sometimes mixed with seminal fluid, continues to ooze. Sometimes hernial protrusion takes place of the tubercular matter. The slight fungus thus formed is easily distinguished from protrusion of the substance of the gland in chronic orchitis by being much softer, of less extent, and more easily broken down. From what will be stated under the head of treat- ment it will be evident that the diagnosis in these cases is very important. It is not often that the whole testicle is destroyed by the disease; in the great majority of cases a considerable portion of the organ remains in a sound state. In an advanced stage of the disease the original humour may not be so easily perceived, on account of general swelling caused by effusion into the tunica vaginalis. The patient in most instances exhibits scrofulous affections in other parts. Anatomical Characters.—The swelling presenting the characters already described depends on tubercular deposit, the seat of which is more frequently in the epididymis than in the testis. Cases have occurred in which the entire epididymis has been found to be occupied with this deposit, while the structure, of the testis was perfectly sound. The desposit is met with in various situations, often at the ends of the epididymis, the globus major being more frequently affected than the minor. It is a question whether tubercular matter is originally formed in the tubuli themselves, or in the cellular tissue connecting them together. The dissections of various competent observers lead to the conclusion, that it may take place both within and without the tubuli. It has been found in the interior ducts forming the epididymis, and in the vas defe- rens, and sometimes in the processes sent in from the tunica albuginea to 568 FIBROUS TRANSFORMATION OF THE TESTIS. support the lobules composing the testis. In the section on Tubercular Tumour will be found an account of the views at present entertained of the origin of Tubercular Deposit, together with a description and de- lineation of its appearance viewed under the microscope. Treatment.—The treatment is both constitutional and local. In this as in other scrofulous affections, constitutional treatment is of the first importance. The constitutional treatment proper in cases of Scrofulous Deposit will be detailed in the section on Tubercular Tumour. With regard to the local treatment, support of the testicle is indispensable in every stage of the disease. In its first stage, and when the morbid action has become chronic, rubbing the part with iodide of potassium ointment, or with an ointment of the iodide of potassium and iodine, or painting it every second day with tincture of iodine, or strapping the testicle with the emplastrum ammoniacum, are suitable local remedies. My own experience leads me to prefer painting the part with tincture of iodine in preference to any other application. When local inflammatory symptoms present themselves, the most useful remedies are, rest, eleva- tion of the testicle, leeches, and cold lotions; and should suppuration occur, early evacuation of the matter by direct incision is important. After evacuation of the matter, it is sometimes advisable to destroy the diseased parts by means of the nitrate of silver, after which a healing action is more readily induced. Should protrusion of the tubular portion occur, the treatment of preserving the part and bringing the integument over it is not suitable, though so successful in the case of fungus in chronic orchitis; but the protruded part should be destroyed by some powerful escharotic, such as the potassa fusa, or the chloride of zinc. Sometimes the destruction of the substance of the testis is so extensive from tuber- cular deposit, suppuration, and sinuses, as to render ineffectual every proceeding except castration. FIBROUS TRANSFORMATION OF THE TESTIS. The principal symptom of this comparatively rare affection is, great induration. In some cases the testis has been found unchanged in size; in some, slightly diminished; in others enlarged. It is distinguished by the absence of pain or any particular inconvenience, by not being of a malignant character, and by occasioning little discomfort, except when the patient becomes alarmed, and the affection is in consequence a source of mental anxiety. I have met with only one example of this disease in my own experience; and in that I was obliged to resort to castration, on account of the patient's excessive anxiety, in consequence of which his general health had been seriously injured. The only local symp- toms in this case wTere, great induration, slight enlargement, and a sense of weight in the affected part. When, from the above-mentioned cause, castration is deemed advisable, it may be resorted to with every prospect of satisfactory success, as the disease is not of a malignant character. No treatment is of any,a vail. The disease seems to consist in the change of the cellular tissue into fibrous, and the new development of fibrous tissue, the presence of which causes obliteration and removal of the secreting structure. Dissection has revealed two varieties of the disease ; one, the more common, in which the testis becomes firm and dense like the fibrous tumour of the womb; and the other, in which the structure is compara- CYSTIC SARCOMA. 569 tively loose, and slightly infiltrated with a serous fluid. The anatomical and microscopic characters of fibrous tumour are more particularly de- scribed in the chapter on Tumours. CYSTIC SARCOMA. Symptoms.—This rare affection, called by some hydatid disease of the testicle—an improper appellation, inasmuch as the cysts are not of the nature of animal hydatids,—is chiefly met with in the middle period of life, rarely before the eighteenth or after the fortieth year. It begins in the testis, and is unattended with pain, tenderness on moderate pres- sure, redness, heat, transparency, enlargement of the cord or glands in the groin, or with any constitutional disturbance, or derangement of the general system. These negative symptoms are very important to be noticed for the purposes of diagnosis. There is a swelling, the pecu- liarities of which are, that it increases very slowly, is usually of an oval form, has a smooth surface, and though somewhat uneven in its general outline, has none of the irregular knotted surface peculiar to scirrhus. The swelling is not so pyriform as in hydrocele, but like the testicle itself, is compressed laterally. It feels heavy, and not only creates inconvenience by its size, but when it becomes large, causes an uneasy sensation and dragging pain in the lumbar regions from its weight, especially when unsupported. With regard to its fluctuation, it has been well remarked, "When the swelling is handled, it communicates an impression that it contains a fluid, for it easily yields on pressure ; yet there is no true fluctuation, for the tumour does not rise at a distance, as it sinks under the pressure of the finger, but it yields only at the spot compressed." It is, in fact, more a yielding than a fluctuation. The veins of the cord are enlarged. By these marks the disease may be distinguished from hydrocele and encephaloid cancer, the only two affections with which there is any risk of confounding it. Anatomical Characters.—The testicle consists of cysts varying much in number, size, thickness of their parietes, and nature of their contents. At an early stage of the disease there may be only a few, but at an ad- vanced period they are almost innumerable ; they are small and vas- cular at first, and contain a transparent fluid. As the cysts increase, the secreting structure of the testicle becomes atrophied and removed, and often wholly destroyed; the cysts increase in number, thickness, and size; and their contents, instead of remaining transparent, become viscid, thick, albuminous, and often present the appearance of a mucous secretion. The contents of the cysts present at least as great varieties as the size and thickness of the parietes in which they are contained; the latter becoming sometimes exceedingly dense and firm. The tunica albuginea and tunica vaginalis become thickened, and the surfaces of the latter more or less adherent. 2Wmen«.—Castration is the only proceeding attended with any ad- vantage, and as the disease is not of a malignant nature, the results of that operation are almost invariably satisfactory. In some exceedingly rare instances, medullary disease has been found combined with the affection ; in such cases an operation is quite unsuitable, inasmuch as it cannot save life. 570 ENCEPHALOID CANCER OF THE TESTIS'. ENCEPHALOID CANCER OF THE TESTIS. This malignant disease, described under the names of soft cancer, fungoid disease, fungus nematodes, medullary sarcoma, pulpy testis, and encephaloid cancer, is by no means uncommon; and, although no age can be said to be exempt from it, many instances of it being recorded even in children and young persons, yet it much more frequently occurs between the ages of eighteen and thirty-five, than at any other period of life. Symptoms.—For the purpose of diagnosis, the peculiarities of the dif- ferent symptoms require to be minutely observed. Swelling is the earliest symptom : it begins in, and is for some time confined to the testicle, and while so confined, is globular, being somewhat of the shape of an orange, instead of being compressed laterally, as the testicle in the normal state is. It is rather hard at first, pretty uniform in its general outline, and entirely destitute of fluctuation. As the disease advances, the epididymis becomes involved, and there may occur slight effusion into the tunica vaginalis, constituting the condition called by some hydro- sarcocele; and when the disease has advanced thus far, the swelling may be less flattened laterally, and present more of the pyriform shape of hydrocele. As the disease advances still further, the cord and the glands in the groin become affected, and at last firmly adhere to the sur- rounding parts. The swelling of the testicle, as has been already stated, is at first round and regular; afterwards it becomes uneven, and on ex- amination has an elastic feel, which is very deceptive, and, unless ex- amined carefully, may be mistaken for fluctuation. If the surgeon be induced by the elastic feel to make a puncture, blood only escapes. In the early stage of the disease, the integument is free from discoloration, and does not adhere to the swelling ; in the next stage it still does not adhere, and has a natural appearance, but the veins in it are varicose; and in the third stage the integument is involved, adheres to the tumour, and presents a dark livid discoloration ; and if the patient do not very soon fall a victim to the disease, the integument at last ulcerates, and a fungus, which frequently bleeds, starts up and increases rapidly. It is, however, very rare to see this fungus, as the disease generally proves fatal by the constitutional symptoms, before it arrives at that stage. I once had an opportunity of seeing the disease in. that stage in a member of the Profession, who was a pupil of my own; and in that case the hemorrhage from the fungus was at times very considerable. The pain at first is not constant, but ultimately becomes very severe, and in the cases which have come under my own observation, the patients have de- scribed the pain as a most distressing feeling of weight, as if a heavy body rested on the testicle. In some instances the tumour in the loins is exceedingly painful; but in others it gives rise to comparatively little uneasiness—a circumstance which Sir Benjamin Brodie supposes to de- pend on the fact of the tumour sometimes pressing on the nerves, and sometimes being in a measure removed from them. The pain in the testicle and in the loins is in some cases most distressing. The extre- mity on the affected side becomes swelled and oedematous: in some in- stances the glands in the opposite groin become affected; and the scrotum, glands of the groin, integument, and pubes, all become firmly EXCISION OF THE TESTICLE. 571 adherent to each other, and in a measure all involved in one diseased mass. It is very rare for both testicles to become affected, and, singular as it is, one testicle is often found to all appearance perfectly sound, while the scrotum around it is completely involved in the disease of the opposite side. The disease increases very rapidly, the appetite fails, the countenance is sallow, the body becomes very rapidly emaciated, and the patient falls a victim to the symptoms of cancerous cachexia. Such are the principal symptoms of this most distressing and incurable disease. Of the present state of our knowledge of the origin, and ana- tomical and microscopical characters of encephaloid cancer, an account will be given in the section on Carcinoma in the chapter on Tumours. The disease is invariably fatal, whether the part be removed or not. No treatment has any effect in arresting its progress, and all that the sur- geon can accomplish by medicine, and indeed the only course that it is proper to pursue, is to alleviate the suffering caused by some of the most urgent symptoms. SCIRRHUS OF THE TESTICLE. This is a very rare disease, and as yet no case of it has come under my observation, either in public or private practice. Sir Astley Cooper says he has seen but a few examples, and gives the following description of the disease :—" A truly scirrhus affection of the testicle begins in the body of it, with an extremely hard swelling, which may immediately inform the surgeon of the nature of the disease. It feels like a marble body lodged within the scrotum, and it is tuberculated on its surface. It sometimes begins in the centre of the testicle, and gradually extends until the whole is involved in the disease. The epididymis next becomes the seat of the disease, that portion being first attacked which communi- cates with the vas deferens. The spermatic cord becomes enlarged, and tubercles of various sizes form upon it. After the spermatic cord has become enlarged, a hard tumour forms beneath the emulgent artery, which may be felt through the abdominal parietes. In true scirrhus the testicle does nof become enlarged to any considerable size. After the swelling in the loins, the thigh becomes enlarged and oedematous on the side of the disease, which arises from the obstruction to absorption; and the pressure on the veins may also have influence in producing this effect." Prognosis is as unfavourable here as in examples of scirrhus in other situations. The common and microscopic characters of fibrous carcinoma are described and delineated in the chapter on Tumours. EXCISION OF THE TESTICLE. The hair having been shaved from the pubes, the patient having been brought under the influence of chloroform, and placed in the recumbent position, with the thighs separated, the surgeon with his left hand grasps the tumour behind, so as to make the integument tense in front, and then makes two elliptical incisions, extending from the external aperture of the inguinal canal to the under part of the swelling, and embracing between them as much integument as it may be necessary to remove with the view of preventing redundancy after the operation. Due allowance, however, must be made for the integument drawn from sur- rounding parts, resiling after removal of the tumour. The cord should 572 HYDROCELE. then be exposed, fj^mly grasped by an assistant, and cut through as low down as may be compatible with the entire removal of the disease. The operator takes hold of the under portion of the cord, and with a few movements of the knife extirpates the testicle. The vessels of the cord having been tied, as well as any other vessels that may be found to bleed, the edges of the wound are approximated, dressed according to approved principles, and supported by a T bandage. The under part of the wound hardly ever heals except by granulation, and on that account it can answer no useful purpose to approximate the edges closely below. HYDROCELE. We shall refer to five forms of hydrocele ; namely, three of the tunica vaginalis, and two of the cord. The former is named, simple hydrocele of the tunica vaginalis testis, congenital hydrocele of the tunica vagi- nalis, and encysted hydrocele of the testis; and the latter, diffuse and encysted hydrocele of the cord. I. SIMPLE HYDROCELE OF'THE TUNICA VAGINALIS TESTIS. Symptoms.—There is swelling, which is generally round at first, but as it increases it assumes a pyramidal form, with its larger extremity downwards, the upper extending as the disease advances, as high as the inguinal canal. When the swelling is very large, the upper extremity expands considerably, and loses the narrowness of its form. If the hydrocele be large, the scrotum, owing to its great distension, loses its natural wrinkles, and assumes a glazed appearance ; and in consequence of the integuments being drawn upon the tumour, the penis seems con- tracted, and the raphe of the scrotum is, as it were, pressed to the oppo- site side: the swelling feels much lighter than a tumour of the same size caused by disease of the testicle. Besides its form and lightness, the swelling has another character which it is of importance to observe, as it assists in making out the diagnosis between hydrocele and hernia—it commences at the under part of the scrotum, and increases from below upwards ; whereas a scrotal hernia commences from above and extends downwards. The history of the symptoms thus become useful for assisting the diagnosis. Fluctuation is usually another symptom of hydrocele, but it is some- times not easily perceptible, when the scrotum is very greatly distended; and its absence is not a proof that a tumour is not hydrocele. Another symptom is transparency, the presence of which is a sure proof of hydrocele. On this subject, Mr. Pott remarks:—" The absence of transparency is not a proof that a tumour is not a hydro- cele;" and Professor Samuel Cooper observes that—"although the absence of transparency is not a proof that a tumour is not a hydro- cele, yet its presence is an infallible test that it is." According to Sir Astley Cooper, we never fail,' on proper examination, to discover trans- parency in such hydroceles as are formed in this country; but in per- sons who have had hydrocele formed in warm climates, the parietes of the scrotum are sometimes rendered so thick as to be no longer trans- parent. Two cases have come under my own observation, in which it was impossible to discover any transparency; the one in private prac- HYDROCELE. 573 tice, the other in a patient under my care in the Royal Infirmary, Aber- deen. In each case the fluid was of a greenish black colour, and very grumous; and to this condition, in both instances, I referred the absence of transparency. In the situation of the testicle the tumour is always opaque. In common hydrocele another symptom useful for diagnosis is, the free state of the cord; in hernia the cord is covered by the swelling, but in hydrocele it can be felt free in the inguinal canal. Another symptom of a tumour being a hydrocele is, its freedom from pain or tenderness under ordinary circumstances, or even on pressure, except at the testicle, where there is slight tenderness on pressure ; but at other parts there is no tenderness, and beyond inconvenience from its bulk and a sense of weight, the swelling gives rise to little or no dis- comfort. State of the Parts.—The swelling is caused by a fluid which is usually transparent, and of an amber, pale yellow, or straw colour, sometimes, though rarely, of a greenish or blackish green colour. Sometimes it is thick, and of a grumous appearance, and occasionally it contains a quan- tity of flaky matter, composed chiefly of albumen ; and in some instances, more especially in old persons, the fluid contains cholesterine in the form of minute shining particles. The seat of the fluid is the tunica vaginalis, which in most instances is transparent and simply distended ; but sometimes it is thickened, and occasionally, in consequence of pre- vious adhesions, it presents a sacculated arrangement, constituting what is called a multilocular hydrocele. The usual situation of the testicle is at the back of the swelling and below its middle, and this is the situation in which, from its natural relations, Fig. 215. it might be expected ; as it is not in the normal condi- tion of the parts adherent to the surrounding parietes laterally or anteriorly, but only posteriorly: but in some cases, in consequence of adhesions having been contracted between the tunica vaginalis propria and the tunica vagi- nalis reflexa by inflammation previous to the occurrence of hydrocele, it is found in the front or in other parts of the swelling. It is, of course, of much practical im- portance to ascertain the situation of the testicle, that it may be avoided in the operation ; the opacity, and the tenderness and doughy feel on pressure will indicate its position. Treatment.—The treatment adopted in all cases, ex- cept those of children, is by operation, and that of two kinds, palliative and radical; the former consisting in merely drawing off the fluid by tapping, the latter in doing this, and also in using means for the purpose of inducing such changes as may prevent the return of the fluid. The radical treatment by injection is that practised at the present day. The instruments necessary for this proceeding are a round trocar, and a caoutchouc bag with a nozzle and stop-cock, or a syringe ; the fluid, port wine or a solution of the sulphate of zinc, or a fluid con- taining one part of the tincture of iodine and three of 574 HYDROCELE. water, or a very small quantity of the tincture of iodine alone. The patient should be placed erect; the surgeon should with his left hand grasp the tumour behind, so as to render it prominent and tense in front, and with his right hand send the trocar and canula through the parietes, holding them perpendicular to the surface until penetration be effected, and then directing them obliquely upwards, so as to diminish the danger of wounding the testicle. The trocar having been withdrawn, and the fluid allowed to escape, the injection is thrown into the canula by adapting to it the nozzle of the caoutchouc bag, or the syringe. The injection is allowed to remain, until the patient feels pain in the loins or testicle, when it is withdrawn. Fig. 216. The time for its remaining varies in different persons ; in adults it is usually from four to seven mi- nutes ; but in all cases it is with- drawn when the patient begins to feel pain in the testicle or along the course of the cord. In addi- tion to the pain, patients often experience a feeling of faintness and sickness. The fluid having been withdrawn, the patient should be put to bed, the testicle sup- ported, and the after-treatment regulated according to the charac- ter of the supervening symptoms. If no symptoms of inflammatory action present themselves, the pa- tient should be induced to move about, and be allowed a generous diet, and the scrotum should be gently compressed and handled so as to occasion friction between the surfaces of the tunica vaginalis ; but if the inflammation threaten to be excessive, or so great as to render suppuration probable, rest, low diet, support of the testis, and the ordinary treatment for acute orchitis, should be enjoined. The tumour usually returns very quickly, and often requires the size of the hydrocele previous to the tapping; but in the course of twelve or fourteen days, under proper treatment, the parts generally resume their usual size% At one time it was supposed that injection effected a radical cure by the obliteration of the cavity of the tunica vaginalis caused by complete adhesions of the surfaces of that membrane ; but it is now known that, although the serous surfaces are sometimes united, this state is not essential, that more commonly the adhesions are only partial, and that the cure is produced by an altera- tion in the secernment function of the membrane. Many different kinds of fluid have been used for injection, as dilute spirits of wine, dilute port wine, port wine undiluted, solution of alum, solution of the sul- phate of zinc, cold water, lime water, and tincture of iodine, either alone Fig. 216. From Liston. HYDROCELE. 575 in very small quantity, or mixed with water in the proportion of one part to three. Until lately, port wine and the solution of sulphate of zinc were the favourite injections, but the tincture of iodine with water is now generally preferred. Mr. Martin, a surgeon in India, was the first who tried iodine injections. His proceeding was, to use one part of the tincture to three of water, to inject only a very small quantity, and to allow it to remain ; and the result of this practice was, that of two thousand three hundred and ninety-three cased treated at the native hospital of Calcutta, the failures were under one per cent. The use of iodine injections has since been tried by surgeons in most parts of the world, and, so far as their experience is recorded, with satisfactory results. Some use a very small quantity of the tincture alone, and allow it to remain. Others, and perhaps a larger number, use the injec- tion of the strength employed by Mr. Martin, and allow it to escape. My own experience in the use of iodine and water, allowing it to escape, has been most satisfactory. In children it is not advisable to have recourse to injections ; neither is it necessary, as the swelling is in most cases easily dispelled by the application of discutient lotions ; and when this treatment is not found to produce the desired result, simple puncture with the lancet, and escape of the fluid, are usually followed by a radical cure. In two other conditions injection is not advisable, namely, when the testicle is diseased, and when, though it is sound, the hydrocele is very large. In the latter case the most prudent method of proceeding is to evacuate the fluid by tapping, to allow its reaccumulation until the hydrocele attain a moderate size, and then to proceed with tapping and injection. Various other methods of treatment have been employed for effecting a radical cure, as incision, excision, caustic, seton, and acupuncture ; but as these methods have almost all fallen into complete desuetude, it is unnecessary to describe them. II. CONGENITAL HYDROCELE OF THE TUNICA VAGINALIS. This differs from common hydrocele, inasmuch as the fluid communi- cates with the cavity of the peritoneum by a vaginal process of that membrane, within the inguinal canal. In this variety, injection must never be employed while the communication remains, as peritonitis might result from the extension of the inflammation to the abdomen. The first indication is, to obliterate the tubular communication with the abdomen; and the best means for this purpose is gentle pressure by the use of a truss. After the obliteration has been accomplished, the tumour is often dispelled in children by the use of discutient lotions, and in adults the usual treatment of injection may be employed. The only judicious operation in any case before obliteration, is the simple drawing 'off of the fluid. III. ENCYSTED HYDROCELE OF THE TESTIS. In this form the fluid is contained in a cyst, or cysts, distinct from the cavity of the tunica vaginalis. These collections present the three following varieties :—first, they occur, and that most frequently, below. 576 HYDROCELE. that part of the tunica vaginalis which covers the epididymis ; and the cysts differ greatly in size, number, and form, being in some instances small and pressed into the epididymis, while in some the tunica vaginalis is raised up by them, and they assume a pendulous, peduncu- lated form, and in others they become large, but remain connected with the epididymis by a broad base; secondly, they occur between the tunica albuginea and the tunica vaginalis testis ; in this, which is the rarest form of all, the cyst is usually single and of small size ; and thirdly, between the layers of the loose or outer portion of the tunica vaginalis. In encysted hydrocele the tumour should not be interfered with, un- less it become troublesome from pain, or inconvenient from its size. When interference is deemed advisable, the most judicious proceeding is merely to draw off the fluid by simple puncture. If the tumour should return, and it be thought advisable to endeavour to effect a permanent cure, as the treatment by injection has not been found to succeed so well as in common hydrocele, the preferable treatment, especially when there is a number of cysts, is the use of a seton, which should be intro- duced and retained until consolidation be effected. HYDROCELE OF THE CORD. Of this affection there are, as has been already stated, two varieties, namely, diffuse and encysted. I. DIFFUSE HYDROCELE OF THE SPERMATIC CORD. This exceedingly rare variety consists of an albuminous fluid of a white or yellowish colour, diffused throughout the cellular tissue con- necting the vessels of the spermatic cord, which tissue is surrounded by a cellular sheath, and this sheath, again, is invested by an expansion of the cremaster muscle and the coverings of the cord external to it. The affection is of the nature of simple oedema; the cells, however, are so greatly distended as to be converted into large vesicles. In some in- stances, at the lower part of the tumour, the cells disappear, and the fluid at that part is contained in a single cavity, where it forms a swell- ing attended with fluctuation. An example of this rare form of hydro- cele has not come under my own observation. Mr. Pott, who appears to have met with more examples of it than any other surgeon, gives the following description of its symptoms and appearances :—" In general, while it is of moderate size, the state of it is as follows : The scrotal bag is free from all appearance of disease ; except that when the skin is not corrugated, it seems rather fuller, and hangs rather lower on that side than on the other, and if suspended lightly in the palm of the hand, feels heavier; the testicle, with its epididymis, is to be felt perfectly distinct below this fulness, neither enlarged nor in any manner altered from its natural state; the spermatic process is considerably larger than it ought to be, and feels like a varix, or like an omental hernia, according to the different size of the tumour ; it has a pyramidal kind of form, broader at the bottom than at the top; by gentle and continued pressure it seems gradually to recede or go up, but drops down again immediately on removing the pressure, and that as freely in a supine as in an erect • posture; it is attended with a very small degree of pain or uneasiness, HYDROCELE. 577 which uneasiness is not felt in the scrotum, where the tumefaction is, but in the loins. If the extravasation be confined to what is called the spermatic process, the opening in the tendon of the abdominal muscle is not at all dilated, and the process passing through it may be very dis- tinctly felt; but if the cellular membrane, which invests the spermatic vessels within the abdomen, be affected, the tendinous aperture is en- larged, and the increased size of the distended membrane passing through it produces to the touch a sensation not very unlike that of an omental hernia." Treatment.—While the swelling is small and unattended with particu- lar inconvenience, the most judicious course is not to interfere with it. When interference becomes necessary, the best mode of treatment is acupuncture. The punctures are made at the under part of the swell- ing, and need not be numerous. The fluid escapes into the cellular tis- sue of the scrotum, and is soon removed by absorption. This mode of treatment is unattended with danger, whereas free direct incision into the cells is not so. II. ENCYSTED HYDROCELE OF THE SPERMATIC CORD. The symptoms of this variety are a swelling, slow in its growth and painless, usually of an oval form, movable on the cord, attended with fluctuation, and in most instances, distinctly transparent. The tumour is generally circumscribed, and the testis can be felt separate. This affection is most common in infants, but it is met with at all periods of life. The fluid is sometimes of a straw colour, but more frequently limpid, and contains little or no albumen. Occasionally more cysts than one are found; but this is unusual, the fluid being generally con- tained in a single cyst. This cyst is in most cases formed of an ob- literated portion of the vaginal process of peritoneum drawn down at the period of the descent of the testicle ; sometimes however the cyst is an adventitious formation. It is embedded in the cellular tissue con- necting the vessels of the cord with each other, and is embraced by the other coverings of the cord. In children, this affection usually disappears under the use of appli- cations calculated to promote absorption, as in simple hydrocele at the same period of life ; and in adults, if interference be necessary, the cure may be accomplished either by tapping and injection, or by the use of a seton. 37 578 CHAPTER XVII. AFFECTIONS OF GENITO-URINARY ORGANS. GONORRHOEA. The essential and characteristic symptom of gonorrhoea is a purulent, or muco-purulent discharge from the urethra of the male, or the vagina of the female. It may be either simple or virulent in its nature. In the former case, it is caused by sympathetic irritation, such as teething ; or it is but a symptom of the existence of other affections, generally of rheumatism or gout. In the latter, it depends upon the direct application of a specific irritant, occurring usually during sexual intercourse. When it assumes a chronic form, it is called gleet, and often resists most obstinately, for months or even longer, every effort for its removal. Besides these varieties, the term spurious or external gonorrhoea has been given to a discharge of the same nature from the surface of the glans, or the lining membrane of the prepuce; some authors term it balanitis. SIMPLE GONORRHOEA. If it arises from simple local or constitutional irritation, such as teething, the use of bougies, violent horse-exercise, a blow on the peri- neum, &c, the only symptom will be a purulent discharge of a whitish colour from the urethra, for the most part unaccompanied with heat, pain, or ardor urinse; but if it is a precursory symptom of gout or rheumatism, in which case it is called arthritic gonorrhoea, the presence of symptoms of local inflammation and of ardor urinse will render the diagnosis between it and virulent gonorrhoea extremely difficult. The discharge, which in the case of gout is supposed to arise from a super- abundance of uric acid in the urine, will disappear immediately upon the development of the disease itself. In this affection scarcely any special treatment is required, the re- moval of the cause of irritation bjiing generally quite sufficient; but if necessary, recourse may be had to mild injections, laxatives, and such remedies as the state of the body may indicate. Sir Astley Cooper has in his lectures strongly pointed out the im- portance, in a medico-legal point of view, of distinguishing accurately between this and the venereal or virulent form of the disease, especially in cases where it is asserted that a rape has been committed on very young children; the only ground of such accusations often being the GONORRHOEA. 579 existence of a discharge from the vagina of the child. The possibility, therefore^ of this being of a harmless nature, and not the consequence of sexual intercourse, must always be kept in mind. VIRULENT, OR VENEREAL GONORRHOEA. Cause.—-This form of gonorrhoea is produced by the application of a specific irritant or virus to the surface of the mucous membrane of the urethra or of the vagina; such application occurring usually, but not necessarily, during sexual intercourse. Nature of the Virus.—This virus is essentially distinct from that of syphilis. The experiments of John Hunter seem, indeed, to disprove this; but they have since been carefully repeated by Benj. Bell and others with an entirely opposite result; and M. Ricord of Paris has completely set this question at rest by his numerous and well-conducted researches.1 Out of five hundred and forty-nine cases, occurring in his male and female wards, of gonorrhoea uncomplicated with chancre, and one hundred and twelve cases of chronic gonorrhoea or gleet, all of which were subjected to a test of inoculation in other parts of the body, not one produced the characteristic pustule which he invariably found to result from inoculation with matter from chancre in any of its forms during the period of infection. The circumstance of gonorrhceal matter having by inoculation produced chancres in the experiments of Hunter and others, M. Ricord attributes to the presence of concealed chancres (chancres larves) in the urethra, which he has shown to be a frequent complication. It is right, however, to state that the late Mr. Carmi- chael, of Dublin, continued to adhere to the opinion, that gonorrhoea virulenta produces the same constitutional effects, and is therefore iden- tical in its nature with that mild form of chancre which precedes the papular eruption. But in his lectures,2 whilst treating upon this subject, he has not taken into consideration the possibility of the existence of concealed chancres, which M. Ricord has pointed out in every one of the five cases quoted by Carmichael in support of his own theory, and which, if acknowledged, would reconcile his view with that generally received, namely, that the gonorrhceal virus is essentially distinct in its nature and effects from that of syphilis. Period of Development.—The time at which the discharge first makes its appearance varies, but is generally from the fourth to the seventh day after infection. Occasionally it shows itself earlier, even in twenty-four hours, of which Sir A. Cooper mentions an instance; sometimes after a much longer period. In this latter case, however, it is often retarded by the co-existence of the premonitory symptoms of another disease, such as fever, on the recession of which disease it may immediately ap- pear. Its duration is very variable, and cannot be predicted from either the nature or the severity of the symptoms. It often runs its whole course 1 "In the Lock Hospital of Edinburgh, Ricord's experiments have lately been repeated in a number of instances with nearly similar results."—Sir George Ballingall's Military Surgery, p. 425. 2 Clinical Lectures on the Venereal Disease, by R. Carmichael, 1842. 580 GONORRHOEA. in a few weeks ; at other times it lingers on for months, or even years, constituting what is termed gleet. The following additional facts respecting gonorrhceal infection appear to be well established. 1. The disease is not communicable, by sexual intercourse before the discharge appears. 2. After the discharge is es- tablished, if the urethra be previously washed out by means of a syringe, it is not probable that the disease will be communicated. 3. The matter possesses the power of infection for an indefinite period; Titley records the case of a girl communicating the disease on the first night after her leaving the Magdalene, where she had been for twelve months. 4. Two people having gleet may have intercourse with impunity; but either of them will communicate gonorrhoea to a sound person. 5. The violence of the symptoms depends much upon the habit of body, the scrofulous diathesis greatly increasing their severity;—thus the same woman may give a very mild form of the disease to one man, and a most severe form to another. 6. The first attack of the disease is always the most violent. 7. The disease is now much milder than formerly. Symptoms.—At first there is merely a slight uneasiness and swelling along the anterior and under portion of the penis, with a tickling, teasing sensation over the glans and anterior portion of the urethra, the lips of which are found to be slightly red and turgid. Upon squeezing the glans a small quantity of a whitish muco-purulent matter exudes. In a few days, the time varying according to the irritability of the constitution, the uneasy tickling sensation gives place to pain, which is often remarkably severe. There is an abundant discharge of yellowish pus, with scalding pains (ardor urinse) during micturition, the calls to which are very frequent. The urethra, in consequence of the inflamed state of the mucous membrane, is much narrowed, causing the urine to be voided in a stream much smaller than usual, and sometimes forked, by reason of bands of lymph stretching across the interior of the canal. There may also be painful erections during the night. The pain pro- gressively increases, and the matter discharged becomes greenish, or perhaps mixed with blood ; and besides the painful erections, chordee may now supervene. This term is given to a distorted condition of the penis, in which it is curved downwards, or to one side during erection, owing to the circumstance that inflammatory effusion into the corpus spongiosum prevents equal expansion with the corpora cavernosa. The inflammation may extend externally over the glans and membrane lining the prepuce, causing effusion into the cellular tissue between it and the integument, narrowing the external orifice, and giving rise to phymosis; or, if the prepuce had been previously retracted, to paraphymosis. This is the general progress of a moderately severe attack of gonor- rhoea. In some cases, however, the inflammation extends along the course of the lymphatics to the inguinal glands, there causing bubo; or backwards along the urethra to the membranous or prostatic portions, the neck of the bladder, or the bladder itself. The testicle may like- wise become involved. Each of these complications will, however, require a separate notice. Treatment.—The progress of gonorrhoea may be divided into three GONORRHOEA. 581 stages—the inflammatory, the suppurative, and the chronic ; in each of which an entirely different mode of* treatment is indicated. Some short time, however, generally intervenes between the first appearances of the gonorrhceal discharge and the accession of the inflammatory stage; and it has been recommended, upon high authority, to take advantage of this interval and check the disease at once, by throwing into the urethra strong injections of the nitrate of silver—ten grains to an ounce of water. This plan, however, is no doubt attended with con- siderable risk, as it may excite high inflammation of the urethra ex- tending perhaps to the bladder. Dr. Titley and Mr. Carmichael agree in strongly deprecating the practice; Ricord, Arnott, and many others, strongly recommend it. It is called the ectrotic or abortive treatment, to distinguish it from the curative ; and the time for its employment is limited to the nascent period of the inflammation,—the object aimed at being to prevent the development of the disease. Dr. Arnott's mode of employing this treatment is as follows :—About a couple of drachms of a solution of the nitrate of silver, in the propor- tion of twelve grains of the salt to an ounce of water, is thrown into the urethra by means of a glass syringe ; the penis being at the same time elevated and compressed about two inches from the orifice, thus insuring complete application of the solution to the urethral membrane within this range, and no further. The solution is retained within the urethra for not less than half a minute, and no urine is to be passed for half an hour after the injection. The immediate visible effect of the application is the formation of a coagulated film on the surface of the urethral membrane; and the diminution of pain which the patient ex- periences during micturition is probably to be attributed to the protec- tion thus afforded to the abnormally sensitive membrane. It is also thought that the effects of the application may be partly attributed to the well-knowrn action of the nitrate of silver in subduing crescent in- flammation. Dr. Arnott thinks that this proceeding is open to only one objection, namely, that the period of its applicability is limited to a stage of the disease which usually excites but little attention. Ricord, while he advocates the adoption of the abortive treatment, admits, as the result of his own experience, that although it has many advantages, it has its drawbacks and unpleasant consequences. He recommends that the urethra should not be compressed during the injec- tion, and that the abortive treatment should also include the internal use of copaiba and cubebs in large doses. Injections modify and create a new action in the mucous membrane, and copaiba and cubebs, by yielding their principle to the urine, contribute powerfully to render that modification more effective. In the female syphilitic ward of the Royal Infirmary of Aberdeen, I have not had opportunities of trying the effect of ectrotic treatment, because the period for its employment is over before patients present themselves for admission : and my oppor- tunities of forming an opinion from personal observation in males in private practice have been too few to enable me to arrive at a decided conclusion: but in the very limited number of cases in which I have employed it, I adopted Dr. Arnott's method, and had every reason to be satisfied with the results. 582 GONORRHOEA. If the disease remain and progress after one, or at most two injec- tions, the continuance of this treatment must be deemed unadvisable. With regard to curative treatment, an entirely different mode is indi- cated in each stage. I. Inflammatory Stage.—A suspensory bandage should be used from the commencement. Rest, attention to cleanliness about the parts, low diet, abstinence from all stimulating drinks, with the use of antimonials in nauseatory doses, must be strictly enforced. If the inflammatory symptoms run extremely high, with much constitutional disturbance, it may be necessary to have recourse to local depletion, and that very freely, a dozen or twenty leeches being applied to the perineum or groin. It would not be advisable to apply them to the penis itself: for if the gonorrhoea should be complicated with concealed chancres, the leech- bites would become infected, and the disease be considerably aggravated. Phymosis might also be the result of such an application, from infiltra- tion of the cellular tissue. The patient should drink largely of diluents, such as barley-water, linseed tea, solution of gum arabic, &c.; these tend to diminish the irritating quality of the urine, and thus modify some of the distressing symptoms. To mitigate the ardor urinse, if very severe, about twenty drops of liquor potassse with thirty drops of tinc- ture of hyoscyamus, or five grains of ext. conii, may be given in cam- phor mixture, three or four times a day, with much benefit; emollient fomentations being at the same time applied to the penis. If painful erections or chordee supervene, a most efficient remedy is camphor with opium, which may be given in the form of pills at bed-time. During the attacks, cold should be applied to the penis and the feet. The paroxysm is often checked by the patient getting out of bed, and put- ting his feet upon the cold floor ; but if these means do not succeed, an opiate enema should be given, or a grain or two of solid opium intro- duced within the rectum. The bowels must be kept moderately open, by means of saline purgatives; but smart purging is to be avoided, because irritation of the rectum increases the pain of the urethra. By these means the inflammatory symptoms, even if of considerable severity, may be subdued; but in most cases, such active treatment is unnecessary. The inflammation is generally slight, and in a few days gives way to rest, cleanliness, low diet, the free use of antimonials, liquor potassae, demulcent drinks, with fomentations and support of the parts. The treatment must then be altered, and such remedies adopted as act favourably upon the inflamed mucous membrane. II. Suppurative Stage.—The inflammatory symptoms being much checked, and the discharge having assumed a purulent character, even if considerable ardor urinse be still present, the use of copaiba or cubebs should be commenced, the antiphlogistic regimen and rest being at the same time strictly enforced. These medicines seem, by the principle they yield to the urine, to exert a favourable action upon the urethra itself; since, when the seat of gonorrhoea is the glans, vagina, or vulva, they appear to be of no ser- vice. The balsam of copaiba may be given alone, or on sugar, or float- ing on water, in doses of about thirty-five drops three times a day; but, as it is then apt to excite nausea, and other disagreeable symptoms, it ■ GONORRHOEA. 583 is better to give it in the form of emulsion, combined if necessary with diuretics. The following is a useful formula for its administration,—a wine-glassful being given night and morning. R Bals. Copaibae.....3vj. Mucilag. Acacias ..... gvj. Spir. JEth. Nitrosi . . . . 3ij. Sacchari Albi......3ss. Aquas Cinnamomi ..... gvj. Fiat Mistura. Another very convenient form of its administration is in pills, made by mixing the balsam with one-sixteenth part of its weight of calcined magnesia. Dr. Titley strongly recommends Morson's soluble extract of copaiba, one drachm of which, dissolved in eight ounces of boiling water and strained, forms an agreeable mixture, and is one of the best forms of exhibiting this medicine. The gelatinous capsules, although they answer the purpose of introducing the balsam into the stomach without being tasted, do not prevent the consequent nausea, and the purity of the copaiba cannot be relied on when disguised in this way. Cubebs when fresh ground and pure are undoubtedly of great service in this disease. They may be given two or three times a day in water or milk, in doses of half-a-drachm, increased afterwards to one or two drachms, a grain or two of nitrate of potass being often added advan- tageously. If the discharge is not suppressed in eight or ten days, the cubebs will have no effect, and may be discontinued. In successful cases the beneficial results generally appear in two or three days, and may be known by the discharge first assuming a ropy character, and then ceasing altogether. Injections.—A considerable number of days must be allowed to elapse after the subsidence of the inflammatory symptoms, before injections can properly be used ; then, however, they are often of the greatest service. Those most in use are, solutions of the diacetate of lead, sulphate of zinc, and nitrate of silver; the last is the most efficient, but must be used very cautiously at first, commencing with a quarter of a grain to an ounce of water, and gradually increasing it to one or even two grains. The diacetate of lead, and sulphate of zinc may be used as strong as two grains to the ounce from the very commencement^ their strength being gradually increased, if necessary. These injections should be used two or three times a day; if, however, they cause pain, they must be diluted; and if the discharge should stop suddenly, or irritation of the urethra be excited by their use, they must be altogether discontinued. By persevering in the use of these remedies, the gonorrhoea in most cases gradually disappears. To prevent its return, the injections must be still used for some days, though with less frequency, and of diminished strength, and after that time they may be entirely discontinued. In some instances, however, the discharge still continues, assuming a chronic form, and constituting gleet. ^ III. Chronic stage or gleet.—All inflammation has now disappeared, but the discharge' continues, accompanied perhaps with slight ardor urinse ; or if it ceases for a few days, it returns again and again without any apparent cause. This state may depend upon relaxation, or per- haps upon the presence of stricture. If the latter be detected, it must 584 GONORRHOEA IN WOMEN. ■ be treated accordingly. In this stage the use of injections must be con- tinued, their strength being increased, if necessary ; and if they are frequently changed, the desired effect is so much the more likely to be produced. M. Ricord strongly recommends an injection of a solution of iodide of iron, commencing with one grain to an ounce of water, and increasing it gradually till it has some effect upon the discharge. This remedy I have found very useful. Generous diet, and cold ablutions are also useful in this stage; but perhaps the best treatment is to pass a bougie several times a day, following up its use by that of stimulating injec- tions. This proceeding at first increases the discharge, but its quality is speedily altered, and at length it ceases altogether. The least irrita- tion or irregularity of life, is, however, very apt to induce its return. Cantharides, taken internally, in the form of tincture, are often of great service, and may be given in doses of fifteen or twenty drops, twice or thrice a day. This dose should be increased until pain and slight strangury be excited in the urethra and neighbourhood of the pubes. The discharge will then be found to have assumed a purulent character, and will gradually subside as the medicine is discontinued. GONORRHOEA IN WOMEN. If the discharge proceed from the urethra, the same plan of treat- ment must be pursued as in the gonorrhoea of males; but its seat is usually the vulva and vagina, often indeed involving the cervix uteri. Out of seventy-two patients in the Female Lock Ward in the Aberdeen Royal Infirmary, only three had the urethra affected. The symptoms are, inflammation and tumefaction of the parts, with pain and scalding at the times of micturition, the latter symptoms appearing most distinctly when the urethra is the seat of the disease: the discharge stains the patient's linen of a greenish yellow colour, and is often very abundant. Upon examination with the speculum, super- ficial excoriations are often perceived upon the cervix uteri, or within the vagina, and sometimes infiltration takes place to a considerable extent into the cellular tissue of the labia and surrounding parts, causing great oedema, and occasionally abscess and sloughing in these situations. If a case come under treatment before the commencement of the inflammatory stage, the urethra not being involved, it may be checked at once by injecting a strong solution of nitrate of silver (ten grains to an ounce); but as this is seldom the case, the antiphlogistic treatment must be employed until the inflammatory symptoms have subsided, warm emollient fomentations and injections being also used if the pain is severe. Should abscess of the labia or external parts ensue, the matter must be evacuated as speedily as possible by a large opening. As soon as the inflammation is subdued, astringent and stimulating injections should be employed. The decoction of oak bark or galls, solutions of sulphate of zinc or alum of considerable strength, are of great service; but perhaps the best is a solution of nitrate of silver, two or three grains to the ounce : the solution should be injected frequently; or, which will be found still more efficacious, the vagina should be plugged with lint dipped in it, and changed two or three times a day. This plan, recommended by both Ricord and Carmichael, seldom fails COMPLICATIONS OF GONORRHOEA. 585 to check the discharge very shortly; it seems to answer two purposes, both acting as a local astringent, and separating the parietes of the vagina, thus removing a constant source of irritation to the sound parts, and insulating the diseased portions. It often happens, however, that notwithstanding these applications, the discharge still continues. In this case the speculum should be used, and the os uteri examined, as it is often found that excoriations or ulcerations exist at this part, and by their constant irritation keep up the discharge. If such be discovered, they should be cauterized with a pencil of nitrate of silver, which M. Ricord recommends also to be gently carried over the vagina itself. This plan will seldom be found to fail. EXTERNAL, OR SPURIOUS GONORRHOEA. Balanitis of some authors, Gonorrhoea Prceputialis of others. These terms are used Avhen the gonorrhoea proceeds only from the glans penis, or from the lining membrane of the prepuce. Rest, moderate diet, and cleanliness, are often sufficient of themselves to remove this affection ; if not, and if no phymosis exist, the prepuce should be drawn back and the parts gently cauterised with a pencil of nitrate of silver, this being repeated every two or three days till the cure is effected. If, however, phymosis be present, accompanied with considerable inflammation, leeches applied to the groin, and emollient fomentations to the affected part will be necessary; and as soon as the inflammation has been subdued, the proper operation must be performed for removing the phymosis, as it tends to keep up the discharge by con- stant irritation. Should any treatment be necessary after this, the gentle cauterising of the part as above directed, or the application of a strong solution of nitrate of silver between the glans and the prepuce will check the discharge. Copaiba and cubebs seem to have no influence on this form of gonor- rhoea. INFLAMMATION OF THE MEMBRANOUS PORTION OF THE URETHRA. Inflammation of the membranous portion of the urethra is often the consequence of an attack of gonorrhoea. When this occurs, the symp- toms become more marked, especially the ardor urinae; the whole penis is much swollen ; the patient is exceedingly distressed with chordee; the discharge becomes fetid, sometimes tinged with blood; any pressure upon the membranous portion of the urethra causes pain to be felt as far back as the anus ; the testicle is usually tender, and sometimes swollen. Local bleeding, the application of poultices and fomentations to the perineum, and, general bleeding, if requisite, constitute the treatment to be employed; and, if matter form, a free vent must be given to it externally, as soon as its presence is detected. INFLAMMATION OF THE PROSTATE GLAND. The gonorrhceal inflammation may extend to the prostate gland. This is marked by the cessation of the gonorrhceal discharge, by pain and a sensation of weight at the neck of the bladder, with continual irritation and desire to pass water, tenesmus, weight and uneasiness in the peri- 586 INFLAMMATION OF THE BLADDER. neum, and tenderness of the gland itself, discoverable on examination through the rectum. If the attack be violent, complete retention of urine will ensue, with great pain from pressure of the contents of the bladder upon the inflamed gland. Not unfrequently abscess is formed, the symptoms of which are at first very obscure, slight hardness and fulness of the perineum being often the only indication of its presence; and it bursts sometimes internally into the urethra, or into the rectum, but more frequently externally. The constitutional symptoms are those of severe inflammatory fever ; rigors generally supervening when abscess occurs. Treatment.—Local depletion by means of leeches; and general depletion also, if the inflammation run high, must be employed; the bowels must be kept open to prevent irritation from the accumulation of faeces ; and if there be much fever, antimonials should be given. Sir B. Brodie recommends calomel, given so as to affect the system slightly. To relieve the pain a warm bath is of great service, and opium may be administered per anum in the form of enema; and the urine, if retention takes place, must be drawn off by the gentle introduction of a small catheter. If, in spite of every effort, suppuration ensue, fomentations and poul- tices must be applied to the perineum, and the matter evacuated by plunging a bistoury deep through the intervening structures, immedi- ately on the detection of fluctuation in the perineum. Sometimes, however, the abscess bursts into the urethra ; the patient must then be confined to the horizontal position; and to prevent infil- tration or its consequences, a small flexible gum-catheter should be re- tained in the urethra for some days; or a silver one gently introduced whenever he desires to void his urine. As this usually occurs in scrofulous habits, and often uncomplicated with gonorrhoea, the general health must likewise be improved by the administration of tonics and generous diet. INFLAMMATION OF THE BLADDER. When inflammation has extended to the bladder, its mucous membrane becomes inflamed, the gonorrhceal discharge ceases, the desire to make water is incessant, the irritation of the mucous coat causes a sensation of fulness even when the bladder is empty, and gives rise to constant straining to effect its evacuation. The pain, however, is most intense when the bladder is distended, and a diagnostic mark is thus established between this affection and calculus. The urine deposits a sediment of a mucous, purulent, or muco-purulent character. Pain and tenderness are felt in the hypogastric region, and symptoms of considerable irrita- tive fever. Treatment.—This consists of perfect rest in the recumbent posture, general depletion if the symptoms be extremely severe, the application of leeches to the hypogastrium, the use of hip baths and warm fomenta- tions, and the administration of gentle laxatives, with opiate enemata to relieve pain. If the urine is acid, saline medicines should be given, and calomel combined with opium several times daily; if alkaline, Sir B. INFLAMMATION OF THE BLADDER. 587 Brodie recommends fifteen or twenty drops of the vinum colchici three or four times a day. Should the inflammation depend upon a metasta- sis of the gonorrhoea, it will most probably cease on the return of the urethral discharge, which should, therefore, be promoted by warm emollient fomentations and the hip bath. CHRONIC INFLAMMATION OF THE BLADDER, OR CATARRHUS VESICAE. Constant desire to pass water, caused by irritation of the mucous membrane, constitutes at first the principal symptom of this affection. After it has existed for some time, the urine becomes loaded with a grayish, ropy, tenacious mucus, sometimes tinged with blood, giving a highly alkaline reaction, and forming a glairy deposit on cooling, often nearly equal in quantity to the urine itself, which is much darker than natural, and emits an offensive ammoniacal odour. Sometimes also streaks of phosphate of lime are deposited with the sediment. This chronic state of inflammation is rarely a primary disease, being generally a consequence of calculus, stricture, or enlarged prostate disease of the rectum. Treatment.—The exciting cause must be removed or modified, before a cure can be effected. Rest in the recumbent posture should be pre- scribed, with the pelvis raised, and opium administered, either by the mouth or as an enema, to relieve pain, together with gentle laxatives. Bleeding, either local or general, unless the inflammation runs very high, seems only to aggravate the symptoms by reducing the patient's strength, and mercurials are, for the most part, worse than useless. Counter-irritation on the hypogastric region in general affords relief. Buchu and mineral acids are often useful. The uva ursi and pareira brava have been strongly recommended in this disease, the latter espe- cially, by Sir B. Brodie, in the form of decoction, made by boiling half an ounce of the root in three pints of water down to one pint, and given in doses of eight or twelve ounces daily, with the addition of small doses of tincture of hyoscyamus and of the mineral acids, if a disposition to deposit phosphates exist. Copaiba, cubebs, and the muriated tincture of iron, have often a beneficial effect when given in small doses; and when the inflammation has greatly abated. As the cure progresses, it has sometimes been found advantageous to use simple injections of tepid water, slightly acidulated by the addition of ten drops of the diluted nitric acid to two ounces of warm water. If, however, pain or irritation be excited by their use, they must be at once discontinued. The bene- ficial effects of this proceeding have always appeared to me to be tem- porary. The best means for washing out the bladder, is a double catheter with a syringe adapted to one of the orifices. Rest, the recum- bent posture, with the pelvis raised, opiate enemata, counter-irritation on the hypogastrium by means of the nitrate of silver, pareira with the mineral acids and tincture of hyoscyamus, the regulation of the bowels by small doses of castor oil, and a regimen rather generous than other- wise, are the remedies most generally useful. [Injecting the bladder with a solution of nitrate of silver, will be found to be attended with the same beneficial results which follow its application in other diseased mucous membranes, and the injection of a 588 PHYMOSIS AND PARAPHYM08IS. solution of the sulphate of morphia, when the pain is distressing, pro- duces great relief.—Ed.] warts. Preputial gonorrhoea frequently gives rise to warts, the position of which may be any part of the surface of the glans and prepuce. They vary much in size and number, being sometimes few and small, some- times large and covering the whole of the parts. If few and small, they soon disappear under the repeated application of the sulphate of copper; but if large, the preferable proceeding is removal by scissors, followed by occasional application of the sulphate of copper. PHYMOSIS AND PARAPHYMOSIS. In most instances the prepuce can be easily retracted over the glans even during erection ; in some cases, however, this is impracticable, and such a stage is termed phymosis. It may be either congenital or accidental. In the latter case it is often produced by inflammation, and consequent swelling of the prepuce from an attack of gonorrhoea, by the cicatrisation of ulcers, the presence of warts, &c. When the phymosis exists only in a slight degree, no great inconve- nience is felt, nor is any special treatment requisite ; but when it occurs to a greater extent, the matter secreted collects beneath the prepuce, giving rise to considerable irritation, and to a discharge, resembling gleet, which often excites ulceration. If the orifice is very much con- tracted, much pain and suffering are experienced in passing water. If inflammation arise, the prepuce becomes enormously distended, and by its mechanical pressure frequently causes great pain. When inflammation occurs, the most active antiphlogistic remedies must be adopted. Fomentations and poultices must be applied, and Fig. 217. Fig. 218. suspension of the part resorted to, together with antiphlogistic treat- ment ; and should the inflammation still continue unchecked, or reten- tion of the urine take place, or should the phymosis depend on warts, on obstinate or irritable sores, or on an ulcerated condition of the sur- Figs. 217, 218. From Liston. PERMANENT STRICTURE. 589 faces of the prepuce and glans, the prepuce must be slit up by an opera- tion. This is effected by inserting a director by the side of the frsenum, introducing a sharp-pointed bistoury upon it, transfixing the prepuce and slitting it up, one or two small sutures being then passed through the edges of the wound to prevent the separation of the internal and external integuments. The unseemly appearance of the flaps is soon almost entirely removed by interstitial absorption. If the phymosis de- pend upon too great length of the prepuce, which not unfrequently happens, especially when it is congenital, this may be drawn forwards from the extremity of the glans, and a portion of it removed by a cir- cular incision—the same precaution being afterwards taken to secure the adhesion of the integuments and lining membranes by slight sutures. An opposite condition of the prepuce often exists, where, having been drawn back over the glans, it is incapable of being returned. This is called paraphymosis. The cause of this is in almost every instance a partial phymosis. When it assumes this condition, it acts as a tight ligature, constricting the urethra and impeding the return of the blood from the glans, which in consequence becomes oedematous and inflamed, and, unless the stran- gulation is quickly relieved, gangrene ensues. When the constriction is only slight, it will yield to the local applica- tion of cold and manipulation of the same nature as the taxis; but if this fail, the constriction must be divided; and this is best effected by depressing the penis, separating the swellings behind and before the constriction, and with a sharp-pointed curved bistoury dividing the stric- ture. The symptoms will be at once relieved, although it may not be practicable to return the prepuce immediately after the operation. PERMANENT STRICTURE. Exciting Causes.—I have included stricture under the head of con- sequences of gonorrhoea, as this is one of the most frequent exciting causes. It may, however, arise from any source of urethral irritation, such as mechanical injury, the use of injections of too stimulating a character, calculus in the bladder, the presence of lithic acid or of phos- phatic deposit in the urine, or contraction consequent on ulceration of the urethra, however such ulceration may have been induced. Seat of Stricture.—Stricture may occur at any situation anterior to the prostatic division of the urethra; but its most frequent sites are at the bulb, at the natural bend of the penis when pendulous, in the mem- branous portion of the urethra, an inch behind the orifice itself, consti- tuting what is called orificial stricture. The two first-mentioned sites are the most common. In seventy-seven out of ninety-eight examples of stricture, referred to by Mr. H. Smith, the constriction was found in the bulb, or in some part between it and the orifice; and in twenty-one, in the membranous division of the urethra. Symptoms.—The urine is observed to pass in a gradually diminishing stream, which at length becomes twisted or forked. A few drops are left in the urethra, after all the urine seems to have been expelled. There is, especially after exposure to cold and damp, a sense of scalding and irritation along some part of the urethra during micturition, the calls to 590 PERMANENT STRICTURE. which are very frequent. The bladder becomes very irritable, and the urine on cooling deposits a flaky mucus. Matter resembling that of gleet is discharged from the urethra, mingled sometimes with blood or pus, indicating the presence of an ulcer or abscess. If the stricture be of long standing, the induration of the part constricted may be felt ex- ternally. Besides these local symptoms, there are often tenesmus, hemorrhoids, pains in the loins, chronic enlargement of the testicle, herpetic eruption on the glans and prepuce, shooting pains in the peri- neum, and in severe cases, complete retention with extravasation of urine, or abscess and fistula in perineo. The great and constant irritation preys upon the constitution, and low hectic fever comes on, the counte- nance assuming a pallid copperish hue. State of the Parts.—Permanent stricture may be the result of a low degree of chronic inflammation, in consequence of which lymph is effused to a greater or less extent beneath the mucous membrane of the urethra, the calibre of which is thus diminished ; and this lymph, after the lapse of some time, becomes indurated. Or, it may depend upon the forma- tion either of a membranous septum stretching across the urethra and pierced by a small aperture, or of a simple band stretching from side to side. In this last case it is termed a bridle stricture. In a case of old stricture, the mucous membrane behind the contracted part may become inflamed and ulcerated; and this condition may extend to the cellular tissue, and an abscess be formed, bursting in the peri- neum and constituting fistula in perineo; or, in consequence of the great dilatation of the urethra behind the stricture, that canal itself may burst, and the urine become extravasated into the perineum. The prostate may become enlarged, and the bladder hypertrophied ; chronic cystitis, or even hernia vesicae, or first functional derangement, and afterwards organic disease of the kidneys may ensue. Treatment.—Of the various methods of treatment the most suitable are the three following—the use of the metallic bougie—that of the silver catheter—and free division of the stricture by the knife, as pro- posed by Professor Syme. In certain classes of cases, each of the methods has its special advantages. In the great majority, assuredly, the most suitable by far is the judicious use of metallic bougies. A bougie is selected of such size as is likely to pass without much difficulty. Having been dipped in warm water and oiled, it is to be passed down, and, on arriving at the stricture, to be steadily but very gently pressed onward, with the view of penetrating the stricture. This having been accomplished, it should be allowed to remain for a few minutes, unless the patient complain of pain, in which case it must be at once withdrawn. In the use of the instrument, lightness of grasp and gentleness of pressure are requisite; for to press forcibly or to grasp tightly would occasion the risk of either pressing the stricture before the instrument, or of perforating part of the urethra. If unsuc- cessful with the bougie first employed, others should be passed down to the stricture in a series of gradually decreasing sizes, until one is inserted into the bladder. When the stricture has been penetrated, the instrument remains fixed after the hand is withdrawn. If, therefore, the instrument resiles, it is PERMANENT STRICTURE. 591 an evidence that penetration has not been effected. The first introduc- tion of the bougie is in some instances attended with severe pain, faint- ness, and rigors; but these unpleasant symptoms are usually felt less at every succeeding operation. There is usually, also, after the first operation, ardor urinse in some degree, together with considerable pain for some time at the stretched parts, and increased difficulty of passing water. The uneasiness and irritation caused by the operation generally subside in the course of two or three days. The operation should then be repeated, the surgeon first using the same bougie as before, then withdrawing it and introducing the next in size; and this proceeding should be resumed at intervals until the normal size of the urethra be attained, and the largest bougie can be introduced without any diffi- culty ; after which a large one should be occasionally used at increas- ingly long intervals, until it be ascertained that there is no tendency to a return of the constriction. The cure is thus accomplished on the principle of dilatation, the effect of which in the first instance is mecha- nical, but ultimately it causes removal of the stricture by interstitial absorption. This mode of treatment is applicable to the great majority of strictures, and wherever applicable it ought to be preferred to every other method. If, however, a stricture be very difficult to dilate—or if there be an irregular condition of the urethra from long continuance of the disease,— or a false passage, or great difficulty in effecting penetration,—or severe rigor following each introduction of the instrument,—or a threatening of retention of urine,—it will be preferable to introduce a silver catheter through the stricture, and retain it by tapes. The orifice of the catheter is generally kept closed, but it is opened from time to time for the eva- cuation of the urine. The pressure of the catheter gives rise to a certain degree of irritation and swelling, in consequence of which it becomes by and by very firmly constricted. The irritation produces a slight grade of inflammation, and a considerable discharge of matter usually ensues, followed by widening, relaxation, and absorption, by which means the desired result is in most instances very speedily obtained. The instru- ment having become perfectly loose is withdrawn, and, after a few days, a larger one may, if necessary, be introduced for a short time. In the class of cases mentioned above, this mode of treatment is found highly satisfactory; and, from what has been stated, the principle of its use- fulness may be easily understood. It must be admitted, however, that it is attended with much greater risk than the usual mode of treatment by the bougie, and should there- fore be restricted to cases in which the latter is less suitable. It is seldom necessary to allow the instrument to remain above three days; and in some cases its use must be limited to a much shorter period. Some surgeons prefer the flexible catheter, but as far as my own ex- perience has enabled me to judge, the silver one is in most instances less irritating. Sir Benjamin Brodie recommends the use of a gum cathe- ter, mounted on a strong unyielding iron stilet, with a flat iron handle like that of a sound or staff. He says : " Being so mounted it is more readily directed into the bladder than when mounted in the usual way on a thin flexible wire. When the gum catheter has entered the blad- 592 PERMANENT STRICTURE. der, withdraw the stilet, and leave the catheter with a wooden peg in its orifice, which the patient is to take out whenever he has occasion to void his urine, it being at the same time secured by a suitable bandage. After three or four days you may withdraw the catheter for twelve hours ; or if much suppuration is induced in the urethra, you may with- draw it for a longer period; then introduce a larger catheter than the first, and thus you may, in the course of ten days or a fortnight, dilate a very contracted urethra to its full diameter." In both these methods of proceeding, namely, by the bougie and by the catheter, the principle of treatment is to induce absorption, the ex- isting cause of which is mechanical dilatation. Professor Syme has recommended a new proceeding for the treatment of permanent stricture, namely, free division of the stricture by the knife. The patient is put under the influence of chloroform; and the limbs having been separated from each other, a small grooved director is passed through the stricture ; and the surgeon makes a free incision about an inch and a half long in the mesial line, and divides the textures external to the urethra over the situation of the stricture. A small straight bistoury is then sent into the groove of the director behind the stricture, and by bringing it forward the whole of the contracted part is divided. A No. 7 silver catheter is introduced through the urethra, and retained for twenty-four hours. Professor Syme has published the results of his proceedings, which have been very satisfactory ; and he states that the advantages of this mode of treatment are, that it is speedy, safe, and effectual. He considers it the best that could be applied, where the stricture is very obstinate and contractile. For the adoption of this method of treatment it is essential that the stricture be not impassable; but Professor Syme contends that, according to his experience, no stric- tures are impassable. On this subject Professor Syme remarks :—" So long back as 1844, I expressed my persuasion that no stricture was truly impermeable, the exit of water being a certain sign that instruments might, through suffi- cient care be introduced. This principle of practice was obviously of great importance, since conviction of its truth would obviously lead to much more prolonged and careful exploration of the passage than would be thought requisite, if belief in the impermeability of stricture was entertained. For my own part it was frankly confessed, that, while sharing in the doctrine of impervious urethras, I had occasionally found them so, and performed the old operation, while ever since adopting the principle that every stricture might be permeated by instruments through time and care, I had not, either in public or private practice, met with one that proved incorrigibly obstinate." This treatment is only suggested as a remedy for strictures which are otherwise incurable. It is perfectly certain that, in many cases, this mode of treatment has been exceedingly satisfactory: while in a very few the cure has not been permanent—a circumstance which may have been owing to neglect of the judicious precaution of occasionally intro- ducing the bougie. Should a case, however, occur, in which an entrance cannot be effected either by the bougie or by the catheter, the preferable mode is to cut CATHETERISM. 593 down upon the stricture and divide it. This, however, is a proceeding which no surgeon is justified in adopting, except under very urgent cir- cumstances, namely, where there is a stricture which cannot be pene- trated, together with retention of urine. The operation consists in introducing a catheter to the stricture, making a direct incision in the raphe down to the dilated urethra behind the stricture, opening the urethra and dividing the stricture by cutting it from behind forwards upon the catheter, which should then be sent back into the bladder and retained. Proper means should then be taken to promote the healing of the wound. Other methods of treatment, in which the cure is attempted on entirely different principles, are—subcutaneous division of the stricture ; forcing a passage through the stricture, as recommended by many French sur- geons : perforation of the stricture by a cutting instrument, commonly called the treatment by the lanceletted stilette, a method strongly advocated by Mr. Stafford for certain cases; and the treatment by the caustic bougie. In this last method, the caustic potass and nitrate of silver have each been used. The caustic has been applied by inserting it into the hollow end of a common wax bougie, but the best mode of its application is by the porte-caustique recommended by M. Lallemand. All these methods are liable to many and serious objections, and, in consequence, they need not here be described. CATHETERISM. No surgical proceeding can be more easily accomplished than passing a catheter in ordinary circumstances ; and on the other hand, as has been acknowledged by the most eminent practical surgeons, there is not in the whole range of surgical proceedings a more difficult operation or one that requires greater skill, caution, and experience, than that of passing the catheter through what has been called an impermeable stricture. 1. Ordinary Proceeding.—When there is no difficulty, the catheter may be passed into the bladder in the following manner. The patient having been placed in the recumbent posture, a silver catheter having been selected, dipped in warm water and oiled, the surgeon takes hold of the penis with his left hand, and raises it up, introduces the point of the instrument in the meatus, with the handle directed to the belly, and gently slides the catheter onwards, keeping the point along the upper aspect of the urethra. The instrument glides onwards until its point engages itself in the part of the urethra embraced by the deep fascia, when the handle should be gently depressed, the point being still kept along the roof of the canal, until it glides into the bladder. In no part of this movement should the slightest force be used; and it is unnecessary even to hold the penis in the left hand, except during the introduction of the instrument into the meatus and anterior portion of the canal. 2. Another Proceeding.—-The "tour demaitre." The instrument having been prepared for use, its point is introduced into the meatus and sent along the upper surface of the urethra, with its convexity directed upwards, until its point is beneath the symphysis, when the 594 RETENTION OF URINE. catheter is made to perform a half turn from right to left, which brings the handle and concavity upwards. This manoeuvre having been exe- cuted, the handle is depressed and by the gentlest effort the point is slipped into the bladder. The only advantage of this mode is, that if the patient be sitting or standing, the front of the abdomen docs not prevent a desirable position of the handle of the instrument in the first part of the proceeding. RETENTION OF URINE. The principal conditions which give rise to retention of urine, together with the appropriate treatment, now come to be considered. I. RETENTION FROM STRICTURE OF URETHRA. Should a case of retention present itself, caused by a hard and gristly stricture situated in front of the scrotum, and should it be found im- possible to penetrate the stricture by the usual gentle manipulation, in which the instrument is held lightly and pressed against the stricture without any force, the surgeon should take hold of the hard part between the forefinger and thumb of the left hand, and pass down the catheter to the stricture, and gently and cautiously effect penetration, and lodge it in the bladder. Should the stricture which causes retention be situated behind the scrotum, and should it be found impracticable to pass the catheter by the most cautious, gentle, and dexterous manipula- tion, the proper practice is to perform the old operation of sending back a catheter to the stricture, cutting into the dilated portion of the urethra behind the stricture, when the urine will escape, and dividing the stricture by cutting forward upon the point of the catheter, and sending it back so as to lodge it in the bladder. Such are the most advisable proceedings when retention is caused by stricture anterior to the prostate gland. II. RETENTION FROM ABSCESS IN THE PERINEUM. Occlusion of the urethra with consequent retention of urine is occa- sionally produced by abscess in the perineum. The proper practice in such circumstances is free direct incision, so as to evacuate the matter and remove the cause of obstruction. III. RETENTION FROM ENLARGEMENT OF PROSTATE GLAND. Enlargement of the prostate gland is not unfrequently a cause of retention. A portion of the gland rising up at the commencement of the urethra acts as an obstacle to the passage of the urine. This cause of retention can in general be readily overcome by attending to the following precautions:—Using a very long catheter, with a large curve, and the point more than usually bent—and depressing the handle to a much greater degree than in performing catheterism in ordinary circum- stances. The accompanying wood-cut will show the importance of these direc- tions. The unusual length of the catheter is necessary on account of the rising up of the bladder, and consequent elongation of the urethra. The peculiarity of form and the depressing of the handle admit of the SYPHILIS. 595 instrument being sent up in front of the obstruction, instead of pressing against the obstruction, as would be the case in using an ordinary catheter in the usual way. Should all efforts to introduce the instru- Fig. 219. ment prove unavailing, the least hazardous proceeding is to perforate the obstruction, in doing which the greatest care must be taken that the point of the instrument be lodged in the prostatic portion of the urethra, and that it be sent in the proper direction into the bladder. Puncturing the bladder from the rectum, which can be safely done for the relief of retention when the prostate gland is not diseased, is unsafe in the con- ditions now under consideration. With regard to puncturing above the pubes, the risk of infiltration is so great that it ought not to be attempted. When it is necessary to penetrate the obstruction in case of a diseased prostate, the catheter ought to be allowed to remain in the bladder for some time; and in all cases of retention, a repetition of the operation is very soon requisite, as secretion of urine takes place rapidly, after the pressure on the kidneys, caused by the distension of the ureters, has been removed. IV. RETENTION FROM PARALYSIS. The detrusor urinse may become paralytic in consequence of over- distension, injury or disease of the spine, or the feebleness of age. In addition to the treatment suitable to the state which has caused the para- lysis, the urine must be drawn off twice in the four-and-twenty hours, to prevent discomfort and allow the weakened parts a chance of regaining tone. SYPHILIS. This term is used to denote various morbid appearances, which are arranged into two grand divisions, namely, the local or primary, and the constitutional symptoms of the disease;—the former consisting of certain ulcerations, commonly termed chancres, and consequent upon them, of swellings of glands, technically called buboes; the latter, which are sub- Fi^PlO. From Liston. 596 SYPHILIS. divided into the secondary and tertiary symptoms, consisting of various morbid affections of the skin, mucous membrane, periosteum, bone, and other textures. LOCAL OR PRIMARY SYMPTOMS. It must not be supposed that all sores on the penis are venereal; for that organ is, like other parts of the body, liable to irritation and in- flammation ; and common excoriation and ulcers may form on it as else- where. Neither must we conclude that all sores consequent on sexual intercourse are syphilitic, as excoriations may be produced by sexual intercourse, which originate in irritation, or in the contact of acrid se- cretions, not venereal or connected with the inoculation of syphilitic virus. Simple excoriations and common sores are distinguished by their history and appearance, and by the absence of the peculiar characters of the various forms of venereal ulcers. Venereal ulcers do not form immediately on the application of venereal poison ; a certain interval elapses, varying in duration according to the manner in which the virus is applied. When the surface to which it is applied is entire, ulcer rarely appears for five or six days, and often the interval is longer; but when it is applied to a broken surface, the ap- pearances come on much more rapidly, the wound becomes painful, and in many instances decided symptoms of syphilitic ulcer are perceptible in twenty-four hours. There are several kinds of venereal ulcers, which, though they all originate from a common cause, namely, the application of venereal virus, yet differ materially from each other both in the character of the primary sores, and in the subsequent constitutional symptoms. As the technical term, chancre, is, strictly speaking, applicable only to those ulcers which have a corroded appearance, many prefer the expressions primary sores, or primary ulcers. Primary venereal sores are of various kinds; but those which are most remarkable, and so clearly defined by their distinctive characters as to present no difficulty of discrimination, are the four following. I. THE SIMPLE VENEREAL ULCER. This,—called by some writers the common venereal ulcer, and by others the elevated ulcer,—is found more frequently on the internal surface of the prepuce, and in the sulcus behind the corona glandis, than in any other situations. It is often also met with on the glans, and usually there are more sores than one. When the sore results from the appli- cation of the virus to an entire surface, the first symptoms are itching and redness, followed by vesication, and the pustule gives way and dis- charges its contents either by the bursting of the cuticle, or by a portion of the scab becoming detached, and thus exposing the ulcer underneath. Such are the changes in the first or inflammatory stage. The form of the ulcer is usually circular, or nearly so; its surface concave; its colour pale, surrounded by a bright inflammatory areola; the discharge rather ichorish; and the pain considerable. Such are the appearances during the second stage wheji the virus contained in the matter is most calculated to propagate tv disease. In the next stage SYPHILIS. 597 the surface of the sore, instead of being depressed, becomes covered over with granulations, which are pale and flabby, and rise like a small fungus above the surrounding parts; the ring of inflammation also becomes indistinct. This is the third stage, or that of reparation or granulation, and is succeeded by cicatrization. By these distinctive characters, and by the absence of any surrounding induration, phage- daena, or elevation of the edges, the diagnosis is easily made out. When the sore originates from the application of the virus to an abraded sur- face, the part very soon becomes painful, a scab forms, and in the sub- sequent progress the appearances are as already described. Treatment.—It is extremely desirable to arrest the progress of the disease as speedily as possible, since there is every reason to believe, that if the removal of the local disease be accomplished very early by the entire destruction of the part affected, a perfect protection is in the great majority of instances insured against constitutional symptoms. That the chance of securing this protection diminishes as the destruction is deferred, there can be no doubt; but if it be effected within the first two or three days from the commencement of the specific or inflamma- tory process, or perhaps at any time until near the period of the burst- ing of the matrix vesicle, while the disease is local, the constitution may be preserved untainted. It is now well known that the virus is contained in the discharge secreted during the second stage, and that this is con- sequently the period which is most favourable for the employment of the test of inoculation, and in which the constitution is so apt to be affected, or the disease to be communicated by sexual intercourse. A principal object, therefore, of the surgeon will be to prevent the occurrence of that stage ; or, to cut it short, if it be too late to prevent: in either case his plan will be to convert the sore into a simple ulcer by the entire destruction of the affected part; or, in other words, to insti- tute the ectrotic treatment. Of the various means adopted for this end, that most generally employed is the application of the solid nitrate of silver, which should be applied so efficiently as to insure the complete destruction of the affected part. This is done in the first stage, not only with the view of stopping the disease, but also of affording a protection against constitutional sequelse ; in the second stage, only with the hope of cutting short the disease. This is the mode of destruction which I have generally preferred; and for after-dressings I have in many cases applied nothing but a piece of dry lint or charpie, and on the falling off of the scab have found the sore healed; in other instances I have used water-dressings. Professor Graves objects to the application of the solid nitrate of silver, if the sore be large, on the ground of its being apt to produce bubo, and recommends the following proceeding, which I have adopted in many cases with the happiest results:—"Pro vide your- self with a common-sized nicely pointed camel's hair pencil, and a solu- tion of lunar caustic, twenty grains to the ounce ; pour a drop or two of this on the cover of a book or on the table, and dipping the brush in a basin of water, cleanse the surface of the sore with it. Dry the sore then completely with a piece of lint, and rinsing the brush, squeeze out the chief part of the water, and, pointing the brush, you may then dip the extreme point of it in the drop of caustic solution, so as to take up 598 SYPHILIS. the smallest possible quantity of fluid, which you may then apply to the centre of the sore. When it has done acting, we may readily judge by the appearance of the surface whether enough has been applied, for the whole surface must be whitened; but it is not, as is usually imagined, proper to burn out the edges. It may be necessary to dip the end of the brush in the solution, and apply it to the sore a second or even a third time, pausing to observe the effects of such applications. By pro- ceeding thus we destroy the diseased surface, and do not produce any inflammation likely to give rise to bubo." Such is the treatment in the second stage ; in the third, the immediate object aimed at is to repress the elevation of the granulations; and that can be very conveniently done by occasionally pencilling them very lightly with nitrate of silver, or sulphate of copper, and in the intervals applying to the part either simple water-dressings, or the solution of the sulphate of zinc, as the appearances may indicate. II. ULCER WITH ELEVATED EDGES. The situations in which this sore is most frequently found are on the prepuce, both on its internal and external surfaces, in the fossa behind the corona glandis, and on the corona glandis itself. It is also very frequently found at the margin of the prepuce, where it is apt to occa- sion phymosis. Its formation may take place very speedily after sexual intercourse, if the virus has been applied to an abraded surface, or not till after some days, if the surface has been entire. The distinguishing peculiarities of this ulcer are, that the margin is elevated above the sore and the surrounding surface, and also slightly indurated ; the surface is excavated and of a brownish raw colour, and of irritable appearance without commencing granulations. The dis- charge is thin, the pain is considerable, and in some instances the destruction by ulceration is somewhat rapid. Among the negative marks of distinction are the absence of phagedaena, and of induration of the base, or the surrounding parts. It is usual to find more than one sore at the same time. The treatment is the same as for the simple venereal sore. III. THE HUNTERIAN OR TRUE CHANCRE. The ordinary sites of this ulcer are the glans penis, the frsenum, the fossa behind the corona glandis, and the body of the penis. The first is the most frequent. The formation of this sore has been known to take place in one day, and, in some instances, to be delayed for weeks; but it is usually found about the third or fourth day, or from that to the seventh, after sexual intercourse. Its distinguishing peculiarities are, that after a pustule containing matter, an ulcer results, the form of which is circular, or approaching to circular; the edges either regular or very slightly indented; the surface much excavated without the appearance of granulations, and covered with a viscid ash-coloured sub- stance ; and the base hard, with this peculiarity, that the hardness is usually defined and terminates abruptly, instead of gradually blending with the surrounding parts. The progress of the ulcer is slow, indo- lence of action being a distinguishing peculiarity. By these peculiari- SYPHILIS. 599 ties, together with the negative signs, namely, the absence of phage- daena, and of a surrounding areola of inflammation, the diagnosis is easily made out. This ulcer, unlike the former, is in most instances solitary. The treatment of this chancre is the same with that of the two former, except that a much more extensive destruction, by means of nitrate of silver, is necessary in order to insure the entire removal of all the parts affected with hardening, and the formation of a simple healthy ulcer on the separation of the eschar. Some surgeons have employed potassa fusa to effect destruction of the diseased parts; I have no experience of its use in these cases, having always preferred nitrate of silver, both because its application is attended with much less pain, and also because the extent of destruction is more easily regulated. Lint dipped in water, in the solution of the sulphate of zinc, or in the black wash, may be applied in the ordinary dressings, as the appearance of the ulcer may indicate. To the employment of mercury in the treatment of the primary sores, we shall refer in a future page. IV. PHAGEDENIC SORE. The three varieties, namely, phagedaena, or phagedaenic sore, slough- ing or gangrenous, and sloughing phagedena, called by some writers the phagedaena gangrenosa, are so similar to each other in the circum- stances in which they are found, in their symptoms and in their treat- ment, that it will be more convenient to describe them together than to assign a separate section to each. The term phagedaena, derived from as advised by many' 1S mOTe mSatl8fa°t0ry' and ^"The^f passes freely in and out only when the wound is dhect Thelungsdo'no,^always collapse£j^^^&* Stotlas^-y'd'epeX adhesion between th/Lg.and pleura, 744 WOUNDS OF THE CHEST. but in others, it is not to be explained. The opening, therefore, of both cavities of the chest is not directly mortal. Williams concludes from his experiments, 1st, that the lobe of the lung when exposed to the air does not collapse, so long as the functions of the other lobe and of the assistant organs continue undisturbed in respiration ; 2d, that one lobe of the lung possesses a peculiar power of moving for some time, entirely independent of the diaphragm and intercostal muscles, when, indeed, the other lung respires; the origin of this power Williams cannot determine; 3d, that a sound lung recovers its natural expansive power when the pressure of the external air is removed; 4th, that although the external air passes freely and uninterruptedly at the same time through tubes of the same size into the cavities of the chest, the lungs, however, do not collapse, if the assistant respiratory organs have their activity still unrestrained; 5th, that a healthy lung never completely fills the cavity of the chest, at least in natural respiration. In my experiments on dogs, I always found great collapse of the lungs, and the motions which I noticed in them seemed to me less dependent on a distinct expansive power in the lungs themselves, than much rather on elevation and depression of the collapsed lungs in the laborious inspiration and expiration of animals, as will be described in accidents of the lungs. " In endeavouring to determine the course which balls take when wounding the chest, Hennen's observation must not be forgotten, that ' a ball striking the body or a limb will run round under the skin, and appear to penetrate right across the member or the cavity. By the deep-seated course which balls sometimes take, the deception is rendered still greater. Thus I have traced a ball by dissection, passing into the cavity of the thorax, making the circuit of the lungs, penetrating nearly opposite the point of entrance, and giving the appearance of the man having been shot fairly across, while bloody sputa seemed to prove the fact, and in reality rendered the same measures, to a certain extent, as necessary as if the case had been literally as suspected. The bloody sputa, however, were only secondary, and neither so active nor alarming as those which pour at once from the lungs when wounded. There is also another source of deception as to the actual penetration of balls into the cavities or the limbs; this is where they strike against a hand- kerchief, linen cloth, &c, and are drawn out unperceived in their folds.' "In regard to the prognosis of wounds of the chest, Hennen observes: —' I should be unwilling to lull either a patient or a surgeon into a false security, or to underrate the real danger of any case ; but I have seen so many wounds of the thorax, both from pike and sabre thrusts, and from gunshot, do well ultimately, that I cannot but hold out great hopes, where the third day has been safely got over, for though occa- sional haemoptysis may come on, at almost any period during a case, and its approach can neither be entirely prevented nor anticipated, the more deadly hemorrhages are usually within the first forty-eight hours; and yet to this alarming symptom, when within moderate bounds, the safety of the sufferer is often due. Dr. Gregory of Edinburgh was in the habit of stating in his lectures, that of twenty-six wounds of the thorax received at the battle near Quebec, two only were fatal.' " Penetrating wounds of the chest are most conveniently treated under the following conditions:—1. Simple penetrating wounds; 2. WOUNDS OF THE CHEST. 745 Wounds complicated with the presence of foreign bodies; 3. Penetra- ting wounds with bleeding ; 4. Penetrating wounds with protrusion of part of the lungs. . . , " Simple penetrating Wounds of the Chest, or those in wnicn tne cavity of the pleura merely is opened, are rare. Their treatment con- sists in the speedy closing of the wound, and in the prevention ot inflammation. The patient, after a deep inspiration, should expire, and then the wound is to be carefully closed with sticking plaster, covered with a compress, and fastened with a broad chest-bandage and a shoulder- bandage. The patient is to be treated on a strictly antiphlogistic plan. If the inflammation be prevented, the wound heals quickly. If inflam- mation come on and be long-continued, consecutive extravasation from exudation of the pleura is frequently produced after a lapse of fourteen days, and renders the opening of the cavity of the chest necessary. « Foreign Bodies, which complicate penetrating wounds of the chest, are either broken pieces of the injuring instrument, balls, pieces ot clothes, driven into the wound, or splinters of the ribs. If the state ot the injury do not itself point out the presence of foreign bodies, the symptoms by which it can be inferred are very equivocal. I hey excite constant irritation, difficult respiration, pain at the wounded part, even though the most severe antiphlogistic treatment has been long-continued £ although the symptoms had diminished, a fresh accession, copious suppuration, and so on, may occur. The circumstances of the accident musPthe arefully reviewed,"in order to determine on the^presence, and Ts ion of the foreign body, which is often most decidedly possible by fh ntroduction of L elastic or metallic sound, for the purpose either Ty suitable enlargement, or by a fresh opening m the mterspa* o the ribs corresponding to its position, when it can be done, to extract it. Th oTger%urSation is Lpt up by a foreign body in the cavi y^ofthe chest, so much more difficult is its extraction because the ^ers^ace is much diminished by the falling together of he ribs Larrey has in one such case cut out the upper edge of the lower rib with the lentlcu lar, as deeply as needful, for the purpose of extracting the ball, and ^ 1^ ^y^to'ti^t, run round the lungs, and pass out rieJjtlo^tl^ point of entrance (1). Instances have Horner's Special Anatomy and Histology, new edition, 2 vols. 8vo., many cuts. Horner's United States Dissector, 1 vol. large royal 12mo., many cuts, 444 pages. 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THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, EDITED BY ISAAC HAYS, M. D., IS PUBLISHED QUARTERLY, ON THE FIRST OF JANUARY, APRIL, JULY, AND OCTOBER, Kij KIjJIJYCHJinn & IjEJM, Philadelphia. Each Number contains about Two Hundred and Eighty Large Octavo Pages, Appropriately Illustrated with Engravings on Copper, Wood, Stone, &c. THE MEDICAL NEWS AND LIBRARY Is Published Monthly, and consists of THIRTY-TWO VERY LARGE OCTAVO PAGES, Containing the Medical Information of the day, as well as a Treatise of high character on some prominent department of Medicine. In this manner its subscribers have been supplied with WATSON'S LECTURES ON THE PRACTICE OF MEDICINE, BRODIE'S CLINICAL LECTURES ON SURGERY, TODD & BOWMAN'S PHYSIOLOGY, WEST ON THE DISEASES OF INFANCY AND CHILDHOOD, AM© MALGAIGWE'S OPERATIVE SURGEKY. And the work at present appearing in its columns is SIMON'S LECTURES ON GENERAL PATHOLOGY. To be followed by The Fourth Fart of Todd & Bowman's Physiology. TERMS. THE SUBSCRIPTION TO THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES IS JFTWJE BOIsIjdlRS PER JUMWUM When this amount is paid in advance, the subscriber thereby becomes entitled to the MEDICAL NEWS AND LIBRARY FOR ONE YEAR, GRATIS. When ordered separately, the price of the " News" is ONE DOLLAR per annum, invariably in advance. For the small sum, therefore, of FIVE DOLLARS, the subscriber can obtain a Quarterly and a Monthly Journal of the highest character, presenting about Fifteen hundred large octavo pages, with numerous Illustrations, Rendering these among The Cheapest of American Medical Periodicals, REDUCTION OF POSTAGE. "Under the new postage law, subscribers to the American Journal of the Medical Sciences arc ■entitled to the benefit of the half rates of postage for advance payment, which is thus defined in the Postmaster-General's circular of June 11th, 1851 :— " When a periodical is published only quarterly, the actual and bona fide subscriber to such periodical may pay in advance, and have the benefit of such advance payment, provided he pay? to the postmaster at the office where he is to receive the periodical, before its delivery." It will therefore be seen that the subscriber has only to pay for each number before taking it out of the office, in order to secure the benefit of the half postage, which is as follows :— For any distance under 500 miles, - - - i cent per ounce. " " between 500 and 1500 miles, - 1 " " " " " 1500 and 2500 " - lj " " When the postage is not thus paid in advance, it will be at double these rates. The Medical News and Library pays postage as a newspaper. Each number weighs between one and two ounces. Subscribers will therefore, under the new postage law, pay in advance for each quarter as follows :— For any distance under 50 miles, ... ii cents per quarter. " " between 50 and 300 miles, - 2i " " « " " 300 and 1000 miles, - 3* " " « " " 1000 and 2000 miles, 5 " " BLANCHARD AND LEA'S PUBLICATIONS. 5 NEW AND ENLARGED EDITION OF NEILL & SMITH'S COM^EN Dl U M-(N OW READY.) AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE, FOR THE USE AND EXAMINATION OF STUDENTS. BY JOHN NEILL, M. D., Surgeon to the Pennsylvania Hospital; Demonstrator of Anatomy in the University of Pennsylvania. AND FRANCIS GURNEY SMITH, M.D., Professor of Institutes of Medicine in the Pennsylvania Medical College. Second Edition, Revised and Improved. In one very large and handsomely printed volume, royal 12mo., of over 1000 large pages, With about 350 illustrations, strongly bound in leather, with raised bands. PREFACE TO THE NEW EDITION. The speedy sale of a large impression of this work has afforded to the authors gratifying evi- dence of the correctness of the views which actuated them in its preparation. In meeting the demand for a second edition, they have therefore been desirous to render it more worthy of the favor with which it has been received. To accomplish this, they have spared neither time nor labor in embodying in it such discoveries and improvements as have been made since its first ap- pearance, and such alterations as have been suggested by its practical use in the class and exami- nation-room. Considerable modifications have thus been introduced throughout all the depart- ments treated of in the volume, but more especially in the portion devoted to the " Practice of Medicine," which has been entirely rearranged and rewritten. The authors therefore again submit their work to the profession, with the hope that their efforts may tend, however humbly, to advance the great cause of medical education. Notwithstanding the increased size and improved execution of this work, the price has not been increased, and it is confidently presented as one of the cheapest volumes now before the profession. COOPER'S SURGICAL LECTURES—(Now Ready.) LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. BY BRANSBY B. COOPER, F. R. S.; Senior Surgeon to Guy's Hospital. In one very large octavo volume, of seven hundred and fifty pages. For twenty-five years Mr. Bransby Cooper has been surgeon to Guy's Hospital; and the volume before us may be said to consist of an account of the results of his surgical experience during that long period. We cordially recommend Mr. Bransby Cooper's Lectures as a most valuable addition to our surgical literature and one which cannot fail to be of service both to students and to those who are actively engaged in the practice of their profession.— TheLancet. .»„„.„ , u i ^ i. • A "ood book by a good man is always welcome; and Mr. Bransby Cooper's book does no discredit to its paternity It has reminded us, in its easy style and copious detail, more of Watson's Lectures, than any book we have seen lately, and we should not be surprised to see it occupy a similar position to that well- known work in professional estimation. It consists of seventy-five lectures on the most important surgical diseases. To analyze such a work is impossible, while so interesting is every lecture, that we feel ourselves really at a loss what lo select for quotation. _ . The work is one which cannot fail to become a favorite with the profession; and it promises to supply a hiatus which the student of surgery has often to deplore.—Medical Times. MALGAIGNE'S SURGERY.—Now Ready. OPERATIVE SURGERY, BASED ON NORMAL AND PATHOLOGICAL ANATOMY. BY J. F. MALGAIGNE. TRANSLATED FROM THE FRENCH, BY FREDERICK BRITTAN, A. B., M.D., M.R.CS.L. WITH NUMEROUS ILLUSTRATIONS ON WOOD. In one handsome octavo volume of nearly 600 pages. This work has during its passage through the columns of the « Medical News and Library" • losnand 185l' received the unanimous approbation of the profession, and in presenting it in m ml etcs form 'the publishers confidently anticipate for it an extended circulation. a comp e best books published on operative surgery .—Edinburgh Med. Journal. Certainly onei oi_ elld it DOtQ t0 practitioners and students, not only as a safe guide in the dissect- We can slr0"f y ,heatre but also as a concise work of reference for all that relates to operative sur- ing-room or opemuuK'""""* > ge^y'"iFMr6M'v,f/lnedormed his task of translator and editor with much judgment. The descriptions are Dr. ^ nUa" r. »„flVIDiicit; and the author's occasional omissions of important operations proposed by B'Lfshburgeons aSiciously supplied in brief noXes.-Medital Gazette. 6 BLANCHARD & LEA'S PUBLICATIONS.—(Surgery.) GROSS ON URINARY ORGANS— (Just Issued.) A PRACTICAL TREATISE ON THE DISEASES AND INJURIES OF THE URINARY ORGANS. BY S. D. GROSS, M. D., &c., Professor of Surgery in the New York University. In one large and beautifully printed octavo volume, of'over seven hundred pages. Witu numerous Illustrations. The author of this work has devoted several years to its preparation, and has endeavored1 to render it complete and thorough on all points connected with the important subject to which it is devoted. It contains a large number of original illustrations, presenting the natural and patholo- gical anatomy of the parts under consideration, instruments, modes of operation, &c. &c, and in mechanical execution it is one of the handsomest volumes yet issued from the American press. Dr. Gross has brought all his learning, experience, tact, and judgment to the task, and has produced a work worthy of his high reputation. We feel perfectly safe in recommending it to our readers as a mono- graph unequalled in interest and practical value by any other on the subject in our language; and we can- not help saying that we esteem it a matter of just pride, that another work so creditable to our country has been contributed to our medical literature by a Western physician.—The Western Journal of Medicine and Surgery. We regret that our limits preclude such a notice as this valuable contribution to our American medical literature merits. We have only room to say that the author deserves the thanks of the profession for this elaborate production; which cannot fail to augment the exalted reputation acquired by his former works, for which he has been honored at home and abroad.—N. Y. Med. Gazette. COOPER OX DISLOCATIONS.—New Edition—(Just Issued.) A TREATISE ON DISLOCATIONS AND FRACTURES OF THE JOINTS, By Sir ASTLEY P. COOPER, Bart., F. R. S., &c. Edited bt BRANSBY B. COOPER, F. R. S., &c. WITH ADDITIONAL OBSERVATIONS BY PROF. J. C. WARREN. A NEW AMERICAN EDITION, In one handsome octavo volume, with numerous illustrations on wood. After the fiat of the profession, it would be absurd in us to eulogize Sir Astley Cooper's work on Disloca- tions. It is a national one, and will probably subsist as long as English Surgery.—Medieo-Chirurg. Review. WORKS BY THE SAME AUTHOR. COOPER (SIR ASTLEY) ON THE ANATOMY AND TREATMENT OF ABDOMINAL HERNIA. 1 large vol., imp. 8vo., with over 130 lithographic figures. COOPER ON THE STRUCTURE AND DISEASES OF THE TESTIS, AND ON THE THYMUS GLAND. 1 vol., imp. 8vo., with 177 figures on 29 plates. COOPER ON THE ANATOMY AND DISEASES OF THE BREAST, WITH TWENTY-FIVE MISCELLANEOUS AND SURGICAL PAPERS. 1 large vol., imp. 8vo., with 252 figures on 36 plates. These three volumes complete the surgical writings of Sir Astley Cooper. They are very handsomely printed, with a large number of lithographic plates, executed in the best style, and are presented at exceed- ingly low prices. _________________ LISTON & MUTTER'S SURGERY. LECTURES ON THE OPERATIONS OF SURGERY, AND ON DISEASES AND ACCIDENTS REdUIRING OPERATIONS. BY ROBERT LISTON, Esq., F. R. S., &c. EDITED, WITH NUMEROUS ADDITIONS AND ALTERATIONS, BY T. D. MUTTER, M.D., Professor of Surgery in the Jefferson Medical College of Philadelphia. In one large and handsome octavo volume of 566 pages, with 216 wood-cuts. STANLEY ON THE BONES—A Treatise on Diseases of the Bones. In one vol. 8vo., extra cloth. 286pp. BRODIE'S SURGICAL LECTURES.—Clinical Lectures on Surgery. 1 vol. 8vo., cloth. 350 pp. BRODIE ON THE JOINTS.—Pathological and Surgical Observations on the Diseases of the Joints. 1 vol. 8vo., cloth. 216 pp. BRODIE ON URINARY ORGANS.—Lectures on the Diseases of the Urinary Organs. 1 vol. 8vo., cloth. 214 pp. %* These three works may be had neatly bound together, forming a large volume of" Brodie'i Surgical Works." 780 pp. RICORD ON VENEREAL.—A Practical Treatise on Venereal Diseases. With a Therapeutical Summary and Special Formulary. Translated by Sidney Doane, M. D. Fourth edition. 1 vol. Svo. 340 pp. DURLACHER ON CORNS, BUNIONS, &c—A Treatise on Corns, Bunions, the Diseases of Nails, and the General Managementof the Feet. In one 12mo. volume, cloth. 134 pp. GUTHRIE ON THE BLADDER, &c—The Anatomy of the Bladder and Urethra, and the Treatment of the Obstructions to which those Passages are liable. In one vol. 8vo. 150 pp. LAWRENCE ON RUPTURES.—A Treatise on Ruptures, from the fifth London Edition. In one 8vo. vol. sheep. 480 pp. BLANCHARD & LEA'S PUBLICATIONS.—(Surgery.) LIBRARY OP SURGICAL KNOWLEDGE. A SYSTEM OF SURGERY. BY J. M. CHELIUS. TRANSLATED FROM THE GERMAN, AND ACCOMPANIED WITH ADDITIONAL NOTES AND REFERENCES, BY JOHN F. SOUTH. Complete in three very large octavo volumes of nearly 2200 pages, strongly bound, with raised bands and double titles. We do not hesitate to pronounce it the best and most comprehensive system of modern surgery with which we are acquainted.— Medico-Chirurgical Review. The fullest and ablest digest extant of all that relates to the present advanced state of Surgical Pathology.— American Medical Journal. If we were confined to a single work on SurgeTy, that work should be Chelius's.—St. Louis Med. Journal. As complete as any system of Surgery can well be.—Southern Medical and Surgical Journal. The most finished system of Surgery in the English language.— Western Lancet. The most learned and complete systematic treatise now extant.—Edinburgh Medical Journal. No work in the English language comprises so large an amount of information relative to operative medi- cine and surgical pathology.—Medical Gazette. A complete encyclopedia of surgical science—a very complete surgical library—by far the most complete and scientific system of surgery in the English language.—N. Y. Journal of Medicine. One of the most complete treatises on Surgery in the English language.—Monthly Journal of Med. Science. The most extensive and comprehensive accountofthe art andscience of Surgery inour language.—Lancet. A TREATISE ON THE DISEASES OF THE EYE, BY W. LAWRENCE, F.R.S. A new Edition. With many Modifications and Additions, and the introduction of nearly 200 Illustrations, BY ISAAC HAYS, M.D. In one very large 8vo. vol. of S60 pages, with plates and wood-cuts through the text. JONES OBT THE EVE. THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDICINE AND SURGERY, BY T. WHARTON JONES, F. R. S., &c. &c. EDITED BY ISAAC HAYS, M.D., &c. la one very neat volume, large royal 12mo. of 529 pages, with four plates, plain or colored, and ninety-eight well executed wood-cuts. A NEW TEXT-BOOK ON SURGERY—(Now Ready.) THE PRINCIPLES AND "PRACTICE OF SURGERY. BY WILLIAM PIRRIE, F.R.S.E., Regius Professor of Surgery in the University of Aberdeen. Edited by JOHN NEILL, M. D., Demonstrator of Anatomy in the University of Pennsylvania Lecturer on Anatomy in the Medical Institute of Philadelphia, &c. In one very handsome octavo volume, of 780 pages, with 316 illustrations. The object of the author, in the preparation of this volume, has been to present to the student a complete text-book of surgery, embracing both the principles and the practice in their mutual rela- 3 according to the latest state of scientific development. In accomplishing this, his aim has been Combine simpl city of arrangement, and conciseness and clearness of description w,th the eluci- dation of"soundprinciples and the modes of practice which his own experience and the teachings of ?hl hit nThoriHes have shown to be the most successful. The Editor has, therefore, found but ittletoadd re pecting European surgery, and his efforts consequently have been directed towards little to add respecting * have been pointed out by the practitioners of the United States, aXuTfurht nXSon "as may be requisite for the guidance of the student in this country.- Of the very numerous illustrations, the greater port.on are from preparations in the author's mu- Ut the very n"™*". . his care. These have been reproduced with great care, and the wh T *n and 51 —The Surgical Dissection of the Superficial Structures of the Male Perineum. Plates 52 and 53!—The Surgical Dissection of the Deep Structures of the Male Perineum.—The Lateral Operation of Lithotomy. 10 BLANCHARD & LEA'S PUBLICATIONS.—(Surgery.) MACLISE'S SURGICAL ANATOMY—(Continued.) Plates 54, 55 and 56.—The Surgical Dissection of the Male Bladder and Urethra.—Lateral and Bilateral Lithotomy compared. Plates 57 and 58.—Congenital and Pathological Deformities of the Prepuce and Urethra.—Struc- ture and Mechanical Obstructions of the Urethra. Plates 59 and 60.—The various forms and positions of Strictures and other Obstructions of the Urethra.—False Passages.—Enlargements and Deformities of the Prostate. Plates 61 and 62.—Deformities of the Prostate.—Deformities and Obstructions of the Prostatic Urethra. Plates 63 and 64.—Deformities of the Urinary Bladder.—The Operations of Sounding for Stone, of Catheterism, and of Puncturing the Bladder above the Pubes. Plates 65 and 66.—The Surgical Dissection of the Popliteal Space, and the Posterior Crural Region. Plates 67 and 68.—The Surgical Dissection of the Anterior Crural Region, the Ankles, and the Foot. Notwithstanding the short time in which this work has been before the profes- sion, it has received the unanimous approbation of all who have examined it. From among a very large number of commendatory notices with which they have been favored, the publishers select the following:— From Prof. Kimball, Pittsfield, Mass. I have examined these numbers with the greatest satisfaction, and feel bound to say that they are alto- gether the most perfect and satisfactory plates of the kind that I have ever seen. From Prof. Brainard, Chicago, HI. The work is extremely well adapted to the use both of students and practitioners, being sufficiently exten- sive for practical purposes, without being so expensive as to place it beyond their reach. Such a work wai a desideratum in this country, and I shall not fail to recommend it to those within the sphere of my acquaint- ance. From Prof. P. F. Eve, Augusta, Ga. I consider this work a great acquisition to my library, and shall take pleasure in recommending it on all suitable occasions. From Prof Peaslee, Brunswick, Me. The second part more than fulfils the promise held out by the first, so far as the beauty of the illustrations is concerned ; and, perfecting my opinion of the value of the work, so far as it has advanced, I need add nothing to what I have previously expressed to you. From Prcf. Gunn, Ann Arbor, Mich. The plates in your edition of Maclise answer, in an eminent degree, the purpose for which they are intended. I shall take pleasure in exhibiting it and recommending it to my class. From Prof. Rivers, Providence, R. I. The plates illustrative of Hernia are the most satisfactory I have ever met with. From Professor S. D. Gross, Louisville, Ky. The work, as far as it has progressed,is most admirable, and cannot fail, when completed, to form a most valuable contribution to the literature of our profession. It will afford me great pleasure to recommend it to the pupils of the University of Louisville. From Professor R. L. Howard, Columbus, Ohio. In all respects, the first number is the beginning of a most excellent work, filling completely what might be considered hitherto a vacuum in surgical literature. For myself, in behalf of the medical profession, I wish to express to you my thanks for this truly elegant and meritorious work. I am confident that it will meet with a ready and extensive sale. I have spoken of it in the highest terms to my class and my profes- sional brethren. From Prof. C. B. Gibson, Richmond, Va. I consider Maclise very far superior, as to the drawings, to any work on Surgical Anatomy with which I am familiar, and I am particularly struck with the exceedingly low price at which it is sold. I cannot doubt that it will be extensively purchased by the profession. From Prof. Granville S. Pattison, New York. The profession, in my opinion, owe you many thanks for the publication of this beautiful work—a work which, in the correctness of its exhibitions of Surgical Anatomy, is not surpassed by any work with which I am acquainted; and the admirable manner in which the lithographic plates have been executed and colored is alike honorable to your house and to the arts in the United States. From Prof. J. F. May, Washington, D. C. Having examined the work, I am pleased to add my testimony to its correctness, and to its value as a work of reference by the surgeon. From Prof. Alden Marsh, Albany, N. Y. From what I have seen of it, I think the design and execution of the work admirable, and, at the proper time in my course of lectures, I shall exhibit it to the class, and give it a recommendation worthy of its great merit. From H. H. Smith, M. D., Philadelphia. Permit me to express my gratification at the execution of Maclise'sSurgical Anatomy. The plates are, in my opinion, the best lithographs that I have seen of a medical character, and the coloring of this number cannot, I think, be improved. Estimating highly the contents of this work, I shall continue to recommend it to my class as I have heretofore done. From Prof. D. Gilbert, Philadelphia. Allow me to say, gentlemen, that the thanks of the profession at large, in this country, are due to you for the republication of this admirable work of Maclise. The precise relationship of the organs in the regions displayed is so perfect, that even those who have daily access to the dissecting-room may, by consulting this work, enliven and confirm their anatomical knowledge prior to an operation. But it is to the thousands of practitioners of our country who cannot enjoy these advantages that the perusal of those plate*, with their concise and accurate descriptions, will prove of infinite value. These have supplied a desideratum, which will enable them to refresh their knowledge of the important structures involved in their surgical cases, thus establishing their self-confidence, and enabling them to undertake operative procedures with every assurance of success. And as all the practical departments in medicine rest upon the same basis, and are enriched from the same sources, I need hardly add that this work should be found in the library of every practitioner in the land. BLANCHARD & LEA'S PUBLICATIONS.—(Surgery.) Tl MACLISE'S SURGICAL ANATOMY—(Continued.) From Professor J. M. Bush, Lexington, Ky. I am delighted with both the plan and execution of the work, and shall take all occasions to recommend it to my private pupils and public classes. The most accurately engraved and beautifully colored plates we have ever seen in an American book— one of the best and cheapest surgical works ever published.— Buffalo Medical Journal. It is very rare that so elegantly printed, so well illustrated, and so useful a work, is offered at so moderate a price.—Charleston Medical Journal. A work which cannot but please the most fastidious lover of surgical science. In it, by a succession of plates, are brought to view the relative anatomy of the parts included in the important surgical divisions of the human body, with that fidelity and neatness of touch which is scarcely excelled by nature herself. While we believe that nothing but an extensive circulation can compensate the publishers for the outlay in the production of the work—furnished as it is at a very moderate price, within the reach of all—we desire to see it have that circulation which the zeal and peculiar skill of the author, the utility of the work, and the neat style with which it is executed, should demand for it in a liberal profession.—N. Y. Jour, of Medicine. This is an admirable reprint of a deservedly popular London publication. Its plates can boast a superi- ority that places them almost beyond the reach of competition. And we feel too thankful to the Philadel- phia publishers for their very handsome reproduction of the whole work, and at a rate within everybody's reach, not to urge all our medical friends to give it, for their own sakes, the cordial welcome it deserves,in a speedy and extensive circulation.— The Medical Examiner. When the whole has been published it will be a complete and beautiful system of Surgical Anatomy, hav- ing an advantage which is important, and not possessed by colored plates generally, viz., its cheapness, which places it within the reach of every one who may feel disposed to possess the work. Every practi- tioner, we think, should have a work of this kind within reach, as there are many operations requiring imme- diate performance in which a book of reference will prove most valuable.—Southern Med. and Surg. Journ. No such lithographic illustrations of surgical regions have hitherto, we think, been given. While the ope- rator is shown every vessel and nerve where an operation is contemplated, the exact anatomist is refreshed by those clear and distinct dissections which every one must appreciate who has a particle of enthusiasm. The English medical press has quite exhausted the words of praise in recommending this admirable treatise. Those who have any curiosity to gratify in reference to the perfectibility of the lithographic art in delinea- ting the complex mechanism of the human body, are invited to examine our copy. If anything will induce surgeons and students to patronize a book of such rare value and every-day importance to them, it will be a survey of the artistical skill exhibited in these fac-similes of nature.—Boston Medical and Surg. Journal. These plates will form a valuable acquisition to practitioners settled in the country, whether engaged in surgical, medical, or general practice.—Edinburgh Medical and Surgical Journal. We are well assured that there are none of the cheaper, and but few of the more expensive works on anatomy, which will form so complete a guide to the student or practitioner as these plates. To practitioners, in particular, we recommend this work as far better, and not at all more expensive, than the heterogeneous compilations most commonly in use, and which, whatever their value to the student preparing for examina- tion, are as likely to mislead as to guide the physician in physical examination, or the surgeon in the per- formance of an operation.—Monthly Journal of Medical Sciences. We know of no work on surgical anatomy which can compete with it.—Lancet. This is by far the ablest work on Surgical Anatomy that has come under our observation. We know ot no other work that would justify a student, in any degree, for neglect of actual dissection. A careful study of these plates, and of the commentaries on them, would almost make an anatomist of a diligent student. Ana to one who has studied anatomy by dissection, this work is invaluable as a perpetual remembrancer, in mat- ters of knowledge that may slip from the memory. The practitioner can scarcely consider himself equipped for the duties of his profession without such a work as this, and this has no rival, in his library. In those sudden emergencies that so often arise, and which require the instantaneous command of minute anatomical knowledge, a work of this kind keeps the details of the dissecting-room perpetually fresh in the memory. We appeal to our readers, whether any one can justifiably undertake the practice of medicine who is not nrenared to eive all needful assistance, in all matters demanding immediate relief. . P We repeat5 hit no medical library, however large, can be complete without Maclise's Surgical Anatomy. The American edition is well entitled to the confidence of the profession, and should command, among them, an ex™" ve sale The investment of the amount of the cost of this work will prove to be a very profitable one and ff Practitioners would qualify themselves thoroughly with such important knowledge as is contained h" works oPthE kind, there would be "fewer of them sighing for employment. The medical profession shouM sS towards such 'an opportunity as is presented in this republication, to encourage frequent repetitions of American enterprise of this kind.-TAe Western Journal of Medicine and Surgery. MILLER'S PRINCIPLES OF SURGERY. NEW AND BEAUTIFULLY ILLUSTRATED EDITION-(Now Ready.) PRINCIPLES~OF SURGERY. BY JAMES MILLER, F. R. S. E., F. R. C. S. E., Professor of Surgery in the University of Edinburgh. THIRD AMERICAN, FROM THE SECOND AND ENLARGED EDINBURGH EDITION. Revised, with Additions, by F. W. SARGENT, M.D., Author of " Minor Surgery," &c. In nnP verv lame and handsome octavo volume, of seven hundred and fifty-two pages, in one ^nu\mvT TW0 hundred and fifty exquisite wood engravings. ThP vorv extensive additions and alterations which the author has introduced into this edition i. IaJJa it Pssentiallv a new work. By common consent, it has been pronounced the most have rendered^^^ t of the res|nt state of the science of surgery in the English lan- complete and ^ough e*Po^erg ^ p^ ration of ^ pregent editi(m have endeavored to guage, and the Amenc. ^P ^.^ ejtm£ed^eputation. The press has been carefully revised render it.inan re P introduced such notes and observations as the rapid progress of surgical by the editor,wn haye rendered n€Cessary. The illustrations, which are very numerous, investigatiori and pain gy ^ ^.^ ^ practical} have been engraved with great care, and and ofa 0gi„t of mechanical execution it is confidently presented as one of the most beautiful volumes as yet published in this country. volumes v y ^ th£ same AUTH0R. THE PRACTICE OF SURGERY. In one octavo volume, of 496 pages. 12 BLANCHARD & LEA'S PUBLICATIONS.—(Anatomy.) SHARPEY AND QUAIN'S ANATOMY.—Lately Issued. HUMAN ANATOMY. BY JONES QUAIN, M. D. FROM THE FIFTH LONDON EDITION. EDITED BY RICHARD QUAIN, F. R. S., and WILLIAM SHARPEY, M. D., F. R. S., Professors of Anatomy and Physiology in University College, London. REVISED, WITH NOTES AND ADDITIONS, BY JOSEPH LEIDY, M. D. Complete in Two large Octavo Volumes, of about Thirteen Hundred Pages. Beautifully Illustrated with over Five Hundred Engravings on "Wood. We have here one of the best expositions of the present state of anatomical science extant. There is not probably a work to be found in the English language which contains so complete an account of the progress and present state of general and special anatomy as this. By the anatomist this work must be eagerly sought for, and nr student's library can be complete without it.— The N. Y. Journal of Medicine. We know of no work which we would sooner see in the hands of every student of this branch of medical science than Sharpey and Quain's Anatomy.— The Western Journal of Medicine and Surgery. It may now be regarded as the most complete and best posted up work on anatomy in the language. It will be found particularly rich in general anatomy.— The Charleston Medical Journal. We believe we express the opinion of all who have examined these volumes, that there is no work supe- rior to them on the subject which they so ably describe.—Southern Medical and Surgical Journal. It is one of the most comprehensive and best works upon anatomy in the English language. It is equally valuable to the teacheT, practitioner, and student in medicine, and to the surgeon in particular.—The Ohio Medical and Surgical Journal. To those who wish an extensive treatise on Anatomy, we recommend these handsome volumes as the best that have ever issued from the. English or American Press.—The N. W. Medical and Surgical Journal. We believe that any country might safely be challenged to produce a treatise on anatomy so readable, so clear, and so full upon all-important topics.—British and Foreign Medico-Chirurgical Review. It is indeed a work calculated to make an era in anatomical study, by placing before the student every de- partment of his science, with a view to the relative importance of each; and so skillfully have the different parts been interwoven, that no one who makes this work the basis of his studies will hereafter have any ex- cuse for neglecting or undervaluing any important particulars connected with the structure of the human frame; and whether the bias of his mind lead htm in a more especial manner to surgery, physic, or physiolo- gy, he will find here a work at once so comprehensive and practical as to defend him from exclusiveness on the one hand, and pedantry on the other.—Monthly Journal and Retrospect of the Medical Sciences. We have no hesitation in recommending this treatise on anatomy as the most complete on that subject in the English language ; and the only one, perhaps, in any language, which brings the state of knowledge for- ward to the most recent discoveries.— The Edinburgh Medical and, Surgical Journal. Admirably calculated to fulfil the object for which it is intended.—Provincial Medical Journal. The most complete Treatise on Anatomy in the English language.—Edinburgh Medical Journal. There is no work in the English language to be preferred to Dr. Quain's Elements of Anatomy.—London Journal of Medicine. THE STUDENT'S TEXT-BOOK OF ANATOMY. NEW AND IMPROVED EDITION —JTJST ISSUED. A SYSTEM OF HUMAN ANATOMY, GENERAL AND SPECIAL. BY ERASMUS WILSON, M. D. FOURTH AMERICAN FROM THE LAST ENGLISH EDITION. EDITED BY PAUL B. GODDARD, A. M., M. D. WITH TWO HUNDRED AND FIFTY ILLUSTRATIONS. Beautifully printed, in one large octavo volume of nearly six hundred pages. In many, if not all the Colleges of the Union, it has become a standard text-book. This, of itself,is sufficiently expressive of its value. A work very desirable to the student; one, the possession of which will greatly facilitate his progress in the study of Practical Anatomy.—New York Journal of Medicine. Its author ranks with the highest on Anatomy.—Southern Medical and Surgical Journal. It offers to the student all the assistance that can be expected from such a work.—Medical Examiner. The most complete and convenient manual for the student We possess.—American Journal of Med. Science. In every respect this work, as a*i anatomical guide for the student and practitioner, merits our warmest and most decided praise.—London Medical Gazette. SIBSON'S MEDICAL ANATOMY—(Preparing.) MEDICAL ANATOMY; Illustrating the Form, Strncturc, and Position of the Internal Organs in Health and Disease. BY FRANCIS SIBSON, M.D., F.R.S., Physician to St. Mary's Hospital. W*ith numerous and beautiful colored Plates. In Imperial Quarto, to match " Maclise's Surgical Anatomy." BLANCHARD & LEA'S PUBLICATIONS.-Ureatomy.) 13 HORNER'S ANATOMY. MUCH IMPROVED jMYI) EJYLARGED EDITIOJY.—(Just Issued.) SPECIAL ANATOMY AMD HISTOLOSY. BY WILLIAM E. HORNER, M. D., Professor of Anatomy in the University of Pennsylvania, &c. EIGHTH EDITION. EXTENSIVELY REVISED AND MODIFIED TO 1851. In two large octavo volumes, handsomely printed, with several hundred illustrations. This work has enjoyed a thorough and laborious revision on the part of the author, with the view of bringing it fully up to the existing state of knowledge on the subject of general and special anatomy. To adapt it more perfectly to the wants of the student, he has introduced a large number of additional wood engravings, illustrative of the objects described, while the publishers have en- deavored to render the mechanical execution of the work worthy of the extended reputation which it has acquired. The demand which has carried it to an EIGHTH EDITION is a sufficient evidence of the value of the work, and of its adaptation to the wants of the student and professional reader. NEW AND CHEAPER EDITION OF SMITI1 Sf BORJTEIVS JUT ATOMICJlX. JITL.JIS. AN ANATOMICAL ATLAS, ILLUSTRATIVE OF THE STRUCTURE OF THE HUMAN BODY. BY HENRY H. SMITH, M.D., &c. UNDER THE SUPERVISION OF WILLIAM E. HORNER, M.D., Professor of Anatomy in the University of Pennsylvania. n one volume, large imperial octavo, with about six hundred and fifty beautiful figures. jjj.^jhe view of extending the sale of this beautifully executed and complete "Anatomical Atlas," the publisiu. nave prepared a new edition, printed on both sides of the page, thus materially reducing its cost, * e{V Sg them to present it at a price about forty per cent, lower than former editions, while, at the same time, tne ^cution of each plate is in no respect deteriorated, and not a single figure is omitted. l • Jltes are well selected, and present a complete and accurate representation of that wonderful fabric, tne ft n body. The plan of this Atlas, which renders it so peculiarly convenient for the student, and its supero arscai execution, have been already pointed out. We must congratulate the student upon the C0™P'? n °^ls Atlas, as it is the most convenient work of the kind that has yet appeared ; and we must add, the very|,autifuj manner in which it is "got up" is so creditable to the country as to be flattering to our national ^e^^^^ Medical Journal. HORNER'S DISSECTOR. THE ImitED STATES DISSECTOR; Being a nfeel ~~ £jicuiciiid" i9 sbm iciaHicuao ucins more cxprGSsi\c *-". • 1 comparison of the present edition with the former one will show a rlerli implement, the au- thor having revised it thoroughly, with the view of rendering it ^npieteiy oi a level with the most advanced state of the science. By condensing the less imnta,nt P°?'on* these numerous additions have been introduced without materially increasing thbu^,0,1 tne ™ume> and while numerous illustrations have been added, and the general execvon of tbe wor! ,mP'°ved, it has been kept at its former very moderate price. To say that it is the best manual of Physiology now before tbe pub°>would not do.nicientja.tic. to the 'tyslSto^hwruWseemthathe had exhausted the. .,*•« °< ^^0^ I" the present, he ^^V^^^^°l^^^^S!^^lm9'estant inthEngUsh lan°uage- -St Louis Med. Journal. ...oDgy, cannot do better tn topossess them- Those who have occasion for an elementary treatise on ph/s.o*'&> > *•»" » selves of the manual of Dr. Carpenter.—Medical Examiner. A New Work by Dr. jrarpenter-(Freparing.) THE VARIETIFS~OF MANKIND; Or, an Account of the Distinctive Characters of the Various Races Men, WITH NUMEROUS ILLUSTRATIONS ON WOOD. In one handsome royal 12mo. volume. BLANCHARD & LEA'S PUBLICATIONS— (Physiology.) 15 DUNGLISON'S PHYSIOLOGY. New and much Improved Edition.—(Just Issued.) HUMAN PHYSIOLOGY. BY ROBLEY DUNGLISON, M. D., Professor of the Institutes of Medicine in the Jefferson Medical College, Philadelphia, etc. etc. SEVENTH EDITION. Thoroughly revised and extensively modified and enlarged, With nearly Five Hundred Illustrations. In two large and handsomely printed octavo volumes, containing nearly 1450 pages. On no previous revision of this work has the author bestowed more care than on.the P™""*' J having been subjected to an entire scrutiny, not only as regards the important matte™ of which treats but also the language in which they are conveyed ; and on no former occasion has hetelt sSatisfied with hi- endeavors to have the work on a level with the existing state of the, science- Pe haps a? no Le in the history of physiology have observers been more>J™™»££*£% found to contain the views cf the most distinguished physiologists ot all Peri0™- f . Amount of additional matter contained jt thi,, .d.tjon ma,■ b. *«™£*™d£Zfi$££ the mere list of authors referred to in its preparation alone extendBovernineiarg H four pages. The number of illustrations has been largely increased, the p esent ea'uo" * addition Hred and seventy-four, while the last had but three, handleUnd^-^^J 4^ :'Zaddedemed > this, many new and superior ^ood-cuts have been f^fj^^^ has also been im- *ficiently accurate or satisfactory. The m£" "^ "S^."^, the great and continued P>ved in every respect, and the whole is confidently presentea as wormy ».* s f"a^ which it has so long received from the profession. ,v„K„a, It..s ,ong,i„ce taken rank asoneof the medical classics of 0- language. *£%*£?»&^£ text-.lk 0f physiology ever published in this country, is butechoing the general tesumu y "|-W.6JSSSS£ ^mof Physiology in 00;^^^Z^^Jnur. Med. Journal. The K. -omniete and satisfactory system of Physiology in the kngnsii iangu 0 Th* «'worifof Ste kind in the English language.-S^^an s Jour*aL ^^ and we u WC ™>°n lwo former occasions brought this excellent work^undethe none ^ ^.^ have now,, tQ g tha, instead of falling behind in the rapid march 01 pny swa brings it nv' the yM.-British and Foreign Med'«» ^""a „ j We have looked over it, . A ^^such a well-known work woud be out of plac at th« present t.^.^ ^ ^ tQ h h v°l"mf LIVING BEINGS.-Lectures on te Physical Phenomena of Living Beings. Edited MA.TTKiJ*-'^1 )ne neat rQ | j2mo. volume, extra elcvh.with cuts—38S pages. by Per|p;,OLOGY-A Treauseon Animal and Vegetable Physiology, with oveT 400 illustrations on ROGER'S r"ctav0 V0|Umes .cloth. c,r „„„„- wood. *, VVrilNES —Outlines of Physiolosrv and Phreioloary. In one octavo volume, cloth—510 paget. ROOET^s OUe;ction BETWEEJN PHYSIOLOGY AND INTELLECTUAL SCIENCE. In one VZmo. 7°.1"''fIa^N',SPpCH YSIOLOGY —Physiological Alatomy and Physiology of Man. With numerous TODD & >< j.cuts. Parts I. II, and HI, in one 8vo. voluae, 552 pp. Part IV will complete the wort. handsome ■»* 16 BLANCHARD & LEA'S PUBLICATIONS.—(Pathology.) NEARLY READY. AN ATLAS OF PATHOLOGICAL HISTOLOGY. BY GOTTLIEB GLUGE, M. D., Professor of Physiology and Pathological Anatomy in the University of Brussels. Translated, with Notes, by JOSEPH LEIDY, M. D. In one volume, very large imperial quarto, WITH THREE HUNDRED AND TWENTY FIGURES, PLAIN AND COLORED, ON TWELVE PLATES. The great and increasing interest with which this important subject is now regarded by the profession and the rapid advances which it is making by the aid of the microscope, have induced the publishers to pre sent this volume, which contains all the most recent observations and results of European investigations. The text contains a complete exposition of the present state of microscopical pathology, while the plates an considered as among the most truthful and accurate representations which have been made of the patholog - cal conditions of the tissues, and the volume as a whole may be regarded as a beautiful specimen of mechar- ical execution, presented at a very reasonable price. WILLIAMS' PRINCIPLES—JYetc and Enlarged Edition. PRINCIPLES OF MEDICINE; Comprising General Pathology and Therapeutics, AND A BRIEF GENERAL VIEW OF ETIOLOGY. NOSOLOGY. SEMEIOLOGY. DIAGNOSIS, PROGNOSIS, AND HYGIENICS, BY CHARLES J. B. WILLIAMS, M. D., F. R. S., Fellow of the Royal College of Physicians, &c. Edited, with Additions, BY MEREDITH CLYMER, M. D., Consulting Physician to the Philadelphia Hospital, &c. &c. THIRD AMERICAN, FROM THE SECOND AND ENLARGED LONDON EDITION. In one octavo volume, of 440 pages. BIIXING'S PRINCIPLES, NEIV EDITION—(Just Issued.) BY ARCHIBALD BILLING, M. D., &c. Second American from the Fifth and Improved London Editi'* In one handsome octavo volume, extra cloth, 250 pages. , , , We can strongly recommend Dr. Billing's " Principles" as a code of instruction whiq^0^aJle,eon~ stantly present to the mind of every well-informed and philosophical practitioner of medic" ' MANUALS ON THE BLOOD AND MNE, In one handsome volume royal 12mo., extra cloth, of 460 large pages, with nurous lllustratl0ns> CONTAINING I. A Practical Manual on the Blood and Secretions of the Human Body. J J0HN WILLIAM CRIFFITH M. D« &c. II. On the Analysis of the Blood and Urine in health and disease, and on f treatment of Urinary diseases. BY G. OWEN REESE, M. D., F. R. S., &c. &c. LFRFD M\nvwirv III. A Guide to the Examination of the Urine in health and disease. Br*14^ MAKKWILK. NEW EDITION—(Just Issued.) URINARY "DEPOfns; THEIR DIAGNOSIS, PATHOLOGY, AND THERA^IC^ INDICATIONS. BY GOLDING BIRD, A. M. M V; &c. A NEW AMERICAN, FROM THE THIRD AND r""*™ LONDONEDITION. In one very neat volume, royal 12mo., w>' oyer 8ixty ,"™£'!>"'-11 . , , Though the present edition of this well-known work is but'"1* S^Mtsubiee T I n!w™f T" tially modified throughout, and fully up to the present state o^ pledge^on its subjec Ti e unammoos les- timony of the medicll press warrants the publishers in prrnU"? " e comPlele a' relldble mai,ual for the student of this interesting and important branch ofme»tial science- ABERCROMBIE ON THE BRAIN.-Pathological an.^ractical Researches on Dis^s of the Brain and Spinal Cord. A new edition, in one small 8vo. volur°f Respiranon and Circulation. Translated and Edited by Swaine. In one volume, 8vo.. pp. a/v. , FRICK ON THE URINE.-Renal Affections, ueir Diagnosis and Pathology. In on»„dBome volume. royaM2mo.. with illustrations. . m ^ - r,„i„„ 0„a innniP1 T„ „, , COPLAND ON PALSY.-Of the Causes, Natire, and Treatment of Palsy and Apoplej i„ one volume, VOGEL-fpATHOLOGICAL ANATOMY.-Pathological Anatomy of the Human be Translated by Day. In one octavo volume, with plates, plun and colored. . , ,, M di „ SIMON'S PATHOLOGY.-Leetures onGen.ral Pathology. Publishing in the ^uiNew« and Li- brary," for 1852. BLANCHARD & LEA'S FVBLICATIOSS.—(Practice of Medicine.) 17 THE PETfJTICE OF MEDICINE. _ A TREATISE ON SPECIAL PATHOLOGY AND THERAPEUTICS. THIRD EDITION. Pr0fess„r of ,„ t ,BY ROBLEY DUNGLISON, M. D., rrotessor of the Institutes of Medicine in the Jefferson Medical College; Lecturer on Clinical Medicine, &c. In two large octavo volumes, of fifteen hundred pages. The student of medicine will find, in these two elegant volumes, a mine of facts, a gathering of precepts and advice from the world of experience, that will nerve him with courage, and faith- Sur ical°Journain tB l° relieve the physical sufferings of the race.—Boston Medical and Upon every topic embraced in the work the latest information will be found carefully posted up. Medical Examiner. It is certainly the most complete treatise of which we have any knowledge. There is scarcely a disease which the student will not find noticed.—Western Journal of Medicine and Surgery. One of the most elaborate treatises of the kind we have.—Southern Medical and Surg. Journal. NEW AND IMPROVED EDITION-(Now Ready.) THE HISTORY, DIAGNOSIsTaND TREATMENT OF THE FEVERS OF THE UNITED STATES, n , BY ELISHA BARTLETT, M.D., Professor of Materia Medica and Medical Jurisprudence in the College of Physicians and Surgeons, N. Y. Third Edition, Revised and Improved. In one very neat octavo volume, of six hundred pages. In preparing a new edition of this standard work, the author has availed himself of such observ- ations and investigations as have appeared since the publication of his last revision, and he has endeavored in every way to render it worthy of a continuance of the very marked favor with which it has been hitherto received. The masterly and elegant treatise by Dr. Bartlett is invaluable to the American student and practitioner. —Br. Holmes's Report to the Nat. Med. Association. We regard it, from the examination we have made of it, the best work on fever extant, in our language, and as such cordially recommend it to the medical public—St. Louis Med. and Surg. Journal. DISEASES OF THE HEART, LUNGS, AND APPENDAGES; THEIR SYMPTOMS AND TREATMENT. BY W. H. WALSHE, M.D., Professor of the Principles and Practice of Medicine in University College, London, fyc. In one handsome volume, large royal 12mo. THE CYCLOPEDIA OF PRACTICAL MEDICINE; COMPRISING Treatises on the Nature and Treatment of Diseases, Materia Medica, and Thera- peutics, Diseases of "Women and Children, Medical Jurisprudence, &c. &c. EDITED BY JOHN FORBES, M. D., F. R. S., ALEXANDER TWEEDIE, M.D., F.R. S., AND JOHN CONOLLY, M. D.j Revised, with Additions, BY ROBLEY DUNGLISON, M. D. THIS WORK IS NOW COMPLETE, AND FORMS FOUR LARGE SUPER-ROYAL OCTAVO VOLUMES, Containing Thirty-two Hundred and Fifty-four unusually large Pages in Double Columns, Printed on Good Paper, with a new and clear type. THE WHOLE WELL AND STRONGLY BOUND, WITH RAISED BANDS AND DOUBLE TITLES. This work^ntains nrfess than FOUR HUNDRED AND EIGHTEEN DISTINCT TREATISES, By Sixty-eight distinguished Physicians. The most complete work on Practical Medicine extant; or, at least, in our language.—Buffalo Medical and Surgical Journal. ... ., T For reference, it is above all price to every practitioner.- Western Lancet. -..,,_, One of the most valuable medical publications of the day—as a work of reference it is invaluable.— Western Journal of Medicine and Surgery. . It has been to us both as learner and teacher, a work for ready and frequent reference, one in which modern English medicine is exhibited in the most advantageous hghl.-Medical Examiner. . We reioire that this work is to be placed within the reach of the profession in this country, it being unques- tionably one of verv great value to the practitioner. This estimate of it has not been formed from a hasty ex- amination hut after an intimate acquaintance derived from frequent consultation of it during the past nine or ten vrars ' The editors are practitioners of established reputation, and the list of contributors embraces many nf hP mnit eminent professor? and teachers of London, Edinburgh, Dublin, and Glasgow. It is, indeed, the rwntniprii of this work that the principal articles have been furnished by practitioners who have not only jrreaimeriio aUention to tne diseases about which they have written, but have also enjoyed opportunities ?eVB pTiensive practical acquaintance with them,—and whose reputation carries the assurance of their tor an ex. ^ appreciate the opinions of others, while it stamps their own doctrines with high and just Z&orilY.-American Medical Journal. 18 BLANCHARD & LEA'S PUBLICATIONS.—(Practice of Medicine.) WATSON'S PRACTICE OF MEDICINE-New Edition. LECTURES' ON THE PRINCIPLES AND PRACTICE OF PHYSIC, BY THOMAS WATSON, M. D., &c. &c. Third American, from the last London Edition. REVISED, WITH ADDITIONS, BY D. FRANCIS CONDIE, M. D., Author of " A Treatise on the Diseases of Children," &c. IN ONE OCTAVO VOLUME, Of nearly ELEVEN HUNDRED LARGE PAGES, strongly bound with raised bands. To say that it is the very best work on the subject now extant, is but to echo the sentiment of the medical press throughout the country.— N. O. Medical Journal. Regarded on all hands as one of the very best, if not the very best, systematic treatise on practical medi- cine extant.—St. Louis Med. Journal. As a text-book it has no equal; as a compendium of pathology and practice no superior.— IV. Y. Annalist. We know of no work better calculated for being placed in the hands of the student^ and for a text book; on every important point the author seems to have posted up his knowledge to the day.—Amer. Med. Journal. One of the most practically useful books that ever was presented to the student.—N. Y. Med. Journal. NEW AND IMPROVED EDITION-(Now Ready.) ON DISEASES~OF THE SKIN. BY ERASMUS WILSON, F. R. S., Author of" Human Anatomy," &c. THIRD AMERICAN FROM THE THIRD LONDON EDITION. In one neat octavo volume, extra cloth, 4S0 pages. Also, to lie had with fifteen beautiful steel plates, embracing 165 figures, plain and colored, representing the Normal Anatomy and Pathology of the Skin. ALSO, THE PLATES SOLD SEPARATE, IN HOARDS. This edition will be found in every respect much improved over the last. Considerable addi- tions have been made, the arrangement altered, and the whole revised so as to make it fully on a level with the existing state of knowledge on the subjects treated. As a practical guide to the classification, diagnosis, and treatment of the diseases of the skin, the book is complete. AVe know nothing, considered in this aspect, better in our language ; it is a safe authority on all the ordinary matters which, in this range of diseases, engage the practitioners attention, and possesses the high quality—unknown, we believe, to every older manual—of being on a level with science's high-water mark—a sound book of practice.—London Medical Times. WILSON ON SYPHILIS-(Now Ready.) ON CONSTITUTIONAL ANlT HEREDITARY SYPHILIS; AND ON SYPHILITIC ERUPTIONS. BY ERASMUS WILSON, F. R. S., Author of" Human Anatomy," " Diseases of the Skin,'' &c. In one very handsome volume, small 8vo., with four beautiful colored plates, Presenting accurate representations of more than thirty varieties of Syphilitic Diseases of the Skin. This work is the result of extensive practical experience in the treatment of this disease, and presents some new views on this difficult and important subject, illustrated by numerous cases. BENEDICT'S CHAPMAN.—Compendium of Chapman's Lectures on the Practice of Medicine. One neat volume, 8vo., pp. 258. BUDD ON THE LIVER.—On Diseases of the Liver. In one very neat 8vo. vol., with colored plates and wood-cuts, pp. 392. CHAPMAN'S LECTURES.—Lectures on Fevers, Dropsy, Gout, Rheumatism, &c. &c. In one neat8vo. volume, pp. 450. THOMSON ON THE SICK ROOM.—Domestic managementof the sick Room, necessary in aid of Medical Treatment for the cure of Diseases. Edited by R. E. Griffith, M. D. In one large royal 12mo. volume, with wood-cuts, pp. 360. HOPE ON THE HEART.—A Treatise on the Diseases of the Heart and Great Vessels. Edited by Pen- nock. In one volume, 8vo., with plates, pp. 572. LALLEMAXD ON SPERMATORRHOEA— The Causes, Symptoms, and Treatment of Spermatorrhoea. Translated and Edited by Henry J. McDougal. In one volume, Svo., pp. 320. PHILIPS ON SCROFULA.—Scrofula: its Nature, its Prevalence, its Causes, and the Principles of its Treatment. In one volume, 8vo., with a plate, pp. 350. WHITEHEAD ON ABORTION, &c—The Causes and Treatment of Abortion and Sterility; being the Result of an Extended Practical Inquiry into the Physiological and Morbid Conditions of the Uterus. In one volume, 8vo., pp. 368. WILLIAMS ON RESPIRATORY ORGANS.—A Practical Treatise on Diseases of the Respiratory Or- gans; including Diseases of the Larynx, Trachea, Lungs, and Pleurae. With numerous Additions and Notes by M. Clymer, M.D. With wood-cuts. In one octavo volume, pp 508. DAY ON OLD AGE.—A Practical Treatise on the Domestic Management and more important Diseases of Advanced Life. With an Appendix on a new and successful mode of treating Lumbago and other forms of Chronic Rheumatism. 1 vol. 8vo., pp. 226. CLYMER ON FEVERS.—Fevers, their Diagnosis, Pathology, and Treatment. Prepared, with large Ad- ditions, from " Tvveedie's Library of Practical Medicine." in one vol 8vo., pp. 604. t>bAivuHAKU & LEA'S PUBLICATIONS.—(Diseases of Females.) 19 MEIGS ON FEMALES, New and Improved Edition—(Lately Issued.) WOMAN; HER DISEASES" AND THEIR REMEDIES; A SERIES OF LETTERS TO HIS CLASS. BY C. D. MEIGS, M. D., F rofessor of Midwifery and Diseases of Women and Children in the Jefferson Medical College of Philadelphia, &c. &c. In one large and beautifully printed octavo volume, of nearly seven hundred large pages. " T am„h7aPPy to offer t0 my Class an enlarged and amended edition of my Letters on the Dis- eases ot Women ; and I avail myself of this occasion to return my heartfelt thanks to them, and to our brethren generally, for the flattering manner in which they have accepted this fruit of my labor."—Preface. r The value attached to this work by the profession is sufficiently proved by the rapid ex- haustion of the first edition, and consequent demand for a second. In preparing this the author has availed himself of the opportunity thoroughly to revise and greatly to improve it. The work will therefore be found completely brought up to the day, and in every way worthy of the reputation which it has so immediately obtained. Professor Meigs has enlarged and amended this great work, for such it unquestionably is, having passed the ordeal of criticism at home and abroad, but been improved thereby ; for in this new edition the author has introduced real improvements, and increased the value and utility of the book immeasurably. It presents so many novel, bright and sparkling thoughts; such an exuberance of new ideas on almost every page, that we confess ourselves to have become enamored with the book and its author; and cannot withhold our congratulations from our Philadelphia confreres, that such a teacher is in their service. We regret that our limits will not allow of a more extended notice of this work, but mu^t content ourselves with thus com- mending it as worthy of diligent perusal by physicians as well as students, who are seekingto be thoroughly instructed in the important practical subjects of which it treats— N. Y. Med. Gazette. It contains a vast amount of practical knowledge, by one wno has accurately observed and retained the experience of many years, and who tells the result in a free, familiar, and pleasant manner.—Du Win Quar- terly Journal. There is an off-hand fervor, a glow and a warm-heartedness infecting the effort of Dr. Meigs, which is en- tirely captivating, and which absolutely hurries the reader through from beginning to end. Besides, the book teems with solid instruction, and it shows the very highest evidence of ability, viz., the clearness with which the information is presented. We know of no better test of one's understanding a subject than the evidence of the power of lucidly explaining it. The most elementary, as well as the obscurest subjects, un- der the pencil of Prof. Meigs, are isolated and made to stand out in such bold relief, as to produce distinct impressions upon the mind and memory of the reader.—The Charleston Medical Journal. The merits of the first edition of this work were so generally appreciated, and with such a high degree of favor by the medical profession throughout the Union, that we are not surprised in seeing a second edition of it. It is a standard work on the diseases of females, and in many respects is one of the very best of its kind in the English language. Upon the appearance of the first edition, we gave the work a cordial recep- tion, and spoke of it in the warmest terms of commendation. Time has not changed the favorable estimate we placed upon it, but has rather increased our convictions of its superlative merits. But we do not now deem it necessary to say more than to commend this work, on the diseases of women, and the remedies for them, to the attention of those practitioners who have not supplied themselves with it. The most select library would be imperfect without it.—The Western Journal of Medicine and Surgery. He is a bold thinker, and possesses more originality of thought and style than almost any American writer on medical subjects. If he is not an elegant writer, there is at least a freshness—a raciness in his mode of expressing himself—that cannot fail to draw the reader after him, even to the close of his work : you cannot nod over his pages; he stimulates rather than narcotises your senses, and the reader cannot lay aside these letters when once he enters into their merits. This, the second edition, is much amended and enlarged, and affords abundant evidence of the author's talents and industry.—N. O. Medical and Surgical Journal. The practical writings of Dr. Meigs are second to none.— The N. Y. Journal of Medicine. The excellent practical directions contained in this volume give it great utility, which we trust will not be lost upon our older colleagues ; with some condensation, indeed, we should think it well adapted for trans- lation into German.—Zeitschriftfur die Gesammte Medecin. NEW AND IMPROVED EDITION-(Lately Issued.) A TREATISE ON THE DISEASES OF FEMALES, AND ON THE SPECIAL HYGIENE OF THEIR SEX, BY COLOMBAT DE L'ISERE, M. D. TRANSLATED, WITH MANY NOTES AND ADDITIONS, BY C. D. MEIGS, M. D. SECOND EDITION, REVISED AND IMPROVED. In one large volume, octavo, of seven hundred and twenty pages, with numerous wood-cuts. We are satisfied it is destined to take the front rank in this department of medical science. It is in fact a complete exposition of the opinions and practical methods of all the celebrated practitioners of ancient and modern times.—New York Journ. of Medicine. ASHWELL ON THE DISEASES OP FEMALES. A PRACTICAL TREATISE BN THE DISEASES PECULIAR TO WOMEN. ILLUSTRATED BY CASES DERIVED FROM HOSPITAL AND PRIVATE PRACTICE. BY SAMUEL ASHWELL, M. D. AVith Additions by PAUL BECK GODDARD, M. D. Second American edition. In one octavo volume, of 520 pages. One of the very best works ever issued from the press on the Diseases of Females.— Western Lancet. ON THE CAUSES AND TREATMENT OF ABORTION AND STERILITY. By James Whitehead, jy[ jj &c. In one volume octavo, of about three hundred and seventy-five pages. BLANCHARD & LEA'S PUBLICATIONS.-(ZW,M of Females.) NEW AND IMPROVED EDITION. THE DISEASES OF FEMALES. INCLUDING THOSE OF PREGNANCY AND CHILDBED. BY FLEETWOOD CHURCHILL, M. D., M. R. I. A., Author of " Theory and Practice of Midwifery," " Diseases of Females," &c. A New American Edition, Revised by the Author. In one large and handsome octavo volume of 632 pages, with wood-cuts. To indulge in panegyric, when announcing the fifth edition of any acknowledged medical authority, were to attempt to "gild refined gold." The work announced above, has too long been honored with the term '•classical" to leave any doubt as to its true worth, and we content ourselves with remarking, that the author has carefully retained the notes of Dr. Huston, who edited the former American edition, thus really enhanc- ing the value of the work, and paying a well-merited compliment. All who wish to be "posted up" on all that relates to the diseases peculiar to the wife, the mother, or the maid, will hasten to secure a copy of this most admirable treatise.— The Ohio Medical and Surgical Journal. We know of no author who deserves that approbation, on " the diseases of females," to the same extent that Dr. Churchill does. His, indeed, is the only thorough treatise we know of on ihe subject, and it may be commended to practitioners and students as a masterpiece in its particular department. The former editions of this work have been commended strongly in this journal, and they have won their way to an extended, and a well deserved popularity. This fifth edition, before us, is well calculated to maintain Dr. Churchill's high reputation. It was revised and enlarged by the author, for his American publishers, and it seems to us, that there is scarcely any species of desirable information on its subjects, that may not be found in this work. — The Western Journal of Medicine and Surgery. We are gratified to announce, a new and revised edition of Dr. Churchill's valuable work on the diseases of females. We have ever regarded it as one of the very best works on the subjects embraced within its scope, in the English language; and the present edition, enlarged and revised by the author, renders it still more entitled to the confidence of the profession. The valuable notes of Prof. Huston have been retained, and contribute, in no small degree, to enhance the value of the work. It is a source of congratulation that the publishers have permitted the author to be, in this instance, his own editor, thus securing all the revision which an author alone is capable of making.— The Western Lancet. As a comprehensive manual for students, or a work of reference for practitioners, we only speak with common justice when we say that it surpasses any other that has ever issued on the same subject from the British press.— The Dublin Quarterly Journal. Churchill's Monographs on Females—(Lately Issued.) ESSAYS ON THE PUERPERAL FEVER, AND OTHER DISEASES PECULIAR TO WOMEN. SELECTED FROM THE WRITINGS OF BRITtSH AUTHORS PREVIOUS TO THE CLOSE OF THE EIGHTEENTH CENTURY. Edited by FLEETWOOD CHURCHILL, M. D., M. R. I. A., Author of "Treatise on the Diseases of Females," &c. In one neat octavo volume, of about four hundred and fifty pages. To these papers Dr. Churchill has appended notes, embodying whatever information has been laid before the profession since their authors' time. He has also prefixed to the essays on puerperal fever, which occu- py the larger portion of the volume, an interesting historical sketch of the principal epidemics of that disease The whole forms a very valuable collection of papers by professional writers of eminence, on some of the most important accidents to which the puerperal female is liable.—American Journal of Medical Sciences. REJVJYETT OJY THE UTERUS—(JVew Edition, JVow Ready.) A PRACTICAL TREATISE ON INFLAMMATION OF THE UTERUS AND ITS APPENDAGES AND ON ULCERATION AND INDURATION OF THE NECK OF THE UTERUS. BY HENRY BENNETT, M. D., Obstetric Physician to the Western Dispensary. Third American Edition. In one neat octavo volume of 350 pages, with wood-cuts. Few works issue from the medical press which are at once original and sound in doctrine; but such, we feel assured, is the admirable treatise now before us. The important praetical precepts which the author inculcates are all rigidly deduced from facts. . . . Every page of the book is good, and eminently practical. So far as we know and believe, it is the best work on the subject on which it treats.—Monthly Journal of Medical Science. A TREATISE ON THE DISEASES OF FEMALES. BY W. P. DEWEES, M. D. NINTH EDITION. In one volume, octavo. 532 pages, with plates. BLANCHARD & LEA'S PUBLICATIONS.—(Diseases of Children.) 21 MEIGS ON CHILDREN—Just Issued. OBSERVATIONS ON CERTAIN OF THE DISEASES OF YOUNG CHILDREN, BY CHARLES D. MEIGS, M. D., Professor of Midwifery and of the Diseases of Women and Children in the Jefferson Medical College of Philadelphia, &c. &c. In one handsome octavo volume of 214 pages. While this work is not presented to the profession as a systematic and complete treatise on In- fantile disorders, the importance of the subjects treated of, and the interest attaching to the views and opinions of the distinguished author must command for it the attention of all who are called upon to treat this interesting class of diseases. It puts forth no claims as a systematic work, but contains an amount of valuable and useful matter, scarcely to be found in the same space in our home literature. It can not but prove an acceptable offering to the profession at large.—N. Y. journal of Medicine. The work before us is undoubtedly a valuable addition to the fund of information which has already been treasured up on the subjects in question. It is practical, and therefore eminently adapted to the general practitioner. Dr. Meigs' works have the same fascination which belongs to himself.—Medical Examiner. This is a most excellent work on the obscure diseases of childhood, and will afford the practitioner and student of medicine much aid in their diagnosis and treatment.—The Boston Medical and Surgical Journal. We take much pleasure in recommending this excellent little work to the attention of medical practition- ers. It deserves their attention, and after they commence its perusal, they will not willingly abandon it, until they have mastered its contents. We read the work while suffering from a carbuncle, and its fasci- nating pages often beguiled us into forgetfulness of agonizing pain. May it teach others to relieve the afflic- tions of the young.— The Western Journal of Medicine and Surgery. All of which topics are treated with Dr Meigs' acknowledged ability and original diction. The work is neither a systematic nor a complete treatise upon the diseases of children, but a fragment which may be con- sulted with much advantage.—Southern Medical and Surgical Journal. NEW WORK BY DR. CHURCHILL. ON THE DISEASES OF INFANTS AND CHILDEEN. BY FLEETWOOD CHURCHILL, M. D., M. E. I. A., Author of" Theory and Practice of Midwifery," "Diseases of Females," &c. In one large and handsome octavo volume of over 600 pages. From Dr. Churchill's known ability and industry, we were led to form high expectations of this work; not were we deceived. Its learned author seems to have set no bounds to his researches in collecting informa- tion which, with his usual systematic address, he has disposed of in the most clear and concise manner, so as to lay before the reader every opinion of importance bearing upon the subject under consideration. We regard this volume as possessing more claims to completeness than any other of the kind with which we are acquainted. Most cordially and earnestly, therefore, do we commend it to our professional brethren, and we feel assured that the stamp of their approbation will in due time be impressed upon it. After an attentive perusal of its contents, we hesitate not to say, that it is one of the most comprehensive ever written upon the diseases of children, and that, for copiousness of reference, extentof research, and per- spicuity of detail, it is scarcely to be equalled, and not to be excelled in any language.—Dublin Quarterly Journal. The present volume will sustain the reputation acquired by the author from his previous works. The reader will find in it full and judicious directions for the management of infants at birth, and a compendious, but clear, account of the diseases to which children are liable, and the most successful mode of treating them. We must not close this notice without calling attention to the author's style, which is perspicuous and polished to a degree, we regret to say, not generally characteristic of medical works. We recommend the work of Dr Churchill most cordially, both to students and practitioners, as a valuable and reliable guide in the treatment of the diseases of children.—Am. Journ. of the Med. Sciences. After this meaere and we know, very imperfect notice, of Dr. Churchill's work, we shall conclude by savin?, that it is one'that cannot fail from its copiousness, extensive research, and general accuracy, to exalt still higher the reputation of the author in this country. The American reader will be particularly pleased to find that Dr Churchill has done full justice throughout his work, to the various American authors on this snhippt The names of Dewees, Eberle, Condie, and Stewart, occur on nearly every page, and these authors are constantly referred to by the author in terms of the highest praise, and With the most liberal courtesy.— The Medical Examiner. We know of no work on this department of Practical Medicine which presents so candid and unpreju- diced a statement or posting up of our actual knowledge as this.-AT. Y. Journal of Medicine. Tta rljiims to merit, both as a scientific and practical work, are of the highest order. Whilst we would „„. -Wat.- it above every other treatise on the same subject, we certainly believe that very few are equal W itfand none svpeiior.-Southern Med. and Surg. Journal. BLANCHARD & LEA'S PUBLICATIONS.—(Diseases of Children.) New and Improved Edition. A PRACTICAL TREATISE OX THE DISEASES OF CHILDREN. BY D. FRANCIS CONDIE, M. L\, Fellow of the College of Physicians, &c. &c. Third edition, revised and augmented. In one large volume, 8vo., of over 700 pages. In the preparation of a third edition of the present treatise, every portion of it has been subjected to a careful revision. A new chapter has been added on Epidemic Meningitis, a disease which, although not confined to children, occurs far more frequently in them, than in adults. In the other chapters of the work, all the more important facts that have been developed since the appearance of the last edition, in reference to the nature, diagnosis, and treatment of the several diseases of which they treat, have been incorporated. The great object of the author has been to present, in each succeeding edition, as full and connected a view as possible of the actual state of the pa- thology and therapeutics of those affections which most usually occur between birth and puberty. To the present edition there is appended a list of the several works and essays quoted or referred to in the body of the work, or which have been consulted in its preparation or revision. Every important fact that has been verified or developed since the publication of the previous edition* either in relation to the nature, diagnosis, or treatment of the diseases of children, have been arranged and incorporated into the body of the work ; thus posting up to date, to use a counting-house phrase, all the valuable facts and useful information on the subject. To the American practitioner, Dr. Condie's remarks on the diseases of children will be invaluable, and we accordingly advise those who have failed to read this work to procure a copy, and make themselves familiar with its sound principles.—The New Orleans Medical and Surgical Journal. We feel persuaded that the American Medical profession will soon regard it, not only as a very good, but as the very best " Practical Treatise on the Diseases of Children."—American Medical Journal. We pronounced the first edition to be the best work on the Diseases of Children in the English language, and, notwithsianding all that has been published, we still regard it in that light.—Medical Examiner. From Professor Wm. P. Johnston, Washington, D. C. I make use of it as a text-book, and place it invariably in the hands of my private pupils. From Professor D. Humphreys Storer, of Boston. I consider it to be the best work on the Diseases of Children we have access to, and as such recommend it to all who ever refer to the subject. From Professor M. M. P alien, of St. Louis. I consider it the best treatise on the Diseases of Children that we possess, and as such have been in the habit of recommending it to my classes. Dr. Condie's scholarship, acumen, industry, and practical sense are manifested in this, as in all his nu- merous contributions to science.— Dr. Holmes's Report to the American Medical Association. Taken as a whole, in our judgment, Dr. Condie's Treatise is the one from the perusal of which the practi- tioner in this country will rise with the greatest satisfaction.— Western Journal of Medicine and Surgery. One of the best works upon the Diseases of Children in the English language.— Western Lancet. We feel assured from actual experience that no physician's library can be complete without a copy ofthis work.— N Y. Journal of Medicine. Perhaps the most full and complete work now before the profession of the United States; indeed, we may say in the English language. It is vastly superior to most of its predecessors.—Transylvania Med Journal. A veritable paediatric encyclopaedia, and an honor to American medical literature.— Ohio Medical and Sur- gical Journal. lf~EST OJV DISEASES OF CHILDREJT. LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. BY CHARLES WEST, M. D., Senior Physician to the Royal Infirmary for Children, &c. &c. In one volume, octavo. Every portion of these lectures is marked by a general accuracy of description, and by the soundness of the views set forth in relation to the pathology and therapeutics of the several maladies treated of. The lec- tures on the diseases of the respiratory apparatus, about one-third of the whole number, are particularly excellent, forming one of the fullest and most able accounts of these affections, as they present themselves during infancy and childhood, in the English language. The history of the several forms of phthisis during these periods of existence, with their management, will be read by all with deep interest.—The American Journal of the Medical Sciences. The Lectures of Dr. West, originally published in the London Medical Gazette, form a most valuable addition to this branch of practical medicine. For many years physician to the Children's Infirmary, his opportunities for observing their diseases have been most extensive, no less than 14,000 children having been brought under his notice during the past nine years. These have evidently been studied with great care, and the result has been the production of the very best work in our language, so far as it goes, on the dis- eases of this class of our patients. The symptomatology and pathology of their diseases are especially exhibited most clearly; and we are convinced that no one can read with care these lectures without deriv- ing from them instruction of the most important kind.— Charleston Med. Journal. A TREATISE ON THE PHYSICAL AND MEDICAL TREATMENT OP CHILDREN. BY W. P. DEWEES, M. D. Ninth edition. In one volume, octavo, of 548 pages. BLANCHARD & LEA'S PUBLICATIONS.—(Obstetrics.) 23 NEW AND IMPROVED EDITION—(Now Ready.) OBSTETRICS: THE SCIENCE AND THE ART. BY CHARLES D. MEIGS, M.D., Professor of Midwifery and the Diseases of Women and Children in the Jefferson Medical College, Philadelphia, &c. &c. Second Edition, Revised and Improved, with 131 Illustrations. In one beautifully printed octavo volume, of seven hundred and fifty-two large pages. The rapid demand for a second edition of this work is a sufficient evidence that it has supplied a desideratum of the profession, notwithstanding the numerous treatises on the same subject which have appeared within the last few years. Adopting a system of his own, the author has combined the leading principles of his interesting and difficult subject, with a thorough exposition of its rules of practice, presenting the results of long and extensive experience and of familiar acquaintance with all the modern writers on this department of medicine. As an American treatise on Mid- wifery, which has at once assumed the position of a classic, it possesses peculiar claims to the at- tention and study of the practitioner and student, while the numerous alterations and revisions which it has undergone in the present edition are shown by the great enlargement of the work, which is not only increased as to the size of the page, but also in the number. Among other addi- tions may be mentioned A NEW AND IMPORTANT CHAPTER ON "CHILD-BED FEVER." As an elementary treatise—concise, but, withal, clear and comprehensive—we know of no one better adapted for the use of the student; while the young practitioner will find in it a body of sound doctrine, and a series of excellent practical directions, adapted to all the conditions of the various forms of labor and their results, which he will be induced, we are persuaded, again and again to consult, and always with profit. It has seldom been our lot to peruse a work upon the subject, from which we have received greater satis- faction, and which we believe to be better calculated to communicate to the student correct and definite views upon the several topics embraced within the scope of its teachings.—American Journal of the Medical Sciences. We are acquainted with no work on midwifery of greater practical value.—Boston Medical and Surgical Journal. Worthy the reputation of its distinguished author.—Medical Examiner. We most sincerely recommend it, both to the student and practitioner, as a more complete and valuable work on the Science and Art of Midwifery, than any of the numerous reprints and American editions of European works on the same subject,—iV. Y. Annalist. We have, therefore, great satisfaction in bringing under our reader's notice the matured views of the highest American authority in the department to which he has devoted his life and talents.—London Medical Gazette. An author of established merit, a professor of Midwifery, and a practitioner of high reputation and immense experience—we may assuredly regard his work now before us as representing the most advanced state of obstetric science in America up to the time at which he writes. We consider Dr. Meigs' book as a valuable acquisition to obstetric literature, and one that will very much assist the practitioner under many circum- stances of doubt and perplexity.— The Dublin Quarterly Journal. These various heads are subdivided so well, so lucidly explained, that a good memory is all that is neces- sary in order to put the reader in possession of a thorough knowledge of this important subject. Dr. Meigs has conferred a great benefit on the profession in publishing this excellent work.—St. Louis Medical and Surgical Journal. TYLER SMITH OX PARTURITION. ON PAKTURITION, AND THE PRINCIPLES AND PRACTICE OF OBSTETRICS. BY W. TYLER SMITH, M. D., Lecturer on Obstetrics in the Hunterian School of Medicine, &c. &c. In one large duodecimo volume, of 400 pages. The work will recommend itself by its intrinsic merit to every member of the profession.—Lancet. We can imagine the pleasure with which William Hunter or Denman would have welcomed the present work; certainly the most valuable contribution to obstetrics that has been made since their own day. For ourselves, we consider its appearance as the dawn of a new era in this department of medicine. We do most cordially recommend the work as one absolutely necessary to be studied by every accoucheur. It will, we may add, prove equally interesting and instructive to the student, the general practitioner, and pure ob- stetrician. It was a bold undertaking to reclaim parturition for Reflex Physiology, and it has been well per- formed.— London Journal of Medicine. LEE'S CLINICAL MIDWIFERY. CLINICAL MIDWIFERY, BY ROBERT LEE, M. D., F. R. S., &c. From the 2d London Edition. In one royal 12mo. volume, extra cloth, of 238 pages. More instructive to the juvenile practitioner than a score of systematic works.-Lan«r. rstSut'ofv^ulble ^r^ltl^s^^rtali Journal of the Medical Sciences. 24 BLANCHARD & LEA'S PUBLICATIONS.—(Obstetrics.) CHURCHILL'S MIDWIFERY, BY OONDIE, NEW AND IMPROVED EDITION-(Just Issued.) THEORY AND PRAGTICE OF MIDWIFERY. BY FLEETWOOD CHURCHILL, M. D., &c. A NEW AMERICAN FROM THE LAST AND IMPROVED ENGLISH EDITION. EDITED, WITH NOTES AND ADDITIONS, BY D. FRANCIS CONDIE, M. D., Author of a "Practical Treatise on the Diseases of Children," &c. WITH OJYJE HUJVDREn JLJYB THMRTV-JYIJYE IJt^JjUSTRATIOJVS. In one very handsome octavo volume. In the preparation of the last English edition, from which this is printed, the author has spared no pains, with the desire of bringing it thoroughly up to the present state of obstetric science. The labors of the editor have thus been light, but he has endeavored to supply whatever he has thought necessary to the work, either as respects obstetrical practice in this country, or its progress in Europe since the appearance of Dr. Churchill's last edition. Most of the notes of the former editor, Dr. Huston, have been retained by him, where they have not been embodied by the author in his text. The present edition of this favorite text-book is therefore presented to the pro- fession in the full confidence of its meriting a continuance of the great reputation which it has acquired as a work equally well fitted for the student and practitioner. To bestow praise on a book that has received such marked approbation would be superfluous. We need only say, therefore, that if the first edition was thought worthy of a favorable reception by the medical pub- lic, we can confidently affirm that this will be found much more so. The lecturer, the practitioner, and the student, may all have recourse to its pages, and derive from their perusal much interest and instruction in everything relating to theoretical and practical midwifery.—Dublin Quarterly Journal of Medical Science. A work of very great merit, and such as we can confidently recommend to the study of every obstetric practitioner.—London Medical Gazette. This is certainly the most perfect system extant. It is the best adapted for the purposes of a text-book, and that which he whose necessities confine him to one book, should select in preference to all others.—Southern Medical and Surgical Journal. The most popular work on Midwifery ever issued from the American press —Charleston Medical Journal. Certainly, in our opinion, the very best work on the subject which exists.—N. Y. Annalist. Were we reduced to the necessity of having but one work on Midwifery, a.nd permitted to choose, we would unhesitatingly take Churchill.— Western Medical and Surgical Journal. It is impossible to conceive a more useful and elegant Manual than Dr. Churchill's Practice of Midwifery. — Provincial Medical Journal. No work holds a higher position, or is more deserving ofbeing placed in the hands of the tyro, the advanced student, or the practitioner.—Medical Examiner. JYEW JEniTIOJV OF RJUUSBOTH&JII OJY JP>ARTURITIOJY—(JYow Ready, 1851.) THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDICINE AND SURGERY, In reference to the Process of Parturition. BY FRANCIS H. RAMSBOTHAM, M. D., Physician to the Royal Maternity Charity^&c. &c. SIXTH AMERICAN, FROM THE LAST LONDON EDITION. Illustrated with One Hundred and Forty-eight Figures on Fifty-five Lithographic Plates. In one large and handsomely printed volume, imperial octavo, with 520 pages. In this edition the plates have all been redrawn, and the text carefully read and corrected. It is therefore presented as in every way worthy the favor with which it has so long been received. From Professor Hodge, of the University of Pennsylvania. To the American public, it is most valuable, from its intrinsic undoubted excellence, and as being the best authorized exponent of British Midwifery. Its circulation will, I trust, be extensive throughout our country. We recommend the student, who desires to master this difficult subject with the least possible trouble, to possess himself at once of a copy of this work.—American Journal of the Medical Sciences. Itstands at the head of the long list of excellent obstetric works published in the last few years in Great Britain, Ireland, and the Continent of Europe. We consider this book indispensable to the library of every physician engaged in the practice of Midwifery.—Southern Medical and Surgical Journal. When the whole profession is thus unanimous in placing such a work in the very first rank as regards the extent and correctness of all the details of the theory and practice of so important a branch of learning, our commendationor condemnation would be of little consequence; but, regarding it as the most useful of all works of the kind, we think it but an act of justice to urge its claims upon the profession.—N. O. Med. Journal. DEWEES'S MIDWIFERY. A COMPREHENSIVE SYSTEM OF MIDWIFERY, ILLUSTRATED BY OCCASIONAL CASES AND MANY ENGRAVINGS. BY WILLIAM P. DEWEES, M. D. Tenth Edition, with the Author's last Improvements and Corrections. In one octavo volume, of 600 j'-a^es. BLANCHARD & LEA'S PUBLICATIONS.—(Materia Medica and Therapeutics.) 25 JPERE IRA'S MATERIA MEDICA—Vol. I.—(JVov> Ready.) NEW EDITION, GREATLY IMPROVED AND ENLARGED. THIS ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS. BY JONATHAN PEREIRA, M. D., F. R. S. and L. S. THIRD AMERICAN EDITION, ENLARGED AND IMPROVED BY THE AUTHOR, INCLUDING NOTICES OF MOST OF THE MEDICINAL SUB- STANCES IN USE IN THE CIVILIZED WORLD, AND FORMING AN ENCYCLOPEDIA OF MATERIA MEDICA. EDITED BY JOSEPH CARSON, M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania. In two very large volumes, on small type, with about four hundred illustrations. The demand for this new edition of" Pereira's Materia Medica" has induced the publishers to issue the First Volume separately. The Second Volume, now at press, and receiving important corrections and revisions from both author and editor, may be shortly expected for publication. The third London edition of this work received very extensive alterations by the author. Many portions of it were entirely rewritten, some curtailed, others enlarged, and much new matter in- troduced in every part. The edition, however, now presented to the American profession, in addition to this, not only enjoys the advantages of a thorough and accurate superintendence by the editor, but also embodies the additions and alterations suggested by a further careful revision by the author, expressly for this country, embracing the most recent investigations, and the result of several new Pharmacopoeias which have appeared since the publication of the London edition of Volume I. The notes of the American editor have been prepared with reference to the new edi- tion of the U. S. Pharmacopoeia, and contain such matter generally as is requisite to adapt it fully to the wants of the profession in this country, as well as such recent discoveries as have escaped the attention of the author. In this manner the size of the work has been materially enlarged, and the number of illustrations much increased, while its mechanical execution has been greatly improved in every respect. The profession may therefore rely on being able to procure a work which, in every point of view, will not only maintain, but greatly advance the very high reputation which it has everywhere acquired. The work, in its present shape, and so far as can be judged from the portion before the public, forms the most comprehensive and complete treatise on materia medica extant in the English language. Dr. Pereira has been at great pains to introduce into his work, not only all the information on the natural, chemical, and commercial history of medicines, which might be serviceable to the physician and surgeon, but whatever might enable his readers to understand thoroughly the mode of preparing and manufacturing various articles employed either for preparing medicines, or for certain purposes in the arts connected with materia medica and the practice of medicine. The accounts of the physiological and therapeutic effects of remedies are given with great clearness and accuracy, and in a manner calculated to interest as well as instruct the reader,— The Edinburgh Medical and Surgical Journal. ROYIiE'S MATERIA MEDICA. MATERIA MEDICA AND THERAPEUTICS; INCLUDING THE Preparations of the Pharmacopoeias of London, Edinburgh, Dublin, and of the United States. WITH MANY NEW MEDICINES. BY J. FORBES ROYLE, M. D., F. R. S., Professor of Materia Medica and Therapeutics, King's College, London, &c. &c. EDITED BY JOSEPH CARSON, M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania. WITH NINETY-EIGHT ILLUSTRATIONS. In one large octavo volume, of about seven hundred pages. Being one of the most beautiful Medical works published in this country. This work is mdeed, a most valuable one, and will fill up an important vacancy that existed between Dr. Pereira's most learned and complete system of Materia Medica, and the class of productions on the other ex- treme, which are necessarily imperfect from their small extent.—British and Foreign Medical Review. POCKET DISPENSATORY AND FORMULARY. A DISPENSATORY AND THERAPEUTICAL REMEMBRANCER. Comprising the entire lists of Materia Medica with every Practical Formula contained in the three British Pharmacopoeias. With rplative Tables subjoined, illustrating by upwards of six hundred and sixty examples, the FvfTm.n«nPous Forms and Combinations suitable for the different Medicines. By JOHN Sr] v«r at■ T) L R C. S., Edin., &c. &c. Edited, with the addition of the formula? of the United States Pharmacopoeia, by R. EGLESFELD GRIFFITH, M. D. In one 12mo. volume, of over three hundred large pages. Tu n„at tvDotrraphy, convenient size, and low price of this volume, recommend it especially to physicians!^apothecaries, and students in want of a pocket manual. 26 BLANCHARD & LEA'S PUBLICATIONS.— (Materia Medica, $c.) NEW UNIVERSAL FORMULARY.—(Lately Issued.) A UNIVERSAL FORMULARY, CONTAINING THE METHODS OF PREPARING AND ADMINISTERING OFFICINAL AND OTHER MEDICINES. THE WHOLE ADAPTED TO PHYSICIANS AND PHARMACEUTISTS. BY R. EQLESFELD GRIFFITH, M. D., Author of "American Medical Botany," &c. In one large octavo volume of568 pages, double columns. In this work will be found not only a very complete collection of formula and pharmaceutic processes, collected with great care from the best modern authorities of all countries, but also a vast amount of important information on all collateral subjects. To insure the accuracy so neces- sary to a work of this nature, the sheets have been carefully revised by Dr. Robert Bridges, while Mr. William Procter, Jr., has contributed numerous valuable formula, and useful suggestions. The want of a work like the present has long been felt in this country, where the physician and apothecary have hitherto had access to no complete collection of formulas, gathered from the pharmacopoeias and therapeutists of all nations. Not only has this desideratum been thoroughly accomplished in this volume, but it will also be found to contain a very large number of recipes for empirical preparations, valuable to the apothecary and manufacturing chemist, the greater part of which have hitherto not been accessible in this country. It is farther enriched with accurate ta- bles of the weights and measures of Europe ; a vocabulary of the abbreviations and Latin terms used in Pharmacy; rules for the administration of medicines ; directions for officinal preparations ; remarks on poisons and their antidotes ; with various tables of much practical utility. To facili- tate reference to the whole, extended indices have been added, giving to the work the advantages of both alphabetical and systematic arrangement. To show the variety and importance of the subjects treated of, the publishers subjoin a very condensed SUMMARY OF THE CONTENTS, IN ADDITION TO THE FORMULARY PROPER, WHICH EXTENDS TO BETWEEN THREE AND FOUR HUNDRED LARGE DOUBLE- COLUMNED PAGES. PREFACE. INTRODUCTION. Weights and Measures. Weights of the United States and Great Britain.— Foreign Weights.—Measures. Specific Gravity. Temperatures for certain Pharmaceutical Ope- rations. Hydrometrical Equivalents. Specific Gravities of some of the Preparations of the Pharmacopceias. Relation between different Thermometrical Scales. Explanation of principal Abbreviations used in Formula. Vocabulary of Words employed in Prescriptions. Observations on the Management of the Sick room. Ventilation of the Sick room.—Temperature of the Sick room.—Cleanliness in the Sick room.— Quiet in the Sick room.—Examination and Pre- servation of the Excretions.—Administration of Medicine.—Furniture of a Sick room.—Proper use of Utensils for Evacuations. Doses of Medicines. Age. — Sex. — Temperament. — Idiosyncrasy. — Habit.—State of the System.—Time of day.—In- tervals between Doses. Rules for Administration of Medicines. Acids.—Antacids.—Antilithics and Lilhontriptics. A ntispasmodics.— Anthelmintics. — Cathartics.— Enemata.—Suppositories.—Demulcents or Emol- lients.—Diaphoretics.—Diluents.—Diuretics.— Emetics. — Emmenagogues. —Epispastics. — Er- rhii.es. — Escharotics. — Expectorants. — Narco- lics.— Refrigerants.— Sedatives.—Sialagogues.— Stimulants.—Tonics. Management of Convalescence and Relapses. DIETETIC PREPARATIONS NOT INCLUDED AMONG THE PREVIOUS PRESCRIPTIONS. LIST OF INCOMPATIBLES. POSOLOGICAL TABLES OF THE MOST IM- PORTANT MEDICINES. TABLE OF PHARMACEUTICAL NAMES WHICH DIFFER IN THE U. STATES AND BRITISH PHARMACOPCEIAS. OFFICINAL PREPARATIONS AND DIREC- TIONS. Internal Remedies. Powders.—Pills and Boluses.—Extracts.—Con- fections, Conserves, Electuaries—Pulps.— Sy- rups.—Mellites or Honeys.—Infusions.—Decoc- tions.—Tinctures.—Wines.—Vinegars.-Mixtures. Medicated Waters.—Distilled, Essential, or Vola- tile Oils.—Fixed Oils and Fats. —Alkaloids — Spirits.—Troches or Lozenges.—Inhalations* External Remedies. Baths—Cold Bath.—Cool Bath.—Temperate Bath. —Tepid Bath—Warm Bath.—Hot Bath.—Shower Bath.—Local Baths—Vapor Bath—Warm Air Bath.—Douches.—Medicated Baths —Affusion.— Sponging.—Fomentations.—Cataplasms, or Poul- tices.—Lotions, Liniments, Embrocations — Vesi- catories, or Blisters.— Issues. — Setons. — Oint- ments.—Cerates.—Plasters.—Fumigations. Bloodletting. General Bloodletting.—Venesection.— Arterio- tomy.—Topical Bloodletting—Cupping. -Leech- ing.— Scarifications. POISONS. INDEX OF DISEASES AND THEIR REMEDIES. INDEX OF PHARMACEUTICAL AND BOTANI- CAL NAMES. GENERAL INDEX. From the condensed summary of the contents thus given it will be seen that the completeness of this work renders it of much practical value to all concerned in the prescribing or dispensing of medicines. BLANCHARD & LEA'S PUBLICATIONS— (Materia Medica, eye.) 27 GRIFFITH'S MEDICAL FORMULARY—(Continued.) From a vast number of commendatory notices, the publishers select a few. A valuable acquisition to the medical practitioner, and a useful book of reference to the apothecary on numerous occasions.—American Journal of Pharmacy. Dr. Griffith^ Formulary is worthy of recommendation, not only on account of the care which has been bestowed on it by its estimable author, but for its general accuracy, and the richness of its details.—Medical Examiner. Most cordially we recommend this Universal Formulary, not forgetting its adaptation to druggists and apothecaries, who would find themselves vastly improved by a familiar acquaintance with this every-day book of medicine.— The Boston Medical and Surgical Journal. Pre-eminent among the best and most useful compilations of the present day will be found the work before us. which can have been produced only at a very great cost of thought and labor. A short description will suffice to show that we do not put too high an estimate on this work. We are not cognizant of the existence of a parallel work. Its value will be apparent to our readers from the sketch of its contents above given. We strongly recommend it to all who are engaged either in practical medicine, or more exclusively with its literature.—London Medical Gazette. A very useful work, and a most complete compendium on the subject of materia medica. We know of no work in our language, or any other, so comprehensive in all its details.—London Lancet. The vast collection of formulae which is offered by the compiler of this volume, contains a large number which will be new to English practitioners, some of them from the novelty of their ingredients, and others from the unaccustomed mode in which they are combined; and we doubt not that several of these might be advantageously brought into use. The authority for every formula is given, and the list includes a very nu- merous assemblage of Continental, as well as of British and American writers of repute. It is, therefore, a work to which every practitioner may advantageously resort for hints to increase his stock of remedies and of forms of prescription. The other indices facilitate reference to every article in the "Formulary;" and they appear to have been drawn up with the same care as that which the author has evidently bestowed on every part of the work.— The British and Foreign Medico-Chirurgical Review. The work before us is all that it professes to be, viz.: " a compendious collection of formulae and pharma- ceutic processes." It is such a work as was much needed, and should be in the hands of every practitioner who is in the habit of compounding medicines.— Transylvania Medical Journal. This seems to be a very comprehensive work, so far as the range of its articles and combinations is con- cerned, with a commendable degree of brevity and condensation in their explanation. It cannot fail to be a useful and convenient book of reference to the two classes of persons to whom it particularly commends itself in the title-page.— The N. W. Medical and Surgical Journal. It contains so much information that we very cheerfully recommend it to the profession.— Charleston Med. Journal. Well adapted to supply the actual wants of a numerous and varied class of persons.—N. Y. Journal of Medicine. CHRISTISON & GRIFFITH'S DISPENSATORY.—(A New Work.) A DISPENSATORY, OR, COMMENTARY ON THE PHARMACOPOEIAS OF GREAT BRITAIN AND THE UNITED STATES: COMPRISING THE NATURAL HISTORY, DESCRIPTION, CHEMISTRY, PHARMACY, ACTIONS, USES, AND DOSES OF THE ARTICLES OF THE MATERIA MEDICA. BY ROBERT CHRISTISON, M. D., V. P. R. S. E., President of the Royal College of Physicians of Edinburgh; Professor of Materia Medica in the University of Edinburgh, etc. Second Edition, Revised and Improved, WITH A SUPPLEMENT CONTAINING THE MOST IMPORTANT NEW REMEDIES. WITH COPIOUS ADDITIONS, AND TWO HUNDRED AND THIRTEEN LARGE WOOD ENGRAVINGS. BY R. EGLESFELD GRIFFITH, M. D., Author of "A Medical Botany," etc. In one very large and handsome octavo volume, of over one thousand closely-printed pages, with numerous wood-cuts, beautifully printed on fine white paper, presenting an immense quantity of matter at an unusually low price. It is enough to say that it appears to us as perfect as a Dispensatory, in the present state of pharmaceuti- cal science^ could be made.—The Western Journal of Medicine and Surgery. CARSOJY'S SYJVOESIS-iJVow Ready.) SYNOPSIS OF THE COURSE DF LECTURES ON MATERIA MEDICA AND PHARMACY, Delivered in the University of Pennsylvania. BY JOSEPH CARSON, M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania. In one very neat octavo volume of 208 pages. . . .__„ ,orvi j Km thorough outline of the very extensive subjects under consideration, wilJ This york. containing a rapid but ho*ou n ou of {he ingtitution for whom u is more rti larly imended"'^also for^se membels'^the profession who may desire to recall their former studies. THE THREE KINDS OF COD-LIVER OIL, r 4-„»iv considered with their Chemical and Therapeutic Properties, by L. J. DE JONGH, Comparative yconsjderjd^wu ^^ an<] Caseg> fay EDWARD CAREY,M. D. To which is rfd d article on the subject from " Dunglison on New Remedies." In one small 12mo. volume, extra cloth. 28 BLANCHARD & LEA'S PUBLICATIONS.—(Materia Medica and Therapeutics.) DUNGLISON'S THERAPEUTICS. XEW AND IMPROVED EDITION.-(Lately Issued.) GENERAL THERAPEUTICsTaND MATERIA MEDICA; ADAPTED FOR A MEDICAL TEXT-BOOK, BY ROBLEY DUNGLISON, M. D., Professor of Institutes of Medicine, See., in Jefferson Medical College; Late Professor of Materia Medica,4c. in the Universities of Maryland and Virginia, and in Jefferson Medical College. FOURTH EDITION, MUCH IMPROVED. With One Hundred and Eighty-two Illustrations. In two large and handsomely printed octavo volumes. The present edition of this standard work has been subjected to a thorough revision both as re- gards style and matter, and has thus been rendered a more complete exponent than heretofore of the existing state of knowledge on the important subjects of which it treats. The favor with which the former editions have everywhere been received seemed to demand that the present should be rendered still more worthy of the patronage of the profession, and of the medical student in particu- lar, for whose use more especially it is proposed; while the number of impressions through which it has passed has enabled the author so to improve it as to enable him to present it with some de- gree of confidence as well adapted to the purposes for which it is intended. In the present edition, the remedial agents of recent introduction have been inserted in their appropriate places; the number of illustrations has been greatly increased, and a copious index of diseases and remedies has been appended, improvements which can scarcely fail to add to the value of the work to the therapeutical inquirer. The publishers, therefore, confidently present the work as it now stands to the notice of the practitioner as a trustworthy book of reference, and to the student, for whom it was more especially prepared, as a full and reliable text-book on General Therapeutics and Materia Medica. Notwithstanding the increase in size and number of illustrations, and the improvements in the mechanical execution of the work, its price has not been increased. In this work of Dr. Dunglison, we recognize the same untiring industry in the collection and embodying of facts on the several subjects of which he treats, that has heretofore distinguished him, and we cheerfully point to these volumes, as two of the most interesting that we know of. In noticing the additions to this, the fourth edition, there is very little in the periodical or annual literature of the profession, published in the in- terval which has elapsed since the issue of the first, that has escaped the careful search of the author. As a book for reference, it is invaluable.— Charleston Med. Journal and Review. It may be said to be the work now upon the subjects upon which it treats.— Western Lancet. As a textbook for students, for whom it is particularly designed, we know of none superior to it.—St. Louis Medical and Surgical Journal. It purports to be a new edition, but it is rather a new book, so greatly has it been improved both in the amount and quality of the matter which it contains.—JV. O. Medical and Surgical Journal. We bespeak for this edition from the profession an increase of patronage over any of its former ones, on account of its increased merit.—N. Y. Journalof Medicine. We consider this work unequalled.—Boston Med. and Surg. Journal. NEW AND MUCH IMPROVED EDITION—Brought up to 1851.—(Just Issued.; NEW REMEDIES, WITH FORMULA FOR THEIR ADMINISTRATION. BY ROBLEY DUNGLISON, M. J)., PROFESSOR OF THE INSTITUTES OF MEDICINE, ETC. IN THE JEFFERSON MEDICAL COLLEGE OF PHILADELPHIA. Sixth Edition, -with extensive Additions. In one very large octavo volume, of over seven hundred and fifty pages. The fact that this work has rapidly passed to a SIXTH EDITION is sufficient proof that it has supplied a desideratum to the profession in presenting' them with a clear and succinct account of all new and impor- tant additions to the materia medica, and novel applications of old remedial agents. In the preparation of the present edition, the author has shrunk from no labor to render the volume worthy of a continuance of the favor with which it has been received, as is sufficiently shown by the increase of about one hundred pages in the size of the work. The necessity of such large additions arises from the fact that the last few years have been rich in valuable gifts to Therapeutics; and amongst these, ether, chloroform, and other so called anaesthetics, are worthy of special attention. They have been introduced since the appearance of the last edition of the " New Remedies." Other articles have been proposed for the first time, and the experience of observers has added numerous interesting facts to our knowledge of the virtues of remedial agents pre- viously employed. The therapeutical agents now first admitted into this work, some of which have been newly introdueed into pharmacology, and the old agents brought prominently forward with novel applications, and which may consequently be regarded as New Remedies, are the following:—Adansonia digitata, Benzoate of Ammonia, Valerianate of Bismuth, Sulphate of Cadmium, Chloroform, Collodion, Canthandal Collodion, Cotyledon Um- bilicus. Sulphuric Ether, Strong Chloric Ether, Compound Ether, Hura Braziliensis, lberis Amara, Iodic Acid, Iodide of Chloride of Mercury, Powdered Iron, Citrate of Magnetic Oxide of Iron. Citrate of Iron and Magnesia, Sulphate of Iron and Alumina, Tannate of Iron. Valerianate of Jron, Nitrate of Lead, Lemon Juice, Citrate of Magnesia. Salts of Manganese, Oleum Cadinum, Arsenite of Quinia, Hydriodate of Iron and Quinia, Sanicula Marilandica, and Sumbul. BLANCHARD & LEA'S PUBLICATIONS.—(Materia Medica, tf-c. 29 MOHR, UEDWOOD, AND PROCTER'S PHARMACY.-Lately Issued. PRACTICAL~PHARMACY. COMPRISING THE ARRANGEMENTS, APPARATUS, AND MANIPULATIONS OF THE PHARMACEUTICAL SHOP AND LABORATORY. BY FRANCIS MOHR, Ph. D., Assessor Pharmacia? of the Royal Prussian College of Medicine, Coblentz; AND THEOPHILUS REDWOOD, Professor of Pharmacy in the Pharmaceutical Society of Great Britain. EDITED, WITH EXTENSIVE ADDITIONS, BY PROFESSOR WILLIAM PROCTER, Of the Philadelphia College of Pharmacy. In one handsomely printed octavo volume, of 570 pages, with over 500 engravings on wood. To physicians in the country, and those at a distance from competent pharmaceutists, as well as to apothecaries, this work will be found of great value, as embodying much important information which is to be met with in no other American publication. After a pretty thorough examination, we can recommend it as a highly useful book, which should be in the hands of every apothecary. Although no instruction of this kind will enable the beginner to acquire that practical skill and readiness which experience only can confer, we believe that this work will much facilitate their acquisition, by indicating means for the removal of difficulties as they occur, and sug- gesting methods of operation in conducting pharmaceutic processes which the experimenter would only hit upon after many unsuccessful trials; while there are few pharmaceutists, of however extensive expe- rience, who will not find in it valuable hints that they can turn to use in conducting the affairs of the shop and laboratory. The mechanical execution of the work is in a style of unusual excellence. It contains about five hundred and seventy large octavo pages, handsomely printed on good paper, and illustrated by over five hundred remarkably well executed wood-cuts of chemical and pharmaceutical apparatus. It comprises the whole of Mohr and Redwood's book, as published in London, rearranged and classified by the American editor, who has added much valuable new matter, which has increased the size of the book more than one-fourth, including about one hundred additional wood-cuts.— The American Journ. of Pharmacy. It is a book, however, which will be in the hands of almost every one who is much interested in pharma- ceutical operations, as we know of no other publication so well calculated to fill a void long felt.— The Medi- cal Examiner. The country practitioner who is obliged to dispense his own medicines, will find it a most valuable assist- ant.—Monthly Journal and Retrospect. The book is strictly practical, and describes only manipulations or methods of performing the numerous processes the pharmaceutist has to go through, in the preparation and manufacture of medicines, together with all the apparatus and fixtures necessary thereto. On these matters, this work is very full and com- plete, and details, in a style uncommonly clear and lucid, not only the more complicated and difficult pro- cesses, but those not less important ones, the most simple and common. The volume is an octavo of five hundred and seventy-six pages. It is elegantly illustrated with a multitude of neat wood engravings, and is unexceptionable in its whole typographical appearance and execution. We take great satisfaction in commending this so much needed treatise, not only to those for whom it is more specially designed, but to the medical profession generally—to every one, who, in his practice, has occasion to prepare, as well as ad- minister medical agents.—Buffalo Medical Journal. JVEW AJVD COMPLETE MEDICAL BOTAJVV. MEDICAL- BOTANY; OR. A DESCRIPTION OF ALL THE MORE IMPORTANT PLANTS USED IN MEDICINE. AND OF THEIR PROPERTIES, USES. AND MODES OF ADMINISTRATION, BY R. EGLESFELD GRIFFITH, M. D., &c. &c. In one lar^e 8vo. vol. of 704 pages, handsomely printed, with nearly 350 illustrations on wood. One of the greatest acquisitions to American medical literature. It should by all means be introduced, at the very earliest period, into our medical schools, and occupy a place in the library of every physician in the land.— Southwestern Medical Advocate. Admirably calculated for the physician and student—we have seen no work which promises greater ad- vantages to the profession.—N. O. Medical and Surgical Journal. One of the few books which supply a positive deficiency in our medical literature.— Western Lancet. We hone the day is not distant when this work will not only be a text-book in every medical school and college in the Union, but find a place in the library of every private practitioner.—N. Y. Journ. of Medicine. ELLIS'S MEDICAL FORMULARY.—Improved Edition. THE MEDICAL FORMULARY: ™NS . roiXECTION OF PRESCRIPTIONS, DERIVED FROVI THE WRITINGS AND PRACTICE OF MANY OF THE iMOST BEim* A. CUl^.BA-11 EMINENT PHYSICIANS OF AMERICA AND EUROPE. To which is added an Appendix, containing the usual Dietetic Preparations and Antidotes for Poisons. THE WHOLE ACCOMPANIED WITH A FEW BRIEF PHARMACEUTIC AND MEDICAL OBSERVATIONS. BY BENJAMIN ELLIS, M. D. NINTH EDITION, CORRECTED AND EXTENDED, BY SAMUEL GEORGE MORTON, M. D. In one neat octavo volume of 268 pages. CARPENTER ON ALCOHOLIC LIQUORS.—(A New Work.) A Prize Essay on the Use of Alcoholic Liquors in Health and Disease. By William B. Carpenter,, M. D. author of " Principles of Human Physiology," &c. In one 12mo. volume. SO BLANCHARD & LEA'S PUBLICATIONS.— (Chemistry.) JVEW EMTIO.V OF GRAHAM'S CHEMISTRY—(.Voir Ready.) ELEMENTS OF CHEMISTRY; INCLUDING THE APPLICATIONS OF THE SCIENCE IN THE ARTS. BY THOMAS GRAHAM, F. R. S., &c. Second American, from the Second, entirely Revised, and greatly Enlarged London Edition. With Notes and Additions by ROBERT BRIDGES, M. D. To be complete in one very large octavo volume, with several hundred beautiful illustrations. PART I, now ready, of about 450 large pages, with 185 illustrations. PART II, completing the work, preparing for early publication. The great changes which the science of chemistry has undergone within the last few years, render a new edition of a treatise like the present almost a new work. The author has devoted several years to the revi- sion of his treatise, and has endeavored to embody in it every fact and inference of importance which has been observed and recorded by the great body of chemical investigators who are so rapidly chnnging the face of the science. In this manner the work has been greatly increased in size, and the number of illus- trations doubled ; while the labors of the editor have been directed towards the introduction of such matters as have escaped the attention of the author, or as have arisen since the publication of the first portion of this edition in London, in 1850 Printed in handsome style, and at a very low price, it is therefore confidently pre- sented to the profession and the student as a very complete and thorough text-book of this important subject. NEW AND IMPROVED EDITION—(Lately Issued.) ELEMENTARY CHEMISTRY, THEORETICAL AND PRACTICAL. BY GEORGE FOWNES, Ph. D., Chemical Lecturer in the Middlesex Hospital Medical School, &e. &c. WITH NUMEROUS ILLUSTRATIONS. THIRD AMERICAN, FROM A LATE LONDON EDITION. EDITED, WITH ADDITIONS, BY ROBERT BRIDGES, M. D., Professor of General and Pharmaceutical Chemistry in the Philadelphia College of Pharmacy, &c. &c. In one large royal 12mo. vol., of over 500 pages, with about 180 wood-cuts, sheep or extra cloth. The work of Dr. Fownes has long been before the public, and its merits have been fully appreciated as the best text-book on Chemistry now in existence. We do not, of course, place it in a rank superior to the works of Brande, Graham, Turner, Gregory, or Gmelin, but we say that, as a work for students,it is prefer- able to any of them.— London Journal of Medicine. The rapid sale of this Manual evinces its adaptation to the wants of the student of chemistry, whilst the well known merits of its lamented author have constituted a guarantee for its value, as a faithful exposition of the general principles and most important facts of the science to which it professes to be an introduction. — The British and Foreign Medico-Chirurgical Review. A work well adapted to the wants of the student. It is an excellent exposition of the chief doctrines and facts of modern chemistry, originally intended as a guide to the lectures of the author, corrected by his own hand shortly before his death in 1849, and recently revised by Dr. Bence Jones, who has made some additions to the chapter on animal chemistry. Although not intended to supersede the more extended treatises on chemistry, Professor Fownes' Manual may, we think, be often used as a work of reference, even by those advanced in the study, who may be desirous of refreshing their memory on some forgotten point. The si/.e of the work, and still more the condensed yet perspicuous style in which it is written, absolve it from the cnarges very properly urged against most manuals termed popular, viz., of omitting details of indispensable importance, of avoiding technical difficulties, instead of explaining them, and of treating subjects of high sci- entific interest in an unscientific way.—Edinburgh Monthly Journal of Medical Science. BOWMAN'S MEDICAL CHEMISTRT-(Lately Issued.) PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. BY JOHN E. BOWMAN, M. D. In one neat volume, royal 12mo., with numerous illustrations. Mr. Bowman has succeeded in supplying a desideratum in medical literature. In the little volume before us. he has given a concise but comprehensive account of all matters in chemistry which the man in practice mav desire to know.—Lancet. BY THE SAME AUTHOR—(Irately Issued.) INTRODUCTION TO PRACTICAL CHEMISTRY, Including Analysis. With Numerous Illustrations. In one neat volume, royal 12mo. GARDNER'S MEDICAL CHEMISTRY. MEDICAL CHEMISTRY, FOR THE USE OF STUDENTS AND THE PROFESSION; BEING A MANUAL OF THE SCIENCE, WITH ITS APPLICATIONS TO TOXICOLOGY PHYSIOLOGY, THERAPEUTICS, HYGIENE, &c. BY D. PEREIRA GARDNER, M. D. In one handsome royal 12mo. volume, with illustrations. SIMON'S ANIMAL CHEMISTRY, with Reference to the Physiology and Pathology of Man. By G. E. Dat. One vol. 8 vs., 700 pages. BLANCHARD & LEA'S PUBLICATIONS. 31 TAYLOR'S MEDICAL, JURISPRUDENCE. MEDICAL JURISPRUDENCE. BY ALFRED S. TAYLOR, SECOND AMERICAN, FROM THE THIRD AND ENLARGED LONDON EDITION. With numerous Notes and Additions, and References to American Practice and Law. BY R. E. GRIFFITH, M. D. In one large octavo volume. This work has been much enlarged by the author, and may now be considered as the standard authority on the subject, both in England and this country. It has been thoroughly revised, in this edition, and completely brought up to the day with reference to the most recent investigations and decisions. No further evidence of its popularity is needed than the fact of its having, in the short time that has elapsed since it originally appeared, passed to three editions in England, and two in the United States. We recommend XVI r. Taylor's work as the ablest, most comprehensive, and, above all, the most practically useful book which exists on the subject of legal medicine. Any man of sound judgment, who has mastered the contents of Taylor's " Medical Jurisprudence," may go into a court of law with the most perfect confi- dence of being able to acquit himself creditably.—Medico-Chirurgical Review. The most elaborate and complete work that has yet appeared. It contains an immense quantity of cases lately tried, which entitle it to be considered what Beck was in its day.—Dublin Medical Journal. TAYLOR OJST POISONS. ON POISONS, IN RELATION TO MEDICAL JURISPRUDENCE AND MEDICINE. BY ALFRED S. TAYLOR, F. R. S., &o. Edited, with Notes and Additions, BY R. E. GRIFFITH, M. D. In one large octavo volume, of 688 pages. The most elaborate work on the subject that our literature possesses.— Brit, and For. Medico-Chirur. Review. One of the most practical and trustworthy works on Poisons in our language.— Western Journal of Med. It contains a vast body of facts, which embrace all that is important in toxicology, all that is necessary to the guidance of the medical jurist, and all that can be desired by the lawyer.—Medico-Chirurgical Review. It is, so far as our knowledge extends, incomparably the best upon the subject; in the highest decree credit- able to the author, entirely trustworthy, and indispensable to the student and practitioner.—iV. Y. Annalist. A NEW WORK ON THE SKIN—(Nearly Ready.) PRACTICAL TREATISE ON DISEASES OF THE SKIN. BY J. M. NELIGAN, M. D., Author of "Medicines, their Uses and Modes of Administration," &c. In one neat volume, royal 12mo. THE LAWS OF HEALTH IN RELATION TO MINE AND BODY. A SERIES OF LETTERS FROM AN OLD PRACTITIONER TO A PATIENT. BY LIONEL JOHN BEALE, M. E. C. S., &c. In one handsome volume, royal 12mo., extra cloth. LETTERS TO A CANDID INQUIRER ON ANIMAL MAGNETISM. BY WILLIAM GREGORY, M. D., F. R. S. E., Professor of Chemislry in the University of Edinburgh, &c. In one neat volume, royal 12mo., extra cloth. PROFESSOR DICKSON'S ESSAYS, ESSAYS ON IIFE, SLEEP, PAIN, INTELLECTION, HYGIENE, AND DEATII. BY SAMUEL HENRY DICKSON, M. D., Professor of the Institutes and Practice of Medicine in the Charleston Medical College. In one very handsome volume, royal 12mo. „...„, tTiinIs MPDicA-L STUDENT.-The Medical Student, or Aids to the Study of Medicine. Revised DUI^r JlVJrf PdiiSn 1 vol. royal 12mo.. extra cloth. 312 pp. RaRTLFTT'S PHILOSOPHY OF MEDICINE.-An Essay on the Philosophy of Medical Science. In 0DeAawdrrmONVCERTAieNTV IN MEDICINE— An Inquiry into the Degree of Certainty in Medicine, B£ucl into the Nature and Extent of its Power over Disease. In one vol. royal 12mo. 64 pp. 32 BLANCHARD & LEA'S PUBLICATIONS. THE GREAT AMERICAN MEDICAL DICTIONARY. Xctv aud. Enlarged Edition—(Now Ready.) MEDICAL "LEXICON; A DICTIONARY OF MEDICAL SCIENCE, Containing a Concise Explanation of the various Subjects and Terms of PHYSIOLOGY, PATHOLOGY, HYGIENE, THERAPEUTICS, PHARMACOLOGY, OBSTETRICS, MEDICAL JURISPRUDENCE, &c. WITH TOE FRENCH AND OTHER SYNONYMES. NOTICES OF CLIMATE AND OF CELEBRATED MINERAL "WATERS; Formulae for various Officinal, Empirical, and Dietetic Preparations, &c. BY ROBLEY DUNGLISON, M. D., Professor of Institutes of Medicine, &c. in Jefferson Medical College, Philadelphia, &c. EIGHTH EDITION, REVISED AND GREATLY ENLARGED. In one very thick 8vo. vol., of 927 large double-columned pages, strongly bound, with raised bands. Every successive edition of this work bears the marks of the industry of the author, and of his determina- tion to keep it fully on a level with the most advanced state of medical science. Thus the last two editions contained about nine thousand subjects and terms not comprised in the one immediately preceding, and the present has not less than foub thousand not in any former edition. As a complete Medical Dictionary, therefore, embracing over fiftj thousand definitions, in all the branches of the science, it is presented as meriting a continuance of the great favor and popularity which have carried it, within no very long space of time, to an eighth edition. Every precaution has been taken in the preparation of the present volume, to render its mechanical exe- cution and typographical accuracy worthy ot its extended reputation and universal use. The very exten- sive additions have been accommodated, without materially increasing the bulk of the volume, by the employ- ment of a small but exceedingly clear type, cast for this purpose. The press has been watched with great care, and every effort used to insure the verbal accuracy so necessary to a work of this nature. The whole is printed on fine white paper; and while thus exhibiting in every respect so great an improvement over former issues, it is presented at the original exceedingly low price. On the appearance of the last edition of this valuable work, we directed the attention of our readers to its peculiar merits ; and we need do little more than slate, in reference to the present re-issue, that notwith- standing the large additions previously made to it, no fewer than four thousand terms, not to be found in the preceding edition, are contained in the volume before us. Whilst it is a wonderful monument of its author's erudition and industry, it is also a work of great practical utility, as we can testify from our own expe- rience ; for we keep it constantly within our reach, and make very frequent reference to it, nearly always finding in it the information we seek.—British and Foreign Medico-Chirurgical Review, April, 1852. Br. Dunglison's Lexicon has the rare merit that it certainly has no rival in the English language for ac- curacy and extent of references. The terms generally include short physiological and pathological de- scriptions, so that, as the author justly observes, the reader does not possess in this work a mere dictionary, but a book, which, while it instructs him in medical etymology, furnishes him with a large amount of useful information. That we are not over-estimating the merits of this publication, is proved by the fact that we have now before us the seventh edition. This, at any rate, shows that the author's labors have been pro- perly appreciated by his own countrymen ; and we can only confirm their judgment, by recommending this most useful volume to the notice of our cisatlantic readers. No medical library will be complete without it. — The London Med. Gazette. It is certainly more complete and comprehensive than any with which we are acquainted in the English language. Few, in fact, could be found better qualified than Dr. Dunglison for the production of such a work. Learned, industrious, persevering, and accurate, he brings to the task all the peculiar talents necessary for its successful performance: while, at the same time, his familiarity with the writings of the ancient and modern " masters of our art," renders him skilful to note the exact usage of the seveqtl terms of science, and the various modifications which medical terminology has undergone with the change of theories or the pro- gress of improvement.—American Journal of the Medical Sciences. One of the most complete and copious known to the cultivators of medical science.—-Boston Med. Journal. This most complete Medical Lexicon—certainly one of the best works of the kind in the language.— Charleston Medical Journal. The most complete Medical Dictionary in the English language.— Western Lancet. Dr. Dunglison's Dictionary has not its superior, if indeed its equal, in the English language.—St. Louis Med. and Surg. Journal. Familiar with nearly all the medical dictionaries now in print, we consider the one before us the most complete, and an indispensable adjunct to every medical library.—British American Medical Journal. We repeat our former declaration that this is the best Medical Dictionary in the English language.— Western Lancet. We have no hesitation to pronounce it the very best Medical Dictionary now extant.—Southern Medical and Surgical Journal. The most comprehensive and best English Dictionary of medical terms extaat.—Buffalo Med. Journal HOBLYN'S MEDICAL DICTIONARY. A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. BY RICHARD D. HOBLYN, A. M., Oxon REVISED, WITH NUMEROUS ADDITIONS, FROM THE SECOND LONDON EDITION BY ISAAC HAYS, M. D., &c. In one large royal 12mo. volume of 402 pages, double column*. We cannot too strongly recommend this small and cheap volume to the library of every student and nrw titioner.— Medico-Chirurgical Review. ^rBC MAY 2 n mq }i& NLM041394167